Volume 1, Special Edition | Current Japanese Acupuncture and Moxibustion 2010

Treatment of Local and Distance Sites for
Diseases of the Locomotor System–Indications and limitations of local therapy,
indications and limitations of distant therapy–
Coordinator: Takayoshi Ogawa
Tokyo Eisei Gakuen
Shuichi Katai
Tsukuba University of Techonology
Shoji Shinohara
Meiji University of Integrative Medicine
I. Introduction
Phrases like "simultaneous treatment of root andtip" regarding acupuncture and moxibustion therapy
indicate that in almost all cases treatment of the region
where the symptoms are located (treatment of theincidental = locally) and treatment of acupoints on
meridians located at a distance where there are no
symptoms, or that are used for the regulation of qi andblood (treatment of the fundamental), or treatment of
acupoints known through experience to be effective forthe particular condition are combined. While in casesof diseases of internal organs or metabolic diseases
determination of specific locations is difficult, therefore,
the function of distant needling therapy and local
treatment of diseases of the locomotor system may be
the subject of debate. Moreover, in order to examine
which of these different treatment forms is safer andmore efficient, symposia were held on the 51st annual
conference of the Japan Society of Acupuncture andMoxibustion (in Ibaragi), the 52nd conference (inKagawa) and the 53rd conference (in Chiba), spanningthe period of these three years.
II. Efficiency of distant needling
Local treatment is performed on the soft tissues in
the region of the symptoms, making the mechanisms ofthe therapeutic effects easy to understand., For
example, the relief of excessive muscle tension is easy
to understand. However,mechanisms in the case of
distant needling and its efficacy still remain difficult tounderstand. At the 52nd conference a symposium washeld to examine the efficacy of distant needling. Mr.
Shinohara from the Meiji University of Integrative
Medicine, conducted an experiment using intradermal
needles on spring points of the relevant meridiansversus sham acupuncture and spring points of othermeridians, demonstrating the efficacy of channel sinew
and distant needling therapy. Dr. Katai from the
National University Corporation Tsukuba University
used the point Chikuhin (zhubin KI9) as well as
treatment of the arms and legs in patients with low
back pain or cervical pain and showed that distantneedling alone is also highly effective. Dr. Shiraishi
from the Oriental Medical Research Institute used thepoint Ichu (weizhong, BL40) among the four command
points and showed that the reactions it elicited at
Jinyu (shenshu, BL23) were even more marked thanthose obtained by direct stimulation of Jinyu directly,
suggesting the effectiveness of distant needling. Mr.
Keiji Yoshikawa from the teaching staff training
institute within the Department of Physical Therapy of
the National University Corporation Tsukuba
University, reported the effectiveness of local
treatment and its contraindications, indicating that
distant needling therapy is associated with a highdegree of unreliability and low reproducibility, andtherefore did not acknowledge its necessity.
Regarding the question of whether to perform both
"local treatment and distant needle therapy" Mr.
Shinohara, while selecting mainly distant sites,
performed

local

treatmentincases,when

manifestations of blood stasis and phlegm wererestricted to certain regions. Dr. Katai used ocal
treatment in case distant needling therapy had beenineffective and Mr. Yoshikawa had decided not to use
distant needle therapy at all. Dr. Shiraishi did not deny
the benefits of local therapy, but emphasized his
opinion, that depending on the selected region
stimulation of distant sites is capable of modulating
the elicited reactions. In particular the effects obtainedby stimulating distant sites would be enhanced, if theretained needles are in addition stimulated electrically,
indicating that an explanation based solely on distantneedling effects mediated via the nervous system
would be difficult. Mr. Tomomasa Moriyama of the
National University Corporation Tsukuba University
reported results, suggesting that the treatment at
distant sites may be effective from a point of view of
movement physiology because of the regulation ofmuscle force alignment.

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Volume 1, Special Edition | Current Japanese Acupuncture and Moxibustion 2010

Therefore, the consensus isthat "stimulation of
distant sites" is also effective for the treatment ofdiseases of the locomotor system. Mr. Yoshikawa
considered the reported evidence of the other three
speakers insufficient and thought, that the definitionof local and distant sites needs to be revised. Even if
the site at which the symptoms are located isconsidered local, the contact of the needles with skinand muscles may also be considered a local contact, or
could it be considered to be a stimulus of the entire
dermatome, muscle bundle or even the entire muscle?
Also, when the needle stimulation is considered to betransmitted to the central nervous system after being
picked up by some form of receptor sensory nerves, it
may be related in some form or other to the autonomic
nervous system etc. If that is true, then what used tohave been considered local mechanisms could possibly
be the mode of action initiated by distant sites.
III. Definition of local and distant needling therapy
A questionnaire was conducted among members of
the society,who have been enrolled in it for many years
to investigate the definitions and the mechanisms
imagined to be underlying the therapeutic effects aswell as the basis for choosing different treatment
modalities. Mr. Ogawa of the Tokyo Eisei Gakuen
College reported that there were no significant
differences pertaining to the definition of local anddistant schools of thought. The concept of "local sites"
was imagined mostly as meaning the location oftenderness, sites at which a radiating sensation may
be elicited or the affected sites themselves, while"distant sites" referred to regions, from wherereactions in meridians, nerves, reactive spots, tenderspots, or even systemic reactions may be induced orsome other form of active sites.
Moreover, based on the results of the above
mentioned questionnaire, the definition of local anddistant sites was determined as follows.
Local sites:
Sites of tenderness accompanying the manifestationof the symptoms, sites of injury, or from where aradiating sensation (like the conduction of a nerve
impulse) can be elicited and the site of lesion itself.
Stimulation applied for therapeutic purpose at these88

sites provides relief of excessive muscle tension,
thereby alleviating nerve entrapment, triggers axonreflexes and has in addition, psychological effects
associated with the provision of treatment of affectedparts.
Distant sites:
Not restricted to the site of symptom manifestation,
treatment applied to sites located along the course of
the meridians can be expected to elicit a generalized
reactions (autonomic nervous system regulation,
central nervous system response etc.), where thestimulation of the relevant sites may not only havetherapeutic purpose, but can be expected to havegeneralized effects.
IV. Mechanisms of distant needling therapy
At the 52nd and 53rd conferences the mechanisms
underlying therapeutic effects were examined. Mr.
Shinohara investigated the effects of intradermal
needles for the treatment of delayed pain based on achannel sinew model and observed that exercise load of
the biceps brachii muscle lowered the tenderness
threshold along the lung meridian, indicating thepossibility of the appearance of selective peripheral
reactive spots during the development of delayed
muscle pain that can be used as therapeutic points. He
also mentioned that at clinically useful acupoints it
might behighly likely that hypersensitivity
phenomena emerge during the generation ofexperimentally induced pain, which provides
experimental evidence for the distant needling therapy.
Dr. Shiraishi showed, following his line of thought fromthe previous conference, that experimental results of
distant needling applied to stimulate Ichu (weizhong,BL40), Shozan (chengshan, BL57), Hiyo (feiyang,
BL58),
Konron(kunlun,BL60),
Yoryosen(yanglingquan, GB34) are capable of producing avariety of changes in the reaction observed at Jinyu(shenshu, BL23) in patients with low back pain. This
does not necessarily require stimulation of points
located on the same meridian, but showed that it ispossible to modify the reactivity within certain zones.
Furthermore, the needling effects from the skinmodifying the input system neuroanatomically are notspecific or selective. This indicated that local treatment

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)

Volume 1, Special Edition | Current Japanese Acupuncture and Moxibustion 2010is not necessarily required and the treatment at
distant sites can be expected to have sufficient clinicaleffects.
Mr. Akihiro Ozaki from the Meiji University ofIntegrative Medicine made a presentation based on
results from human and animal experiments showingthat needling both in close proximity and at distantsites have the effect of inhibiting kinetic reflexes, sothat both local and distant sites were found to beeffective. The stimulus information provided both inclose proximity of the lesion and at distant sites thenconverges onto the same neuron and is thereupon
subject to modulation, so that the differences in
information processing at the neuronal level may bestrongly involved in the manifestation of different
effects. Investigations of the differences in the effects
obtained through local and distant treatment may thus
also need to take into account differences in the input
forms other than the site of stimulation, symptom
patterns etc. They need to be discussed
comprehensively. Mr. Moriyama expounded on thebasis of biomechanics indicating that a poor condition
at a certain distant location may influence prevailing
local conditions. He introduced the meridian test as
one useful method to find poor local conditions that
may be difficult to be realized by the patient
him/herself, but nevertheless could lead to thedevelopment of disorders. That means that the
microscopic observation employed during examinationand treatment may require a macroscopic point of view
including the entire body into its field of vision, so thatthe above mentioned two different ways of looking at a
certain object should not be separated.Only together
can they represent the essential concept of treatment.
From the audience, questions were asked anddiscussed, indicating that the mechanisms of analgesia
in case of needling nerves and muscle cannot yet beunderstood, or that the effects of both local and distanttreatment are based on the same mechanisms, thus
making their clarification a task for the future.
Mr. Katsuhiro Yamada of The Japan School of
Acupuncture, Moxibustion and Physiotherapy reported
that treatment of distant sites in cases of inflammatory
lesions associated with tissue injury, localized muscle
spasms or structural causes seems to have little

potential to improve the condition, while local
treatment is effective here. Yet, the local treatment
may in certain cases also aggravate the condition.
Mr. Kawakita from the Meiji University ofIntegrative Medicine reported that regarding
inhibition of pain the DNIC (diffuse noxious inhibitory
controls) phenomenon and involvement of humoral
factors like endorphin in the manifestation of pain
phenomena are both activated regardless of where on
the entire body the stimulation is applied, while axonreflexes occur only locally at the site of the stimulation.
Mr. Ozawa from the National University
Corporation Tsukuba University explained that theneedling stimulation produces locally at the site of thestimulation via axon reflexes an increase in blood flow
and at the same time via spinal reflexes or supraspinal
reflexes various responses in various internal organ
effectors. Also, he stated that the mode of action varies
depending on differences in the site of stimulation andtype of effector.
V. Pathologic conditions for which treatment at local
and distant sites is effective:
A questionnaire was conducted among 41
authoritative people in this field representing thedifferent treatment styles. The results showed that
local treatment was considered to be effective forconditions including diseases of the locomotor system,bruises, sprains, external injuries etc. where the local
symptoms are clearly defined and the site of the lesions
is often restricted locally, whereas stimulation at
distant sites seemed to be effective for conditions otherthan diseases of the locomotor organs, like diseases ofthe viscera and bowels, and employed in case local
treatment had been ineffective, or in cases where thepoint selection was based on more than 70% onclassical meridian theory.
VI. Conclusions
Throughout the three symposia, treatment of local
and distant sites was considered separately whilecommon concepts were thought to have been found.
The effectiveness of local treatment for diseases of thelocomotor system and its clinical significance wasrecognized. The mechanisms of distant needling

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therapy and its effectiveness were also acknowledged.
In particular, it was acknowledged that needling of thearms or legs induces systemic responses throughsupraspinal reflexes, so that in case the affected areas
is located on the arms or legs, the locally placed needles
do not only elicit a local, but also a generalized
response. Moreover, in case the affected region is
located on the trunk, it was generally agreed that there
is a high probability for the need to also needle thearms and legs. However, while researchers in the fieldof basic research emphasized the common aspects(non-specific responses), suggesting just needling
anywhere, even if performed by beginners, would still
be effective, because this can be called an inherently
human physiologic response. Because of the very
presence of this response, acupuncture andmoxibustion therapy has been used continuously over
several thousand years. Further in-depth research is
required in order to enhance the effectiveness ofacupuncture and moxibustion specific effects
superimposed on the above mentioned non-specificresponse, or else to establish still more effective
therapies.

90

The differences between the conditions for which
either the treatment of local or distant sites is effective
or specific could also be clarified to a certain extent, but
it cannot be denied, that this is still only the beginning.
For example, in case of low back or leg pain needling of
Ichu (weizhong, BL40) or similar points on the legs has
a completely different significance, even if the results
were the same, depending on whether this site isneedled, because it is the site of symptom
manifestation, or whether a reactive spot has been
needled in order to cure the low back as the causativesite for the low back or leg pain. Although these
symposia helped to clarify this point, the expectations
based on the initially planned scope, covering not only
the muscular and skeletal systems, but that also
included internal organs or metabolic systems in thescope to be clarified were not met. In-depth research isgoing to be continued and similar symposia will be
held.
Responsibility for the wording:
Takuro Ogawa, Major course of clinical education,
Tokyo Eisei Gakuen College,

The Journal of Kampo, Acupuncture and Integrative Medicine (KAIM)