IN-DEPTH: INTEGRATIVE MEDICINE (COMPLEMENTARY & ALTERNATIVE MEDICINE)

Acupuncture and Pain Management

James D. Kenney, DVM

There is a large and expanding body of scientific evidence supporting the use of acupuncture in pain
management. In the last decade, our understanding of how the brain processes acupuncture anal-
gesia has undergone considerable development. Profound studies on neural mechanisms underlying
acupuncture analgesia have evolved rapidly and predominately focus on cellular and molecular
substrate and functional brain imaging. The currently understood mechanisms of acupuncture
analgesia are complex and involve direct and indirect neurohumoral effects that block pain percep-
tion, reduce the pain response, relieve muscle spasms, and reduce inflammation. The analgesic
mechanisms of acupuncture involve the spinal cord grey matter, hypothalamic-pituitary axis, mid-
brain periaqueductal grey matter, medulla oblongata, limbic system, cerebral cortex, and autonomic
nervous system. Electroacupuncture (EA) stimulation of these sites results in activation of descend-
ing pathways that inhibit pain through endogenous opioid, noradrenergic, and serotonergic sys-
tems. There are growing numbers of human trials supporting the use of acupuncture as an evidence-
based practice for pain management in human medicine. There are many studies that support the
efficacy of acupuncture for low back pain, neck pain, chronic idiopathic and migraine headaches, knee
pain, shoulder pain, fibromyalgia, temporomandibular joint pain, and postoperative pain. Although
the number of well-designed, controlled clinical research studies in veterinary medicine is lagging
behind the number of studies in human medicine, much of the basic science research has been done
in animals with neurophysiology that is more similar to veterinary patients than humans. Although
there is research to support EA as an evidence-based practice for the control of back pain in horses,
additional studies are needed in other clinical situations in veterinary medicine where pain manage-
ment is required. Authors address: PO Box 717, Clarksburg, NJ 08510-0717; e-mail: jdkenneydvm@
msn.com. 2011 AAEP.

1. Introduction
According to the World Health Organization (WHO),
the effectiveness of acupuncture analgesia has been
established in controlled clinical trials, and the use
of acupuncture to control chronic pain is comparable
with morphine without the risk of drug dependence
and other adverse side effects.1 Acupuncture is an
effective treatment for many types of pain, is well-
tolerated by patients, and has a minimal likelihood
of serious adverse effects.13 Modern and tradi-
tional acupuncture techniques have been shown to
provide relief from low back pain, neck pain, chronic
idiopathic or tension headaches, migraine head-
aches, knee pain, shoulder pain, fibromyalgia, tem-
peromandibular joint pain, and postoperative pain.2
Acupuncture was more effective for chronic pain
than placebos (sham acupuncture) based on the re-
sults of systematic reviews of pooled data from high-
quality randomized controlled trials.1,3 For short-
term outcomes (less than 6 mo), acupuncture was
significantly superior to sham treatments for back
pain, knee pain, and headache. For longer-term

NOTES

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Table 1. Definitions of Terms

Term Definition

Neuropathic pain Pain from damage to the nervous system

Nociceptive pain Pain from stimulation of nociceptors
Peripheral nerve endings in the skin, muscles, ligaments, joints, viscera, and
Nociceptors other structures that initially respond to a painful stimulus
Nociception Pain sense
Mechanical, thermal, or chemical stimulus that alters nociceptors and causes
Noxious pain
Analgesia Reduced sensitivity to painful stimuli
Anti-nociception Analgesia
Internuncial neuron Neuron interposed between and connecting two other neurons
Inhibit receptors on neurons; examples are serotonin, GABA,
Inhibitory neurotransmitters norepinephrine, and epinephrine
Excitatory
neurotransmitters Activate receptors on neurons; examples are glutamate and aspartate
Periaqueductal grey matter that surrounds the cerebral aqueduct in the
PAG midbrain
Hyperalgesia Increased sensitivity to pain
Allodynia Non-noxious stimuli perceived as painful
Primary hyperalgesia Hypersensitivity of the peripheral nociceptors
Central sensitization and hypersensitivity of CNS neurons associated with
Secondary hyperalgesia synaptic plasticity
Ability of the connection or synapse between two neurons to change in
Synaptic plasticity strength and responsiveness
Endogenous opioid polypeptide neurotransmitters that inhibit pain stimuli
similar to morphine; includes -endorphins, enkephalins, dynorphins,
Endorphins endomorphin-1, and endomorphin-2
Neurons with cell bodies in the spinal cord whose axons form peripheral
Lower motor neurons motor nerves and terminate in skeletal, cardiac, and smooth muscles

outcomes (6 12 mo), acupuncture was significantly
more effective for knee pain and tension-type head-
ache but inconsistent for back pain (one meta-anal-
ysis was positive and one meta-analysis was
inconclusive).
Acupuncture can effectively treat chronic pain of
the locomotor system with restricted movements of
the joints, because it not only alleviates pain but
also reduces the muscle spasm that causes reduced
mobility.4,5 Muscle spasm can result in abnormal
loads placed on joints, often causing clinical signs of
pain before changes are demonstrable on radio-
graphs. In controlled studies of joint pain of un-
known etiology, acupuncture was superior to
conventional therapy, delayed-treatment controls,
and several other sham acupuncture techniques.
According to the WHO analysis of controlled studies,
acupuncture can effectively reduce pain from cervi-
cal spondylitis and other causes of neck pain, peri-
arthritis of the shoulder, fibromyalgia, fasciitis,
epicondylitis, low back conditions, sciatica, osteoar-
thritis, and radicular and pseudoradicular pain syn-
dromes.1 In some cases, acupuncture integrated
with conventional treatments was more effective
than conventional treatments alone.
Although acupuncture may not reduce pain to the
degree that some conventional treatments reduce
pain, it is associated with a low incidence of serious
adverse side effects.1 For example, acupuncture
122 2011 Vol. 57 AAEP PROCEEDINGS
may not be as effective as corticosteroids for pain
relief in some patients with rheumatoid arthritis,
but chronic corticosteroid use may result in gastro-
intestinal ulceration, osteopenia, muscle loss, and
other adverse effects. Acupuncture not only re-
duces pain and inflammation but has positive effects
on the immune system, which directly benefits pa-
tients with rheumatoid arthritis, and less conven-
tional medication may be needed.1
2. Pain Pathways and Modulation
Pain may be classified as acute or chronic, adaptive
or maladaptive, and neuropathic or nociceptive, and
these types of pain have different underlying mech-
anisms.2 Neuropathic pain occurs from damage to
the peripheral or central nervous system (PNS or
CNS, respectively). Pain associated with activa-
tion of sensory (afferent) receptors (nociceptors) by
mechanical, thermal, or chemical stimuli is consid-
ered nociceptive pain and will primarily be reviewed
here. The pathways involved in nociceptive pain
are also involved with the modulation of pain by
acupuncture. Understanding PNS and CNS pain
pathways is essential to understanding acupuncture
analgesia.6 Terms associated with pain and pain
modulation are defined in Table 1.
Nociception (the sensation of pain) is extremely
complex and involves more than simple transmis-
sion of pain signals from nociceptors of the PNS to
 IN-DEPTH: INTEGRATIVE MEDICINE (COMPLEMENTARY & ALTERNATIVE MEDICINE)

Fig. 1. The basic three neuron pathways of pain (blue, first-order neurons; red, second-order neurons; green, third-order neurons) of
the neo-spinothalmic system and the multisynaptic pathways of the paleo-spinoreticulo-diencephalic system and the bilateral
spinothalamic system common in non-primate animals (black broken lines).

regions of the CNS for conscious perception. Pain
signals are modified by substances released from
cells at the site of pain, within the spinal cord grey
matter, and by the concomitant stimulation of CNS
inhibitory descending pathways from higher brain
centers. The main neuroanatomic structures in-
volved in the complex process of pain perception
include the peripheral sensory receptors (nocicep-
tors), afferent peripheral nerve fibers, dorsal horns
of the spinal cord (body) or sensory nucleus of the
trigeminal nerve (head), ascending pathways to the
reticular formation in the medulla oblongata and
midbrain, thalamus, hypothalamus, limbic system,
and cerebral cortex as well as descending CNS path-
ways from all these sites.6,7
Ascending Pathways
From a simplified functional neuroanatomic stand-
point, the most direct pain pathways, like other sen-
sory systems, can be basically viewed as a three
neuron system: first-order, second-order, and
third-order neurons (Fig. 1).7 Noxious (painful)
mechanical, thermal, or chemical stimuli are de-
tected by nociceptors (primarily free nerve endings)
of somatic and visceral first-order afferent nerves.
When a specific threshold of excitation is reached,
electrical action potentials transmit along their pe-
ripheral processes to cell bodies in the dorsal root
ganglia and then into the spinal cord, where they
synapse on second-order neurons in the dorsal horn
grey matter. Stimulated second-order neurons
propagate electrical signals along their axons, form-
ing ascending tracts in the spinal cord and brains-
tem that synapse on third-order neurons in the
thalamus and other brain stem structures. The ac-
tivated third-order neurons propagate electrical sig-
nals along their axons that terminate in the
somatosensory cortex of the cerebrum as well as
other regions of the brain, where conscious percep-
tion and evaluation of pain occur (Fig. 1). Con-
scious perception of pain may occur at both thalamic
and cortical levels in animals.7
For nociception from the head, electrical impulses
of first-order neurons ascend in the trigeminal nerve
(cranial nerve V) to cell bodies in the trigeminal
ganglia and continue on to enter the brainstem and
synapse with second-order neurons in the trigemi-
AAEP PROCEEDINGS Vol. 57 2011 123
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nal sensory nuclei in the medulla oblongata, pons,

Medulla SC Lamina

Medulla SC Lamina
and midbrain (Fig. 1).6,7 The second-order neu-

SC Laminae I and
SC Laminae I, II,
rons, from the trigeminal sensory nuclei, ascend the

Termination

VII (T1-L1)

VII (T1-L1)
brainstem to synapse with third-order neurons in

site
the thalamus and other brainstem regions similar to

Medulla

and V
second-order neurons from the body and viscera.
The first-order neurons that transmit pain and

II
other sensations are classified according to their
diameter, speed of conduction, function, and degree
of myelination (Table 2).6 There are two classifica-

Gracilus and cuneatus

Paleo-spino-reticulo-
Neo-spino-thalamic
tions for these fibers, numerical and alphabetical,

(dorsal columns)
tract system
Ascending
which can be confusing when reading the literature.

Spino-cerebellar

Spino-cerebellar
The alphabetical Erlinger-Gasser classification will
be used throughout this review. The A and C fi-

thalamci
bers primarily conduct signals from nociceptive
stimuli. A fibers are myelinated, are rapidly con-
ducting, and mainly sense pain from the skin, and C
fibers are unmyelinated, are slowly conducting, and
sense pain from skin, bone, viscera, and other struc-
tures (Table 2). If A and C fibers are stimulated

Proprioception and touch

simultaneously, the pain experienced will come in

Pain and temperature

two phases. The first phase will be sharp and lo-

Sensation
calized and may be of short duration, because it is

Touch, pain, and

mediated by the faster-conducting A fibers. The

temperature
Proprioception

Proprioception
later phase is from the smaller and slower-conduct-
ing C fibers, and it will be dull and non-localized but
last longer.
The second-order neuron cell bodies are located in
one or more physiologically distinct layers (laminae)
of the spinal cord dorsal horn grey matter (Table

cutaneous mechanoreceptors
2).6,7 There are six laminae in the dorsal horn (I-
VI), three in the ventral horn (VII-IX), and an addi-

Muscle spindles and all

tional column of cells clustered around the central
Receptors

canal as Lamina X. The C fibers terminate mainly in

Free nerve endings

Free nerve endings

Golgi tendon organ

Laminae I and II, where their axons secrete Sub-

Muscle spindles

stance P or Vasoactive Intestinal Polypeptide de-

pending on whether they arise from somatic or
visceral structures, respectively. The A afferents
terminate primarily in Laminae I, II, and V.
Axons of the second-order neurons of the spinal
cord grey matter form two main ascending pathway
systems that carry nociception: the neo-spinotha-
velocity (m/s)
Conduction
Table 2. Sensory Peripheral Nerve Types and Their Function

80120

80120

lamic pathway system and the paleo-spino-reticulo-

0.52.0
3575

330

*Unmyelinated; all other types have some myelin.

diencephalic pathway system (Fig. 1 and Table

3).4,6 8 In Laminae I and V, where the majority of
A nerves terminate, second-order neurons immedi-
ately cross to the opposite side and form the neo-
Diameter

spinothalamic tract system in the anterolateral

0.21.5
1220

1320

612
(m)

15

portion of the spinal cord. These neurons termi-

nate on third-order neuron cell bodies in the ventral
posterior lateral (VPL) nucleus of the thalamus and
Medulla, medulla oblongata.

project to the somatosensory cortex (Fig. 1 and Table

Erlanger-Gasser

3). The neo-spinothalamic system is direct, fast,

system

A ()

A ()

A ()

A ()

and localizing and is the basic three-neuron system

C*

of discriminative pain.
The paleo-spino-reticulo-diencephalic pathways
primarily originate from neurons in Laminae VII
and VIII in the ventral horn of the spinal cord grey
matter, with some input from Lamina V, and they
Fiber
type

IV*

connect to C fibers that terminate in Laminae I and

III
Ia

Ib

II

II through internuncial neurons (Fig. 1 and Table

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Table 3. Comparison of the Two Main Central Pain Pathway Systems
Neo-Spinothalamic System
Origination Laminae I, IV, and V (stimulated by A
neurons)
Transmission Direct fast
speed
Subcortical targets None
Thalamic nuclei Ventral posterior lateral
Cerebral cortex Parietal lobe (primary somatosensory cortex)
Pain type Sharp pain, discriminative pain, and pin-prick
pain
2).4,6 8 Most axons from neurons in Laminae VII
and VIII cross to the opposite side in primates and
form their pathways in the anterolateral portion of
the spinal cord adjacent to the neo-spinothalamic
pathways. They pass medially into the reticular
formation (central core) of the brain stem and the
medial intralaminar nuclei of the thalamus, and
then, they project to the cingulate gyrus and frontal
cortex (Table 2).8
In non-primates, some second-order neurons cross
and others remain on the same side to form crossed
and uncrossed spinothalamic pathways.6,7 The
spinothalamic pathways in animals are interrupted
by axons exiting and reentering after synapsing
with other spinal cord neurons, forming diffuse,
bilaterally represented multisynaptic pathways.
Some second-order nociceptive neurons may also as-
cend to the thalamus and other brainstem regions
through the dorsal column medial-lemniscal system,
which mainly transmits proprioceptive information
as well through multifunctional spinoreticular
tracts and the fasciculus proprius.7
The reticular formation (central core of the me-
dulla oblongata, pons, and midbrain) contains bifur-
cating axons that project up through the paleo-
spino-reticular-diencephalic pathways to the
diencephalon (thalamus and hypothalamus) and
down through reticulospinal tracts to the spinal cord
to influence muscle tone. Axons from the reticular
formation that terminate in the hypothalamus also
synapse with autonomic neurons, which descend to
the medulla oblongata and spinal cord to affect au-
tonomic lower motor neurons and alter vascular
tone, heart rate, gastrointestinal function, and other
visceral functions.4,6 8 Consequently, pain may
cause autonomic signs of increased heart and respi-
ratory rates, vasoconstriction, nausea, and
vomiting.
Part of what makes the pain experience so com-
plex and varied between individuals is the interpre-
tation of pain by higher brain centers. The limbic
system, which includes the hypothalamus, hip-
pocampus, amygdala, and cingulate gyrus, is
thought to control the motivational, behavioral, and
emotional responses to pain.4,6 8 The pain stimu-
Paleo-Spino-Reticulo-Diencephalic System
Laminae I, IV, and V (stimulated by C neurons)
connect through internuncial neurons to Laminae
VII and VIII
Indirect slow
Reticular formation, hypothalamus, and limbic
system
Intralaminar nuclei and other midline nuclei
Cingulate gyrus, prefrontal cortex, and frontal lobe
Dull pain, affective arousal components of pain, and
tissue-damage pain
lus projected to the frontal cortex is interpreted
along with past experiences, mood, and current cir-
cumstances, and this combination influences the
pain experience.
Pain Modulation
The normal neurophysiology of pain modulation is
also important to review to better understand poten-
tial sites of acupuncture pain control.6 When a
noxious stimulus is experienced, endogenous net-
works are activated that modulate pain at the pe-
ripheral nociceptors within tissues, in the dorsal
horn grey matter of the spinal cord, in the network
of relay stations between the dorsal horn and the
cerebral cortex, and within the cerebral cortex (Fig.
2).4,6 8
The first-order afferent fibers not only connect to
second-order neurons for the ascending pain path-
ways but also send off branches that synapse with
inhibitory internuncial neurons in the spinal cord
grey matter.4,6 8 Considerable modulation of pain
occurs at the dorsal horn grey matter, where inhib-
itory internuncial neurons secrete -aminobutyric
acid (GABA) and other neurotransmitters that in-
hibit C fibers and reduce activation of second-order
spinal cord nociceptive neurons. Larger-diameter
afferent nerves, like A and A fibers, terminate on
inhibitory internuncial neurons in the dorsal horn
grey matter, which in turn, inhibit the nociceptive C
fibers and reduce the amount of Substance P re-
leased (Fig. 2).4,6,8
The ascending pathways of second-order nocicep-
tive neurons give off branches that synapse with
neurons at several sites in the brainstem that form
descending pathways that inhibit pain. Neurons in
the midbrain periaqueductal grey matter (PAG)
send descending projections to the rostral ventrome-
dial medulla and spinal cord dorsal horn, which
form the primary neuroanatomical pathways medi-
ating opioid-based analgesia (Fig. 2).4,6,8 10 Endor-
phins (-endorphin, enkephalin, and dynorphin) are
neurotransmitters released by neurons in response
to painful stimuli and used internally to reduce
pain. -Endorphin is found primarily in the pitu-
itary gland, but enkephalin and dynorphin are pro-
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Fig. 2. Three main regions for normal pain modulation and sites of EA pain suppression. (1) Spinal cord dorsal horn. Some of the
painful stimuli from C fibers (blue) are blocked (black bar) by impulses from the A and A fibers (purple) stimulated by EA and pain,
which arrive first and compete for sites on the second-order neurons in the spinal cord dorsal horn grey matter. In addition, branches
of the A fibers stimulate spinal cord internuncial neurons that release enkephalin, dynorphin, GABA, and other inhibitory
substances. (2) Descending endogenous opioid pathways. Neurons in the diencephalon, midbrain PAG, and medulla oblongata
(stimulated by ascending pain pathways and EA) release endorphins through descending pathways to the spinal cord grey matter to
block ascending pain impulses (red line represents the primary pathways mediating opioid-based analgesia) as well as into the blood
through the pituitary. (3) Descending seratonergic and noradrenergic inhibitory pathways. Neurons in the cerebrum, diencephalon,
midbrain, pons, and medulla (stimulated by ascending pain pathways and EA) release serotonin, norepineprine, and other inhibitory
neurotransmitters through descending pathways to the spinal cord grey matter to block ascending pain impulses (green line
represents the primary seratonergic pathways).

duced throughout the nervous system, including the
dorsal grey matter of the brainstem and spinal cord.
Enkephalinergic internuncial neurons are located
on the border of Laminae I and II of the spinal cord
grey matter and alter the responses of second-order
nociceptive neurons located there. Endorphins in-
teract with opioid receptors on neurons to reduce the
intensity of pain. Opioid receptors are found in
many areas of the brain, but they are especially
concentrated in the PAG and dorsal horns of the
spinal cord.
Serotoninergic descending inhibitory pathways
are also suggested to be an important mechanism of
analgesia (antinociception). Serotonin (5-hydroxy
tryptophan [5HT]) is a neurotransmitter, which in-
126 2011 Vol. 57 AAEP PROCEEDINGS
hibits pain transmission, leading to a decrease in
perceived pain. Descending pathways from the
midbrain PAG and locus coeruleus and raphe nuclei
of the medulla oblongata are inhibitory to dorsal
grey column nerves of the spinal cord, and some of
the inhibition is mediated by serotonin (Fig.
2).6,7,9,10 The pain suppressing effect of antidepres-
sants is probably because of their ability to enhance
transmission down these pathways by blocking the
uptake of 5HT.
Pathological Pain States
The peripheral terminals of C fibers become sensi-
tized during tissue damage and subsequent inflam-
mation by the release of bradykinin, serotonin,
 IN-DEPTH: INTEGRATIVE MEDICINE (COMPLEMENTARY & ALTERNATIVE MEDICINE)
potassium, adenosine 5-triphosphate (ATP), prosta-
glandins, and leukotrienes from damaged tissue and
inflammatory cells. These sensitized C fibers se-
crete Substance P (a neuropeptide) and calcitonin
gene-related peptide, which have a vasodilatory ef-
fect on local blood vessels and stimulate additional
release of inflammatory mediators, further sensitiz-
ing the peripheral nociceptors.4,8 Sensitization
lowers the threshold for activation, increases the
magnitude and duration of activation, and results in
peripheral (primary) hyperalgesia and allodynia
(non-noxious stimuli being perceived as painful).
If there is massive or prolonged stimulation of C
fibers, there is activation of N-methyl-D-aspartate
(NMDA) receptors, which reduces the receptor
threshold for activation of the dorsal horn neurons
and spontaneous depolarization. This activation
results in increased pain impulses ascending to
higher levels in the brain.4,6 Chronic pain stimu-
lation not only causes local and spinal cord hyper-
sensitivity to pain but also increases sensitivity
through its effects on higher synaptic sites in the
brainstem and cerebrum. These changes are a type
of synaptic plasticity and central (secondary) hyper-
algesia and allodynia result.4,11
Chronic pain, as distinct from acute pain, distin-
guishes itself by its persistence in the absence of
inflammation or other obvious ongoing tissue-dam-
aging processes, delay in onset after the precipitat-
ing injury, and abnormal or unpleasant sensations
such as burning, searing, or deep, aching pain un-
responsive to conventional anti-inflammatory
drugs.11 Persistent pain and sensitization can of-
ten lead to additional loss of function from reduced
range of motion in joints and the mechanical effects
of muscle shortening. Prolonged limitations of
movement can result in disuse atrophy of muscles,
which also limits mobility.
Pain not only originates from cutaneous struc-
tures but also arises from nociceptive receptors in
muscles, tendons, and joints.4,5 Focal acute pain
may be associated with muscle spasm and lactic acid
accumulation and may result in muscle shorten-
ing.11 A major consequence of muscle shortening is
the continuous, unremitting pull on the structures
to which the muscle attaches. Muscle contraction
that spans a joint can create pressure within the
joint, abnormal patterns of motion, arthralgia (joint
pain), injury, and finally, degenerative joint disease.
The presence of muscle shortening also has delete-
rious effects on the tendons and ligaments. Unre-
lenting muscle tension on these structures may be
the precipitating factor in bicipital bursitis, epicon-
dylitis, hock and stifle degeneration, upper suspen-
sory pain, chondromalacia of the stifle joint, and
other pathologic conditions that are frequently seen
in veterinary practice. Continuous pressure on
vertebral joint surfaces from muscle contractions
causes vertebral facet degeneration, which may be a
key factor in interspinal osteoarthrosis (spondylosis)
or kissing spine conditions in the equine and other
species.
Neuropathic pain is also common in humans and
animals. Inflammation and primary damage to
nerves alter their normal response to stimulation
and modulation and can cause muscle spasm and
shortening, which also amplify the
pain.4,5,11 Nerve root inflammation from spondylo-
sis, intervertebral disk protrusion and other degen-
erative vertebral column changes causes spasm and
shortening of paravertebral muscles that compress
intervertebral discs and create a self-perpetuating
cycle of contraction, inflammation, radiculopathy,
and pain.11
3. Mechanisms of Acupuncture Pain Control
Acupuncture is the stimulation of specific pre-deter-
mined points (acupoints) near the surface of the
body, which produces a therapeutic effect by evoking
homeostatic mechanisms within the nervous, im-
mune, endocrine, cardiovascular, and other body
systems to promote self-healing.6,8 12 Acupunc-
ture stimulates small nerve endings and other struc-
tures around the acupoints, which result, in both
local and distant changes within the body. Ancient
traditional Chinese medical theories have explained
the effects of acupuncture based on empirical obser-
vations and descriptions of naturally occurring phe-
nomena, and the underlying complex neurochemical
mechanisms behind their observations have been
explored in scientific studies for the past 50 yr.13
Our understanding of how the brain processes
acupuncture analgesia has undergone considerable
development.14 Acupuncture analgesia is mani-
fested only when the intricate feeling (soreness,
numbness, heaviness, and distension) of acupunc-
ture in patients occurs after acupuncture manipula-
tion. Manual acupuncture (MA) is the insertion of
an acupuncture needle into an acupoint followed by
the twisting of the needle up and down by hand.
In MA, all types of afferent fibers (A, A, and C) are
activated. In electrical acupuncture (EA), a stimu-
lating current through the inserted needle is deliv-
ered to acupoints. Electrical current intense
enough to excite A and part of A fibers can induce
an analgesic effect. Acupuncture signals ascend
mainly through the spinal ventrolateral funiculus to
the brain. Many brain nuclei composing a compli-
cated network are involved in processing acupunc-
ture analgesia, including the nucleus raphe magnus
(NRM), PAG, locus coeruleus, arcuate nucleus (Arc),
pre-optic area, nucleus submedius, habenular nu-
cleus, accumbens nucleus, caudate nucleus, septal
area, amygdale, etc. Acupuncture analgesia is es-
sentially a manifestation of integrative processes at
different levels in the CNS between afferent im-
pulses from pain regions and impulses from acu-
points. In the last decade, profound studies on
neural mechanisms underlying acupuncture analge-
sia predominately focus on cellular and molecular
substrate and functional brain imaging and have
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developed rapidly. Diverse signal molecules con-
tribute to mediating acupuncture analgesia, such as
opioid peptides (-, -, and -receptors), glutamate itary axis, midbrain PAG, pons, medulla oblongata,
(NMDA and AMPA/KA receptors), 5HT, and chole-
cystokinin octapeptide (CCK-8). Among these mol-
ecules, the opioid peptides and their receptors in the
Arc-PAG-NRM-spinal dorsal horn pathway play a
pivotal role in mediating acupuncture analgesia.
The release of opioid peptides evoked by electroacu-
puncture is frequency-dependent. EA at 2 and 100
Hz produces, respectively, releases of enkephalin
and dynorphin in the spinal cord. CCK-8 antago-
nizes acupuncture analgesia. The individual dif-
ferences of acupuncture analgesia are associated
with inherited genetic factors and the density of
CCK receptors. The brain regions associated with
acupuncture analgesia identified in animal experi-
ments were confirmed and further explored in the
human brain by means of functional imag-
ing. There are still many unanswered questions
concerning the mechanisms of acupuncture analge-
sia, but there is no doubt that acupuncture produces
effects at many different sites that result in
analgesia.9,10,12,13
The analgesic effects of EA on brain function can
be visualized using functional magnetic resonance
imaging (fMRI) and positron emission tomography
(PET) scans.9 With a painful stimulus, the fMRI
shows activation of areas in the cingulate cortex,
thalamus, and other regions of the brain, but there
is a significant decrease of activation in these areas
after acupuncture. This finding suggests that acu-
puncture desensitizes or blocks pain at these levels.9
This finding may be associated with acupuncture
modulation of pain at the dorsal horn grey matter
and a reduction of ascending impulses along the
spinothalamic pathway systems, or it may be asso-
ciated with neurochemical alterations higher in the
brainstem.
The currently understood mechanisms of acu-
puncture pain control are complex and involve direct
and indirect neurochemical effects that block pain
perception, reduce the pain response, relieve muscle
spasm, and reduce inflammation. The acupunc-
ture technique used affects the degree of pain con-
trol. In studies comparing EA with dry-needle
acupuncture, EA produced greater brain changes on
fMRI than dry needles and also elicited a better
analgesic effect.15,16 In other studies, bilateral EA
stimulation was superior to unilateral stimulation
for analgesia, and unilateral stimulation had the
most powerful analgesic effects on the contralateral
side.17,18 EA is recommended over non-manipu-
lated, dry-needle acupuncture for pain management
and is used in most studies of acupuncture analge-
sia.13,19 fMRI data suggest that acupuncture nee-
dle stimulation at two different depths of needling,
superficial and deep, does not elicit significantly
different blood oxygen level-dependent (BOLD)
responses.20
128 2011 Vol. 57 AAEP PROCEEDINGS
Analgesic effects of EA have been shown to occur
in the spinal cord grey matter, hypothalamic-pitu-
limbic system, cerebral cortex, and autonomic ner-
vous system (Fig. 2). Changes in EA stimulation
frequency can alter the site of antinociceptive activ-
ities, and the antinociceptive effects of EA in normal
and hypersensitized painful humans and animals
can be quite different.6,13 A striking feature of acu-
puncture-induced analgesia is its long-lasting effect,
which has a delayed onset and gradually reaches a
peak even after acupuncture needling is terminated.
A non-repeated, event-related (NRER) fMRI para-
digm and control theory-based approach was ad-
opted to capture the detailed temporal profile of
neural responses induced by acupuncture.21 Neu-
ral activities at the different stages of acupuncture
presented distinct temporal patterns in which con-
sistently positive neural responses were found dur-
ing the period of acupuncture needling, whereas
much more complex and dynamic activities were
found during a post-acupuncture period. The
amygdala and perigenual anterior cingulate cortex
(pACC), exhibited increased activities during the
needling phase, which decreased gradually to reach
a peak below the baseline. The PAG and hypothal-
amus presented saliently intermittent activations
across the whole fMRI session. The overall find-
ings indicate that acupuncture may engage differen-
tial temporal neural responses as a function of time
in a wide range of brain networks.
A relatively new analysis method, functional con-
nectivity fMRI (fcMRI), has great potential for
studying continuous treatment modalities such as
EA. Compared with sham acupuncture, EA can
significantly reduce PAG activity when subse-
quently evoked by experimental pain. Findings in-
dicate the intrinsic functional connectivity changes
among key brain regions in the pain matrix and
default mode network during genuine EA compared
with sham EA.22
One of the earliest proposed mechanisms of EA
pain control used the Melzack-Wall Gate Control
Theory in which modulation of pain occurred
through normal antinociceptive neuronal circuits in
the spinal cord.6 Based on this theory, it was pro-
posed that EA stimulates A and A nerve fibers
(Table 1), which would transmit impulses to the
spinal cord faster than C nerve fibers and engage
synaptic sites on dorsal horn neurons. The later
arriving pain signals from C fibers would have fewer
sites on which to synapse, because the gates would
be closed (synaptic sites are already occupied) (Fig.
2). Using this theory, EA was thought to induce a
segmental spinal inhibition of nociceptive inputs
and result in an immediate, short-term, non opioid-
mediated analgesia because of reduced release of
Substance P from C fibers.6,9,23
The analgesic effects of EA are more complex than
can be described using the Gate Control theory
alone, because branches of A and C fibers also
 IN-DEPTH: INTEGRATIVE MEDICINE (COMPLEMENTARY & ALTERNATIVE MEDICINE)
synapse with inhibitory internuncial neurons in the
spinal cord grey matter, resulting in the release of
inhibitory neurotransmitters that block incoming
and outgoing pain impulses.13,19,23 EA of the A
fibers results in the stimulation of inhibitory en-
kephalinergic internuncial neurons in the outer part
of Lamina II of the spinal cord that block C fiber
pain impulses. Low-frequency EA at ST-36 signif-
icantly inhibited cold allodynia in a rat tail model of
neuropathic pain through stimulation of GABA in-
hibitory interneuron systems in the spinal cord,
whereas sham EA at a non-acupoint and dry-needle
acupuncture at ST-36 were ineffective.16 The anal-
gesic effects of EA have also been shown to be re-
lated to inhibition of the release of excitatory
neurotransmitters (glutamate and aspartic acid),
which normally transmit pain signals from the spi-
nal cord to higher brain levels.24
Activation of the NMDA subtype of glutamate re-
ceptors and subsequent nitric oxide (NO) production
are important factors in central sensitization and
the development of hyperalgesia.4,6,25,26 In a study
of the role of NO in a carrageen-induced inflamma-
tion model, it was suggested that EA was a biochem-
ical modulator in the spinal cord and prevented the
activation of the NMDA receptors and central sen-
sitization.25 The combination of EA with ket-
amine, an NMDA receptor antagonist, also
enhanced the antihyperalgesic effect. In another
rat neuropathic pain model study, EA stimulation
decreased NO synthase expression in the L4 5 spi-
nal cord and decreased mechanical allodynia second-
ary to nerve injury.26
Other studies have shown the profound effect of
EA on the hypothalamic-pituitary axis.6,13,19,27
The hypothalamic-pituitary axis not only produces
the well-known neuroendocrine effects, but it is part
of the central descending pain-inhibitory pathways
involving endogenous opioids and most likely also
plays a role in cholinergic anti-inflammatory mech-
anisms through the vagus nerve.28 EA has been
shown to increase circulating -endorphin in the
blood, which is most likely associated with ascend-
ing afferent stimulation of the hypothalamus and
release of these substances from the
pituitary.6,13,19,23,27
EA also activates neurons in the midbrain PAG
region that stimulate the descending endogenous
opioid inhibitory pathways to reduce pain (Fig.
2).4,6,13,18,23 Low-frequency EA (10 20 Hz) stimu-
lates the release of -endorphin, enkephalin, and
endomorphin, which activates the - and -opioid
receptors, and higher-frequency (100 200 Hz) EA
stimulates dynorphin, which activates the -opioid
receptors to produce analgesia.13 A mixture of fre-
quencies (low-frequency stimulation for a period fol-
lowed by high-frequency stimulation) is suggested to
be most effective, because it stimulates all opioid
receptors.23 In a carrageenan-induced arthritis
pain model in rats, low-frequency EA pre-treatment
had an antinociceptive effect against inflammatory
pain through the -opioid receptor.18 EA of 10 Hz
at ST-36 significantly improved the weight-bearing
force, and this positive effect was abolished when a
selective antagonist of the -opioid receptor was
administered.
Central sensitization (secondary hyperalgesia)
can be associated with tissue inflammation or pe-
ripheral nerve injury and is an important cause of
persistent pain. Animal models of capsaicin-in-
duced pain have well-defined peripheral and central
sensitization components, and therefore, they are
useful for studying the peripheral and central anal-
gesic effects of acupuncture. In a recent study of
the analgesic effects of EA on capsaicin-induced cen-
tral sensitization, EA produced a stimulation point-
specific analgesic effect that was mediated by
activating endogenous - and -opioid receptors in
the spinal cord.29 In a mouse cancer pain model,
EA decreased the overexpression of Substance P in
the dorsal horn, increased -endorphin, and reduced
the pain response to mechanical stimulation, show-
ing the effectiveness of EA to control pain, even in
the presence of central sensitization.30
High-frequency EA (100 200 Hz) not only induces
dynorphin release in the spinal cord but also in-
creases the release of serotonin, epinephrine, and
norepinephrine (inhibitory neurotransmitters),
which inhibit pain signals.6,13,19,31 In another rat
neuropathic pain model, studying pain modulation
in the PAG region, EA completely abolished hista-
mine and dopamine release, which is normally in-
creased after a painful stimulus, and increased the
release of norepinephrine in the PAG regions.32
EA is thought to also enhance the effects of descend-
ing serotoninergic pain inhibition.13 EA has been
shown to activate neurons containing serotonin, epi-
nephrine, and norepinephrine in the nucleus raphe
magnus and locus coeruleus of the medulla oblon-
gata, which suppress pain and hyperalgesia through
descending pathways to the spinal cord.33
In a study of neuropathic pain in rats, changes of
spinal synaptic plasticity were affected by EA.34
EA at a low frequency of 2 Hz at acupoints ST-36
and SP-6 reduced neuropathic pain and induced
long-term depression of the C fiber-evoked poten-
tials in a spinal nerve ligation model in rats.
Muscle contracture (non-voluntary muscle con-
traction) creates an energy crisis and pain in short-
ened muscles but can be relaxed by inserting
needles into the corresponding acupoints to restore
normal muscle physiology.4,11,35 Acupuncture can
alleviate the pain, and it can allow the muscles to
relax and the associated structures to return to nor-
mal patterns of motion. Intramuscular stimulation
(IMS) is a modified version of acupuncture and is
based on neuroanatomic principles.11 A basic tenet
of IMS is that acupuncture points are usually situ-
ated close to motor points within muscles or at mus-
culotendinous junctions. Points that are effective
for treatment are at the same segmental level as the
presenting clinical signs or the injury. These
AAEP PROCEEDINGS Vol. 57 2011 129
 IN-DEPTH: INTEGRATIVE MEDICINE (COMPLEMENTARY & ALTERNATIVE MEDICINE)
points usually coincide with palpable muscle bands
that are tender to manual pressure. Tender points
are distributed in a segmental fashion in muscles
supplied by both dorsal and ventral nerve roots,
indicating radiculopathy. Muscles with tender
points are shortened from spasm and contracture.
Symptoms and signs typically disappear when the
tender and tight muscle bands are stimulated with
acupuncture.11 Surface electromyography (EMG)
can measure gross muscle fiber strength and show
the fatigue and asymmetrical recruitment associ-
ated with myofascial pain syndromes. The typical
myofascial pain patient has surface EMG evidence
of one or more inhibited muscles. Evidence of fa-
tigue shown by asymmetrical scalene muscle con-
tractions and the increased activity of the muscles
recorded on the EMG when an acupuncture needle
is inserted can be shown.11 Another clinical exam-
ple of the use of IMS is acupuncture of Ashi points
for the treatment of piriformis muscle pain (pirifor-
mis syndrome). In a recent study of 80 cases of
piriformis syndrome, one-half of the cases were ran-
domly assigned to a group that received an inhibi-
tory-needling acupuncture method on Ashi points,
and the other one-half of the cases received a rou-
tine-needling acupuncture method at GB-30, BL-54,
and GB-34. Both groups responded positively (92%
in Ashi points inhibitory-needling group and 82.5%
in transpositional acupoint routine-needling group),
but stimulating Ashi points produced a significantly
better response than routine stimulation of transpo-
sitional acupoints (p 0.05).36
The midbrain PAG region not only inhibits pain
through the release of endogenous opioids but also
causes changes in the heart and respiration rates
and blood pressure associated with pain through the
hypothalamus and autonomic nervous system.
EA alters the effects of pain on viscera and blood
vessels by its effects on the PAG and hypothalamic
regions and descending pathways from these re-
gions to the vagus nerves and parasympathetic and
sympathetic spinal cord lower motor neurons. EA
also induces local spinal cord segmental reflexes
that affect vascular tone and other autonomic func-
tions.6,13 EA affects the inflammatory reflex
through the autonomic nervous system, regulates
the immune system, and reduces inflammation-in-
duced hyperalgesia.13 At 10 Hz, EA significantly
reduced complete Freunds adjuvant-induced hind
paw edema and increased plasma levels of cortico-
sterone, but it produced no noticeable signs of stress.
At 10 Hz but not 100 Hz, EA suppresses inflamma-
tion by activating the hypothalamus-pituitary-adre-
nal axis (HPA) and the nervous system.37 Besides
the mediation by different central structures, acu-
puncture may have direct effects on regulating pe-
ripherally the release of some inflammatory and
pain mediators.38 It has been shown that EA sig-
nificantly suppresses behavioral hyperalgesia in a
rat model of persistent inflammatory pain by sup-
pressing the spinal neurokinin-1 (NK-1) receptors
130 2011 Vol. 57 AAEP PROCEEDINGS
and that NK-1/Substance P receptors play impor-
tant roles in nociception and hyperalgesia at the
spinal cord level.39 Electroacupuncture can effec-
tively decrease the pro-inflammatory cytokine of in-
terleukin-1 (IL-1) and IL-6, increase the inhibition
cytokine of IL-4 and IL-10, and improve the internal
environment of occurrence and progression of rheu-
matoid arthritis.40
Chronic pain syndromes often involve the auto-
nomic nervous system, and persistent increased
sympathetic tone causes regionalized hypothermia
from vasoconstriction.41 Because these pain syn-
dromes are not related to inflammation, they are
unresponsive to anti-inflammatory medication.
The types of pain experienced include hyperesthe-
sia, burning, aching, throbbing, and allodynia.
Thermal imaging provides objective, measurable ev-
idence of the ability of acupuncture to restore nor-
mal blood flow through effects on autonomic
regulation of vasomotor tone.41 Increased sciatic
nerve blood flow measured in rats by laser Doppler
flowmetry was observed with nerve root stimulation
(100%) compared with lumbar muscle acupuncture
(56.9%), suggesting that, in addition to its influence
on the pain inhibitory system, acupuncture triggers
a transient change in blood circulation.42
EA may also affect the motivational, behavioral,
and emotional responses to pain through effects on
the hypothalamic, limbic, and higher cortical re-
gions.6,19 The effects of acupuncture to calm Shen
and reduce anxiety are well-known, and anxiety and
depression are factors in chronic pain. In a study of
changes in cortical metabolites using fMRI in de-
pressed and normal human patients, EA was shown
to have a significant effect on brain neurochemistry
compared with controls and EA positively affected
depressed patients.44
Known variations in the response of individuals to
acupuncture treatment complicates the evaluation
of acupuncture for pain control.9 According to the
work by Cho et al.,9 about 28% of humans are excel-
lent responders, 64% are good and average respond-
ers, and 8% are weak or non-responders.9 In a pilot
study of psychophysical pain responses in humans
after dry-needle, EA, and sham treatments, all sub-
jects receiving one of the acupuncture techniques
had improved pain tolerance, but some responded
better to EA, and others responded better to dry
needles.44 The results of this study indicate the
existence of both individual subject and acupuncture
mode variability in the analgesic effects of acupunc-
ture. This finding suggests that switching the acu-
puncture mode may be a treatment option for
unresponsive patients.
4. Clinical Research on Acupuncture for Pain Control
in Humans
A review of all the clinical research for pain control
in humans is beyond the scope of this paper, but a
few current studies that are applicable to veterinary
medicine will be discussed here. Although clini-
 IN-DEPTH: INTEGRATIVE MEDICINE (COMPLEMENTARY & ALTERNATIVE MEDICINE)
cians have continued their respect and reverence for
tradition in their training, they have also recognized
the need for evidence-based medicine in their prac-
tice of acupuncture. The evidence base for acu-
puncture treatment in humans has changed. For
example, in 2000, an article in Cochrane Database
System Review45 stated that the evidence summa-
rized in the systematic review did not indicate that
acupuncture was effective for the treatment of back
pain.45 In 2005, an updated systematic review of
chronic low back pain research, within the frame-
work of the Cochrane Database System Review col-
laboration, indicated that acupuncture was more
effective for pain relief and functional improvement
than no treatment or sham treatment.46 Immedi-
ate and sustained pain relief was observed in people
with low back pain from lumbar spinal canal steno-
sis and herniated intervertebral discs who received
EA at the nerve root compared with manual acu-
puncture.42 Acupoint electrical stimulation at the
true acupoints, compared with placebo and sham
groups, effectively reduced postoperative pain and
analgesic usage in patients with spinal surgery re-
ceiving patient-controlled analgesia.47
A randomized, controlled trial was conducted in
255 human practices in Germany to assess quality of
life, costs, and cost-effectiveness of acupuncture
treatment plus routine care versus routine care
alone in osteoarthritis patients.48 Four hundred
eighty-nine patients with chronic pain caused by
osteoarthritis of the knee or hip were evaluated for
quality of life and costs at baseline and after 3 mo
using health insurance funds data and standardized
questionnaires. Patients receiving acupuncture
had an improved quality of life but had significantly
higher costs over the 3-mo treatment period com-
pared with routine care alone. This increase in
costs was primarily because of the cost of acupunc-
ture. The study concluded, however, that acupunc-
ture was an effective treatment strategy in patients
with chronic osteoarthritis pain but might cost more
than some conventional drugs.48
Moxibustion at San-yin-jiao (SP 6) can relieve
uterine contraction pain and has no side effect to
mother and infant; it is safe, effective, and a simple
non-drug analgesia method.49 One hundred seven-
ty-four cases of singleton pregnancy and cephalic
presentation primipara were single-blinded and
randomly divided into three groups: observation
group (59 cases), placebo-treated group (57 cases),
and control group (58 cases). The observation
group was treated with moxibustion at San-yin-jiao
(SP 6) for 30 min when the uterus cervix opening
was 3 cm, the placebo-treated group was treated
with moxibustion at no acupoint for 30 min, and the
control group was treated with routine labor nurs-
ing; the uterine contraction pain and safety of the
mother and infant were compared among the three
groups. (1) The uterine contraction pain was tested
by the Visual Analogue Scale (VAS): the scores of
VAS in the observation group were obviously de-
creased after 15 and 30 min moxibustion (both p
0.05), there were no obvious changes of the VAS
scores in the placebo-treated and control groups, and
the scores of VAS in the observation group decreased
much more obviously than the scores in the other
two groups (all p 0.05). (2) The midwife rated the
uterine contraction pain: after 30 min moxibus-
tion, the effective rate of labor analgesia was 69.5%
(41/59) in the observation group, which was higher
than the rates of 45.6% (26/57) in the placebo-
treated group and 43.1% (25/58) in the control
group, with significant differences between them
(both p 0.05). (3) The post-partum hemorrhage
amount of the observation group was obviously
lower than the amounts of the placebo-treated and
control groups (both p 0.05). (4) The Apgar score
of newborn was higher in the observation and pla-
cebo-treated groups than the control group (both p
0.05).
Cancer pain can destroy the quality of life of hu-
mans and animals. Treatment with opioid analge-
sics has significant adverse effects, including
inhibition of respiratory function, constipation, ad-
diction, and tolerance that further decrease quality
of life. EA may be used to reduce cancer pain.
In a study of neuropathic cancer pain, sarcoma cells
were inoculated around the sciatic nerves of mice.30
The presence of embedded cancer cells that induced
mechanical allodynia was confirmed by MRI. EA
treatment significantly prolonged paw withdrawal
latency as well as shortened cumulative lifting du-
ration compared with tumor control, suggesting re-
duced pain after EA.
In a review of five studies of 1,334 patients with
chronic knee pain, acupuncture was found to be
superior to sham acupuncture for pain reduction
and improved function.50 The differences were still
significant when patients were followed long term.
Their conclusions were that adequate acupuncture
treatment is superior to sham acupuncture and no
treatment for improving pain and function in pa-
tients with chronic knee pain.
A systematic review and meta-analysis of ran-
domized controlled trials of acupuncture for neck
pain found that acupuncture was more effective
than controls in the treatment of neck pain.51 A
randomized controlled multicenter trial in Germany
was performed in 14,161 patients with chronic neck
pain (duration 6 mo).52 Treatment with acu-
puncture added to routine care in patients with
chronic neck pain was associated with improve-
ments in pain and reduced disability compared with
treatment with routine care alone.
Pain is a prevalent consequence of spinal cord
injury that can persist for years after the injury
and can have a significant impact on physical and
emotional function and quality of life. In a re-
view of several studies, acupuncture was as effec-
tive to treat neuropathic pain from spinal cord
injury as anticonvulsant agents and tricyclic
antidepressants.53
AAEP PROCEEDINGS Vol. 57 2011 131
 IN-DEPTH: INTEGRATIVE MEDICINE (COMPLEMENTARY & ALTERNATIVE MEDICINE)
The etiology of peripheral neuropathy (PN) often
remains elusive, resulting in a lack of objective ther-
apeutic strategies. Data suggest that there is a
positive effect of acupuncture on PN of undefined
etiology, which was measured by objective parame-
ters.54 In a pilot study to evaluate the therapeutic
effect of acupuncture on PN as measured by changes
in nerve conduction and assessment of subjective
symptoms, 192 consecutive patients with PN as di-
agnosed by nerve conduction studies (NCS) were
evaluated over a period of 1 yr. Of the 47 patients
who met the criteria for PN of undefined etiology, 21
patients received acupuncture therapy according to
classical Chinese medicine, whereas 26 patients re-
ceived the best medical care but no specific treat-
ment for PN. Sixteen patients (76%) in the
acupuncture group improved symptomatically and
objectively as measured by NCS, whereas only four
patients in the control group (15%) did. Three pa-
tients in the acupuncture group (14%) showed no
change, and two patients showed aggravation (10%),
whereas in the control group, seven patients showed
no change (27%); additionally, in the control group,
15 patients showed aggravation (58%). Impor-
tantly, subjective improvement was fully correlated
with improvement in NCS in both groups.
Acupuncture combined with rehabilitation ther-
apy may improve motion recovery of impaired joints.
Compared with rehabilitation therapy alone, EA
combined with rehabilitation therapy can achieve a
significant effect on the motion function recovery of
the elbow joint after fracture repair.55 EA and ex-
ercise have a greater therapeutic effect (p 0.001)
compared with exercise on movement disorders of
shoulder joint after surgical repair of fracture of the
neck of the humerus.56 Acupuncture combined
with rehabilitation was superior to rehabilitation
alone in pain score, passive range of motion of shoul-
der joint, muscle strength of the middle group of
the deltoid, and upper limb motion post-stroke.57
Treatment of acute soft-tissue injury of the shoulder
joint with EA and exercise was more effective than
oral administration of ibuprofen slow-release cap-
sules.58 Specific, one-time acupoint stimulation
significantly improved gait performance statistically
during geriatric ward rehabilitation.59 In a multi-
ple-blinded, randomized, controlled intervention
trial, gait performance was objectively measured by
an electronic walkway before and after needling.
All gait parameters showed statistically significant
improvement in velocity, cadence, stride length, cy-
cle time, step time, single support, and double sup-
port after verum acupuncture compared with control
treatment.
Acupuncture may be much safer than conven-
tional treatments. Previous surveys indicated that
there was a significant but low risk of serious side
effects with acupuncture in humans ranging from
1:10,000 to 1:100,000.60 A comprehensive review of
the complementary and alternative therapies data-
base, Medline database (1966 1993), with extensive
132 2011 Vol. 57 AAEP PROCEEDINGS
cross-referencing concluded that there were 216 re-
ported instances of serious complications worldwide
over a 20-yr period.61
In a report of the adverse effects of 32,000 acu-
puncture treatments, minor adverse events, defined
as any ill effect, no matter how small, that is unin-
tended and non-therapeutic, even if not unex-
pected, resulted from 6.71% of treatments. Most
common minor events were needle site bleeding
(3.1%), needle site pain (1.1%), and aggravation of
symptoms (0.96%), but 70% of symptoms subse-
quently improved.62 In a second report, 574 acu-
puncturists reported adverse effects of 34,000
acupuncture treatments.63 Minor adverse events
occurred in 15% of cases; the most common events
were aggravation of symptoms (2.8%), bruising
(1.7%), needle pain (1.2%), and needle site bleeding
(0.4%). Most (86%) aggravated symptoms im-
proved, possibly indicating a healing crisis, which is
a therapeutic process involving temporary exacerba-
tion of existing symptoms that precedes improve-
ment. These two studies reported no life-
threatening events associated with acupuncture.
The extent of actual risk of acupuncture treatment
is difficult to quantify; however, there is a low but
significant incidence of adverse effects, usually mi-
nor, which includes needle pain, bruising, nausea or
syncope (mild and transient), and aggravation of
symptoms.64 A few case reports describe serious
side effects such as pneumothorax, spinal cord in-
jury, hepatitis, cellulitis, and trauma from broken or
embedded needles. The serious adverse affects of
acupuncture treatment reported in the literature
may easily be prevented by straightforward precau-
tions.60 Conditions that increase the risk of com-
plications in acupuncture treatment in humans
include hemophilia, advanced liver disease, antico-
agulation therapy, diabetes, human immunodefi-
ciency virus (HIV) infection, and other forms of
immunosuppression, such as high-dose corticoste-
roid administration.65
5. Clinical Research on Acupuncture for Pain Control
in Animals
Currently, much of the practice of acupuncture in
animals is based on the results of pilot research
studies, case reports, and clinical experi-
ences. Compared with human acupuncture, the
clinical application of veterinary acupuncture is in
the early stages of development as a science. On
the basis of the findings of a systematic review per-
formed in 2006, there is no compelling evidence to
recommend or reject acupuncture for any condition
in domestic animals. Some encouraging data do
exist that warrant additional investigation in inde-
pendent rigorous trials.66 There is a mixture of
results in clinical trials of acupuncture for pain con-
trol in animals, but there are only a few high-quality
research studies in animals that evaluate EA for
pain control.
 IN-DEPTH: INTEGRATIVE MEDICINE (COMPLEMENTARY & ALTERNATIVE MEDICINE)
Analgesic effects from acupuncture have been ob-
served in horses and other species.31,6774 Acu-
puncture has been used clinically to treat lameness
and chronic back pain, including fibromyalgia syn-
drome.23,75 84 There are several studies that mea-
sured the release of -endorphin and cortisol during
equine acupuncture.23,85,86 In one study, dry-nee-
dle acupuncture and EA provided cutaneous analge-
sia in horses without adverse cardiovascular and
respiratory effects, and EA was more effective than
dry-needle acupuncture for activating spinal cord
release of -endorphin into the CSF of horses.86
Controlled clinical trials have shown significant
improvement of thoracolumbar pain in horses using
objective methods of pain evaluation.83,84 In a
study of 15 horses with thoracolumbar pain, EA was
compared with phenylbutazone and saline using
thoracolumbar pain scores before and after treat-
ment. Thoracolumbar pain scores were based on
behaviors recorded on videotape and were evaluated
and scored by a blinded, independent investigator.
EA significantly lowered pain scores of horses with
chronic thoracolumbar pain compared with phenyl-
butazone or saline.83 In a randomized, double-
blind, controlled trial of 23 sport horses with back
pain, objective measurements of pain threshold lev-
els were obtained with a pressure algometer.84
Painful points (trigger points) were identified on
each horse, and baseline pain threshold measure-
ments were taken. EA was performed at GV-20
and GV-6 and bilaterally at BL-26, BL-54, BL-21,
and BL-17 at a frequency of 20 Hz for 15 min and
80 120 Hz for 15 min. After five treatments, pres-
sure-induced pain was significantly reduced at trig-
ger points in the treatment group compared with the
control group.
In another blinded, controlled study using an ex-
perimental model of lameness in the horse, the ef-
fects of EA were studied for pain control of the hoof
sole.23 Lameness scores were assigned based on an
established lameness scale with two independent
evaluators; one evaluator assessed lameness by
watching video only and was blinded to treatment.
Lameness was evaluated before tightening the
screw, after tightening the screw, after treatment
with either EA, a 0.5% bupivacaine nerve block (pos-
itive control), or a saline nerve block (negative con-
trol), immediately after loosening the screw, and 95
min later. The EA caused a significant reduction in
the lameness score compared with the saline nerve
block (negative control) as well as a significant in-
crease in plasma -endorphin.
Equine myofascial trigger points can be identified
and have similar objective signs and electrophysio-
logical properties as those signs documented in hu-
man and rabbit skeletal muscle tissue.87 Four
horses with chronic pain signs and impaired perfor-
mance showed signs compatible with the diagnosis
of myofascial trigger points in their brachiocephalic
muscle (i.e., localized tender spots in a taut band of
skeletal muscle that produced a local twitch re-
sponse on palpation). Needle EMG activity and
twitch responses were recorded at 25 positions at
the trigger point and at a nearby control point dur-
ing the course of each horses acupuncture treat-
ment. All subjects showed objective signs of
spontaneous electrical activity, spike activity, and
local twitch responses at the myofascial trigger
point sites within taut bands. The frequency of
these signs was significantly greater at myofascial
trigger points than control sites (p 0.05).
EA can reduce visceral pain, regulate gastrointes-
tinal motility, and improve regional blood flow in
animal models.23,88,89 However, EA was not as ef-
fective as butorphanol in one rectal distention
model, and bilateral EA at Guan-yuan-shu was in-
effective in reducing the acute signs of discomfort
induced by small intestinal distention in a clinical
model.90,91 These results indicate the need for ad-
ditional research in acupuncture for domestic ani-
mal visceral pain. EA at Nei-guan (PC-6)
significantly inhibits the frequency of transient
lower esophageal sphincter relaxations (TLESR)
and the rate of common cavity during TLESR in
cats. This effect seems to act on the brain stem and
may be mediated through NO, CCK-A receptor, and
-opioid receptors.92 Electroacupuncture with a
high frequency at ST-36 enhances lower esophageal
sphincter pressure (LESP) as well as esophageal
motility, whereas EA with a low frequency decreases
LESP. The effect of EA is acupoint-specific, and
this effect seems to be mediated through gastrin,
motilin, and vasoactive intestinal peptide.93
Cardiac MRI (CMRI), an important tool in moni-
toring cardiovascular diseases, provides a reliable
method to monitor the effects of electroacupuncture
on the cardiovascular system. Ketamine/xylazine
cocktail anesthesia caused a transient hypertension
in the cats; EA inhibited this anesthetic-induced
hypertension and shortened the post-anesthesia re-
covery time, countering the negative effects of anes-
thetics on cardiac physiology.94
In a recent study of the use of EA for postoperative
pain in intervertebral disk disease in dogs, the total
dose of fentanyl administered during the first 12 h
after surgery was significantly lower in the EA
group than in the control group, but dosages of an-
algesics administered from 12 to 72 h after surgery
did not differ between groups. Pain scores were
significantly lower in the treatment group than in
the control group 36 h after surgery but did not
differ significantly between groups at any other
time.95 The clinical efficacy of EA and acupuncture
combined with medication for the treatment of tho-
racolumbar intervertebral disc herniation in dogs
was compared with dogs treated with conventional
medicines alone in paraplegic dogs with intact deep
pain perception.96 Treatment efficacy was evalu-
ated by postoperative neurologic function, ambula-
tion, relapse, complication, and urinary function.
The results suggest that a combination of electro-AP
and AP with conventional medicine is more effective
AAEP PROCEEDINGS Vol. 57 2011 133
 IN-DEPTH: INTEGRATIVE MEDICINE (COMPLEMENTARY & ALTERNATIVE MEDICINE)
than conventional medicine alone in recovering am-
bulation, relieving back pain, and decreasing re-
lapse. EA was more effective than decompressive
surgery for recovery of ambulation and improve-
ment in neurologic deficits in dogs with long-stand-
ing severe deficits attributable to thoracolumbar
IVDD.97 The clinical success for dogs that under-
went decompressive surgery and EA was
intermediate.
In controlled, double-blind clinical trial of chronic
hip pain from hip dysplasia in 78 dogs, the effect of
gold bead implants in acupoints was compared with
a sham treatment 2 wk, 3 mo, and 6 mo after treat-
ment.98 The dogs with gold bead implants in acu-
points had reduced pain and greater mobility
compared with control dogs receiving the sham
treatment.
EA may be combined with conventional anesthetic
agents to reduce dose requirements for maintenance
of anesthesia and improve cardiopulmonary func-
tion.90,99 In a study of goats, EA plus low-dose xy-
lazine provided analgesia that was significantly
better than EA or xylazine alone.99 Furthermore,
EA plus xylazine administration at 0.1 mg/kg pro-
vided better analgesia than xylazine alone at 0.4
mg/kg.
As is the case for humans, few adverse side effects
have been associated with acupuncture in animals.
In a review of 1,292 acupuncture treatments that
were performed on 221 animals (cats, cattle, dogs,
and horses), adverse reactions to acupuncture nee-
dles totaled 4 of 12,274 needles or approximately 1
per 3,000 needles.100 Two of these reactions con-
sisted of transient superficial edema of the skin, and
because they did not require treatment, did not ap-
pear painful, and did not show other more serious
signs, they were considered to be clinically trivial.
There was one abscess, which resolved with antibi-
otic treatment, and one seizure event in a 7-yr-old
spayed female Beagle that resolved without treat-
ment and did not reoccur within a 7-mo follow-up
period. Neither complication required hospitaliza-
tion nor was life-threatening. There were 377
treatments of 74 horses using a total of 2,865 nee-
dles. A 10-yr-old Hanoverian gelding being treated
for back pain and palmar heel pain of the left fore-
limb experienced a mild local swelling on the axial
surfaces of heel bulbs on the treated foot for 1 wk
after its treatment. Treatment was resumed, and
13-mm needles were placed in the extranavicular
points; no additional adverse events were noted.
Although safe in most conditions, acupuncture
should be used with caution in animals with debili-
tation, frailty, or febrile illness. Needles should not
be inserted directly into skin infections, ulcers, tu-
mors, or scar tissue. There is a traditional contra-
indication to acupuncture in the first trimester of
pregnancy, and ST-12, ST-25, SP-6, BL-60, CV-1,
CV-3 through CV-7, LI-4, and BL 67 are the trans-
positional acupoints typically avoided during
pregnancy.101
134 2011 Vol. 57 AAEP PROCEEDINGS
Other than pain relief, acupuncture does not di-
rectly address any specific clinical sign but normal-
izes physiological homeostasis and promotes self-
healing through normal endogenous pathways.
Thus, acupuncture, in terms of its therapeutic mech-
anisms, is non-specific.9 As a physiological ther-
apy, the efficacy of acupuncture depends on the
pathology involved and the healing potential intrin-
sic to each patient. Therefore, acupuncture effec-
tiveness varies from person to person and animal to
animal.
In conclusion, there is a well-researched scientific
basis for the mechanisms of acupuncture analgesia,
the extent and depth of which continues to expand.
As well, there are growing numbers of human trials
supporting the use of acupuncture as an evidence-
based practice for pain management in human med-
icine. Although the number of well-designed
clinical studies in veterinary medicine is lagging
behind human medicine, the basic science research
has been done in species with neurophysiology more
similar to non-primate animals than humans, and
therefore, the scientific basis for the use of acupunc-
ture in domestic animals is clear. Although there
is research to support EA as an evidence-based
practice for the management of back pain in horses,
additional studies are needed in other clinical situ-
ations where analgesia is required. As contempo-
rary conventional biomedical and laboratory
research merges with the practical clinical experi-
ence of traditional Chinese medicine, it is reasonable
to believe that the neurophysiologic mechanisms of
actions of acupuncture will be further understood,
and it will be shown to be an effective means of
managing many different types of acute and chronic
pain as well as other disorders.
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