Acupressure and pain thresholds

It has been shown that pain thresholds can be dramatically raised by pressure techniques applied to specific points. Researchers at the Peking Medical College conducted complex experiments which demonstrated that finger pressure acupuncture produced a rise of 133% in pain threshold of rabbits (using radiant heat as the painful stimulus). When cerebrospinal fluid was perfused from one rabbit to another after such experiments, the recipient rabbit was found to have achieved a rise in pain threshold of up to 80%. This suggested the presence of hormone-like substances produced by the brain in response to the original acupressure stimulus. These substances are now known to be enkephalins and endorphins, and these play a role in NMT pain control. The point used in these tests was equivalent to the acupuncture point known as Bladder 60, posterior to the ankle (externally) and just anterior to the Achilles tendon.

Acupuncture points and trigger points: not all agree that they are the same phenomenon

As outlined earlier, because they spatially occupy the same positions in at least 75% of cases (Wall & Melzack 1989, Dorsher 2004, Dorsher & Fleckenstein 2008) there are strong indications that trigger points are in fact no more than active acupuncture points. Wall & Melzack (1989) have concluded that: ‘trigger points and acupuncture points when used for pain control, though discovered independently and labelled differently, represent the same phenomenon’.

Baldry (1993) does not agree, however, claiming differences in their structural make-up. He states:

Clearly, stimulation of an area that has, beneath the contacting instrument or digit, both an acupuncture and a trigger point will influence both types of neural transmission and both ‘points’. Which route of reflex stimulation is producing a therapeutic effect, or whether other mechanisms altogether are at work – endorphin or endocannabinoid release, as examples – is therefore open to debate. This debate can be further widened if we include the vast array of other reflex influences identified by other systems and workers, as discussed later in this chapter.

Whereas traditional oriental concepts focus on ‘energy’ imbalances in reaction to acupuncture points, there exist also a number of Western interpretations.

Melzack et al (1977) have assumed that acupuncture points represent areas of abnormal physiological activity, producing a continuous low-level input into the central nervous system (CNS). They suggested that this might eventually lead to a combining with noxious stimuli deriving from other structures, innervated by the same segments, to produce an increased awareness of pain and distress. They found it reasonable to assume that trigger points and acupuncture points represented the same phenomenon, having found that the location of trigger points on Western maps, and acupuncture points used commonly in painful conditions, showed a remarkable 75% correlation in position.

It is interesting that the link between the source of pain or tender points, and the referred area of pain noted in trigger points, in many instances seems to travel along the routes of traditional acupuncture meridians, but certainly not always. Spontaneous pain in such a point, according to acupuncture tradition, indicates the need for urgent attention. It is not the intention of this book to provide instruction in acupuncture methodology, nor necessarily to endorse the views expressed by traditional acupuncture in relation to meridians and their purported connection with organs and systems. However, it would be short-sighted to ignore the accumulated wisdom that has led many thousands of skilled practitioners to ascribe particular roles to these points, for example Alarm, Associated and Akabane points as described in this chapter.

As far as a manual therapy is concerned, there seems to be value in having awareness of the reported roles of particular acupuncture points, and of incorporating this into diagnostic and therapeutic settings.

As we palpate and search through the soft tissues, in basic neuromuscular technique, we are bound to come across areas of sensitivity that relate to these points. They are also often found to overlap with neurolymphatic and neurovascular points, as described elsewhere in this text.

For example, reflex number 19 in Chapman’s reflexes, which relates to the urethra, is identical to the neurovascular point of the bladder, and the acupuncture alarm point of the Bladder meridian. Careful comparison shows many such overlaps.

General guidance as to how to treat acupuncture points, which are sensitive, must relate to whether a stimulating or sedating effect is desired. The body often seems to utilize therapeutic stimulation to its best advantage.

Selye has shown us (see Ch. 1) that homeostatic mechanisms are at work, so that any stimulus, if appropriate and not excessive, can result in a beneficial response. In accord with the methods used in treating neurolymphatic and neurovascular points (described elsewhere in this chapter) it is suggested that, to some extent, the ‘feel’ of the tissues be allowed to guide the practitioner. A change (in the sense of a release of tension, or a softening, or a sensing of a gentle pulsation in the tissues) is often an indication of an adequate degree of therapy. In order to sedate what is an overactive point, up to 5 minutes of sustained or intermittent pressure, or rotary contact, may be required.

For stimulation, the timing could involve between 20 seconds and 2 minutes. By this time, some degree of change should be palpable. As must be clear, if pressure is sustained beyond a certain point quite the opposite effect will be achieved. This is a common natural phenomenon which occurs in response to all factors in life that are initially stimulating. If prolonged, they become enervating or exhausting, and in terms of therapy this is undesirable unless anaesthesia is required.

A short cold (water) application, for example, will stimulate, whereas a long one will sedate, and too much can kill. The words of Speransky and Selye should be recalled and the minimum effort used, consistent with achieving a response.

We have noted previously that many of the different reflex systems have points that seem to be interchangeable, and that many of these are traditional acupuncture points. In terms of local pain, the view of Chifuyu Takeshige (Takeshige 1985), Professor of Physiology at Showa University, is that: ‘The acupuncture point of treatment of muscle pain is the pain-producing muscle itself.’

Respected acupuncture clinicians, such as George Ulett, suggest that ‘acupuncture points are nothing more than time honoured muscle motor points’. Professor C. Chan Gunn, however, finds this too simple an explanation, and states: ‘Calling acupuncture points “motor points” or “myofascial trigger points” is too simple. They are Golgi tendon organs.’ These, and other researchers, are quoted by Stephen Botek, Assistant Professor of Clinical Psychiatry, New York Medical College (Ernst 1983).

Botek (1985) believes that ‘myofascial needling’ is the term of choice to define the type of acupuncture that dispenses with traditional explanations as to the effects of acupuncture. The points utilized in one study were Large Intestine 4 (Hoku) in the web between thumb and the first finger, and Stomach 36 (Tsu san li) below the knee. The study recorded skin temperature of the face, hands and feet. It was found that, compared with a resting period, both manual and electrical stimulation of both points induced a general warming effect. This was immediate in the face (Lewith & Kenyon 1984) and appeared after 10–15 minutes in hands and feet. The temperature increase was notably more marked after manual acupressure than after electrical stimulation. Manual stimulation of these points was shown to be more effective than other forms of stimulation.

Lewith & Kenyon (1984) point to a variety of suggestions having been made as to the mechanisms via which acupuncture, or acupressure, achieves pain-relieving results. These include neurological explanations such as the ‘gate control theory’. This, and variations on this theme, look at the various structures of the CNS and the brain in order to define the precise mechanisms involved in acupuncture’s pain-relieving action.

This, in itself, is seen to be an incomplete explanation, and humoral (endorphin, endocannabinoid release, etc.) and psychological factors, are also shown to be involved in modifying the patient’s perception of pain.

A combination of reflex and direct neurological elements, as well as the involvement of a variety of secretions, such as enkephalins and endorphins, is thought to be the modus operandi of acupressure, and probably of all of the various systems of reflex activity discussed in this section (neurolymphatics, etc.).

Many of the points of referred pain and tenderness used in Western medical diagnosis are also acupuncture points, for example:

The degree of overlap between these well-known points can also be noted when comparing other classification systems of points.

Location of Alarm points

Alarm points (Table 4.1, Fig. 4.2) are on the anterior surface of the body. Spontaneous pain at any point is considered to indicate a disorder of the affiliated meridian. If tenderness is elicited on light pressure, a deficiency of energy in the meridian is assumed, whereas tenderness elicited on heavy pressure indicates an excess of energy in the meridian.

Table 4.1 Alarm points

Figure 4.2 Location of Alarm points, which lie on the anterior surface of the body. If spontaneous pain develops in any alarm point, the associated meridian is thought to be involved. If light pressure produces tenderness, an ‘energy deficiency’ is considered to exist; if heavy pressure produces tenderness, an ‘energy excess’ is assumed. An understanding of the organs and functions associated with particular meridians is necessary in order to utilize these points therapeutically or diagnostically.

These are reflex points for meridian function, and awareness of the roles apparently played by the various meridians in body energy economics is necessary to evaluate the significance of reactions that produce tenderness in Alarm points.

Location of Associated points

Associated points are on the dorsum of the body (Fig. 4.3). Spontaneous pain is thought to indicate a disorder in the meridian associated with it. Tenderness elicited on light pressure indicates a deficiency in energy in that meridian, and tenderness elicited on heavy pressure indicates an excess of energy in the associated meridian. These points are all on the Bladder meridian and their associations are given in Table 4.2. The points are slightly lateral to the median line bilaterally and are also reflex points for the meridians with which they are associated.

Table 4.2 Associated points

Location of Akabane points

Akabane points (Table 4.3, Fig. 4.4) represent the terminal points of the meridians. Sensitivity of these is thought to relate to imbalance in the energy of the meridian. Comparative sensitivity shows relative imbalance in organ (energy) systems. Manual or electronic testing is possible.

Table 4.3 Akabane points

Figure 4.4A,B Location of Akabane points, which represent the terminal points of the 12 meridians. Sensitivity of the points is thought to relate to imbalance in related organs (energy) systems. Both manual and electronic testing of these points is possible.

Characteristics

Patriquin (1997) describes the characteristics of Chapman’s reflexes as:

Sometimes they are described as feeling like small pearls of tapioca, lying, partially fixed, on the deep aponeurosis or fascia.

Clinical value of the reflexes

Because the location of these palpable tissue changes is relatively constant in relation to specific viscera, it is possible to establish the location of pathology without knowing its nature. The value of these reflexes is threefold:

Mechanism of the reflexes

Regarding the mechanism whereby these reflexes act, it would appear that, in so far as the intercostal reflexes are concerned, stimulation of the receptor organs that lie between the anterior and posterior layers of anterior intercostal fascia acts through the intercostal nerve, which enervates the external and internal intercostal muscles and thus, through the sympathetic fibres, affects the intercostal arteries, veins, lymph nodes, etc. Stimulation thus causes afferent and efferent vessels draining these tissues to increase or decrease, permitting lymph flow to be increased or decreased, thus affecting the drainage of the entire lymph system in the area. Through the sympathetic fibres associated with these tissues, the lymph nodes of the vital organs are also affected.

Explaining results of neuromuscular technique

These reflexes seem to offer explanations for the sometimes startling results obtained through neuromuscular technique. Stanley Lief placed great emphasis on normalizing the tissues of the intercostal spaces and the paravertebral areas – sites of many major neurolymphatic reflexes. He also stressed the importance of not overtreating, a consideration that cannot be repeated too often.

Research evidence supports Chapman’s reflex usefulness

Nimmo’s dismissal of the Chapman reflexes

An element of disinformation has emerged regarding Chapman’s neurolymphatic reflexes.

Vannerson & Nimmo (1971) writing in The Receptor – the journal of the organization that used (in the 1960s) to teach Nimmo’s receptor-tonus technique (see Ch. 2) – stated:

These two authors then deride Chapman’s assertion that the reflexes could exist at specific sites, an idea that they call ‘fantastic’.

Vanneron & Nimmo’s first point is in contradiction to Gray’s Anatomy (Gray 1973), which tells us that lymph moves in a number of ways. Filtration occurs, generated by filtration of fluid from the capillaries. There is also a degree of movement engendered by contraction of surrounding muscles, which compress lymph vessels, the movement of which is determined by the presence of valves. This muscular contraction is dependent upon normal activity, and muscular contraction–relaxation sequences. Lymph is further capable of being moved, in such regions, according to Gray, by massage movements. Pulsating arterial vessels, in close proximity, also assist lymph movement, as does respiratory movement. Also in contradiction of Vanneron & Nimmo, Gray states: ‘The smooth muscle in the walls of the lymphatic trunks is most marked just proximal to the valves; stimulation of sympathetic nerves accompanying the trunks, results in contraction of the vessels; the intrinsic muscle of the vessels thus probably aids the flow of the lymph.’

In 1979, rhythmic pulse waves were recorded from the lymphatic vessels of five healthy, upright, motionless males at a rate of 8–10 per minute, asynchronous with respiration or leg movement (Oszeweski & Engeset 1979). Degenhardt & Kuchera (1996) describe the process as follows: ‘The regulation of the intrinsic contractility of the lymphatic system is based on transmural distension of the vessel walls and neural and humoral mediators.’

They comment:

This evidence, therefore, suggests that the term ‘neurolymphatic reflex’, as described by Chapman, may indeed be an accurate description of the phenomenon.

Vanneron & Nimmo’s second observation (relating to the specificity of the reflex sites) may be more valid, especially if anatomical individuality is taken into account. Points of the body surface are never likely to be precisely identifiable by description of anatomical position. However, a general identification as to site is possible. McBurney’s point, for example, if present in appendicitis, is usually located within a few degrees of its commonly described location. There are exceptions, of course, and in the inscrutable manner of the Orient, the Chinese have taken this well into account, in describing the locations of acupuncture points. The invention of the ‘human inch’, which takes account of the individual anatomical proportions of each person, allows for such individualization. In terms of the charts and maps to be found in this text, the same factor should be borne in mind. The positions are approximate, because variations exist from person to person.

Dysfunction in soft tissues is, however, palpable, and not dependent upon maps. Thus, the general guidelines provided by charts are useful, but cannot take the place of palpatory skills.

A complete illustrated list of Chapman’s reflexes is found in Chapter 5, which deals with diagnosis and treatment using NMT.

Palpating for, and treating, the neurolymphatic points

Kuchera (1997) suggests: ‘If Chapman’s [neurolymphatic] myofascial tender points are to be tested, palpate them early in the examination because motion of the myofascial tissues in their area decreases their sensitivity. In this case their diagnostic clue, tenderness with palpation, may not be evident.’

If, during NMT assessment mode application to the anterior thorax and abdominal region (see Ch. 7) unusual tenderness is noted in the region of the umbilicus, this may relate to bladder, kidney or adrenal dysfunction (see points 15, 16 and 37 on Figs 5.8A & 5.8B); similarly, tenderness in the area if an anterior point is noted in the left fifth or sixth intercostal interspace (see points 13 and 14 on Fig. 5.8A), the patient may usefully be asked about, for example, stomach or digestive symptoms.

Treatment of the lymphatic aspects of these dysfunctional organs or functions (should their existence be corroborated by other clinical evidence) might usefully include gentle applications of rotary pressure to the posterior points, in the sequence described in Chapter 5.

Arbuckle (1977) writes of Chapman’s reflexes:

Periosteal pain points

These painful areas (Table 4.4) usually relate to acute or chronic contraction of associated muscles and tendons.

Table 4.4 Periosteal pain points (adapted from Lewit 1992)

Felix Mann, pioneer acupuncture researcher and author, describes periosteal acupuncture as being more effective than ordinary acupuncture in a number of conditions (Mann 1963). He lists the sites given in Table 4.5 amongst the common sites usefully employed in this approach. Clinical experience indicates that NMT ischaemic compression techniques and muscle energy methods are as likely as traditional needling to produce benefit when treating these points.

Table 4.5 Periosteal acupuncture points and associations