Obesity Reduction

SP6-ST36Researchers find acupuncture effective for the treatment of obesity. Results were obtained by implementing a protocolized body acupuncture point prescription without a diet or exercise program. [1] In a five week clinical trial, patients receiving acupuncture achieved a 2.9 kg mean weight loss and the decrease in mean BMI (body mass index) was 1.43. The laboratory findings, including serum levels of insulin, leptin, ghrelin, and cholecystokinin are consistent with the results. The controlled study documents that sham acupuncture does not produce significant positive patient outcomes, only true acupuncture achieves clinical results. Based on the evidence, the hospital researchers conclude that acupuncture treatment regulates weight for patients with obesity.

Obesity is an increasingly prevalent chronic condition that is associated with serious morbidity and mortality. [2] The risk of hypertension, heart disease, hypercholesterolemia, diabetes mellitus, cerebrovascular disease, gallbladder disease, and some types of cancer are higher for overweight (BMI>25) and obese (BMI>30) individuals. [3] Weight control treatments include diet therapy, behavioral treatment, pharmacotherapy, surgical procedures, and acupuncture. The downside to anti-obesity medications and surgery is the potential for iatrogenic illness. [4] In addition, a World Health Organization Report on acupuncture states that acupuncture demonstrates a therapeutic effect for the treatment of obesity. [5]

Laboratory data supports the conclusions of the researchers in this controlled clinical trial. After 5 weeks of acupuncture treatment, mean serum insulin and leptin levels decreased by 6.87 μIU/ml (43%) and 3.32 ng/ml (25%) respectively. No significant change was seen in these variables after sham treatment. Differences between the two study groups in these parameters were documented. The mean serum insulin and leptin levels in the acupuncture group were lower than in the sham acupuncture group by 8.27 μIU/ml and 6.17 ng/ml respectively. The true acupuncture group also demonstrated significant improvements in mean plasma ghrelin and CCK levels. The researchers note, “acupuncture treatment decreased insulin and leptin levels and induced weight loss, together with a decrease in BMI compared with sham acupuncture.”

Group Selection Process
The subject selection process was as follows. An acupuncture study was announced in a university hospital (Etlik Zubeyde Hanim Obstetrics and Gynecology Training and Research Hospital) for employees and people attending routine wellness examinations. Female obese volunteers who wanted to be involved in this study underwent the selection process and 40 of these with BMI>30 were accepted after routine medical examinations. Subjects selected for inclusion had normal physical examination findings and did not have hypertension, diabetes, nephropathy, heart failure, and were not receiving any medications.

The statistical breakdown for each randomized group was as follows. The mean age of participants was 34.6 ±6.3 years for the sham acupuncture group and 36.8 ±7.8 years for the acupuncture group. Pre-sham and pre-acupuncture groups showed no significant differences in weight, BMI, serum insulin and leptin levels. All participants successfully completed specified treatments without any dropouts or unintended outcomes.

True vs. Sham Acupuncture
The acupuncture group received traditional Chinese type general body acupuncture at the follow acupoints bilaterally:

  • LI4 (Hegu)
  • HT7 (Shenmen)
  • ST36 (Zusanli)
  • ST44 (Neiting)
  • SP6 (Sanyinjiao)

Treatment commenced with patients in a supine position. After disinfection of the acupoint sites, a disposable stainless steel needle (25 mm length, 0.25 mm diameter, Kingli brand) was inserted into each acupoint, reaching a depth of 5–10 mm. Twisting, lifting, and thrusting manual acupuncture techniques were applied to elicit deqi.

Patients in the other group were treated with sham acupuncture. The needles were not inserted but were applied under a tape at the same points. Both groups received two sessions per week for a total of 10 sessions. Duration of each session was 20 minutes. Both treatments were performed by a certified acupuncturist. All patients were asked not to follow dietary treatments, not to undergo heavy physical exercise, and not to take supplementary medications.

Auricular Points
Sun et al. conclude that acupuncture combined with auricular acupressure achieves an average weight loss of 5.04 kg after three months of treatment, The sample size was 110 obese female patients. [6] One study group received body acupuncture plus auricular acupressure (every 3–5 days for 3 months) and another received Capsulae Olei Oenothera Erythrosepalae, a weight control substance. Body weight of the acupuncture group reduced by an average 5.04 kg while that of the control group by an average of 2.08 kg. The differences between the two groups and between values of the same group before and after treatment were statistically significant. The primary body acupoints used in the study were the following:

  • ST25 (Tianshu)
  • SP6 (Sanyinjiao)
  • P6 (Neiguan)
  • ST40 (Fenglong)
  • ST36 (Zusanli)

Rapid needle insertion was performed. Twisting, lifting, and thrusting manual acupuncture techniques were applied to elicit deqi. After the arrival of deqi, the needle retention time was 15 minutes. The needling was administered every 3–5 days, 30 days as one course of treatment, for a total of three courses. For auricular acupressure, the researchers used the following ear acupoints:

  • Mouth
  • Esophagus
  • Stomach
  • Abdomen
  • Hunger
  • Shenmen
  • Lung
  • Endocrine

A grain of Vaccariae seed was affixed to each otoacupoint with a 5×5 mm piece of adhesive tape. The two auricles were used in alternation, and the patients were advised to apply digital pressure on the seed pellets three times daily at home, every 3 – 5 days, for a total of 3 months. The study was a single-blinded, randomized investigation comparing acupuncture and auricular acupressure with a weight control substance. The researchers conclude, “Acupuncture and auricular acupressure produced superior patient outcomes for obese patients including decreasing body weight, appetite, blood triple cholesterol (TC), and triglycerides (TG).”

Acupuncture demonstrates clinical efficacy for the treatment of obesity in two controlled investigations. Based on the data, additional research is warranted. Larger sample sizes will help to confirm these preliminary findings.

Common to both studies reviewed in this article are acupoints SP6 (Sanyinjiao) and ST36 (Zusanli). According to Traditional Chinese Medicine (TCM) principles, both acupoints are indicated for the treatment of digestion related disorders and stimulate the body’s transforming and transporting functions of the digestive system. In this respect, these acupoints are choices consistent with the goals of the research.

[1] Güçel F, Bahar B, Demirtas C, Mit S, Cevik C. Influence of acupuncture on leptin, ghrelin, insulin and cholecystokinin in obese women: a randomised, sham-controlled preliminary trial. Acupunct Med. 2012 Sep;30(3):203-7.
[2] Lehnert T, et al. Health burden and costs of obesity and overweight in Germany: an update. Eur J Health Econ. 2015;16(9):957–67.
[3] Carnethon MR. Diabetes mellitus in the absence of obesity: a risky condition. Circulation. 2014;130(24):2131–2.
[4] Ingrid Z, et al. The duodenal–jejunal bypass liner for the treatment of type 2 diabetes mellitus and/or obesity: a systematic review. Obes Surg. 2014; 24: 310–23.
[5] apps.who.int/iris/handle/10665/42414
[6] Sun Q, Xu Y. Simple obesity and obesity hyperlipemia treated with otoacupoint pellet pressure and body acupuncture. J Tradit Chin Med 1993;13:22–6.

Acupuncture Provides Parkinson’s Disease Relief

from HealthCMi 7/7/18park-image-one

Acupuncture is an effective treatment modality for the alleviation of Parkinson’s disease. Zhejiang University of Traditional Chinese Medicine (Hangzhou, China) researchers conducted a study comparing the effects of drug therapy as a standalone procedure with acupuncture plus drug therapy in an integrated treatment protocol. Based on the data, the researchers conclude that acupuncture plus antiparkinsonian drug therapy is significantly more effective than using only antiparkinsonian drug therapy. [1]

Two groups were compared. In one group, Parkinson’s disease patients received only levodopa-benserazide as a means to alleviate symptoms. In the second group, levodopa-benserazide was combined with acupuncture therapy. The acupuncture plus drug therapy group had a total effective rate of 89.4% after four courses of treatment, whereas the drug therapy only group had a 52.6% total effective rate for the management of Parkinson’s disease.

The results indicate that acupuncture is an important treatment option for patients receiving benderizine-levodopa for the purposes of Parkinson’s disease treatment. Levodopa-benserazide is a medication containing two ingredients: levodopa and benserazide. Levodopa is a precursor to dopamine, the latter of which is needed in the brain of Parkinson’s disease patients. Benserazide prevents the conversion of levodopa to dopamine prior to reaching the brain and reduces some of levodopa’s adverse effects. This combination is used to reduce symptoms for patients suffering from Parkinson’s disease.

Multiple subjective and objective instruments were used to measure patient outcomes before and after treatment. First, the Unified Parkinson’s Disease Rating Scale (UPDRS), which is the most widely used clinical rating scale for Parkinson’s disease, was used to record symptomatic improvement at several data points: before treatment, after two treatment courses, after four treatment courses. Second, the superoxide dismutase (SOD) activity and lipid peroxidation levels in plasma and red blood cells were recorded. Independent studies have proven that oxidative stress plays an important role in the degeneration of dopaminergic neurons in Parkinson’s disease (PD) patients, which is characterized by decreased SOD activity and increased lipid peroxidation. [2]

After four treatment courses, the scores in the acupuncture plus drug group were significantly improved (i.e., lower) than scores before treatment and for those in the drug control group (P<0.05). After four treatment courses, the SOD activity was significantly higher (i.e., improved) in the acupuncture plus drug group and were also better than scores in the drug control group (P<0.05). The lipid peroxidation levels in the acupuncture plus drug group were significantly lower (i.e., improved) than scores before treatment and were also better than scores in the drug control group.

Parkinson’s disease (PD) is the second most common progressive neurodegenerative disorder. [3] PD is characterized by both motor and non-motor symptoms, such as bradykinesia, resting tremors, and muscle rigidity (which occur due to dopamine deficiency). [4] Diagnostically, Parkinson’s disease is distinguished from essential tremors in that essential tremors are more prevalent with activity and Parkinson’s disease tremors worsen at rest. Levodopa (LD) remains the gold standard pharmacological treatment for PD. However, LD’s effectiveness may decrease overtime. In addition, it has side effects including motor response oscillations and dyskinesia. [5]

New treatment strategies that overcome these limitations are required. Acupuncture has been widely used as a complementary and alternative medicine to relieve the symptoms of PD in Asia, Europe, and in the United States. Previous studies have proven that acupuncture is effective for relieving the symptoms for patients with PD. With the help of acupuncture, both motor symptoms (gait disorder and balance) and non-motor symptoms (psychiatric disorders, sleep problems, gastrointestinal symptoms) can be relieved. In this study, the researchers note that “the use of acupuncture in an integrated treatment protocol can reduce the dosage of LD to eliminate its side effects.” [6]


The Zhejiang University of Traditional Chinese Medicine researchers (Yang et al.) used the following study design. A total of 38 patients diagnosed with Parkinson’s disease were treated and evaluated in this study. They were randomly divided into an acupuncture plus drug treatment group and a drug control group, with 18 patients in each group. There were no significant statistical differences in age, gender, severity of disease, and course of disease relevant to patient outcome measures for patients initially admitted to the study (P>0.05).

Treatment Procedure

The control group received 62.5 – 500 mg of levodopa-benserazide (2 – 4 times per day). Dosage was dependent upon the severity of Parkinson’s disease. Patients in the control group were not treated with acupuncture. The treatment group received both scalp and body style acupuncture in addition to the identical drug treatment protocol administered to the control group. The acupoints used for scalp acupuncture included the following:

  • MS1 (middle line of forehead)
  • MS5 (middle line of vertex)
  • MS6 (anterior oblique line of vertex-temporal)

The acupoints used for body style acupuncture included the following:

  • LI4 (Gegu)
  • SI3 (Houxi)
  • LI5 (Yangxi)
  • SI6 (Yanglao)
  • LI11 (Quchi)
  • PC3 (Quze)
  • LU5 (Chize)
  • LV3 (Taichong)
  • ST41 (Jiexi)
  • KI3 (Taixi)
  • GB34 (Yanglingquan)
  • SP9 (Yinlingquan)
  • BL40 (Weizhong)
  • GB30 (Huantiao)

For scalp acupuncture, treatment commenced with patients in a supine position. A 0.25 mm × 40 mm disposable acupuncture needle was inserted transverse-obliquely into each acupoint, to a standard depth. Each needle was manipulated with the twirling method for three minutes. Once manual acupuncture achieved the arrival of deqi, electroacupuncture stimulation was added to the acupoints using a dense wave. The intensity level was set to patient tolerance levels. A 30 minute needle retention time was observed.

For body style acupuncture, needles were rapidly inserted perpendicularly and were manipulated with mild reinforcing and reducing (Ping Bu Ping Xie) manipulation methods. After achieving a deqi sensation, the needles were retained for 30 minutes. An acupuncture treatment was applied every two days. Each treatment course consisted of 10 acupuncture sessions, followed by a 7 day break before the next course of treatments. All patients received four treatment courses in total.


The results indicate that acupuncture combined with levodopa-benserazide into an integrated treatment protocol is more effective than levodopa-benserazide as a standalone therapy. Based on the data, Yang et al. conclude that acupuncture is safe and effective for the treatment of Parkinson’s disease.

The Zhejiang University of Traditional Chinese Medicine clinical trial confirms additional research. University of Arizona surgery and neurology department doctors find acupuncture effective for the treatment of balance and gait disorders in Parkinson’s disease patients. Acupuncture produced significant clinical improvements in balance, gait speed, and stride length for Parkinson’s disease patients. The results of the sham controlled trial were published in Neurology, the journal of the American Academy of Neurology.

Each acupuncture session was 30 minutes in length. Patients received one acupuncture treatment per week for a total of three weeks. Patients receiving true acupuncture had a 31% improvement in balance, 10% improvement in gait speed, and 5% increase in stride length. Patients in the sham acupuncture control group did not demonstrate any improvements. The University of Arizona research team notes, “EA [electroacupuncture] is an effective therapy in improving certain aspects of balance and gait disorders in PD [Parkinson’s disease].” [7]


[1] Yang DH, Shi Y, Jia YM. Influence of acupuncture plus drug in the amelioration of symptoms and blood antioxidant system of patients with Parkinson’s disease. Chinese Journal of Clinical Rehabilitation, 2006 (19) :14 -16
[2] Dias V1, Junn E, Mouradian MM. The role of oxidative stress in Parkinson’s disease [J]. J Parkinsons Dis. 2013;3(4):461-91.
[3] I.H. Sturkenboom, M.J. Graff, G.F. Borm, et al., Effectiveness of occupational therapy in Parkinson’s disease: study protocol for a randomized controlled trial, Trials 14 (2013) 34.
[4] W. Poewe, K. Seppi, C.M. Tanner, et al., Parkinson disease, Nat. Rev. Dis. Prim. 3 (2017) 17013.
[5] Dias V1, Junn E, Mouradian MM. The role of oxidative stress in Parkinson’s disease [J]. J Parkinsons Dis. 2013;3(4):461-91.
[6] Yang DH, Shi Y, Jia YM. Influence of acupuncture plus drug in the amelioration of symptoms and blood antioxidant system of patients with Parkinson’s disease. Chinese Journal of Clinical Rehabilitation, 2006 (19) :14 -16.
[7] Lei, Hong, Nima Toosizadeh, Michael Schwenk, Scott Sherman, Stephen Karp, Saman Parvaneh, Esther Esternberg, and Bijan Najafi. “Objective Assessment of Electro-acupuncture Benefit for Improving Balance and Gait in Patients with Parkinson’s Disease (P3. 074).” Neurology 82, no. 10 Supplement (2014): P3-074.


Acupuncture and Chronic Fatigue Syndrome

From HealthCMi 6/7/18 Acupuncture Found Effective for Chronic Fatigue Syndrome

Acupuncture is effective for the treatment of chronic fatigue syndrome (CFS). Researchers at the Beijing Chaoyang Fatou Community Health Service Center conducted a study comparing the effects of warm needling acupuncture, standard acupuncture, and sham acupuncture. [1] Based on the data, the researchers conclude that warm needling acupuncture is significantly more effective than using only standard acupuncture or sham acupuncture.

Three groups were compared. In one group, patients received sham acupuncture (a placebo control system used to simulate true acupuncture used in single-blinded and double-blinded trials). In the second group, patients received standard acupuncture as a means to control chronic fatigue syndrome. In the third group, standard acupuncture was combined with moxibustion therapy. The results demonstrate that sham acupuncture does not produce significant positive patient outcomes; however, standard acupuncture and warm needling acupuncture produce significant clinical results. The researchers note, “Acupuncture (and moxibustion) can be used as alternative and safe treatment protocols for chronic fatigue syndrome.”

About CFS
Chronic fatigue syndrome is defined as an illness characterized by severe disabling fatigue lasting for at least six months that is worsened by minimal physical or mental exertion. In the sphere of biomedicine, no definitive etiology has been identified. There are no key features or typical symptoms, but a sore throat, depression, and myalgia may all be present. [2]

The biomedical etiology of chronic fatigue syndrome (CFS) remains unclear. However, it has been suggested that psychological and social factors, viral loads, and immune system dysfunction may contribute to the condition. Previous studies find that CFS may be associated with a bias towards a Th2 type of response in Th1/Th2 immune balances. [3] Acupuncture’s ability to balance Th1 and Th2 may be one mechanism responsible for its effective action in the treatment of CFS.

Th1 (T helper 1) and Th2 (T helper 2) cells are types of T cells that play important roles in the adaptive immune system. Th1 cells secrete IL-2, interferon-gamma (IFN-γ), and tumor necrosis factor (TNF). Th2 cells produce IL-4, IL-5, IL-6, and IL-13. [4] In a Th2 immune response, IL-4 production by T cells is predominant over IFN-γ. Researchers Wang et al. note, “Acupuncturing at bilateral GV20 (Baihui), CV4 (Guanyuan), and ST36 (Zusanli) could elevate the serum IFN-γ concentration and the ratio of IFN-γ/IL-4 and regulate Th1/Th2 immune balance.” [5] This finding indicates that acupuncture may be of benefit to CFS patients with T cell imbalances.

The study involved 133 voluntary patients from the Beijing Chaoyang Fatou Community Health Service Center. All were diagnosed with CFS. Inclusion criteria were established based on the CDC (US Centers for Disease Control and Prevention) criteria for CFS and included the following:

  • Experienced unexplained persistent or relapsing chronic fatigue for more than six months, which is not substantially alleviated by rest, and results in substantial reduction in previous levels of occupational, educational, social, or personal activities. [6]

In addition, the aforementioned is concurrent with four or more of the following symptoms:

  • Substantial impairment in short-term memory or concentration
  • Sore throat
  • Tender lymph nodes
  • Muscle pain
  • Multi-joint pain without swelling or redness
  • Headaches of a new type, pattern, or severity
  • Unrefreshing sleep
  • Post-exertional malaise lasting more than 24 hours

Patients were randomly divided into three groups: warm needling acupuncture group (n=44), acupuncture group (n=47), sham control group (n=42). For the warm needling acupuncture group, the average age of participants was 33.9 years. There were 20 males and 24 females. For the acupuncture group, the average age was 34.2 years (21 males and 26 females). For the sham control group, the average age of participants was 35.1 years (19 males and 23 females). The acupoints selected for the acupuncture and acupuncture plus moxibustion groups were the following:

  • GV20 (Baihui)
  • CV17 (Danzhong)
  • CV6 (Qihai)
  • CV4 (Guanyuan)
  • ST36 (Zusanli)
  • SP6 (Sanyinjiao)
  • LI4, LV3 (Siguan: Hegu plus Taichong)

For the sham acupuncture control group, body points selected were neither meridian acupoints nor special acupoints. They were located at the following areas:

  • 2 cm lateral to GV20
  • 2 cm lateral to CV17
  • 2 cm lateral to CV6
  • 2 cm lateral to CV4
  • 1.5 cm lateral to ST36
  • 1.5 cm lateral to SP6
  • 1 cm lateral to LI4, LV3

Chinese Medicine
The researchers provided a Chinese medicine theoretical basis for the protocols used in this acupuncture continuing education research. In Traditional Chinese Medicine, CFS falls in the scope of deficiency taxation (Xu Lao), wilting pattern (Wei Zheng), depression disease (Yu Bing), and hundred-union disease (Bai Hu Bing). CFS presentations are categorized into several differential diagnostic patterns including spleen qi deficiency, kidney jing-essence deficiency, spleen and kidney yang deficiency, liver depression, and qi stagnation. The treatment principle is to supplement deficiencies, support upright qi (Zheng Qi), and restore the liver’s function to control the smooth flow of qi.

Acupoints were selected to achieve the therapeutic actions guided by the treatment principles. Baihui is located on the Governing Vessel (Du Mai). Administering acupuncture at this acupoint lifts yang, boosts qi, and revives the spirit mind (shen). Danzhong, Qihai, and Guanyuan are located on the Conception Vessel (Ren Mai). Needling Danzhong restores the free flow of qi and supplements ancestral qi (Zong Qi). Acupuncture at the other two acupoints supports upright qi (Zheng Qi) and benefits the kidneys. Zusanli combined with Sanyinjiao is often used in modern clinical settings to strengthen the spleen and stomach and to benefit qi and blood. Siguan (a combination of bilateral Hegu and Taichong) was applied to restore the liver’s function to control the smooth flow of qi and activate qi and blood circulation.

For all three groups, each point was pierced with a disposable 0.25 mm × 40 mm needle (Huatuo brand), adhering to standard needling depths. For Baihui and Danzhong, the needles were inserted transverse-obliquely towards the direction of meridian energy flow. For the remaining acupoints, the needles were inserted perpendicularly. When a deqi sensation was obtained, Baihui, Qihai, Guanyuan, and Zusanli were manually stimulated with Bu (tonifying) manipulation techniques, while other acupoints were stimulated with the Ping Bu Ping Xie (attenuating and tonifying) manipulation techniques. Next, a needle retention time of 30 minutes was observed.

For the warm needling group, moxibustion was added to Baihui, Qihai, Guanyuan, and Zusanli. Medicinal moxa pieces of approximately 2 cm were attached to the needle handles and ignited. Thick paper heat shields were placed over the skin for protection. Moxa was left in place for 20 minutes per 30 minute needle retention time.

Acupuncture and moxibustion sessions were administered once per day. Each treatment course consisted of ten acupuncture treatments. All patients received two treatment courses in total. To evaluate the treatment effective rate, patients were scored before and after the treatments based on the Chalder Fatigue Scale as well as the Self-rating Satisfaction Scale. The Chalder Fatigue Scale is a measurement tool used for quantifying the severity of tiredness in CFS patients across multiple parameters (e.g., physical fatigue scores, mental fatigue scores, general fatigue scores).

After the treatment, the scores of the Chalder Fatigue Scale including physical fatigue scores, mental fatigue scores, and general fatigue scores were significantly decreased in the standard acupuncture and acupuncture warm needling groups, but not in the sham acupuncture group. The physical, mental, and general fatigue scores of the standard acupuncture and warm needling groups were significantly better than those of the sham acupuncture group, while the physical and general scores of the warm needling group were markedly better than those of the standard acupuncture group (P<0.05). Interestingly, the CFS patients’ satisfactory rates of the standard acupuncture and acupuncture plus warm needling groups were 36.2% (17/47) and 72.7% (32/44) respectively—indicating that moxibustion was well-received by patients. All groups had no adverse effects resulting from treatment or other medical procedures in the protocols.

The results indicate that warm needling acupuncture or standard acupuncture is more effective than sham acupuncture. The study by Lu et al., mentioned in this report, demonstrates that acupuncture is safe and effective for the treatment of chronic fatigue syndrome. Important features of TCM protocols are that they produce a high total effective rate without any significant adverse effects.

Major causes of suffering include pain, paralysis, mental illness, nausea, immune system imbalances, and fatigue. CFS and other clinical scenarios involving severe fatigue are a significant source of suffering and may be as severe as any other form of illness or complication. One concern is that since there is no clearly defined etiology within hospital medicine for CFS, patients may be marginalized or receive incomplete care.

There are instances in which patients are given psychiatric medications without addressing the biophysical sources of CFS. This focus on treating only the symptom and not the root cause of CFS potentially leads to prolonged suffering. Given the results of the research data, acupuncture with moxibustion is a reasonable treatment option, referable by primary healthcare physicians.

[1] Lu C, Yang XJ, Hu J. Randomized Controlled Clinical Trials of Acupuncture and Moxibustion Treatment of Chronic Fatigue Syndrome Patients. Acupuncture Research, 2014, 39(4):313-317.
[2] Fukuda K, Straus SE, Hickie I, Sharpe MC, Dobbins JG, Komaroff A. The chronic fatigue syndrome. a comprehensive approach to its definition and study. Ann Intern Med. 1994;121:953 – 9. International Chronic Fatigue Syndrome Study Group.
[3] Skowera, A et al. “High Levels of Type 2 Cytokine-Producing Cells in Chronic Fatigue Syndrome.” Clinical and Experimental Immunology 135.2 (2004): 294–302.
[4] Choi, P, and H Reiser. “IL-4: Role in Disease and Regulation of Production.” Clinical and Experimental Immunology 113.3 (1998): 317–319.
[5] Wang XY, Liu CZ, Lei B. “Effect of Manual Acupuncture Stimulation of Baihui, Guanyuan, Zusanli on Serum IFN-γ and IL-4 Contents in Rats with Chronic Fatigue Syndrome.” Acupuncture Research 2014, 39 (05): 387 – 389.
[6] Fukuda K, Straus SE, Hickie I, Sharpe MC, Dobbins JG, Komaroff A. The Chronic Fatigue Syndrome: A Comprehensive Approach to its Definition and Study. Ann Intern Med. 1994 Dec 15;121(12):953-9.

Acupuncture Relief Of Nasal Allergies Confirmed

LI20-maniken4/26/18 in HealthCMi

Acupuncture soothes nasal allergy symptoms. Investigators at Beijing University of Traditional Chinese Medicine Affiliated Hospital conducted a meta-analysis of 30 independent clinical trials with a sample size of 2,602 allergic rhinitis patients. [1] The researchers (Tang et al.) conclude, “Acupuncture, either used alone or combined with other treatments such as moxibustion, herbal medicine, and western medicine, were proven to have both short and long-term clinical benefits to allergic rhinitis sufferers.” The following is a basic overview of common acupuncture points used for the treatment of allergic rhinitis across the multiple studies in the meta-analysis:

  • LI20 (Yingxiang
  • Yintang (extra)
  • LI4 (Hegu
  • ST36 (Zusanli)
  • EX-HN8 (Shangyingxiang, Bitong)

Allergic rhinitis (AR) is an inflammatory disorder of the nasal mucosa induced by allergen exposure that triggers IgE (immunoglobulin E) mediated inflammation. [2] In the USA, approximately 40–60 million people suffer from allergic rhinitis. [3] AR is clinically characterized by rhinorrhea (thin and primarily clear nasal discharge), sneezing, nasal itching, and nasal congestion. AR is also associated with decreased concentration and focus, irritability, sleep disturbances, and fatigue. This impacts the quality of life and reduces work productivity. In addition, there is a high risk of developing asthma for AR patients. [4] Common medications for the treatment of allergic rhinitis include intranasal corticosteroids, oral H1-antihistamines, and leukotriene receptor antagonists (LTRAs). While effective, these medications often produce adverse effects and may be contraindicated during pregnancy and for children, the elderly, and patients with specific medical conditions. [5]

The following are clinical details of the meta-analysis. A total of 27 out of 30 studies made extensive use of the Yingxiang point. This point is anatomically located on the nasolabial groove, at the midpoint of the lateral border of the ala nasi. This acupuncture point is located on the hand Yangming large intestine meridian. It is also the crossing point of the stomach and the large intestine meridians. Needling this point smooths the flow of qi in the meridians and clears obstructions from the nasal orifice.

This point is traditionally indicated for Bi Yuan (nasal congestion), Bi Qiu (sniveling nose), and Bi Niu (nosebleed). According to Traditional Chinese Medicine principles, the lungs and large intestine have an interior-exterior relationship (i.e., the lungs and large intestine are functionally interconnected). As a result, diseases of the lungs can be treated by needling acupuncture points on either the lung meridian or the large intestine meridian.

A total of 23 studies document use of the Yintang point. This acupoint is located between the two medial ends of the eyebrows in the glabella. Yintang plays a key role in “opening the orifices and regulating the spirit.” Needling this point promotes qi and blood circulation of the head and also stabilizes the mind and spirit. A total of 17 studies used the Hegu point. Hegu is the Yuan-source point of the hand Yangming large intestine meridian. Needling this point disperses obstructions in the Yangming meridian and regulates the lung qi.

A total of 14 studies used Zusanli. Zusanli is the He-confluence point of the foot Yangming stomach meridian, which starts at the side of the nose. The stomach meridian of foot yangming primary channel begins at the side of the nose at Yingxiang (LI20) and then ascends to the root of the nose where it intersects with Jingming (BL1). Zusanli activates local qi and blood circulation and removes local obstructions affecting the meridians. Needling this point also regulates the stomach, intestines, and lungs for purposes of strengthening the internal organs related to allergic rhinitis. A total of 11 studies used Shangyingxiang (also known as Bitong). Needling this point promotes local qi and blood circulation and relieves nasal congestion. This acupoint is located near the upper end of the nasolabial groove, at the junction of the maxilla and the nasal cavity.

The researchers conclude that acupuncture provides both long and short term relief as a standalone therapy, in combination with other Chinese medicine treatment modalities, and in combination with medications. Other independent sources indicate that acupuncture is effective for the alleviation of allergic rhinitis. The National Institutes of Health (NIH, USA) website covering the topic of seasonal allergies and complementary medicine states, “There are data from some randomized controlled trials that suggests that acupuncture may improve some symptoms of allergic rhinitis, as well as quality of life.” The NIH website notes that a clinical practice guideline issued by the American Academy of Otolaryngology states, “Clinicians may offer acupuncture, or refer to a clinician who can offer acupuncture, for patients with allergic rhinitis who are interested in nonpharmacologic therapy.” [7]

The NIH website references a meta-analysis with a sample size of 2,365 allergic rhinitis patients, “compared with a control group, the acupuncture treatment group had a significant reduction in nasal symptom scores, medication scores, and serum IgE, and an increase in quality of life scores.” [8,9] In addition, the NIH website notes that “there are high-quality randomized controlled trials that demonstrate efficacy for acupuncture in the treatment of both seasonal and perennial allergic rhinitis….” [10]

Scientific investigations confirm that acupuncture is a reasonable treatment option for patients with allergic rhinitis. To learn more, consult with your primary licensed acupuncturist or licensed acupuncturists in your area.
[1] Qu SH, Liu YX. Systematic Review and Meta-analysis of the Randomized Controlled Trial of Acupuncture for Allergic Rhinitis [J]. World Journal of Integrated Traditional and Western Medicine, 2016,11(07):900-906+948.

[2] Varshney J, Varshney H. Allergic Rhinitis: an Overview [J]. Indian J Otolaryngol Head Neck Surg. 2015 Jun; 67(2): 143–149.

[3] acaai.org/allergies/types/hay-fever-rhinitis

[4] Palma-Carlos AG1, Branco-Ferreira M, Palma-Carlos ML. Allergic rhinitis and asthma: more similarities than differences [J]. Allerg Immunol (Paris). 2001 Jun;33(6):237-41.

[5] ncbi.nlm.nih.gov/pubmedhealth/PMH0072670/

[6] Xia J, Peng D. Acupuncture Combined with Herbal Medicine for Treatment of Allergic Rhinitis and Its Effectiveness on Downregulating Ig E、TNF-α、IL-4 and IL-12 [J]. International Journal of Laboratory Medicine, 2018,39(03):374-377.

[7] nccih.nih.gov/health/providers/digest/allergies-science. documented 4-25-18.

[8] Ibid.

[9] Feng, Shaoyan, Miaomiao Han, Yunping Fan, Guangwei Yang, Zhenpeng Liao, Wei Liao, and Huabin Li. “Acupuncture for the treatment of allergic rhinitis: a systematic review and meta-analysis.” American journal of rhinology & allergy 29, no. 1 (2015): 57-62.

[10] Taw, Malcolm B., William D. Reddy, Folashade S. Omole, and Michael D. Seidman. “Acupuncture and allergic rhinitis.” Current opinion in otolaryngology & head and neck surgery 23, no. 3 (2015): 216-220. Authors: UCLA Center for East-West Medicine, UCLA (University of California, Los Angeles) Department of Medicine, David Geffen School of Medicine at UCLA bIntegrative Healthcare Policy Consortium, Pinecrest Wellness Center cDepartment of Family Medicine, Morehouse School of Medicine dDepartment of Otolaryngology – Head and Neck Surgery, Henry Ford Health System, Michigan.

Acupuncture Relieves Asthma Attacks

Researchers find acupuncture effective for relieving allergic asthma, a type of asthma triggered by allergens (e.g., dust mites, mold, pollen, foods). Symptoms include wheezing, difficulty breathing, itchy eyes, sinusitis, rhinitis, a general feeling of malaise, and sneezing. In a randomized controlled trial of 1,445 patients, acupuncture provided lasting relief for six months.

Acupuncture was provided for a maximum of 15 treatments over a three month period. Patients receiving acupuncture demonstrated significant relief from allergic asthma at all data points, including the six month post-treatment follow-up data point. Only manual acupuncture was administered. Laser acupuncture, electroacupuncture, and moxibustion were not permitted for the purposes of eliminating variables in the investigation. Healthcare costs for acupuncture treatment were covered by a cooperative agreement between insurance companies and the university researchers conducting the study.

Patients receiving acupuncture had marked reductions of allergic asthma during strenuous and moderate exercise, work and social activities, and during sleep. The overall quality of life scores for patients receiving acupuncture were significantly higher than patients in the control group receiving no acupuncture.

All patients were allowed usual care and acupuncture was an additional treatment modality for patients in the the acupuncture groups. The researchers note, “study results reveal that the use of acupuncture as adjunct to the routine care of allergic bronchial asthma was superior to routine care alone in improving both specific symptoms and general quality of life.” [1] Secondary outcome measures document that patients were satisfied with acupuncture treatment results.

The study allowed for real life clinical applications of acupuncture, except for the limitation to manual acupuncture. The acupuncture point prescriptions, including the number of acupoints used, were individualized for each patient. This differs from many research designs wherein a primary acupuncture point prescription is designated for all patients. Secondary acupuncture points are often allowed for specific medical considerations. In this study, the researchers allowed for complete customization of all acupuncture points based upon clinical presentations with no limitations to primary and secondary acupoint protocols.

The researchers note that after the three months of acupuncture treatments, patients had significant improvements in global quality of life scores and individual parameters such as symptoms, activities, emotions, physicality, and mental function. An important finding, the durability of acupuncture was confirmed by a six month follow-up. Despite not having any acupuncture for three months following the completion of the study’s treatment regimen, the six month data point measured improvements “comparable to the 3 months’ improvements.”

The researchers note, “In this pragmatic randomized trial, allergic asthma patients treated with acupuncture in addition to routine care showed clinically significant improvements in disease specific and general quality of life compared to patients who received routine care alone.” [2] The researchers indicate that the findings demonstrate that acupuncture is safe, effective, and is an appropriate referral recommendation. The researchers note, “This study provides further evidence for the safety of acupuncture as an intervention. This conclusion is consistent with findings in large, previously published surveys and trials.”

The researchers were from Charité – Universitätsmedizin Berlin, Universität Freiburg, and University of Zurich. They provided basic statistics on the prevalence of asthma. Incidence varies between countries, with a range of 4–32%. They add that corticosteroids are standard in usual care. They note that in China, “herbal medicine and acupuncture have traditionally been utilized in the treatment of lung disease, including asthma.” In addition, “A reasonable estimate is that about 30% of adults and 60% of children in the U.S. use some form of complementary and integrative medicine (CIM) therapy for their asthma.”

Research from Anyang General Hospital confirms the results of the aforementioned European research. [3] Acupuncture was determined safe and effective as an adjunct to usual care for the treatment of asthma. In the two week study, patients receiving only drug therapy were compared with patients receiving treatment with both drug therapy and acupuncture. The data indicates that acupuncture greatly improves treatment outcomes. [4]

The acupuncture treatment and drugs-only groups received drug therapy with beclometasone dipropionate and theophylline. Beclometasone dipropionate (a steroid) was provided in the form of an inhaler, 250 µg each dose, one time per day. Theophylline (a bronchodilator) was taken once per day in the from of 0.2 gram sustained-release tablets.

Acupuncture was applied twice per day if an acute asthma attack occurred and only once per day otherwise. Total treatment time for all patients was 14 days. The following acupuncture points were administered to patients in the acupuncture group:

  • Feishu (BL13)
  • Yuji (LU10)
  • Lieque (LU7)
  • Dingchuan (MBW1)
  • Dazhui (GV14)

The following secondary acupoints were applied, varying for each patient according to Traditional Chinese Medicine (TCM) differential diagnostics:

  • Ashi points
  • Neiguan (PC6)
  • Shanzhong (CV17)
  • Fengmen (BL12)

Yuji (LU10) was inserted first to an insertion depth of 0.5–1 cun. The needle was manipulated with strong attenuation techniques and was retained for 25 minutes. During retention, the needle was manipulated every five minutes. Feishu (BL13) and Dazhui (GV14) received standard insertion with equal reinforcement and attention techniques with lifting, thrusting, and rotating. Feishu (BL13) and Dazhui (GV14) were retained for 15 minutes, followed by cupping or warm needle acupuncture. For the remaining acupoints, the needles were manipulated with attenuation techniques (moderate to strong stimulation) and were then retained for 25 minutes. The results demonstrate that acupuncture provides significant relief from asthma when added to a usual care regimen.

In a separate investigation, an examination of Taiwan’s Bureau of National Health Insurance (BNHI) records yielded a sample size of 12,580 asthmatic children. Children with asthma receiving a combination of acupuncture, herbal medicine and drug therapy have superior patient outcomes, less visits to emergency rooms, and fewer hospitalizations than children receiving only drug therapy. In a 15 multi-hospital five year study, Traditional Chinese Medicine (acupuncture, herbal medicine, Chinese Tuina massage, herbal pastes) was combined with pharmaceutical drugs including inhaled bronchodilators and steroids in the study protocol.

The integrative medicine approach (TCM plus drug therapy) produced an astonishing result. Not a single child receiving integrative medicine during the study required an emergency room (ER) visit or hospitalization. The superior clinical outcomes and reduction of medical emergencies indicates that integrating TCM into conventional protocols benefits children with asthma. [5] The BNHI paid for all medical visits and examined the cost-effectiveness of combining TCM therapies with drug therapy. It was found that there is an additional upfront cost to provide TCM therapies but there is a savings on the backend in reduced emergency room visits and hospitalizations. [6]

[1] Brinkhaus, Benno, Stephanie Roll, Susanne Jena, Katja Icke, Daniela Adam, Sylvia Binting, Fabian Lotz, Stefan N. Willich, and Claudia M. Witt. “Acupuncture in patients with allergic asthma: a randomized pragmatic trial.” The Journal of Alternative and Complementary Medicine 23, no. 4 (2017): 268-277.
[2] Ibid.
[3] Wu JH. Effective observation on treating 68 cases of bronchial asthma by acupuncture plus medicine [J]. Clinical Journal of Chinese Medicine, 2016, 8(13): 109-111.
[4] Ibid.
[5] Hung, Yu-Chiang, I-Ling Hung, Mao-Feng Sun, Chih-Hsin Muo, Bei-Yu Wu, Ying-Jung Tseng, and Wen-Long Hu. “Integrated traditional Chinese medicine for childhood asthma in Taiwan: a Nationwide cohort study.” BMC complementary and alternative medicine 14, no. 1 (2014): 389.
[6] Ibid.

Article from HealthCMi 4/7/18

Acupuncture Found Effective For IBS-D


from HealthCMi 2/26/18

Investigators find acupuncture effective for the treatment of IBS (irritable bowel syndrome). In a controlled study, Yiwu Central Hospital researchers conclude that acupuncture has a 90.7% total effective rate for IBS-D patients. Perhaps more importantly, acupuncture produces a 34.9% complete recovery rate. The total recovery rate accounts for all patients showing significant improvements and the complete recovery rate is a quantitative measure of all patients cured of IBS-D by acupuncture therapy.

Results were determined from both subjective and objective data. Subjectives were based on improvements in bowel movement frequency, shape, texture, and consistency. Subjectives also included measures of abdominal discomfort, anxiety, and sleep improvements. Objective data was based on changes of 5-hydroxytryptamine (5-HT), neuropeptide Y (NPY) and calcitonin gene-related peptide (CGRP) serum expression using automated ELISA analysers. The 90.7% total effective rate and the 34.9% complete recovery rate were calculated based on the the subjective and objective data.

About IBS
In this article, we are going to take a close look at the acupuncture points that achieved the results. First, let’s review a little about IBS before getting into the details. Irritable bowel syndrome (IBS) is a disorder affecting the digestive system. It is characterized by recurring abdominal pain and discomfort associated with alterations in the frequency of bowel movements or consistency of stool. At present, the occurrence of IBS is related to the patient’s history of gastroenterological viral infections, psychological factors, age, gender, occupation, history of medications, intestinal microflora balance, metabolic disorders of brain-intestinal axis, and other factors.

Based on the main pathological manifestations, IBS can be classified into four subtypes: IBS-D (diarrhea-predominant), IBS-C (constipation-predominant), IBS-M (mixed), and unspecified IBS (IBS-U). According to Traditional Chinese Medicine (TCM) principles, diarrhea-predominant IBS (IBS-D) belongs to the “diarrhea” (xie xie) and “abdominal pain” (fu tong) categories. The main causes of IBS are stagnation of liver qi, deficiency of the spleen and kidneys, and the invasion of cold and heat pernicious influences. [1] These result in gastrointestinal imbalances. TCM principles note that IBS is easily exacerbated by changes in the diet.

Yiwu Central Hospital researchers conducted a two-arm study of 86 IBS-D patients between January 2016 and December 2016. [2] Patients were randomly divided into control group and an observation group, with 43 cases in each group. Patients were identified using the Rome III Diagnostic Criteria for Irritable Bowel Syndrome (IBS) as well as the TCM standards related to liver qi-stagnation and spleen-deficiency (gān yù pí xū) in the “Consensus on the Diagnosis and Treatment of Irritable Bowel Syndrome.” [3–4]

Patients in the control group were given the following herbal medicines over a 30-day period. The first medication was Spleen and Bowel-Reinforcing Pills (bǔ pí yì cháng wán), manufactured by China Resources Pharmaceutical Group Ltd. It was administered in 6-gram doses that were orally administered 3 times per day, after meals. In addition, patients were given herbal medicine in the form of Xiao Yao Wan (Hubei Wushi Pharmaceuticals) in 6-gram doses. The herbal pills were orally administered twice per day, after breakfast and after dinner.

Acupuncture Treatment
Patients in the observation group received acupuncture therapy in addition to the same herbal medicines administered to the control group. With patients in the supine position, needles were inserted swiftly to a depth of 20 mm. Twisting and reinforcing-reducing techniques were applied to achieve a deqi sensation of soreness, distention, numbness, or a radiating sensation towards the abdomen. Needles were then left in place for 30 minutes. The following are the acupoints used for all observation group patients:

  • Yintang MHN3 (Hall of Impression)
  • Baihui GV20 (Hundred Meetings)
  • Shangjuxu ST37 (Upper Great Void)
  • Tianshu ST25 (Heaven’s Pivot)
  • Sanyinjiao SP6 (Three Yin Intersection)
  • Zusanli ST36 (Leg Three Miles)
  • Taichong LV3 (Great Rushing)

Twenty minutes of moxibustion therapy was also applied to the following acupoints:

  • Shenque CV8 (Spirit Gateway)
  • Tianshu ST25 (Heaven’s Pivot)

Patients experiencing severe diarrhea and cold syndromes received ginger moxibustion (ge jiang jiu) at Shenque CV8. Treatment was administered 5 times per week, over the course of 30 days.

Chinese Medicine
The above acupoints are key for benefitting the liver and spleen. The combined use of these acupoints is able to sooth the liver and strengthen the spleen (shu gan jian pi), firm the intestines and stop diarrhea (gu chang zhi xie), and promote the harmonious rise and fall of spleen and stomach qi. As IBS sufferers are prone to emotional disorders, acupuncture therapy at Yintang (MHN3) and Baihui (GV20) was added for a tranquilizing effect.

Efficacy of Treatment
Clinical efficacy was evaluated and compared after one course of treatment by assessing indicators such as main symptoms, psychological status, and sleep quality. Expressions of 5-hydroxytryptamine (5-HT), neuropeptide Y (NPY) and calcitonin gene-related peptide (CGRP) in serum samples were measured and compared before and after the intervention.

Main symptoms were scored based on the “Guiding Principles of Clinical Research on New TCM Drugs,” with each symptom given a score between 0 and 3. [5] The main symptoms included the following:

  • Abdominal discomfort (0: no discomfort, 1: mild discomfort, 2: moderate pain, 3: severe pain)
  • Stool frequency (0: 1 to 2 times/day, 1: 2 to 5 times/day, 2: 5 to 10 times/day, 3: ≥ 10 times/day)
  • Shape, texture and consistency of stool (0: normal, 1: soft stool, 2: mushy stool, 3: watery stool)
  • Presence of mucus in the stool and feeling of incomplete relief after bowel movement (0: never, 1: rarely, 2: frequently, 3: every time)

Psychological status of the patients was assessed using the Self-Rating Anxiety Scale (SAS) and the Self-Rating Depression Scale (SDS):

  • SAS: Patients who scored 50–59 points had mild levels of anxiety, 60–69 points had moderate levels of anxiety, and ≥70 points had extreme levels of anxiety.
  • SDS: Patients who scored 53–62 points had mild levels of depression, 63–72 points had moderate levels of depression, and >72 points had extreme levels of depression.

Sleep quality was evaluated using the Pittsburgh Sleep Quality Index (PSQI), and was scored on a range of 0 to 21 points, with higher scores depicting better sleep quality. Serum levels of 5-HT, NPY, and CGRP were analyzed (5 mL of fasting peripheral venous blood was obtained from each patient 1 day before the start of treatment and one day after the entire course of treatment). Blood samples were centrifuged at 3000 r/min for five minutes to obtain the serum for analysis.

Efficacy standards were based on earlier research conducted by Affiliated Hospital of Shandong University of Traditional Chinese Medicine: [6]

  • Treatment cured IBS: Absence of abdominal discomfort and related symptoms. Bowel movement appears normal and patients pass stool no more than 2 times daily.
  • Treatment was highly effective: Significant improvement of various symptoms and reduction in stool frequency. Shape, texture and consistency of stool appear normal.
  • Treatment was fairly effective: Alleviation of abdominal discomfort, reduction in stool frequency and improvement in shape, texture and consistency of stool.
  • Treatment was ineffective: No improvement or worsening of the main symptoms.

The recovery rate was 34.9% and the total effective rate was 90.7% in the observation group, versus 18.6% and 79.1% in the control group, and the total clinical efficacy of the observation group was significantly better than that of the control group (P<0.05). Both groups displayed significant improvements in the main symptoms after the intervention (P<0.05), with main symptoms scores of the observation group significantly better than those of the control group (P<0.05).

Both groups’ SAS, SDS, and PSQI scores improved after treatment (P<0.05) and the post-treatment SAS, SDS, and PSQI scores of the observation group were better than those of the control group (P<0.05). Only 5-HT levels were downregulated in the control group after the treatment (P<0.05). Levels of 5-HT, NPY and CGRP were downregulated in the observation group after the treatment (P<0.05). All three indicators were lower in the observation group than those in the control group after the intervention (P<0.05).

The results indicate that acupuncture is an effective treatment modality for patients with IBS-D. Patients interested in acupuncture for the treatment of IBS are encouraged to consult with local licensed acupuncturists to learn more about treatment options.

1. Liu ZH, Qi AZ,Li ZR et al. Pathological analysis of Irritable Bowel Syndrome in Chinese Medicine [J] Shaanzi Journal of TCM,2005,26(9):974–975.

2. Li GY. Clinical Observation of Acupuncture-moxibustion in Treating Irritable Bowel Syndrome [J] Shanghai Journal of Acupuncture and Moxibustion, 2018, 37(2):187–191.

3. Drossman DA. The functional gastrointestinal disorders and the Rome Ⅲ process[J]. Gastroenterology, 2006,130 (5):1377-1390.

4. Chinese Society of Traditional Chinese Medicine Branch of the Spleen and Stomach. Consensus on Diagnosis and Treatment of Irritable Bowel Syndrome [J] China Journal of Traditional Chinese Medicine and Pharmacy, 2010,25(7):1062-1063.

5. Zheng XY. Guiding Principles of Clinical Research on New TCM Drugs (Trial) [S].Beijing: China Medical Science and Technology Publishing House,2002:139-143.

6. Kong SP,Wang WQ,Xiao N,et al. Clinical Study on Diarrhea-Predominant Irritable Bowel Syndrome Treated by Acupuncture and Ginger Moxibustion [J]. Shanghai Journal of Acupuncture and Moxibustion,2014,33(10):895-898.

Acupuncture Enhances Fertility Treatment, Lowers Adverse Effects

from HealthCMi 1/8/18

CV4-GuanyuanAcupuncture boosts the efficaciousness of fertility treatments. Three independent studies confirm that acupuncture increases positive patient outcome rates. Two studies find acupuncture effective for increasing the the efficacy of clomifene for the treatment of infertility due to ovulatory dysfunction. Another study finds acupuncture effective for reducing the adverse effects caused by bromocriptine treatments for hyperprolactinemia related infertility. The study also confirms that acupuncture balances hormone levels.

Ovulatory Dysfunction
Ovulatory dysfunction accounts for approximately 25–30% of female infertility. The root of ovulatory dysfunction is related to disorders of the hypothalamic–pituitary–gonadal axis (HPG axis) because it is closely related to the uterine and ovarian roles in menstruation cycles. The hypothalamus secretes gonadotropin-releasing hormone (GnRH). GnRH stimulates the anterior pituitary to produce two important hormones essential for folliculogenesis and ovulation: luteinizing hormone (LH) and follicle-stimulating hormone (FSH). As a result, dysfunction of the HPG axis may lead to problems in proper follicle development, maturation, and rupture.

Treatment for this type of infertility includes ovulation inducing drugs, surgical intervention, and assisted reproductive technology (ART) including artificial insemination, in-vitro fertilization, etc. Clomifene is often a prescribed drug for ovulation induction, and while it has a high efficacy rate, it also has common adverse effects. It may deleteriously affect cervical mucus or decrease the amount produced. Vaginal dryness due to thicker cervical mucus is a common adverse effect, which impedes sperm transport and is ultimately counterproductive to the drug’s other properties that promote fertility. Anti-estrogenic actions of clomifene reduce uterine vascularization, eventually lowering endometrial receptivity. Therefore, though clomifene helps patients to ovulate, it may not be entirely conducive to the goal of conceiving. It is therefore beneficial to use other treatments with fertility boosting value to complement clomifene ovulation induction.

Hyperprolactinemia (HPL) is characterized by elevated serum prolactin. The occurrence of HPL in females with reproductive disorders falls between 9% and 17%. Infertility from HPL arises from the inhibitory effect of prolactin on GnRH secretion. Some HPL patients, despite having elevated serum prolactin, do not show signs of pituitary or central nervous system diseases, nor any other identifiable causes of increased prolactin secretion. In these cases, we term this condition idiopathic hyperprolactinemia (IH).

Bromocriptine is a medication option for IH treatment because it normalizes serum prolactin levels. However, the drug comes with a downside. According to research, approximately 12% of IH patients choose to discontinue bromocriptine intake due to adverse effects such as dizziness, nausea, hallucinations, and uncontrollable movements. It is important for treatments to be tolerable. An effective treatment cannot realize its full potential if patients are unable to comply with treatment regimens. The research reveals that acupuncture is well-suited as a complementary therapy to prevent or attenuate bromocriptine adverse effects.

According to Traditional Chinese Medicine (TCM) principles, hyperprolactinemia is a condition arising from spleen and kidney deficiency, liver qi stagnation, excess dampness, and imbalances in the Chong and Ren channels. Acupoints Qihai (CV6), Guanyuan (CV4), and Zusanli (ST36) are included in primary acupuncture point protocols because they are useful for nourishing the female reproductive system and correcting the aforementioned constitutional imbalances. Qihai and Guanyuan are particularly useful for correcting Ren channel related deficiencies and Zusanli is administered to tonify qi and promote blood circulation. Together, these acupuncture points fortify yuan qi.

Ovulatory Dysfunction Study #1
The first study was conducted by researchers Zhong Weihua and Chen Qiuping. Their research finds that acupuncture effectively raises hormone levels and benefits endometrial thickness among ovulatory dysfunction patients taking pharmaceutical drugs. The 2-month clinical trial compared two patient groups, both receiving clomifene and one receiving acupuncture additionally. The results demonstrate that acupuncture creates a more fertile environment for successful conception.

Two indicators were used to evaluate clinical efficacy: hormone levels and endometrial thickness. Before and after treatment, 3 mL of peripheral blood was taken from each patient. Estrogen (E2), FSH, and LH levels were measured via enzyme-linked immunosorbent assay (ELISA). Sonography was used to measure endometrial thickness. In addition to ELISA and sonography, the overall treatment efficacy was also surveyed. With reference to “Guidelines for the Clinical Study of New Drugs of Traditional Chinese Medicine,” the treatment efficacy for each patient was categorized into 1 of 3 tiers:

  • Clinical recovery: Successful conception.
  • Effective: Ovulation detected via ultrasound. Basal body temperature (BBT) showed bi-directional trend. Periodical change detected via exfoliative vaginal cytology. No successful conception.
  • Not effective: No ovulation detected after treatment for 3 menstrual cycles.

The clomifene plus acupuncture group achieved a treatment effective rate of 92.11%. The group receiving only clomifene had a 68.42% rate. The treatment effective rate for each group was derived using the following formula:

  • [Clinical recovery + Effective] / [Total number of patients in group] * 100%

The data demonstrates that patients receiving acupuncture in addition to clomiphene have significantly higher positive patient outcome rates. The group receiving acupuncture and clomiphene had a boost in hormone levels:

  • E2 (ng/L) was 317.34 ±24.83 before treatment and 418.34 ±27.56 after treatment. For the group receiving only clomifene, E2 was 319.83 ±24.46 before and 367.45 ±25.34 after.
  • Interesting numbers for FSH (IU/L) were documented. The acupuncture plus clomiphene group was 7.98 ±1.54 before and 23.42 ±2.75 after. The clomiphene only group was 8.04 ±1.50 before and 15.78 ±1.93 after.
  • LH (IU/L) for the clomiphene plus acupuncture group was 13.47 ±1.46 before and 54.84 ±4.50 after. The group receiving only clomifene was 13.42 ±1.50 before and 29.75 ±2.04 after.

The post-treatment levels for clomifene plus acupuncture were all markedly higher than that of standalone clomifene. The difference in post-treatment results indicates that acupuncture promotes the production of E2, FSH, and LH, making the uterine environment more conducive for healthy folliculogenesis and ovulation.

Endometrial thickness results document a similar trend. Before treatment, the mean endometrial thickness for both groups were equivalent, at 6.34 ±0.48 mm for clomifene plus acupuncture and 6.39 ±0.45 mm for clomifene only. After treatment, the results increased to 8.12 ±0.32 mm for clomifene plus acupuncture and 7.31 ±0.37 mm for clomifene only. Both treatments were effective when compared to pre-treatment results, but clomifene plus acupuncture produced greater endometrial thickness than clomifene. The results demonstrate that acupuncture is valuable in maintaining healthy folliculogenesis, ovulation, and endometrial receptivity, which are essential aspects of successful conception.

The study was set up as a comparative clinical trial as described henceforth. A total of 76 patients with ovulatory dysfunction infertility participated in the study. They were diagnosed between September 2014 and September 2016. The following selection criteria were applied in choosing trial participants:

  • Fulfilled diagnostic criteria based on “Male and Female Infertility,” by Luo Lilan (1998).
  • 18 – 40 years of age and aiming to conceive.
  • Male partner had healthy reproductive function.
  • Signed informed consent.

The following exclusion criteria were applied:

  • Congenital anomalies in reproductive organs.
  • Ovulatory dysfunction due to sexual physiological defects.
  • Uterine leiomyomas (fibroids) or endometriosis.
  • Recently took steroids.
  • Premature ovarian failure.
  • Severe liver, cardiac, renal, or hematopoietic diseases.

Patients were randomly divided into two groups of 38: treatment and control. Both groups were comprised of equivalent demographics. The treatment group ranged between 23 – 37 years of age, (mean age 30.84 ±1.64), duration of infertility 2 – 12 years (mean duration 7.30 ±1.27 years). The control group ranged between 22 – 39 years (mean age 31.02 ±1.56 years), duration of infertility 2 – 13 years (mean duration 7.23 ±1.31 years). Both groups received drug treatment with clomifene. In addition, the treatment group received acupuncture. Treatment was administered for 2 menstrual cycles. The following primary acupoints were treated for the treatment group:

  • Guanyuan (CV4)
  • Sanyinjiao (SP6)
  • Zhongji (CV3)
  • Zigong (extra)
  • Zusanli (ST36)
  • Taichong (LV3)
  • Taixi (KD3)

Stainless steel filiform acupuncture needles were used to administer acupuncture. For abdominal acupoints, the needles were diagonally inserted facing downwards. After achieving deqi, needles were retained for 30 minutes. Moxibustion was applied to Shenque (CV8) and Sanyinjiao (SP6). Treatment commenced from the 5th day of menstruation, at a rate of once per day. For drug treatment, clomifene was orally administered starting from the 5th day of menstruation. The prescribed dosage was 50 mg each time, once per day, for 5 consecutive days. The addition of acupuncture to clomiphene treatments increased the total effective rate by 23.69%.

Henan Zhengzhou Huashan Hospital
The second study was conducted by Sheng et al. from Henan Zhengzhou Huashan Hospital. The team finds that acupuncture increases the conception rate in patients with ovulatory dysfunction. The 5-month clinical trial compared two patient groups, both groups receiving ovulation induction treatment with drugs and one group receiving additional acupuncture treatment. The results show that acupuncture increases fertility rates.

Ovulation and conception rates were used to evaluate clinical efficacy. The rates represented the percentage of patients in each group that successfully achieved ovulation and conception. Ovulation was monitored by ultrasonography. Starting from the 9th day of menstruation, ovarian development was observed via ultrasound and LH tests. Ovulation was confirmed upon detection of ≥18 mm follicles, follicle rupture, and a ≥20 mIU/mL increase in LH levels. The definitive standards for conception were:

  • 50 consecutive days without menstruation.
  • Subsequent detection of gestational sac via ultrasound.
  • Subsequent positive human chorionic gonadotropin (hCG) urine test.
  • Subsequent detection of fetal heartbeat.

The data shows that the drugs and acupuncture group achieved an ovulation rate of 67.8% and a conception rate of 52.5%. The drugs only group achieved an ovulation rate of 51.9% and a conception rate of 30.4%. Though the ovulation rate did not differ significantly between both patient groups, the conception rate was much higher for the drugs plus acupuncture group. The data shows that acupuncture effectively creates a healthier internal environment and increases the chances of conception.

The study was set up as a comparative clinical trial as detailed hereafter. A total of 138 patients from the infertility division of Henan Zhengzhou Huashan Hospital, diagnosed with ovulatory dysfunction infertility, participated in the study. The diagnostic criteria for patients were in accordance with “TCM New Medicine Clinical Research Guidelines: 1st Edition” and “Integrative Medicine Diagnosis and Treatment Guidelines for Endometriosis, Gestational Hypertension and Female Infertility,” listed below:

  • Menstrual cycle >35 days or <21 days.
  • Continuous ultrasonography throughout ≥1 menstrual cycle showing slow follicle growth, absence of dominant follicles, premature follicle shrinkage or termination, no follicle rupture, and abnormally thin endometrium.

For the diagnosed patients, the following selection criteria were applied in choosing trial participants:

  • No follicle ruptures.
  • No severe complications.
  • No response after 2 – 3 cycles of clomifene treatment.

The selected patients were randomly divided into 2 groups: treatment and control. Both groups had equivalent demographics. The treatment group with 59 patients were aged between 20 – 38 years (mean age 25.00 ±2.37 years), duration of infertility was 2 – 4.5 years (mean duration of fertility 3.00 ±1.37 years). The control group with 79 patients were aged between 19 – 37 years (mean age 25.00 ±2.07 years), duration of infertility was 2 – 4 years (mean duration of fertility 3.00 ±1.09 years).

Both groups received ovulation induction treatment with the pharmaceutical drugs clomifene, menotropins, and hCG (human chorionic gonadotropin). In addition, the treatment group received acupuncture. Both groups received treatment for 3–5 months. All patients were monitored by ultrasound and were advised to have intercourse during ovulation. The following primary acupoints were used:

  • Zhongji (CV3)
  • Guanyuan (CV4)
  • Zigong
  • Zusanli (ST36)
  • Neiguan (PC6)
  • Sanyinjiao (SP6)

Treatment consisted of conventional acupuncture, electroacupuncture, and indirect moxibustion. Hwato brand acupuncture needles (Suzhou Medical Appliances Factory Co., Ltd.) were used. An SDZ-II model electroacupuncture device (Suzhou Medical Appliances Factory Co., Ltd.) was used for electroacupuncture. 10 mm x 200 mm moxa cigars (Nanyang Wolong Hanyi Moxa Factory Co., Ltd.) and single-vent bamboo moxa boxes (Guangzhou Shangguan Beauty Supplies Factory Co., Ltd.) were used for indirect moxibustion.

Conventional acupuncture was applied to Zhongji, Guanyuan, Zusanli, and Neiguan. Electroacupuncture was administered to Zigong and Sanyinjiao. Both acupoints were stimulated until deqi was achieved. Next, the electroacupuncture device was connected to the needles and set to a low continuous frequency (2 Hz) for 30 – 45 minutes. Shenque (CV8) was treated with indirect moxibustion. A lit moxa cigar was inserted, lit side down, into a moxa box. After ensuring that the temperature was warm but not too hot, the moxa box was placed over Shenque and left for 30 – 45 minutes. One treatment cycle was administered per menstrual cycle. A treatment cycle started on the 9th day of menstruation and was comprised of 7 – 10 consecutive treatment days, one session per day.

For both groups, the following protocol was observed for ovulation induction treatment with pharmaceutical drugs. Starting from the 3rd day of menstruation, clomifene citrate capsules (GKH Pharmaceutical Ltd.) were given orally. The prescribed dosage was 50 mg each time, twice per day, for 5 consecutive days. Starting from the 5th day of menstruation, injectable menotropins (Ningbo Renjian Pharmaceutical Group Co., Ltd.) was administered via intramuscular injection. The prescribed dosage was 75 U each time, once per day, for 7 consecutive days. In the event that no ovulation was detected after treatment with 75 U for 2 menstrual cycles, the dosage was increased to 150 U each time. Starting from the 9th day of menstruation, when sonography showed ≥18 mm average follicle diameter, one shot of hCG (Ningbo Renjian Pharmaceutical Group Co., Ltd.) was administered via intramuscular injection. The prescribed dosage was 5000 – 10000 U.

Drugs plus acupuncture achieved an ovulation rate of 67.8% and a conception rate of 52.5%. Drugs without acupuncture achieved an ovulation rate of 51.9% and a conception rate of 30.4%. The data indicates that acupuncture optimizes positive patient outcome rates.

Mawangdui Hospital
The third study was conducted by Hu et al. from Mawangdui Hospital of Hunan. The research finds that adding acupuncture reduces infertility drug adverse effects and improves hormone level regulation in women with idiopathic hyperprolactinemia (IH) infertility. Patients receiving only bromocriptine were compared with patients receiving both bromocriptine and acupuncture in this 1-year clinical trial. The results highlighted the importance of acupuncture in supporting bromocriptine treatment by reducing adverse effects and balancing hormones.

Referring to the guidelines by the Obstetrics and Gynecology Committee of the World Federation of Chinese Medicine Societies, the study evaluated treatment efficacy by considering hormone normalization time, adverse effects, and conception rates. Before and throughout treatment, hormone levels of prolactin, E2, progesterone (P4), and FSH were measured. The time taken for hormone levels to adjust to normal levels was recorded. The number of patients that did or did not experience adverse effects was also recorded. Finally, the conception rate was recorded. The conception rate for each group was defined as the percentage of patients that successfully conceived within 6 months after the start of treatment.

Similar results were recorded for the acupuncture plus bromocriptine and bromocriptine only groups for some parameters. Both groups took 2 – 3 menstrual cycles for prolactin levels to be normalized. For the bromocriptine group, the longest normalization time was 3 menstrual cycles and the shortest normalization time was 2 menstrual cycles. For the bromocriptine with acupuncture group, the normalization time was 2 menstrual cycles for all. The conception rates varied, acupuncture plus bromocriptine had a 43.3% conception rate and standalone bromocriptine produced a 20.0% rate.

The bromocriptine group had 19 patients who experienced adverse effects during treatment while the bromocriptine with acupuncture group had 7 patients that experienced adverse effects during treatment. The data shows that acupuncture effectively alleviates the adverse effects caused by bromocriptine intake. Considering that many patients discontinue bromocriptine due to adverse effects, acupuncture may be helpful to improve long-term compliance.

The time for hormones E2, P4, and FSH to reach normal levels differed (P < 0.05) between both groups. For the bromocriptine group, the longest normalization time was 6 menstrual cycles and the shortest normalization time was 3 menstrual cycles. For the bromocriptine with acupuncture group, the longest normalization time was 4 menstrual cycles and the shortest normalization time was 2 menstrual cycles. Here, the study shows that acupuncture is advantageous in creating hormonal balance.

The study was designed as a comparative clinical trial as detailed hereafter. A total of 60 IH patients from the gynecological division of Mawangdui Hospital (Hunan) participated in the trial. All 60 patients were recorded in the final results since none were disqualified for failure to complete treatment, failure to follow treatment protocols, adverse effects, or severe complications. The diagnostic criteria for patients were in accordance with the 7th edition of “Gynecology,” by People Health Publishing House and “TCM Gynecology,” listed below:

  • Normal sex life.
  • No conception for ≥ 2 years without contraception.
  • Irregular periods, galactorrhea, amenorrhea or pre-menstrual mastalgia.
  • Easily agitated, weakness and soreness in waist/knees, constant thirst, red tongue with thin coating, thin and taut pulse.
  • Serum prolactin concentration 40 ng/mL.

For the diagnosed patients, the following selection criteria were applied in choosing trial participants:

  • 26 – 33 years of age.
  • Male partner with healthy sperm quality.
  • The following exclusion criteria were applied:
  • Pregnant or lactating.
  • Taking medication which influences serum prolactin.
  • Pituitary tumors.
  • Hyperthyroidism, hypothyroidism, or kidney dysfunction.
  • Congenital reproductive anomalies.

Patients were randomly separated into 2 groups of 30: treatment and control. Both groups were equivalent in age, duration of illness, serum prolactin levels, and other hormone levels (E2, P4, FSH). The treatment group had a mean age of 28.77 ±1.74 years, mean duration of illness 4 years, and 24 patients with abnormal hormone levels. The control group had a mean age of 28.47 ±1.72 years, mean duration of illness 4 years, and 20 patients with abnormal hormone levels. Both groups received drug treatment and the treatment group received acupuncture treatment. The treatment period was 1 year. Patients also complied with a 1-year long follow-up after treatment ended. The following primary acupoints were applied to the acupuncture treatment group:

  • Qihai (CV6)
  • Guanyuan (CV4)
  • Zusanli (ST36)
  • Sanyinjiao (SP6)
  • Taichong (LV3)
  • Taixi (KD3)
  • Ligou (LV5)

Hwato brand 0.30 x 40 mm acupuncture needles were used. Qihai, Guanyuan, Taixi, and Zusanli were applied with reinforcing needle manipulation techniques. Taichong and Ligou were applied with attenuating techniques. Needles were retained for 30 minutes. One treatment cycle was conducted per one menstrual cycle. A treatment cycle started on the 8th day of menstruation and was comprised of 10 consecutive treatment days, one session per day.

For drug treatment, bromocriptine was administered. Patients were initially prescribed 1.25 mg each time, twice per day, after meals. After the first 7 days, the prescribed dosage was increased to 2.5 mg each time, twice per day, after meals. BBT (basal body temperature) was monitored throughout treatment. If there was no bidirectional trend in BBT after 3 months of treatment, clomifene was prescribed, in ovulation induction dosages. The data indicates that acupuncture reduces infertility drug adverse effect rates and improves hormone level regulation in women with idiopathic hyperprolactinemia (IH) related infertility.

Acupuncture is a proven complementary therapy for women receiving drug therapy for the treatment of infertility. Acupuncture increases positive patient outcome rates and reduces the adverse effects caused by medications. Patients interested in learning more about acupuncture and herbal medicine for the treatment of infertility are advised to consult with local licensed acupuncturists.

Zhong WH, Chen QP. Curative Efficacy of Feizhen Acupuncture Combined with Ovulation. Stimulants in Treatment of Anovulatory Infertility and its effects on Sex Hormone and Endometrium [J]. Hebei Medicine, 2017, 23(10): 1715-1718.

Zhou X, Fu CH, Huang JZ, et al. Progress of TCM research on ovulatory dysfunction infertility [J]. Henan TCM, 2014, 34(06): 1154-1156.

Zheng XY. Guidelines for the Clinical Study of New Drugs of Traditional Chinese Medicine [M]. Beijing: China Medical Science Press, 2002. 23.

Li JX, Zhou B. Clinical research on acupuncture with Bushenhuoxuetang Decoction in treating ovulatory dysfunction infertility [J]. TCM Journal, 2016, 31(08): 1156-1159.

Sheng YH, Liu HZ, Jiang CY, et al. Observation of clinical efficacy of acupuncture with medication in treating ovulatory dysfunction infertility 59 cases [J]. Hebei TCM, 2015(8): 1216-1217.

Ministry of Health of the People’s Republic of China, TCM New Medicine Clinical Research Guidelines: 1st Edition [S]. Beijing, 1993: 276.

Wang M, Yu J, Qian ZQ. Integrative Medicine Diagnosis and Treatment Guidelines for Endometriosis, Gestational Hypertension and Female Infertility (Revised in the 3rd Academic Conference by the Obstetrics & Gynecology Committee of the Chinese Association of Integrative Medicine) [J]. Integrative Medicine Journal, 1991, 11(6): 376-379.

Feng YJ, Shen K. Obstetrics & Gynecology [M]. 2nd edition. Beijing: People’s Medical Publishing House, 2010: 256-261.

Yang JR, Ma YY, Liu YL, et al. Case-control study of acupuncture in treating infertility of endocrine origin [J]. China Acupuncture, 2005, 25(5): 299-300.

Zheng SL, Song FJ, Ma DZ. Clinical efficacy assessment of acupuncture in treating ovulatory dysfunction infertility [J]. Clinical Acupuncture Journal, 2007, 23(1): 9-10.

Huang LC. Clinical observation of TCM with acupuncture in treating ovulatory dysfunction infertility 25 cases [J]. New TCM, 2011, 43(8): 113-114.

Hu J, Yan XL, Wang ZX. Acupuncture and Bromocriptine in the Treatment of Special HPL in Infertile Women [J]. Acupuncture Clinical Journal, 2014, 30(7): 7-9.

Liu Shu J, Zhang ZB. A brief TCM analysis of idiopathic hyperprolactinemia [J]. Hebei TCM, 2013, 35(8): 1157-1158.


Acupuncture Reduces Hypertension Confirmed

University of California School of Medicine researchers have proven that acupuncture lowers blood pressure in subjects with hypertension. [1] The depth and breadth of the research extends across multiple university controlled studies. The investigations also reveal how acupuncture works; the biological mechanisms stimulated by acupuncture are no longer a mystery.

The University of California School of Medicine, Irvine, researchers determined several key items. Acupuncture produces long-lasting lowering of blood pressure in subjects with hypertension. Acupuncture regulates sympathetic nervous system responses resulting in lower blood pressure in cardiovascular related centers of the brain and “specific neurotransmitter systems.” [2] In addition, their cross-over double blinded research identifies specific acupuncture points and procedures that are especially effective for lowering blood pressure.

The researchers note that electroacupuncture is effective “at two sets of standardized acupoints known to provide input to brain stem regions that regulate sympathetic outflow lowers blood pressure….” [3] They highlight three key points. First, electroacupuncture that is administered once per week in 30 minute acupuncture sessions over a period of 8 weeks is effective for lowering blood pressure in patients with hypertension. [4] Second, results are observed by the second week of acupuncture therapy and last for 4–6 weeks if no follow-up treatment is administered after completion of the 8 weeks of acupuncture therapy. [5] Third, monthly acupuncture maintenance treatments maintain the healthy low blood pressure for at least 6 months.[6]

The University of California School of Medicine researchers find electroacupuncture a mediator of the autonomic nervous system. Plasma norepinephrine and renin-aldosterone measurements indicate that electroacupuncture lowers blood pressure by downregulating sympathetic nervous system outflows. [7] This mechanism resulted in a lowering of both systolic and diastolic blood pressure in subjects with hypertension. Furthermore, the researchers successfully differentiated acupuncture points that were effective from those that were not.

Acupuncture Points
Electroacupuncture applied to PC5 (Jianshi)–PC6 (Neiguan) and ST36 (Zusanli)–ST37 (Shangjuxu) was found effective for lowering blood pressure. Electroacupuncture applied to LI6 (Pianli)–LI7 (Wenliu) and GB37 (Guangming)–GB39 (Xuanzhong, Juegu) was ineffective. Using 24/7 ambulatory blood pressure monitoring equipment, electroacupuncture applied to PC5–PC6 and ST36–ST37 was effective for reducing peak and average systolic and diastolic blood pressure. [8] The results were published in the Journal of Intensive and Critical Care.

Point Specificity
A closer look reveals extensive prior research by University of California School of Medicine researchers. One investigation demonstrates that electroacupuncture applied to PC5–PC6 produces “point-specific effects on cardiovascular reflex responses.” [9] The researchers add that sympathetic cardiovascular rostral ventral lateral medulla neurons that respond to both visceral (reflex) and electroacupuncture nerve stimulation “manifest graded responses during stimulation of specific acupoints.” [10]

The researchers conclude that electroacupuncture “demonstrates a range of cardiovascular responses” and the levels of “visceral reflex pressor responses are influenced by the anatomic location of somatic nerves beneath the acupoints.” [11] They identified specific responses; “deep nerves exerting strong influence and superficial cutaneous nerves demonstrating little or no attenuation of cardiovascular reflex responses.” [12] The acupuncture continuing education results were published in the American Journal of Physiology – Regulatory, Integrative and Comparative Physiology.

Another investigation by the University of California researchers was published in Autonomic Neuroscience. The research identifies specific regions of the brain regulated by acupuncture. Based on the findings, they conclude that electroacupuncture “suppresses elevated blood pressure (BP) by activating the arcuate nucleus, ventrolateral periaqueductal gray (vlPAG), and inhibiting cardiovascular sympathetic neurons in the rostral ventrolateral medulla.” [13] The research documents that “a reciprocal excitatory glutamatergic neural circuit between the arcuate and vlPAG contributes to long-lasting EA [electroacupuncture] cardiovascular inhibition.” [14] Glutamatergic biochemicals regulate the excitatory amino acid system throughout the body and brain.

Endocannabinoids and Serotonin
In another investigation, the researchers mapped the effects of electroacupuncture on endocannabinoids and the cardiovascular system. The researchers determined that a “long-loop pathway, involving the hypothalamic arcuate nucleus (ARC), ventrolateral periaqueductal gray (vlPAG), and the rostral ventrolateral medulla (rVLM), is essential in electroacupuncture (EA) attenuation of sympathoexcitatory cardiovascular reflex responses.” [15] They note that electroacupuncture “releases endocannabinoids and activates presynaptic CB1 receptors to inhibit GABA release in the vlPAG. Reduction of GABA release disinhibits vlPAG cells, which, in turn, modulate the activity of rVLM neurons to attenuate the sympathoexcitatory reflex responses.” [16]

University of California researchers completed another study mapping the effects of electroacupuncture on serotonin. They determined that electroacupuncture applied to PC5–PC6 “activate serotonin (5-HT)-containing neurons in the nucleus raphe pallidus (NRP).” [17] They note that “activation of the NRP, through a mechanism involving serotonergic neurons and 5-HT (1A) receptors in the rVLM during somatic stimulation with EA [electroacupuncture], attenuates sympathoexcitatory cardiovascular reflexes.” [18] In another study, the researchers document additional pathways. They conclude that the arcuate nucleus is required for prolonged suppression of reflex cardiovascular excitatory responses by electroacupuncture. [19] In the rostral ventrolateral medulla, opioids and GABA (γ-aminobutyric acid) are active in long-term electroacupuncture inhibition of sympathoexcitatory cardiovascular responses. [20]

High and Low Frequency Electroacupuncture
In another investigation, the researchers discovered that manual acupuncture and electroacupuncture produce similar results at PC5 and PC6. The researchers conclude that “there is little difference between low-frequency EA [electroacupuncture] and MA [manual acupuncture] at P 5–6. Furthermore, simultaneous stimulation using two acupoints that independently exert strong effects did not lead to an additive or a facilitative interaction.” [21] Low frequency acupuncture proved more effective than higher frequencies. Two Hz electroacupuncture “activated more somatic afferents than” 10 or 20 Hz electroacupuncture. [22] The researchers add that the “similarity of the responses to EA and MA and the lack of cardiovascular response to high-frequency EA appear to be largely a function of somatic afferent responses.” [23]

The above-mentioned studies are only a fraction of the published research on acupuncture and its mediation of cardiovascular and cortical activity. Important is that there is both clinical and laboratory research that is blinded, randomized, and sham controlled. The findings determine efficacy rates for specific acupuncture points for specific conditions and the biological mechanisms responsible for positive patient outcomes. The University of California School of Medicine, Irvine, (UCI) researchers provide us with great insight into the active mechanisms involved in acupuncture treatments.

1. Tjen-A-Looi, Stephanie C. “Reduction of Blood Pressure by Electro Acupuncture in Mild to Moderate Hypertensive Patients: Randomized Controlled Trial.” Journal of Intensive and Critical Care 3, no. 1 (2017): 2, pg.1.
2. Ibid.
3. Ibid.
4. Ibid.
5. Ibid.
6. Ibid.
7. Ibid, 2.
8. Ibid, 1.
9. Tjen-A-Looi SC, Li P, Longhurst JC (2004) Medullary substrate and differential cardiovascular responses during stimulation of specific acupoints. Am J Physiol Regul Integr Comp Physiol 287: R852-R862.
10. Ibid.
11. Ibid.
12. Ibid.
13. Li P, Tjen-A-Looi SC, Guo ZL, Longhurst JC (2010) An arcuateventrolateral periaqueductal gray reciprocal circuit participates in electro acupuncture cardiovascular inhibition. Auton Neurosci 158: 13-23.
14. Ibid.
15. Tjen-A-Looi SC, Li P, Longhurst JC (2009) Processing cardiovascular information in the vlPAG during electroacupuncture in rats: roles of endocannabinoids and GABA. J Appl Physiol 106: 1793-1799.
16. Ibid.
17. Moazzami A, Tjen-A-Looi SC, Guo ZL, Longhurst JC (2010) Serotonergic projection from nucleus raphe pallidus to rostral ventrolateral medulla modulates cardiovascular reflex responses during acupuncture. J Appl Physiol 108: 1336-1346.
18. Ibid.
19. Tjen-A-Looi SC, Li P, Longhurst JC (2007) Role of medullary GABA, opioids and nociceptin in prolonged inhibition of cardiovascular sympathoexcitatory reflexes during electro acupuncture in cats. Am J Physiol Heart Circ Physiol 293: H3627-H3635.
20. Ibid.
21. Zhou W, Fu LW, Tjen-A-Looi SC, Li P, Longhurst JC (2005) Afferent mechanisms underlying stimulation modality-related modulation of acupuncture-related cardiovascular responses. J Appl Physiol 98: 872-880.
22. Ibid.
23. Ibid.

Acupuncture for … Multiple Myeloma

Excerpt from Cure Today by Katie Kosko 9/27/17
“Researchers from Memorial Sloan Kettering Cancer Center (MSK) in New York City and MD Anderson Cancer Center in Houston, examined if acupuncture could help manage symptom burden of hematopoietic stem cell transplantation (HCT) in patients with multiple myeloma.

HCT used in combination with high-dose chemotherapy can offer patients a chance for durable remission. However, patients who undergo this can experience fatigue, disturbed sleep, lack of appetite, nausea, drowsiness and physical weakness…

Combining non-drug therapy with drug therapy for better symptom management is the future direction of cancer supportive care,” he said [Gary E. Deng, M.D., Ph.D., medical director, Integrative Medicine Service at MSK].

In the trial, patients underwent high-dose melphalan – a prescription chemotherapy drug used as a conditioning treatment prior to HCT – followed by autologous HCT, which is when the cells used in the transplant are the patient’s own.

Among the 60 patients participating, some received true acupuncture, while others received sham acupuncture, a research technique that removes the non-specific effects of acupuncture. This happened once a day for five days, starting the day after chemotherapy.Patients and clinical evaluators did not know which patients were assigned to either group.”
“Results: Among 60 participants, symptoms that are significantly reduced by true acupuncture more than sham acupuncture at 15 days include the following: nausea, lack of appetite, and drowsiness (p = 0.042, 0.025, and 0.010, respectively). Patients receiving sham acupuncture were more likely to increase use of pain medication post-transplantation (odds ratio 5.31, p = 0.017). “

Deng plans to take this research further. He hopes to get funding to support a larger study, which would allow him to examine acupuncture to alleviate symptom burden of HCT with a bigger patient population.

“This is the first study that suggests acupuncture being a non-drug therapy that reduces symptoms and use of pain medications in bone marrow transplant patients,” said Deng. “If confirmed in a larger study, we would have one more therapy that helps those patients through the course of transplantation.”

Deng, G., Giralt, S., Chung, D. J., Landau, H., Siman, J., Coleton, M., … & Cassileth, B. (2017). Acupuncture for reduction of symptom burden in multiple myeloma patients undergoing autologous hematopoietic stem cell transplantation: a randomized sham-controlled trial. Supportive Care in Cancer, 1-9.

Acupuncture Painful Menstruation Relief Finding

from HealthCMi 9/6/17

Over half of all women experience primary dysmenorrhea, and many consider their menstrual pain inevitable. However, the prevalence of pain implies neither normalcy nor necessity. In the occident, acupuncture has recently gained popularity for women’s reproductive health conditions, especially infertility. Nevertheless, believing that pain an inevitable consequence of being born a woman, many do not seek acupuncture to treat their dysmenorrhea; in some cases, it is only after seeking out acupuncture for other conditions that women are educated in its potential to treat their menstrual pain. In Traditional Chinese Medicine (TCM), dysmenorrhea (including menstrual pain and other pre-menstrual symptoms) is considered a disorder just as worthy of treatment as any disease. Researchers at The National Institute of Complementary Medicine at Western Sydney University in Australia conducted a study to compare the efficacy of manual acupuncture and electro-acupuncture, at two timing intervals, for the treatment of primary dysmenorrhea. The researchers found that, in all cases, acupuncture leads to a significant reduction in the intensity and duration of menstrual pain after three months of treatment, and the results were sustained one year after trial entry. [1] This study, along with others in the same vein, will hopefully be encouraging for those women who suffer each month from dysmenorrhea.


Menstrual Cycle Chart


Primary dysmenorrhea is menstrual pain that has no identified organic cause; women with endometriosis, or other biomedically defined uterine conditions, may have menstrual pain, but that pain is considered secondary dysmenorrhea since the etiology is known. Primary dysmenorrhea is most common in young women under the age of 25. The characteristic symptoms are cramps — colicky spasms of pain in the suprapubic area — occurring within 8–72 hours of menstruation, and the pain usually peaks with the increase in menstrual flow during the first few days of a woman’s menstrual cycle. “In addition to painful cramps, many women with primary dysmenorrhea experience other menstrual-related symptoms, including back and thigh pain, headaches, diarrhoea, nausea and vomiting.” [2] Iacovides et al. note that “the prevalence of primary dysmenorrhea is highly underestimated, yet difficult to determine, because few affected women seek medical treatment, despite the substantial distress experienced, as many consider the pain to be a normal part of the menstrual cycle rather than a disorder…. Prevalence estimates vary between 45 and 95% of menstruating women, with very severe primary dysmenorrhea estimated to affect 10–25% of women of reproductive age. As such, dysmenorrhea appears to be the most common gynecological disorder in women irrespective of nationality and age. [3]

Amongst women, dysmenorrhea is the most common cause of absenteeism from school and work, and it may also lead to “a reduction in academic performance, reduced participation in sport and social activities and an overall significant decrease in women’s quality of life. Despite the significant negative impact and disruption to daily living that primary dysmenorrhea has on women most do not seek medical treatment. When women do present to their doctor with primary dysmenorrhea, the most commonly prescribed treatments are non-steroidal anti-inflammatories (NSAIDs) and the combined oral contraceptive (COC) pill.” [4] While these treatments help some women, they are ineffective or unpalatable for others. “Lack of satisfaction in standard treatment leads to an increase in self-care, with women commonly using complementary therapies to deal with their menstrual pain in addition to, or instead of, pharmaceutical pain relief, due to a lack of perceived effectiveness or a dislike of using analgesic medication” [5] Alternative therapies such as acupuncture are gaining traction as women find practitioners that take their conditions seriously and offer tangible relief without medication.

In Traditional Chinese Medicine (TCM), dysmenorrhea refers to recurrent abdominal or lumbosacral pain experienced before, during, or after menstruation. According to TCM theory, there are three primary etiologies, each manifesting according to its root cause: liver qi stagnation, cold accumulation, and qi and blood deficiency. [6] Liver qi stagnation causes distending pain in the lower abdomen, which may refer to the waist and back; when qi stagnation leads to blood stasis, there may be spells of sharp, stabbing pain, which is relieved by the passing of small clots of menstrual blood. Stagnated liver qi can also cause the irritability and emotional issues associated with PMS. Similarly, cold accumulation will slow and coagulate the blood, causing blood stasis; this pattern causes the sharp, stabbing pain associated with blood stasis, as well as the cramping or contracting of the uterine muscles due to cold accumulation. Alternatively, deficient qi and blood fail to nourish the uterus, leading to dull, aching pain that may occur during or after menstruation. Both the excess cold and qi and blood deficiency patterns can be alleviated by warmth, and thus moxibustion — the burning of mugwort on or near the body at acupoints or around the area of pain — is indicated for both of these etiologies. [7] According to Hsu et al., “the syndrome of cold coagulation and blood stasis is mostly seen,” [8] though, considering how few women seek out treatment for dysmenorrhea, it is possible that this pattern is more common clinically because of the extreme pain and cramping associated with this pattern, as compared to the relatively mild — or manageable — pain associated with the patterns.

According to scientific studies, dysmenorrhea is linked to an increase in both the tension and contraction frequency of the uterine muscles, as well as a discord in the rhythm of shrinkage; the uterine muscles contract and do not relax fully between contractions. These abnormalities cause a disorder in uterine micro-circulation that leads to ischemia and hypoxia. [9] Tests conducted on lab rats by Hsu et al. find, “dysmenorrhea of the cold coagulation syndrome presents a high intensity of uterine tension and high contraction of the microvascular diameter, the uterine microcirculation, and tension have negative correlation. The uterine microvascular and capillary contraction decreases the uterine microvascular blood flow and increases uterine contraction wave number. This furthermore explains that dysmenorrhea could cause uterine muscle spasm, increase contraction, and produce microcirculation disorder. Accordingly, it proves that uterine contraction and uterus microcirculation are closely related to dysmenorrhea environment.” [10]

The prevailing theory is that the changes in uterine micro-circulation and contractility associated with dysmenorrhea are related to the disordered production of endometrial prostaglandins (PGs), endogenous hormone-like lipid compounds. During the luteal phase, women have increased levels of PGs. However, women with dysmenorrhea have notably higher levels of circulating PGs than eumenorrheic women, especially during the first 48 hours of their menses, when their symptoms peak. Furthermore, “the severity of menstrual pain and associated symptoms of dysmenorrhea are directly proportional to the amount of PGs released,” [11] confirming that altered PG levels are the likely cause of pain. In another study, Zahradnik et al. studied the menstrual blood collected from both eumenorrheic and dysmenorrheic women and found that dysmenorrheic women had a concentration of prostaglandin F2α (PGF2α) that was 2.5 times higher than eumenorrheic women, though their levels of prostaglandin E2 (PGE2) were identical. [12] Hsu et al. attributed dysmenorrheic pain to this increase in the ratio between PGF2 and PGE2: “while PGE2 may result in either myometrial contraction or relaxation, PGF2a always causes potent vasoconstriction of uterine blood vessels, and myometrial contractions.” [13] As vasoconstriction causes a decrease in blood flow, myometrial contractions increase the need for oxygenated blood; the prevalence of these two factors together lead to hypoxia. Doppler ultrasonography, used to investigate uterine blood flow, has similarly shown, “that the strong and abnormal uterine contractions in women with dysmenorrhea during menstruation are associated with reduced uterine blood flow and resultant myometrial ischemia, and hence pain.” [14] PGs also have a range of biological effects on a wide variety of physiological and pathological activities — including pain, inflammation, body temperature, and sleep regulation [15] — so disproportionate production may be related to some of the secondary effects of dysmenorrhea as well.

There are a variety of theories regarding the mechanisms by which TCM therapies can relieve pain from dysmenorrhea. Armour et al. suggest there are “plausible mechanisms of action for acupuncture to improve primary dysmenorrhea, including endogenous opioid release, reduction of inflammation, alterations in uterine blood flow and changes in prostaglandin levels.” [16] In a study conducted by Yang et al. to investigate the efficacy of moxibustion at the acupoints CV4 (Guanyuan), CV8 (Shenque), and SP6 (Sanyinjiao), the researchers found that pain levels decreased over the three month trial, and that the therapeutic effect of moxibustion was sustained in the three months after the trial ended. Through blood tests, the researchers also found that moxibustion decreased levels of both PGF2 and PGE2, which allows for increased blood flow and decreased contractility of the uterus. [17] Heat is also well understood to regulate menstrual pain — “an abdominal heat wrap was found to be as effective as ibuprofen, and more effective than acetaminophen in relieving dysmenorrheic pain” [18] — and thus it is not surprising that heat from moxa, especially directly over the abdomen, would be similarly effective for inducing vessel dilation and increasing blood flow to decrease pain. [19] The acupoint SP6 (Sanyinjiao) may be distal, but it is effective for the treatment of dysmenorrhea, “likely due to the fact that SP6 is segmental to the uterus… This segmental activation at the level of sacral spinal nerve 2 (S2) may lead to reflex sympathetic inhibition of the uterus resulting in increased uterine blood flow.” [20]

In the exploratory study conducted by Armour et al., the researchers used a 2×2 factorial design “to test the individual and combined effects of changing 1) treatment timing, and 2) mode of stimulation. This study used a pragmatic clinical trial design with some qualifications, including the use of a manualised acupuncture protocol designed to reduce the amount of variation between practitioners.” [21] Each patient was given acupuncture by one of two modalities: manual acupuncture (MA) or electro-acupuncture (EA). Manual acupuncture is the insertion of fine needles at specific points on the body which, in this trial, were stimulated again 10–15 minutes after insertion; [22] electro-acupuncture uses the same points but adds electrical stimulation to the points. In this case, an ITO ES-160 electro-acupuncture machine with a 2Hz / 100Hz square wave pulse of 200ms for 20 minutes was employed. [23]

DeQi was obtained at all acupoints at the beginning of the treatment. “DeQi (the arrival of Qi) is the sensation generated by the insertion and/or manipulation of an acupuncture needle in an acupuncture point,” and TCM practitioners consider this important an important variable in the efficacy of a treatment. [23a] For the patient, DeQi feels like soreness, pressure, or heaviness at the site of insertion; for the practitioner, it is an indication that the qi has begun to flow at the acupoint, accessing the unique energy of the point to heal.

Treatment timing was tested by separating the participants into high and low frequency test groups. “All women in the study were scheduled to receive 12 treatments over the course of three menstrual cycles. Women in the high frequency (HF) group received three treatments in the seven days prior to the estimated day one of the menstrual cycle. Women in the low frequency (LF) group received three treatments in the time between menses, approximately every seven to ten days’ dependent on cycle length.” [24] The 2×2 factorial design lead to a total of 4 test groups: LF-MA, HF-MA, LF-EA, and HF-EA.

Treatment was based on the eight principles of TCM, as well as Zang Fu (visceral organ) diagnosis. “Once a TCM diagnosis had been ascertained, the practitioners had the flexibility with their point selection to address the diagnosed pattern of disharmony as per the treatment handbook.” [25] Up to two concurrent patterns of disharmony were supported by this trial, distinguished into primary (root) and secondary (branch) patterns. [26] No more than 7 unique acupoints were chosen for each patient, according to the diagnosis, and all points were needled bilaterally, with the exception of those for which unilateral insertion is indicated, such as opening the extraordinary vessels. [27] “Each pattern also has moxibustion as a compulsory, optional or forbidden component of the treatment. Indirect moxa was administered via smokeless moxa stick for 5–10 minutes on one of the selected acupuncture points. Each patient was given a diet and lifestyle advice sheet during their first treatment session. These were grounded in TCM theory.” [28]

The primary outcome of this study was the decrease in peak menstrual pain one year after trial entry. [29] All groups showed a significant reduction in peak pain and duration of pain over time, and neither the mode nor frequency of treatment showed a stronger effect by the one-year follow-up. However, manual acupuncture provided more immediate pain reduction. “The proportion of responders with clinically significant pain reduction of 30% in their peak pain was highest in the HF-MA group across all three days (55%, 60% and 61% of women respectively) and over a third of women in this group had a 70% reduction in their peak pain. Almost three-quarters (72%) of the women in the HF-MA group had a clinically significant 30% reduction in their average pain, with 69% of the LF-MA group, 61% of the LF-EA group and the 47% of the HF-EA group achieving this reduction. Almost 60% of the LF-MA group and 55% of the HF-MA group had a 50% reduction in average pain from baseline to one-month follow-up. The electro-acupuncture groups had lower scores, with 42% and 33% of the HF-EA and LF-EA groups achieving a 50% reduction.” [30]

The researchers also compared health related quality of life (HRQoL), supplementary analgesic use, and secondary symptoms. HRQoL measures subjective physical and mental well-being, by collecting participant data on factors including body pain, vitality, social function, and mental health. Decreased nonsteroidal anti-inflammatory drug (NSAID) use, measured in mean doses per day, [31] is thought to be another way of measuring pain relief, since patients will only take medications once their pain meets their personal threshold. Secondary symptoms may vary between women, but common symptoms include mood changes, bloating, and breast tenderness. [32] The results indicate that high frequency and manual treatments show better results for these factors. “Health related quality of life increased significantly in six domains in groups having high frequency of treatment compared to two domains in low frequency groups. Manual acupuncture groups required less analgesic medication than electro-acupuncture groups.” [33] More specifically, manual acupuncture provides the same — or greater — pain relief, while simultaneously decreasing the analgesic medication required. [34] Of all groups, HF-MA had the best results for the reduction of secondary menstrual symptoms compared: [35] “after the course of acupuncture treatment, participants had less problems with work or daily activities as a result of their physical health, less pain and subsequent limitations due to pain, more energy, and less interference from physical and emotional problems in social activities, all of which are commonly experienced by women with primary dysmenorrhea.” [36] The use of moxa for indicated conditions, which was found by Yang et al. to regulate PGF2 and PGE2 levels, [37] may have also contributed to the lasting effects of the course of treatment.

While this study did not include a control group that did not receive acupuncture treatment, a previous study conducted by Armour “that included a no-treatment or wait-list control group showed that the acupuncture intervention appeared to provide an immediate analgesic effect, irrespective of the dose delivered,” [38] and that treatment before the onset of menses produced greater pain reductions than treatment during menstruation. [39] Other studies focus on point selection and technique. Zhao et al. found that SP6 (Sanyinjiao) is the most commonly used acupoint to treat dysmenorrhea, inducing significant analgesic effects, and that achieving DeQi, “improves the immediate analgesic effect of acupuncture at SP6 in patients with primary dysmenorrhea,” [40] especially for those patients with the specific TCM diagnosis of cold and dampness stagnation. [41] Hsu et al. found similar results in rats, showing that acupuncture at SP6 with DeQi significantly increased microvascular uterine blood velocity as compared with the model control group that received the same treatment without DeQi. [42]

Self-care advice may also play an important role in TCM treatment. Both practitioners and their patients have expressed that acupuncture treatment is “more than needles,” [43] and women interviewed about their experience with acupuncture for the treatment of dysmenorrhea felt that, “TCM self-care advice was related to positive outcomes for their dysmenorrhea and increased their feelings of control over their menstrual symptoms.” [44] Women responded well to the advice regarding diet and lifestyle choices and, “discussed how the context in which these explanations and advice were delivered, in a nonjudgmental and supportive environment, was different to their previous experiences with general practitioners and how this relationship with their acupuncture practitioners impacted their ability to understand their menstrual cycle better and implement the self-care advice given.” [45] Additionally, TCM practitioners tend to spend more time talking — and most importantly, listening — to their patients, allowing practitioners to better understand the life-world of the client and provide explanations and self-care advice that was appropriate and achievable for the individual, [46] whereas patients often report that they do not get sufficient explanations for their condition from orthodox medical consultations. [47] Furthermore, “empathy from practitioners has been shown to increase enablement and is linked to positive treatment outcomes through the improvement of self-efficacy. Improved self-efficacy is also linked to increased optimism of future improvements.” [48] The women interviewed overwhelmingly confirmed that the explanations about menstrual physiology, as well as the advice on self-care, increased their self-efficacy. [49]

The most important result of this study, and others like it, is that menstrual pain is not inevitable. Many women may feel that medications — either NSAIDs or oral contraceptives — are their only option for treating their monthly symptoms, but acupuncture has been shown to be equally effective, and its effects last long after the course of treatment. Additionally, TCM practitioners provide individualized advice that helps women take an active role in caring for themselves. Acupuncture can provide a safe and effective alternative to medications. This study shows that the abdominal pain and emotional symptoms of primary dysmenorrhea can be addressed with TCM, and it will hopefully empower women to address their menstrual pain holistically and efficiently.

1 Armour, Mike, Hannah G. Dahlen, Xiaoshu Zhu, Cindy Farquhar, and Caroline A. Smith. “The role of treatment timing and mode of stimulation in the treatment of primary dysmenorrhea with acupuncture: An exploratory randomised controlled trial.” Plos One 12, no. 7 (2017). pg 2.

2 Armour et al, The role of treatment timing and mode of stimulation, pg 2.

3 Iacovides, Stella, Ingrid Avidon, and Fiona C. Baker. “What we know about primary dysmenorrhea today: a critical review.” Human Reproduction Update vol 21, no 6, (2015). Pg 764.

4 Armour et al, The role of treatment timing and mode of stimulation, pg 2.

5 Armour et al, The role of treatment timing and mode of stimulation, pg 2.

6 Cheng, Xinnong, ed. Chinese Acupuncture and Moxibustion. Beijing: Foreign Languages Pr, 2012. Pgs475-477.

7 Chinese Acupuncture and Moxibustion, pgs 475-477.

8 Hsu, Wing-Sze, Xiao-Yu Shen, Jia-Min Yang, Li Luo, Ling Zhang, Dan-Dan Qi, Song-Xi Shen, Shi-Peng Zhu, Ya-Fang Zhao, Xiao-Xuan Ren, Meng-Wei Guo, Xiao-Hong Li, Bo Ji, Lu-Fen Zhang, and Jiang Zhu. “Effects of Acupuncture Applied to Sanyinjiao with Different Stimuli on Uterine Contraction and Microcirculation in Rats with Dysmenorrhea of Cold Coagulation Syndrome.” Evidence-Based Complementary and Alternative Medicine 2014 (2014): 6.

9 Hsu et al., Effects of Acupuncture Applied to Sanyinjiao, pg 6.

10 Hsu et al., Effects of Acupuncture Applied to Sanyinjiao, pg 7.

11 Iacovides, et al., What we know about primary dysmenorrhea today, pgs 765-6.

12 Zahradnik, H. P., and M. Breckwoldt. “Contribution to the pathogenesis of dysmenorrhea.” Archives of Gynecology 236, no. 2 (1984): 99-108.

13 Iacovides, et al., What we know about primary dysmenorrhea today, pg 766.

14 Iacovides, et al., What we know about primary dysmenorrhea today, pg 766.

15 Iacovides, et al., What we know about primary dysmenorrhea today, pg 764-5.

16 Armour et al., The role of treatment timing and mode of stimulation, pg 2.

17 Yang, M., Chen, X., Bo, L., Lao, L., Chen, J., Yu, S., . . . Liang, F. (n.d.). Moxibustion for pain relief in patients with primary dysmenorrhea: A randomized controlled trial.

18 Iacovides, et al., What we know about primary dysmenorrhea today, pg 772.

19 Yang et al., Moxibustion for Pain Relief, pg 12.

20 Armour, M., & Smith, C. A. (2016). Treating primary dysmenorrhoea with acupuncture: a narrative review of the relationship between acupuncture ‘dose’ and menstrual pain outcomes. Acupuncture in Medicine, 34(6), pg 422.

21 Armour et al., The role of treatment timing and mode of stimulation, pg 3.

22 Armour et al., The role of treatment timing and mode of stimulation, pg 4.

23 Armour et al., The role of treatment timing and mode of stimulation, pg 4.

23a Xing-Yue Yang, Guang-Xia Shi, Qian-Qian Li, Zhen-Hua Zhang, Qian Xu, and Cun-Zhi Liu, “Characterization of Deqi Sensation and Acupuncture Effect,” Evidence-Based Complementary and Alternative Medicine, vol. 2013, Article ID 319734, 7 pages, 2013.

24 Armour et al., The role of treatment timing and mode of stimulation, pg 4.

25 Armour et al., The role of treatment timing and mode of stimulation, pg 4.

26 Armour et al., The role of treatment timing and mode of stimulation, pg 4-5.

27 Armour et al, The role of treatment timing and mode of stimulation, pg 5.

28 Armour et al., The role of treatment timing and mode of stimulation, pg 6.

29 Armour et al., The role of treatment timing and mode of stimulation, pg 1.

30 Armour et al., The role of treatment timing and mode of stimulation, pg 12.

31 Armour et al, The role of treatment timing and mode of stimulation, pg 9.

32 Armour et al., The role of treatment timing and mode of stimulation, pg 14.

33 Armour et al, The role of treatment timing and mode of stimulation, pg 1.

34 Armour et al., The role of treatment timing and mode of stimulation, pg 15.

35 Armour et al., The role of treatment timing and mode of stimulation, pg 1.

36 Armour et al., The role of treatment timing and mode of stimulation, pg 14.

37 Yang et al., Moxibustion for Pain Relief, pg 1

38 Armour & Smith, Treating Primary Dysmenorrhea with Acupuncture, pg 422.

39 Armour & Smith, Treating Primary Dysmenorrhea with Acupuncture, pg 416.

40 Zhao, M., Zhang, P., Li, J., Wang, L., Zhou, W., Wang, Y., . . . Zhu, J. (2017). Influence of de qi on the immediate analgesic effect of SP6 acupuncture in patients with primary dysmenorrhoea and cold and dampness stagnation: a multicentre randomised controlled trial. Acupuncture in Medicine. pg 5.

41 Zhao et al., Influence of De Qi on the immediate analgesic effect of SP6, pg 2.

42 Hsu et al., Effects of Acupuncture Applied to Sanyinjiao, pgs 4-5.

43 Armour, M., Dahlen, H. G., & Smith, C. A. (2016). More Than Needles: The Importance of Explanations and Self-Care Advice in Treating Primary Dysmenorrhea with Acupuncture. Evidence-Based Complementary and Alternative Medicine, 2016, pg 5.

44 Armour, Dahlen & Smith, More Than Needles, pg 1.

45 Armour, Dahlen & Smith, More Than Needles, pg 5.

46 Armour, Dahlen & Smith, More Than Needles, pg 7.

47 Armour, Dahlen & Smith, More Than Needles, pg 8.

48 Armour, Dahlen & Smith, More Than Needles, pg 7.

49 Armour, Dahlen & Smith, More Than Needles, pg 5.