Where to Place the Needles and for How Long?

Anthony Campbell

Major revision 25 August 2018

This article is loosely based on a talk given to a meeting of the British Medical Acupuncture Society in 1999 (Acupunct Med 1999;17:2 113-117). Naturally my view of acupuncture has evolved in the intervening decades (I'd be worried if it hadn't!), and this is therefore a pretty radical revision of the original article. But I've preserved the title of the piece, along with some of the original text, because it still covers the same territory although in a different way.

I. Where to needle?

Newcomers to acupuncture generally spend a lot of time asking where they should place the needles. They often yearn for firm instructions; they want to be told that in disorder A you should put the needles in points x, y, and z, while in disorder B you should put them in points p, q, and r, and that provided you do this you should get the hoped-for results. There are numerous 'cook books' which purport to give this information. When the beginner attends an introductory acupuncture course he or she may get the impression that there is a firmly established body of rather arcane knowledge which must be gradually acquired, so that becoming an expert acupuncturist is partly a matter of learning more and more acupuncture points with their specific properties and effects.

As time goes by, however, the aspiring acupuncturist is likely to find that this rather simplistic view of the matter doesn't correspond to what actually obtains. Different teachers of acupuncture have quite divergent ideas about how to choose which points to needle, as well as about the duration and intensity of needling and other matters. This can create a certain amount of confusion in the mind of the student. But I think it is possible to clarify things if we think systematically about the various options that exist. Here I briefly summarise the main methods of choosing where to needle and then propose a composite view which, I suggest, represents a satisfactory compromise among all of them.

A. Traditional methods

Traditional Chinese Medicine (TCM)

TCM theory postulates the existence of numerous acupuncture points with specific effects, but the research evidence for point specificity is thin. Most randomised controlled trials in the West have found little if any difference between so-called real and sham acupuncture. For this reason many modern acupuncturists are more or less sceptical about the existence of acupuncture points as usually understood. (An interesting paper by Cheng1 may offer the point concept a modified kind of validity. See Note 1 below.)

Neo-TCM

I use the expression 'neo-TCM' to refer to a rather heterogeneous collection of treatments that have some kind of affinity with the traditional system but depart from it in various ways. Examples include systems based on proposed localised body maps, such as ear acupuncture (auriculotherapy) and scalp acupuncture. These generally retain the concept of 'points' in some form and suffer from the same drawback as TCM, being unsupported by good scientific evidence for their efficacy and basic assumptions.

B. Non-traditional methods

The remaining methods of choosing where to needle are modern; they seek to reinterpret acupuncture on the basis of current ideas of neuroanatomy and neurophysiology. In principle, they ought to provide acupuncture students with rational ways of choosing where to needle that are easier to accommodate within a scientific world view than those offered by TCM, and to quite a large extent this is the case. The methods described include acupuncture based on body segments (dermatomes, myotomes, sclerotomes, viscerotomes), which is mainly used to treat inaccessible structures such as viscera, and myofascial trigger points (MTrPs), which are important for musculoskeletal pain, especially the myofascial pain syndrome. For a useful summary of the present situation, see Cummings2.

However, our current knowledge cannot explain all the acupuncture effects that are seen clinically and a good deal of the treatment still has to be empirical. It works but we don't yet know why. So, at the clinical level, I prefer to use a purely descriptive approach, which works well in practice and can accommodate all the modern ideas that are current today. It can also accommodate those practitioners who wish to retain at least some traditional points, as quite a number do, provided they are willing to accept that we need to think in terms of areas rather than small localised 'points'.

Four principles of acupuncture3

I suggest that acupuncture treatments can be categorised under four principles, four methods which we can use to decide where to needle.

Method 1. Needle the site of pain

This is the simplest form of acupuncture and is often all that is required. Insert one or more needles in the painful area itself. For example, widespread back pain, due perhaps to ankylosing spondylitis or osteoporosis, can be treated by needling the paraspinal muscles. A localised area of pain in the chest wall can be treated by inserting a few needles subcutaneously over the painful area.

Method 2. Needle a remote site to influence the site of pain

This depends on the phenomenon of referred pain and covers both MTrPs and segmental acupuncture but is not confined to these. One example would be needling the ulnar side of the hand at the site known to TCM as Small Intestine 3 (C8/T1 dermatome) for upper thoracic pain. Another is pain in the dorsum of the wrist which can be treated by needling a MTrP helow the elbow, in extensor digitorum.

Method 3. Needle the periosteum

Needling the periosteum seems to have been introduced by Mann4; it figures little or not at all in the traditional system. It is most commonly used to treat intrinsic joint pain such as that due to osteoarthritis, but can also act on wide areas of the body. For example, periosteal needling of the articular pillar in the neck can influence symptoms in the upper half of the body, and needling the pelvic periosteum in the region of the sacroiliac joint can do the same for the lower half.

Method 4. Needle for generalised (central) effect

In some cases acupuncture produces widespread and quite profound generalised effects. This appears to be a central phenomenon, probably mediated at least in part by limbic system structures. Responses of this kind can occur no matter where the needles are inserted but the hands and feet seem to be most effective. This can be used either on its own, e.g. for allergies, or to reinforce treatments using the other methods.

Summary

I think that these four methods make acupuncture 'simple but not too simple'. But please note the following.
1. The headings are guides, not rules. They suggest how to think about treatment but they don't say what you must do. They are meant to help you shape your thinking but not to limit it.

2. The methods are not mutually exclusive, They can be combined and often are.

3. Some treatments could be described under more than one heading. For example, many local treatments (Method 1) may also have central effects (Method 4).

4. The scheme is theory-neutral; it does not imply anything about how acupuncture works. It merely describes the possible treatment options that exist.

II. How long to needle?

Most traditionalists, and some modernists, leave needles in place for at least 20 minutes, often with intermittent manual or electrical stimulation. My own practice is different: I favour brief needling, which means about 2 minutes maximum per needle, often less. At the extreme, this becomes minimalist (micro) acupuncture, in which needles are inserted for only a few seconds, with little or no stimulation. Periosteal acupuncture is always very brief.

The use of brief needling may be counter-intuitive but it works in practice and is less likely to cause aggravations than more prolonged needling. The following considerations may make this method appear less counter-intuitive.

1. The nervous system habituates very quickly to a new stimulus. What it notices is change in intensity. For example, if you are exposed to a continuous noise, such as a distant car alarm, you notice it at first but cease to do so after a few minutes; you only become conscious of it again when it stops. What the system registers is 'news of a difference'.

2. I think of acupuncture as a means of switching patterns of activity in the nervous system. The operative word is 'switching'; you don't keep your finger on the light switch for 20 minutes.

3. Even though the needle is withdrawn it has created an area of disturbance in the tissues and this, presumably, will continue to modulate the nervous system for hours or even days.

4. Anyway, it works in practice!

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Note 1

Instead of looking at individual points and their alleged effects, we could consider them in groups and hence as areas rather than points. This produced some interesting results. Cheng's1 conclusions are as follows.
(1) The acupuncture points in the trunk and their stated effects on the internal organs in the trunk have a segmental relationship—that is, acupuncture points within certain spinal segments in the trunk affect the functioning of the organs that receive autonomic innervation from the same spinal segments. This is consistent with the concept of segmental acupuncture and the idea that acupuncture may act via the somatic sympathetic reflex with a spinal pathway to affect the trunk organs.

(2) The acupuncture points in the trunk and extremities have a musculoskeletal effect that is local or regional, but not distal. This is consistent with some of the models of acupuncture mechanisms on musculoskeletal effects in the Western medical acupuncture approach.

(3) The acupuncture points on the head and neck preferentially affect the nearest organ. This presumably reflects the belief in TCM that acupuncture can somehow regulate the functioning of the proximal organ. No clear relationship can be identified between the myotome level of the acupuncture points in the extremities and their non-musculoskeletal clinical indications.
This research seems to offer a partial reconciliation between TCM acupuncture and the modern approach.

References

1. Cheng KJ. Neuroanatomical characteristics of acupuncture points: relationship between their anatomical locations and traditional clinical indications Acupuncture in Medicine Dec 2011, 29 (4) 289-294; DOI: 10.1136/acupmed.2011.010056
2. Cummings M. Western medical acupuncture—the approach to treatment. Filshie J, White A, Cummings C. Western medical acupuncture: a western scientific approach (second edition). Elsevier, London 2018:100–124.o
3. Campbell A. Acupuncture without points. Filshie J, White A, Cummings C (editors): Western medical acupuncture: a western scienrific approach (second edition). Elsevier, London 2018:125–132.
4. Mann F. Reinventing acupuncture: a new concept of ancient medicine. Oxford: Butterworth Heinemann; 1992.