Dkendall Mechanismsofacup LN

Understanding the Mechanisms
of Acupuncture to Enhance
Clinical Outcomes
by
Donald Kendall
O.M.D., Ph.D
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Clinical Outcomes
Mechanisms of Needling
D.E. Kendall, O.M.D, Ph.D
Lotus Institute Of Integrative Medicine

www.eLotus.org info@eLotus.org
Tel: (626) 780-7182 Fax: (626) 609-2929
© 2010 Donald Kendall & Lotus Institute of Integrative Medicine

Shall not be copied, duplicated, or distributed in any format or be used for teaching without prior written consent from Lotus Institute.
Miracle of Needling Therapy

z Needling triggers pain fibers, immune
responses, inflammation, gamma loop,
propriospinal system, and ANS
z Patients rarely feel any pain of needling
and inflammation restricted around needle
z These imperceptible reactions trigger
potent descending control normalization
z Restorative effects achieved by rational
selection and use of neurovascular nodes
Longitudinal Organization
z Chinese first discovered that main blood
vessels, muscles, and nerves are
longitudinally distributed through body
z Collaterals of longitudinal vessels gave
rise to neurovascular nodes (acupoints)
z Correlated organ referred pain with a few
specific nodes (segmental effects)
z Nodal pathways traversing visceral pain
areas then associated with specific organs
© Donald Kendall & Lotus Institute of Integrative Medicine, PO Box 92493, City of Industry, CA 91715
Tel: 626-780-7182 • Fax: 626-609-2929 • Website: www.eLotus.org • Email: info@eLotus.org
Shall not be copied, duplicated, or distributed in any format or be used for teaching without prior written consent from Lotus Institute 1
Segmental Dominance
z Longitudinal organization with segmental
neural dominance first evolved in flat
worms 600-570 million years ago
z Found in all vertebrates from 510-439
million years ago to present
z Genius of Chinese led to discovery that
needling was mediated by segmental and
longitudinal body relationships

Enhancing Clinical Outcomes

z Subtleties of needling are complex but well
understood and explainable by known
anatomical and physiological sciences
z Relies on application of spinal segmental
dominance and longitudinal relationships
z Already learned in acupuncture training but
never explained by any useful terms
z This knowledge improves outcomes, patient
satisfaction, and acceptance in healthcare
See appendix 1 for enlarged picture

1 PM
Posterior Lateral Hand

(PLH)
9 AM
3 PM
Standard Chinese
anatomical orientation Anterior Lateral Foot
(ALF) Posterior Lateral Foot
with respect sun (PLF)
position over 24 hour

7 AM
period showing 5 PM
longitudinal regions for Anterior Lateral Hand Great Yang (Taiyang)

time period with sun
(ALH)
distribution of blood angles indicated by
arrows
vessels, skeletal
muscles, and neuro- 5 A.M.
Sunrise or Bright Yang
vascular nodes (Yangming) time period
with sun angles indicated
by arrows
Lesser Yang (Shaoyang)

referring to stars visible at
this time with sun angles
indicated by arrows while 9 P.M.
on opposite side of earth
Deke Lateral Hand
(LH)
Lateral Foot
1 A.M. (LF) 11 P.M.
Chinese anatomical division nomenclature for neurovascular nodes
(acupoints) versus (Vs) usage introduced by Soulié de Morant
Chinese French Chinese French

AMH 1 to 11 Vs LU 1 to 11 ALH 1 to 20 Vs LI 1 to 20
ALF 1 to 45 Vs ST 1 to 45 AMF 1 to 21 Vs SP 1 to 21
PMH 1 to 9 Vs HT 1 to 9 PLH 1 to 19 Vs SI 1 to 19
PLF 1 to 67 Vs BL 1 to 67 PMF 1 to 27 Vs KD 1 to 27
MH 1 to 9 Vs PC 1 to 9 LH 1 to 23 Vs IM1 1 to 23
LF 1 to 44 Vs GB 1 to 44 MF 1 to 14 Vs LV 1 to 14
1. Internal Membrane System (sānjiāo 三焦)


Temporalis Frontalis
Scalenus Anterior
Superior Serratus Anterior
Muscles of the lateral foot (LF)

longitudinal body region described
in: Neijing Lingshu 13 Jīng Jīn 经筋
External Oblique
(Longitudinal Muscles) (With Internal Oblique &
Transverse Abdominis deeper)
Gluteus Medius Tensor Fascia Latae

Gluteus Minimus
Muscle and nodal Iliotibial Tract
distributions pathways Biceps Femoris Vastus Lateralis

(Short Head)
determined by propagated
sensation phenomena
Peroneus Longus
Peroneus Brevis
Extensor Digitorum Brevis
Deke
4th Dorsal Interosseous
SENSORY CORTEX
Dao of Chinese Medicine, Figure 14.3,
Oxford University Press © 2002 THALAMUS
PERIAQUEDUCTAL GRAY
DORSAL RAPHE
Norepinephrine Serotonergic
Neurons Neurons
Dorsal Root Ganglia Enkephalin
A-δ and C Nociceptive Neurons Interneuron Anterior
& Group II Static Load Neurons Lateral
Propriospinal
Tract
Pathways
Node 3
Antidromic DRR
Pathway
Tract of Lissauer
PS and DLF
Node 2
Antidromic DRR
Pathway
Dorsal
PS
Columns
Node 1
Needling Sensation &
Proprioceptive Signals
Ventral Spinal Cord

Funiculi Segment
Skin, Muscle, Connective
Tissue, Fine Vessels, Afferent
Nerve Endings, & Intrafusal
Muscle Spindle Fibers

See appendix 4 for enlarged picture CNS Descending Control
ALT
5HT NE Crossed
Skin Fibers
ENK
DRGN
SP Somatic Nociceptive Afferent
Axon Reflex
SP ENK
DRGN
NE
SP
Local Blood Spinal Cord
Visceral Paravertebral Dorsal Horn
Vessels
Nociceptive Ganglia
Afferent NE
ENK
ACH
NE Autonomic Motor
Neurons
Viscus Prevertebral ACH
Ganglia
Gamma Motor
Neurons Spinal Cord
Dromic Direction Ventral Horn
Antidromic Direction
Oxford University Press © 2002
Microtrauma of Needling Induces

Amplified Restorative Response
z Skeptics have argued that tissue damage
by fine needles is insignificant and not able
to produce any useful response
z Needling provokes blood coagulation and
immune complement systems that have
feed-forward amplification loops
z These interactions amplify and sustain
tissue and neural responses

Unique Features of Neurovascular

Nodes (Acupoints)
z Distributed along longitudinal pathways of
body where collaterals supply fine vessels
z Corneum stratum of skin is slightly thinner
with lower electrical resistance
z Contain more sensory nerves than non
nodal sites
z Have more fine vessels with sequestered
mast cells than non sites (motor points?)
Understanding Mechanisms
Important to Clinical Application
z Needling provokes known cascade of
complex tissue and neural reactions
z Influenced by depth and strength of needle
manipulation
z Influenced by needle retention time
z Selecting neurovascular nodes in terms of
local & adjacent, proximal, and distal to
problem directs restorative processes
Phases of Tissue Responses

z Tissue reactions to needling induced
microtrauma follow a set order
z Initial response is to mount strong
defensive reaction
z Important to keep blood clots from
forming so immune cells can flow in
z All needling induced inflammatory
reactants neutralized in final phase
Time Dependencies
z Vasodilatory, nociceptive nerve excitation,
chemotactic, solubility activities
predominate during initial phases of
needling response
z Tissue repair and inactivation of reactants
predominate during intermediate and latter
phases of reaction

Needling Induced Tissue Reaction Phases
Reaction Activity
Vasodilatory Hageman Factor XII dependent reactants, bradykinin,
complement, degranulation of mast cells, kinin protease, and
substance P released by axon reflex
Nociceptive Bradykinin B2 excites substance P A-delta and C fiber, and
Excitation sustains reaction by axon reflex vasodilatation acting on tissues
and sympathetic fibers
Chemotatic Attracts immune cells, including basophils, neutrophils,
monocytes and eosinophils
Solubility Activates C3 and C1, lysis fibrin, inhibits thrombin, disaggregates
platelets, and clears needle damage products
Tissue Repair Attraction, aggregation and degranulation of platelets, local
vascular constriction, and formation fibrin and clots
Inactivation Degradation of Hageman Factor XII, heparin and heparan
sulfate, SRS-A (LT C, D, & E), and histamine, and inhibits
formation of Arachidonic Acid
Anatomical Substrates to Needling

z Local fine vessels with sequestered mast
cells
z Slightly deeper veins that force egress of
immune cells at needling site
z Afferent Substance P nociceptive pain
nerve fibers that mediate “needling
response” and sustains needling reaction
by axon reflex

Muscle Spindle Afferents

z Static load spindle serves as feed back
control sensor essential to motor function
z Static load fibers needed to provoke
“propagated sensation” (PS) along vessel
pathway
z Spindles affected by local temperature and
pressure which can influence PS

Autonomic NS Participation
z Sympathetic (SNS) afferent and efferent
fibers of local blood vessels
z Parasympathetic fibers activated by
needling, but no PSNS nerves in extremities
z SNS normalization restores blood flow and
both SNS and PSNS participate to restore
visceral homeostasis

Central Nervous System

z Afferent nociceptive fibers synapse on
dorsal lateral funiculus (DLF) and
crossed anterior lateral tract (ALT)
z ALT comprised of spinothalamic (STT),
spinorecticular (SRT), and
spinomesencephalic (SMT) tracts
z Information processed mainly in brain
stem with descending control down DLF

Spinal Afferent Processing

System Involvement
z Transmits needling induced somatic
nociceptive and proprioceptive afferent signals
to stimulate higher CNS levels
z CNS directs descending control to inhibit
nociceptive fibers, plus somatic and autonomic
motor fibers over same spinal cord range
z Inhibit pain fibers; restores ANS balance,
normalizing vascular and visceral tone; relaxes
muscular tissue over range of needle insertion
Summary of Needle Stimulated Pathways
z CNS provides descending control to regions

of spinal cord that mediate:
– Inhibition of pain
– Relaxation of muscular tissue
– Normalization of vascular tone
– Restoration of visceral homeostasis
z Descending control processes directed by
practitioner to obtain desired clinical effect
Main Benefit of Needling

z Restore proprioceptive and motor function
through propriospinal reflexes, and by
direct influence on motor nerves
z Restores flow of nutrients (yíng 营),
oxygen from air (qì 气), defensive
substances (wèi 卫), substances of vitality
(hormones jīngshén 精神), and blood flow
to muscles and organs by normalization of
SNS signals
Role of Neurovascular Nodes

z Nodes exist at collateral branches of
longitudinal distribution vessels
z Contain high concentration of sensory
fibers, fine blood vessels, fine lymphatic
vessels, and mast cells
z Anatomical and histological properties
make nodes responsive to minute tissue
damage

Defensive Role of Skin
z Chinese noted skin has primary defensive
role
z Body evolved efficient defense against
pricking injuries, pathogenic assault, insect
bites, and animal bites
z Involves many factors of blood coagulation
system which then triggers the immune
complement system

Defensive Role of Skin

z Has complex neurovasculoimmune network
of cutaneous tissues, fine vessels, immune
cells, somatic afferents, and SNS fibers
z Important mediators include substance P
(NK 1), bradykinin (B1 & B2), and cytokines

Tissue Response to Needling

z Nodal sites contain high concentration of
fine vessels, nerve fibers, and mast cells
z Needle insertion causes visible immune
reaction flare response around needle
z Flare inhibited by capsaicin that depletes
substance P or by interrupting nerve
(Lewis c.1935)
z Mediators include mast cell histamine,
PAF, and leukotrienes, plus substance P
Response to Needle Insertion
z Inserting a needle or any other object
that pierces skin causes tissue trauma
z Insignificant trauma by needle results in
tissue and capillary damage products
z This includes collagen, microfibrils, and
fragments of basement membrane

Blood Coagulation System

z Involves certain proteins (zymogens) that
continually circulate in blood system
z Most are produced in the liver and are
responsible for keeping blood flowing
smoothly in vascular system
z Always balanced between clotting for
vessel repair and maintaining solubility
z Balance of clotting versus hemorrhaging

Blood Coagulation System

z Needle damage products activate
Hageman Factor XII to XIIA
z XIIA simultaneously activates the kinin,
fibrinolytic, and coagulation features of
blood coagulation system
z Causes localized immune defense to
needle involving vasodilatation, immune
cell egress, and nociceptive excitation
See appendix 5 for enlarged picture Needle Insertion
Damage to Endothelium of Small

Blood Vessels & Capillaries
Collagen, Microfibils
& Basement Membrane
Kinin Protease
Hageman Factor XII XIIa
from Mast Cells
(Plasma & Tissue Zymogen) & Basophils
Activates Immune
Plasminogen Plasmin Complement C3
Inhibited by Heparin XIIa Alternative Pathway
Prothrombin Thrombin
Blood Coagulation XIIa
System Provokes Kallikrien Chemotaxis

Needling Response
Plasma Kininogen
Bradykinin
Potent Vasodilitation & Nociceptive

Smooth Muscle Contraction Excitation Deke

Immune Complement System

z Basic defense mechanism that uses at
least 30 proteins in circulating blood
z Named "complement" because system
helps antibody kill invaders
z Marks any cell that does not have certain
protective protein coatings
z However, has an alternative pathway that
is activated by minute tissue trauma
Immune Complement
System
Classical Pathway
Involves attack by C1
when antibody bound to
antigen in an antigen-
antibody complex is
encountered.

Shall not be copied, duplicated, or distributed in any format or be
used for teaching without prior written consent from Lotus Institute.
Complement Alternative Pathway
z Alternate pathway is activated by the

blood coagulation system response to
tissue damage
z Does not require antibody to function
z Interacts with blood coagulation system to
amplify inflammatory response

Immune Complement
System
C3 Feed-Forward Pathway
C3 activated by Plasmin
immediately forms C3b
binding with Factor B which
then activates more C3 in a
feed-forward amplification

z Plasmin activates C3 provoking the

immune complement system
z Complement proteins C3 and C5 cause
potent vasodilatation by degranulating
mast cells and plasma basophils
z Released heparin inhibits thrombin

Needle
Insertion
Hageman
Factor XII Microfibrils and
Basement Membrane
Damage Products
Factor XIIa Plasmin

Activates C3
C3
Plasminogen
Kininogen Immune
Blood Coagulation Amplification
Complement System
System Loop
Prothrombin Alternative Pathway
(Inhibited by
Heparin from C3 C5 C3b,Bb
Kinin
Mast Cells) Protease
Bradykinin Mast Cell and

Arachidonic Acid Immune Cell
By-products ECF-A Attraction
NCF-A
Histamine LT C, D & E
Heparin PGE2
Nociceptive Excitation Potent Local Dao of Chinese Medicine, Figure 14.1,

Via B2 Receptors Vasodilation Oxford University Press © 2002


z Released kinin protease stimulates
production of more C3
z Neutrophilic and eosinophilic chemotactic
factors of anaphylaxis (NCF-A & ECF-A)
released
z These attract neutrophils and eosinophils
to damage site
z Neutrophils are plasma equivalent of mast
cell

Role of Mast Cells

z Are fixed in tissue usually associated with
fine blood vessels
z Contain heparin statically bound to
histamine which is degranulated by
action of C3a, C5a or C4a
z Selected phospholipids cell membrane
produces arachidonic acid (AA) to form
leukotrienes and prostaglandins

Basophil
z Also enters tissue and release cytokines
and proteins
z Resemble but are not identical to mast
cells, but do contain histamine and
heparin
z Participate in immediate-type hyper-
sensitivity
z Ranges from mild urticaria, rhinitis, and
to severe anaphylactic shock
Eosinophil
z Abundant in mucosa of gastrointestinal
tract to defend against parasites
z Play a role in fighting viral infections and
capable of killing off invading organisms
z Circulating eosinophils increased in
allergic reactions
z Includes asthma, other respiratory
diseases, and gastrointestinal diseases
Platelets
z Smallest corpuscular components with
half life of about 4 - 8 days
z Cytoplasm contain actin, myosin,
glycogen, lysosomes, and two types of
granules including serotonin
z Aggregation fostered by platelet
activating factor (PAF) secreted by
neutrophils, monocytes, and platelets

Mast Cells Selected Other Cell
and Baosophils Phospholipids Types
Phospholipase A2 or
Phospholipase C + Diglyceride Lipase (1)
Arachidonic
5 - Lipoxygenase (2) Cyclooxygenase (3)
Acid
5-HPETE PGG2
Modulates motility and

Leukotriene A4 5-HETE possibly glucose transport
Prostaglandin H2
SRS-A Potent Causes dissagregation

Pathway LTB4 chemotactic of platelets PGI2
agent
comparable Potent broncho and
Cleaved by vasodilators that regulate
Arly Sulfatase B to C5A PGE2
tissue microenviornment
Powerful bronchial
LTC4 constrictor
PGF2
100X More potent than histamine
1000X in producing bronchospasm Potent vasodilator
LTD4 preferently in human PGD2
100X More potent than histamine lung
100X on vascular permeability
LTE4 Potent regulators Thromboxane A2
of blood coagulation
1. Blocked by steroidal antiinflamatory drugs and homeostasis
2. Blocked by 5-LOX inhibiters
3. Blocked by selective and non-selective non-steriodal antiinflamatory
Thromboxane B2
drugs (NSAIDs) as COX-1 and COX-2 inhibiters Deke

Combined Action
z Blood coagulation system and alternative
pathway immune complement system
interact to amplify response
z C3 causes mast cell and basophils
degranulation and release of kinin
protease
z This preferentially causes more
production of bradykinin to stimulate
nociceptive fibers

Needle
Insertion
Hageman
Factor XII Microfibrils and
Basement Membrane
Damage Products
Factor XIIa Plasmin

Activates C3
C3
Plasminogen
Kininogen Immune
Blood Coagulation Amplification
Complement System
System Loop
Prothrombin Alternative Pathway
(Inhibited by
Heparin from C3 C5 C3b,Bb
Kinin
Mast Cells) Protease
Bradykinin Mast Cell and

Arachidonic Acid Immune Cell
By-products ECF-A Attraction
NCF-A
Histamine LT C, D & E
Heparin PGE2
Nociceptive Excitation Potent Local Dao of Chinese Medicine, Figure 14.1,

Via B2 Receptors Vasodilation Oxford University Press © 2002

Enhancing Vasodilatory Response
z Tissue mast cells, intimately sequestered
with fine blood vessels and nerve endings,
are primary proinflammatory agents
z In addition to C3 & C5, axon reflex release
of substance P, has prime role in mast cell
degranulation
z Activation of SNS fibers constricts slightly
deeper veins to enhance upstream
plasma leakage
Sustaining Reaction by Axon Reflex

z Bradykinin B2 activated SP (DRGC)
fibers mediate two axon reflexes
z Terminal branch SP release promotes
dilatation in local arterioles, capillaries,
and venules via NK 1 receptors
z SP fibers also branch to paravertebral
ganglia to constrict slightly deeper veins
z Provides differential control to mediate
neurogenic inflammation
CNS Descending Control

See appendix 4 for enlarged picture ALT
5HT NE Crossed
Skin Fibers
ENK
DRGN
Axon Reflex
SP ENK
DRGN
NE
SP
Vessels
Nociceptive Ganglia
Afferent NE
ENK
ACH
NE Autonomic Motor
Neurons
Ganglia
Gamma Motor
Neurons Spinal Cord

Nociceptive Activation
z Bradykinin B2 from needling response
excites local afferent nociceptive SP fibers
z These dorsal root ganglia cells (DRGC)
distribute to several laminae of dorsal horn
z Synapse on dorsal lateral funiculus (DLF)
and crossing anterior lateral tract (ALT) fibers
z Signals to afferent processing circuits involve
brain, spinal cord, muscles, vessels and
organs
Spinal Integration Sites

z SP nociceptive Aδ and group III DRGC
project to lamina I with collaterals to
laminae III-IV of spinal cord dorsal horn
z SP group IV and C fibers project to outer
region of lamina I
z Somatic and visceral SP fibers form links
giving rise to somatovisceral relationships
z Somatic SP fibers also stimulate group II
static load fibers in ventral horn giving rise
to propagated sensations
Ascending Pathways
z ALT comprised of spinothalamic (STT),
spinorecticular (SRT), and
spinomesencephalic (SMT) tracts
z Somatic and visceral nociceptive signals
synapse on ALT crossed fibers
z Major portion of SRT and SMT fibers
project to the pons, midbrain, and medulla
z A small portion of STT fibers projects to
the thalamus, which sends fibers to
sensory cortex
Spinal Cord Laminae

I-VI: Posterior/dorsal
horn
I: Posteromarginal nucleus
II/III: Substantia gelatinosa
of Rolando
III/IV/V: Nucleus proprius
VI: Nucleus dorsalis
VII-IX: Anterior/ventral
horn
VII: Intermediolateral
nucleus
VIII: Motor interneurones
IX: Motor neurons
X: Neurons bordering
Central canal

Propriospinal Participation
z Nociceptive fibers activate propriospinal
fibers to produce muscle flexion responses
z Muscle reflexes also trigger skeletal
muscle vasculature SNS efferents
z Proprioceptive group II afferents send
terminal branches to all laminae except II,
and ultimately synapse on motor fibers
z Propriospinal short and long fibers traverse
the length of the DLF

z Disorders in this system can result in
paralysis, stiffness, pain and tenderness
z Static load fibers needed to provoke PS
z Spindle affected by local temperature and

Flexor Withdrawal Reflex
z Stimulated by cutaneous and tissue Aδ
(Group III) and C (Group IV) pain fibers
z Activates ipsilateral flexors and inhibits
ipsilateral extensors
z Activates contralateral extensors and
inhibits contralateral flexors
z Usual pattern is ipsilateral flexion and
contralateral extension
Two main types of intrafusal (fusimotor) fibers


z Disorders in this system can result in
paralysis, stiffness, pain and tenderness
z Static load fibers needed to provoke PS
z Spindle affected by local temperature and

Dorsal Root Potentials and Reflexes
z Somatic and visceral nociceptive fibers
and proprioceptive fibers, trigger dorsal
root potentials and reflexes (DRR)
z These reflect up and down the DLF firing
nerves above and below entry signal level
z Have possible role mediating afferent
inputs and supraspinal descending control
z Muscle potentials can be provoked causing
PS when threshold conditions permit
SENSORY CORTEX
PERIAQUEDUCTAL GRAY
DORSAL RAPHE
Neurons Neurons
Propriospinal
Tract
Pathways
Node 3
Antidromic DRR
Pathway
Tract of Lissauer
PS and DLF
Node 2
Antidromic DRR
Pathway
Dorsal
PS
Columns
Node 1
Ventral Spinal Cord

Funiculi Segment
Tissue, Fine Vessels, Afferent
Nerve Endings, & Intrafusal © 2010 Donald Kendall & Lotus Institute of Integrative Medicine
Muscle Spindle Fibers
Shall not be copied, duplicated, or distributed in any format or be used
for teaching without prior written consent from Lotus Institute.
Propagated Sensation
z Subjective feeling of nerve activation that
travels along nodal pathways of body
z On extremities, pathway is about 1-2 cm
wide and 10 cm wide on trunk and face
z Muscle action potentials (MAP) can be
measured along course of PS
z Can be blocked by mechanical pressure
on node or lowered temperature
indicating involvement of static load
muscle spindle fibers
PS as Neural Reflex
z Result of stimulating high threshold SP
nociceptive fibers to activate muscle spindle
afferents to produce DRRs of the DLF
z Afferent neural signals enter spinal cord over
several segmental levels
z This overlap allows higher and lower levels to be
activated if threshold conditions permit
z Progressive activation of overlapping segments
produces PS along nodal pathways
Controlling Pathways
z Needling based on practitioner selection
of nodes to direct restorative responses
z Clinical effects mediated through several
key nuclei in brain stem
z Supply supraspinal pathways to specific
spinal cord levels via the DLF and TOL

Supraspinal Control
z Descending signals provide:
– Inhibition of somatic and visceral pain fibers
– Restoration of somatic motor functions and
reduces spasms
– Promote homeostasis by restoring
sympathetic and parasympathetic autonomic
motor function to viscera and blood vessels

Endogenous Control
z Reflex activity of spinal afferent system
by needling activates supraspinal
descending control
z These processes are same as those
involved in endogenous control of pain,
visceral functional activities, and
homeostasis

Descending Control
z Influenced by:
– Somatosensory cortex via thalamus
– Nuclei within limbic lobe
– Basal ganglia systems
z Most significant control of needling
effects mediated by centers in brain stem

Descending Control
z Nucleus raphe magnus (NRM) in final
pathway to spinal cord perhaps most
important
z Both 5HT (serotonin) and NE
(norepinephrine) nerve fibers involved in
descending control via DLF
z Analgesia only completely abolished
when both sets of these fibers are
destroyed
Multiple Pathways
z Main beneficial descending control
pathway involves enkephalin-containing
5HT neurons
z Possibly mediates endogenous pain and
visceral homeostatic control processes
z Other pathway involves NE neurons
possibly related to stress analgesia

NE Pathway
z Activated when external stimuli are
potentially life threatening and brought
into play as part of stress response
z Needling stimulation not usually directed
to stimulate this pathway
z If input stimulus is excessive, stress
pathway may be activated

Stress Analgesia
z May only differ as result of magnitude of
applied stimulus to bring about the
reaction
z Influenced by severity of stimulation
z Induced by electrical stimulation as well
when amplitude and frequency are
increased

Analgesia Characteristics
z Plasma cortisol levels show little change
while NE and cyclic adenosine
monophosphate (cAMP) show
significant decreases in normal needling
z Cortisol, NE and cAMP show significant
increase with stress analgesia
z Morphine produces analgesia as well
and influences certain brain nuclei
Tolerance Development
z Repeated use of needling therapy can
produce tolerance
z Can involve either 5HT or NE pathways
z Can show a cross tolerance to
morphine
z Patients typically show effect after 21
days of needling

Brain Nuclei
z Most important nuclei in 5HT needling
mediated descending control pathways:
– Periaqueductal gray (PAG)
– Dorsal raphe nucleus (NDR)
– Nucleus raphe magnus (NRM)
– Nucleus reticularis paragigantocellularis
(NRPG)
– Arcuate nucleus of hypothalamus (ARC)

Noradrenergic Nuclei
z NE supraspinal pathways also include:
– Locus ceruleus (LC)
– Lateral reticular nucleus (NRL)
– Descending NE fibers from cell groups A1
and A5

Provoking Analgesia
z Electrical stimulation of previous brain
areas produces descending inhibition of
afferent nociceptive signals and motor
fibers
z Stimulation of the PAG inhibits both
proprioceptive and C fiber afferents

Provoking Analgesia
z Most of these nuclei participate in
mediating needling analgesia, ENT,
stress analgesia, morphine analgesia,
and tolerance
z Stress analgesia mostly involves the
NDR, LC and ARC

Provoking Analgesia
z Morphine analgesia involves the ARC
as well
z Final descending control pathways to
trigeminal nucleus and spinal cord
involve both 5HT and NE

Final Pathways
z PAG is primary reception site for
ascending nociceptive information as well
as receiving descending inhibition from
somatosensory cortex via circuits that
distribute to NDR
z NRM is perhaps most important final
integration site for descending 5HT fibers,
possibly involving 5HT1 receptors

Final Pathways
z Neurons in PAG or NRM that respond
to somatic or visceral noxious stimuli
have significant ipsilateral projection
fibers to trigeminal nucleus and spinal
cord via DLF
z Analgesia produced by electrical
stimulation of PAG is attenuated by
ipsilateral lesion of DLF

Final Pathways
z Many descending fibers are enkephalin
containing 5HT neurons which synapse
onto dorsal horn nociceptive inhibitory
interneurons which have opiate
receptors
z Possibly inhibiting NK1 receptors on
substance P neurons

Final Pathways
z Analgesia by mu-opiate receptors may
involve postsynaptic second-order
nociceptive interneurons in spinal
trigeminal nuclei and spinal cord dorsal
horns in rat

of Acupuncture to Enhance Clinical Outcomes
Needling for Consistent Clinical Results
by
Donald Kendall, L.Ac., O.M.D., Ph.D.

Clinical Outcomes
Needling for Consistent Clinical Results
D.E. Kendall, OMD, PhD
Lotus Institute Of Integrative Medicine

www.eLotus.org info@eLotus.org
Tel: (626) 780-7182 Fax: (626) 609-2929

Needling to Treat Disease

z Disease seen as deviations in physiological
balance & function (zhèngqì 正气)
z Needling operates by the same pathways
manifesting with pain and dysfunction
z Needling provokes high threshold signals
that stimulate ascending pathways not
responding to the pathology
z Resulting descending control reduces pain
& inflammation, and restores balance
Controlling Pathways
z Promote homeostasis by restoring internal
organ and endocrine function, restoring
blood flow, reducing pain and spasms,
restoring muscle control and function,
clearing inflammation, reducing stress,
and calming the mind.
z This involves descending supraspinal
pathways to specific spinal cord levels via
the DLF and TOL (Tract of Lissauer)
Shall not be copied, duplicated, or distributed in any format or be used for teaching without prior written consent from Lotus Institute. 1
Characteristics of Chinese assigned organ vitalities
and related endocrine glands
Vitalities Vigor (pò 魄) Drive (zhì 志) Mood (hún 魂) Vitality (shén 神) Intent (yì 意)
Location Air1 Essence2 Blood3 Vessels4 Nutrients5
Primary Lungs Kidneys Liver Heart Exocrine
Organ(s) Pancreas
Paired Bowel Large Bladder Gallbladder Small Intestine Stomach
Intestine
Related Tissue Skin Bone Muscle Vessels & Flesh
Nerves
Vitality Vigor; Drive; Will; Mood; Soul; Vitality; Intent;
Characteristics Physical Aspiration Spirit Mentality; Desire;
Strength; Expression; Inclination;
Animation; Natural Abilities; Thought;
Life Animal Spirit Idea
Endocrine Thyroid Adrenal Pineal Pituitary Endocrine
Gland(s) (thyroxin) Glands (melatonin) (oxytocin) Pancreas
Emotions Grief & Worry Fear & Fright Anger Joy Pensiveness
Earth Phase Metal Water Wood Fire Soil
1. Inhaled air (qì 气); 2. Refined substances (jīng 精); 3. Blood (xuè 血); 4. Indicates both blood
vessels (mài 脉) and nerves (shénjīng神经); 5. Nutrients (yíng 营). © D.E. Kendall

See appendix 3 for enlarged picture SENSORY CORTEX

PERIAQUEDUCTAL GRAY
DORSAL RAPHE
Neurons Neurons
Propriospinal
Tract
Pathways
Node 3
Antidromic DRR
Pathway
Tract of Lissauer
PS and DLF
Node 2
Antidromic DRR
Pathway
Dorsal
PS
Columns
Node 1
Ventral Spinal Cord

Funiculi Segment
Tissue, Fine Vessels, Afferent © 2010 Donald Kendall & Lotus Institute of Integrative Medicine
Nerve Endings, & Intrafusal
Muscle Spindle Fibers Shall not be copied, duplicated, or distributed in any format or be used
for teaching without prior written consent from Lotus Institute.
See appendix 4 for enlarged picture CNS Descending Control

ALT
5HT NE Crossed
Skin Fibers
ENK
DRGN
Axon Reflex
SP ENK
DRGN
NE
SP
Vessels
Nociceptive Ganglia
Afferent NE
ENK
ACH
NE Autonomic Motor
Neurons
Ganglia
Gamma Motor
Neurons Spinal Cord

Needling Induced Tissue Reaction Phases
Reaction Activity
Vasodilatory Hageman Factor XII dependent reactants, bradykinin,
complement, degranulation of mass cells, kinin protease, and
substance P released by axon reflex
Nociceptive Bradykinin B2 excites substance P A-delta and C fiber, and
Excitation sustains reaction by axon reflex vasodilatation acting on
tissues and sympathetic fibers
Chemotatic Attracts immune cells, including basophils, neutrophils,
monocytes and eosinophils
Solubility Activates C3 and C1, lysis fibrin, inhibits thrombin,
disaggreagates platelets, and clears needle damage products
Tissue Repair Attraction, aggregation and degranulation of platelets, local
vascular constriction, and formation fibrin and clots
Inactivation Degradation of Hageman Factor XII, heparin and heparan
sulfate, SRS-A (LT C, D, & E), and histamine, and inhibits
formation of Arachidonic Acid
Fine Needle LS 1 & 78

z Used to treat cold and hot rheumatic pains
situated in the collateral vessels
z Can be retained for longer time to reduce
pain, clear inflammation, and restore
physiological balance (zhèngqì 正气)
z By influence on metabolic processes
(zhēnqì 真气) causing dissipation of
pathogenic (xiéqì 邪气) conditions

Fundamental Metabolism
z Metabolic processes (zhēnqì 真气) under
genetic control inherited from mother
z Involves use of oxygen from inhaled air
(qì 气) and glucose from absorbed
nutrients (yíng 营) to fuel bodily function
z Basic energetic process now known to
occur within cellular mitochondria
controlled by mother’s mDNA
z First described in West by Krebs in 1937
Metabolic Anatomical & Physiological
Substrates Components
Plasma
Qi (Air) - Oxygen - & Cells
- Blood (Xue)
Ying - Absorbed - Blood Vessels (Mai)
Nutrients
Jing - Refined
Wei - Defensive - Lymphatics &
Substances Zhengqi or
Substances Immune System
Shenjing - Hormones - Endocrine Glands Physiological
Shenqi - Nerve Signals - Brain & Nerves Function
Zongqi - Heart & Lung - Blood Circulation (Homeostasis
Functional (Qi) Function & Respiration + Allostasis)
Aspects Zangfuqi - Internal Organ - Digestion, Fluids,
Function & Elimination
Zhenqi - True Function or - Cellular Level
Deke Energy Production Metabolism
Modern view of metabolic, functional, anatomical, and physiological

components of Chinese concept of physiological function (Zhèngqì 正气)
regulated by homeostatic (feedback) and allostatic (feed forward) means

1 PM
Posterior Lateral Hand

(PLH)
9 AM
3 PM
Standard Chinese
anatomical Anterior Lateral Foot
(ALF) Posterior Lateral Foot
orientation with (PLF)
respect sun position

7 AM
over 24 hour period 5 PM
showing longitudinal Anterior Lateral Hand Great Yang (Taiyang)

time period with sun
(ALH)
regions for angles indicated by
arrows
distribution of blood
vessels, skeletal 5 A.M.
Sunrise or Bright Yang
muscles, and neuro- (Yangming) time period
with sun angles indicated
vascular nodes by arrows
Lesser Yang (Shaoyang)

referring to stars visible at
this time with sun angles
indicated by arrows while 9 P.M.
on opposite side of earth
Deke Lateral Hand
(LH)
Lateral Foot
1 A.M. (LF) 11 P.M.

Selection of Nodal Sites

z Depends on vessels, muscles, and
longitudinal organization of spinal cord
z Somatotopically related nodes for visceral
and musculoskeletal problems
z Distal, proximal, and special effect nodes
selected to direct therapeutic processes
z Logical treatment approach relies on
understanding descending control by CNS

Needle Manipulation
z Characteristics of treatment controlled
by strength of needling, insertion depth,
and retention time
z Stronger stimulation produces more
needle induced tissue damage products
z Longer needle retention time favors
restorative anti-inflammatory response

Node Indications Show

Segmental Correspondence
z Back shu and front mu nodes show good
segmental correspondence between
somatic and visceral integration levels
z Nodes for all longitudinal vessels only
show similar correspondences for
specific regions of body
z Nodes are viewed separately for visceral
and somatic indications
z Nodes also have distal indications
Front Mu - Recruitment Nodes

AMH 1 Zhongfu - Lung
REN 17 Shanzhong - PC
REN 14 Juque - Heart
MF 14 Qimen - Liver
LF 24 Riyue - Gallbladder
REN 12 Zhongwan - Stomach
LF 13 Zhangmen - Pancreas/Sp
LF 25 Jingmen - Kidney
ALF 25 Tianshu - Large Int.
REN 6 Qihai
REN 5 Shimen - Int. Membrane
REN 4 Guanyuan - Small Int.
REN 3 Zhongji - Bladder
Deke

1.5
Back Shu - Communication Nodes
PLF 13 Feishu - Lung
C7
T1 PLF 14 Jueshu - PC
PLF 15 Xinshu - Heart
PLF 16 Dushu
PLF 17 Geshu - Diaphragm
EX. PT . Weiguanxi a
PLF 18 Ganshu - Liver
PLF 19 Danshu - Gallbladder
PLF 20 Yi-Pishu - Pancreas/Spleen
PLF 21 Weishu - Stomach
L1
PLF 22 Sanjiaoshu - Int. Membranes
PLF 23 Shenshu - Kidney
PLF 24 Qihaishu
PLF 25 Dachangshu - LI
PLF 26 Guanyuanshu
PLF 27 Xiaochangshu - SI
PLF 28 Pangguanshu - Bladder
DU Nodes Deke PLF 29 Zhonglushu
PLF 30 Baihuanshu
Somatovisceral Relationships
z One of most important theories and
discoveries of Chinese medicine
z Involves common integration sites of
nerves supplying nodes and organs
z Shown by retrograde studies of injected
horseradish peroxidaze (HRP) into specific
nodal sites and internal organs
z HRP transported by nerves to spinal cord
Somatovisceral Reflexes
z Response to stimulating cutaneous,
muscular and articular sensory afferents
are measured in internal organs and
major vessels
z Some reflexes display dominant
sympathetic efferent participation and
others have parasympathetic efferent
attributes

Nature of SV Reflexes
z Spinal cord may have functionally
distinct reflex pathways unique to
different aspects of vascular system and
to each organ
z These spinal circuits may be basis for
all homeostatic regulation involving
autonomic systems represented in brain
stem and hypothalamus

Node Location
z Effect on PENS on rat hind paw pain:
– Inhibited by Zusanli (ALF 36)
– Ineffective by Xiaguan (ALF 7)
z Analgesic effect abolished by lesion of
nucleus raphe magnus (NRM)

Electro Activity Study

z Response of neurons at T2-T3 level in
rabbit by PENS to Neiguan (MH 6) or
Zusanli (ALF 36)
z5 of 6 were excited and 1 inhibited by
Neiguan (MH 6)
z6 fibers responding to both nodes were
inhibited by Zusanli (ALF 36)

Heart Afferent HRP Studies
z Neiguan (MH 6), Shenmen (PMH 7),
and Shaohai (PMH 3) HRP retrograde
in rabbit and cat
z Show corresponding overlap at same
spinal cord levels
z Consistent with spinal cord induced
DRPs by PENS of Neiguan (MH 6)

Heart HRP Studies

z Heart sympathetic afferent neuron
projection to spinal cord in cat by HRP
retrograde
z Showed segmental distribution from C8 –
T9 for heart and cardiac nerve
z Labeled fibers observed in laminae III –
VII of spinal cord

Stomach HRP Studies

z Projection sites to brain stem by HRP
injection of anterior stomach wall
z Reaches localized areas of Vagus
center, including dorsal motor nuclei
z Those found in nodular ganglia of Vagus
center mostly from pylorus

Superficial temporal a. Zygomaticoorbital a.
See appendix 9 for enlarged picture External carotid a.
8
1
Anugular a.
Dorsal nasa a.
7 2
Common carotid a. 3
6 4 Superior and inferior labial aa.
Subclavian a. 5 Facial a.
9
12 10 Brachiocephalic trunk
13 11
14 Arteries suppling
Internal thoracic a.
15 teeth are not shown
Aorta
16
17
Celiac trunk
18 19
Splenic a.
20
21 Right Left
Superior and inferior 22
gastric a. gastric a.
23
epigastric aa. 24
25
26
27
28
29
30
31 External iliac a.
Femoral a.
32
33
34
Lateral superior
35
and inferior aa.
36
37
Anterior tibial a.
40 38
39
ALF Nodal Pathway

Dorsalis pedis a. 41
42
Arcuate a. with Underlying
Dorsal metatarsal a. 43
Dorsal digital aa.1, 2
45
44
Deke
Blood Vessels
1. Medial aspect of the third toe and lateral side of the second toe
2. Lateral and medial dorsal digital arteries of the first toe and
medial aspect of the second toe

Somatic indications for ALF vessel nodes in the head region along
with associated distal nodes
ALF Distribution Vessel Nodes
Indications 1 2 3 4 5 6 7 8 40 41 42 43 44 45
Eyelid Twitching X X X X
Facial Paralysis X X X X X X X
Facial Pain X X X X
Toothache X X X X X X
Pain in Upper Teeth X
Mouth Deviation X X X
Cheek & Face Swelling X X X X X

Motor Impairment of Jaw X
Headache X X X

Sibai (ALF 2) Projections

z Afferent fiber HRP retrograde from Sibai
(ALF 2) showed distribution to:
– Semilunar ganglion of trigeminal nerve
– Facial motor nerve nucleus
– Oculomotor nucleus
– Upper cervical ganglion
– Motor nucleus of trigeminal nerve

Visceral indications for ALF vessel nodes in the head region along
with associated distal nodes
Indications 1 2 3 4 5 6 7 8 34 36 39 40 44 45
Redness, Swelling, and X X
Pain of Eye
Lacrimation X X
Opthalmalgia X
Night Blindness X X
Itching of Eye X
Epistaxis X X X
Salivation X
Excess Sputum X
Trismus X X
Mumps X
Deafness, Tinnitus, and X

Otorrhea
Somatic indications for ALF vessel nodes in the trunk

with no associated distal nodes
ALF Distribution Vessel Nodes*

Indications 1 2 3 4 5 6 7 8 11 12 15 26-30
Neck Pain & Rigidity X
Supraclavicular Pain X
Pain in Costal Region X
Hernia X
*ALF 17 (Ruzhong) is used as a landmark and has no indications; both needling and
moxibustion are contraindicated

Visceral indications for ALF vessel nodes in the neck

and upper thoracic region along with associated distal nodes

Indications 9 10 11 12 13 14 15 16 18 34 36 39 40 44 45
Dizziness X X X
Flushing of Face X
Goiter X X
Hiccup X X
Sore Throat X X X X X
Hoarse Voice X
Asthma X X X X X X X X X X
Cough X X X X X X X X X
Chest Fullness X X X X
Chest Pain X X X X X X
Hypochondrium Pain X X
Mastitis X X X X X
Insufficient Lactation X
*ST 17 (Ruzhong) is used as a landmark and has no indications, both needling and moxibustion is contraindicated

Stomach HRP Studies
z Unilateral HRP injection of into Ruzhong
(ALF 17) and Zusanli (ALF 36) in rat
z Respectively showed transport to T4 – 6
and L4 – 5 spinal segments
z PENS of Ruzhong (ALF 17) and Zusanli
(ALF 36) caused increased HRP uptake
z Also spread of labeled cells to adjacent
dorsal roots

Stomach HRP Studies

z HRP injection of into cardia, pylorus, and
tunica serosa of rabbit stomach labeled
visceral afferents from C4 – L7
z Results in small overlap with Zusanli
(ALF 36) projection to T10 – S2
z Stomach wall afferent projection to spinal
ganglia (T3 – L4) shows better
correspondence with Zusanli (ALF 36)

Visceral indications for ALF vessel nodes in the upper and

lower abdominal regions along with associated distal nodes

Indications 19 20 21 22 23 24 25 26 30 36 37 40 41 43 44 45
Abdominal Distension X X X X X X X X X
Abdominal/Gastric X X X X X X X X X X X X
Pain
Anorexia X X X X
Vomiting X X X X
Acid Regurgitation X
Diarrhea X X X X X X
Constipation X X X X X X
Dysentery X X X X
Borborygmus X X X X X
Enteritis X X

Gallbladder Afferents
z HRP injection in Ganshu (PLF 18), Pishu
(PLF 20), Liangmen (ALF 21) and Qimen
(MF 14) of guinea pigs
z HRP injection in gallbladder in separate
group of animals
z Mutual overlap of 5 – 7 spinal segments
observed between four nodes and
gallbladder
Gallbladder Contractions
z Needling Yanglingquan (LF 34),
Dannang (extra), and Zusanli (ALF 36)
on right side induces gallbladder
contractions
z Measurable electrical muscular activity
and contractions in Oddi sphincter of
gallbladder
z Shousanli (ALH 10) showed little effect
Ejecting GB Stones
z Needling Jujue (AMF 16) and Burong
(ALF 19) along with leg sites promote
contraction in common bile duct
z Needling Qimen (MF 14) (LV Mu Node)
and Riyue (LF 24) (GB Mu Node)
overlying gallbladder region needed to
be employed to actually eject gallstones

Visceral indications for ALF vessel nodes in the abdominal
region along with associated distal nodes

Indications 22 23 24 25 26 27 28 29 30 36 37 40 41 43 44 45
Edema X X X X
Indigestion X X
Irritability X
Mania X X X X X
Epilepsy X X
Insomnia X X
Pain around X
umbilicus
Lower Abdominal X X X X X
Pain/Distension
Dysuria X
Retention of Urine X

Visceral indications for ALF vessel nodes in the lower abdominal

region along with no associated distal nodes

Indications 22 23 24 25 26 27 28 29 30 36 37 40 41 43 44 45
Seminal Emission X
Premature X
Ejaculation
Irregular X X X
Menstruation
Dysmenorrhea X X X X
Amenorrhea X
Sterility X
Leukorrhea X
Uterus Prolapse X
External Genitalia X
Pain
*Remaining indications: ALF 36 for emaciation due to deficiency, and ALF 44 & 45 for febrile diseases
Somatic indications for ALF vessel nodes

in the thigh, lower leg, and foot region
Indications 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45
Pain in Thigh X
Pain & Numbness of X X

Lower Limbs
Motor Impairment of X X X X
Lower Extremities
Muscular Atrophy of X X
Lower Limb
Pain & Paralysis of X X X X

Lower Limb
Pain in Lumbar and X

Iliac Region
Backache Referring to X
the Testis

in the thigh and lower leg region
Indications 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45
Knee Coldness X
Leg & Knee Pain X X X

and Numbness
Knee Pain, X
Numbness, and
Motor Impairment
Knee Joint and Leg X

Pain


in the lower leg and foot region
Indications 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45
Paralysis due to X
Stroke
Hemiplegia X
Weakness & Motor X

Impairment of Foot
Shoulder Pain & X
Motor Impairment
Pain in Ankle Joint X
Muscular Atrophy & X

Impairment of Foot
Pain & Swelling of X X
Dorsum of Foot
Leg & Foot Coldness X

Bladder Afferents
z Visceral afferents from rabbit bladder
integrate in cord from T6 – Cox 1
z Somatic afferents from tibial and
peroneal nerves distribute to L6 – S3
z Somatic afferents from Zhiyin (PLF 67)
integrate in cord from L2 – S1
z Shows overlap with bladder afferent
integration level
Bimodal Distribution
z Bladder afferents show concentration
between L2 – L4 and between S2 – S5
z Upper group corresponds to Shenshu
(PLF 23) and sympathetic function
z Concentration in lower area corresponds
with Pangguanshu (PLF 28) and
parasympathetic function

Zhiyin (PLF 67) and Uterus

z HRP in rabbit show uterus afferent
fibers spread from T11 – S3
z Showing overlap with afferents of Zhiyin
(PLF 67) of L2 – S1
z One study with moxibustion on Zhiyin
(PLF 67) corrected breech presentation
in 98 of 130 fetuses (75.4%)

Nodes Selected for Specific

Muscular or Visceral Problem
z Local and Adjacent: One or more nodes
involving affected area or have
somatovisceral utility
z Proximal: located closest to appropriate
spinal cord segment to focus descending
control at correct spinal level
z Distal: on affected distribution (vessel or
muscle) to direct descending control to
lowest spinal level to assure wide coverage
Brain
Needle
Needle Insertion
Insertion Descending
Descending Stem
Along
AlongVessel
Vessel Inhibition
Inhibition
Proximal
Proximal Proximal Segemental
Nodes
Nodes Region Level
Afferent
Localand
Local and Signals
Region of Segemental
Adjacent
Adjacent
Nodes Problem Level
Nodes
Distal
Distal Distal Segemental
Nodes
Nodes Region Level
Use of Nodes in Relation to Problem

Dao of Chinese Medicine: Figure 15.1, Oxford University Press
Longitudinal Muscles LS 13
z Describes six lateral and medial muscle
distributions originating on the hand and
feet on each side of body
z Only the gastrocnemius, quadriceps,
sternocleidomastoid, and diaphragm are
specifically named
z Others described by insertion and origins
z Lateral distributions preferentially used in
treatments
Longitudinal Muscles LS 13
z Also describes pain and muscular problems
along each distribution
z Provides a quick reference for each joint to
determine likely distribution involved
z Often need to perform orthopedic
assessment to fully understand problem
z Essential in Workers’ Compensation and
insurance cases, patient files, and reports
Kinesiology & Other Data
z Important to understand function of prime
and assistant movers of each articulation
z Also important to know the muscles in each
Chinese muscle distribution (MD)
z Essential to also know spinal segment of
nerve roots supplying specific muscles to
understand rational selection of nodes for
treatments

Function of prime mover (PM) and assistant mover (AM) muscles

moving the humerus (example)
Muscle MD Nerve Root Extension Flexion Abduction Adduction Internal External
Rotation Rotation
Supraspinatus LH C4, 5, 6 PM
Infraspinatus PLH C(4), 5, 6 PM
Teres minor PLH C5, 6 PM
Teres major PLH C5, 6, 7 PM PM PM
Anterior deltoid AMH C5, 6 PM AM AM
Middle deltoid ALH C5, 6 PM
Posterior deltoid LH C5, 6 AM AM AM
Subscapularis ALH C5, 6, 7 AM1 AM1 AM2 PM
Latissimus dorsi PLF C6, 7, 8 PM PM AM
Pectoralis major, U MH C5, 6, 7 PM AM
Pectoralis major, L PMH C6, 7, 8, T1 PM
Triceps, long head PLH C6, 7, 8, T1 AM AM
Biceps brachii (LH) ALH C5, 6 AM AM
Biceps brachii (SH) AMH C5, 6 AM AM AM
Coracobrachialis MH C6, 7 AM AM2 AM2 AM3
1. Varies with joint position and synergistic muscle activity; 2. Only when arm is above horizontal; 3. Only from
position of rotation to neutral point.
Possible Clinical Signs in Muscles

Moving the Posterior Aspect of Neck
Distribution Clinical Signs Related to Region or Articulation

PLF Inability to bend the head forward, or to turn neck left or
right; abnormal curvature in the nape of the neck; and
muscular spasms in the nape of the neck
PMF Inability to bend the head backwards
PLH Spasms in the neck muscles, which can result in fistula

of these muscles; swelling in the neck

Regional selection of nodes for pain
of the posterior aspect of the head and neck
Head & Local & Adjacent MD Proximal Nodes Distal Nodes

Neck Nodes
Posterior Fengchi (LF 20) PLF Tianzhu (PLF 10) Feiyang (PLF 58)
Aspect Jianjing (LF 21) Dazhu (PLF 11) Kunlun (PLF 60)
Jianzhongshu PMF Tianzhu (PLF 10) Zhubin (PMF 9)
(PLH 15) Dazhu (PLF 11) Taixi (PMF 3)
PLH Tianzhu (PLF 10) Houxi (PLH 3)
Dazhu (PLF 11)


Moving the Lateral Aspect of Neck

LF Pain and spasms in the muscles and tendons in anterior
lateral aspect of the neck
ALH Pain, spasms and acute cramps along lateral aspect of neck;
inability to turn the neck left or right to look either direction
LH Acute cramps and spasms along lateral aspect of neck

PLH Spasms in the neck muscles, which can result in fistula of
these muscles; swelling in the neck

Regional selection of nodes for

pain of the lateral aspect of the head and neck
Head & Local & Adjacent MD Proximal Nodes Distal Nodes

Neck Nodes
Lateral Fengchi (LF 20) LF Fengchi (LF 20) Zulingqi (LF 41)/
Aspect Tianyou (LH 16) Diwuhui (LF 42)
Tianchuang (PLH 16)
Jianjing (LF 21) ALH Dazhu (PLF 11) Hegu (ALH 4)
Feishu (PLF 13)
LH Fengchi (LF 20) Zhongzhu (LH 3)
PLH Jianzhongshu (PLH 15) Houxi (PLH 3)

Moving the Humerus (Shoulder Joint)
PLH Pain in the posterior aspect of the arm, shoulder and axilla; pain
wrapping around the scapula
LH Acute cramps and spasms along posterior deltoid muscle and upper
scapular region
ALH Pain, spasms and acute cramps along medial deltoid muscle and
subscapular regions; with inability to raise the shoulders
AMH Acute cramps and spasms along anterior deltoid muscle
MH Acute cramps and spasms along clavicle and upper sternal
pectoralis muscle, and anterior region of the chest with dypsnea
related to the region of the cardia
PMH Acute cramps and muscular pain in the lower sternal, costal and
abdominal pectoralis muscles; pain and pressure in the chest and
heart radiating down arm and elbow
PLF Cramp like pain in the axilla, involving the latissimus dorsi muscle,
extending to the supraclavicular region
Candidate regional, proximal and distal nodes

for pain and disorders of the shoulder
Shoulder Local & Adjacent MD Proximal Nodes Distal Nodes

Nodes
Anterior Yunmen (AMH 2) AMH Fengchi (LF 20) Hegu (ALH 4)
Lateral Jugu (ALH 16) ALH
Jianyu (ALH 15) Dazhu (PLF 11)*
Jianliao (LH 14) Feishu (PLF 13)*
Lateral Jugu (ALH 16) ALH Dazhu (PLF 11) Hegu (ALH 4)
Posterior Jianliao (LH 14) Feishu (PLF 13)
Jianzhen (PLH 9) LH Fengchi (LF 20) Zhongzhu (LH 3)
Naoshu (PLH 10) PLH Tianzhu (PLF 10) Houxi (PLH 3)
Jianzhongshu(PLH 15)
* Add if signs of subscapularis tendonitis or pain


Moving the Scapula (Shoulder Girdle)

PLF Inability to raise shoulders due to pain in trapezius and neck
PLH Pain wrapping around the scapula and leading up to the neck
ALH Pain, spasms and acute cramps from region of rhomboids traveling
up along neck; inability to raise shoulders due to pain in the region of
the rhomboids
AMH Spasms in sides of the upper ribs associated with the pectoralis
minor muscle muscles
MH Acute cramps and spasms along serratus anterior and
coracobrachialis muscles
LF Pain and spasms along top of shoulder

Regional Selection of Nodes for
Pain and Disorder of the Scapula
Scapula Local & Adjacent MD Proximal Nodes Distal Nodes

Nodes*
Jianzhen (PLH 9) ALH** Dazhu (PLF 11) Hegu (ALH 4)
Naoshu (PLH 10) Feishu (PLF 13)
Tianzong (PLH 11)
Bingfeng (PLH 12) LH Fengchi (LF 20) Zhongzhu (LH 3)
Jianwaishu (PLH 14)
Gaohuangshu (PLF 43) PLH Tianzhu (PLF 10) Houxi (PLH 3)
Jianzhongshu (PLH 15)
*Can add Jianjing (LF 21) for pain in top of shoulder

** Can consider Huatuojiaji nodes at T1 and T3 level


Moving the Forearm

AMH Acute cramps and spasms along anterior medial aspect of
arm involving brachioradialis and biceps brachii, short head
ALH Pain, spasms and acute cramps along the anterior lateral
aspect of arm involving biceps brachii, long head
LH Acute cramps and spasms along posterior region of arm
involving triceps brachii, lateral head
PLH Pain in posterior lateral aspect of arm involving triceps
brachii, long head
PMH Acute cramps and pain in muscles along the medial posterior
arm involving triceps brachii, medial head and the brachialis

Regional Selection of Nodes

for Pain and Disorder of the Elbow and Forearm
Elbow & Local & Adjacent MD Proximal Nodes Distal Nodes

Forearm Nodes
Quchi (ALH 11) ALH* Dazhu (PLF 11) Hegu (ALH 4)
Zhouliao (ALH 12) Feishu (PLF 13)
Chize (AMH 5)
Tianjing (LH 10) LH Fengchi (LF 20) Zhongzhu (LH 3)
Xiaohai (PLH 8) Jianzhongshu (PLH 15)
PLH Tianzhu (PLF 10) Houxi (PLH 3)
Jianzhongshu (PLH 15)
* Can consider Huatuojiaji nodes at T1 and T3 level.

Possible Clinical Signs in Muscles of the Back

PLF Muscular spasms and pain in the upper back, often radiating up to
the neck and head; inability to turn the upper body to the left or to the
right; abnormal curvature in the back due to contraction of the
superficial muscles, resulting in the inability to bend forward;
abnormal lateral curvature in the back due to contraction of the
muscles on one side resulting in scoliosis; and low back pain,
possibly radiating down one or both legs
PMF Acute cramps and pain in the muscles of the upper back and nape of
neck; contraction of deeper muscles in the back with inability to bend
backwards; and low back pain, possibly radiating down one or both
legs


for Treatment of Anterior and Lateral Trunk
Anterior & Anterior Nodes MD Proximal Nodes Distal Nodes
Lateral Trunk
Diaphragm Zhongting (RN 16) AMH Tianzhu (ALF 10) Geshu (ALF 17)
Zhangmen (MF 13) Feishu (ALF 13) Taiyuan (AMH 9)/
Burong (ALF 22) Yuji (AMH 10)
Intercostals* Yuzhong (PMF 26) AMF Dazhu (ALF 11) Zusanli (ALF 36)
Bulang (PMF 22) Pishu (ALF 20)
Fuai (AMF 16)
Fujie (AMF 14)
Obliques & Riyue (LF 24) LF Geshu (ALF 17) Zulingqi (LF 41)
Transverse Burong (ALF 22)** Danshu (ALF 19)
Abdominis Qichong (ALF 30)** Qihaishu (ALF 24)
Rectus Burong (ALF 22)** ALF Xinshu (ALF 15) Zusanli (ALF 36)
Abdominis Guilai (ALF 29)** Weishu (ALF 21)
*Candidate anterior nodes can be replaced by either relevant ALF or PMF nodes.
**Nodes selected over this range depending on specific location of problem.


for Spinal and Upper Back Pain
Back Local & Adjacent MD Proximal Nodes Distal Nodes

Nodes
Spinal Shenzhu (DU 12) PLF Baihui (DU 20) Shugu (PLF 65)
Pain Yaoyangguan (DU 3) PMF Renzhong (DU 26) Kunlun (PLF 60)
Upper Feishu (PLF 13) PLF Feiyang (PLF 58)

Back Jinsuo (DU 8)
Ganshu (PLF 18) PMF Zhubin (PMF 9)

Candidate regional, proximal and distal nodes
for low back pain and related disorders (bilateral application)
Low Back Candidate Local & MD Proximal Distal Nodes
Pain Adjacent Nodes* Nodes
Shenshu (PLF 23) PLF Feiyang (PLF 58)
Mingmen (DU 4)
Dachangshu (PLF PMF Zhubin (PMF 9)
25)
Huantiao (LF 30)
With Kidney Xu Taixi (PMF 3)
Acute Presentation Yaotongdian
(Extra)
*For pain reflecting in sacral area add: Xiaochangshu (PLF 27), Zhonglushu (PLF 29)
MD = Muscle Distribution

Regional Selection of Nodes in Treatment of Sacral Pain
Sacral Local & Adjacent MD Proximal Nodes Distal Nodes

Nodes*
Yaoyangguan (DU 3) PLF Pangguanshu Feiyang

Guanyuanshu (PLF 26) (PLF 28) (PLF 58)
Zhonglushu (PLF 29)
Yaoshu (DU 2) PM Shenshu (PLF 23) Zhubin (PMF 9)
F Mingmen (DU 4)
*Can also consider substituting particular Baliao nodes (PLF 31 - 34) if pain
is concentrated in specific region of sacrum.
Pain in coccyx: add Changqiang (DU 1) and Xialiao (PLF 34)


Moving the Femur (Hip Joint)
PLF Pain in the buttocks sometimes radiating down the posterior thigh
LF Stretched muscles and acute cramps in lateral aspect of thigh; tight
and stretched muscles in anterior aspect of thigh, and posteriorly in
sacral region; and pain extending above to cause pain in lateral
abdomen and hypochondrium
ALF Acute cramps and spasms in the rectus femoris muscle; and
swelling and edema in anterior aspect of thigh
AMF Stretching pain sensation along the inner thigh; and cramping pain
around the genitalia
MF Pain and acute cramps of inner thigh; and dysfunction of sexual
organs including impotence due to internal injury
PMF Acute cramps and pain in inner aspect of thigh and pubic region

Regional Nodes Considered in Treatment
of Hip Joint Pain and Dysfunction
Hip Joint Candidate Local & MD Proximal Nodes Distal Nodes

Pain or Adjacent Nodes
Disorder
Guanyuanshu (PLF 26) LF Danshu (PLF 19) Zulinqi (LF 41)/
Huantiao (LF 30) Diwuhui (LF 42)
Juliao (LF 29)
Fengshi (LF 31)
Xuanzhong (LF 39)

Regional Nodes in Treatment

of Pain and Dysfunction in Moving the Hip
Thigh Pain Candidate Local & MD Proximal Nodes Distal Nodes

or Disorder Adjacent Nodes
Zhibian (PLF 54) PLF Pangguanshu (PLF 28) Shugu (PLF 65)
Chengfu (PLF 36) LF Danshu (PLF 19) Zulinqi (LF 41)
Huantiao (LF 30) ALF Weishu (PLF 21) Xiangu (ALF 43)
Yanglingquan (LF 34)
Liangqiu (ALF 34)


Moving the Lower Leg

PLF Contractions and pain in the back of thigh and knee
LF Stretched muscles and acute cramps in lateral aspect of thigh
and knee; knee unable to bend or extend; and contractions in
back of knee, with tight and stretched muscles in anterior
aspect of the thigh
ALF Acute cramps and spasms in the rectus femoris muscle
AMF Acute cramps and pain in medial knee with pain in the upper
medial fibula
MF Pain and acute cramps of the inner thigh and medial aspect of
knee
PMF Acute cramps and pain in region of knee at major insertion
sites of kidney muscles
Regional, proximal and distal nodes
for knee pain and dysfunction
Knee Joint Candidate Local & MD Proximal Nodes Distal Nodes

Pain or Adjacent Nodes
Disorder
Dubi (ALF 35) PLF Shenshu (PLF 23) Shugu (PLF 65)
Xiyan (Extra) ALF Weishu (PLF 21) Xiangu (ALF 43)
Heding (Extra) LF Danshu (PLF 19) Zulinqi (LF 41)
Xiyangguan (LF 33)
Yanglingquan (LF 34)
Xuehai (AMF 10)
Yinlingquan (AMF 9)

Appendix 1

Appendix 2

Appendix 3

Appendix 4

Appendix 5

Appendix 6

Appendix 7

Appendix 8
Spinal Cord Laminae

I-VI: Posterior/dorsal horn
I: Posteromarginal nucleus
II/III: Substantia gelatinosa of

Rolando
III/IV/V: Nucleus proprius
VI: Nucleus dorsalis
VII-IX: Anterior/ventral horn
VII: Intermediolateral nucleus
VIII: Motor interneurones
IX: Motor neurons
X: Neurons bordering Central

canal

Appendix 9

Abbreviation Reference
5HT - serotonin
ALT - anterior lateral tract
ARC - arcuate nucleus of hypothalamus
DLF - dorsal lateral funiculus
DRGC - dorsal root ganglia cells
DRR - dorsal root potentials and reflexes
ECF-A - eosinophilic chemotactic factors of anaphylaxis
HRP - horseradish peroxidaze
LC - locus ceruleus
MAP - muscle action potentials
NCF-A - neutrophilic chemotactic factors of anaphylaxis
NDR - dorsal raphe nucleus
NE - norepinephrine
NRL - lateral reticular nucleus
NRM - nucleus raphe magnus
NRPG - nucleus reticularis paragigantocellularis
PAF - platelet activating factor
PAG - periaqueductal gray
PS - propagated sensation
SMT - spinomesencephalic tract
SNS - sympathetic nervous system
SP - substance P
SRT - spinorecticular tract
STT - spinothalamic tract
TOL - Tract of Lissauer
SV - somatovisceral
Cross-Reference of Chinese anatomical division nomenclature with meridian names

AMH LU
ALF ST
ALH LI
AMF SP
LF GB
LH SJ
MF LV
MH PC
PLF BL
PLH SI
PMF KD
PMH HT
© 2010 Donald Kendall Lotus Institute of Integrative Medicine

Selected terms related to important Chinese discoveries and concepts
by D.E. Kendall, O.M.D, Ph.D, L.Ac.
World's first description of continuous blood circulation 2,000 years before Harvey's 1628
experimental proof, from the Guǎnzǐ (管子): Treatise on Water and Earth (c.375 BCE):
Earth is the root source of all things and the foundation of all life and luxuriant growth… Water is
the blood (xuè 血) and breath (qì 气) of earth in a similar manner to blood and breath circulation
through blood vessels and muscles. Deke
zhēn 针 (針): metal needle: including nine different styles first described in Lingshu 1 and 78.
zhēnzhì 针(針) 治: needling therapy: unfortunately translated as acus (needle)
punctura (puncture) or pungera (pricking) by Jesuits about 200 years after Marco Polo's
famous 17 year stay in China. The most disastrous problem is the term "acupuncture" is
always associated with Soulié de Morant's impossible metaphysical concepts of blood
and energy circulation by invisible meridians. He saw his error in his last book in 1955
by realizing that it was the blood vascular system that supplied energy to the tinniest cells
and carried away the metabolic waste products. However, widespread promotion of this
bogus idea has virtually precluded "needling therapy" of being integrated into the medical
system in the USA. Meanwhile, training programs in China have always taught real
medical sciences and graduates of certain approved schools can set for the Step 1 & 2 of
the United States Medical Licensing Examination (USMLE) to enter a third year
clerkship level in medical schools.
qì 气 (氣): 1) air, inhaled breath, vapor, gas, weather. 2) used as a second character: function;
demeanor; temper; force; vital substances:
tiānqì 天气: sky airs; weather conditions
biānshí 砭石: stone point used therapeutically by pricking the skin to release a few drops of
blood.
cìfǎ 刺法: needling or pricking method.
jiāo 焦: burnt; shriveled; dried
sānjiāo 三焦: internal membrane system
jié 节 (節): node; neurovascular node; critical juncture: location where collateral blood vessels
branch from the longitudinal vessels to supply the superficial body regions
jīmài 奇脉: singular vessels; the eight singular vessels: including the chōngmài 冲脉 aorta;
rènmài 任脉: vena cava; dūmài 督脉 azygos, hemiazygos, and ascending lumbar veins; and
including five additional superficial veins.

jīng 经 (經): longitude; longitudinal; longitudinal scroll (nèijīng 内经/內經 internal scroll:
jīngjīn 经筋: longitudinal muscles; skeletal muscles distributed along the 12 anatomical
body regions of each side of the body that comprise the external body and not related to
the internal organs
jīngluò 经络: longitudinal and collateral blood vessels
jīngmài 经脉 (經脈): longitudinal blood vessels; 12 main longitudinal vessels on each
side of body that give rise to superficial neurovascular nodes (acupoints) and with related
collaterals mainly of the aorta and vena cava (and portal vein) supplying and draining the
internal organs
luò 络 (絡): collateral
luòmài 络脉: collateral blood vessels that branch from the main longitudinal blood
vessels
sūn 孙 (孫): grandchild, descendant
sūnmài 孙脉: arterioles, capillaries, and venules
shén 神: vitality; mentality; expression; natural abilities; animal spirit
jīngshén 精神: refined substances of vitality which mediate emotions and
physiological function (hormones and other biologically active substances)
shénqì 神气: nerve signals.
shénjīng 神经: longitudinal nerves.
jísuǐ 脊髓: Spinal cord; backbone nerves.
jísuǐ shénjīng 脊髓神经 or jí shénjīng 脊神经: spinal nerves; backbone longitudinal
nerves.
yuán 原: original, source; vitality; a person's constitution
yuánqì 原气: primordial source function; contributed by both parents during
conception; father's contribution supports the immune function while mother's
contribution acts as the primary motive force for life activities involving nutrients now
known to involve mitochondrial DNA (mDNA) that drives:
zhēnqì 真气: true function; basic cellular metabolism (cell respiration) first
elucidated in the West by Sir Han Adolph Krebs in 1937.
zhèng 正: right, straight, correct
zhèngqì 正气: physiological function or balance: includes the idea of feed-back control
homeostasis and unstable feed forward processes of allostasis.

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environmentally friendly, health conscious contributor to the health-
care community at large. Evergreen was founded by Dr. John Chen
and Tina Chen, siblings and coauthors of the Chinese Medical
Herbology and Pharmacology, and the Chinese Herbal Formulas
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Understanding the Mechanisms

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Lotus Institute of Integrative Medicine

D.E. Kendall, O.M.D, Ph.D

Lotus Institute Of Integrative Medicine

© 2010 Donald Kendall & Lotus Institute of Integrative Medicine

Miracle of Needling Therapy

© 2010 Donald Kendall & Lotus Institute of Integrative Medicine

Enhancing Clinical Outcomes

See appendix 1 for enlarged picture

Posterior Lateral Hand

position over 24 hour

longitudinal regions for Anterior Lateral Hand Great Yang (Taiyang)

Lesser Yang (Shaoyang)

Chinese French Chinese French

© 2010 Donald Kendall & Lotus Institute of Integrative Medicine

See appendix 2 for enlarged picture

Superior Serratus Anterior

Muscles of the lateral foot (LF)

Gluteus Medius Tensor Fascia Latae

Muscle and nodal Iliotibial Tract

distributions pathways Biceps Femoris Vastus Lateralis

Extensor Digitorum Brevis

Ventral Spinal Cord

© 2010 Donald Kendall & Lotus Institute of Integrative Medicine

Microtrauma of Needling Induces

© 2010 Donald Kendall & Lotus Institute of Integrative Medicine

Unique Features of Neurovascular

Phases of Tissue Responses

© 2010 Donald Kendall & Lotus Institute of Integrative Medicine

Anatomical Substrates to Needling

© 2010 Donald Kendall & Lotus Institute of Integrative Medicine

Muscle Spindle Afferents

© 2010 Donald Kendall & Lotus Institute of Integrative Medicine

© 2010 Donald Kendall & Lotus Institute of Integrative Medicine

Central Nervous System

© 2010 Donald Kendall & Lotus Institute of Integrative Medicine

Spinal Afferent Processing

z CNS provides descending control to regions

Main Benefit of Needling

Role of Neurovascular Nodes

© 2010 Donald Kendall & Lotus Institute of Integrative Medicine

© 2010 Donald Kendall & Lotus Institute of Integrative Medicine

Defensive Role of Skin

© 2010 Donald Kendall & Lotus Institute of Integrative Medicine

Tissue Response to Needling

© 2010 Donald Kendall & Lotus Institute of Integrative Medicine

Blood Coagulation System

© 2010 Donald Kendall & Lotus Institute of Integrative Medicine

Blood Coagulation System

Damage to Endothelium of Small