Module 2: The Autoimmune Patient in Chinese Medicine
In the last section, acupuncture was introduced as a potential complementary treatment for autoimmune disease. Before diving into acupuncture’s effects as they relate to autoimmunity, let’s first look at what acupuncture is and how it works.
One of the eight branches of Chinese Medicine, a holistic healing modality dating back over 3,000 years, acupuncture is the practice of inserting hair-thin needles into the skin at designated points to evoke a healing response and promote internal balance. The more than 361 acupuncture points exist in spacial and sequential relationships along fourteen meridians which traverse the body; the effects produced by needling vary according to the points themselves as well as to the areas of the body being treated.
From a biomedical perspective, a number of mechanisms have been proposed to explain how acupuncture exerts its physiological effects. The different mechanisms are understood to be complementary and integrative rather than exclusive or exhaustive, and yield local, somatic-autonomic and central effects, demonstrating the integration of acupuncture with human physiology at multiple levels. Given that acupuncture’s evidence-based and clinically-cited effects address numerous facets of the patient’s experience, from pain to digestion to mood, energy and beyond, this model of multiple interconnected mechanisms serves as a sound and logical foundation.
First, acupuncture exerts its effects locally by inducing a microinjury to the muscle tissue; this stimulates A-delta and C fibers, promoting the release of vasodilating neuropeptides and therefore, improving circulation.13 This sequence of events constitutes the ‘axon reflex’ response to injury and serves as the catalyst for the healing response that follows acupuncture needling.13,14 Attributed with having the most enduring vasodilatory effect among the neuropeptides released is CGRP (Calcitonin Gene Related Peptide), which, though known primarily as an inflammatory substance, has demonstrated potent anti-inflammatory effects in small doses, likely contributing to the healing effect of acupuncture.14,15 Other neuropeptides released in response to acupuncture include Substance P (SP) and Vasoactive Intestinal Peptide (VIP).14
Additionally, the direct stimulation of a given nerve locally may produce distal effects in the case of dichotomising nerves, whose branches extend to different areas of the body. For example, stimulation of the saphenous nerve may induce vasodilation of the sciatic nerve, possibly explaining the clinical utility of needling points to affect pain or other discomfort distally.14
Concerning the local analgesic effect of acupuncture, the microinjury induced by needling stimulates the release of endorphins which, along with their receptors, may accumulate locally for two to three days after the treatment; this endorphin accumulation contributes to peripheral opioid analgesia, which may explain why some patients’ post-acupuncture pain relief may be delayed by one or even a few days.13,14 Other observed local effects include increased blood flow and enhanced metabolism, further facilitating the immune system’s response to injury in the periphery.13,14,16
Second, acupuncture’s visceral effects – comprising its often-cited ‘balancing’ and ‘harmonizing’ influence – can be attributed to its impact on the sympathetic and parasympathetic branches of the autonomic nervous system. Acupuncture can impact neuronal pathways through a somatic autonomic reflex, which operates at both spinal level and brain (central) levels. Spinal level effects pertain to acupuncture points needled on the trunk and occur when the myotome or dermatome in which an acupuncture point is needled and the autonomic innervation of the target visceral organ lie within the same spinal segment. Put another way, acupuncture needling on the trunk sends an efferent signal to the spinal cord and the ensuing afferent signal travels to a visceral target within the same spinal segment as the dermatome or myotome in which the acupuncture point is located.13 This may account for, by way of example, how needling a point on the back designated for its gastrointestinal effects may achieve said effects, despite not being located near the affected visceral organs.
Additionally, the concepts of long term potentiation and long term depression come into play at the spinal segmental level. Long term potentiation refers to neural plasticity that is directed towards increasing the strength of a synapse; long term depression, by contrast, refers to neural plasticity directed towards decreasing the strength of a synapse. Long term potentiation, or LTP, is a pathological phenomenon that contributes to central sensitization and heightened pain responses to both painful and benign stimulation (hyperalgesia and allodynia); it is implicated in a number of chronic pain conditions. Stimulation of A-delta fibers, which acupuncture is known to do, can not only induce long term depression (LTD) but also reverse LTP, highlighting the potential for acupuncture to regulate nociception and rectify maladaptive pain responses.14 As responses to acupuncture vary widely according to patients’ unique physiology, the chronicity of pain and other factors, these effects are not to be taken as absolute and should rather be understood as potential outcomes.
The impact of acupuncture has been shown to operate through brain-level pathways, indicating central effects. Acupuncture has demonstrated the capacity to stimulate the dorsal motor nucleus of the vagus nerve to mediate its effects on the gastrointestinal system, and its effects on cardiovascular system – regulated blood pressure, for example – are through to be mediated by its communication with the arcuate nucleus of the hypothalamus, the ventrolateral PAG and the ventrolateral medulla.16 Acupuncture may modulate the HPA axis in different ways depending on the intensity of the stimulation it delivers. Intense and even painful stimulation – often the objective of acupuncture administered in research settings – increases sympathetic outflow and causes subsequent rises in ACTH and cortisone, essentially inciting a healing response through an initial excitation of the stress response. On the other hand, low stimulation acupuncture – as seen more often in clinical treatment settings – reduces sympathetic outflow, decreasing adrenal secretion of adrenalin and noradrenalin as well as plasma levels of adrenalin and cortisone, effectively inhibiting the stress response.14 Additionally, acupuncture can induce the release of oxytocin from the pituitary, allowing for longer-lasting pain relief and anxiolytic effects.14
While research efforts aimed at understanding the mechanisms and efficacy of acupuncture are robust and ongoing, it is worth noting that this ancient healing modality does not readily map to a western research construct, which has questioned and at times, dismissed, the validity of its physiological influence. Many critics have relegated acupuncture’s effects to the realm of placebo, however the research suggests otherwise. Because the art and science of acupuncture is predicated on the belief that a given patient’s presentation at the time of treatment guides the treatment strategy, including point prescription, needle retention time, intensity of needle manipulation and application of adjunctive therapies, the administration of a static treatment protocol – the standard of research – is antithetical to the Chinese medicine approach. Unlike medication, which is delivered in standardized doses the patient takes on an ongoing basis, perhaps being adjusted after a period of time, acupuncture is a treatment that most patients receive on a weekly basis, the form and content of which will change with each visit based on not only how the patient’s main complaint has changed or not changed, but also on a number of other factors, including sleep, stress, energy, digestion, appetite, temperature and any factors that improve or worsen the patients’ conditions. The concept underlying this approach is that interactions with our surroundings, including what we put into and on our bodies, our personal and professional relationships and our exposure to the environment, shapes us in such profound and constant ways that who we are today is sufficiently different from who we will be tomorrow to warrant careful reexamination and administration of treatment. Whereas in Chinese medicine a patient’s presentation is seen as the fluid and adaptive result of a complex network of systems, all of which are related and significant, allopathic medicine and the research that informs it are reductionist in nature, seeking to distill a patient’s presentation down to symptoms and to address those symptoms in isolation. Biomedical research, though unequivocally essential to progressing our collective understanding of both pathology and treatment, in order to adhere to the principles of the scientific method that guide it, must eliminate all variables that might contribute to or conflate the effect of a given therapeutic intervention to isolate and validate the true treatment effect. For a number of reasons, in this context, acupuncture is a proverbial square peg in a round hole. First, because individual responses to acupuncture vary widely, determining and delivering a universal dose and point prescription for a given condition lies outside the realm of possibility. Unlike pharmaceutical research in which the benefits and harms of a drug can be directly studied to inform the standard LD50, acupuncture’s effects are by their very nature not exclusive to needling alone but are instead the result of a confluence of tangible and intangible factors – from needling to patient-practitioner interactions to the ritual aspect of treatment, to the amount of time and attention given to the patient, which often exceeds what allopathic practitioners have the capacity to provide.
Second, while biomedical research mandates that an appropriate control group be compared with a therapeutic intervention group, controls – which may include wait-list control, standard care or sham acupuncture – rarely parallel the context of acupuncture in such a way that would evoke a true controlled trial. For instance, sham controls, which often take the form of needling at non acupuncture points, needling actual acupuncture points deemed irrelevant to the given treatment objective or non-insertive needling, are not physiologically inert, and are often associated with some measure of benefit for the patient. Research has demonstrated differences in brain activation patterns related to acupuncture analgesia and placebo analgesia, supporting the notion that acupuncture effects extend beyond the realm of placebo.104 Furthermore, while placebo effects are typically short-lived, acupuncture has repeatedly been associated with long-lasting effects.17
For these and other reasons beyond the scope of this discussion, acupuncture does not neatly and cleanly sit within the allopathic care and research paradigm. That it is not widely or well understood should not dictate its exclusion from an integrative care approach, particularly one pertaining to patients whose complex physical, mental and emotional needs render them vulnerable and likely to benefit from Chinese medicine’s patient-centric, holistic methods.
While some components of the Chinese medicine approach to patient care have been touched on above, it is important to note that the principles guiding diagnosis, treatment and disease prevention are rooted in a practice thousands of years old; with limited technology at their disposal, practitioners of Chinese medicine had to rely on the body to provide feedback that would inform their treatment decisions. In our modern era dominated by automated technology, the rudimentary tactics of palpating a patient’s abdomen, taking his pulse to determine not only speed but also a number of qualitative factors, inspecting his tongue for signs of internal disharmony and paying careful attention to his mannerisms, voice, and overall appearance may seem unsophisticated and insufficient, however it could be argued that these simple approaches lend a certain human element to the treatment that can have profound effects. The allopathic medical paradigm is built in such a way that curbs that human element, and though well-intentioned practitioners are not at fault for this, patients suffer all the same.
While acupuncture forms the basis of this investigative journey, it is but one of eight branches of Chinese medicine. Acupuncturists’ education, though primarily focused on acupuncture, provides training on and emphasizes the importance of other branches to utilize as tools for identifying and rectifying imbalances; this may include giving exercise recommendations appropriate to a given patient’s physical needs, manual bodywork, and counseling regarding diet, meditative practices and herbal therapy, among other modalities. It is not atypical for an acupuncturist to educate patients on simple and feasible yet profound ways to make dietary and lifestyle modifications to support the work he or she does through needling. This is of great relevance to the autoimmune disease patient, whose condition significantly impacts lifestyle, often requiring that a great deal of attention and effort be devoted to these factors. This type of approach is designed not to create additional work for the patient but rather to simplify and make accessible the art of self care, with the ultimate goal of empowering the patient to be an active participant in his or her own health journey.
Autoimmune patients are often disempowered by their illnesses in many ways: the path to diagnosis can be lengthy and turbulent, they experience significant stress – due to the inherently stressful nature of their conditions and simply because being sick and prohibited by sickness gives rise to stress, they may be insufficiently informed about their conditions, and their treatment regimens may be onerous and may create side effects that amplify the burden of disease. Acupuncture is a modality that strives to work with the patient’s physiological resources to reignite the body’s capacity for self-healing. Though some severe cases of autoimmunity may progress beyond the possibility of engendering self-healing, the practice of Chinese medicine essentially meets the patient where he’s at, adapting and responding to his unique needs at that time to yield the best possible outcome, whether through abortive or palliative treatment.