Acupuncture For Cancer Patients

RESEARCH
THE CLINIC OF THE COLLEGE OF

CHINESE MEDICINE
ACUPUNCTURE FOR CANCER PATIENTS
Kirsten Dhar The Clinic of the College of Chinese Medicine,
26-28 Finchley Rd, St Johns Wood, London, NW8 6ES
Kirsten Dhar - The College of Chinese Medicine, Research and Development

ACUPUNCTURE FOR CANCER PATIENTS
A COLLECTION OF ABSTRACTS, STUDIES AND ARTICLES ON THE USE OF
ACUPUNCTURE FOR SYMPTOM CONTROL IN THE TREATMENT OF CANCER PATIENTS
1. Neurological Mechanisms of Acupuncture
2. Abstracts Nausea and Other Symptoms
3. Studies Two Articles with Protocol
4. Pain management with Acupuncture

1. Neurological Mechanisms of Acupuncture
Acupuncture was originally thought of as being simply a modality

which can alter the bodys perception of pain. Research into the exact
neurological mechanisms behind this have led to new theories and
understanding of the extend to which acupuncture can regulate the
bodys function in dealing with disease, rather than just pain. A great
deal of neurophysiological research has been conducted in this field
and evidence-based scientific work has been published, predominantly
in Germany and the USA, by Zieglgansberger, Takeshige, Pomeranz,
Han and many others. According to these findings, acupuncture
appears to be effective in influencing neuro-endocinological functions
to rebalance the system and reinstate homeostasis.
The mechanisms behind acupuncture in the treatment of diseases and

pain control lie in prompting the brain to initiate physiological
processes aimed to re-establish the bodys homeostasis. In this
context, connections between higher, intermediate and lower brain are
most relevant, with the limbic system, in particular the amygdala, and
the hypothalamus playing an important role.
The amygdala is, in simple terms, the mediator between prefrontal

cortex (the decision making part of the brain) and the diencephalon,
namely the hypothalamus. It is also the major intermediary between
sensory and motor hierarchy. Sensory input signals derive from the
sensory cortex and are passed back, via the entorhinal cortex, to the
amygdala (limbic) where input information is combined with previous
experience (physical and emotional) and transmitted to the prefrontal
cortex for decision making. Decisions are passed back to the amygdala
and from there to the hypothalamus for execution. The hypothalamus,
being the most important control center for the bodys homeostasis,
and thus survival, executes all decisions via endocrine functions,
autonomic functions and diffuse modulatory functions of
neurotransmitters and modulators (i.e. amines and monoamines

acetylcholine, dopamine, norepinephrine and serotonin in the
brainstem). In this way, acupuncture influences electro-chemical
activity on a presynaptic level, triggering synapses all the way from
sensory nerves to the spinal cord, brain stem, mid-brain and finally to
the prefrontal cortex of the higher brain.
Recent MRI mapping of meridians (energy transmitting channels) and

various studies suggest that acupuncture points are part of the
peripheral nervous system and overlap nerve receptor endings. On the
basis of this assumption, it can now be understood how acupuncture
signal inputs project to the brain. Sensory neurons translate stimuli
(mechanical, thermal, pressure, vibrations, etc.) into neural signals via
depolarization.
The insertion of an acupuncture needle irritates or damages cells in the

area causing them to release chemicals (bradikinin, substance P,
prostaglandins, etc.), which then activate the cells membrane
potentials. The signaling process occurs by receiving sufficient stimuli
to initiate sensitization by alteration of cell membrane potential which
will result in an action potential transmitted to the CNS. There are
several synapses involved, after the peripheral synapse involving
sensory neurons, before a signal reaches the CNS and the higher
brain. The major pathway of acupuncture-induced signaling is the
spinothalamic tract, the spinoreticular tract and the
spinomesencephalic tract.
An important discovery is the activation of the cortex by acupuncture

stimulation. This led to the hypothesis that the acupuncture stimulus
projected to the higher brain contains survival information picked up
by passing through the limbic system. This allows the higher brain to
issue appropriate commands to be passed back to the limbic system
and on to the hypothalamus for execution via endocrine, autonomic
and neuro-chemical functions. Thus, pain control is only a small part of
acupuncture and research into acupuncture as disease treatment is a
growing area.

Never the less, pain control is an important aspect for the cancer
patient. By understanding the biomolecular mechanisms behind pain
and acupuncture, we could potentially create therapeutic ways to alter
pain memory imprints in the brain, pain perception and the bodys
functions of responding to pain. Furthermore, acupuncture is a safe
and cheap tool for oncology nurses and other therapists working in
cancer care, reducing the need for pharmaceutical intervention and
sustaining the patient throughout treatments such as chemo- and
radiotherapy and after operations.

2. Abstracts Nausea and Other Symptoms
Acupuncture and self-acupuncture for long-term treatment of

vasomotor symptoms in cancer patients audit and treatment
algorithm. Filshie J, Bolton T, Browne D, Ashley S; Royal Marsden Hospital, London and Surrey,
UK; Acupunct. Med. 2006 Jun;24(2):92-6; PMID: 16430125 [PubMed - indexed for MEDLINE]
INTRODUCTION: Since hormone replacement therapy given for long periods is now
recognised to produce serious side effects, patients with troublesome vasomotor
symptoms are increasingly using non-hormonal treatment including acupuncture.
Several randomised controlled trials have shown that acupuncture reduces
menopausal symptoms in patients experiencing the normal climacteric. It may have
this effect by raising serotonin levels which alter the temperature set point in the
hypothalamus. Vasomotor symptoms can be extreme in breast cancer patients and
patients with prostate cancer who are undergoing anticancer therapy. The safety of
some herbal medicines and phytoestrogens has been questioned, as they could
potentially interfere adversely with the bioavailability of tumouricidal drugs. A
previous study reports short term benefit from acupuncture and the aim of this
report is to describe our approach to long term treatment. ACUPUNCTURE
APPROACH: After piloting several approaches, six weekly treatments were given
initially at LI4, TE5, LR3 and SP6 and two upper sternal points, but avoiding any limb
with existing lymphoedema or prone to developing it. If there were no
contraindications, patients were given clear instructions on how to perform self
acupuncture using either semi-permanent needles or conventional needling at SP6,
weekly for up to six years, for long term maintenance. AUDIT METHODS AND
RESULTS: A retrospective audit of electronic records was carried out by a doctor not
involved in treatment. A total of 194 patients were treated, predominantly with
breast and prostate cancer. One hundred and eighty two patients were female. The
number of pre-treatment hot flushes per day was estimated by the patient: in the
159 cases providing adequate records, the mean was 16 flushes per day. Following
treatment, 114 (79%) gained a 50% or greater reduction in hot flushes and 30
(21%) a less than 50% reduction. Treatment was abandoned in those who
responded poorly or not at all. The duration of treatment varied from one month to
over six years with a mean duration of nine months. Seventeen patients (9%)
experienced minor side effects over the six year period, mostly minor rashes; one
patient described leg swelling but this was likely to be due to a concurrent fracture.
CONCLUSION: Acupuncture including self acupuncture is associated with long-term

relief of vasomotor symptoms in cancer patients. Treatment is safe and costs appear
to be low. An algorithm is presented to guide clinical use. We recommend the use of
self acupuncture with needles at SP6 in preference to semi-permanent needles in the
first instance, but poor responders use indwelling studs if they fail to respond
adequately to self acupuncture with regular needles. Point location may be of less
importance than the overall 'dose', and an appropriate minimum dose may be
required to initiate the effect.

Electro-acupuncture for control of myeloablative
chemotherapy-induced emesis: A randomized trial. Shen J, Wenger N,
Glaspy J, Hays RD, Albert PS, Choi C, Shekelle PG; National Institutes of Health, Laboratory of Clinical
Studies, Bethesda MD, USA; JAMA 2001 Feb 28; 285(8):1016;PMID: 11105182 [PubMed - indexed for
MEDLINE]
CONTEXT: High-dose chemotherapy poses considerable challenges to emesis

management. Although prior studies suggest that acupuncture may reduce nausea
and emesis, it is unclear whether such benefit comes from the non-specific effects of
attention and clinician-patient interaction. OBJECTIVE: To compare the effectiveness
of electro-acupuncture vs minimal needling and mock electrical stimulation or anti-
emetic medications alone in controlling emesis among patients undergoing a highly
emetogenic chemotherapy regimen. DESIGN: Three-arm, parallel-group, randomized
controlled trial conducted from March 1996 to December 1997, with a 5-day study
period and a 9-day follow-up. SETTING: Oncology centre at a university medical
centre. PATIENTS: One hundred four women (mean age, 46 years) with high-risk
breast cancer. INTERVENTIONS: Patients were randomly assigned to receive low-
frequency electro-acupuncture at classic anti-emetic acupuncture points once daily
for 5 days (n = 37); minimal needling at control points with mock electro-stimulation
on the same schedule (n = 33); or no adjunct needling (n = 34). All patients
received concurrent triple anti-emetic pharmacotherapy and high-dose
chemotherapy (cyclophosphamide, cisplatin, and carmustine). MAIN OUTCOME
MEASURES: Total number of emesis episodes occurring during the 5-day study
period and the proportion of emesis-free days, compared among the 3 groups.
RESULTS: The number of emesis episodes occurring during the 5 days was lower for
patients receiving electro-acupuncture compared with those receiving minimal
needling or pharmacotherapy alone (median number of episodes, 5, 10, and 15,
respectively; P<.001). The electro-acupuncture group had fewer episodes of emesis
than the minimal needling group (P<.001), whereas the minimal needling group had
fewer episodes of emesis than the anti-emetic pharmacotherapy alone group (P
=.01). The differences among groups were not significant during the 9-day follow-up
period (P =.18). CONCLUSIONS: In this study of patients with breast cancer
receiving high-dose chemotherapy, adjunct electro-acupuncture was more effective
in controlling emesis than minimal needling or anti-emetic pharmacotherapy alone.

Acupuncture for side effects of chemo-radiation therapy in
cancer patients. Lu W; Leonard P Zakim Center for Integrated Therapies, Dand Faber Cancer
Institute, Boston, USA; Semin. Oncol. Nurs. 2005 Aug; 21(3):190-5; PMID: 16092807 [PubMed - indexed
for MEDLINE]
OBJECTIVE: To review strategies and recommendations to improve utilization of

acupuncture treatment for side effects of chemo-radiation therapy in cancer centres.
DATA SOURCES: Research studies and articles, government reports, and author
experience. CONCLUSION: Recent evidence in clinical research indicates that
acupuncture is beneficial for chemotherapy-induced nausea, vomiting, and cancer
pain. Other preliminary data also suggests acupuncture might be effective for
chemotherapy-induced leukopenia, post-chemotherapy fatigue, radiation therapy-
induced xerostomia, insomnia, and anxiety. However, the utilization rate of
acupuncture remains low despite the wide use of other complementary and
alternative medical therapies among cancer patients. This low usage of acupuncture
in cancer patients indicates a health care quality issue. IMPLICATIONS FOR NURSING
PRACTICE: Oncology nurses need to increase their awareness of the available
evidence in the use of acupuncture in the supportive care of cancer patients.
Acupuncture point stimulation for chemotherapy-induced

nausea or vomiting. Ezzo JM, Richardson MA, Vickers A, Allen C, Dibble SL, Issell BF, Lao L,
Pearl M, Ramirez G, Roscoe J, Shen J, Shivnan JC, Streitberger K, Treish I, Zhang G; James P. Swyers
Enterprises, Baltimore, Maryland, USA; Cochrane Data. Syst. Rev. 2006 Apr 19; (2):CD002285; PMID:
16625560 [PubMed - indexed for MEDLINE]
BACKGROUND: There have been recent advances in chemotherapy-induced nausea

and vomiting using 5-HT(3) inhibitors and dexamethasone. However, many still
experience these symptoms, and expert panels encourage additional methods to
reduce these symptoms. OBJECTIVES: The objective was to assess the effectiveness
of acupuncture-point stimulation on acute and delayed chemotherapy-induced
nausea and vomiting in cancer patients. SEARCH STRATEGY: We searched MEDLINE,
EMBASE, PsycLIT, MANTIS, Science Citation Index, CCTR (Cochrane Controlled Trials
Registry), Cochrane Complementary Medicine Field Trials Register, Cochrane Pain,
Palliative Care and Supportive Care Specialized Register, Cochrane Cancer
Specialized Register, and conference abstracts. SELECTION CRITERIA: Randomized
trials of acupuncture-point stimulation by any method (needles, electrical
stimulation, magnets, or acupressure) and assessing chemotherapy-induced nausea
or vomiting, or both. DATA COLLECTION AND ANALYSIS: Data were provided by
investigators of the original trials and pooled using a fixed effect model. Relative
risks were calculated on dichotomous data. Standardized mean differences were
calculated for nausea severity. Weighted mean differences were calculated for
number of emetic episodes. MAIN RESULTS: Eleven trials (N = 1247) were pooled.
Overall, acupuncture-point stimulation of all methods combined reduced the
incidence of acute vomiting (RR = 0.82; 95% confidence interval 0.69 to 0.99; P =

0.04), but not acute or delayed nausea severity compared to control. By modality,
stimulation with needles reduced proportion of acute vomiting (RR = 0.74; 95%
confidence interval 0.58 to 0.94; P = 0.01), but not acute nausea severity. Electro-
acupuncture reduced the proportion of acute vomiting (RR = 0.76; 95% confidence
interval 0.60 to 0.97; P = 0.02), but manual acupuncture did not; delayed symptoms
for acupuncture were not reported. Acupressure reduced mean acute nausea severity
(SMD = -0.19; 95% confidence interval -0.37 to -0.01; P = 0.04) but not acute
vomiting or delayed symptoms. Non-invasive electro-stimulation showed no benefit
for any outcome. All trials used concomitant pharmacologic anti-emetics, and all,
except electro-acupuncture trials, used state-of-the-art anti-emetics. AUTHORS'
CONCLUSIONS: This review complements data on post-operative nausea and
vomiting suggesting a biologic effect of acupuncture-point stimulation. Electro-
acupuncture has demonstrated benefit for chemotherapy-induced acute vomiting,
but studies combining electro-acupuncture with state-of-the-art anti-emetics, and in
patients with refractory symptoms, are needed to determine clinical relevance. Self-
administered acupressure appears to have a protective effect for acute nausea and
can readily be taught to patients though studies did not involve placebo control. Non-
invasive electro-stimulation appears unlikely to have a clinically relevant impact
when patients are given state-of-the-art pharmacologic anti-emetic therapy .
Clinical observation on electric stimulation of Yongquan (Kl 1)

for prevention of nausea and vomiting induced by Cisplatin. Fu J,
Meng ZQ, Chen Z, Peng HT, Liu LM; Dept. of TCM, Cancer Hospital, Fudan University, China; Zhongguo
Zhen Jiu 2006 Apr 26(4):250-2; PMID: 16642608 [PubMed - indexed for MEDLINE]
OBJECTIVE: To search for an effective method for controlling nausea and vomiting
induced by chemotherapy. METHODS: Eighty-eight cases of hepatic cancer with
interventional therapy of Cisplatin were randomly divided into a treatment group and
a control group, 44 cases in each group. The treatment group were treated with an
anti-emetic and electro-acupuncture at Yongquan (KI 1), and the control group only
with the anti-emetic. The controlling rates for nausea and vomiting were compared
between the two groups. RESULTS: The controlling rates for acute nausea, vomiting
and delayed vomiting in the treatment group were better than those in the control
group (P < 0.05). CONCLUSION: Electro-acupuncture at Yongquan (KI 1) can
prevent and greatly improve the symptoms of nausea and vomiting in the patient
with chemotherapy of Cisplatin.

Complementary and alternative medicine in breast cancer
patients. Nahleh Z, Tabbara IA; George Washington University Medical Center,
Washington, DC, USA; Palliat. Support Care 2003 Sep;1(3):267-73; PMID:
16594427 [PubMed - indexed for MEDLINE]
OBJECTIVE: Complementary and Alternative Medicine (CAM) is becoming

increasingly popular among cancer patients, in particular those with breast cancer. It
represents one of the fastest growing treatment modalities in the United States.
Therefore, knowledge of CAM therapies is becoming necessary for physicians and
other health care providers. CAM encompasses a wide range of modalities including
special diet and nutrition, mind-body approaches, and traditional Chinese medicine.
METHODS: We reviewed the biomedical literature on CAM use in breast cancer
patients, using Medline search from 1975 until 2002. In addition, consensus reports
and books on CAM and breast cancer were included in the review. We evaluated the
prevalence of CAM use in breast cancer patients, the reasons cited for its use, the
different available modalities, and the reported outcomes. RESULTS: Use of CAM in
breast cancer patients ranges between 48% and 70% in the United States. The most
commonly used CAM modalities include dietary supplements, mind-body approaches,
and acupuncture. The reasons cited for using CAM were to boost the immune
system, improve the quality of life, prevent recurrence of cancer, provide control
over life, and treat breast cancer and the side effects of treatment. Several studies
reported favourable results including improved survival, better pain control, reduced
anxiety, improvement in coping strategies and significant efficacy in treating nausea
and vomiting. Other less well-organized trials have reported either no benefit or
negative effect of CAM and potential toxicity of some commercial products.
SIGNIFICANCE OF RESULTS: CAM is a growing field in health care and particularly
among breast cancer patients. Knowledge of CAM by physicians, especially
oncologists, is necessary. Oncologists should be willing to discuss the role of CAM
with their patients and encourage patients to participate in well-organized research
about CAM.
Electro-acupuncture for refractory acute emesis caused by

chemotherapy. Choo SP, Kong KH, Lim WT, Gao F, Chua K, Leong SS; Dept. of Oncology,
National Cancer Center, Singapore; J. Altern. Complem. Med. 2006;12(10):963-9; PMID: 17212568
[PubMed - in process]
PURPOSE: To evaluate the efficacy of electro-acupuncture in preventing

anthracycline-based chemotherapy-related nausea and emesis refractory to
combination 5HT(3)-antagonist and dexamethasone. PATIENTS AND METHODS:
Cancer patients with refractory emesis after their first cycle of doxorubicin-based
chemotherapy were accrued into this study. Electro-acupuncture was given during
the second cycle of chemotherapy. Each patient was evaluated for the number of
emetic episodes and grade of nausea within the first 24 hours after chemotherapy

and electro-acupuncture. RESULTS: Forty-seven of a total of 317 patients screened
were eligible for this study. Of these, 27 patients agreed to participate. Twenty-six
(26; 96.3%) of them had significant reduction in both nausea grade and episodes of
vomiting after electro-acupuncture. There was complete response with no emetic
episodes in 37%. Subjectively, 25 (92.6%) of the total 27 patients believed that
acupuncture was an acceptable procedure and was helpful in reducing emesis.
Electro-acupuncture was well-tolerated with a median pain score of 3 of 10.
CONCLUSION: Electro-acupuncture is well-tolerated and effective as an adjunct in
reducing chemotherapy-related nausea and emesis.
Acupuncture in prevention of postoperative nausea and

vomiting. Schlager A; Abteilung fur Anasthesie, Universitatsklinik fur Anasthesie und Allgemeine
Intensivmedizin, Innsbruck, Austria; Wien. Med. Wochenschr. 1998;148(19):454-6; PMID: 10025044
[PubMed - indexed for MEDLINE]
In this review the effectiveness of the acupuncture point Pericard 6 (P 6) on

postoperative nausea and vomiting (PONV) is described. Use of the acupuncture,
acupressure as well as the laser stimulation of P 6 proved as efficient prophylaxis of
PONV in numerous studies. These methods are free of side effects and represent
therefore a good alternative to the pharmacological prophylaxis and treatment of
PONV.
Evidence for symptom management in the child with cancer.

Ladas EJ, Post-White J, Hawks R, Taromina K; Division of Pediatric Oncology, Integrative Therapies
Program for Children with Cancer, Columbia University, New York, USA; J. Pediatr. Hematol. Oncol. 2006
Sep;28(9):601-15; PMID: 17006267 [PubMed - indexed for MEDLINE]
The use of complementary/alternative medicine (CAM) has been well documented

among children with cancer. This report summarizes the research evidence on the
role of CAM therapies for prevention and treatment of the most commonly reported
cancer-related symptoms and late effects among children with cancer. Small clinical
trials document evidence of effectiveness for select therapies, such as acupuncture
or ginger for nausea and vomiting, TRAUMEEL S for mucositis, and hypnosis and
imagery for pain and anxiety. Several relatively small clinical trials of varying quality
have been conducted on these CAM therapies in children with cancer. Some herbs
have demonstrated efficacy in adults, but few studies of herbs have been conducted
in children. Larger randomized clinical trials are warranted for each of these
promising therapies. Until the evidence is more conclusive, the providers' role is to
assess and document the child's use of CAM, critically evaluate the evidence or lack
of evidence, balance the potential risks with possible benefits, and assist the family
in their choices and decisions regarding use of CAM for their child with cancer.

Psychological well-being improves in women with breast
cancer after treatment with applied relaxation or electro-
acupuncture for vasomotor symptom. Nedstrand E, Wyon Y, Hammar M, Wijma
K; Division of Obstetrics and Gynecology, Faculty of Health Sciences, Linkoping University Hospital,
Linkoping, Sweden; J Psychosom. Obstet. Gynaecol. 2006 Dec;27(4):193-9 PMID: 17225620 [PubMed -
indexed for MEDLINE]
The aim of this study was to evaluate the effect of applied relaxation and electro-
acupuncture (EA) on psychological well-being in breast cancer-treated women with
vasomotor symptoms. Thirty-eight breast cancer-treated postmenopausal women
with vasomotor symptoms were included in the study. They were randomized to
either treatment with electro-acupuncture (EA) (n = 19, three of them with
tamoxifen) or applied relaxation (AR) (n = 19, five of them with tamoxifen) over a
12-week study period with six months follow-up. Vasomotor symptoms were
registered daily. A visual analogue scale was used to assess climacteric symptom,
estimation of general well-being was made using the Symptom Checklist, and mood
using the Mood Scale. These were applied during treatment and at follow-up. In total
31 women completed 12 weeks of treatment and six months of follow-up. Hot
flushes were reduced by more than 50%. Climacteric symptoms significantly
decreased during treatment and remained so six months after treatment in both
groups. Psychological well-being significantly improved during therapy and at follow-
up visits in both groups. Mood improved significantly in the electro-acupuncture
treated group. In conclusion psychological well-being improved in women with breast
cancer randomized to treatment with either AR or EA for vasomotor symptoms and
we therefore suggest that further studies should be performed in order to evaluate
and develop these alternative therapies.
Chemotherapy and Acupuncture in Cancer Patients Brenda Golianu, MD,
Elizabeth Sebestyen, MD
OBJECTIVE: To describe the use of electro-acupuncture as a complementary

modality in combination with chemotherapy in the treatment of three types of
cancer. Background: Cancer patients may benefit from complementary or alternative
medical therapies. Electrical-acupuncture may be a modality that potentiates
chemotherapy.
Design, Setting, and Patients: Case series between May 2002 and July 2004 at two
US centers including patients with mucoepidermoid carcinoma of the parotid gland,
small cell lung cancer, and metastatic ovarian cancer.
Intervention: Points were chosen along meridians surrounding the cancer and
metastatic sites. Positive polarity was oriented proximally and cephalad to the tumor
site, while negative polarity was oriented distally, along the extremities, on the same
meridian. Main Outcome Measure: Alteration of tumor growth.
Results: In all three cases, the tumors had a response to chemotherapy that

exceeded expectations or previous response patterns.
CONCLUSION: Electro-acupuncture may be a useful adjunct to conventional

chemotherapy. Further research is needed, both in the laboratory and in randomized
controlled clinical trials, to measure efficacy and explore mechanisms of action.
Effect of acupuncture on interleukin-2 level and NK cell-

immuno-activity of peripheral blood of malignant tumour
patients Wu B, Zhou RX, Zhou MS First Affiliated Hospital, Huaxi Medical University Chendu;
Zhongguo Zhong Xi Yi Jie He Za Zhi; 1994 Sep; 14(9):537-9 PMID: 7866002 [PubMed - indexed for
MEDLINE]
This paper deals with the observation of acupuncture therapy affecting interleukin-
2(IL-2 level and natural killer (NK) cell immuno-activity in the peripheral blood of
patients with malignant tumours. In this clinical-laboratory test research, randomized
double blind method was used. The patients were divided into an acupuncture
treated group (n = 25) and a control group (n = 20). The former group was treated
using points, ST36, LI11, RN6 and locations of symptomatic points bilaterally. They
received one treatment of 30 minutes daily for 10 days. The results showed that the
IL-2 level and NK cell activity were lower than normal in patients with malignant
tumour, but there was an increase in the acupuncture group after 10 days of
treatment. Significance was found to be remarkable (P < 0.01). The difference
between the two groups was also significant (P < 0.01). This increase might be
related to the mechanism of acupuncture that adjusting the body's immune function.
Thus, acupuncture therapy could enhance the cellular immune function of patients
with malignant tumours and providing a beneficial effect in anti-cancer treatment.
Effect of acupuncture on T-lymphocyte and its subsets from the

peripheral blood of patients with malignant neoplasm . Yuan J, Zhou
R, Zhen Ci Yan Jiu; 1993; 18(3):174-7 PMID: 7923712 [PubMed - indexed for MEDLINE]
Effect of acupuncture on the T-lymphocyte and its subsets from the peripheral blood
of patients with malignant neoplasm has been researched in this study. 51 patients
were divided into two groups: one in acupuncture treatment and the other without
any treatment. 48 healthy adults were also studied as normal control group. The
results showed that the percentages of OKT3+, OKT4+, OKT8+ cells in the
peripheral blood of the 51 patients were lower than those of the normal adults
respectively. After the acupuncture treatment, the percentages of OKT3+, OKT4+,
OKT8+ cells were obviously higher than those before acupuncture; the control group
of patients showed no significant variation. This result revealed that acupuncture
seemed to have more effect on OKT4+ cells than on OKT8+ cells. From our study we
believe that acupuncture can be used as one of the many treatments for patients
with cancer.

Clinical effectiveness of electro-acupuncture in combination
with invasive therapy for massive liver cancer. Xin Y, Liu D, Meng X Dept.
of Thoracic Surgery, China-Japan Friendship Hospital, Beijing; Zhonghua Wai Ke Ze Zhi; 2001 Oct;
39(10):756-8; PMID: 16201187 [PubMed - indexed for MEDLINE]
OBJECTIVE: To investigate the clinical effectiveness of electro-acupuncture therapy

(EAT) in combination with liver artery intubation chemotherapy for massive liver
cancer. METHODS: A total of 106 patients were divided into 3 groups. In group A,
patients underwent EAT in combination with invasive therapy. In group B, patients
received EAT alone. In group C, patients underwent invasive therapy of liver artery
intubation chemotherapy. In groups A and B, subcostal oblique incision was
performed to expose liver cancer, and electrodes were inserted into the tumour
under direct vision. In group A, liver artery intubation was performed during
operation. After operation, chemotherapy was given from the tube. Liver artery
intubation chemotherapy was performed only in group C. RESULTS: The effective
rate was 73.7% (28/38), 55.6% (20/36) and 28.1% (9/32) in groups A, B and C,
respectively. CONCLUSIONS: The effect of electro-acupuncture therapy in
combination with liver artery intubation chemotherapy achieves the best results.
Therefore, acupuncture is an effective therapy for massive liver cancer.
Effect of electro-acupuncture in treating patients with lingual

hemangioma. Li JH, Xin YL Zhang W, Liu JT, Quan KH Chinese Journal for Integrated Medicine;
2006 Jun; 12(2):146-9; PMID: 16800996 [PubMed - indexed for MEDLINE]
OBJECTIVE: To explore the clinical effect of electro-acupuncture (EA) in treating

patients with lingual hemangioma (LHG). METHODS: EA therapy was applied on 36
patients by directly inserting the platinum needles into LHG through a trocar with
plastic insulating cannula to protect the normal tissues and connecting the needles
with the electro-chemical therapeutic apparatus of model ZAY-B. Then electricity was
given until the tumour body got contracted and rigid. The result was assessed 6
months after EA was started. RESULTS: All patients were treated effectively, namely,
the effective rate was 100%, with the therapeutic effect reaching grade I in 29
patients (80.6%), grade II in 7 (19.4%), and all having the function of tongue
recovered to normal. CONCLUSION: EA shows special superiorities in treating LHG,
proved to bring about less injury and quick recovery and being simple in operation.
Especially when applied on huge LHG, it could not only remove the tumour, but also
preserve the function of the tongue, so it is a brand-new approach that is likely to be
accepted by patients.

Electro-acupuncture: Treatment Method for Arm Edema,
Following Surgery for Breast Cancer. C. Moldovan, et al. (Institute of
Oncology, Bucharest, Romania). International Medical Acupuncture Conference, London, England,
May 4-8, 1986
Upper limb edema (bloating from retention of water) occurs following surgery for
breast cancer in approximately 8-30% of the cases. Existing means have relatively
limited efficiency. This study presents a treatment method with electro-acupuncture
(acupuncture in which weak electrical currents are sent through the needles) on a
group of 21 patients with upper limb edema. Treatment response was based on
objective criteria including clinical and thermoelectric measurements. Complete
recovery from edemas was obtained in 33% of the cases, while partial recovery was
seen in 43% of the cases. No response was seen in 24%.
3. Studies Two Articles with Protocol
a) ACUPUNCTURE TO REDUCE NAUSEA DURING CHEMOTHERAPY

TREATMENT OF RHEUMATIC DISEASES A. Josefson, M. Kreuter, Dept. of
Rheumatology and Inflammation Research, Sahlgrenska University Hospital, Goteborg, Sweden.
Published: Rheumatology 2003;42:1149-1154, 2003 British Society for Rheumatology
ABSTRACT
Objective. To study if acupuncture, combined with ondansetron treatment, reduces

nausea and vomiting associated with cyclophosphamide infusion in patients with
rheumatic diseases.
Methods. Thirty-nine patients were treated with acupuncture at point PC 6 and/or in

the ear to decrease nausea and vomiting. The patients reported the severity of
nausea and number of bouts of vomiting at the start of chemotherapy and after 4, 8,
24, 48 and 72 h.
Results. Compared with ondansetron treatment alone, the combined acupuncture

ondansetron treatment significantly decreased both the severity of nausea and the
number of bouts of vomiting 24 and 48 h after the subjects had received acupuncture
at the first treatment session (nausea: P < 0.0001; vomiting: P < 0.0035). Nearly
the same results were seen 48 and 72 h after the subjects had had their last
treatment of acupuncture (nausea P < 0.0080). Similar results were found after 24 to
48 h, when a comparison was made between two sessions close in time (nausea: P <
0.0001 after 24 h, P < 0.0003 after 48 h; vomiting: P < 0.0007).
Conclusions. Our results clearly indicate that combined treatment with acupuncture
and ondansetron reduces the severity and the duration of chemotherapy-induced
nausea as well as the number of bouts of vomiting as compared with ondansetron
therapy alone, in patients with rheumatic diseases.
INTRODUCTION
Acupuncture is a scientifically accepted method for treating pain. It has also been
shown to reduce nausea effectively in seasickness and morning sickness during
pregnancy, as well as in patients pre-medicated with opioids before surgery. Nausea
of varying intensity is a very common side-effect of chemotherapy. Dundee et al.
reported that 96% of their patients felt sick after the first chemotherapy treatment,
that the feeling of sickness is likely to accompany any subsequent drug
administration, and that tolerance did not appear to develop to the side-effects of
cancer chemotherapy agents. They found that acupuncture administered at point PC
6 (Neiguan) significantly improved nausea in 97% of the 130 cancer patients
studied. This effect was absent when a placebo point was tested. To determine if the
beneficial effect on nausea attributed to acupuncture is due to non-specific effects of
attention and clinicianpatient interaction, Shen et al. performed a three-arm
randomized controlled trial in 104 patients with high-risk breast cancer. Studying the
effects of electroacupuncture during 5 days of chemotherapy and a 9-day follow-up
period, they found that electroacupuncture was more effective in controlling emesis
than minimal needling or anti-emetic pharmacotherapy alone. However, the observed
effect had a limited duration and the differences between the groups were not
significant at 9-day follow-up. A review by Mayer showed that acupuncture as a
treatment in general is useful and presented evidence that acupuncture is effective
for treatment of chemotherapy-induced nausea and vomiting in cancer patients.
Patients with rheumatic diseases are nowadays also often treated with

immunosuppressive drugs. This includes patients with extra-articular rheumatoid
arthritis (RA), Wegeners granulomatosis and other primary vasculitides, systemic
lupus erythematosus (SLE), scleroderma and mixed connective tissue disease
(MCTD). Immunomodulating treatment is used primarily to suppress the activity of
the disease by down-regulation of the proliferation of immunocompetent cells and
the secretion of pro-inflammatory cytokines, such as interleukin 1 and tumour
necrosis factor- . The side-effects of cyclophosphamide treatment, an alkylating
agent frequently used in cases of severe rheumatic disease, are dose dependent.
Cells of the bone marrow and the mucous membranes of the intestines and the
urinary bladder are especially sensitive to the action of cyclophosphamide. Delayed
nausea and vomiting in connection with cyclophosphamide treatment are commonly
observed in clinical practice. Some patients suffer from nausea just once, while the
majority may have severe symptoms for several days after each treatment. To
relieve this side-effect, patients are given anti-emetic drugs such as ondansetron. In
spite of this anti-emetic treatment, many patients still suffer from severe nausea and
vomiting. To our knowledge, no studies have investigated the effects of acupuncture
on nausea and vomiting in patients with rheumatic diseases receiving chemotherapy
on repeated occasions over a long period of time. Results from the cancer studies
mentioned above are not necessarily directly applicable to patients with rheumatic
diseases. Furthermore, in those studies patients were treated on only one occasion or
during one period. Originally we intended to randomize the patients into two
treatment groups, one receiving acupuncture and no ondansetron and the other both
acupuncture and ondansetron. However, randomization did not succeed since almost
all patients clearly expressed a wish to have a combined acupuncture and
ondansetron treatment. The aim of this study was thus to investigate the effect of
acupuncture in combination with ondansetron on nausea and vomiting in patients
with severe rheumatic diseases treated with chemotherapy.

PATIENTS AND METHODS
Patients
An increasing number of patients with rheumatic diseases are treated with
intravenous chemotherapy throughout the world. The immuno-modulating
medication, mainly cyclophosphamide, is used in lower doses than is employed for
cancer treatment. The dose level is usually between 750 and 1500 mg, depending on
the patients weight and need of immuno-suppression. The treatment, so-called
intermittent pulse treatment, is mostly administered as one infusion once a month
for 4 months up to 2 yr, depending on the activity of the disease/exacerbation and on
the rapidity of the clinical response to the treatment. Consecutive in-patients at the
department of rheumatology with the diagnosis of SLE, RA, MCTD, primary vasculitis
or other rheumatic systemic diseases with pulmonary or nephritic manifestations
were invited to participate in the study and offered acupuncture as an additional
treatment against nausea. The inclusion criterion was a prior session with
cyclophosphamide followed by experience of nausea despite simultaneous treatment
with ondansetron. Exclusion criteria were severe psychiatric illness, sensitivity to
needlesticks owing to hyperaesthesia or prolonged bleeding time, or lymphatic
oedema in the arms. The patients who agreed to participate in the study were
contacted by one of the authors and asked to fill in a study protocol at every session
of chemotherapy. All patients were informed about the experiences of acupuncture as
a treatment in general and its possible beneficial effect on nausea. Seventy-six
patients entered the study and 39 completed it. Fifteen patients who had
acupuncture treatment only once or twice were excluded from the study because
cyclophosphamide treatment was terminated owing to lack of effect on the
underlying illness. In addition, 16 of the patients who had tried acupuncture
treatment once or twice did not consider their nausea to be troublesome enough to
continue the acupuncture and were therefore excluded from the study. Six patients
dropped out without providing any reason. Of the 39 patients who completed the
study, 32 were women and seven men. The median age was 47 yr (range 2172).
Thirteen patients had SLE, 11 had primary vasculitis, four MCTD, six scleroderma and
five persons RA with either amyloidosis or secondary necrotizing vasculitis.
Methods
A pre-experimental pretestpost-test design was used. Such a design enables

questions to be answered over time by performing a pretest before the independent
variable is introduced. If the probands are tested both before and after the
procedure, it is possible to assess a difference in the results of the dependent
variable. A pilot study comprising 10 patients was first conducted to test the method
and the protocol. This resulted in some changes in the protocol to make it easier for
the patients to fill in. The patients filled in the number of bouts of vomiting and rated
the degree of nausea on a four-step scale (0 = no nausea, 1 = slight nausea, 2 =
moderate nausea and 3 = severe nausea) at the start of the infusion and after 4, 8,
24, 48 and 72 h. The three observation times of the first 24 h were chosen after
other studies, but as cyclophosphamide is known to give a delayed sickness,
observations of 48 and 72 h after the infusion were added. The following information
was entered into the study protocol from the patients records: date of treatment,
dose of cyclophosphamide, diagnosis and consecutive treatment number. The
acupuncture points, and time and duration of acupuncture were also noted. The
acupuncture points chosen were the PC 6 (Neiguan) and/or two acupuncture points
in the ear (Lung and Liver). These points are considered to be equal in their effect
on nausea. The needles were inserted into the patients unilaterally or bilaterally at
least 1530 min before the cyclophosphamide infusion was started. The normal time
for acupuncture was 3045 min. Stimulation was made so De Qi (the needle
sensation in most cases described as a complex feeling of numbness, pressure,
tenderness and warmth/cold) was achieved when inserting and removing the
needles, but not in-between. An experimental design of the study is outlined in. The
patients were included in all four groups, depending on the acupuncture treatment
(phase 16).
Phase 1. The patients underwent 13 sessions of chemotherapy without acupuncture

treatment, and severity of nausea and bouts of vomiting were measured.
Phase 2. First session of chemotherapy with acupuncture and the same registrations
of side-effects were measured. This could in some cases mean that the time interval
between the first time of chemotherapy without acupuncture and the first time with
acupuncture could vary from 46 weeks up to 3 months.
Phase 3. The severity of nausea and bouts of vomiting were followed during a series
of chemotherapy treatments combined with acupuncture treatment, but were not
included in the analysis. The number of treatments varied between 1 and 5 and was

determined by practical clinical reasons.
Phase 4. One to two chemotherapy treatments without acupuncture were then

provided again, as the intention was to make extra comparisons with phases 1, 2 and
3.
Phase 5. Further sessions of chemotherapy combined with acupuncture treatment

then followed. The number of treatments varied between 3 and 24 and depended on
how many sessions of chemotherapy the patients were undergoing (based on the
response of the disease to the treatment).
Phase 6. The last session of chemotherapy treatment with acupuncture was

registered.
Analysis 1. A comparison of the data of these observations (phase 1 and phase 2)

was made. If more than one session was notified in phase 1, the analysis of the first
one was used.
Analysis 2. A comparison between data from phase 3 and phase 4 was made. In
phase 3 the last session of acupuncture was chosen and the first of no acupuncture
in phase 4.
Analysis 3. Data from phase 1 were compared with data from phase 6.
Analysis 4. Data from phase 2 were compared with data from phase 6.
Every session of chemotherapy was administered once every 46 weeks. Study

protocols were distributed each time the patients received chemotherapy treatment.
The protocols were brought back at the time of the next chemotherapy session or
sent by post 10 days after chemotherapy, in connection with blood tests.
Statistical methods
Wilcoxons signed rank sum test for paired observations was used for testing
differences between different treatments of the patient group. Discrete data (degree
of nausea) were presented as frequencies and the distribution of variables of
continuous data (number of bouts of vomiting) was presented as means, medians
and range.

Ethical considerations
It was not necessary to obtain ethical approval from the Research Ethic's Committee,
as this study was an evaluation of a common clinical treatment. The patients were
informed about the study and gave their consent verbally.
RESULT Acupuncture significantly reduced the severity, especially the duration, of

nausea, as well as the number of bouts of vomiting following cyclophosphamide after
24 to 48 h. The number of bouts of vomiting was significantly reduced at the first
session of acupuncture. The same results could also be seen when the interim
between treatments (ondansetron alone vs acupunctureondansetron combined) was
short (within 46 weeks) and when the patients health status was considered more
stable.
Eighteen patients had less than 5 acupuncture treatments, fourteen patients had 6
10, two patients had 12, two had 16 and three were treated 2124 times. The
median number of acupuncture sessions was 7 (range 224). The total number of
acupuncture treatments was 294 for the 39 patients. The effects of acupuncture on
the severity of nausea and number of bouts of vomiting in patients treated with
chemotherapy prior to acupuncture and at the first session of acupuncture are
presented in (described in the Methods section as analysis 1 comparing data from
phase 1 and phase 2). At the start of chemotherapy and after 4 and 8 h there were
no significant differences between treatment modalities, as most patients did not feel
nausea at all after that short observation time. However, significant decreases in the
severity of nausea with acupuncture were found after 24 and 48 h (P < 0.0001) and
after 72 h (P < 0.0106). The mean number of bouts of vomiting was 3.3 without
acupuncture compared with 0.6 when the patients were treated with acupuncture (P
< 0.0035.
After receiving chemotherapy and acupuncture a number of times, 13 sessions of

chemotherapy without acupuncture were measured again, and compares the
treatment modalities on two occasions close in time (in the Methods section
described as analysis 2 comparing data from phase 3 and phase 4). There was a
significant difference in the severity of nausea in the patients treated with
acupuncture after 24 h (P < 0.0001), after 48 h (P < 0.0003) and after 72 h (P <
0.0254). The number of bouts of vomiting was significantly reduced when the

patients were treated with acupuncture (P < 0.0007). Other comparisonsnot shown
in the tableswere also made. First, between chemotherapy without acupuncture
treatment and the last session of acupuncture (described in the Methods section as
analysis 3, comparing data from phase 1 and phase 6). No significant differences
were found in the initial period after acupuncture though differences in the severity of
nausea were found after 48 h (P < 0.0151) and 72 h (P < 0.0080). There were no
significant differences in the number of bouts of vomiting.
Finally, comparisons were made to evaluate if there was a cumulative effect of

acupuncture on the degree of nausea and number of bouts of vomiting between the
first and last sessions of acupuncture (described in the Methods section as analysis 4,
comparing data from phase 2 and phase 6). Evidence of such an effect was observed.
Significant differences were found in the severity of nausea after 48 h (P < 0.0059)
and in the number of bouts of vomiting (P < 0.0005), but not in the rest of the
observations. As a whole, the patients kept their pattern of reaction to acupuncture
and we assume that each acupuncture treatment had a similar effect on nausea.
DISCUSSION
Compared with an efficient pharmacological anti-emetic treatment (ondansetron), it

seems that acupuncture combined with ondansetron significantly decreased both the
severity and duration of nausea, as well as the number of bouts of vomiting following
intravenous cyclophosphamide therapy. The details of the underlying mechanisms of
acupuncture on nausea and vomiting are largely unknown. Acupuncture may affect
the sympathetic system via mechanisms at the hypothalamic and brainstem levels.
Indeed, the hypothalamic beta-endorphinergic system exerts inhibitory effects on the
vasomotor centre. There is evidence that hypothalamic nuclei have a central role in
the mediating effects of acupuncture and that afferent input of somatic nerve fibres
has a significant effect on autonomic functions. Why there is a potentiating anti-
emetic effect of the combination of acupuncture and anti-emetic medication cannot
be answered at present. It is apparent that the usual anti-emetic medication is not
effective enough for many patients. Some of our patients (not included in this study)
have tried acupuncture without ondansetron on some occasions, but found
acupuncture alone to be unsatisfactory and therefore resumed the combined
treatment with ondansetron and acupuncture.

There are some limitations in our study that deserve comments. Several previous
acupuncture studies have been criticized for lacking adequate control groups.
Although our study used the patients as their own controls, we had no placebo group.
One reason for this is that placebo needles were not available when this study was
initiated. On the other hand, it may be hard to deceive patients using the currently
available sham acupuncture methods. Differences in the number of acupuncture
treatments that patients underwent in this study depend to a certain extent on when
the patients entered into the study. Some of the patients included here are still
undergoing chemotherapy and data are still being collected from them.
The inclusion criterion was a prior treatment with cyclophosphamide followed by

experience of nausea despite simultaneous treatment with ondansetron. As a good
many patients on the ward did not experience nausea at all or did not consider it to
be troublesome, they were thus not included in the study. The 39 persons who were
both included and completed the study are in our opinion a group of patients with a
generally more severe nausea problem. Another limitation of the study concerns the
response scale used to assess the severity of nausea. A ceiling effect may have
resulted from setting the upper endpoint to 3, since judging from comments in the
protocols the patients would have marked a higher score if such had been available.
This may explain why some patients marked 3 for nausea but still thought they were
better off with acupuncture than without it. Furthermore, the follow-up period
perhaps should have been extended to 5 or 7 days.
We conclude that acupuncture combined with ondansetron reduces nausea and

vomiting compared with ondansetron alone and may thus be a treatment of benefit
to patients with rheumatic diseases on chemotherapy. Based on the results from our
study, we recommend acupuncture as a treatment to supplement anti-emetic drugs.
As the method is reasonably easy to perform and carries minimal risk, its clinical use
could be extended in order to make chemotherapy more endurable for patients.
However, successful implementation of this treatment requires well-organized
cooperation and planning among the staff.
In our ward we have developed a carefully planned schedule to accommodate this

treatment. The treatment days are concentrated to 2 days a week. Blood tests are
taken the day before the cyclophosphamide infusion, which makes it possible to start
all infusions at the same time on each occasion. This enables us to administer

acupuncture routinely despite the hectic working situation on our ward. Supported by
grants from the F.R.F.-Foundation, Sweden, the Swedish Rheumatism Association, Legitimerade
Sjukgymnasters Riksfrbunds Minnesfond and the Rune and Ulla Amlv Foundation.
b) ACUPUNCTURE FOR CANCER PATIENTS RESEARCH AND

CASE STUDIES
INTRODUCTION
Complementary therapies can be useful adjunctive modalities in the treatment of
many cancers. Between 7% and 36% of cancer patients use complementary
therapies while being treated for cancer, when these services are covered by their
insurance.1,2 There is a need for further research into the efficacy of complementary
therapies.3 Several studies have reported that acupuncture can be effective in the
treatment of chemotherapy-related nausea and vomiting, post-chemotherapy
fatigue, and cancer-related pain.4-6 Some recent human and animal studies have
reported that adjunctive electrical acupuncture may be effective in enhancing
chemotherapy.7-9 We present 3 cases in which electro-acupuncture was added to the
conventional chemotherapy treatment planned for the patient and may have played
a synergistic role.
METHODS
Needling technique was determined by following a protocol practiced by Dr. Jin Zhui
and Dr. Qian Xin at the Guang Zhou Medical School in the People's Republic of China
for the treatment of patients with metastatic cancer. The protocol is based upon the
hypothesis that a positive charge surrounding the tumor destabilizes the tumor cell
membranes, rendering them more susceptible to chemotherapy.
First, the meridians that pass through or around the tumor are located. Points along
these meridians are selected that are 1-2 cm proximal to the known tumor sites on
those meridians. They are needled using the Flying Needle insertion technique (quick
insertion using wrist action), with a dispersion method (slight counterclockwise
rotation). These points receive a positively charged electrical stimulus. Distal points
are selected by locating major points on each meridian, preferably on the arms or
legs, and are used to ground the circuit. The positive clip of the stimulator is
connected to the proximal needle and the negative clip to the distal needle of the
same meridian. A Chinese Multipurpose Electrical Stimulator was used (Wujin Great

Wall Medical Device Co). The following specifications were used: continuous pulse
duration Tao = 0.5 (0.15) ms; repeated pulse frequency selectivity g=1-100 Hz;
output peak voltage Vp1>= 40V10V at a 500-ohm load. The stimulator produced a
low-intensity and low-frequency (0.5-2 Hz) pulsed current for 25 minutes.
All needles were 34 gauge, 30-mm stainless steel. They were placed to elicit a De Qi
sensation and subsequently rotated as described below. The treatment was
performed 2-5 times per week for 30 minutes each time. The treatments continued
for 4 months for the 1st patient, 2 months for the 2nd patient, and 7 months for the
3rd patient. During this time, the patients continued treatment with conventional
chemotherapy as prescribed by the treating oncologist.
Calibration Techniques
Using a conventional oscilloscope, calibrated according to the manufacturer's

recommendations, we measured the electrical output of the Chinese Multipurpose
Electrical Stimulator. We used a frequency of 2 Hz. The waveform was a square wave
with an average magnitude of 70 mV and duration of 0.5 ms.
CASE REPORTS
Case 1
A 43-year-old man was diagnosed with T3N2bM1 poorly differentiated

mucoepidermoid carcinoma of the parotid gland and had undergone right
parotidectomy and radical neck dissection with 2 positive nodes. It was not possible
to obtain clear tumor margins. Following surgery, a positron emission tomography
(PET) scan prior to initiation of chemotherapy showed hypermetabolic left submental
and left jugular lymph nodes, innumerable hypermetabolic foci within thoracic
vertebral bodies (C3, T12-L4), ribs, sternum, right ischium, and right acetabulum,
suggesting osseous metastatic disease. An extensive uptake of glucose suggested
involvement of the majority of the L4 vertebral body. The patient was advised that
chemotherapy would not be effective for this tumor but was offered it nonetheless as
a palliative modality. The patient underwent 3 courses of chemotherapy consisting of
carboplatin and 5-fluorouracil, lasting 3 months. During this time he also underwent
acupuncture treatment 5 times per week for 30 minutes (Table 1).

Table 1. Points Used in Case 1
Meridian Positive Points Negative Points
Points With Electrical Stimulation
ST 1, 2, 34 12, 11, 36
GB 30 39
TH 20 5
SI 19 11
BL 10 23
LI 4 20
Hua Tuo Jia Ji Points C2, T1, T10, L3 C7, T9, L2, BL 57
Points Without Electrical Stimulation*
SP 6 sedation mode
KI 3,7 tonification mode
LR 3 sedation mode
CV 17 tonification mode
*Sedation mode refers to hand manipulation in a counterclockwise direction;
tonification mode, hand manipulation in a clockwise direction.

Fig1 Iodine-123 metaiobenzylguanidine Fig2 MIBG scan of case 1 after 4
(MIBG) scan of case 1 before treatment months of chemotherapy and
Note multiple areas of uptake acupuncture. Only 1 area of active
(representing metastatic sites) uptake at T8 is shown.
including sternum, ribs, and thoracic
and lumbar vertebrae.
During treatment, recurrent hyperemia was noted at the tumor site, which resolved
after acupuncture treatment, but recurred after 24 hours. The treatments continued
5 times per week for 4 months. Follow-up PET scan 4 months later showed persistent
hypermetabolic activity at T8 only (Figures 1 and 2). This was the only active
metastatic disease. The multiple lesions seen on prior PET scan did not show any
hypermetabolic activity on this follow-up study.
Case 2
A 73-year-old woman was diagnosed with stage IV small cell lung cancer, with
multiple liver metastases, periportal, mesenteric, and para-aortic lymphadenopathy.
The initial lung mass was 6 cm in diameter. The patient received 6 cycles of
carboplatin and etoposide, resulting in decreased tumor size to 4 x 3 cm measured
by computed tomography (CT). Electroacupuncture was added 2 times per week
(Table 2) to the chemotherapeutic regimen. Seven months later, the patient
interrupted both chemotherapy and acupuncture for a trial of a dietary regimen.

Eight months after diagnosis, the tumor measured 4.5 x 3.7 cm on follow-up CT.
Chemotherapy was restarted with ironotecan for 4 cycles and the patient restarted
acupuncture treatments 5 times per week. The acupuncture treatment protocol is
shown in Table 2. Ten months after diagnosis, the central lung mass decreased to
3.0 x 1.0 cm. There was a marked improvement in the liver metastases and near
complete resolution of the periportal, mesenteric, and para-aortic lymphadenopathy.

KI 27, 21 22, 3
ST 3, 19 18, 36
SP 20 3
LR 14 2
GB 24 39
LU 1 9
KI 7, 10 tonification mode
SP 6, 9,10 sedation mode
LR 3 sedation mode
LI 4 sedation mode
CV 17, 18 tonification mode
*Sedation mode refers to hand manipulation in a

counterclockwise direction; tonification mode, hand
manipulation in a clockwise direction.
Case 3
A 69-year-old woman was diagnosed with stage IV ovarian adenocarcinoma, multiple

liver metastases, and periaortic and pelvic lymph node involvement bilaterally. She
underwent bilateral oophorectomy and started low-dose chemotherapy with
carboplatin and taxol for 7 cycles with stabilization, but no improvement of the liver
lesions or lymphadenopathy.
Six months later, electroacupuncture was added 2 times per week according to the
protocol shown in Table 3. Repeat PET scan 13 months later showed complete
resolution of both liver metastases and lymphadenopathy.

KI 21, 12 16, 3
ST 19, 29 25, 36
SP 21 3
LU 9 1
LR 14 2
GB 24 39
KI 7, 10 tonification mode
SP 6, 9, 10 sedation mode
LR 3 sedation mode
LI 4 sedation mode
CV 17, 18 tonification mode
*Sedation mode refers to hand manipulation in a

counterclockwise direction; tonification mode, hand
manipulation in a clockwise direction.
DISCUSSION
Although these 3 cases obviously do not allow us to draw any definitive conclusions,
we report these findings because the use of electroacupuncture merits further
research. We cannot determine whether electroacupuncture was responsible for
tumor regression. The chemotherapy itself may have been entirely responsible for
the observed phenomena, although these results were significantly better than those
that were expected. If acupuncture played some role in tumor regression, the
mechanism is speculative.
Electrical stimulation of sympathetic nerve endings may stimulate vasoconstriction or

stimulate an immune response. There is some evidence that acupuncture may be
able to affect the sympathetic and parasympathetic nervous systems. 10,11 Recent

interest in influencing angiogenesis and tumor blood supply 12,13 suggests that using
methods that create vasoconstriction may have a role in treatment. A recent animal
experiment showed that electroacupuncture enhanced natural killer cell activity in
rats, and that this enhancement was suppressed by anterior hypothalamic lesions in
the animals.14 Electroacupuncture may also improve immune function in humans. 15
Another possible mechanism might be that daily one-on-one time with the patient for
30 minutes could have elicited a powerful placebo effect.
CONCLUSIONS
Acupuncture can be a useful modality to complement conventional cancer treatment

and may potentiate the effects of chemotherapy. Further research is needed to
determine efficacy and the mechanisms of action. The results of these case reports
are preliminary, and we are aware of the many limitations of these reports. We plan
further exploration of this phenomenon in animal models, and with a larger sample
of patients in a prospective, randomized controlled trial.
ACKNOWLEDGEMENTS
We wish to thank the American Academy of Medical Acupuncture (AAMA). Some of

these cases were presented at the 2004 annual meeting and received 1st place for
original research. We also wish to thank Drs Nancy Federspiel, Elliot Krane, Emily
Ratner, and Richard Niemtzow for their energetic advice and support.
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4. Pain Management with Acupuncture
Introduction
Patients undergoing cancer treatment will, most likely, during the

course of the disease suffer from pain. Statistically, 60 to 90 percent
of cancer patients require a pain-relieving therapy at some point.
However, not all cancers produce pain equally, and some cancers,
even when advanced, may not cause pain at all. Cancers that are
more typically painful include tumors of the bone (either primary or
through spread) and the organs of the abdomen.
Types of pain are: Somatic pain, from the cancer itself, may come
from a bone damaged by tumor invasion or from an obstruction in the
intestine or urinary tract. Neuropathic pain, from nerve involvement, is
either related to direct tumor spread such as the spread of colon
cancer into the pelvis where the nerves to the legs or pelvic structures
reside, or is secondary to irritating substances that tumors secrete
near nerves. Neuropathic pain may also result from pressure on the
nerves due to tumor formation. Surgery may cause both somatic and
neuropathic pain. Chemotherapeutic drugs can have a detrimental
effect on sensory receptors in the peripheral nervous system.
Mucositis, sometimes a side effect of these drugs, is one example of
somatic pain resulting from chemotherapy. Drugs such as antiviral
agents or vincristine, cisplatin, carboplatin, Taxol and Navelbine can
cause peripheral neuropathy, which is often felt as a burning in the
hands and feet. After radiation therapy, pain may be due to skin
damage, breakdown of mucous membranes or even scarring of the
nerves (fibrosis), which can produce a neuropathic pain.
Side Effects of Pain Medications: Not all patients tolerate all analgesic
drugs equally well. Some people are allergic to certain medications or
develop sensitivity over prolonged periods of drug treatment. Side
effects vary from individual to individual and can present yet another
burden on the patient undergoing cancer treatment. While 90 to 95
percent of patients receive adequate pain control (see: the WHO

guidelines for analgesics in cancer patients), there are still 5 to 10
percent of patients who do not achieve any marked relief. There are
other ways, through direct intervention, to relief pain. These
interventions include nerve blocks with local anesthetics or nerve-
destroying agents, alternative delivery systems such as administering
narcotics under the skin (subcutaneous) or into the spine, spinal local
anesthetics or other therapies that destroy nerves causing the pain.
Acupuncture is one modality which can bring relief for patients with
acute or chronic pain and, whilst it is not sufficient during episodes of
very severe pain, it can provide an alternative and, importantly,
effective support for other methods of pain relief, reducing the need
for analgesics and other medication. Acupuncture is also effective in
symptoms of fatigue which is often a direct result of pain and reported
by the majority of cancer patients at some point during their illness.
A series of different studies conducted in the US have shown that 90%

of patients with advanced cancer experience severe pain and that pain
occurs in 30% of all cancer patients, regardless of the stage of the
disease. These studies also show that 50% of patients feel they do not
receive satisfactory treatment to relieve their discomfort. Pain usually
increases as cancer progresses. The most common cancer pain arises
from tumors that metastasize to the bone, followed by tumors
infiltrating nerves and hollow viscera. Tumors near neural structures
may cause the most severe pain. The third most common pain
associated with cancer occurs as a result of chemotherapy, radiation or
surgery. Pain can be chronic, persistent or what is termed
breakthrough pain which is a brief flare-up of severe pain and can
occur while the patient is on regular pain medication.
At the College of Chinese Medicine, London, we specialize in spinal

acupuncture and use, together with local and distal points along the
meridian pathways, points alongside the spine to influence peripheral
innervations. Pain occurs when neurons the periphery get stimulated
by tissue damage or by inflammatory signaling mechanisms such as
prostaglandins (PGs). PGs, produced by neutrophils at the injury site,

bind to their receptors on peripheral nerve terminals and trigger a pain
message to the central nervous system (CNS). Non-neuronal cells of
the CNS such as astrocytes and microglia get turned on by the
incoming message and produce yet more PGs and inflammatory
cytokines that further amplify the pain signal.
Not only is acupuncture effective as a complementary therapy for pain

but, through its anti-inflammatory properties often replaces generally
accepted pharmacological intervention. The attributive effect of
acupuncture has been investigated in inflammatory diseases, including
asthma, rhinitis, inflammatory bowel disease, rheumatoid arthritis,
epicondylitis, complex regional pain syndrome type 1 and vasculitis.
Large randomised trials demonstrating the immediate and sustained
effect of acupuncture are yet missing in the UK, but have been
conducted for some years now in the US, Germany, Japan and China.
Mechanisms underlying the ascribed immuno-stimulating actions of
acupuncture have been investigated and documented. Studies and
research shows that the acupuncture-controlled release of
neuropeptides from nerve endings and subsequent vaso-dilative and
anti-inflammatory effects through calcitonine gene-related peptide is
hypothesised (see: Mediators of Inflammation, Volume 12 (2003)
Issue 2). The complex interactions with substance P, the analgesic
contribution of -endorphin and the balance between cell-specific pro-
inflammatory and anti-inflammatory cytokines tumor necrosis factor-
and interleukin-10 are discussed in this context. A great deal of
investigations into the molecular and neuroendocinological
mechanisms of acupuncture, brain mapping and others are still on the
way any should bring exciting new insight and greater understanding
of acute and chronic pain.
Research Extracts by Prof. W. Zieglgansberger, Max

Planck Institute, Munich, Dept. of Neuropharmacology
and Chronic Pain Research
THE USE OF ACUPUNCTURE IN CHRONIC PAIN AND

UNDERSTANDING PAIN MECHANISMS
More and more research into the mechanisms of acupuncture and how

it works on a cellular and neurological level is being done worldwide.
At the forefront of this research is the Max-Planck Institute, Munich,
Germany. Professor Dr Walter Zieglgansberger, at the Department for
Clinical Neuropharmacology at the Max-Planck Institute, is one of the
leading figures in the field of pain mechanism research in Europe and
an ardent advocate of acupuncture as an invaluable tool in the
treatment of patients suffering from acute and chronic pain. Below are
small extracts from some of Prof. Zieglgansbegers research explaining
the pathways of pain and how the effects of acupuncture can be
understood in the context of molecular neuroendocrinology.

What Do We Know About The State Of Chronic Pain?
Chronic pain syndromes are characterized by altered neuronal

excitability in the pain matrix. The ability to rapidly acquire and store
memory of aversive events is one of the basic principles of nervous
systems throughout the animal kingdom. These neuroplastic changes
take place e. g. in the spinal cord, in thalamic nuclei and cortical and
subcortical (limbic) areas integrating pain threshold, intensity and
affective components. Chronic inflammation or injury of peripheral
nerves evokes the reorganization of cortical sensory maps. Neurons
conveying nociceptive information are controlled by various sets of
inhibitory interneurons. The discharge activity of these interneurons
counteracts long-term changes in the pain matrix following nociceptor
activation, i. e. it prevents the transition of acute pain signaling to
chronic pain states. Our most recent research suggests that pain
states may be sensitive to novel families of agents and therapeutic
measures not predicted by traditional preclinical pain models as well as
human pain states. The endogenous cannabinoid system plays a
central role in the extinction of aversive memories. We propose that
endocannabinoids facilitate extinction of aversive memories via their
selective inhibitory effects on GABAergic networks in the amygdala.
Klinik fur Anasthesiologie, Schmerzambulanz, Klinikum Grosshadern, Ludwig-Maximilians-Universitat

Munchen. Article in German (Zieglgansberger W, Azad SC) PMID: 14648318 [PubMed - indexed for
MEDLINE]
Understanding Neuropathic Pain
Neuropathic pain is defined as a chronic pain condition that occurs or

persists after a primary lesion or dysfunction of the peripheral or
central nervous system.Traumatic injury of peripheral nerves also
increases the excitability of nociceptors in and around nerve trunks
and involves components released from nerve terminals (neurogenic
inflammation) and immunological and vascular components from cells
resident within or recruited into the affected area. Action potentials
generated in nociceptors and injured nerve fibers release excitatory
neurotransmitters at their synaptic terminals such as L-glutamate and
substance P and trigger cellular events in the central nervous system
that extend over different time frames. Short-term alterations of
neuronal excitability, reflected for example in rapid changes of

neuronal discharge activity, are sensitive to conventional analgesics,
and do not commonly involve alterations in activity-dependent gene
expression. Novel compounds and new regimens for drug treatment to
influence activity-dependent long-term changes in pain transducing
and suppressive systems (pain matrix) are emerging.
Department of Clinical Neuropharmacology, Max Planck Institute of Psychiatry, Kraepelinstrasse 2, 80804

Munich, Germany. (Zieglgansberger W, Berthele A, Tolle TR) Published: CNS Spectrum, 2005 Apri;
10(4):298-308 PMID: 15788957 [PubMed - indexed for MEDLINE]
The Pain Matrix Presented at ICMART 2000 International

Medical Acupuncture Congress
Emerging knowledge related to the diversity of pain-related systems in

the central and peripheral nervous systems suggests that besides
"classical" neurotransmitters, e.g., L-glutamate, substance P, g-
aminobutyric acid (GABA) and monoamines, biologically active
molecules such as peptide hormones, neurosteroids, trophic factors or
cytokines participate in the integration of somatosensory information
in the pain matrix. These substances are released synaptically or non-
synaptically from terminals, neighboring neurons, glia cells or
components of the immune system or from the circulation. These
neuronal and hormonal systems, which act in concert to help the
individual to cope with pain, have been detailed by the modern
neurosciences.
By detailing the multiplicity of transducing and suppressive systems

novel compounds and new regimes for drug treatment and afferent
stimulation to prevent activity-dependent long-term changes are
emerging. Chronic pain states arise from a variety of
pharmacologically distinct systems which offer novel targets for
selective pharmacotherapy and appear sensitive to families of agents
that were otherwise not predicted by traditional preclinical pain models
as well as human pain states.
The activation of a nociceptor in the peripheral tissue triggers sets of

neuronal events which extend over a time frame ranging from

milliseconds to hours, days or weeks. Most nociceptors in the
peripheral tissue are polymodal: they respond to noxious heat, strong
mechanical stimuli, and to a battery of exogenous and endogenous
chemical stimuli (including prostaglandins, bradykinin, histamine,
cytokines). These multimodal nociceptors can be sensitized by a
number of factors released by the damaged tissue leading to primary
hyperalgesia. Sensitization causes specific upregulation of expression
of ion channels and receptors on these structures.
A major facilitatory effect of the central nervous system responding to

noxious stimuli involves the interaction between L-glutamate and
substance P, a neuropeptide long thought to have a role in pain
perception. GABA is a major inhibitory neurotransmitter in the
mammalian CNS and GABA binding sites and GABA containing neurons
have been characterized in almost all pain-related structures. Even
slight alterations in the excitability of multi-receptive dorsal horn
neurones (wide-dynamic-range, WDR neurons) can dramatically
influence the size of their receptive fields measured in the peripheral
tissue, i.e. the area in the periphery where a stimulus will trigger
action potentials in this neuron. The excitatory receptive fields are
most commonly surrounded by inhibitory receptive fields. The size of
the excitatory receptive field can be increased by the application of L-
glutamate into the vicinity of these neurons and can be reduced in size
by the application of the inhibitory neurotransmitter GABA. Repetitive
electrical stimulation of the inhibitory receptive field can induce a long-
lasting suppression of neuronal discharge activity of WDR neurons.
While the earliest short-term responses are reflected in rapid changes
of neuronal discharge activity the long-term changes most commonly
require alterations in gene expression. The importance of WDR
neurons in the establishment of hyperalgesia and allodynia suggests a
strategic focus for drug treatment or interventions by peripheral
stimulation, e.g. by acupuncture or physical therapy, on this first stage
of sensory integration in the CNS. Activity-dependent modulation of
gene expression is a feature of highly integrated systems and greatly
expands the capacity to react in a more plastic manner to
environmental stimuli. Immediate-early-genes (IEGs) are thought to

participate as third messengers in the late phase of the stimulus
transcription cascade. They code for transcription factors and alter
gene expression and translation into the corresponding protein
products such as enzymes, receptors or neurotransmitters. The
amount of several IEG-coded proteins, produced by central neurons, is
proportional to the degree of synaptic excitation following somatic and
visceral acute noxious.
Similar neuroplastic changes take place in other components of the

pain matrix, e.g. in areas integrating pain threshold and intensity or its
unpleasantness in the neocortex or subcortical limbic areas. Chronic
inflammation or injury of peripheral nerves evokes the reorganization
of cortical sensory maps. These recent advances in
electrophysiological, molecular and cellular biological techniques have
profoundly changed the face of pain research. The multitude of
dynamic changes which occur during chronic pain states may also offer
explanations for some of the effects observed following acupuncture
and treatment with related techniques.
W. ZIEGLGANSBERGER (Germany), Max-Planck Institute, Munchen
Other Abstracts and Reports from the ICMART 2000

International Medical Acupuncture Congress. (The following original
translations from German have been edited, in terms of grammar and sentence
structure, with an endeavor to stay as true to the original as possible.)
Acupuncture as Post-operative and Post-traumatic Treatment

Spacek A, Department of Anesthesia, General Hospital, Vienna, Austria.
Within the last 30 years, acupuncture has become increasingly

accepted within orthodox medicine and has gained great popularity
among patients, primarily as a therapeutic option in the treatment of
various chronic diseases. Moreover, acupuncture has been used
increasingly in trauma and in connection with surgery. One of the best
documented areas of the efficacy of acupuncture is the treatment of

postoperative nausea and vomiting. Acupuncture appears to be as
effective as specific anti-emetic medication, both in prevention and in
the treatment of postoperative nausea and vomiting, but without the
side effects of pharmaceutical intervention. Great efficacy of
acupuncture has also been shown for its analgesic action in treating
painful conditions due to surgery or trauma. Electro-acupuncture
treatment provides a significant reduction of postoperative opioid
requirement and seems to be a good alternative in treating headaches
after spinal anesthesia in caesarean section. Acupuncture has also
been reported to be superior to placebo treatment in preventing
postoperative dental pain and can reduce postoperative pain after total
knee replacement by more than 20%. Although acupuncture is less
effective than narcotic analgesics, it helps to alleviate the severity of
complications such as postoperative urinary retention, impairment of
bronchial function, intestinal paresis, vomiting, nausea and pain in 40-
80% of cases. It has also been found that electro-acupuncture
significantly attenuates catecholamine responses in comparison to
placebo treatments during postoperative recovery. The effect of ear-
acupuncture (point P 29) on blood pressure regulation has also been
investigated and findings that bilateral stimulation of the P 29
mitigates hypotensive effects after induction of anesthesia. This simple
technique has absolutely no risks nor side effects and may be
beneficial in preventing post-induction hypotension in patients. Taking
all these facts into consideration, one must conclude that the use of
acupuncture as part of a comprehensive treatment concept (combined
with drug therapy) in the management of postoperative and post-
traumatic pain seems to be desirable.
Atomic Physics and Neurophysiology on the Concept of

Meridian Qi (Energy) Warnke U, University of Saarland, Germany
In modern science, the considered electromagnetic and mechanical

neuron activity is, up to now, not sufficient remarked:

a) As long as resting potential is stable, electrons within the cell
membrane have a potential energy of approx. 70meV. During
depolarization, this energy is set free as a coherent radiated
electromagnetic oscillation with the quantum energy of 70 meV = 1,7
x 10 Hz. At the same time, the molecule dipoles fixed in their
movement previously through the high electrostatic field of the resting
potential of the membrane (up to 10 V/m) suddenly oscillate and, in
this way, send coherent electromagnetic oscillations of different
frequencies outside and inside the neurite.
b) Through the high electrostatic field force of the resting potentials, a

very high compression of the membrane is caused. At depolarization,
the membrane snaps back to its real expansion (electrostriction). The
desultory expansion is causing the mechanical resonance of the
membrane elements which thus send out a sound wave. As the sound
wave runs through the tissue and the fluids it modulates, through
periodic pressure fluctuation, the dielectric constant of the medium in
the rhythm of the sound frequency. Thereby the membrane sends out
in addition to the coherent electromagnetic oscillation an
electromagnetic dispersion wave. The triggered sound wave is directly
coupled with the emission of the dispersion wave. Both work in the
same tissue and fluid volume and in this way they amplify one
another. Through dielectric focusing, e.g. through the walls of blood
vessels, this radiation can be focused again. The stream of blood
works like an antenna and pulls in the electromagnetic field analogous
to the warmth, then, guided forward, the field conductive and
connective proteins have a habit to changing their geometric form,
e.g. they twist their side chains around an anticipated angle of torsion.
This happens likewise as a consequence of specific energy absorption.
The electromagnetic radiation of some activated enzymes is fixed in
resonance to the microwave area (10/12 - 10/13 Hz.). That is exactly
the area in which membranes of neurons send out coherent
oscillations in the case of depolarization.

Post-operative Pain Management with Acupuncture Grube T, Kornberg
A, Uhlemann C, Meissner W, Scheele J, Surgical Clinic, Jena, Germany
Background: Acupuncture has become very popular in several fields of

pain management, especially in treatment of chronicle pain. The
purpose of this study is the assessment of acupuncture in the
treatment of postoperative pain.
Material and methods: After defined operations (vaginal and

laparoscopic hysterectomy, laparoscopic appendectomy), all patients
received patient controlled analgesia (PCA) with piritramid and we
randomized in three groups;
Group 1 (n = 18) received PCA and acupuncture after a defined time

table.
Group 2 (n = 17) received PCA and 1 g metamizol at the same time.
Group 3 (n = 17) PCA only was.
At defined points of time, patients were asked to comment on pain

intensity, nausea and frequency of vomiting using visual analog scale
(VAS). At the same time, blood pressure, heart frequency and skin
temperature were noted. At the end of the evaluation, levels of
piritramid taken were documented.
Results: The use of acupuncture (group 1) lead to a reduction of

piritramid use of more than 50 percent compared to group 3. In group
2, the intake of piritramid was less than in group 3, but still higher
than in group 1. We also noticed very good results of acupuncture in
the treatment of nausea and vomiting.
Conclusion: Using scientific and reproducible parameters, acupuncture

alone proved to be sufficient in the management of postoperative pain,
nausea and vomiting. Especially multi-morbid patients at risk of
suffering from surgery-related or pharmacological side effects benefit
from acupuncture. We noted no effect of acupuncture regarding blood
pressure and heart rate.

Mechanisms of Acupuncture Analgesia Produced by
Low-FrequencyElectrical Stimulation of Acupuncture
Points
By Chifuyu Takeshige
Introduction
Three noteworthy phenomena have been recognized in surgical

acupuncture analgesia (AA) produced by low-frequency electrical
stimulation of acupuncture points (APs): 1) Consciousness is
maintained, allowing the patient to talk during surgery; 2) Stimulation
of specific acupuncture points is essential to maintain analgesia; and
3) Analgesia persists long after stimulation has been terminated,
allowing the patient to move without pain after surgery. The
mechanisms by which AA is produced might be clarified by
investigating these phenomena. This review will explore possible
mechanisms based on results from animal experiments.
Consciousness depends on activation of the brainstem ascending
reticular activating system (RAS) that produces widespread stimulation
of the cerebral cortex and non-specifically maintains consciousness
through the reticular nucleus in the thalamus. The RAS is activated by
collateral pathways that diverge from each specific sensory afferent
pathway that projects to each sensory cortex. Neurophysiological
research has shown that anesthetic drugs used during surgical
operations inhibit activity of the RAS. Since consciousness is
diminished under this condition, sensory information reaching the
sensory cortex is not translated into perception. On the other hand, it
is also commonly observed that normally painful stimuli are
suppressed on the battlefield of war and on the playing field of
aggressive sports such as rugby. Such analgesia is thought to be
brought about by activation of the descending pain inhibitory system
(DPIS) originating from the limbic system that blocks pain information
as it enters the central nervous system. Consciousness can thus be
maintained in such a condition. If stimulation of a specific acupuncture
point activates the DPIS through a particular pathway connected to the
brain system which suppresses pain, it can be assumed that AA is
produced by activation of the DPIS. This assumption has been
examined in our laboratories by several animal experiments.

1. Classification of acupuncture afferent and efferent pathways
for producing acupuncture analgesia [11,12,13,16,22,23]
The neuronal structures comprising the AA-producing brain pathway

can be identified when microelectrode stimulation induces analgesia in
a manner that mimics AA and by tissue ablation that results in
subsequent blockage of AA. However, the nature of the analgesia
produced depends upon the brain areas stimulated and can be
classified into two categories. The first category includes analgesia that
1) is naloxone-reversible, 2) disappears after hypophysectomy, 3)
persists long after stimulation of the acupoint is terminated, and 4)
exhibits individual variation in effectiveness. These features are similar
to those of AA. In this category, brain potentials are evoked by
stimulation of acupoints in the same areas that produce analgesia.
Stimulation of brain areas associated with the second category
produces analgesia that 1) is not naloxone-reversible, 2) is not
affected by hypophysectomy, 3) is produced only during stimulation,
and 4) exhibits no individual variation in effectiveness. Evoked
potentials are not obtained from brain regions producing analgesia of
this second category, but non-synchronized neuronal activities are
obtained by stimulation of acupoints [16].
Brain regions producing analgesia of the first category appear to
comprise an afferent pathway for acupuncture, since the pituitary
gland is involved in this analgesia and electrical potentials are evoked
in these brain regions by stimulation of acupoints. Similarly, areas
producing analgesia related to the second category appear to comprise
an efferent pathway for acupuncture, since the pituitary gland is not
involved and synchronized electrical potentials are not evoked in these
regions by stimulation of acupoints [12,16,19]. All brain regions
producing analgesia associated with the second category seem to be
connected to the DPIS; AA is produced by activation of the DPIS that
is excited by stimulation of specific acupoints through a particular
pathway connected to the DPIS. This DPIS-producing analgesia related
to the second category is defined as the acupuncture efferent
pathway, whereas the particular pathway from specific acupoints to
the DPIS is defined as the acupuncture afferent pathway.
1a. Acupuncture efferent pathway [13,16,24]
AA can be abolished by concurrent lesions of the Raphe nucleus and

the reticular paragigantocellular nucleus that are known as the origins
of the serotonergic and the noradrenergic descending pain-inhibitory
systems. Stimulation of these nuclei respectively produces
serotonergic and noradrenergic analgesia of the second category. The

final production of AA is induced by activation of these descending
pain-inhibitory systems. The descending pain-inhibitory pathway
serves as the acupuncture efferent pathway from the hypothalamic
ventromedian nucleus (HVM); it is divided into two parts that connect
to the descending serotonergic and noradrenergic systems. The
posterior part of the hypothalamic arcuate nucleus (P-HARN) is
anatomically connected to the HVM. Analgesia produced by stimulation
of both the HVM and the P-HARN is associated with the second
category. Synaptic transmission from the P-HARN to the HVM is
apparently dopaminergic, since analgesia produced by stimulation of
the P-HARN is blocked by lesions of the HVM or by dopamine
antagonists.
1b. Acupuncture afferent pathway [11,12,23]
The acupuncture afferent pathway starts from an acupoint, ascends

through the contralateral anterolateral tract to the dorsal
periaqueductal central gray, and reaches the medial part of the
hypothalamic arcuate nucleus (M-HARN). Brain regions belonging to
the AA afferent pathway can be identified by exhibition of analgesia of
the first group related to anatomically known connections. The rostral
and caudal relations between these regions have been identified by the
loss of stimulation-produced analgesia of the caudal region that follows
lesions of the rostral region.
1c. Synaptic connections between acupuncture afferent and

efferent pathways [25,28].
The final region of the acupuncture afferent pathway is found in the M-

HARN, which is anatomically close to the P-HARN, the initial region of
the acupuncture efferent pathway. Microinjection of the dopamine
antagonist haloperidol antagonizes AA dose-dependently while
microinjection of dopamine into the P-HARN induces a dose-dependent
analgesia. Dopamine thus seems to serve as the neurotransmitter
between the M-HARN and the P-HARN, i.e. as the neurotransmitter at
the interface between the acupuncture afferent and efferent pathways.
This possibility is further supported by neuronal activity in the P-HARN.
Neurons in the P-HARN that respond to acupoint stimulation also
respond to iontophoretically administered dopamine, whereas neurons
in the M-HARN that do not respond to acupoint stimulation also do not
respond to iontophoretically administered dopamine [25].
A branch of the acupuncture afferent pathway ascending to the M-
HARN diverges at the lateral hypothalamus (LH) to reach the pituitary
gland. Lesions of brain nuclei near this pathway to the pituitary, e.g.

the preoptic area (POA) or the median eminence (ME), abolish AA.
Electrical potentials are evoked in these brain areas by stimulation of
acupoints, but stimulation of these particular brain structures does not
produce analgesia [25,28] (Fig.1, 2 and 5). Since both acupuncture
analgesia and pain relief produced by stimulation of the acupuncture
afferent pathway to the M-HARN -endorphin released from the
pituitary glandare abolished by hypophysectomy, may play an
essential role in dopaminergic transmission in the P-HARN [25].
Microinjection of naloxone to the P-HARN antagonizes AA -endorphin
or morphine producesdose-dependently and microinjection of
-endorphinanalgesia dose-dependently. Analgesia produced by
microinjection of disappears after denervation of the M-HARN, but
analgesia produced by microinjection of dopamine to the P-HARN
remains [25]. These findings -endorphin might act presynaptically at
dopaminergic synapses insuggest that the P-HARN. This notion is
further supported by the activity of P-HARN neurons. Neuronal activity
in the P-HARN that occurs in response to acupuncture stimulation is
not affected by iontophoretic administration of morphine or by
-endorphin via picosprizer [22].
-ultramicroinjection
Since -endorphin released from -endorphin act similarly in the P-
HARN, morphine and the pituitary gland might be the neurohumoral
factor acting presynaptically on axon terminals of the M-HARN neurons
that innervate P-HARN neurons. Although -endorphin into the P-HARN
produces analgesia, electricalmicroinjected stimulation of the POA or
ME in the pathway to the pituitary gland does not; -endorphin by such
stimulation is nottherefore, the released amount of sufficient to
activate the P-HARN neurons without afferent impulse from the
-endorphin might also act in other areas of the AAM-HARN. Morphine
and afferent pathway. This possibility was explored by recording
electrical potentials evoked by stimulation of the acupoint in the final
station of the AA afferent pathway, the M-HARN. Such potentials are
enhanced by intravenously administered morphine (0.5 mg/kg) and
are abolished by hypophysectomy. The abolished evoked-potentials
are temporarily restored by morphine [12]. -endorphin released from
the pituitary glandTherefore, sites responsive to might be
widespread in the AA afferent pathway. Opioid receptors have also
been reported in many regions of the acupuncture afferent pathway
[1,5,10].
2. Stimulation of specific acupoints for production of

acupuncture analgesia [23]

Low-frequency (1 Hz) electrical stimulation of the first dorsal finger
muscle and the anterior tibial muscle in rats [11, 23] that are the
muscles underlying, respectively, the human LI 4 (Hegu) and ST 36
(Zusanli) acupoints, produces behavioral analgesia, as evaluated by
tail-flick latency. The intensity of electrical stimulation must be
sufficient to cause muscle contraction in order to obtain AA. In
contrast to this effect, stimulation of other muscles does not produce
behavioral analgesia. Hence, the Hegu and Zusanli acupoints seem
uniquely able to activate the DPIS through the particular pathway
connected to the DPIS [3].
3. Differentiation of acupoints and non-acupoints by responses

of central neuronal structures [11,14,15,17,18]
Potentials can be evoked specifically in the bilateral dorsal areas of the

periaqueductal central gray (D-PAG) by stimulation of the muscles
underlying the Hegu and Zusanli acupoints, but not by stimulation of
other muscles. Lesions of the D-PAG abolish AA. Microelectrode
stimulation of this region produces analgesia of the first category that
can be reversed by either naloxone or hypophysectomy. Stimulation of
the auricular levator muscle beneath the X 18 (Chihmo) acupoint in
rabbits elicits evokes potentials in the D-PAG [11,23]. Stimulus
conditions as stated above which lead to AA were confirmed by
potentials in the D-PAG. Therefore, only three acupoints for producing
AA have been identified: Hegu, Zunsanli, and Chihmo.
Stimulation of muscles beneath Hegu and Zusanli also produces
nonspecific potentials bilaterally in the lateral parts of the
periaqueductal central gray (L-PAG) [17]. Potentials in the L-PAG are
gradually decreased by 1 Hz repetitive stimulation of these muscles
and disappear completely 10 minutes after the onset of stimulation
[15,17]. Hence, potentials in the L-PAG are inhibited by such
stimulation in a self-inhibiting fashion. Lesions of the L-PAG do not
affect AA, but analgesia is produced by stimulation of the rostral L-
PAG. This analgesia is largely reversible with dexamethasone and the
dexamethasone-insensitive portion is readily blocked by naloxone or
hypophysectomy. Hence, acupoints are connected via the D-PAG to
the particular pathway that is not self-inhibited during the production
of AA. On the other hand, acupoints as well as non-acupoints are
connected to the other, self-inhibiting pathway nonspecifically, via the
L-PAG. The latter brain region belongs to a pathway distinct from the
AA afferent pathway, whose analgesia production is self-inhibiting.
These results imply that acupoints and non-acupoints can be
differentiated by their connections with different analgesia-producing
central pathways [14,17].

4. Similarities between acupuncture analgesia and morphine
analgesia
Analgesia produced by 0.5 mg/kg morphine is of a similar degree to

that produced by low frequency electroacupuncture. In addition, both
types of analgesia are abolished by hypophysectomy, by lesions of
either the AA afferent or efferent pathways, by naloxone or by
antagonists of transmitters involved in the AA efferent pathway. In
addition, individual variation in effectiveness between AA and
morphine analgesia are highly correlated. Animals can be classified as
responders or non-responders by the presence or absence of a
significant increase (P < 0.05) in tail-flick latency.
5. Activation of the spinal acupuncture analgesia afferent

pathway by morphine [8,11,12,14,18]
Potentials evoked in the D-PAG by stimulation of acupoints are blocked

by contralateral lesions of the anterolateral tract or by intrathecal
administration of the antiserum to methionine-enkephalin (Met-
enkephalin). These potentials are also blocked by naloxone, but not by
the administration of antisera to leucine-enkephalin or dynorphin [18]
supporting the involvement of a met-enkephalin pathway that is
activated by morphine. In AA-responder animals, dose-response
curves of analgesia were obtained for both low and high doses of
morphine, administered either intraperitoneally or intrathecally.
However, in non-responder animals, only a single dose-response curve
for higher doses of morphine was obtained. In AA responders, bilateral
lesions of the anterolateral tract, or lesions of the D-PAG that is part of
the AA afferent pathway abolished dose-dependent responses to low
doses of morphine without affecting the dose-response to high doses
of morphine. Therefore, morphine analgesia produced by lower doses
is probably induced by activation of the AA afferent pathway through
Met-enkephalin receptors in the spinal cord [18]. Such receptors in the
spinal AA afferent pathway are likely to be those that are activated by
intraperitoneal morphine at 0.5 mg/kg or by intrathecal morphine at
0.05 mg/kg, that produce morphine analgesia of a degree similar to
that of AA [8,11]. This mechanism may explain the reason for the
similarity between AA and morphine analgesia.
Summary

Acupuncture analgesia is produced by activation of the DPIS through a
specific pathway connected to the acupoints while still allowing
maintenance of consciousness. The AIS, in contrast, is activated by
stimulation of acupoints or non-acupoints, leading to a non-specific
inhibition of different interconnected pathways. Therefore, acupoints
and non- acupoints can be distinguished by their anatomically distinct
brain pathways. The after-effects of AA might be produced -endorphin
released from the pituitary by the actions of an increased amount of
gland on components of the AA-producing pathway.
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Acupuncture For Cancer Patients

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Acupuncture For Cancer Patients

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RESEARCH

THE CLINIC OF THE COLLEGE OF

ACUPUNCTURE FOR CANCER PATIENTS

Kirsten Dhar The Clinic of the College of Chinese Medicine,

26-28 Finchley Rd, St Johns Wood, London, NW8 6ES

Kirsten Dhar - The College of Chinese Medicine, Research and Development

A COLLECTION OF ABSTRACTS, STUDIES AND ARTICLES ON THE USE OF

ACUPUNCTURE FOR SYMPTOM CONTROL IN THE TREATMENT OF CANCER PATIENTS

1. Neurological Mechanisms of Acupuncture

2. Abstracts Nausea and Other Symptoms

3. Studies Two Articles with Protocol

4. Pain management with Acupuncture

Kirsten Dhar - The College of Chinese Medicine, Research and Development

Acupuncture was originally thought of as being simply a modality

The mechanisms behind acupuncture in the treatment of diseases and

The amygdala is, in simple terms, the mediator between prefrontal

Kirsten Dhar - The College of Chinese Medicine, Research and Development

Recent MRI mapping of meridians (energy transmitting channels) and

The insertion of an acupuncture needle irritates or damages cells in the

An important discovery is the activation of the cortex by acupuncture

Kirsten Dhar - The College of Chinese Medicine, Research and Development

Kirsten Dhar - The College of Chinese Medicine, Research and Development

Acupuncture and self-acupuncture for long-term treatment of

Kirsten Dhar - The College of Chinese Medicine, Research and Development

Kirsten Dhar - The College of Chinese Medicine, Research and Development

CONTEXT: High-dose chemotherapy poses considerable challenges to emesis

Kirsten Dhar - The College of Chinese Medicine, Research and Development

OBJECTIVE: To review strategies and recommendations to improve utilization of

Acupuncture point stimulation for chemotherapy-induced

BACKGROUND: There have been recent advances in chemotherapy-induced nausea

Kirsten Dhar - The College of Chinese Medicine, Research and Development

Clinical observation on electric stimulation of Yongquan (Kl 1)

Kirsten Dhar - The College of Chinese Medicine, Research and Development

OBJECTIVE: Complementary and Alternative Medicine (CAM) is becoming

Electro-acupuncture for refractory acute emesis caused by

PURPOSE: To evaluate the efficacy of electro-acupuncture in preventing

Kirsten Dhar - The College of Chinese Medicine, Research and Development

Acupuncture in prevention of postoperative nausea and

In this review the effectiveness of the acupuncture point Pericard 6 (P 6) on

Evidence for symptom management in the child with cancer.

The use of complementary/alternative medicine (CAM) has been well documented

Kirsten Dhar - The College of Chinese Medicine, Research and Development

Chemotherapy and Acupuncture in Cancer Patients Brenda Golianu, MD,

OBJECTIVE: To describe the use of electro-acupuncture as a complementary

Kirsten Dhar - The College of Chinese Medicine, Research and Development

CONCLUSION: Electro-acupuncture may be a useful adjunct to conventional

Effect of acupuncture on interleukin-2 level and NK cell-

Effect of acupuncture on T-lymphocyte and its subsets from the

Kirsten Dhar - The College of Chinese Medicine, Research and Development

OBJECTIVE: To investigate the clinical effectiveness of electro-acupuncture therapy

Effect of electro-acupuncture in treating patients with lingual

OBJECTIVE: To explore the clinical effect of electro-acupuncture (EA) in treating

Kirsten Dhar - The College of Chinese Medicine, Research and Development

May 4-8, 1986

3. Studies Two Articles with Protocol

a) ACUPUNCTURE TO REDUCE NAUSEA DURING CHEMOTHERAPY

Rheumatology and Inflammation Research, Sahlgrenska University Hospital, Goteborg, Sweden.

Published: Rheumatology 2003;42:1149-1154, 2003 British Society for Rheumatology

Objective. To study if acupuncture, combined with ondansetron treatment, reduces

Methods. Thirty-nine patients were treated with acupuncture at point PC 6 and/or in

Results. Compared with ondansetron treatment alone, the combined acupuncture

Kirsten Dhar - The College of Chinese Medicine, Research and Development

Kirsten Dhar - The College of Chinese Medicine, Research and Development