x CHAPTER 3: COMMONLY USED MERIDIAN POINTS
CHAPTER 3:
COMMONLY USED MERIDIAN POINTS

This is Chapter 3 from R. C. Schafer, DC, PhD, FICC's best-selling book:
“Applied Physiotherapy in Chiropractic”

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The Theoretical Basis of Meridian Therapy
    Theoretical Concepts
    The Nonneural Theories
    The Neural Theories
        The Cutaneovisceral Reflex
        The Viscerocutaneous Reflex
        Segmental and Intersegmental Effects
        Near and Distant Effects
        The Gate Control Theory and Its Clinical Significance
        Scientific Evidence 
        Empirical Evidence 
Meridian Trigger points and Their Palpation
    Standard Methods of Stimulation 
    Site Location 
    Locating Points 
        Background  
        Preparation 
        Types and Characteristics of Acupuncture Points
        Electrical Analysis 
    The Human Inch
Major Points: Locations, Primary Indications, and Precautions
    The Lung Meridian
    The Large Intestine Meridian
    The Stomach Meridian 
    The Spleen Meridian
    The Heart Meridian
    The Small Intestine Meridian
    The Urinary Bladder Meridian
    The Kidney Meridian
    The Heart Constrictor Meridian
    The Triple Heater Meridian
    The Gallbladder Meridian
    The Liver Meridian

    The Conception Vessel Meridian
    The Governing Vessel Meridian

    Alarm Points
    Master Points
    Association Points

Closing Remarks
References

Chapter 3: Commonly Used Meridian Points

This chapter delineates a few of the many theories attempting to explain the mechanisms of acupuncture point (acupoint) stimulation and meridian therapy. Stimulation of specific points on the body as a mechanism for pain control has achieved great interest in this country in recent years. The majority of studies center on stimulating endorphin production in the body. See Table 3.1. Antidotal and clinical evidence as well as patient records from Oriental cultures point to numerous cases where specific point stimulation has affected visceral and functional disease processes. In the context of physiologic therapeutics, the location, primary indications, and precautions associated with the major points (ie, those most commonly used) are reviewed.

     Table 3.1.   Isolated Peptides of the Endorphin Superfamily

  I.   Peptides of the pro-opiamelanocortin series A. Opioid peptides
b–endorphin
a–endorphin
n–endorphin
B. Nonopioids
n MSH
b MSH
n MSH3  II.   Enkephalins Met5–enkephalin
Leu5–enkephalin
Met5-Arg6-Phe7–enkephalin		 III.   C–terminally extended enkephalins Dynorphin
a–neoendorphin
b–neoendorphin IV.   Others Kyotorphin
Dermophin
Casei-morphin
After Fields [47]
-------------------------------

Both Western and Eastern cultures developed systems for treating specific points on the body. It is hoped that future generations will be able to integrate the best of traditional Western and Oriental medicine into a single health-care delivery system for all people. [1]

     The Theoretical Basis of Meridian Therapy

Forms of stimulation to specific sites on the skin have been used for at least 3000 years. However, it is only in the last 25 years that comprehensive studies of acupuncture as an alternative therapy have been seriously undertaken in this country. The fact that meridian therapy has a beneficial effect on the control of disease processes seems evident today on the basis of empiric evidence and clinical studies.

Theoretical Concepts

Although it generally matters little to patients as to why they get well under a certain therapy, they do, however, expect that the doctor rendering that therapy has an acceptable explanation and understanding of the biologic mechanisms that are probably involved. That is, the patient has a natural tendency to believe that their doctor selects a particular procedure of treatment for their condition on the basis of his or her knowledge of the nature of their problem, and the knowledge of the underlying principles behind a particular method of therapy. Also, since the study and effective application of meridian therapy require some basic knowledge of its theoretical scientific basis, the need for this explanation is established.

In the case of meridian therapy, a number of theories have been advanced that generally fall under the headings of "Neural" or "Nonneural" concepts. These concepts attempt to explain the scientific basis for the biologic effects of meridian therapy in terms of our present understanding of human anatomy and physiology. Although scientific verification of the concept of "vital energy" as a physiologic probability and the "meridian" system as an anatomical fact have yet to be conclusive, verification for some of the effects of meridian therapy does exist on the basis of these concepts. [2]

The Nonneural Theories

One of the most commonly mentioned nonneural concepts attempts to explain the meridian system by proposing an elaborate conducting system of what is referred to as "Bong Han Ducts and Corpuscles." This theory, put forth by a North Korean physiologist and acupuncturist, Kim Bong Han, is a histologic description of elongated tubular cells lying deep in the skin. Han also thinks that a "unique" fluid circulates through these channels, which contains a high concentration of ribonucleic and other amino acids. Han believes that this fluid travels slowly through the meridians, completing a cycle each 24 hours. [3, 4]

Han’s theory, however impressive as it might be, has for all practical purposes been refuted by other investigators. Kellner has shown that some of this theory is based on artifacts occurring in preparation of the histologic slides, and other attempts at duplicating the work of Han reveal that he was probably describing the lymphatic channels of the body. [5, 6]

Various other theories have attempted to explain acupuncture and the existence of the meridians. [7] For example, magnetic fields, quantum mechanics, contraction waves of skeletal muscles, discharging of electrical potentials, and the release of histamine and epinephrine by stimulation of points have all been put forth as possible mechanisms. Others have likened the pinprick in the body to the electrical discharge of a condenser. At one time, Felix Mann proposed a theory based on the lateral line system in fish. These theories, along with others, have now been dismissed in favor of one of the neurologic explanations.

One of the most recent theories has been postulated by Koyo Takase in Japan who concluded that the so-called Qi energy circulating through a "meridian" in acupuncture therapy is actually extravascular sodium. [8] His studies involved the use of radioisotopes.

The Neural Theories

It is generally conceded that the mechanisms of many effects of acupuncture are similar to but not identical to those of the nervous system. There are many questions, however, that remain unanswered. [9]

When an acupuncture point is stimulated, it has been observed that the patient will often experience a change in seconds and this change frequently occurs at the opposite end and contralateral side of the body from the point stimulated. The exact mechanism of this action is not yet fully understood, although certain aspects appear to be based on established neurophysiologic concepts. This indicates that some type of nerve conduction occurs, as nerve fibers transmit impulses at an extremely rapid rate through their pathways. Such a rapid speed of conduction excludes the blood and lymphatic systems as possible mediators of this response.

      THE CUTANEOVISCERAL REFLEX

Acupuncture is founded on the premise that stimulation of the skin has an effect on distant internal organs and functional mechanisms of the body. Various experimental data tend to support the involvement of a cutaneovisceral reflex. [10–13]

Proof for the existence of such a reflex has strong scientific support. In a series of experiments, Kuntz and Hazelwood stimulated the skin on the back of rabbits and rats and noted changes in various parts of the gastrointestinal tract that were related to the dermatomal segment stimulated. [14–16] In Germany, Wernoe stimulated a small segment of the skin of fish and amphibians with silver nitrate and, after a delay of several months, demonstrated vasoconstriction of the part of the intestine dermatomally related. [17] After these experiments, he deduced that vasodilation was mediated by a spinal reflex and that vasoconstriction was mediated by a postganglionic sympathetic reflex.

Travell and Rinzler found that complete and prolonged relief resulted when trigger points on the front of the chests of patients with angina pectoris or acute myocardial infarction were infiltrated with procaine or cooled with ethyl chloride. [18] Thus, the cutaneovisceral reflex is of prime importance in acupuncture. It is strongly believed that, by its mediation, an acupuncture needle placed in the correct part of the skin is able to influence the related organ or diseased part of the body.

New hypotheses are being brought forth rapidly. For example, it has been established for years that the ear is a hologram of the body as a whole, and this is the basis of auriculotherapy. However, Dale has recently proposed an elaborate hypothesis that most any part of the body is a hologram of the body as a whole. [19]

      THE VISCEROCUTANEOUS REFLEX

Next, an explanation of how a visceral problem can relate to areas of the skin should be given. One method is by postulating the viscerocutaneous reflex. The importance of such a reflex rests in two primary areas: (1) diagnosis and (2) lowering the threshold of stimulation required in treatment with acupuncture. [20]

Various researchers have attempted to show that visceral problems may refer to the skin and give rise to trigger points, acupuncture points, and/or subluxations. [21–23] Diagnostically, certain superficial areas have long been known to relate to an underlying visceral condition such as pain at McBurney’s point in appendicitis, in the left arm in angina pectoris, and of the right shoulder in gallbladder disease. It is often noted clinically that a disease in an internal organ will produce pain, tenderness, hyperesthesia, or hypesthesia, etc, in some area of skin. The viscerocutaneous reflex is thought to be mediated by unknown pathways of the sympathetic chain. [24]

The Head-McKenzie Sensory Zone, as described by Judovich and Bates, shows how visceral pain can radiate to certain parts of the skin. A familiar example is cardiac ischemia with radiating pain to the left arm. [25, 26] In this context, Wernoe stimulated the rectum of a decapitated plaice electrically and found that the skin became pale. He also stimulated areas of the gastrointestinal tract of the eel and cod and noted that in each case the skin became lighter over an area of several dermatomal segments. [27] It can therefore be readily appreciated that a visceral problem can exhibit in a specific dermatomal segment via a viscerocutaneous reflex and that the stimulation of the skin can have a distinct effect on a related visceral area via a cutaneovisceral reflex.


      SEGMENTAL AND INTERSEGMENTAL EFFECTS

Most of the reflexes used to explain the effects of acupuncture are segmental and follow specified dermatomal patterns. [28–30] Others, however, are intersegmental. For instance, stimulation of acupuncture points of the foot has been shown to affect organs over 10 dermatomes away. [31, 32] A possible explanation of this phenomenon is via the long reflex of Sherrington. [33, 34] In contrast, those reflexes that fit into the dermatomes are segmental reflexes, often referred to as Sherrington’s short reflexes. The scratch reflex of a dog is a good example of an intersegmental cutaneomotor reflex.

      NEAR AND DISTANT EFFECTS

One of the most perplexing problems is that some of the effects of acupuncture cannot be explained neurologically by either segmental or intersegmental mechanisms. For example, the effects of stimulating the acupuncture points of the head cannot be readily explained. However, some research has shown that a distinct reflex may probably exist between the nose and the heart or between the turbinates and the sexual organs. [35, 36] Some scientific explanation for this is therefore likely.

The scientific proof for these reflexes is important, but it does not fully or even adequately explain exactly what happens according to the empiric results obtained. The Chinese for many years have attempted an explanation in the philosophical terms of Taoism with reference to Yin/Yang (law of opposites) and to the circulation of biologic energy (life force, Qi [pronounced chi]).


      THE GATE CONTROL THEORY AND ITS CLINICAL SIGNIFICANCE

The next consideration is the more recent Gate Theory, as described in Chapter 2. Although this theory, originally set forth by Melzack and Wall, has been amended to some extent, it is basically the same as originally proposed, and it would be well to summarize it here. [37–39]

The gate theory holds that the large myelinated nerve fibers of the skin have an inhibitory effect, when stimulated, on the small pain-evoking fibers that enter the same segment of the cord. [40] The large, rapid-conducting, alpha and beta fibers of the skin conduct impulses via the dorsal columns to the brainstem and from there to the cerebral cortex. Small diameter, slow-conducting C fibers convey protopathic or pathologic and traumatic pain signals of the small fibers that arise from the deeper tissues of the body. If this were not so, the body would be in a constant state of pain. The stimuli from the dermis specifically produce inhibition in the cells of the substantia gelatinosa of Rolando, which is found in the dorsal horn of the spinal cord. It is believed that the dermal stimulus depolarizes the cells here, which renders them incapable of receiving and transmitting pain signals. Thus, painful stimuli are blocked (ie, the "gate" is closed), according to Melzack and Wall. If, however, the small fiber system is excessively stimulated by some disease process, the small fiber system then gains dominance and the patient perceives pain. It is then said that the pain gate has been opened by the increased stimulation from the small fibers of the deep somatic and visceral tissues.

This theory has many practical applications in clinical practice. For example, let us suppose that the "gates" are open and the patient is in severe pain. What can be done to relieve this suffering? Studies have shown that the inhibitory effects are enhanced when the large diameter fibers of the skin are sufficiently stimulated and the pain gate in the dorsal horn may be closed. In addition, these fast-conducting fibers may also arouse inhibitory responses in the brainstem that produce a downward projection of impulses to various levels of the spinal cord that further inhibit the transmission of pain signals that would normally progress to the brain. [41] It is by way of this system of inhibitory projections that the full value (ie, relief from pain) can be realized.

Surgical research on patients with intractable pain has shown that the implantation of a dorsal column stimulator (ie, TENS) can often completely block the transmission of painful or protopathic impulses. [42, 43]

      SCIENTIFIC EVIDENCE

Meridian therapy with needles, moxa, electrical stimulation, or by means of other modalities most likely work by such a mechanism; viz, by blocking pain signals in or to the brain by projecting inhibitory impulses to the thalamus and/or cerebral cortex and ultimately to the cord, and finally, by blocking noxious stimuli through the pathophysiologic reflex and thus producing muscular relaxation. Therefore, it should be noted that acupuncture is veiled in empiric evidence. Obviously, then, current scientific proof for acupuncture explains in part much of what happens when acupoints are stimulated.

Although the Melzack-Wall theory explains how pain pathways can be blocked, it does not adequately explain any possible localized tissue changes that are known to occur. By extension of this theory, however, local tissue changes may be postulated on the basis of localized vascular changes; ie, improvement in the local microcirculation. [44]

Recent studies, several without a credible basis, have been advocated. In France, ECG readings on heart patients showed improvement after acupuncture treatments. [45] In Russia, a sensitive stethoscope supposedly noted different sounds over acupoints. The Russians also noted a difference in the skin temperature over acupuncture points.

Much research still needs to be performed. It appears to be that there are demonstrable entities called acupuncture points, but scientific verification for chartable meridians connecting these points is still wanting at this writing. However, according to a 1985 paper from Russia referring to research being conducted at the Department of Neurology of the Kiev Institute for Physicians, Macheret and his associates have shown the existence of complex functional relationships between various parts of the human body and the internal organs. Their findings appear to support the existence of "channels" that are identical to those that the Orientals call meridians. "The ‘body channels’ in their peripheral link are connected with somatic and vegetative conductors running both independently in the form of nerve trunks, and like plexuses that get around the vessels and the muscles and reach the ‘root’ spinal cells and truncus sympathicus nodes from which the corresponding segmental associations pass to the internal organs." According to these researchers, the channels in their central link constitute the conductive pathways of the spinal cord and the brain. [46]

      EMPIRIC EVIDENCE

The volume of recently acquired empiric evidence cannot be denied. To mention just a few for example, Fields has shown that acupuncture, through the stimulation of endorphins, is an effective modality in the treatment of pain, behavior modification, relief of the symptoms of drug withdrawal, and stimulating the autoimmune system. [47] After treating just one point for acute dysmenorrhea in 10 patients, Slagoski found complete effectiveness in the resolution of the pain syndrome. [48] Tseung and Vazharov describe case after case of musculoskeletal disorders, anxiety and depression, growth problems, primary infertility, impotence, induction of labor, episcleritis, chronic asthmatic bronchitis, and canker sores (aphthous stomatitis) that responded to acupuncture after failing to respond under Western medical treatment. [49, 50]

Kitzinger, a medical doctor, believes that even if acupuncture may achieve good, even spectacular, results by itself, he recommends combining it with neural therapy (electrical), manipulative therapy (chiropractic), and other standard physiotherapeutic modalities when vertebrogenic disorders are treated. He states that "Combining acupuncture with manipulative therapy for a blockage is not only feasible, but also in some cases, the only correct procedure to achieve a therapeutic breakthrough." [51] Shafshak compared the effectiveness of electroacupuncture to that of standard physiotherapy in the treatment of tension myositis: 93.3% responded completely to electroacupuncture and 90.9% recovered completely in response to physiotherapy. [52]

While acupuncture per se has not been as effective in treating disorders of a purely psychic nature, it has been in relieving physiologic disturbances. Odell reports that when it is used in conjunction with hypnosis and visualization techniques, it has shown to be a consistent and invaluable tool in a behavioral reprogramming technique. [53]


     Meridian Trigger points and Their Palpation

Standard Methods of Stimulation

Acupuncture points are commonly stimulated by several methods:

  1. Using 30-, 32-, or 34-gauge, 1/2 to 1-1/2-inch stainless steel needles that are carefully inserted at specific preselected sites for durations ranging from a few seconds to 20 minutes or more.

  2. Using electrical stimulation with any modality designed for this purpose.

  3. Using a specially designed blunt instrument (teishin).

  4. Using finger or thumb pressure.

  5. Using a helium neon or infrared laser (controversial).

  6. Using tiny beads sometimes called acupatches or acu-aids.

Other methods of stimulation include use of moxa (a herb that is burned near or on the skin), sparks from a hand-held device, and microcurrent stimulators, to name a few.

When low-volt electric modalities are used in stimulating acupoints, it is generally believed that a frequency of approximately 5 pulses per second (pps) is ideal for maximal endorphin release. The intensity of current, using a small diameter electrode, should be as high as the patient can comfortably tolerate. Stimulating the most painful trigger point contralateral to the patient's pain (eg, elbow) while the patient moves the involved part has been found effective in rapidly alleviating musculoskeletal pain.

In summary, when acupuncture sites are stimulated by means of low-volt electric current, several factors should be kept in mind:

1.   The exact site of the point or of its contralateral partner must be stimulated.

2.   A small diameter electrode must be used.

3.   The correct frequency must be selected.

4.   The correct duration must be determined.

It should be noted that many of these factors are also important when other methods are used.


Site Location

Acupuncture points are usually tender to the touch and located in palpable depressions under the skin. Although most pertinent sites are usually tender, there are many situations where a lack of normal tenderness at a site may also be diagnostic.

As previously described, recent evidence suggests that acupuncture works by means of an extravascular transport mechanism. This means that the points will be located at a certain depth below the skin surface. Some research studies indicate that stimulation primarily affects the nervi vasorum (autonomic fibers congruent with the blood vessels), and this further lends credence to inserting the needle to a specific depth.


Locating Points

Of prime importance in meridian/trigger point therapy are the proper palpation and localization of the acupoint. But first, a specific definition of a meridian point should be attempted.

Felix Mann states that in all diseases, physical or mental, tender areas are present at certain points on the surface of the body —points that disappear when the illness is cured. He calls these sites acupuncture points. In Chinese literature, we find descriptions of over a thousand of these points. The more common 365 points are located on certain fixed lines or pathways called meridians. It is our opinion that an acupuncture point is, in many instances, identical to the trigger point described by Travell or the concepts described by Matsumoto and Hiyodo in their writings.

In locating important acupoints for treatment and meridian dysfunction, one technique involves systemic palpation (ie, of alarm points) of the body at predetermined sites. These points will be described later in this chapter.

      BACKGROUND

The palpating hands of the examiner contain sensitive nerve endings that are quite perceptive to changes in tissue tone, temperature, texture, surface humidity, etc. The fingertips are particularly well supplied with touch and pressure receptors, while the dorsal surface of the hand is especially endowed with heat receptors. For these reasons, both the fingertips and the back of the hand should be used during the evaluation procedure. As examiners gain experience in point location, they will find it increasingly easier to locate critical sites.

Acupoints will often be found that are spontaneously tender. For instance, a patient with appendicitis will point to McBurney’s point as being exquisitely painful. Individuals with headaches often relate a spontaneously tender area on the nuchal line of the occiput. In other cases, areas will be painful only when pressure is applied. Many of the points above the ankles and in the hand and wrist belong to this category. A third type of acupoint is not tender even when moderate pressure is applied. Many acupuncture points are of this type.

      PREPARATION

In searching for the acupuncture point, the patient must first be positioned in a comfortable position. The patient should be disrobed in such a fashion that the points are readily accessible to palpation. Care must be taken in all cases to preserve the modesty of the patient. As during the routine physical examination, it is generally best to have the patient undress and then robed in a gown that ties in the back. The waist band of the patient should be loosened for comfort and to afford free access to points of the lumbar, sacral, and lower abdominal areas.

Most examiners find it convenient to begin the examination with the patient seated on a low stool, and then transfer the patient to a comfortable cushioned table for examination in the prone and supine positions. Prior to searching for acupuncture points, the doctor should remove any jewelry that might scratch or irritate a patient. Personal hygiene, as always, is of utmost importance. The examiner’s hands should be thoroughly washed before and after each examination.


      TYPES AND CHARACTERISTICS OF ACUPUNCTURE POINTS

Several types of acupuncture points or lesions might be discovered:

  1. Fibrositic nodules.   Most commonly, the fibrositic nodule will be the point located. This area feels like a small node or mass of tissue several millimeters in diameter. It will be tender to pressure and often spontaneously painful. It is similar to the fibrositic rheumatoid nodules often located at the back of the neck, in the shoulders, or in the lumbar area.

  2.   Indurated areas.   In many instances, a hard (indurated) area will be found. Instead of a nodule, the palpator might feel a localized area of tense muscle fibers in a muscle.

  3. Atrophic areas.   In other cases, the acupuncture point might be characterized as a localized swollen and discolored area or an atrophied area of tissue.


      ELECTRIC ANALYSIS

The examiner might be unable to locate acupuncture points by palpation. In these cases, it may be of value to make use of one of the many electric devices available for their detection. These instruments measure skin resistance to an electric current, showing areas where the resistance is altered. Once a point is localized, whether manually or with an electric device, it should be carefully marked with a skin pencil or felt-tipped pen and then charted in the patient’s records so that a comparison can be made from one visit to another.

In Japan, Nakatani mapped out areas of altered skin resistance into pathways that correlate with meridians. He treats the most altered points. This system is called Ryodoraku, [54] which, when translated, means good electroconduction system.

The fact that an acupuncture point exhibits altered electrical resistance allows an examiner to determine specific sites by using any instrument that measures (objectively with an ohmmeter or subjectively by the intensity of the sound made by an instrument) skin resistance at an isolated point. It is presently thought that sites that are reactive (ie, involved in a complaint), especially when we are dealing with a musculoskeletal complaint, are more conductive than surrounding tissue. These points are usually more tender and conduct current more readily (less resistance to an electric current). These points give a higher reading on an ohmmeter and produce a louder sound. Chinese physicians refer to these sites as ah shi (ouch) points; American physicians usually call them as trigger points.

If the correct site is chosen for stimulation, the most common reaction will be hyperemia (histamine reaction) around the point stimulated. Also noted, especially when needles are used, will be a sensation of tingling or numbness radiating or referred distally from the site stimulated. This sensation is called the deqi (also spelled tae chi). [55] A lack of hyperemia or deqi appears to correlate with poor results, thus indicating that the proper site was not treated.

In 1984, studies conducted by Y. M. Sin showed that acupuncture stimulation not only gave good symptomatic relief in inflammatory disease but also suppressed the underlying progress of the disease. [56]


The Human Inch

Besides palpation and measuring electrical resistance, charted acupuncture points can be located by using a topographic system of anatomical measurement. The unit of measure is called the human inch, tsun, or cun, and the system of measurement uses the patient’s own anatomical proportions to establish the parameters to be used in (1) locating points and (2) determining the depth of needle insertion.

The human inch for a particular patient can be determined by measuring the distance between the patient’s two joint creases of the volar surface of the middle phalanx of the middle finger when it is flexed. It can also be determined by measuring the width of the patient’s thumb. Either hand can be used unless one thumb has been deformed by trauma or disease.

Once the human inch is known, various portions of the patient’s body may be measured lengthwise or transversely and that measurement may be divided into a certain number of human inches. Because a human inch is a proportional measurement for a specific individual, the number of cuns on a body part (eg, a forearm or leg) is approximately the same whether the patient is young or old, tall or short, or lean or obese. [55] The only exception to this is where obvious growth, surgical, or pathologic asymmetries are present (eg, disproportionate limb-trunk dwarfism).




     Major Points: Locations, Primary Indications, and Precautions

As the result of millions of observations of patient responses over several centuries, Oriental physicians have charted over 300 major points on the body and have attributed certain related functions to these locations. As a general rule, however, it is thought that any localized point in an area of musculoskeletal pain can be stimulated to inhibit pain in that location.

In 1984, Peter Eckman, MD, PhD, developed a schematic model of the general effects of acupuncture. [57]

In the following sections, we will attempt to describe the most common sites of stimulation and the indications for treatment as cited by various authorities. We must state unequivocally, however, that little or no scientific verification has been done in the West to substantiate these projected effects. Thus, the reader is cautioned to use every possible diagnostic tool available necessary to evaluate the patient’s complaints and to use this chapter as a reference to those sites used by Oriental physicians. The complete validity of the effects described must await further research substantiation.


 Points on the Lung Meridian

The major points on the lung (LU) meridian are LU-1 and LU-7.




LU-1

Location. The site of this point (Zhongfu) is found on the anterior lateral aspect of the chest. Using your finger, palpate below the clavicle and seek a tender spot in the space between the first and second rib, approximately 6 cun lateral to the anterior midline of the chest.

Indications. This point is the alarm point for the lung meridian, thus it may be tender in any condition related to the lung meridian. This site is primarily used for chronic respiratory complaints because it is the major point influencing the lungs. Stimulation may also be made at this site for shoulder disorders, especially those exhibiting painful adduction.


LU-7

Location. This point (Lieque) may be found just lateral to the radial artery at a spot 1.5 cun from the transverse crease on the volar aspect of the wrist, proximal to the styloid process of the radius. A slight depression marks the site of LU-7.

Indications. According to some authorities, this is one of the seven master points of the body. Its primary indication is in the reduction of localized edema of musculoskeletal origin.


Points on the Large Intestine Meridian

The major points on the large intestine (LI) meridian are LI-4, LI-11, and LI-20.




LI-4

Location. When the thumb and index finger are brought together, such as when making a fist, this point is frequently located at the highest spot on the domed muscle bulge between the thumb and index finger. More specifically, the point is half way between the proximal and distal aspects of the 2nd metacarpal, just lateral to its radial side.

Indications. This point (Hoku or Hegu) is another master point. Many authorities feel it is the most powerful acupoint of the upper body. It has been studied most extensively and is stimulated more often than any other site of the body. Extensive research has established a connection between stimulation of this site and alleviation of pain in the upper extremity and anterior neck or head. Stimulation of this site with electrodes attached to inserted needles is used to bring about anesthesia in the lower jaw or scalp prior to dental work or during certain surgical procedures. When it is used in combination with the most tender trigger point (Ah shi), pain in the upper extremity and anterior neck or head can be alleviated. We have also found that prolonged stimulation at this site (eg, over 15 minutes with needles) will trigger evacuation of the bowels in a patient who is constipated and promote drainage of body fluids.

When used in combination with other sites, LI-4 may also influence other conditions. For example:

LI-4 + LI-11 — dermatologic complaints

LI-4 + ST-36 — gastrointestinal complaints

LI-4 + SP-6 — gynecologic complaints.

Precautions: As this is a highly sensitive point, adverse reactions have been recorded with this site, the most frequent of which is syncope. Thus, if the patient complains of weakness, faintness, or nausea during therapy, the treatment should be discontinued. This site is also contraindicated during pregnancy, except to promote labor or medical abortion.


LI-11

Location. The location of this point (Quchi) is located just distal to the lateral end of the transverse crease of the elbow joint when the arm is flexed on the forearm. This point is frequently tender.

Indications. This point is treated for pains associated with lateral epicondylitis (eg, "tennis elbow" syndrome) and is a special point used in the treatment of acute torticollis. Some studies have also indicated that, when stimulated bilaterally, it may lower blood pressure and affect the motor aspects of the nervous system. Used in conjunction with LI-4, it may be useful in the management of dermatologic and allergic nasorespiratory complaints.


LI-20

Location. This point (Yingxiang) is found at the nasolabial groove on the side of the nasal ala.

Indications. Stimulation of this site promotes drainage of the nasal sinuses and may be effective in combination with other focal sites in the treatment of facial paralysis.


Points on the Stomach Meridian

The major points on the stomach (ST) meridian are ST-2, ST-7, ST-25, and ST-36.


ST-2

Location. This point (Sibai) is found just below the orbit of the eye at the site of the infraorbital foramen.

Indications. Stimulation at this site promotes drainage of the maxillary sinuses and is another site that may be used in patients with facial paralysis.

Precautions: Great care must be taken to avoid bruising the sensitive tissues in this area. Injury may readily lead to subcutaneous hemorrhage (ie, a "black eye").


ST-7

Location. This point (Xiaguan) is found in the depression of the inferior border of the zygomatic arch, just in front of the condyloid process of the mandible. Palpation of this point should be made when the patient's mouth is closed.

Indications. Stimulation of this point is effective for patient's experiencing painful TMJ dysfunction and may be effective for patients with facial nerve palsy.


ST-25

Location. This point (Tianshu) is located at the level of the umbilicus, 2—3 cun lateral to the midsagittal line, at the border of the rectus abdominis muscle.

Indications. This point is the alarm point for the large intestine. It appears that therapy here is effective in treating many gastrointestinal disorders. It is often treated in conjunction with CV-4 and CV-12.


ST-36

Location. This point is found in a depression that is 3 cun below the plateau of the tibia, located between and slightly distal to the tibiofibular articulation. The depression is located about one finger’s width lateral to the anterior crest of the tibia.

Indications. This point (Dusanli) is another of the seven master points of the body, and many authorities feel it is the most powerful acupoint of the lower body. It is thought to be the major body point for systemic tonification. Because of its location, it is also used in the treatment of conditions localized in the lateral aspect of the knee joint. Several studies have related this point to the cellular elements of the blood; thus, it has been indicated by some to be effective in the treatment of anemia and to increase the white cell count in patients with infections. Stimulation of this point is often used in conjunction with LI-4 (thought to be the most powerful acupoint of the upper body) in the treatment of chronic gastrointestinal complaints.


Points on the Spleen Meridian

The major points on the spleen (SP) meridian are SP-6 and SP-9.




SP-6

Location. This point (Sanyinjiao) is found on the medial aspect of the ankle on the lower calf. It can be located by placing the lateral aspect of an ankle on the opposite flexed knee (as in the familiar male seated position) and placing the little finger of your hand (flexed knee side) on the medial malleolus of the exposed ankle so that the thumb points toward your flexed and rotated knee. The point is located 3 cun up the medial aspect of the calf, proximal to the medial malleolus. The point is located just posterior to the border of the tibia.

Indications. This point is called the crossroads of the three Yin meridians of the leg because the spleen, liver, and kidney meridians transverse at this site. Due to this fact, the point has multiple indications. As one of the seven master points, it is often used in the treatment of patients with gynecologic disorders, especially irregular or painful menstrual complaints and male sexual dysfunctions. It is also referred to as the master of the circulatory system as it affects various vascular conditions such as patients with cold extremities or those that bruise easily.


SP-9

Location. This point (Yinlingquan) is located on the medial aspect of the knee joint, just below the lower border of the medial condyle of the proximal tibia.

Indications. This point is primarily stimulated in the treatment of patients with osteoarthritis of the knee or sprains of the medial collateral ligaments.


Points on the Heart Meridian

There are two major points on the heart (HT) meridian: HT-3 and HT-7.




 HT-3

Location. This point (Shaohai) is located when the patient's elbow is flexed. It is between the medial end of the transverse antecubital crease and the medial epicondyle of the humerus. Palpation reveals an extremely tender point.

Indications. This point is treated in medial epicondylitis (eg, golfer's elbow) or other disorders of the medial aspect of the elbow. Some authorities report success in treating this point in patients with angina-like symptoms.


HT-7

Location. This acupoint (Shenmen) is located on the ulnar surface of the anterior wrist, just proximal to the pisiform bone. Exact localization places this point in a depression located just to the radial side of the flexor carpi ulnaris tendon, just medial to the ulnar artery.

Indications. This specific point is stimulated in an attempt to relieve patients with symptoms of nervousness, irritability, anxiety, depression, hypertension, insomnia, and abnormal forgetfulness.


Points on the Small Intestine Meridian

The major points on the small intestine (SI) meridian are SI-3, SI-9, and SI-19.


SI-3

Location. To locate this point (Houxi), make a tight fist and note the small triangular bulge on medial aspect of the supinated hand. The point is located at the end of the transverse crease just proximal to the head of the 5th metacarpophalangeal joint.

Indications. This point is treated when patients have pain in the contralateral lower back region and in patients suffering with various types of arthritis.


SI-9

Location. To locate the exact site of this point (jianzhen), have the patient hold their relaxed arm at the side. In this position, the point is located 1 cun above the top of the posterior axillary fold.

Indications. This point is stimulated whenever a patient complains of pain when reaching or putting their arm behind their back (extension plus internal rotation) or when a patient exhibits signs of degenerative joint disease of the shoulder joint.


SI-19

Location. This point (Tinggong) can be found by placing an index finger just anterior to the tragus of the ear and palpating for the gap between the tragus and the temporomandibular joint when the patient opens the mouth.

Indications. This site is stimulated in various disorders of the ear such as earache, hearing loss, or tinnitus.

Precautions: Care must be taken when using a needling procedure to avoid major nerve and vascular structures in this area.


Points on the Urinary Bladder Meridian

The major points on the bladder (BL) meridian are BL-10, BL-23—25, BL-31, BL-51, BL-54, BL-57, and BL-60.



A large portion of the bladder meridian is composed of points called as association or associated points. These points, which will be described later in this chapter, are located along the medial most aspect of this meridian. They appear to be related to specific viscera in a manner similar to that described in Meric Analysis where specific spinal segments are related to specific organs.

:


BL-10

Location. This point (Tianzhu) is located two finger widths lateral to the midline below the occiput in the suboccipital musculature just lateral from the border of the trapezius muscle.

Indications. This site is thought of as the atlas of acupuncture. Stimulation here is believed to have profound effects on the autonomic nervous system. Its stimulation may also relieve patients with thoracic outlet syndromes, and perhaps, suboccipital headaches, suboccipital myalgia and tenderness, or torticollis.


BL-23, BL-24, and BL-25

Location. These three points (Shenshu, Qihaishu, and Dachangshu) are found two finger widths lateral to the midpoints of the spinous processes of L2—L3, L3—L4, and L4—L5, respectively, in the intervertebral depressions between the thoracic transverse processes or lumbar mamillary processes.

Indications. Stimulation of these points is made in patients with low-back pain, usually bilaterally, and sometimes combined with stimulation of GB-30 and/or other points. The choice of specific stimulation in this area depends on the determined level of spinal involvement.


BL-31

Location. This point (Shangliao) is found in the depression of the first sacral foramen.

Indications. This is an important point in the treatment of IVD syndromes, lumbar sprains and strains, and other afflictions of the lower back. Some reports of experiments with male animals indicate that treatment of this point may elevate sperm quantity.


BL-51

Location. This point (Yinmen) is found in the longitudinal midline of the posterior thigh, halfway between the gluteal and popliteal creases.

Indications. This is an important point in the treatment of low-back pain, especially when there is sciatic radiation to the thigh.


BL-54

Location. This posterior point (Weizhong) is located on the transverse crease of the posterior knee, in the center of the popliteal space.

Indications. Stimulation of this point is made in patients with arthritis of the knee or sciatic pain that radiates to the knee.

Precautions: If needling is conducted, it is best to slightly flex the joint so that tension will be removed from the popliteal tissues. Care must be taken not to pierce one of the many vascular structures in this area.


BL-57

Location. This point (Chengshan) is found halfway down the back of the calf, at the longitudinal midpoint between the knee and the ankle joints, at the split of the gastrocnemius muscle.

Indications. Stimulation of this point is indicated in cases of sciatica that manifest pain radiating to the calf.


BL-60

Location. This point (Kunlun) is found on the external side of the ankle, at a level of the midpoint of the lateral malleolus longitudinally and halfway between the Achilles tendon and the lateral malleolus transversely.

Indications. This site has been found to be of value in patients with generalized body pain, foot problems, and sciatic-like pains that radiate from the lower back to the ankle.


Points on the Kidney Meridian

The major points of the kidney (KI) meridian are KI-1, KI-2, and KI-27.




KI-1

Location. This point (Yongquan) is found on the plantar surface of the foot in a depression at the junction of the anterior and middle third of the sole, between the 2nd and 3rd metatarsophalangeal joints.

Indications. Although one of the most tender acupuncture sites of the body, this point is one of the best sites to stimulate when a patient has problems related to the feet. It is also stimulated in patients with dry skin and complaints of impotence.


KI-2

Location. This point (Rangu) is found just anterior and inferior to the medial malleolus of the ankle. If an imaginary line is drawn from the midpoint of the foot (midpoint between the front and back), the point can be located in a depression at the anterior-inferior border of the navicular bone.

Indications. Stimulation of this point is often made when patients show signs of excessively moist skin (ie, hyperhidrosis).


KI-27

Location. The site of this point (Shufu) is found in the depression between the 1st rib and the lower border of the clavicle, just lateral to the manubrium of the sternum.

Indications. This point is often referred to as the "reset button" by kinesiologists. Manual stimulation of this site is thought to temporarily balance the meridians or to "reset" them before muscle testing or checking for overall energy balance in the meridians.


Points on the Heart Constrictor Meridian

There is only one major point of the heart constrictor (HC) meridian, HC-6. It should be noted that this meridian is also referred to just as frequently by many authorities as the pericardium (P) or circulation/sex (CS or CX) meridian.




HC-6

Location. This point (Neiguan) is found on the anterior surface of the forearm, directly in the midline, 2 cun from the largest transverse crease of the wrist.

Indications. Stimulation of this point is indicated for patients presenting with thoracic pain (eg, rib pain, intercostal neuralgia, postherpetic neuralgia, thoracic strain/sprain, and painful disorders of the lungs). Some authorities have reported that stimulation of this site may stop singultus (hiccups), although we have yet to have our first success using this point for hiccups.


Points on the Triple Heater Meridian

The major points on the triple heater (TH) meridian are TH-5 and TH-17.



TH-5

Location. This point (Waiguan) is positioned on the dorsum of the wrist, exactly in the center, at a point two cun proximal from the flexure crease of the wrist. It is located directly opposite to HC-6.

Indications. This site is the major point of energy balance in the body. Stimulation of this point is thought to equalize the autonomic nervous system.


TH-17

Location. This point (Yifeng) is found posterior to the earlobe in the depression located between the mastoid bone and the angle of the mandible.

Indications. The indications for stimulating TH-17 are hearing loss, tinnitus, and earache.

Precautions: If needling is performed, insertion to a depth greater than 1-1/2 cun is absolutely forbidden.


Points on the Gallbladder Meridian

The major points on the gallbladder (GB) meridian are GB-20, GB-21, and GB-34.




GB-20

Location. This point (Fengchi) is found just inferior and medial to the mastoid process, in a depression (usually tender) that is located between the sternocleidomastoideus and the trapezius muscles.

Indications. This site, one of the seven master points, influences the autonomic nervous system. It is also an excellent point to stimulate in patients with suboccipital headaches.

Precautions: When needling, the line of insertion is directed toward the opposite eye. Deep insertion of a needle greater than 1-1/2 cun may trigger adverse effects; thus, such depth is forbidden.


GB-21

Location. The site of this point (Jianjing) is located midway between the spine and the acromion of the shoulder. With the patient seated, hands folded in the lap, head forward, run your palpating finger from the tip of the acromion halfway up toward the spine, splitting the trapezius down the middle. The site will be found as a tender depression at the halfway point.

Indications. This is probably the best point there is to stimulate patients with muscle spasm in the upper half of the body.

Precautions: Perpendicular needle insertions are discouraged. Insertion should be at an angle directed toward the midline. Do not exceed a depth of 1 cun, as the apex of the lung might be punctured.


GB-34

Location. This point (Yanglingquan) is found in a depression located anteroinferiorly to the head of the fibula.

Indications. This point appears to be the best site on the body to influence patients with muscle spasm, especially spasm in the lower half of the body. The point may also be stimulated in patients with pain on the lateral aspect of the thigh and/or leg.


Points on the Liver Meridian

The major point on the liver (LV) meridian is LV-3.



LV-3

Location. This point (Taichong) is found on the dorsum of the foot between the 1st and 2nd metatarsals, approximately 2 cun from the margin of the web between the toes.

Indications. This point is often stimulated in an attempt to detoxify the body and for the treatment of patients with neurologic complaints. Some evidence indicates that it is one of the best points on the body for treating patients with migraine.


Points on the Conception Vessel Meridian

There are two unilateral meridians on the body: one on the anterior midline that bisects the chin, navel, and pubis (the conception vessel or Ren meridian), and one on the posterior midline that cuts through the spinous processes (the governing vessel or Du meridian).

There are two major points on the conception vessel (CV), CV-4 and CV-8.




CV-4

Location. This point (Guanyuan) is located in the anterior midline, 3 cun below the navel.

Indications. Stimulation of this point is thought to affect patients with pelvic disorders (eg, menstrual pain, gastroenteritis, polyuria, etc). Treatment may also be given to this point to generally relax the patient.


CV-8

Location. This point (Shenjue) is found in the center of the navel.

Indications. This is a "forbidden" point that should never be needled.


Points on the Governing Vessel Meridian

The major points on the governing vessel (GV) meridian are GV-3, GV-14, GV-16, GV-20, and GV-26.




GV-3

Location. This point (Yaoyangguan) is found between the spinous processes of L4 and L5.

Indications. This point is a good point to treat for low-back pain.


GV-14

Location. This point (Dazhui) is found between the spinous processes of C7 and T1.

Indications. This point is used in the treatment of thoracic outlet syndromes, neck pain, and shoulder pain. It is referred to as a reunion point because it interconnects with other meridians and often takes on the functions of those meridians.


GV-16

Location. This point (Fengfu) is found directly in the midline just below the external occipital protuberance, at the base of the occiput.

Indications. Stimulation of this point is used in the treatment of suboccipital headaches. Some studies have indicated a relationship between this point and the endocrines.


GV-20

Location. This point (Baihui) is located in the midsagittal line of the scalp, on a line drawn between the apex of both ears.

Indications. Relationships have been drawn between this point and treatment of patients with hemorrhoids and hypertension.


GV-26

Location. The site of this point is found at the philtrum, in the angle formed by the nose and the upper lip.

Indications. Firm manual stimulation of this point is indicated in patients who feel faint.


Alarm Points



As previously described briefly, there are several reflex points for the meridians that are located on the anterior surface of the body. Spontaneous pain, pain on pressure, or excessive electropermeability at one of these points may indicate that some disorder is present in the associated meridian. For example, it is empirically claimed that spontaneous pain at LU-1 indicates a problem in the lung meridian, whose alarm point is LU-1.

All alarm (Mu) points are located on the ventral surface of the thorax and the abdomen, and each point is associated with one of the 12 main meridians and its function. Six of the meridian alarm points are located on the conception vessel meridian, thus they are unilateral. The other six alarm points are bilateral, giving a total of 18 alarm points in all.

It is thought by Oriental physicians that tenderness or pain elicited by light pressure on or spontaneous pain at any of these points indicates that the meridian has excessive energy (Chi). Tenderness only on heavy pressure indicates that there is a deficiency of Chi. Generally, the alarm points are associated with the Yin types of diseases; viz, those diseases associated with cold, depression, and weakness.

Table 3.2 lists the alarm points for the 12 meridians and gives the anatomical location of each.

     Table 3.2. Alarm Points of the Body

Meridian
Alarm Point
Location
BILATERAL POINTS
Lung
LU-1
1 cun below clavicle, lateral interspace of 2nd—3rd ribs
Liver
LV-14
On vertical nipple line, between 6th—7th ribs
Gallbladder
GB-24
On vertical nipple line, between 7th—8th ribs
Spleen
LV-13
Anterior tip of 11th rib
Kidney
GB-25
Anterior tip of 12th rib
Large intestine
ST-25
2 cun lateral to navel
MIDLINE POINTS
Heart constrictor
CV-17
Midsternal, nipple level, 3/4ths down from episternal notch
Heart
CV-14
6 cun above navel, just below xiphoid process
Stomach
CV-12
 4 cun above navel, epigastrium, midway between the xiphoid process and navel
Triple heater
CV-5
2 cun below navel
Small intestine
CV-4
3 cun below navel
Bladder
CV-3
4 cun below navel


 Master Points

The seven master points are the primary points of the body, and, according to some authorities, they are used more frequently than other points. Generally, they will all be tender to the touch and the effects from stimulating them are usually pronounced. These points, in review, are: 

      LI-4     ST-36
      SP-6     GB-20
      BL-54    LV-3
      LU-7



Association Points

Associated points were briefly described with the bladder meridian. An association point (or associated point, as it is sometimes called) is a reflex site for an affiliated meridian. Generally, it allegedly becomes tender when the meridian’s Chi is abnormally disturbed.

All meridians have an associated point. This point is located along the back on the medial course of the bladder meridian, 1-1/2 cun from the spinous processes, on either side of the vertebral column. That is, all association points may be found approximately two finger widths lateral to the midline of the spine. There are also associated points that do not correspond with a specific meridian. See Table 3.3.

     Table 3.3. Associated Points

Meridian
Association Point
Location
LU
BL 13
1-1/2 cun lateral to spinous processes, between T3 and T4
HC
BL 14
1-1/2 cun lateral to spinous processes, between T4 and T5
HT
BL 15
1-1/2 cun lateral to spinous processes, between T5 and T6
GV
BL 16
1-1/2 cun lateral to spinous processes, between T6 and T7
LV
BL 18
1-1/2 cun lateral to spinous processes, between T9 and T10
GB
BL 19
1-1/2 cun lateral to spinous processes, between T10 and T11
SP
BL 20
1-1/2 cun lateral to spinous processes, between T11 and T12
ST
BL 21
1-1/2 cun lateral to spinous processes, between T12 and L1
TH
BL 22
1-1/2 cun lateral to spinous processes, between L1 and L2
KI
BL 23
1-1/2 cun lateral to spinous processes, between L2 and L3
LI
BL 25
1-1/2 cun lateral to spinous processes, between L4 and L5
SI
BL 27
At the level of the S1 foramen
BL
BL 28
At the level of the S2 foramen




In this context, a special point to be noted is KI-27. This point is located on the anterior surface of the body and supposedly acts as an associated point for the entire series. It is sometimes referred to as the "home of all associated points."

Some authorities contend that these association points, when tender, are the best points to treat for tonification or sedation of the affiliated meridian because of a lesser possibility of an adverse reaction or side effects.

The associated points have certain characteristics in contrast to the alarm points, according to Felix Mann:

1.   Classically, they are points of sedation. Sedation of an association point in turn causes sedation of the meridian preceding it and the meridian that follows it. This is typically the reverse of what occurs when alarm points are stimulated.

2.   These points, because of their general calming effect, are used in Yang diseases such as those associated with fever and/or overexcitation.

3.   Association points also serve well as points of tonification.

4.   Chinese osteopathy uses these points in the correction of minor displacements of the vertebrae.


 Closing Remarks

Although needling procedures are frequently described in this chapter, the skillful use of penetrating techniques requires specialized instruction beyond the scope of this discourse. However, this information as presented will be of extreme value when non-needling techniques (eg, electric stimulation) are used in adjunctive therapeutics.


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Since 6-19-2010

Updated 12-19-2011