Osteopathic Manipulative Medicine

and Acupuncture Combined:

A Retrospective case study to determine if order of treatment makes
a difference in outcome for acute mechanical low back pain
William H. Stager

Abstract the central position of the neuromusculoskeletal system in

Background: Osteopathic Manipulative Treatment (OMT) illness and injury, with osteopathic palpatory diagnosis and
and acupuncture can be used as treatment modalities for acute treatment being integrated into successful health care.1 OMT
low back pain. They may be used alone or in combination. There has been the subject of a growing body of research especially
have not been any studies to determine if, during the same treat- for the purposes of treating pain and dysfunctions of all types,
ment session, using one before the other is more effective. including low back pain.2
Objective: To determine if there is any difference in relief Back pain of various kinds, especially low back pain, affects
of acute, mechanical low back pain if OMT is followed by millions of Americans of all ages and backgrounds.3 Patients with
acupuncture or if acupuncture is followed by OMT during the many types of back pains, acute (less than six months duration)
same treatment session. and chronic (greater than six months), are treated by physicians
Design, Setting, and Patients: A retrospective two-year case of many specialties, including neuromusculoskeletal medicine
study of 30 patients seen in the author’s private practice for acute, and osteopathic manipulative medicine (NMM/OMM), family
mechanical low back pain of less than six months. medicine, orthopedics, neurology, rheumatology, and internal
Intervention: All treatments included both OMT and acupunc- medicine. Non-physician health care practitioners including
ture. Fifteen patients received OMT followed by acupuncture. nurses, physical therapists, and occupational therapists also play
The other group received acupuncture followed by OMT during a significant role in the patient care milieu. The spectrum of back
the same session. All treatment sessions lasted 30 minutes, once pain is treated with a broad spectrum of pharmacological and
a week for four weeks. non-pharmacological modalities.4
Main Outcome Measure: Patients reported pain levels before Acupuncture has an ancient and interesting history. It is
the first treatment and at the end of the last (fourth) treatment, enjoying a recent surge in interest, development, refinement,
using a simple 0-10 pain scale. and research.5 Acupuncture is practiced around the world in a
Results: Both groups showed similar beginning and ending number of styles by a wide variety of health care practitioners
pain scale values. They also showed nearly identical improve- for probably all known illnesses and injuries.5 Osteopathic (DO)
ment. and allopathic (MD) physicians of all specialties in America
Conclusion: OMT and acupuncture during the same session may integrate acupuncture into their practices.6,7 The National
for acute mechanical low back pain over four weekly sessions Institutes of Health (NIH) delivered their “Acupuncture, NIH
resulted in significant lessening of symptoms. The order in which Consensus Statement 1997”, reviewing over 2300 research
OMT and acupuncture were done did not result in any difference papers addressing the use of acupuncture for a wide variety of
in pain symptom outcome between the two groups. illnesses and injuries, including their recommendation for its
use in low back pain.8,9 The World Health Organization (WHO)
Key Words recognizes and encourages the use of acupuncture for a number
Osteopathic Manipulative Treatment (OMT), acupuncture, of conditions, including low back pain.5
acute mechanical low back pain, somatic dysfunction, Ming A computer-based literature search through large, online
Men. sources such as the National Library of Medicine, Medline, Ovid,
PubMed, and DO-Online will reveal thousands of papers and
Introduction books on acupuncture and as well as OMT, for a wide spectrum
OMT is a recognized, well-documented, and effective of conditions. There are a few references of combining the two
treatment modality for somatic dysfunction.1 Andrew Taylor or combining the two for low back pain.5,10-32 No studies have
Still, MD, in 1874, founded a philosophy and medical system been done to determine if the sequence of OMT and acupuncture
with a holistic perspective of health and disease, emphasizing affect clinical outcomes.
➝

December 2007 The AAO Journal/11

Methods some relief after each treatment session, with maximum relief
The author conducted a two-year retrospective case study felt and recorded after the fourth session.
(2004-2005) of 30 patients in his practice specializing in OMT Acupuncture was performed on every patient, either before
and medical acupuncture. The patients all had acute, mechanical or after OMT. Acupuncture points GV-4, BL-23 bilaterally, and
low back pain. Acute symptoms were defined as less than six BL-52 bilaterally (total of 5 points, also called “Ming Men”)
months from onset. Most were seen within a few days of onset were chosen for their individual and combined known effects on
and all were former patients who had been treated by the author the local sensory and motor signs and symptoms, as well as their
for various conditions in the past with OMT, or OMT and energetic properties.5,34 Acupuncture was performed with sterile,
acupuncture combined. Patients were a mix of male (n = 18) and single-use, stainless steel needles, 0.22 mm in diameter and 25
female (n = 12) with ages ranging from 22-84 years old (average mm in length (Helio Medical Supplies, Inc., San Jose, CA).
62.6). The risks and benefits of the OMT and acupuncture Needles were inserted 25 mm in depth, in manual tonification
treatments were explained verbally to each patient before (i.e., pointing them in the direction of the flow of the meridian
treatment. Each patient gave verbal consent to treatment. and turning them clockwise, eliciting a De Qi or sensation of
All the patients presented with symptoms of acute low back energy response felt by the patient and physician), and were left
pain including: localized lumbar pain, lumbar to hip region in place for 10 minutes per session.
pain, pain radiating to the anterior pelvic area, numbness or The first group of 15 patients treatment protocol was
tingling in the low back and/or pelvis, stiffness, and difficulties examination for 10 minutes, OMT for their low back pain for 10
with various activities such as sitting, bending, standing, etc. minutes followed by the acupuncture protocol for 10 minutes.
Pain was measured on a verbal scale from 0-10, with 0 being Total session time was 30 minutes each. The second group of 15
no pain, and 10 feeling like the worst or most severe pain patients was examined then treated with acupuncture followed
possible. This pain scale is a well-recognized and documented by OMT. The time allocations were the same. If any patient had
pain measurement tool.33 Pain values were recorded on the other areas of somatic dysfunction he or she was gently treated
first visit before treatment, and on the last visit after treatment. in those areas while the acupuncture needles were in place.
Some of the patients had no known predisposing or prior low Treatment was administered so as not to disturb the needles or
back conditions, while others had chronic, low back conditions. low back area in any way. Patients were treated once a week
Other medical conditions were not used as inclusion or exclusion for four weeks.
criteria. No analgesic medications were prescribed and patients
used their own discretion as to whether to use over the counter Results
analgesic agents. There were no adverse events from treatments. Eighteen
were male (60%) and twelve were female (40%). The average
Diagnosis of acute, mechanical low back pain was age of the group that received OMT first was 60.6 years old
made from the patients’ history and physical exam with (ranging from 28-80 years old). The average age of the group
special emphasis on osteopathic palpation. Every patient that received acupuncture first was 64.6 years old (ranging from
was diagnosed using some combination of standard 22-84 years old). For the OMT first group, the average pain
osteopathic methods. Visual and palpatory measurements score before the first treatment was 6.66, and then 0.933 after
of body position and/or motion were noted on the patients. the last treatment. For the acupuncture first group, the average
Active and passive range of motion tests were performed. pain score before the first treatment was 6.46, and then 1.0 after
Somatic dysfunction was diagnosed in every patient, the last treatment.
justifying the OMT. Group statistics for the OMT first group were: N = 15, Mean
Somatic dysfunction is defined as: “impaired or = 5.80, Standard Deviation = 0.676, and Standard Error Mean
altered function of related components of the somatic (body = 0.175. For the acupuncture first group the data were: N = 15,
framework) system: skeletal, arthrodial, and myofascial Mean = 5.53, Standard Deviation = 0.743, and Standard Error
structures, and related vascular, lymphatic, and neural Mean = 0.192. P < 0.05. The Independent Samples Test/t-test
elements”.1 Somatic dysfunction may also be described for equality of means for the pain differences between the two
in terms of visual and palpatory positional and motion groups showed a standard error difference of .259, and a 95%
aspects, using the simplified mnemonic “TART”: “tissue Confidence Interval of the difference as lower -.265 and upper
texture abnormality, asymmetry, restriction of motion, .798. There was practically no difference between the outcomes
and tenderness, any one of which must be present for the of the two groups. See Tables 1-4 The statistical analysis was
diagnosis”.1 done using statistical software SPSS 11.0.

Because there was a wide range of segmental dysfunctions, Discussion

a variety of OMT techniques were used in the treatments. The Low Back Pain
author chose techniques and sequencing taking into consideration Back pain can have many causes: neuromusculoskeletal,
the many factors of the patients’ conditions, responses, etc. postural, scoliotic, arthritic, vascular, visceral, emotional,
The results of the combined OMT and acupuncture treatments traumatic, post-surgical, infectious, cancerous, etc. Acute (less
were: relief of somatic dysfunction, improved ranges of motion, than six months) and chronic (greater than six months) back pain
decreased pain, decreased swelling, normalized skin temperature, has plagued humanity since time immemorial. Back pain of all
and relief of the patient’s fears and anxieties. Every patient felt types, especially low back pain, affect millions of Americans,
12/The AAO Journal December 2007
account for a large proportion of doctor’s visits, millions of Osteopathic Manipulative Medicine
dollars spent on treatment, and millions of work hours lost from Osteopathic manipulative treatment (OMT) – holistic
productivity.1-4,35-38 Physicians representing many specialties, osteopathic palpatory diagnosis and treatment – is indicated for
physical and occupational therapists, and other health care most illnesses and injuries.1 OMT techniques, done by Doctors
practitioners all play a role in the diagnosis and treatment of low of Osteopathy (DO), cover a broad range of treatments to aid
back pain, using a wide spectrum of pharmacological and non- and enhance in the treatment of every part of the body, mind,
pharmacological treatment modalities.4 OMT and acupuncture, and soul, its solids, liquids, gases, and energies. The techniques
separately and together, are used, researched, and recommended vary with the skills, knowledge, background, and temperament
for the treatment of low back pain.1-32,39-42,66-85 of the practicing osteopathic physician. Skilled and imaginative
Acute, mechanical, low back pain is usually due to some practitioners may combine and modify techniques in response
activity such as bending or lifting. It presents as various symptoms to their needs as well as the needs of their patients. The holistic
including localized lumbar, sacral, or hip pain, pain radiating from osteopathic philosophy and principles allow and encourage
the lumbar to pelvic or lower extremity areas either posteriorly or individuality, inventiveness, and inclusiveness. Osteopathic
anteriorly, muscle, fascial, tendonous, ligamentous and/or joint techniques are easily integrated with those from other traditions.
pains, strains, or sprains, stiffness, numbness or tingling in the low ➝
back or pelvis, and/or difficulties or
dysfunction with activities such as
sitting, standing, bending, etc.
Evaluation of back pain is
done in many ways including:
lumbar, sacral, and pelvic palpatory
testing for somatic dysfunction,
visual assessment of the lumbar,
sacral, pelvic, and lower extremities
for asymmetry, the anterior spinal
compression spring test, spinal
lumbosacral spring test, lumbar and
pelvic ranges of motion, Thomas
test for psoas muscle shortening,
sensory, motor, and reflex testing of
the areas innervated by the lumbar
and sacral nerve roots (patellar
L4-5 reflex, Achilles S1-2 reflex,
lower extremity dermatomes, etc.),
and muscle testing for strength,
range of motion, and tender points
(the reader is referred to chapter
50 of Foundations for Osteopathic
Medicine for an excellent and
complete review and explanation
of these tests).1
About fifty OMT techniques
are listed in the glossary of
the Osteopathic profession’s
standard textbook Foundations
for Osteopathic Medicine, and the
author used mainly two of them
to treat somatic dysfunctions:
myofascial release and strain-
counterstrain. The techniques were
chosen after visual and palpatory
diagnosis, as well as taking into
consideration the many factors of
the patients’ history, conditions,
pain levels, and response to past
treatment.

December 2007 The AAO Journal/13

Any technique may take seconds to minutes. Medicines may be of anatomy, physiology (and neurophysiology in particular),
added at any time. Acupuncture on any region at any time during and biomechanics explains many of the osteopathic principles
the treatment may also be combined successfully.5-6,10-32 and treatments. The unifying anatomical and physiological
Osteopathic manipulative medicine (OMM) finds its properties of fascia provide for much of OMM’s diagnostic and
efficacy in its addressing of the principles of the interrelatedness treatment success. Fascia has many properties and functions as
of form and function, anatomy and physiology. Anatomy is it pervades practically everywhere throughout the body. Fascia
said to be the foundation of medicine. “O Lord! Give me more provides structure, supporting, dividing, connecting, covering,
anatomy each day I live…” said Dr. Still.43 An understanding maintaining, nourishing, and communicating with all parts

14/The AAO Journal December 2007

of the body. It has biochemical, biomechanical, bioelectrical its mechanisms of action and ability to treat most illnesses and
(piezoelectrical), and communicating properties, which define injuries surface every day. Professional and popular books,
its many functions, which can be affected by dysfunction of journals and research papers in every language are just the tip of
any kind, anywhere. These, in turn, may be treated by virtue the iceberg promoting and explaining this phenomenon. Where
of fascia’s many properties and pervasive presence.44 It is did it come from and how did it get here?
this author’s personal experience that, because of fascia’s Acupuncture’s long and winding road began thousands of
ubiquitous presence and properties, any one part of the body years ago when ancient peoples around the world began using
may be used to diagnose and treat any other part of the body. sharp objects to treat their ailments. Stone needles were invented
This vitally important holistic concept is emphasized as well in in China around 4000 B.C. The most important written records
acupuncture. Dr. Still gave fascia an important and prominent in China began with the Yellow Emperor’s Classic of Internal
part in his writings, philosophy, and techniques.43 Diseases (from about 500-200 B.C.), which formed the basis for
Pain (nociceptive and neuropathic) mechanisms, as well as the hundreds of Chinese textbooks on the subject that followed
various reflexes (facilitated reflexes, inappropriate proprioceptor over the centuries.5
reflexes, etc.) also help determine patient signs and symptoms, The ancient Egyptian papyrus scrolls from 1550 B.C. dis-
and subsequent treatments. Nerves do more than simply convey cuss lines of energy throughout the body, which we now call
signals over their length. They also contain and transport trophic meridians. The Ayurvedic physicians in India used acupuncture
factors responsible for homeostasis, growth, and maintenance for thousands of years. Various forms of acupuncture, using
of their destination organs. Various reflexes have been identified simple sharp objects, were practiced by such diverse groups and
throughout the body, including viscerosomatic (from internal cultures as South African Bantu tribes, Arabs in North Africa and
organs to the more external neuromusculoskeletal regions), so- Arabia, Eskimos (Inuit) and South American natives. Chinese
matovisceral (from external to internal), viscerovisceral (internal acupuncture concepts spread all over Asia, including and espe-
to internal), and somatosomatic (external to external).1,45 cially in Japan, Korea, and Southeast Asian countries, where it
Every cell has an electric charge, multiplied in effect through blended with and was shaped by the local populations.5
the many organs of the body. James Oschman, PhD writes and Since the 16th century, acupuncture and acupuncture texts
speaks specifically about osteopathy and OMT, and describes in were translated and brought to Europe, especially France and Ger-
detail the consequences of alignment of the body’s collagenous many, where it is taught today in many modern medical schools
networks for the energy field of the body. He describes magnetic as part of the curriculum. Again, acupuncture is refined and
fluxes through the vertebral column and surrounding tissues modified with each culture, even in modern Europe. The French
which give rise to the overall field of the body, as well as the have provided some of the most important research and advances
effects of derangements of the parallel collagenous fibers, which in ear acupuncture, called auriculotherapy or auricular medicine,
reduce the total magnetic flux through the system and reduce where the entire body can be diagnosed and treated through the
the overall energy field.46,47 Osteopathic physician/authors have ear, using either tiny needles or electrical stimulation.5
also contributed to the subject.44,48-53 Another new and novel Acupuncture came from Europe to the Americas with the
concept published in 2005 is that OMT may be mediated by the early colonists. Dr. Franklin Bache, Benjamin Franklin’s great
endocannabinoid system.54 grandson, wrote the first medical acupuncture article in the U.S.
Myofascial release techniques combine several types of in 1825, entitled “Memoirs on Acupuncture” and translated
OMT, including cranial osteopathy, visceral manipulation, strain French acupuncture textbooks into English. Dr. Edward Warren’s
counterstrain, facilitated positional release, etc., and can be com- 1863 medical and surgical text discussed the use of acupuncture
bined with any form of OMT. Myofascial release techniques are and acupressure. Acupuncture was used during the U.S. Civil
directed to all the soft tissues of the body, and can be basically War. Sir William Osler, one of the most famous physicians of
divided into either direct (to or through a barrier/restriction) or the 19th century, in his 1892 textbook, Principles and Practice
indirect (away from the barrier/restriction). Myofascial release of Medicine, recommended acupuncture for the treatment of
techniques may be used for virtually any diagnosis of somatic many conditions, especially back pain and sciatica. He wrote,
dysfunction, either alone or in combination with other manipula- “For lumbago, acupuncture is, in acute cases, the most efficient
tive techniques. The techniques may be passive (patient relaxed treatment”.5
and not assisting) or active (physician and patient both actively Acupuncture research has expanded exponentially in the
participate) or both.1 The main object of the technique (and last 50 years, mostly in China, Japan, Europe, America, and
perhaps all manual techniques) is to affect or enhance motion. Canada. Tens of thousands of research articles and books have
Other goals and physiological principles of treatment have been been printed in dozens of languages. Almost all known diseases,
summarized.55,56 Strain-Counterstrain (or simply counterstrain) is every organ system in the body as well as psychiatric conditions
an indirect, myofascial release technique developed by Lawrence are affected by acupuncture and have all been researched using
H. Jones, DO, FAAO, in the 1960s.57-65 acupuncture. The many acupuncture systems with their multiple
effects help describe a working model of a multisystem informa-
Acupuncture tion network all contributing to the explanations of the various
Acupuncture is being rediscovered in America and flourish- aspects of acupuncture.5
ing with a momentum matched only by its efficacy. Acupuncture Acupuncture points as seen under the microscope are found to
is both old and new. It has been found in various forms in vari- be vertical columns with the tissue, myelinated and unmyelinated
ous cultures for thousands of years, and new discoveries about ➝

December 2007 The AAO Journal/15

nerves, lymph, and blood vessels concentrated, woven, and at Stanford University, California, speculates that there seems to
organized in a distinctive fashion, with a thinning of the epidermis be a driving electrical field pushing positive ions to the surface
at the acupuncture point.5 Acupuncture points have a lowered of the skin, organized electrical fields from internal organs, as
electrical resistance, allowing for increased electrical conductance well as an electromagnetic field along the acupuncture pathways
along fascial planes in the body. Electrical resistance to a current (meridians), all combining and creating an additional induced
passed between acupuncture points has been shown to be consistently bioelectrical field at the skin’s surface.5 The standing wave su-
lower (i.e., greater conductance) than resistance between nearby perposition hypothesis proposes that the body’s many electrically
control points.5 In fact, transmission of acupuncture electrical charged ions, electrolytes, and proteins all create bioelectrical
activity is not entirely dependent on an intact nervous system, fields pulsing through the body. The body contains many charged
but rather moisture and electrolytes appear to be the necessary oscillators, emitting electromagnetic radiation of various wave-
vectors between points.5 Fascia has been shown to mechanically lengths (as per the discussion above measuring organ electrical
couple with the acupuncture needle, possibly delivering a output with the ECG, EEG, etc.). These waves travel throughout
mechanical signal into the tissue.66,67 Technetium 99, a radioactive the body, subject to decay, reflection and refraction at vari-
tracer, when injected into acupuncture points, diffuses in fascial ous boundaries of various densities or states of health (bones,
trajectories which topographically correspond to classically muscles, etc.). The accumulation of these waves creates inter-
described acupuncture pathways or meridians, giving substantial ference patterns, with the fascia and unique acupuncture point
and modern proof of these ancient phenomena. When technetium morphology with its increased electrical conductance, creating,
99 was injected in nonacupuncture sites, no linear tracing pattern channeling, and forming these cumulative wave amplitudes at
was observed. Stimulation of the injected acupuncture points the sites we call acupuncture points. These bioelectrical wave
with a needle, electricity, or helium-neon laser all increased patterns from all over the body also accumulate at certain areas
the migration rate along the meridian trajectories.5 Fascia is of the body to form somatotopic reflex patterns such as at the
electron-rich crystal lattice, allowing electron transfer and ear (ear acupuncture or auriculotherapy) and other sites (this
bioelectric fields to be transduced throughout the body, making author has counted some 25 such holographic microsystem sites
an ideal semiconductive matrix and communicating network that throughout the body). The propagation of energy signals along
conveys biochemical and bioelectrical information throughout the neuro-myo-fascial acupuncture pathways would occur with-
the body, from a microscopic to a macroscopic level, throughout out loss of charge because the body’s metabolic energy constantly
the fascial planes/meridians. The bioelectrical properties of regenerates the standing fields and waves.5 The bioenergetic
acupuncture points in particular and fascia in general help provide fields and waves might, in fact, fluctuate with corresponding
a reasonable explanation for the meridians or acupuncture states of health and disease or somatic dysfunction, reflecting
energy pathways. Researchers have described acupuncture points physical, emotional, and/or energetic blockages anywhere in the
as penetrations of nerve-vessel bundles through perforations in system and their consequent treatment. Sensitive practitioners
the fascia.5 It should not be surprising that the Chinese term for of any tradition can sense these changes and diagnose and treat
acupuncture point – xue wei – means “hole between the fascia”, accordingly.5
thus underscoring the importance of fascia. A number of explanations, researches, and hypotheses
Several studies have been done, and correlations have been have arisen over time to provide and explain some aspect of
made between acupuncture points and trigger points (71%), acupuncture’s many mechanisms of action, and a few have been
tender points (virtually 100% since any acupuncture point can provided here. Each of these explanations provides a piece to
be tender during a disease process, these are called “ah shi” or the larger puzzle of its multisystem model, and each will create
“ouch” points in Chinese), strain-counterstrain points (80%), further investigation. These include:
and Chapman’s points (60%).27 A recent osteopathic article on
trigger points suggests that trigger points (and possibly acupunc-
ture points) are evoked by abnormal depolarization of motor • Fascia as bioelectrical conductor
end plates.31 Trigger points have always responded to multiple • Distinctive neuro-hemo-lymphatic point morphology
treatment techniques, including dry needling (acupuncture) and • Bioelectrical transmission of signals
OMT.68-70 • Biochemical transmission and signaling of neu-
Acupuncture signals modulate the relative contrast between rotransmitters, endorphins, enkephalins, hormones,
background neuronal activity and pain signals, predominantly and immunomodulators
with the endogenous opioids, though major neurotransmitters • Peripheral and central nervous system cascades
are all involved and extensively documented at various levels: • Diffuse noxious inhibitory control (DNIC) system
serotonin, norepinephrine, substance P, gamma aminobu- modulation
tyric acid, dopamine, adrenocorticotropic hormone (ACTH), • Increased vasodilation, blood flow, and temperature
beta-endorphin, methionine-enkephalin, leucine-enkephalin, • Homeostatic control of blood glucose (increasing
dynorphins, histamine, bradykinin, prostaglandins PGE2 and blood glucose levels if they are hypoglycemic, and
PGF2 alpha, angiotensin, vasoactive intestinal peptide, and decreasing the levels if they are hyperglycemic)
cholecystokinin.5 • Reducing serum triglycerides and cholesterol
Bioelectromagnetic hypotheses add possible explanations • Immune system modulation (increasing lymphocyte
to acupuncture’s many mechanisms of action. William Tiller, blastogenesis, increased phagocytic and fibrinolytic
PhD, Professor Emeritus of the Department of Materials Science activity, increased beta and gamma globulins)

16/The AAO Journal December 2007

 • Vibrational resonance handle.5 The variety and combinations of acupuncture points,
• Hologramatic interrelatedness of the body meridians and needling techniques are virtually endless. And
• Enhancing the body’s resistance to stresses through combined with other healing modalities, especially OMT, the
its autonomic and immune effects (Dr. Hans Selye, possibilities for treating and effectiveness are that much greater.
the pioneer researcher of stress, suggested acupunc- The Food and Drug Administration (F.D.A.) in 1996 classified
ture for these reasons) acupuncture needles as medical devices.
• Microtubules and cytoskeleton bioelectrical and
biochemical transmission The three acupuncture points used in this study are described
• Bioelectromagnetic hypotheses below.
• Thermoelectrical phenomena: when an acupuncture
needle is inserted into the body, the tip is warmer • GV-4 (Governing Vessel #4). Its Chinese name “Ming
than the handle, creating an electrical and tempera- Men” is approximately translated as “Gate of Life”.
ture gradient and flow of electrons.5 GV-4 is located in the posterior midline depression
inferior to the spinous process of the 2nd lumbar verte-
Most ancient systems have named the effects of acupunc- bra (L2). It is used frequently with BL-23 and Bl-52
ture by basically describing it as an energy phenomenon. Every bilaterally (these total of five needles are called “Ming
language or tradition has devised names for the energy, the most Men”), reinforces and strengthens the lumbar region
frequently used being “chi” or “qi” (Chinese) or “ki” (Japanese). and back in general.34
More modern practitioners have used the terms this author tends • BL-23 (Bladder #23). It’s Chinese name “Shen Shu”
to use, such as bioenergy or bioelectrical energy, etc. The Asian is translated as “Kidney Shu”, the “Shu” points being
acupuncturists describe various types of chi or energy, but the a series of 12 points on the Bladder meridian on the
generic “energy” or “bioenergy”, etc., is sufficient for the pur- back which affect each of the 12 major or Principal
poses of this paper. These generic terms are easier to use when meridian/organ systems. BL-23 is 1 ½ cun (a Chinese
integrating acupuncture into modern medical usages.5 term referring to body “inches”), or two fingers’ width
The meridians or bioenergetic pathways have been called by bilateral from GV-4.34
many names over time. There are several circuits of meridians or • BL-52 (Bladder #52). Its Chinese name “Zhi Shi” is
meridian systems in the body, some paired left and right (mirror approximately translated as “Will Chamber”. BL-52 is
images of each other), some unpaired, and some as combina- located 3 cun (4 fingers’ breadth) lateral to the inferior
tions of the others. A meridian forms a number of bioenergetic border of the spinous process of L2, thus 3 cun bilater-
circuits and subcircuits through fascial planes, and thus develops ally from GV-4 or 1 ½ cun from BL-23.34
from the embryo.5
Acupuncture points as well as their names have a long Together these five points, the midline GV-4 and the bilat-
and interesting history. It is probably safe to assume that most eral BL-23 and BL-52, are a special combination, greater than
acupuncture points and treatments were first discovered seren- the sum of their parts, called Ming Men. A careful reading of
dipitously. The Chinese have poetically and elaborately named acupuncture textbooks reveals that these points are quite strong,
and described each acupuncture point extensively, sometimes affect the body and mind in many powerful and profound ways,
writing pages for a single point and its effects. There are over and address low back pain. As powerful and versatile as this
300 traditional points on the meridians, with several hundred acupuncture combination is, there were no English language
more not on the meridians. The points were originally named. articles found through an online literature search on the use of
The numbering system now used is a recent innovation. New Ming Men. The Helms Institute course of Medical Acupuncture
acupuncture points and their effects are being discovered every for physicians, sponsored through U.C.L.A.’s and Stanford
year. Both old and new points are used in new combinations to University’s medical schools recommends the use of Ming Men.
treat old as well as modern diseases.5 Dr. Helms’ course textbooks Acupuncture Energetics, A Clinical
Acupuncture needles have evolved over time. Acupuncture Approach for Physicians and Point Locations and Functions5,6,34
needles come in a variety of lengths and diameters, ranging from also recommends Ming Men. This author is impressed by its
lengths of less than a centimeter to several centimeters, and efficacy for many conditions, and has used it often. The com-
diameters from .2 to .4 millimeters in general. Needles may be bined effects of reducing back pain and energizing the usually
used for most areas of the body, thus determining their size, from energy-drained patient more than recommend and justify its use.
tiny needles in the shallow surface of the ear to large needles in It may be combined with other acupuncture points or protocols
the large muscles of the back or legs. Needles may be inserted for added effects.
and left in place anywhere from seconds to minutes (sometimes There are a number of major and minor acupuncture styles,
even hours or days), depending on the condition/patient, with a philosophies, and techniques evolving throughout the world.
rough average probably being 10-20 minutes. Needles may be These include Traditional Chinese Medicine (TCM), many
manipulated, stimulated with magnets or electricity of varying Japanese styles such as Toyo Hari and Ryodoraku, Yamamoto
frequencies and amps, positive or negative charges (by attaching New Scalp Acupuncture, Five Element, Auriculotherapy and
an electric clip to the needle handle), or various herbal, homeo- Auricular Medicine (ear acupuncture), Korean hand acupunc-
pathic, or medicinal preparations may be attached to the needle ture, French energetic acupuncture, Percutaneous Electrical
➝

December 2007 The AAO Journal/17

Nerve Stimulation (PENS), periosteal stimulation, and a number The second article is an interview with Harold S. Saita, DO,
of acupuncture microsystems (5). As mentioned above, it is who explains in detail how he treated patients with acupuncture
hypothesized that some combination or interaction of various and combined it with OMT. He observed that there was a cor-
wave fields and/or hologramatic patterns may be responsible for relation between acupuncture points, Chapman’s points and
forming the many microsystems within the body (5). trigger points.
The National Institutes of Health is spending millions of The third article reported Henry Nemerof, DO, demonstrat-
dollars on acupuncture research. It convened a consensus con- ing acupuncture that same year on the Mike Douglas show.
ference in 1997 on acupuncture, reviewing over 2300 research Dr. Nemerof, a physiatrist, had lectured on acupuncture at the
papers on acupuncture, determining that there is clear evidence American Osteopathic College of Rehabilitation Medicine
for some uses of acupuncture, and is appropriate as part of conference. He experimented with acupuncture and electrical
comprehensive care in many medical conditions. Chairperson, currents, sound waves and vibro-massage. He combined OMT
Dr. David J. Ramsay (President of the University of Maryland) with acupuncture.
stated, “There are a number of situations where it really does, The last article was a review and discussion on what little
in fact, work – the evidence is very clear-cut. It has few side was known at the time of acupuncture, including comments by
effects and is less invasive than many other things we do. It Dr. I. M. Korr: “Acupuncture appears to have a neural basis, but
is time to take it seriously.”71 The World Health Organization it seems to involve pathways not yet known.” These four articles
recognizes and encourages the use of acupuncture for a variety together are a little piece of history, for they are the beginnings
of conditions, as do mainstream medical organizations like the of the Osteopathic profession’s exploration of the “new” world
American Osteopathic Association: of acupuncture and integrating it into their own.
“Whereas, Osteopathic Medicine is not limited in the use of
any beneficial therapeutic or diagnostic modality; now, there- The next seven articles are out of print:
fore, be it resolved, that the American Osteopathic Association • Clinical Experiences with Acupuncture, by H. Nemerof,
recognizes that acupuncture may be a part of the armamentarium DO14
of qualified and licensed physicians.”72 • Acupuncture in the Service of Osteopathic Medicine: A
Pathway to Comprehensive Patient Management, by H.
Literature Review of Combined OMT and Acupuncture Nemerof, DO15
A computer-based English literature search through several • Modern Scientific Medical Acupuncture, by H.S. Saita,
large sources, including the National Library of Medicine, Ovid, DO16
PubMed, Medline, and DO-Online reveals thousands of papers • Acupuncture – A Measured View, by D.H. Mills17
on acupuncture, OMT and other manipulative modalities, and • Acupuncture: Its Status Today, by H.A. Ross and H.
recommends these as separate treatments for patients/conditions. Nemerof, DO18
Only a very small number of papers, books, and lectures have • American Acupuncture, Editorial19
been written specifically combining OMT and acupuncture. They • Acupuncture in the Management of Headache, by H.
will be listed here in chronological order with brief comments. Nemerof, DO20
• Trigger Points vs. Acupuncture Points, by Louis Vanders-
• The May 1972 issue of The D.O. contained four articles chot, DO.21 This was originally presented to the American
on the subject of acupuncture, only the second and third College of Sclerotherapy at the 1975 AOA Convention.
recommended combining OMT and acupuncture: He correlated acupuncture points with trigger points, and
1. Chinese Medicine: a Firsthand View (an interview recommended combining OMT, acupuncture, and sclero-
with Kenneth Riland, DO by Barbara Peterson);10 therapy.
2. How One DO Uses Acupuncture (an interview with • Correspondences Between Chapman’s Reflexes and
Harold S. Saita, DO, by George W. Northrup, DO);11 Acupuncture Points, by John E. Upledger, DO.22 This
3. DO Demonstrates Acupuncture on National TV, paper correlates 48 Chapman’s points with a number of
Teaches at Rehabilitation Conference (a report on Henry acupuncture points, as well as “Associated Points” (now
Nemerof, D.O., by Barbara Peterson);12 called “Shu” points) on the back with their paravertebral,
4. Acupuncture: Notes from Written Sources (an article segmental, and visceral relationships. He mentions his
by Barbara Peterson).13 combination of treating acupuncture points with Chap-
man’s reflex points.
The first article, an interview with Kenneth Riland, DO, • Osteopathic Medicine and Traditional Chinese Medicine,
was in response to President Richard Nixon’s 1972 visit to and by John E. Upledger, DO, FAAO.23 This brief paper
establishing diplomatic relations with the People’s Republic of describes acupuncture concepts, and describes several
China. Dr. Riland was President Nixon’s personal physician, ways in which acupuncture and osteopathic philosophies
and while accompanying him to China, was invited to observe and techniques complement one another. “Their philoso-
acupuncture treatments, including surgery and anesthesia, which phies are based on widely divergent cultural experiences,
totally amazed him. Dr. Riland, an avid supporter and practitioner but share an underlying holistic approach to man as the
of OMT, knew nothing about acupuncture prior to this visit. This maker of his own medicine… In my experience, the two
visit opened relations between the U.S. and China, and sparked schools of medicine complement each other well.”23
the new renaissance of acupuncture in the States. • Integration of Acupuncture and Manipulation, by John E.

18/The AAO Journal December 2007

 Upledger, DO, FAAO.24 Indications and complications nerve at the elbow. The nerve was reattached a week after
of acupuncture are discussed, then several conditions the accident but the expectation for recovery by the sur-
are addressed, using small 25 or 27 gauge disposable geon was extremely low. The patient has regained most of
hypodermic needles instead of acupuncture needles, and his strength and sensation over time with combined OMT
combining all with OMT: acute low back pain, sciatica, and acupuncture.
acute sacroiliac dysfunction, specific intervertebral mo- • Travell Trigger Points – Molecular and Osteopathic
tion restrictions, acute intercostal neuralgia and herpes Perspectives, by John M. McPartland, DO, MS.31 This
zoster, mobilization of the diaphragm, relaxation of the paper goes into great detail on trigger points and the latest
cervical musculature, and headache. research and theories of origin, perpetuation, and treat-
• Management of Autogenic Headache, by John E. Upledg- ment, including OMT and acupuncture.
er, DO, FAAO, and Jon D. Vredevoogd.25 This article • Yamamoto New Scalp Acupuncture (YNSA) Acupoint
discusses combining cranial techniques with acupuncture. Frequency in the Treatment of Herniated Lumbar Disc,
• Acupuncture: A Comprehensive Text, by John O’Connor Lumbar Radiculopathy, and Mechanical Low Back Pain,
and Dan Bensky, DO.26 This large (741 pages) textbook, by Richard A. Feely, DO, FAAO, FCA, FAAMA.32 YNSA
coauthored by an osteopathic physician/acupuncturist, is a fascinating, new (since 1973), and complete acupunc-
has become a classic in acupuncture literature since 1981. ture micro system. All the treatment points are located on
OMT is recommended with acupuncture for several the head and face. This study of 115 patients concluded
conditions: cerebrovascular accident (CVA), headache, that YNSA and OMT for low back pain resulted in im-
chronic low back pain, and stiff neck. mediate relief with a minimum of needles.
• Acupuncture Energetics, A Clinical Approach for Physi-
cians, by Joseph M. Helms, MD.5 This is the premier As further examples of some of the hundreds of papers and
acupuncture textbook for physicians (757 pages), and this books written on the separate subjects of OMT and acupuncture,
author has quoted from it extensively in this paper.5 Dr. two textbooks and eleven papers are listed in the reference sec-
Helms has traveled all around the world for thirty plus tion for the interested reader.73-85
years learning and then teaching acupuncture. Probably
more than any other physician, he is responsible for in- Conclusion
troducing and teaching medical acupuncture in the USA, Osteopathic manipulative treatment (OMT) and acupuncture
as well as founding the American Academy of Medical can be used to treat patients with acute mechanical low back
Acupuncture. He recommends the combination of OMT pain. The two modalities can be used separately or combined
(especially cranial osteopathy) with medical acupuncture, together for effective results. To date, there have not been any
and has devoted a subchapter in his textbook to this topic. studies to determine if order of treatment makes any difference
• Acupuncture and Osteopathy, by David E. Teitelbaum, in outcome. The results of this small retrospective case study
DO.27 This lecture was given at the 1999 American reveal that the order of treatment did not result in any significant
Academy of Osteopathy Convocation in St. Louis, MO. difference in outcome of pain relief.
Dr. Teitelbaum delineated the many similarities between An overview and explanation of OMT and acupuncture,
OMT and acupuncture, philosophically and in practice, including some of the latest scientific research and theories have
correlating acupuncture points with Chapman’s Points, been discussed. They share a great deal in their holistic, inclusive
Travell’s trigger points, and Jones’ Strain/Counterstrain philosophies, and their many and similar mechanisms of action,
points. He also touched upon the efficaciousness of OMT along with their central theme of the all-pervading fascia and its
and acupuncture treatments of energetic, psychological, many biomechanical, biochemical, and bioelectrical properties.
and spiritual conditions. Palpatory diagnosis and treatment are also central to both
• Integrating Acupuncture and Manual Medicine, by Jay systems, from a physical to an energetic perspective.
Sandweiss, DO, and Dan Bensky, DO.28 This paper
discusses the similarities and differences between manual Limitations of this study include:
medicine (and OMT) and acupuncture. It shows how It has a small number of subjects.30
putting them together synergistically complements their It is a retrospective study.
therapeutic efficacy. The author had previously treated all of the patients for
• Osteopathic Vertebral Manipulation and Acupuncture various conditions, so they could have had expectations that
Treatment Using Front Mu and Back Shu Points, by Da- could account for a possible placebo effect.
vid E. Teitelbaum, DO.29 An anatomic analysis of Mu and The osteopathic diagnosis was individualized to the
Shu acupuncture points, which are used to affect visceral patient.
function, proposes that they have a similar mechanism of The osteopathic manipulative ireatments were similar but
action to OMT in alleviating hypersympathetic visceroso- not identical.
matic reflexes.
• Acupuncture and Osteopathic Manipulative Medicine for It is hoped that this paper will lead to future studies
Ulnar Neuropathy, by William H. Stager, DO, MS.30 A addressing such issues as: do OMT and acupuncture impact
case report describing combining OMT and acupuncture frequency, severity, and/or duration of a condition, costs, etc.
on a patient who had accidentally severed his left ulnar
➝
December 2007 The AAO Journal/19
 Combining osteopathic manipulative medicine and Headache. Osteopathic Annals. 7:61. June 1979. pp 232-241.
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27. Teitelbaum DE. Acupuncture and Osteopathy, lecture. 1999.
AAO Convocation. St. Louis, MO.
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10.1096/fj.01-0925fje. Published online April 10, 2002. CME QUIZ
68. Travell JG and Simons DG. Myofascial Pain and Dysfunction: The purpose of the quiz found on the next page is
The Trigger Point Manual: The Upper Extremities. Vol 1. Balti- to provide a convenient means of self-assessment for
more, MD. Williams and Wilkins. 1983. your reading of the scientific content in the “Osteopathic
69. Travell JG and Simons DG. Myofascial Pain and Dysfunction: Manipulative Medicine and Acupuncture Combined: A
The Trigger Point Manual: The Lower Extremities. Vol 2. Retrospective case study to determine if order of treatment
Baltimore, MD. Williams and Wilkins. 1992. makes a difference in outcome for acute mechanical low
70. Simons DG, Travell JG, Simons LS, Travell and Simons’
back pain” by William H. Stager, DO, FAAO. Answer
Myofascial Pain and Dysfunction: The Trigger Point Manual.
Vols. 1 & 2. 2nd Edition. Baltimore, MD. Lippincott, Williams each of the questions listed. The correct answers will be
and Wilkins. 1999. published in the March 2008 issue of the AAOJ.
71. Frank BL. Medical Acupuncture: An Integrated Approach to To apply for Category 2-B CME credit, transfer your
Healthcare. course handout. 2002. answers to the AAOJ CME Quiz Application Form answer
72. AOA Yearbook and Directory. 2000/01. Chicago, IL, sheet on the next page. The AAO will record the fact that
American Osteopathic Association. 2000. 91st Edition. you submitted the form for Category 2-B CME credit and
AOA Position Papers. p 625. will forward your test results to the AOA Division of CME
73. DiGiovanna EL and Schiowitz S. An Osteopathic Approach to for documentation.
Diagnosis and Treatment. Philadelphia, PA. J.B. Lippincott Co.

December 2007 The AAO Journal/21