Meridians

Acupuncture meridians have been named in many languages by international standards. The most widely accepted nomenclature and abbreviations in English are listed below:

LU        = Lung Meridian 
LI, CO    =  Large  Intestine Meridian 
ST        = Stomach Meridian 
SP        = Spleen Meridian 
HT, HE   =  Heart Meridian 
SI         = Small Intestine Meridian 
BL, UB  = Bladder Meridian 
KI      = Kidney Meridian 
P, PC, HC  =  Pericardium, Heart Constrictor Meridian 
TW, TH, SJ = Triple Warmer, Tri-Heater, Triple Burner, San Jiao meridian 
GB = Gallbladder Meridian 
LV, LI, LIV  =  Liver Meridian 
CV, VC, Ren=  Conception Vessel Meridian 
GV, VG, Du  =  Governing Vessel Meridian

The abbreviations LI and CO were used in some older books for the liver and large intestine, respectively.

Clinical Effects of Acupuncture: Methodological Considerations

The methodological quality of many randomized clinical trials evaluating acupuncture is inadequate. The major problem in these studies is the lack of an adequate placebo control. Sham acupuncture is used as a common control procedure. Accordingly, the needles are inserted into unsuitable meridians or areas outside the meridians. In sham acupuncture, more superficial needle insertion is frequently performed than in the real acupuncture group.1 Linde et al. conducted a meta-analysis of 37 randomized controlled trials evaluating acupuncture. In this analysis, they compared sham with placebo acupuncture (nonspecific effect) and sham with real acupuncture (specific effect). They stated that sham acupuncture was more effective than placebo acupuncture, and real acupuncture was more effective than sham acupuncture.

Analgesic Effects of Acupuncture

Different hypotheses have been proposed to explain the analgesic effects of acupuncture based on human and animal studies. These effects are complex and largely the result of the interaction of neurochemical, physiological, and psychological factors associated with patients' expectations.

There is evidence to support the role of endogenous opioids (encephalin, dynorphin, endorphin, and endomorphin) and serotonin (5-HT) in acupuncture analgesia. Mayer et al. and Pomeranz et al. showed that Acupuncture Analgesia supporting the role of endogenous opioids was blocked with Naloxone, in mice and humans.

Neural Mechanisms of Acupuncture Analgesia (AA)

Muscle (stimulation of small-diameter nerves) 
Medulla spinalis

Chemical transmitters (monoamines such as endorphin, serotonin, NA, etc.)

Midbrain

Blockade of hypophysis pain transmission (Bruce Pomeranz,1987)

Positron emission tomography (PET) studies show increased binding of opioids at mu receptors in the brain after acupuncture. -5- In addition, fMRI has shown activation of the basal anterior brain, the limbic system, and other areas of the brain associated with affective and somatosensory functions with acupuncture treatment.

The role of Capicolaminas and Cerotoninas which are effective cerebral neurotransmitters, in acupuncture analgesia is under research. The release of these neurotransmitters can produce analgesic, muscle relaxation, anti-inflammatory, mild anxiolytic, and antidepressant effects. Electroacupuncture generates CXCL 10 at the inflammation location and stimulates antinociception via peripheral opioid peptides.

Endogenous opioid peptides such as beta-endorphin are associated with acupuncture analgesia. They activate opioid receptors in the spinal cord, as in peripheral sensory neurons in the peripheral inflammatory area. Opioid-containing leukocytes migrate to the inflamed tissue and secrete opioids such as endorphin, met-encephalin, and dynorphin A.

Thus, they form antinociception by binding opioid receptors on peripheral nociceptive neurons.

Indications for Acupuncture Accepted by the World Health Organization in 2003

• Backache

• Neck pain

• Sciatica

• Tennis elbow

• Knee pain

• Shoulder circumference arthritis

• Sprains and muscle spasms

• Facial pain

• TMJ pain

• Headache

• Toothache

• Renal colic

• Acute and chronic gastritis

• Rheumatoid Arthritis

• Initiating the birth

• Arrival maneuvers during birth

• Morning sickness

• Nausea and vomiting

• Postoperative pain

• Stroke-paralysis

• Essential hypertension

• Primary hypotension

• Leukopenia

• Radiation/chemotherapy reactions

• Allergic rhinitis

• High fever

• Biliary colic

• Depression

• Acute bacillary dysentery

• Primary dysmenorrhea

• Acute epigastralgia

• Peptic ulcer

• Nausea and vomiting after surgery and chemotherapy

• Toothache

The effectiveness of the American National Institute of Health (NIH) Acupuncture Consensus Development Program alone has been widely accepted.

Acupuncture as adjunctive therapy or an acceptable alternative treatment:

• Addiction

• Stroke rehabilitation

• Headache 

• Menstrual cramps

• Tennis elbow

• Fibromyalgia

• Myofascial pain

• Osteoarthritis

• Waist and back pain

• Carpal tunnel syndrome

• Asthma

Classical Acupuncture Meridians and Points

National Institute of Health (NIH) Acupuncture Final Declaration

However, there are some reservations about creating a control group, placebo, and blind studies due to the form of the method. Nevertheless, the effectiveness of acupuncture has been proven in the suppression of toothache, postoperative and post-chemotherapy nausea, and vomiting. There is very strong evidence that it is beneficial in carpal tunnel syndrome, low back pain, fibromyalgia and myofascial pain, tennis elbow, headache, stroke rehabilitation, and drug addiction.

Cancer Pain

It is stated that Electronic Acupuncture (EA) is also effective in the treatment of pancreatic cancer pain. Chen H. et al. applied EA to T8-T12 bilateral Jiaji (Ex-B2) points of patients once a day for 30 minutes for 3 days. There was a significant decrease in pain intensity in the EA group compared to the control group (p<0.001).

It is stated that there is no difference between the benefits of acupuncture versus conventional medication in nonspecific advanced cancers, the benefits of auricular acupuncture versus placebo for cancer-related chronic neuropathic pain, and conventional analgesia and acupuncture in the first 10 days of treatment in gastric cancer. 

Postoperative Pain Management

It is stated that acupuncture reduces pain and opioid use on the first postoperative day. Thus, it is recommended to use acupuncture as adjuvant therapy in the treatment of postoperative pain.

The list of indications published by John McDonald and Stephen Janz, co-authors of the “Acupuncture Evidence Project” in 2017, is as follows: 

Areas of Application with Strong Evidence in favor of Acupuncture

• Allergic Rhinitis

• Knee osteoarthritis

• Nausea and vomiting caused by chemotherapy

• Prevention of migraine attack

• Headache (tension-type and chronic)

• Nausea and vomiting after surgery

• chronic low back pain

• Post-operative pain

Areas of Application with Evidence in favor of Acupuncture

• Acute Low Back Pain

• Raising The Threshold Of Emotional Perception

• Acute Stroke

• Neck Pain

• Outpatient Anesthesia

• Obesity

• Anxiety

• Insomnia During And After Menopause

• Joint Pain Caused By Aromatic Suppressants

• Hip Pain

• Asthma in Adults

• Post-stroke Insomnia 

• Back And Groin Pain During Pregnancy

• Cancer Pain

• Shoulder Pain After Stroke

• Cancer-Related Burnout

• Post-Stroke Muscle Stiffness

• Constipation

• Post-Traumatic Stress Disorder

• Neurosurgery anesthesia

• Prostate inflammation and chronic groin pain

• Depression (with antidepressants)

• Recovery after colon cancer surgery

• Dry eye

• Restless legs syndrome

• Hypertension (with medications)

• Schizophrenia (with antipsychotic drugs)

• Insomnia

• Sciatic pain

• Irritable bowel syndrome

• Shoulder impingement syndrome (with exercise in the early period)

• Labor pains

• Shoulder pain

• Lateral elbow pain

• Smoking cessation (approximately 3 months)

• Hot flashes during menopause

• Stroke Rehabilitation

Moxa Treatment

Moxa therapy is one of the traditional Chinese medical treatment methods that is done by stimulating the acupuncture points directly or indirectly with the burning dry Artemisia vulgaris (mugwort) plant. It is possible to dissolve pathological cold, and warm meridians, regulate collaterals, stimulate blood circulation, remove the obstruction, support yang, dissolve blood stasis, and prevent diseases, with moxa treatment. Moxa can be used in the treatment of many diseases such as arthritis, gastrointestinal diseases, gynecological problems, and pain. When Moksa is applied, the skin temperature reaches 130 ° C outside and 56 ° C inside. Therefore, moxa is considered an inflammatory response to heat stimulation. The inflammatory response stimulates vascular changes. Vasoconstriction occurs in the skin area where Moksa is applied, and vasodilation occurs around this area. Histamine and substance P is responsible for vasodilation on the skin. The histamine released during moksa treatment causes vasodilation on the skin. As a result of increased permeability, degranulation occurs in mast cells. Substance P and galanin are neurotransmitters released by acupuncture and moxa therapy. These neurotransmitters are known to play a role in neurological diseases such as pain, spasm, anxiety, and depression.

Prof. Dr. İlhan ÖZTEKİN

Yeditepe University Kosuyolu Hospital
Department of Anesthesia and Reanimation Algology