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Table of Contents
ACUPUNCTURE & MOXIBUSTION
Year : 2015  |  Volume : 1  |  Issue : 1  |  Page : 59-66

Acupuncture mechanisms: Anesthesia, analgesia and protection on organ functions


1 Peking University Institute of Mental Health; Peking University Sixth Hospital; Key Laboratory for Mental Health, National Committee of Health and Family Planning (Peking University), Beijing 100191, China
2 Neuroscience Research Institute, Peking University; Key Laboratory for Neuroscience, Ministry of Education/National Committee of Health and Family Planning, Beijing 100191, P.R. China

Date of Web Publication11-Sep-2020

Correspondence Address:
You Wan
Neuroscience Research Institute, Peking University, 38 Xueyuan Road Beijing 100191
P.R. China
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Source of Support: None, Conflict of Interest: None


DOI: 10.15806/j.issn.2311-8571.2014.0012

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  Abstract 


Acupuncture, as a healing art in traditional Chinese medicine, has been widely used to treat various diseases. In the history of acupuncture anesthesia, in the past decades, mechanisms of acupuncture analgesia has been widely investigated, and in recent years, acupuncture protection on organ functions has attracted great interest. This review summarized the research progress on mechanisms of acupuncture for analgesia and its protection against organ function injury in anesthesia, and its perspective of analgesia, immunomodulation, neuroendocrine regulation and multiple organ protection. The current evidence supports that acupuncture analgesia and its organ protection in anesthesia is associated with the integration of neuroendocrine-immune networks in the level of neurotransmitters, cytokines, hormones, neuronal ensembles, lymphocytes, and endocrine cells. Although the mechanisms of acupuncture analgesia and its organ protection are still not completely understood, basic as well as clinic researches on the mechanisms and applications of acupuncture and related techniques are being carried out.

Keywords: Acupuncture, acupuncture analgesia, acupuncture anesthesia, organ function protection, immunomodulation


How to cite this article:
Wang J, Wan Y. Acupuncture mechanisms: Anesthesia, analgesia and protection on organ functions. World J Tradit Chin Med 2015;1:59-66

How to cite this URL:
Wang J, Wan Y. Acupuncture mechanisms: Anesthesia, analgesia and protection on organ functions. World J Tradit Chin Med [serial online] 2015 [cited 2023 Feb 3];1:59-66. Available from: https://www.wjtcm.net/text.asp?2015/1/1/59/294849



Acupuncture, as an important component of traditional Chinese medicine (TCM), has been used for more than two thousand years to treat diseases and relieve pain. Acupuncture is a procedure in which fine needles are inserted into an individual at discrete points (acupoints), and then manipulated, with specific sensations referred to as deqi[1],[2], including aching, numbness, tingling, and even warmth. Although Western medicine once treated acupuncture with considerable skepticism[3], a broader worldwide population has now granted it acceptance. For instance, the World Health Organization endorses acupuncture for at least two dozen conditions[4] and the US National Institutes of Health issued a consensus statement in 1997 proposing acupuncture as a therapeutic intervention for complementary medicine[5]. In addition to traditional manual acupuncture (MA), new acupuncture modalities, such as electroacupuncture (EA) and transcutaneous electrical acupoint stimulation (TEAS) are gaining in popularity.

Reviews conducted in the United States, United Kingdom, Europe and Canada suggest that acupuncture is effective for post-operative and chemotherapy nausea and vomiting, nausea of pregnancy, and post-operative dental pain[6]. For a number of other pain-related conditions, including but not being limited to, re-habilitation, headache, menstrual cramps, tennis elbow, fibromyalgia, low back pain, carpal tunnel syndrome, and asthma, acupuncture may be also effective as an adjunct therapy[5]. In the last decades, there has been growing interest in acupuncture anesthesia. Although there is increasing evidence supporting the effectiveness of acupuncture and related techniques in anesthesia, there is still much skepticism about it and the mechanisms of acupuncture anesthesia is still not very clear. Therefore, this review aims to sumarrize some evidence and applicability of acupuncture and related techniques for the underlying mechanisms of acupuncture analgesia and anesthesia. In addition, mechanisms of acupuncture effects on immunoreguation, endocrine regulation and organ protection are also included because of their close relations with acupuncture anesthesia.


  1. Clinical Practice of Acupuncture Anesthesia Top


Acupuncture as a functional modality employed in modern surgical technique was initiated in China more than 50 years ago. In 1958, the first report of surgery being performed with only acupuncture as an anesthetic in China indicated the official birth of acupuncture anesthesia[7]. Acupuncture anesthesia works for a wide range of conditions. The clinical application of acupuncture anesthesia started from small-scale surgical operations, such as tonsillectomy, appendectomy and thyroidectomy, and then expanded to major surgeries, like pneumonectomy, brain tumor resection, mitral commissurotomy, subtotal gastrectomy, subtotal splenectomy, caesarean section, subtotal hysterectomy, and kidney, bladder surgeries, et al[7],[8].

The initial goal was to develop acupuncture anesthesia as the substitution of chemical anesthetic drugs, considering its remarkable advantages as follows: Firstly, it was safe without drug-related adverse reactions; Secondly, the physiological functions of the body, such as the pulse rate and bold pressure, remained consistently stable during anesthesia; Thirdly, it kept the patient consciousness; Fourth, it was economic and simple. However, as anesthesiology developed safer and more reliable drugs, while manual acupuncture remained a complicated method to use in practice, clinicians transitioned to acupuncture-assisted anesthesia, using acupuncture itself as an adjuvant, and making it possible to achieve better outcomes with fewer anesthetic drugs[9]. Finally a new modality of “pre-operative induction – perioperative anesthesia – post-operative analgesia” was built up, which was also the turning point of the development of acupuncture anesthesia[10].


  2. Mechanisms of Acupuncture Anesthesia Top


Increasing experimental and clinical evidence supports that acupuncture and related techniques are effective in analgesia, neuroendocrine modulation, immunomodulation, and organ protection. In several decades, basic researchers have tried to explore acupuncture anesthesia from the anatomical and histological substrates of the traditional acupoints and meridians.

2.1. Acupuncture analgesia

Manual acupuncture or electro-acupuncture (EA) has convincing therapeutic effects in various painful conditions, and these effects could last for a long period of time even hours after acupuncture application being terminated[11],[12],[13]. The mechanisms of acupuncture analgesia have been widely explored since 1970s.

2.1.1. Peripheral mechanisms underlying acupuncture analgesiaa

2.1.1.1. Acupoints and meridians: trigger of acupuncture analgesia Based on the classical meridian theory, the meridians consist of channels “Jing” and their branches “Luo”, with 361 acupoints being located. The meridians, as a network system, link acupoints via “Qi” (energy) streaming in the meridians. A disease-induced blockade of which causes pain perception. Given that no convincing evidence supports the existence of anatomical foundations of meridians and the meridian theory has been effectively used for treatment in traditional Chinese medicine, the meridians might be a functional constellation including the nervous, circulatory, endocrine and immune systems, in which fictive channels link various acupoints[14].

Traditional acupuncturists emphasize the functional specificity of acupoints according to the meridian theories. A general principle is to select the adjacent points or “Ashi” points. Fruitful clinical researches document the acupoint specificity based on clinical efficacy[15]. Increasing neuroimaging studies also provide the evidence for the specificity of acupuncture effects. A PET study in patients with migraine found traditional acupuncture treatment was more effective for pain reduction and showed different levels of cerebral glucose metabolism in pain-related brain regions, compared with the control acupuncture treatment[16]. An fMRI study in healthy subjects found that manual acupuncture at three acupoints (LI4, ST36, and LV3) showed common responses in the right subgenual BA25, medial subgenual cingulate and right BA31, and preferential differences in major sections of the medial prefrontal and medial temporal lobes among the three acupoints[17]. Besides, the analysis of the whole brain functional connectivity demonstrated that acupuncture at different acupoints elicit different correlations between brain regions, which indicated specific acupoints may exert heterogeneous modulatory effects on the post-stimulus resting brain[18].

2.1.1.2. Afferent nerve fibers activation by acupuncture Since the intensity, frequency, duration, modality, and interval between acupuncture stimuli directly influence the type of activated receptors, increasing evidence has revealed that the types of afferent nerve fibers activated by acupuncture are diverse. Accumulating studies suggest that gentle acupuncture stimulation induces the “De-qi” feeling, excites mainly Aδ-type fibers and activates the gate control system in the spinal cord to relieve pain. However, when the needles are twisted up and down repetitively, the deep tissues, particularly muscle, are locally injured, proinflammatory mediators are released and excite nociceptors directly or indirectly[19]. It is therefore, conceivable that C-type fibers are involved in manual acupuncture-induced analgesia, via activating the negative feedback regulatory mechanism or diffuse noxious inhibitory control in the brainstem[14].

The stimulating current at various parameters applied to acupoints through acupuncture needles can also produce bilateral analgesic effects in human subjects and experimental animals[20]. Since the 1970s, it has been controversial which kind of afferent fibers mediate EA analgesia. Numerous results support that the excitation of Aβ-type fibers and some Aδ-type fibers are involved in EA or transcutaneous electrical nerve stimulation (TENS) analgesia[20], whereas some studies seem to indicate the notion of C-type fiber involvement in EA analgesia[21]. The conflicting results may stem from the variety of stimulation parameters used, such as different frequencies, intensities and types of pulses.

2.1.2. Central mechanisms underlying acupuncture analgesia

Current researches mainly hold that acupuncture analgesia consists of psychological factors and physiological effects. There is considerable debate on whether acupuncture or EA analgesia equals to the placebo analgesia. A PET study compared real acupuncture, placebo acupuncture and skin-prick[22]. Although real acupuncture and placebo (with the same expectation of effect as real acupuncture) caused greater activation than skin prick (no expectation of a therapeutic effect) in some brain regions, such as the right dorsolateral prefrontal cortex, anterior cingulate cortex and midbrain, the insula ipsilateral to the site of needling was activated to a greater extent during real acupuncture than during the placebo intervention. This result suggests that real acupuncture has a specific physiological effect. Another fMRI study also indicated that real acupuncture produced greater fMRI signal decrease in pain related brain regions during application of the heat pain stimuli, although real acupuncture with high expectation and sham acupuncture with high expectation induced subjective reports of analgesia of equal magnitude[23]. These findings provide convincing evidence for the existence of different mechanisms underlying acupuncture analgesia and expectancy evoked placebo analgesia.

A large body of researches shows that acupuncture analgesia manifested the integrative processes at different levels of the central nervous system (CNS) between the afferent impulses from the pain regions and impulses from acupoints[14]. The electrophysiological findings indicate that both pre- and post-synaptic inhibition probably get involved in EA or acupuncture-induced antinociceptive responses in spinal neurons. For example, researchers found that EA stimulation at “Huantiao” and “Yanglingquan” or “Zusanli” induced significant enhancement of depolarization in pre-synaptic primary C-afferent terminals and thus resulted in inhibition of release of neurotransmitters, such as substance P and glutamate, from terminals[24],[25]. Our previous studies have reported that electro-acupuncture at low frequency of 2 Hz had greater and more prolonged analgesic effects on mechanical allodynia and thermal hyperalgesia than EA at high frequency of 100 Hz in rats with neuropathic pain, and induced long term depression (LTD) of the C-fiber-evoked potential in dorsol horn in spinal nerve ligation (SNL) rats[26],[27], which suggests involvement of post-synaptic inhibition in EA analgesia.

The ascending (lateral system and medial system) and the descending pathways of pain are well-documented[28],[29]. Our previous behavioral studies in animal models showed that the periaqueductal gray (PAG) – rostral ventromedial medulla (RVM) system plays a key role in acupuncture or EA analgesia. In addition, anterior cingulate cortex is also crucial for contra- but not ipsi-lateral EA in the formalin-induced inflammatory pain model of rats[30]. Our and other clinical observations and experimental studies suggest that the pathways of acupuncture signals are interwoven with pain pathways[31],[32],[33], acupuncture or EA elicits widespread changes in cerebrocerebellar brain regions, such as RVM, PAG, hypothalamus, thalamus, prefrontal cortex, somatosensory cortex, and limbic system.

By activating or deactivating these brain structures, acupuncture stimulus, on one side, inhibits the activities of nociceptive-sensitive neurons through the cortical-subcortical systems, on the other side, blocks the nociceptive afferents through PAG – RVM – spinal dorsal cord descending inhibition pathway[14]. Both impulses originating from pain sites and from acupoints get converged in the spinal dorsal horn and medial thalamus[14]. Some fMRI studies found long-period TEAS could elicit more secure and spatially extended connectivity of both the default mode network (DMN) and sensorimotor network (SMN)[34], and alter the nodal efficiencies in short-range connections of brain functional networks and the limbic system[35]. In addition, fMRI studies found that electrical acupoint stimulation (EAS) with low and high frequencies seemed to be mediated by different, though overlapped, brain networks[33]. Another study showed different functional connectivity of different networks recruited in different acupuncture modalities[36].

Acupuncture could also directly affect electroencephalogram (EEG) activities on healthy volunteers as well as on animals[37],[38],[39]. Under the tonic pathological pain conditions, our work found that EA treatment decreased the power at high frequency bands and reversed the enhancement of cross-frequency coupling strength between high and low-frequency bands induced by the postincisional pain[40].

2.1.3. Roles of neurotransmitters and neuromodulators in acupuncture analgesia

Numerous findings in human and animal studies have demonstrated that acupuncture analgesia is a complex physiological process mediated by various neurotransmitters and neuromodulators, such as opioid peptides, 5-hydroxy-tryptamin (5-HT), noradrenalin (NA), glutamate and its receptors, y-amino-butyric acid (GABA), substance P, angiotensin II, somatostatin, arginine vasopressin, neurotensin, dopamine (DA), and so on[14].

Han and his colleagues have made important contributions to this field[20]. Their work showed that under the physiological pain conditions, 2 and 100 Hz EA-induced analgesic effects were mediated by accelerating the release of β-endorphin and enkephalins in the CNS, respectively, and EA effects were differentially reduced by blockade of μ-/δ- and κ-opioid receptors. Further studies showed that low and high frequency EA induced different brain network activation[14], and lesions of the arcuate nuclei abolished high-frequency EA-induced analgesia, whereas selective lesions of the parabrachial nuclei attenuated high-frequency EA-induced analgesia[41], which indicated that low- and high-frequency EA analgesia were probably mediated by different brain nuclei.

Evidence has shown the involvement of cholecyctokinin octapeptide (CCK-8) in EA analgesia. In the behavioral test, intrathecal administration of CCK-8 or CCK receptor antagonists significantly depressed or potentiated EA-induced antinociception, respectively[42]. Besides, the blockade of NMDA and AMPA/KA receptors can reinforce acupuncture analgesia. In the rat neuropathic pain model of spinal nerve ligation (SNL), ketamine, an NMDA receptor antagonist, potentiated the anti-allodynic effects induced by 2 Hz EA[43]. Immunochemical studies further revealed that low-frequency EA reduced the enhanced expression of NMDA receptor subtype NR1 immunoreactivity in the spinal superficial laminae in the rat SNL model[44]. Also, in the CFA-induced inflammatory pain model of rats, EA decreased the expression of NR1 and NR2 GluR1 in the spinal cord and the number of DRG neurons with IB4 and NR1 double-labeling[45],[46]. The early work from Han and his colleagues found that EA increased the central content of 5-HT and its metabolic products, particularly in the nucleus raphes magnus (NRM) and the spinal cord[47],[48]. Further studies found that intrathecal injection or intracerebroventricular administration of antagonists of 5-HT1A and 5-HT3 receptors, but not 5-HT2A antagonists, significantly blocked the EA-induced analgesia[49],[50]. About the role of GABA receptors in acupuncture analgesia, current studies show that EA analgesia induces an increase of GABA concentration, and GABAB receptors in the supraspinal structures contribute to mediating acupuncture analgesia, whereas both GABAA and GABAB receptors in the spinal cord are associated with acupuncture analgesia[14].

The endocannabinoid system has also been verified to get involved in EA analgesia. In an animal model of inflammatory pain, EA potentiates the local release of endogenous anandamide and reduces proinflammatory cytokines from inflammatory skin tissues th activation of cannabinoid CB2 receptors CB2Rs[51],[52]. Further study found EA increased endogenous opioid expression in keratinocytes and infiltrating immune cells at the inflammatory site through CB2R activation[53].

In addition, increasing evidence has revealed that analgesic effects of EA might be associated with its counter-regulation to spinal glia activation. Connexin 43 (Cx43) is a gap junction protein, which is extensively expressed in the CNS and serves in signal transmission between glia and neurons. In Cx43 gene knock-out mice, EA analgesia was partially reduced in comparison with the wild-type mice[54]. Some studies have indicated the inhibition of extracellular signal-regulated protein kinase (ERK) phosphorylation, increased expression of the c-fos gene and nuclear factor-kappa B (NF-κB) in the spinal dorsal horn[14], and increased release of adenosine around the site of acupoints[55] might also be involved in EA or acupuncture analgesia.

As mentioned above, there are individual differences and EA frequency-dependency in acupuncture analgesia. Our previous work also revealed the effect of genotype on sensitivity to EA analgesia using 10 common inbred mouse strain, suggesting the different allelic forms of the gene show variation in their analgesic responses to EA[11]. The further study was conducted to identify and characterize the genes that differ between high-responders and low-responders to acupuncture stimulation in human volunteers, and found 353 and 22 genes were up- and down- regulated, respectively[56]. These findings hint inherited genetic factors as a possible explanation of individual differences in acupuncture analgesia.

It is, therefore, conceivable that acupuncture analgesia has physiological, anatomical and neurochemical basis, despite the involvement of psychological factors in acupuncture treatment of patients and stress in animal behavioral tests. Acupuncture analgesia is essentially a manifestation of integrative processes involving various molecules, proteins and neuronal ensemble networks at different levels of the CNS.

2.2. Immunomodulation of acupuncture

A large number of clinical evidences confirm that acupuncture or EA can reduce nausea and vomiting, improve postoperative analgesia, and reduce opioid consumption in surgery[57]. The immune fuction is disturbed by the surgical trauma and anesthesia during the perioperative period. It is believed that acupuncture or acupuncture assisted anesthesia (AAA) plays its immunomodulatory role through local immunity and neuro-immunitiy mediated by endogenous opioid peptides, cytokines, NK cells and T lymphocytes and other mechanisms, which is of far reaching significance in the peri-operative application[58].

NK cells, as the third lymphocyte population, play a vital role in innate immune responses. Fruitful findings suggest that the EA or acupuncture stimulation can enhance the NK cell activity, which is probably mediated by increased levels of interferon-γ (IFN-γ) and β-endorphin secretion caused by EA or acupuncture[59]. Another study noticed that the enforcement of NK cell cytotoxicity induced by EA was abolished by lesion in the lateral hypothalamic area[60]. Studies[59] at the transcriptional level showed that EA treatment increased NK cell activity through decreasing mRNA expression of protein tyrosine phosphatases-q (SHP-1) and up-regulating expression of protein tyrosine kinase (PTK), and anchored cell to the target cells by increasing gene expression of vascular cell adhesion molecule-1 (VCAM-1) through the increased level of IFN-γ.

Acupuncture-induced modulation of Th1/Th2 balance is considered as another key mechanism in the treatment of various immune disorders. Generally, Th1 cells produce interleukin-2 (IL-2), IFN-γ and tumor necrosis factor-β (TNF-β) that are mainly involved in cell mediated immunity or delayed-type hypersensitivity (DTH), whereas Th2 cells produce humoral immunity-related IL-4, IL-5, IL-10 and IL-13. The Th1- and Th2-specific cytokines augment the development of the same subset and inhibit the proliferation and activity of the other subset[59]. A previous study[61] found that sequential EA stimulation at acupoints ST36 greatly decreased the elevated serum levels of IgE by suppressing the increase of Th2 cytokines, especially IL-4. Interestingly, for the Th1 dominant disorders, the positive effect of acupuncture seems to be mediated by down-regulating serum levels of TNF-α and IFN-γ, which are linked to the induction of Th1 responses.

In addition, macrophages and neutrophil seem to be involved in the immunomodulation induced by acupuncture. A study[62] found that EA suppressed the production of the TNF-α by the macrophages induced by lipopolysaccharide (LPS), which could be antagonized by naloxone. Another study found that the acupuncture treatment reversed the neutrophil impairment, and enhanced their migration toward the peritoneal cavity in rats with sepsis[63].

It is well-documented that the acupuncture- or EA-induced release of opioids in the CNS could facilitate either sympathetic or parasympathetic nervous systems. The hypothalamus, as a primary core for neuroendocrineimmune modulation, has been widely reported to be activated, and the amount of β-endorphin, which is mainly released from the hypothalamus, was also largely increased by EA treatment, coincided with the increase of IFN-γ levels and NK cell activity, and naloxone pre-treatment reduced such an effect on IFN-γ and NK cells[63]. In addition, there has been evidence, however, suggesting non-opioid mechanisms, such as catecholamine and serotonin systems, are also involved in the modulatory effects of acupuncture on the immune system. For example, pre-administration of phentolamine (an α-adrenoceptor antagonist) completely blocked the inhibitory effect of EA on antigen-specific IgE in serum and IL-4 production[64]. Gene expression of serotonin receptor 3a in the hypothalamus markedly increased after EA with enhanced NK cell activity[65]. In addition, a recent study[66] reported that sciatic nerve activation with EA controlled systemic inflammation and rescued mice from polymicrobial peritonitis by inducing vagal activation of aromatic L-amino acid decarboxylase, leading to the production of dopamine in the adrenal medulla.

2.3. Neuroendocrine regulation of acupuncture

The endocrine regulation of acupuncture or EA is mainly mediated by the CNS, including the hypothalamo-pituitary-adrenal (HPA) axis and hypothalamus-pituitary-thyroid (HPT) axis. As mentioned before, hypothalamus, as an integrative hug of “neuroendocrine converter”, plays a critical role in interactions and couplings between neuro-transmitters and hypothalamic hypophysiotropic hormones. Increasing evidence have suggested that EA stimulation exerted an anti-depressive effect through weakening the metabolism of 5-HT in the cortex, enhancing the activities of 5-HTergic neurons and regulation of NE/5-HT balance. A series of researches verified that EA markedly reversed the decreased concentration of thyroxine 3 (T3) and T4 in the serum in hypothyroidism, and decreased the level of T3 and T4 in hyperthyroidism. In addition, EA or acupuncture stimulation is effective to the regulation of the estrogen, androgen, insulin, and growth hormones[67],[68],[69].

2.4. Organ protection of acupuncture

Increasing evidence has shown that acupuncture or EA exerts protective effect on multi-organ systems, including the brain, the heart, the gastrointestinal system and others.

In the aspect of brain protection, acupuncture significantly improved memory impairment induced by cerebral multi-infarction via regulating the expression of apoptosis related anti-apoptotic gene Bcl-2 and pro-apoptotic Bax gene in the hippocampus[70]. Compelling evidence suggests that δ-opioid receptor activation attenuates oxidative injury in the ischemic rat brain, EA with specific intensity and frequency can increase cerebral blood flow and effectively protects the brain from ischemic injury, which might be mediated by EA-induced maintenance of blood-brain barrier (BBB) integrity, inhibition of apoptosis, activation of endocannabinoid system, and attenuation of glutamate excitotoxicity[71],[72],[73].

Studies on the effectiveness of EA in the treatment of Parkinson’s disease (PD) found that long-term high-frequency EA is effective in halting the degeneration of dopaminergic neurons in the substantia nigra (SN) and up-regulating the levels of brain-derived neurotrophic factor (BDNF) in the subfields of the ventral midbrain[74].

Studies on the cardioprotection of acupuncture have shown that in rat model with ischemia and reperfusion, EA or acupuncture treatment significantly attenuated the elevated ST segment of electrocardiogram (ECG), cardiac arrhythmia score, and the ratio of the infarct size/risk zone, which was mediated via inhibition of cardiac β-adrenoceptors signaling pathway as well as opioid peptides and protein kinase C (PKC)-dependent pathways[75],[76],[77],[78]. A recent study also showed that acupuncture alleviated the pathological changes of cardiac tissue of rats with myocardial ischemia and regulated the protein expression of cystic fibrosis trans-membrane conductance regulator (CFTR) and CL- channels CLC02[79]. In addition, direct electrical or peripheral neural stimulation might evoke the release of cardioprotective substances into the bloodstream with comparable effects to that of remote ischemic pre-conditioning by limb ischemia (rIPC)[80].

In gastroenterology, acupuncture has also been used successfully to treat different gastrointestinal disorders, since its efficacy in the regulation of gastrointestinal motor activity, the secretion of opioid peptides and the gastric acid, and other neural pathways[67].


  3. Conclusion Top


Current available data compellingly support that acupuncture has it considerable overwhelming advantages in analgesia, preventing postoperative nausea and vomiting, neuroendo-crine-immunomodulation, and multi-organ protection, as shown in [Table 1]. The mechanisms of acupuncture are not completely understood. Nevertheless, it has been understood that interaction and integration of neurotransmitters, neuronal activities, and neuronal ensemble networks coordinate the acupuncture effects. It has been paid more attention to the modulation of acupuncture or EA on neuroendocrineimmune network and organ protections. Because of these effects, the use of acupuncture and application of acupuncture anesthesia will manifest it greater prospect in the future, with the gradual illumination of the underlying mechanism of acupuncture effects.
Table 1: Summary of mechanisms underlying acupuncture effects

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  References Top

1.
Hui KK, Nixon EE, Vangel MG, Liu J, Marina O, Napadow V, Hodge SM, Rosen BR, Makris N, Kennedy DN. Characterization of the “deqi” response in acupuncture. BMC complementary and alternative medicine 2007, 7: 33.  Back to cited text no. 1
    
2.
Kong J, Gollub R, Huang T, Polich G, Napadow V, Hui K, Vangel M, Rosen B, Kaptchuk TJ. Acupuncture de qi, from qualitative history to quantitative measurement. J Altern Complement Med 2007, 13(10): 1059-1070.  Back to cited text no. 2
    
3.
Culliton BJ. Acupuncture: Fertile Ground for Faddists and Serious NIH Research. Science 1972, 177(4049): 592-594.  Back to cited text no. 3
    
4.
Bonafede M, Dick A, Noyes K, Klein JD, Brown T. The effect of acupuncture utilization on healthcare utilization. Medical care 2008, 46(1): 41-48.  Back to cited text no. 4
    
5.
NIH Consensus Conference. Acupuncture. JAMA: the journal of the American Medical Association 1998, 280(17): 1518-1524.  Back to cited text no. 5
    
6.
Birch S, Hesselink JK, Jonkman FA, Hekker TA, Bos A. Clinical research on acupuncture. Part 1. What have reviews of the efficacy and safety of acupuncture told us so far? J Altern Complement Med 2004, 10(3): 468-480.  Back to cited text no. 6
    
7.
Hamalainen MM, Gebhart GF, Brennan TJ. Acute effect of an incision on mechanosensitive afferents in the plantar rat hindpaw. Journal of neurophysiology 2002, 87(2): 712-720.  Back to cited text no. 7
    
8.
Shi H-y. Acupuncture anesthesia development study. Journal of Practical Traditional Chinese Internal Medicine 2008, 22(8): 74-75.  Back to cited text no. 8
    
9.
Han JS. Acupuncture anesthesia (AA) versus acupuncture-assisted anesthesia(AAA). Zhen ci yan jiu = Acupuncture research / [Zhongguo yi xue ke xue yuan Yi xue qing bao yan jiu suo bian ji] 1997, (1-2): 97-100.  Back to cited text no. 9
    
10.
Zhang Yuan YJ-b. Acupuncture for modern anesthesia. Int J Anesth Resus February 2013, 34(2): 145-149.  Back to cited text no. 10
    
11.
Wan Y, Wilson SG, Han J, Mogil JS. The effect of genotype on sensitivity to electroacupuncture analgesia. Pain 2001, 91(1-2): 5-13.  Back to cited text no. 11
    
12.
Huang C, Huang ZQ, Hu ZP, Jiang SZ, Li HT, Han JS, Wan Y. Electroacupuncture effects in a rat model of complete Freund’s adjuvant-induced inflammatory pain: antinociceptive effects enhanced and tolerance development accelerated. Neurochemical research 2008, 33(10): 2107-2111.  Back to cited text no. 12
    
13.
Chang KH, Won R, Shim I, Lee H, Lee BH. Effects of Electroacupuncture at BL60 on Formalin-Induced Pain in Rats. Evidence-based complementary and alternative medicine: eCAM 2012, 2012: 324039.  Back to cited text no. 13
    
14.
Zhao ZQ. Neural mechanism underlying acupuncture analgesia. Progress in neurobiology 2008, 85(4): 355-375.  Back to cited text no. 14
    
15.
Zhao L, Chen J, Liu CZ, Li Y, Cai DJ, Tang Y, Yang J, Liang FR. A review of acupoint specificity research in china: status quo and prospects. Evidence-based complementary and alternative medicine: eCAM 2012, 2012: 543943.  Back to cited text no. 15
    
16.
Yang J, Zeng F, Feng Y, Fang L, Qin W, Liu X, Song W, Xie H, Chen J, Liang F. A PET-CT study on the specificity of acupoints through acupuncture treatment in migraine patients. BMC complementary and alternative medicine 2012, 12: 123.  Back to cited text no. 16
    
17.
Claunch JD, Chan ST, Nixon EE, Qiu WQ, Sporko T, Dunn JP, Kwong KK, Hui KK. Commonality and specificity of acupuncture action at three acupoints as evidenced by FMRI. The American journal of Chinese medicine 2012, 40(4): 695-712.  Back to cited text no. 17
    
18.
Feng Y, Bai L, Zhang W, Ren Y, Xue T, Wang H, Zhong C, Tian J. Investigation of acupoint specificity by whole brain functional connectivity analysis from fMRI data. Conference proceedings: Annual International Conference of the IEEE Engineering in Medicine and Biology Society IEEE Engineering in Medicine and Biology Society Conference 2011, 2011: 2784-2787.  Back to cited text no. 18
    
19.
Mayer DJ. Biological mechanisms of acupuncture. Progress in brain research 2000, 122: 457-477.  Back to cited text no. 19
    
20.
Han JS. Acupuncture: neuropeptide release produced by electrical stimulation of different frequencies. Trends in neurosciences 2003, 26(1): 17-22.  Back to cited text no. 20
    
21.
Cao X. Scientific bases of acupuncture analgesia. Acupuncture & electro-therapeutics research 2002, 27(1): 1-14.  Back to cited text no. 21
    
22.
Pariente J, White P, Frackowiak RS, Lewith G. Expectancy and belief modulate the neuronal substrates of pain treated by acupuncture. NeuroImage 2005, 25(4): 1161-1167.  Back to cited text no. 22
    
23.
Kong J, Kaptchuk TJ, Polich G, Kirsch I, Vangel M, Zyloney C, Rosen B, Gollub R. Expectancy and treatment interactions: a dissociation between acupuncture analgesia and expectancy evoked placebo analgesia. NeuroImage 2009, 45(3): 940-949.  Back to cited text no. 23
    
24.
Li C, Zhu L, Li W, Ji C. [Relationship between the presynaptic depolarization effect of acupuncture and r-aminobutyric acid, opioid peptide and substance P]. Zhen ci yan jiu = Acupuncture research / [Zhongguo yi xue ke xue yuan Yi xue qing bao yan jiu suo bian ji] 1993, 18(3): 178-182.  Back to cited text no. 24
    
25.
Fung SJ, Chan SH. Primary afferent depolarization evoked by electroacupuncture in the lumbar cord of the cat. Experimental neurology 1976, 52(1): 168-176.  Back to cited text no. 25
    
26.
Xing GG, Liu FY, Qu XX, Han JS, Wan Y. Long-term synaptic plasticity in the spinal dorsal horn and its modulation by electroacupuncture in rats with neuropathic pain. Experimental neurology 2007, 208(2): 323-332.  Back to cited text no. 26
    
27.
Xing G, Liu F, Wan Y, Yao L, Han J. [Electroacupuncture of 2 Hz induces long-term depression of synaptic transmission in the spinal dorsal horn in rats with neuropathic pain]. Beijing da xue xue bao Yi xue ban = Journal of Peking University Health sciences 2003, 35(5): 453-457.  Back to cited text no. 27
    
28.
Heinricher MM, Tavares I, Leith JL, Lumb BM. Descending control of nociception: Specificity, recruitment and plasticity. Brain research reviews 2009, 60(1): 214-225.  Back to cited text no. 28
    
29.
Treede RD, Kenshalo DR, Gracely RH, Jones AK. The cortical representation of pain. Pain 1999, 79(2-3): 105-111.  Back to cited text no. 29
    
30.
Yi M, Zhang H, Lao L, Xing GG, Wan Y. Anterior cingulate cortex is crucial for contra- but not ipsi-lateral electro-acupuncture in the formalin-induced inflammatory pain model of rats. Molecular pain 2011, 7: 61.  Back to cited text no. 30
    
31.
Fang J, Jin Z, Wang Y, Li K, Kong J, Nixon EE, Zeng Y, Ren Y, Tong H, Wang P et al. The salient characteristics of the central effects of acupuncture needling: limbic-paralimbic-neocortical network modulation. Human brain mapping 2009, 30(4): 1196-1206.  Back to cited text no. 31
    
32.
Hui KK, Liu J, Makris N, Gollub RL, Chen AJ, Moore CI, Kennedy DN, Rosen BR, Kwong KK. Acupuncture modulates the limbic system and subcortical gray structures of the human brain: evidence from fMRI studies in normal subjects. Human brain mapping 2000, 9(1): 13-25.  Back to cited text no. 32
    
33.
Zhang WT, Jin Z, Cui GH, Zhang KL, Zhang L, Zeng YW, Luo F, Chen AC, Han JS. Relations between brain network activation and analgesic effect induced by low vs. high frequency electrical acupoint stimulation in different subjects: a functional magnetic resonance imaging study. Brain research 2003, 982(2): 168-178.  Back to cited text no. 33
    
34.
Jiang Y, Hao Y, Zhang Y, Liu J, Wang X, Han J, Fang J, Zhang J, Cui C. Thirty minute transcutaneous electric acupoint stimulation modulates resting state brain activities: a perfusion and BOLD fMRI study. Brain research 2012, 1457: 13-25.  Back to cited text no. 34
    
35.
Zhang Y, Jiang Y, Glielmi CB, Li L, Hu X, Wang X, Han J, Zhang J, Cui C, Fang J. Long-duration transcutaneous electric acupoint stimulation alters small-world brain functional networks. Magnetic resonance imaging 2013, 31(7): 1105-1111.  Back to cited text no. 35
    
36.
Jiang Y, Wang H, Liu Z, Dong Y, Xiang X, Bai L, Tian J, Wu L, Han J, Cui C. Manipulation of and sustained effects on the human brain induced by different modalities of acupuncture: an fMRI study. PloS one 2013, 8(6): e66815.  Back to cited text no. 36
    
37.
Hsu SF, Chen CY, Ke MD, Huang CH, Sun YT, Lin JG. Variations of brain activities of acupuncture to TE5 of left hand in normal subjects. The American journal of Chinese medicine 2011, 39(4): 673-686.  Back to cited text no. 37
    
38.
Yin CS, Park HJ, Kim SY, Lee JM, Hong MS, Chung JH, Lee H. Electroencephalogram changes according to the subjective acupuncture sensation. Neurological research 2010, 32 Suppl 1: 31-36.  Back to cited text no. 38
    
39.
Kim MS, Cho YC, Moon JH, Pak SC. A characteristic estimation of bio-signals for electro-acupuncture stimulations in human subjects. The American journal of Chinese medicine 2009, 37(3): 505-517.  Back to cited text no. 39
    
40.
Wang J, Li X, Li D, Li XL, Han JS, Wan Y. Modulation of brain electroencephalography oscillations by electroacupuncture in a rat model of postincisional pain. Evidence-based complementary and alternative medicine: eCAM 2013, 2013: 160357.  Back to cited text no. 40
    
41.
Wang Q, Mao L, Han J. The arcuate nucleus of hypothalamus mediates low but not high frequency electroacupuncture analgesia in rats. Brain research 1990, 513(1): 60-66.  Back to cited text no. 41
    
42.
Huang C, Hu ZP, Jiang SZ, Li HT, Han JS, Wan Y. CCK(B) receptor antagonist L365,260 potentiates the efficacy to and reverses chronic tolerance to electroacupuncture-induced analgesia in mice. Brain research bulletin 2007, 71(5): 447-451.  Back to cited text no. 42
    
43.
Huang C, Li HT, Shi YS, Han JS, Wan Y. Ketamine potentiates the effect of electroacupuncture on mechanical allodynia in a rat model of neuropathic pain. Neuroscience letters 2004, 368(3): 327-331.  Back to cited text no. 43
    
44.
Sun RQ, Wang HC, Wan Y, Jing Z, Luo F, Han JS, Wang Y. Suppression of neuropathic pain by peripheral electrical stimulation in rats: mu-opioid receptor and NMDA receptor implicated. Experimental neurology 2004, 187(1): 23-29.  Back to cited text no. 44
    
45.
Choi BT, Lee JH, Wan Y, Han JS. Involvement of ionotropic glutamate receptors in low frequency electroacupuncture analgesia in rats. Neuroscience letters 2005, 377(3): 185-188.  Back to cited text no. 45
    
46.
Wang L, Zhang Y, Dai J, Yang J, Gang S. Electroacupuncture (EA) modulates the expression of NMDA receptors in primary sensory neurons in relation to hyperalgesia in rats. Brain research 2006, 1120(1): 46-53.  Back to cited text no. 46
    
47.
Han J, Re M, Tang J, Fan S, Xu J, Guan X. The role of central catecholamine in acupuncture analgesia. Chinese medical journal 1979, 92(11): 793-800.  Back to cited text no. 47
    
48.
Han CS, Chou PH, Lu CC, Lu LH, Yang TH, Jen MF. The role of central 5-hydroxytryptamine in acupuncture analgesia. Scientia Sinica 1979, 22(1): 91-104.  Back to cited text no. 48
    
49.
Kim SK, Park JH, Bae SJ, Kim JH, Hwang BG, Min BI, Park DS, Na HS. Effects of electroacupuncture on cold allodynia in a rat model of neuropathic pain: mediation by spinal adrenergic and serotonergic receptors. Experimental neurology 2005, 195(2): 430-436.  Back to cited text no. 49
    
50.
Chang FC, Tsai HY, Yu MC, Yi PL, Lin JG. The central serotonergic system mediates the analgesic effect of electroacupuncture on ZUSANLI (ST36) acupoints. Journal of biomedical science 2004, 11 (2): 179-185.  Back to cited text no. 50
    
51.
Chen L, Zhang J, Li F, Qiu Y, Wang L, Li YH, Shi J, Pan HL, Li M. Endogenous anandamide and cannabinoid receptor-2 contribute to electroacupuncture analgesia in rats. The journal of pain: official journal of the American Pain Society 2009, 10(7): 732-739.  Back to cited text no. 51
    
52.
Su TF, Zhao YQ, Zhang LH, Peng M, Wu CH, Pei L, Tian B, Zhang J, Shi J, Pan HL et al: Electroacupuncture reduces the expression of proinflammatory cytokines in inflamed skin tissues through activation of cannabinoid CB2 receptors. Eur J Pain 2012, 16(5): 624-635.  Back to cited text no. 52
    
53.
Su TF, Zhang LH, Peng M, Wu CH, Pan W, Tian B, Shi J, Pan HL, Li M. Cannabinoid CB2 receptors contribute to upregulation of beta-endorphin in inflamed skin tissues by electroacupuncture. Molecular pain 2011, 7: 98.  Back to cited text no. 53
    
54.
Yu WC, Huang GY, Zhang MM, Zhang Q, Wang W. [The role of connexin 43 gene in acupuncture analgesia]. Zhongguo zhen jiu = Chinese acupuncture & moxibustion 2007, 27(3): 195-198.  Back to cited text no. 54
    
55.
Goldman N, Chen M, Fujita T, Xu Q, Peng W, Liu W, Jensen TK, Pei Y, Wang F, Han X et al: Adenosine A1 receptors mediate local antinociceptive effects of acupuncture. Nature neuroscience 2010, 13(7): 883-888.  Back to cited text no. 55
    
56.
Chae Y, Park HJ, Hahm DH, Yi SH, Lee H. Individual differences of acupuncture analgesia in humans using cDNA microarray. The journal of physiological sciences: JPS 2006, 56(6): 425-431.  Back to cited text no. 56
    
57.
Chen X. The effect of acupuncture anesthesia on the immune function. Medical Recapitulate 2013, 19(1006-2084): 23-25.  Back to cited text no. 57
    
58.
Chen Xue AL-x. The effect of acupuncture anesthesia on the immune function. Medical Recapitulate 2013, 19(1).  Back to cited text no. 58
    
59.
Kim SK, Bae H. Acupuncture and immune modulation. Autonomic neuroscience: basic & clinical 2010, 157(1-2): 38-41.  Back to cited text no. 59
    
60.
Choi GS, Oha SD, Han JB, Bae HS, Cho YW, Yun YS, Lee WK, Ahn HJ, Min BI. Modulation of natural killer cell activity affected by electroacupuncture through lateral hypothalamic area in rats. Neuroscience letters 2002, 329(1): 1-4.  Back to cited text no. 60
    
61.
Park MB, Ko E, Ahn C, Choi H, Rho S, Shin MK, Hong MC, Min BI, Bae H. Suppression of IgE production and modulation of Th1/Th2 cell response by electroacupuncture in DNP-KLH immunized mice. Journal of neuroimmunology 2004, 151(1-2): 40-44.  Back to cited text no. 61
    
62.
Aoki E, Kasahara T, Hagiwara H, Sunaga M, Hisamitsu N, Hisamitsu T. Electroacupuncture and moxibustion influence the lipopolysaccharide-induced TNF-αlpha production by macrophages. In Vivo 2005, 19(3): 495-500.  Back to cited text no. 62
    
63.
Scognamillo-Szabo MV, Bechara GH, Ferreira SH, Cunha FQ. Effect of various acupuncture treatment protocols upon sepsis in Wistar rats. Annals of the New York Academy of Sciences 2004, 1026: 251-256.  Back to cited text no. 63
    
64.
Lee Y, Kim SK, Kim Y, Lee H, Shin MK, Hong MC, Min BI, Bae H. The alpha-adrenoceptor mediation of the immunomodulatory effects of electroacupuncture in DNP-KLH immunized mice. Neuroscience letters 2007, 423(2): 149-152.  Back to cited text no. 64
    
65.
Rho SW, Choi GS, Ko EJ, Kim SK, Lee YS, Lee HJ, Hong MC, Shin MK, Min BI, Kee HJ et al. Molecular changes in remote tissues induced by electro-acupuncture stimulation at acupoint ST36. Molecules and cells 2008, 25(2): 178-183.  Back to cited text no. 65
    
66.
Torres-Rosas R, Yehia G, Pena G, Mishra P, del Rocio Thompson- Bonilla M, Moreno-Eutimio MA, Arriaga-Pizano LA, Isibasi A, Ulloa L. Dopamine mediates vagal modulation of the immune system by electroacupuncture. Nature medicine 2014, 20(3): 291-295.  Back to cited text no. 66
    
67.
Cabyoglu MT, Ergene N, Tan U. The mechanism of acupuncture and clinical applications. The International journal of neuroscience 2006, 116(2): 115-125.  Back to cited text no. 67
    
68.
Zhang J. The modulation of acupuncture on endocrine hormone. Chinese Journal of Integrative Medicine on Cardio/Cerebrovascular Disease 2010, 8(9): 1124-1126.  Back to cited text no. 68
    
69.
Jia-you Wang S-qP, Bao-gui Su. The relationship between the regulation of nerve endocrine immune network and acupuncture treatment: the advance on acupuncture pathways. Anatomy Research 2003, 25(3): 229-232.  Back to cited text no. 69
    
70.
Wang T, Liu CZ, Yu JC, Jiang W, Han JX. Acupuncture protected cerebral multi-infarction rats from memory impairment by regulating the expression of apoptosis related genes Bcl-2 and Bax in hippocampus. Physiology & behavior 2009, 96(1): 155-161.  Back to cited text no. 70
    
71.
Yang Y, Xia X, Zhang Y, Wang Q, Li L, Luo G, Xia Y. delta-Opioid receptor activation attenuates oxidative injury in the ischemic rat brain. BMC biology 2009, 7: 55.  Back to cited text no. 71
    
72.
Zhou F, Guo J, Cheng J, Wu G, Xia Y. Electroacupuncture increased cerebral blood flow and reduced ischemic brain injury: dependence on stimulation intensity and frequency. J Appl Physiol (1985) 2011, 111(6): 1877-1887.  Back to cited text no. 72
    
73.
Li X, Luo P, Wang Q, Xiong L. Electroacupuncture Pretreatment as a Novel Avenue to Protect Brain against Ischemia and Reperfusion Injury. Evidence-based complementary and alternative medicine: eCAM 2012: 195397.  Back to cited text no. 73
    
74.
Liang XB, Liu XY, Li FQ, Luo Y, Lu J, Zhang WM, Wang XM, Han JS. Long-term high-frequency electro-acupuncture stimulation prevents neuronal degeneration and up-regulates BDNF mRNA in the sub-stantia nigra and ventral tegmental area following medial forebrain bundle axotomy. Brain research Molecular brain research 2002, 108 (1 -2): 51 -59.  Back to cited text no. 74
    
75.
Gao J, Fu W, Jin Z, Yu X. A preliminary study on the cardioprotection of acupuncture pretreatment in rats with ischemia and reperfusion: involvement of cardiac beta-adrenoceptors. The journal of physiological sciences: JPS 2006, 56(4): 275-279.  Back to cited text no. 75
    
76.
Tsou MT, Huang CH, Chiu JH. Electroacupuncture on PC6 (Neiguan) attenuates ischemia/reperfusion injury in rat hearts. The American journal of Chinese medicine 2004, 32(6): 951-965.  Back to cited text no. 76
    
77.
Gao J, Fu W, Jin Z, Yu X. Acupuncture pretreatment protects heart from injury in rats with myocardial ischemia and reperfusion via inhibition of the beta(1)-adrenoceptor signaling pathway. Life sciences 2007, 80(16): 1484-1489.  Back to cited text no. 77
    
78.
Zhou W, Ko Y, Benharash P, Yamakawa K, Patel S, Ajijola OA, Mahajan A. Cardioprotection of electroacupuncture against myocardial ischemia-reperfusion injury by modulation of cardiac norepi- nephrine release. American journal of physiology Heart and circulatory physiology 2012, 302(9): H1818-1825.  Back to cited text no. 78
    
79.
Cheng ZD, Li CR, Shao XJ, Rong PJ, Zhang XQ, Liang FR, Li Y, Chen YG. The impacts of along-channel acupuncture on the protein expressions of the chloride channel of the rats with myocardial ischemia. Evidence-based complementary and alternative medicine: eCAM 2013, 321067.  Back to cited text no. 79
    
80.
Redington KL, Disenhouse T, Strantzas SC, Gladstone R, Wei C, Tropak MB, Dai X, Manlhiot C, Li J, Redington AN. Remote cardioprotection by direct peripheral nerve stimulation and topical capsaicin is mediated by circulating humoral factors. Basic research in cardiology 2012, 107(2): 241.  Back to cited text no. 80
    



 
 
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