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The Illegal and Unsafe Practice of Acupuncture 

 

Under the Term “Dry Needling”,

 

10 Facts You Should Know

 

Here are 10 facts you should know about the illegal and unsafe practice of acupuncture under the term “dry needling:”

1. “Dry needling” is acupuncture.

“Dry needling” was first described over 2,000 years ago in China’s earliest and most comprehensive extant medical treatise, the Yellow Emperor’s Inner Classic (Huangdi neijing), where it discusses in detail using tender or painful points, also known as “trigger points” or “motor points,” to treat pain and dysfunction, particularly of the neuromusculoskeletal system. Simply described, “dry needling” involves inserting an acupuncture needle into a tender or painful point and then appropriately manipulating (rotating and/or pistoning) it for therapeutic purposes.

 

2. Tender or painful points, also known as “trigger points” or “motor points,” are acupuncture points.

Tender or painful points are located in muscles and connective tissues, and, as their name suggests, are identified through tenderness or pain on palpation. This was, in fact, one of acupuncture’s earliest forms of point selection. China’s preeminent physician, Sun Si-Miao (581–682 C.E.), called these tender or painful points “ashi” points. In Chinese, ashi means Ah yes!(That’s the right spot.). So, when the tender or painful point is pressed, the patient feels an unexpected local and/or referred “wince-pain” and says Ah yes! That’s the right spot. Incidentally, in a 1977 study published in Pain (the official journal of the International Association for the Study of Pain), Melzack, Stillwell and Fox established that “every trigger point [reported in the Western medical literature] has a corresponding acupuncture point.”* A number of studies subsequently published in the Western medical literature have reached this same basic conclusion.

 

* Source: Melzack R, Stillwell DM, Fox EJ. Trigger points and acupuncture points for pain: correlations and implications. Pain. 1977 Feb;3(1):3–23.

 

3. “Dry needling” is not “manual therapy;” it is acupuncture.

It is important to emphasize that “dry needling” is an invasive, acupuncture needle intervention (that is, it is acupuncture, a specialized form of minimally invasive surgery), whereas manual therapy is a noninvasive, hands-on intervention (for example, massage, mobilization/manipulation). Manual therapy certainly does not include the practice of surgery in any form.

 

4. “Dry needling” is not a “technique;” it is acupuncture.

To make clear, the act of inserting an acupuncture needle into the body, under any pretense, or for any purpose whatsoever, is the practice of acupuncture.

 

5. Physical therapists and other allied health professionals who are not licensed by law to practice acupuncture cannot legally purchase acupuncture needles.

The Food and Drug Administration (FDA) classified acupuncture needles as Class II medical devices subject to strict regulations under the federal Food, Drug, and Cosmetic Act (FDCA) and FDA’s regulations. Individuals purchasing or receiving acupuncture needles who are not licensed by law to practice acupuncture are directly violating both civil and criminal provisions of the FDCA intended to protect public safety. 21 U.S.C. § 331(a)–(c), (g). These include the FDA’s requirements that acupuncture needles can only be sold to “qualified practitioners of acupuncture.” 61 Fed. Reg. 64616 (December 6, 1996). FDA prescription labeling requirements themselves specifically prohibit the sale of acupuncture needles to anyone who is not a qualified practitioner of acupuncture. The required FDA prescription labeling on the package from which acupuncture needles are to be dispensed states: “Caution: Federal law restricts this device to sale by or on the order of qualified practitioners of acupuncture as determined by the States.” 21 CFR § 801.109(b)(1) (emphasis added). Any individual who is not licensed by law to practice acupuncture is directly violating the FDCA and FDA’s civil and criminal prohibitions when they purchase or receive acupuncture needles for use in “dry needling.”

 

6. Physical therapists and other allied health professionals who are not licensed by law to practice acupuncture are using acupuncture needles to perform “dry needling.”

Physical therapists and other allied health professionals who are not licensed by law to practice acupuncture would have you believe that they are not using acupuncture needles to perform “dry needling,” when they are, in fact, using acupuncture needles, which are clearly labeled as such on the dispensing package.

 

7. Physical therapists and other allied health professionals who are not licensed by law to practice acupuncture are not qualified to perform “dry needling.”

“Dry needling” is far outside both physical therapists’ and other allied health professionals’ scope of practice and their scope of education and training. In most states, to become a licensed acupuncturist, an applicant must complete a minimum of 1,905 hours of education and supervised clinical training (1,245 hours of education and 660 hours of supervised clinical training). Yet physical therapists and other allied health professionals who are not licensed by law to practice acupuncture are inserting acupuncture needles (up to four inches or more in length) into unsuspecting patients with as little as a weekend workshop in acupuncture.

 

8. There are real risks associated with the use of acupuncture needles by physical therapists and other allied health professionals who lack the education and supervised clinical training of licensed acupuncturists.

These real risks include, but are not limited to, blood vessel, nerve and organ injury from inappropriate acupuncture needle angle and depth of insertion or from inappropriate acupuncture needle manipulation; and infection and cross infection from nonsterile acupuncture needles, poor hygiene in acupuncture needle handling, and inadequate skin preparation.

 

9. There have been recently reported cases of injury or harm from the use of acupuncture needles by physical therapists and other allied health professionals who lack the education and supervised clinical training of licensed acupuncturists.

In one such case, Emily Kuykendall, a high school teacher from Maryland, had suffered nerve damage from the use of acupuncture needles by a physical therapist. In another such case, Kim Ribble-Orr, a former Olympic athlete from Canada, had suffered a punctured lung and a pneumothorax (the presence of air in the cavity between the lungs and the chest wall, causing collapse of the lung) from the use of acupuncture needles by a massage therapist.

*If you or someone you know has suffered injury or harm from the use of acupuncture needles by a physical therapist or other allied health professional who lacked the education and supervised clinical training of licensed acupuncturists, we want to hear from you. Our phone number is 775-301-5255.

 

10. It is illegal for physical therapists or any other providers to submit claims for payment to Medicare for “dry needling” (a non-covered service) as “physical therapy” (a covered service).

Since “dry needling” is acupuncture, it is not a covered service. Use of acupuncture needles is not a covered service, whether an acupuncturist or any other provider renders the service. 42 U.S.C. § 1395y(a)(1). Its billing under Current Procedural Terminology (CPT) codes 97112 (neuromuscular reeducation) or 97140 (manual therapy techniques) is a misrepresentation of the actual service rendered and is considered fraud by Medicare. 31 U.S.C. §§ 3729–3733.

*If you suspect Medicare fraud, call the Medicare Fraud Hotline at 1-800-HHS-TIPS (1-800-447-8477). TTY users should call 1-800-377-4950.

*Information on this page is used with consent from the National Center for Acupuncture Safety and Integrity

http://www.acupuncturesafety.org/10Facts

 

 

 

转自  http://www.th55.cn/history/ldmy/1409/281342.html

刘邓大军是中原野战军的别称,该军曾经建立了晋冀鲁豫根据地,千里跃进大别山,创造了许多战争奇迹。中医学有两种著名的内科治病方法,一是针灸,一是药物,相传已几千年了。鲜为人知的是,该军卫生部副部长鲁之俊十分重视利用针灸为军民服务,并发挥了重要的作用。
领袖:中西医结合好
1935年10月,党中央和中央红军到达陕北后,当时毛泽东身体十分瘦弱,一只胳膊抬不起来,关节痛(肩周炎)复发,影响工作和休息。延安著名中医李鼎铭建议服中药,有的西医对此不信任,认为中医不行。毛泽东说:“李鼎铭先生提出来了么,试一试,看看效果如何。”李鼎铭开了3帖中药,让毛泽东服用。不久,毛泽东的胳膊果然不痛了,还能做几下简单的单杠运动。毛泽东高兴地说:“还是中西医结合好!”以后,毛泽东有病时常请李鼎铭先生开药方,有时还请李为他按摩治疗。毛泽东还常常从李鼎铭那里借来《黄帝内经》《金匮要略》等中医经典著作阅读,以了解中医治病的奥秘和机理。毛泽东在与李鼎铭交往过程中,李鼎铭进言中西医团结合作的观点,促进了毛泽东关于中西医合作,结成医疗统一战线,更好地为人民服务的思想形成。此后,毛泽东把李鼎铭先生介绍给朱德、周恩来、林伯渠、谢觉哉、王稼祥等许多中央领导治病,时常在有关会议上谈中医药的好处,要求人们尊重中医,支持中医。
1940年11月,在纪念白求恩逝世周年大会上,毛泽东应邀来到中国医科大学,在新落成的学校大礼堂里对全体师生讲话中说:“要好好学习白求恩对病人极端负责的精神,在治疗工作中不能马虎大意”,并讲述必须团结中西医的重要意义。
1942年夏季的一个下午,毛泽东的保健医生黄树则随傅连障去看望毛泽东,毛泽东详细询问延安有多少中医,调查过没有。然后殷切地嘱咐他们:“要和中医老先生多来往来往,交交朋友。”傅连唪汇报了最近李富春同志向卫生部门传达毛主席关于团结中西医的指示,“我们已经开过几次中西医座谈会,讨论学习。”毛泽东强调说:“西医中医,要交朋友,不要不相往来。这一条很重要。”当问到黄树则读过中国古代哪些医书时,黄树则如实回答:“我读得很少。”毛泽东说:“你应该拿三个月时间,把主要的中医书都读上一遍。”
1944年4月,毛泽东正式提出“中西医合作,开展群众卫生运动”。同年5月24日,毛泽东在延安大学开学典礼上的讲话中又说:“近来延安疫病流行,我们共产党在这里管事,就应当看得见,想办法加以解决。我们边区政府的副主席李鼎铭同志是中医,还有些人学的是西医,这两种医生历来就不大讲统一战线。我们大家来研究一下,到底要不要讲统一战线?我不懂中医,也不懂西医,不管是中医还是西医,作用都是要治好病。治不好病还是医术问题,不能因为治不好病就不赞成中医或者不赞成西医。能把娃娃养大,把生病的人治好,中医我们奖励,西医我们也奖励。我们提出这样的口号:这两种医生要合作。”

“针神”到延安
1941年4月,针灸名医任作田主持的延安针灸疗病所,在延安城南门外的马家湾成立了。这在当时属于因人设事,人尽其才。
任作田(1886-1950年),乳名任东立,近代医家。1886年生于辽宁省辽阳县,原籍文安县大围河公社东柏木桥人,1922年至1923年,他任过黑龙江省拜泉县县长,后因被贪腐官员绥兰道尹常润亭排挤愤而辞职,专门从事社会慈善事业。
1906年,任作田在辽阳县做警察分局的文书时,一天十二三个小时忙个不停,月薪七八元,家庭生活由他妻子蔡更新和母亲支持。他干的工作,又常与日本浪人冲突,事情一报到上级就不了了之。这样天长日久,他总忘不了在日俄战争中死去的父亲、家中苦难的妻母、国家的懦弱、同胞的灾难,忧思成疾,气愤伤身,息了慢性胃炎和支气管炎。自2l岁至24岁,尚可勉强工作,25岁至27岁,业已食不下咽,行路困难。此时中西医药无效,任作田已奄奄一息。幸遇一位锦县姜文远老先生,此人精通针灸术,一连给他诊治了8个月,才使其得以痊愈。姜文远一面行医,一面将他一生的针灸技巧与经验传述给任作田。姜文远去黑河前嘱咐任作田,离开案牍工作,免去许多劳心伤脑的无谓气愤,做个医生治病救人。任作田立马请了长假,日夜学道学医。有时外出给人治病,只收车费及病人痊愈后的随意酬劳。
由于任作田的针灸技术得其恩师姜文远的精要秘传,医术精湛,加上为人乐善好施,被当地群众尊崇为“针神”。
1931年,日本侵占东北后,他参与组织难民垦荒队,经绥远(今内蒙古)、榆林、绥德,历经坎坷进入延安,被安排在边区政府保安处工作。为响应机关简政号召,他决定自谋职业,利用自己的一技之长,创立民办公助的针灸疗病所。
由于任作田针灸技法高超,态度和蔼,服务周到,开业不久,原先一个窑洞的诊所已拥挤不堪,在边区政府有关部门的帮助下,同年6月搬迁到七里铺新修建的四孔窑洞。另外,调配其次子任进之协助其开展针灸临床和出诊工作,再加两位同志担任司药。
这是当时延安唯一的针灸诊疗所,两年时间里,依靠传统针灸疗法,治疗各种疾病和疑难杂症的临床治愈率达到80%以上,在干部群众中享有很高的声誉。中央、边区和军队的很多领导人,都在这里治愈了多年不治的痼疾。
鲁之俊拜师
1944年10月,任作田参加边区文教大会,参加中西医合作讨论,襟怀坦荡,主动抛开宗派和保守观念,破除门户之见,带头公开医技,主动传技于人,努力开办医学教育,普及针灸疗法,愿意和西医同志合作研究针灸学说。会场上当时就有包括白求恩国际和平医院院长鲁之俊在内的几位西医报名,表示愿意向他学习针灸疗法。任作田不顾年高体弱、门诊量大,破例收下拜他为9币的高级西医为门生。在此基础上,又进一步扩大规模,举办多次针灸培训班。
鲁之俊虽然报名表示愿意学习传统针灸疗法,但碍于医院工作繁忙,实际上前一个月都没有正式从师学习。一个月后,国际和平医院有一位住院很久的面部神经麻痹病人,经过西医多种方法治疗都无效。病人要求到院外针灸,鲁之俊院长同意了。4天后,病人回到医院,面部竟然完全恢复正常。鲁之俊和内科主任德国医生汉斯•米勒都觉得惊奇。这更促使鲁之俊坚定学习研究针灸的决心。从此以后,他就去离医院约20里路远的任作田处学习针灸了。
鲁之俊(191卜1999),江西黎川人,1928年考入天津北洋军医学堂,随校迁移北平,1933年毕业于北平陆军军医学校,接受过比较系统的西医理论和临床实践教育。曾任广西军医院医师、广东军医总院外科主治医师兼德文翻译,以及广东重伤医院外科专科医师等职。
1939年1月,鲁之俊从广州出发,经桂林、贵阳、重庆、西安,奔赴延安。先后担任八路军卫生学校教官,八路军医院医务主任、院长。1939年12月,为纪念白求恩大夫不幸殉职,中央决定将八路军医院更名为“白求恩国际和平医院”,鲁之俊继续担任院长职务,坚持临床外科医疗工作。他曾参与为周恩来延河坠马右肘受伤会诊治疗的工作。
进入任作田针灸疗病所,鲁之俊发现针灸治疗的病症很广泛,尤其是对多发性关节炎、各种疼痛、妇科病和眼病,都有良好的效果。真理所存,师之所在。鲁之俊学习针灸热情高涨,几乎达到着迷的程度。门诊用针灸,病房用针灸,对中国医科大学实习的学生也教授针
灸,并且,努力将自己学习掌握运用针灸的经验体会,与西医科学理论相对照,索证,求解,寻找中西医汇通的途径。
任作田在向西医传授针灸技|法的同时,虚心学习现代医学知识,既当先生,又当学生,与西医相互学习,共同攻关。他提出“练心、练指、练法”的针灸练习三要素,总结出“八法”“十术”的用针技法,将自己多年积累的临床实践经验毫无保留地贡献出来,与西医学员们共同探讨针灸疗法的科学规则和医学原理。特别是与鲁之俊合作,对80例患者进行临床观察,包括半身麻痹、顽固痒疹、肺结核盗汗、急慢性胃炎、眼结膜炎、咽喉炎、风湿性关节炎等病症,治疗都获得显著疗效。涉及内科、外科、妇科、儿科、五官科等多个西医门类,经过中西医比照研究,认为“针灸方法有刺激血液环境、增加白血球、兴奋神经机能、增强新陈代谢的作用,使疾病消除,与苏联发现的神经系治疗方法,在理论上有共同之处”。
1945年6月,鲁之俊在《解放日报》上发表《针灸治疗的初步研究》一文。鲁之俊对其中的63个案例进行具体分析研究,经过针灸治疗,痊愈者9人,近愈者7人,有明显疗效者26人,疗效无法确定者17人.无效者4人。通过对各种不同医疗结果的病症、病史、病情分析,总结出针灸疗法对于主要由神经系统引起的疾病具有显著疗效,其医学原理在于针灸可以调整自主神经、消退各类炎症、增加^体抵抗能力、帮助诊断,从而证明针灸疗法符合医学科学原理。文章中,他援引苏联脑科学研究成果创立“神经病理”学说,确认中国传统医学上的“针灸”“是一种刺激神经的治疗法”。最后,他强调,根据医书所载,针灸可以治疗102种疾病,“差不多内科病都包括在内,并且有不少急性传染病据经验也有效。而现在我们只是开始做了初步的试验,至于更广的应用范围和效力的确定,理论上进一步的说明、技术操作等,这还需要我们医务界同志以更大的努力进行钻研,需要我们虚心地,以十分重视和诚恳的态度向中医们学习。”文章结尾处,鲁之俊向任作田表示致敬,“在此特向富有针灸经验的中医任作田老医师对我的赤诚的指教表示钦敬!”
1945年7月,陕甘宁边区政府特别褒奖任作田、鲁之俊两位医生,分别授予“中西医合作模范医生”光荣称号。

Please say No To dry needling by PT. It is a public safety issue!
The public comment period is open now through December 30th, 2015.

Please write your comments: Physical therapist only receive less than 100 hour post graduate course for acupuncture. It is irresponsible for untrained physical therapists to practice acupuncture with the name of “dry needling”. It is illegal for Physical therapist to use acupuncture needle to practice ” dry needling”, it is illegal to bypass acupuncture law to practice “dry needling”,

The link to comment and review the document is: http://www.townhall.virginia.gov/L/comments.cfm?stageid=7246

original source: http://ashi-acupuncture.com/dry-needling-vs-ashi-acupuncture/

acu_day_02-3227

Dry Needling History

Dry needling is a term coined by Dr. Janet Travell in the 1980’s. This term distinguishes between trigger point injection, where an anesthetic or other substance is injected into a trigger point (a tender focal area of tension within a muscle or other soft tissue), and simply piercing the trigger point with a needle (hypodermic or filiform).

Who Uses Dry Needling?

Dry needling is now practiced by physical therapists, chiropractors, M.D.s, and acupuncturists. Is there a difference between ashi (literally “ah that’s it”) style acupuncture and dry needling? In my opinion, no. Dry needling now usually uses a filiform needle (an acupuncture needle) and tender spots are needled (classically described ashi points).

Controversy

There is now a turf war going on (“scope of practice”) between various practitioners and involving the various state licensing bodies. Whoever wins in any given state is granted a monopoly to legally perform the dry needling procedure.

I think it is a tribute to the effectiveness of this therapy that many practitioners are interested in learning it. But the fact is that acupuncture needles have been used on tender spots in the body for thousands of years and it’s been called ashi acupuncture. Now certain practitioners want to perform the same therapy but call it dry needling. Isn’t this analogous to someone adjusting the spine like a chiropractor but now wanting to call it “crickety crack” to avoid licensing laws?

Two Specialties of Acupuncture

I really think that there are 2 specialties of acupuncture; “meridian” style acupuncture (maybe it could be called “distal point acupuncture”?) and ashi style acupuncture. Studying “meridian” style acupuncture really doesn’t prepare one well to practice ashi style and vice versa. Learning “meridian” style necessitates the study of the signs and symptoms of dysfunction of the internal organs as described by the ancient Chinese. Tongue and pulse reading may also be important. But with ashi style anatomy is paramount. And study of texts by M.D.s on trigger point work or pain referral patterns of the various muscles is often much more clinically useful than ancient Chinese concepts of physiology.

Would a rose by any other name smell as sweet? Regardless of what we call it, inserting a needle into the taut tender areas of the muscles is incredibly effective for treating pain.

Original article source: http://tcmaaa.org/JAMAresponse.shtml

In 2009, NHMRC funded a research grant (No. 566783; $687,239) to Dr. Rana S Hinman and her team as “ Laser acupuncture in patients with chronic knee pain: a randomised placebo-controlled trial ”. The grant resulted in a publication in the October 2014 issue of the Journal of American Medical Association (JAMA) titled “ Acupuncture for Chronic Knee Pain: A Randomized Clinical Trial ”. The authors (Hinman and her colleagues) concluded that “in patients older than 50 years with moderate or severe chronic knee pain, neither laser nor needle acupuncture conferred benefit over sham for pain or function. Our findings do not support acupuncture”. Following the publication, expert researchers called for explanations to study errors and inconsistencies. With unsatisfactory answers from Hinman and her colleagues, acupuncture organizations (23 organizations) filed three complaints with the University of Melbourne in May through July 2015, but in a letter dated 16 September 2015, the University denied all complaints without providing any reasonable supporting evidence and research documents…     Click here to read more …

Dr. Arthur Yin Fan published a series of articles poking the flaws in Hinman’s study:
► The methodology flaws in Hinman’s acupuncture clinical trial, Part I: Design and results interpretation
► The methodology flaws in Hinman’s acupuncture clinical trial, Part II: Zelen design and effectiveness dilutions
► The methodology flaws in Hinman’s acupuncture clinical trial, Part III: Sample size calculation

Article on Medical Acupuncture by Dr. Kehua Zhou:
► Acupuncture for Chronic Knee Pain: A Critical Appraisal of an Australian Randomized Controlled Trial

Response to JAMA by Dr. Qinhong Zhang et al:
► Acupuncture treatment for chronic knee pain: study by Hinman et al underestimates acupuncture efficacy

Commentary on Acupuncture in Medicine by White A and Cummings M.:
► Hinman’s Trial underestimated the acupuncture effectiveness

Article on The American Acupuncturist Summer 2015 by Jacob Godwin and Arthur Y Fan
► Evidence-Based Medicine Skills for Acupuncturists Part I: The Hinman Trial on Chronic Knee Pain…

Responses to JAMA:
► Responses to JAMA by Dr. Yong Ming Li, Lixing Lao, Hongjian He, etc.

Interview by Acupuncture Today:
► Chinese Doctors Poke Holes in Australian Study By Bill Reddy, LAc, Dipl. Ac.

Dr. Changzheng Gong’s article on International Journal of Clinical Acupuncture:
► Acupuncture Storms JAMA

By Jacob Godwin, DAOM, Dipl OM, LAc;  Arthur Fan, CMD, PhD, LAc

Abstract

Evidence-based medicine (EBM) skills are critical to clinical effectiveness and to developing and maintaining an effective intellectual ecosystem of clinicians, researchers, policy-makers, and academics. One important competency within the evidence-based medicine paradigm is the ability to appraise research papers critically. The authors first discuss the value of research literacy among acupuncturists and then demonstrate the importance of this skill by critically appraising a randomized controlled trial (RCT) on chronic knee pain published by Hinman et al. in The Journal of the American Medical Association (JAMA) in 2014. Keywords: evidence-based medicine, Hinman trial, acupuncture, research literacy, acupuncture competencies Introduction Four universally accepted core competencies in EBM are required of clinicians: the ability to 1) turn clinical practice problems into focused questions, 2) systematically retrieve published literature to address their questions, 3) appraise the literature they find for applicability and scientific validity, and 4) apply their appraisal to the clinical case before them (1). This paper focuses on the third competency, the ability to appraise clinical research critically for scientific validity and applicability to a clinical question. The example described below, a small (n=282) RCT of chronic knee pain published by Hinman et al. in 2014 (2), is particularly applicable to the issue of validity.

Read more at: Godwin J, Fan AY. Evidence based medicine skills for acupuncturist part I- The Hinman Trial on Chronic Knee Pain and the Importance of Critical Appraisal Skills. J Am Acupunct 2015;70 Summer 22-29.

原文http://blog.39.net/%E9%92%88%E7%81%B8%E5%8D%9A%E5%A3%AB/a_721782.html#
作西方针刺疗法(Western Acupuncture)的灵魂—激痛点(TriggerPoint),与传统针灸学的腧穴理论有太多的相似。经比较发现,147块肌肉中的255个激痛点,超过92%的激痛点腧穴在解剖上相对应。而79.5%针灸灸穴位所主治的局部疼痛与其对应的MTrP相似。二者均可以引发类似的线性感传。其中二者完全一致或基本完全一致达76%,另有14%也有部分一致。其次,二者均可主治内脏性症状,如腹泻、便秘、痛经等。因此,二者在解剖位置,临床主治,针刺引起线性感传等方面,都有着十分的相似性。

 

近年来,在中国传统针灸疗法的基础之上,西方提出了所谓的西方医学针灸疗法(Western Medical Acupuncture)或西方针灸疗法(WestAcupuncture)。由于其主要刺激点是激痛点(Trigger Point),所以又称之为激痛点针刺疗法(Trigger Point Acupuncture)或干针疗法(DryNeedling)。这种新针刺疗法在欧美等国家和地区迅速发展并成熟,影响越来越大。

 

 

激痛点是指按压时可出现局部敏感痛点,甚至可引起远端疼痛,有时还可产生感传性植物神经症状及本体感觉障碍的部位。它的产生常与内脏性疼痛、神经根性疼痛及肌筋膜性疼痛有关。从其临床特征来看,它与传统针灸学中的阿是穴十分类似,但它更系统,且有其现代医学的理论与临床基础。新近的研究显示,在治疗肌筋膜疼痛方面,激痛点针刺疗法临床疗效也似乎较传统针灸更好。由于它与包括阿是穴在内的传统针灸穴位无论是主治、针感、还是生理、病理特征、临床主治均有一定的联系。而且,针刺等机械刺激它也可产生类似循经感传的现象。因此,积极跟踪激痛点与穴位比较研究的有关成果,对于阐述循经感传现象的机理,穴位的实质,甚至针灸治疗的原理等无疑有重要的帮助。

1位置的重叠性

目前,临床上以肌筋膜激痛点(Myofascial Trigger Point,MTrP)的研究最为广泛和深入。MTrP是指骨骼肌内可触及之紧绷肌带所含的局部高度敏感的压痛点。按压它时,可激发特征性的整块肌肉痛、并扩散到周围或远隔部位的感传痛(Referred Pain)或称“牵涉痛”。它不同于其它激痛点,如皮肤性、韧带性、骨膜性及非肌筋膜性的激痛点等。根据其是否伴有自发性疼痛,它可分为活性激痛点(Active Trigger Point)与隐性激痛点(Latent Trigger Point)。前者可自发地引致疼痛,而后者在受压下才会引起疼痛。

MTrP是骨骼肌中可触摸的紧绷肌带中的高度敏感小点。它常常位于受累肌肉的中部或肌腹上,或肌肉与肌腱交界处,肌筋膜边缘易拉伤处,肌肉附着于骨突的部位等。其面积通常小于1cm2的压痛点,持续压迫(10s)或针刺常可引起该肌肉相关区域的牵涉痛,此处亦可触及小结节。

有关激痛点的经典著作——《肌筋膜疼痛与机能障碍:激痛点手册》(Myofascial pain and dysfunction:thetrigger point manual),全身存在255个激痛点。它大约是中国传统针灸经穴的2/3稍多,主要用于治疗肌筋膜炎引起的疼痛综合征等。由于MTrP所诱发的疼痛可以沿整块肌肉向远端部位传导,产生感传性疼痛,且当机械刺激如针刺它时,可长时间地减轻疼痛。这与针刺刺激穴位的效应十分相似。因此,早在1977年,提出疼痛“闸门学说”的 Melzack R等比较了二者的疼痛主治及感传痛路线,发现激痛点与传统针灸穴位具有高度的一致性,二者符合率达71%。但由于他将3cm范围内的穴位与MTrP均视为重叠,因此,这一结果遭到Travell JG.和Simons DG.的否定。Travell JG.和Simons DG认为,MTrP与传统的针灸穴位是固定的不一样,每个人的MTrP位置都不一样,只是为了叙述方便,才在书上标记出来,没有任何两个人的MTrP位置完全一样。此后,BirchS发现,传统针灸教科书中许多针灸穴位的主治中并没有提到主治局部疼痛病证,通过进一步的分析与比较,他认为,较之经穴及经外奇穴,激痛点跟阿是穴更相似。Hong CZ也认为,阿是穴与激痛点的位置相当类似,甚至重叠。但是,激痛点理论的创始人Travell等并不认同这些观点,认为MTrP不同于正常的腧穴,也不同于中医的阿是穴。

本人认为,腧穴与MTrP确有不同之处。前者不仅有病理属性,还有生理属性;而后者则仅属于病理性。但近年来的研究表明,MTrP的位置确有与其周围组织不同之处,有其独特的生理特性。其次,腧穴的位置虽然相对固定,但其具体位置也常因人而异。因此,Travell JG.和Simons DG的否定也难以令人信服。

由于针灸腧穴既有远治作用,又有近治作用。这样,所有的腧穴,均应可主治近处的局部疼痛。而BirchS.以部分针灸腧穴未有疼痛主治为由,否定所有腧穴均可治疗疼痛的事实,这一观点显然是有所欠缺。其次,众所周知,早期的针刺部位实际上就是当今我们所谓的阿是穴,即“以痛为腧”。如《灵枢?背俞篇》说:“则欲得而验之,按其处,应在中而痛解,乃其俞也。”后来发展为孙思邈的“阿是之法”。正是随着这种“阿是穴”的增加,人们发现有些穴位的位置相对固定,才逐渐开始有了固定的名称,并逐渐积累,越来越多。随着经络理论的发展,由于许多腧穴位于经络线上或附近,这样,古人逐渐给这些穴位安个“家”–“归经”,于是便有了“经穴”与“非经穴”的区别。《黄帝内经》成书时,归经的腧穴只有161个,《针灸甲乙经》问世时,经穴已达349个。由于不同时代、不同医家的观点各异,因此,对同一穴位便出现了不同的归经。直至清代《针灸逢源》问世,361个穴位才有了统一的,并被公认的“家”[12]。在归经过程中,许多不确定因素[13]都曾或多或少地影响到其归经。因此,可以认为,经穴与经外奇穴在本质上是没有区别的。例如,膏膏肓俞、厥阴俞、风市等在《千金方》还原本是经外奇穴,后来才被归为经穴;现在所谓的“阑尾穴”、“胆囊穴”最初也只是阿是穴,后来才逐渐成为奇穴。其实,它们都位于经脉线上,因此,本质上仍属经穴。因此,上述的研究结果显示,无论MTrP是与经穴、经外奇穴,还是阿是穴相关,均说明它与传统的针灸穴位有着深刻的相关性。

Dr.Dosher利用解剖软件和解剖图,共比较了255个MTrP和747个经穴及经外奇穴的符合程度。将激痛点和针灸穴位相距在其2厘米以内,而且位于同一块肌肉,称之为对应点(Correspondingpoint)。并比较了这些对应点的临床疼痛主治,以及相对应的激痛点的疼痛感传路线与相应的针灸穴位所在的经络分布。结果发现92%的MTrP与针灸穴位在解剖上相对应。针灸穴位中,其中79.5%的穴位所主治的局部疼痛与其对应的MTrP相似。

由于头顶部及四肢未端的穴位密度大,如果按作者“将2厘米以内,且位于同一肌肉内的穴位与MTrP定义为对应点”,那么,势必导致多个穴位与同一个MTrP“对应”,其结果也肯定会有所偏颇。但是众所周知,穴位并非一个“点”,而是一个“小区”。因此,事实上有的穴位本身就有可能重合。这也可能是穴位的功能只具有相对的特异性的原因之一。因此,可以认为,MTrP与传统的穴位在解剖位置上确实具有相当高的重合率。

 

2 针感的相似性

针刺穴位时,施针者常会感觉到针下的局部有一定的沉重感,正所谓“气之至也,如鱼吞钩饵之浮沉”(《标幽赋》)。这种沉重感主要是由于腧穴部位肌肉轻微紧张性收缩所造成的。如果针感强烈,还会出现明显的肌肉收缩现象。即《类经附翼》所形容的“气至,如摆龙尾”。这一现象与机械刺激MTrP时出现的局部抽搐现象(Local Twitch Response, LTR)完全一致。

其次,机械刺激时,病人的主观感觉也大同小异。针刺得气时,大多数受试者可有以酸、胀、麻为主的混合性感觉;少数患者可出现流水感、蚁行感、冷感及热感等。感觉的多样性常与刺激方法与强度有关,如艾灸多为温热感;电刺激出现麻感;毫针刺激多为酸胀感;指压刺激则以胀感为主。感觉的种类还与刺激的部位等有关。如针刺神经时多引起麻感;针刺血管多引起痛感,刺激肌腱、骨膜多引起酸感;刺激到肌肉多引起酸胀感。

穴位区域的皮下及深部组织中有多种感受器,如痛、温、触、压觉感受器等,这些感受器可分别接受不同能量形式的刺激。如毫针的机械刺激,艾热的温度刺激,电针的电流刺激,磁穴疗法的磁场刺激,推拿按摩的触压刺激等。进一步的研究显示,穴位处的感受器,大多在深、浅筋膜分布处。这与MTrP的组织学定位也是一致。

激痛点针刺后也会出现类似“得气”的针感,多表现为钝性痛或锐痛,酸痛,胀痛等。激痛点也包含有多种感受器成分,既有运动小点,还有感觉小点。目前有关激痛点的有效刺激方法也有很多,如干针疗法,注射疗法,肌肉伸展疗法,按摩疗法,激光疗法,热疗法等。

除了局部针感及有效的刺激方法相似以外,针刺二者均会沿一特定路径出现一些感传性反应,如感传性疼痛、感传性植物神经反应等。穴位针刺后,可出现沿古典经络循行线大体一致的循经性感传现象,包括酸胀麻痛,神经血管反应等。尤其是在四肢的感传,其循经性十分明显。在《灵枢?/SPAN>经筋》篇所列十二经筋,系统地叙述了这种感传痛的路径。如“手太阳之筋,……“其病小指支,肘内锐骨后廉痛,循臂阴入腋下,腋下痛,腋后廉痛,绕肩胛引颈而痛,应耳中鸣痛,引颔目暝,良久乃得视,颈筋急则为筋痿颈肿”。显示古人已察觉到感传痛的现像。

循经感传现象研究显示,感传路线所处的深度随机体部位而有不同,在肌肉丰厚的地方位置较深,在肌肉浅薄的地方则较浅,似乎位于皮下。这表明循经感传与肌肉有明显的关联。

受累的肌肉常有多个不同的固定的MTrP,而且,每一个MTrP都有自己固定的诱发感传痛区域。一个原发性MTrP可继发性地诱发另一个邻近的MTrP,第二个继发性MTrP又可诱发更远处的MTrP,从而造成远距离感传痛。这样,原发性与继发性的MTrP 便形成了一条感传线。每一个MTrP均有相对固定的感传线。Dr.Dosher研究发现,在相互对应的针灸腧穴与MTrP中,其肌筋膜疼痛感传路线与相应的经穴所在的经络分布完全或基本完全一致的占76%,另外至少有14%属部分一致。除了感传性疼痛以外,机械刺激MTrP还可诱发出相应路径的神经血管反应,这与循经感传现象也十分相似。

这一切都说明,从针感的表现形式及产生机理等来看,二者临床上也十分相似。

3 主治的相关性

腧穴针刺可以治疗本经远端疼痛等不适。同样,针刺灭活原发性MTrP后,也可抑制并减轻其继发性的卫星MTrP所诱发的疼痛。说明MTrP同样有一定的“远治”作用。

其次,二者均可在一定程度反应内脏疾病。并均可作为内脏疾病的有效治疗部位。

穴位是人体脏腑经络之气输注并散发于体表的部位,是与脏腑经络之气相通并随之活动变化的感受点和反应点,也是针灸的施术部位。因此,历代医家都把腧穴和异常反应点作为诊断疾病的重要依据。如《灵枢?九针十二原篇》说:“五脏有疾也,应出于十二原,十二原各有所出,明知其原,睹其应,而知五脏之害也。”这说明腧穴和“异常反应点”可以在一定程度上反应脏腑疾病。在近代,也发现了一些非常有价值的新腧穴和异常反应点。如阑尾炎患者的压痛点一般都在阑尾穴或天枢穴;胃溃疡的患者多在承满穴或右溃疡点有压痛;急性黄疸型肝炎多在至阳穴或肝炎点有压痛;良性肿瘤多在新内郄穴有明显的异常反应,恶性肿瘤多在新大郄穴有异常反应。经临床验证,都有一定实用价值。

由于肌筋膜炎不仅可以引起疼痛,肌肉运动与感觉障碍。还可引起一些感传性植物神经功能障碍,如血管收缩、局部肿胀、流涎、头晕、耳鸣,汗出异常,腹泻、便秘,月经紊乱、痛经等。因此,一些表面看起来是内脏疾病的症状,但实际上可能是MTrP引起的。针刺灭活这些MTrP后,可以帮助减轻或消除这些症状。

其次,MTrP还可作为内脏疾病的病理产物而存在。内脏疾病的牵涉痛常涉及到一定的皮肤区域、特定的肌肉或内脏的体表投影区。不同的疾病均有其相对固定的牵涉区或感传区。如众所周知的心绞痛,可放射到胸大肌,肩胛间区,左肩和左上臂内侧等;输尿管结石的绞痛沿患侧腹直肌的边缘向侧腹部和腹股沟,甚至向会阴部及大腿内侧等感传性疼痛等。前列腺痛向会阴、腰骶部及外生殖器等处放射。女性盆腔疾病疼痛向腰骶部及会阴等处放射。哮喘患者后头有沉重感,肩部酸胀感,上肢的拇指桡侧也会出现反应等。这种内脏疾病引起体表的放射痛,还可能与古代足厥阴肝经等的形成的重要临床依据。

4 结语

基于激痛点理论的西方针刺疗法,其治疗疼痛类疾病的疗效也十卓著,影响也越来越大。因此,近年来,西方针刺疗法不仅在理论上、临床应用方面得到了相当程度的认可,而且,其有关内容还被正式纳入到大学的正规教育。如英国的赫特福德大学(University ofHertfordshire)便开设了西方医学针刺疗法的硕士生课程。其次,有关激痛点的生理病理特征,诊断方法,产生的原因等的现代研究也越来越多,日趋丰富。从现有的研究结果来看,传统的针灸穴位与肌筋膜激痛点,无论是在解剖位置方面,还是在临床主治,反应病证,针刺引起线性感传等功能方面,都有着十分的相似性。不仅如此,二者在生理、病理特征方面有着千丝万缕的联系,作者将就此另外探讨。为何二者如此高度地相似?激痛点是针灸腧穴的一个分支?还是传统腧穴的重新发现?这些仍有待进一步深入研究与探讨。如果二者完全一致,这无疑将是传统针灸学的一个重大的发展,也将为针灸学率先走向科学迈出坚实的一步。

 

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