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Background: The concept of acupuncture point localisation in Traditional Chinese Medicine (TCM) is based on millenary practical experience. Modern imaging methods such as PET, MRI and SPECT have been used primary for the investigation of the mechanisms of action of acupuncture. In this pilot single-case study we have evaluated the technical possibilities for in-vivo imaging of the anatomical relations of acupuncture points using state of the art MRI. Methods: Preliminary experiments relating to the quality of acupuncture needles under the setting of MRI were done both with stainless steel and gold needles. In a second step, in-vivo imaging was carried out. A licensed acupuncture practitioner (RM) chose two points belonging to the so-called extraordinary vessels. In 2 sequential, separate procedures, he inserted himself gold acupuncture needles using a neutral technique (known as Ping Bu Ping Xie) into the Dai mai and Shen mai points, i.e. gall bladder 26 and bladder 62. Imaging was done on a Siemens Magnetom Avanto MR scanner using a head array and body coil. Mainly T1-weighted imaging sequences, as routinely used for patient exams, were used to obtain multi-slice images. Results: In the preliminary experiments only acupuncture needles made of gold showed enough stability in order to be used for further imaging procedures. Using an onion and a banana as an object, further studies showed that the gold needles produced a void defect that corresponds to the tip of the inserted needle, while at the same time an artefactually increased diameter was observed. The in-vivo experiments showed that the Dai mai point was in relation to the abdominal internal oblique muscle. The Shen mai point artefact showed up close to the longus and brevis peroneal tendons at the fibular malleolus. Side effects related to heating or burning were not observed. Improved anatomical recognition was obtained using 3D-volume rendering techniques. Conclusion: Through an adequate choice of acupuncture material (gold needles) as well as of ideal MRI imaging sequences it has been possible to visualize the anatomical characteristics at the acupuncture points Dai mai and Shen mai in-vivo. At the selected sites the needles showed a relation to tendino-fascial and muscular structures. These anatomical structures fit well into the recently described WOMED concept of lateral tension in which these acupuncture points play a regulatory role. Page 1 of 7 (page number not for citation purposes) BMC Medical Imaging 2007, 7:4 http://www.biomedcentral.com/1471-2342/7/4 Background The neurophysiological model of acupuncture mecha- nisms has been matter of research in the past years. In this quest, imaging methods such as PET, SPECT and fMRI have been used to investigate changes of brain perfusion or activation in response to acupuncture techniques [1-3]. In spite of these advances little has been done for the in- vivo characterization of the acupuncture points using modern imaging techniques. Co Figure 1 mparison of the needles used in the preliminary testing Attempts to characterize acupuncture points have been Comparison of the needles used in the preliminary testing. made by radionuclide imaging. Lazorthes et al. investi- The upper needle is the usual stainless steel needle. The gated several acupuncture points (LI4, LI11, LI14, SI3, lower needle is the one made of gold. Both needle types TH5, GB34, Ren mai 12, and Du mai 4). The most impor- made by Shenzhou, China. The size of the needles was: 25 × tant anatomical aspect found here was that the amount of 0.25 mm for the stainless steel needle and 40 × 0.13 mm for radioactivity in the blood was negligible after the acu- the gold needle. puncture points had been injected, thus suggesting that meridians and blood vessels are not related . Chan and In-vivo Acupuncture Imaging Bensoussan refer to components of the peripheral nerv- ous system in relation to acupuncture points [5,6]. Similar Acupuncture procedures were carried out by a licensed relations have been presented by Bossy [7,8]. Melzack and medical practitioner (RM) on himself. The anthropomet- Dung have considered acupuncture points to be related to rical and functional characteristics of the subject are: age = trigger points  as well as to tenderness of the skin , 51 years, height = 174 cm, weight = 67 kg, BMI = 22.1, -1 -1 respectively. In the past years Langevin and collaborators, body fat = 12%, VO max = 53 mL·kg ·min . The study based on post-mortem tissue sections of the arm, have described an association of acupuncture points to connec- tive tissue structures . The aim of this single case pilot study was to test the fea- sibility of a combined TCM and technological approach for the in-vivo characterization of acupuncture points using state-of-the art MRI imaging . Methods Prior to in-vivo imaging a series of preliminary experi- ments were done in order to evaluate the interaction of the needles with the MRI scanner. Preliminary imaging sequences Preliminary experiments were done with conventional stainless steel acupuncture needles (Shenzhou, China, 0.25 × 25 mm). In the subsequent studies, acupuncture needles made of gold (Shenzhou, China, 0.13 × 40 mm) were used. The needles are shown in Figure 1. Both types of needles were obtained from Bacopa (Bacopa, Waidern 42, 4521 Schiedlberg, Austria ). The stability in place of the needles under operational MRI conditions was tested by placing them in a closed glass container. After Prel int Figure 2 o an imin oni ary i on maging procedure using the gold needle inserted evaluating the needle material, further preliminary exper- Preliminary imaging procedure using the gold needle inserted iments were done by inserting the needles into an onion into an onion. Note the image attenuation area around the and into a banana in order to evaluate the characteristics needle. In these experiments the length of the inserted por- of the images being obtained. tion corresponded to the length of the image attenuation effect. The width of the defect was much larger than the width of the gold needle. Page 2 of 7 (page number not for citation purposes) BMC Medical Imaging 2007, 7:4 http://www.biomedcentral.com/1471-2342/7/4 Preli Figure 3 minary imaging procedure using the gold needle inserted into a banana Preliminary imaging procedure using the gold needle inserted into a banana. Note the image attenuation area around the nee- dle similar to that shown in figure 2. In these experiments the length of the inserted portion corresponded to the length of the image attenuation effect. The width of the defect was much larger than the width of the gold needle. protocol was approved by the institutional ethics commit- dure was done on the Dai mai followed by the Shen mai tee. point. MRI imaging The acupuncture points chosen for the investigation were the Dai mai, i.e. gall bladder 26, and the Shen mai, i.e. MRI imaging was done on a Siemens Magnetom Avanto bladder 62, points. A neutral needling technique was MR scanner using an array head and body coil. Mainly T1- used. Neutral needling is known as Ping Bu Ping Xie and weighted imaging sequences, as routinely used for patient it refers to an equilibrated tonification and dispersion exams, were used to obtain multi-slice images of the anat- technique. The depth of needle insertion was done omy around the inserted needle. Imaging sequences were according to current descriptions . The characteristics obtained using T1 weighted fast spin echo sequences in of the points can be found in : "The Dai mai point is various orientations. The following imaging parameters located in the depression one inch and eight fen below the were used: turbo factor: 3, TR: 500 or 721 ms, TE: 11 or 19 th region of the free ribs (11 rib). This point corresponds to ms, flip angle of refocusing pulses: 150°, slice thickness: 3 the intersection jiaohui point of the foot shao yang gall or 2 mm, slice gap 10–30%, number of slices: 20–23, bladder channel and the girdling vessel. The Shen mai band width: 200 Hz/pixel, FOV: 400, 340 or 170 mm, point is located in the depression five fen below the outer acquisition matrix 320 or 384. Imaging was started within anklebone. It corresponds to the confluence-jiaohui point 5 minutes after needle insertion. of the eight extraordinary vessels (yang motility vessel)". The term "fen" corresponds to 1/10 of a "cun" which is Image reconstruction the traditional proportional body unit. One cun corre- The abdominal MR slices corresponding to the Dai mai sponds to the width of the interphalangeal joint of the point were reconstructed using dedicated software from thumb . The imaging was done with only one needle Nuclear Diagnostics (Hermes Medical Solutions AB, at a time using the gold needles. The first imaging proce- Skeppsbron 44, 111 30 Stockholm, SWEDEN; . The Page 3 of 7 (page number not for citation purposes) BMC Medical Imaging 2007, 7:4 http://www.biomedcentral.com/1471-2342/7/4 In iFigure 5 nto -vivo loca the Dai mai poi lisation of the gold a nt cupuncture needle inserted In-vivo localisation of the gold acupuncture needle inserted into the Dai mai point. The site of needle insertion is indi- cated by the white arrow. Image processing and reconstruc- In-vivo localisation into the Da tion Figure 4 i mai poof the gold int as seen acup in a saggital slic uncture needle in e reconstruc- serted tion was done using the 3D volume rendering procedure of In-vivo localisation of the gold acupuncture needle inserted the multimodality module on the Hermes workstation. The into the Dai mai point as seen in a saggital slice reconstruc- color coding of the image allows the easy recognition of mus- tion. The white arrow simulates the direction of needle cular structures of the abdomen. In this reconstruction the insertion. Image reconstruction was done with the J-Vision void effect of the gold needle is seen as a black area which software of the TIANI workstation. MRI acquisition data: TR reaches the muscular structures of the internal oblique mus- = 721, TE = 19, flip = 150, TH = 3, TF = 3, FOV = 370, MA = cle. Original MRI acquisition data: TR = 721, TE = 19, flip = 150, TH = 3, TF = 3, FOV = 370, MA = 320. procedure multimodality 3D was used to generate a vol- compromise the stability of the needle. At the Dai mai ume rendered image. point (lateral abdomen), the tip of the needle was in con- tact with the superficial fascia of the abdominal internal oblique muscle. Figures 4 and 5 show the position of the Results Preliminary imaging sequences needle at the Dai mai point in 2 different reconstruction The preliminary experiments using the stainless steel nee- slices. Figure 4 shows a saggital slice and Figure 5, the 3D- dle showed erratic movements of the needle when the volume rendered abdominal MRI image. At the Shen mai magnetic field was applied. Contrasting with this, the gold point (ankle), the artefact of the tip of the needle was needle was stable in place in the closed glass container. located close to the tendons of the peroneal muscles at the For this reason all further experiments were done with the fibular malleolus. The calcaneo-fibular ligament was gold needles. In the experiments using an onion and a untouched (Figure 6). The sequence of the experiments is banana (Figures 2 and 3) an imaging artefact that pro- summarized in Figure 7. duced an area of image attenuation around the needles was observed. In comparison to the diameter of the nee- Discussion dles, the artefacts were about 6–8 times wider. On the In this pilot investigation we have been able to show that other hand, the tip of the artefact area corresponded to the it is feasible to indirectly identify the anatomical struc- tip of the needle. The length of the artefact corresponded tures related to acupuncture points in-vivo using gold nee- to the length of the inserted portion of the needle, thus dles. Magnetizable steel acupuncture needles, e.g. making it possible to recognize which structures are found stainless steel material, will be erratically displaced when at this depth. tested under the MRI equipment and are therefore not suitable for MRI studies. In-vivo imaging of the Dai mai and Shen mai points During the study there were no side-effects such as local- Metallic needles inserted into the body are known to pro- ized hyperthermia, reddening of the skin or pain. A de qi duce artefacts in MRI imaging. This type of artefacts have sensation was felt at both points. The interaction of the been described as: "as a blooming ball-shaped signal needles with the MRI machine was limited to a slight void" and can be seen with biopsy needles . In spite of bending of the handle of the needle. This bending did not having a central signal void characteristic, the position of Page 4 of 7 (page number not for citation purposes) BMC Medical Imaging 2007, 7:4 http://www.biomedcentral.com/1471-2342/7/4 ing of de qi sensation even though a neutral needling technique was used. Previous investigations on the characterization of acu- puncture points have used radionuclide methods which could clearly show that "meridian" flow was different to blood flow . Other investigators have looked at acu- puncture points in relation to components of the periph- eral nervous system [5-8]. Melzack and Dung have considered acupuncture points to be related to trigger points  as well as to tenderness of the skin , respec- tively. In spite of these approaches, the anatomical basis of acupuncture points has not been defined. Langevin and associates have described an association of acupuncture points to connective tissue structures based on studies on post-mortem tissue sections of the arm . Post-mortem studies, however, cannot obviate the problem of turgor loss as compared to in-vivo studies. Our study has shown that an in-vivo localization of anatomical structures related to acupuncture points on the abdomen and ankle is feasible using state-of-the-art MRI. An improved visual- ization of the results can be obtained by using 3D-volume rendering procedures. Loc Shen mai point on the right ankle Figure 6 alisation of the gold acupuncture needle inserted into the In a recent publication Moncayo and Moncayo have Localisation of the gold acupuncture needle inserted into the described a general model of disease which is related to an Shen mai point on the right ankle. A small image attenuation eccentric body position . This eccentric position defect can be observed at the site where the needle was affects both the feet and the head. Negative postural inserted (arrow). The tip of the needle was located close to effects of this eccentric muscle position can be neutralized the tendons of the peroneal muscles at the fibular malleolus. by using the acupuncture points described in this paper. It It should be noted, that the fibulo-maleolar ligament has not can thus be concluded, that the WOMED model of lateral been reached. MRI acquisition data: TR = 500, TE = 11, flip = tension is related to musculoskeletal structures and that at 150, TH = 2, TF = 3, FOV = 170, MA = 384. the same time, these structures, or acupuncture points as shown here, exert a regulating function on the system. the tip of the artefact corresponds to the tip of the needle and therefore to its length or depth of insertion. In our Conclusion preliminary experiments we were able to confirm this by An in-vivo investigation on the anatomical localisation measuring the length of the inserted portion of the needle and relationship of acupuncture points using MRI is feasi- and the length of the artefact. For the evaluation of the in- ble. The location of the tip of the needle corresponds to vivo imaging of gold acupuncture needles one can rely on the tip of the signal void artefact seen on the images thus the tip of the void area as an adequate indicator of the showing the underlying anatomy. These findings lend underlying anatomy. In our study the tip of the inserted support to a musculoskeletal relation of the WOMED con- needles was in close relation to fasciae and tendons in the cept of lateral tension . ankle, as well as to muscular structures in the abdomen. We are not aware of any similar studies that have used Competing interests high resolution methods such as MRI for in-vivo imaging The author(s) declare that they have no competing inter- of acupuncture points in humans. ests. Due to the physical characteristics of the acupuncture nee- Authors' contributions dles, i.e. gold material and a small size, side effects related RM planned the study, carried out the acupuncture proce- to heating during the MRI procedure were not found. dures, wrote the draft of the manuscript. AR and CK were Another interesting characteristic of gold needles is that involved in the MRI procedures, data processing and they have a rougher surface as compared to stainless steel image interpretation. MD carried out the 3D-image ren- needles . This might be the explanation for our find- dering on the Hermes workstation. All authors read and approved the final manuscript. Page 5 of 7 (page number not for citation purposes) BMC Medical Imaging 2007, 7:4 http://www.biomedcentral.com/1471-2342/7/4 F vivo imaging Figure 7 low chart showing a summary of the study including the preliminary evaluations, the non-human images, and the human in- Flow chart showing a summary of the study including the preliminary evaluations, the non-human images, and the human in- vivo imaging. Page 6 of 7 (page number not for citation purposes) BMC Medical Imaging 2007, 7:4 http://www.biomedcentral.com/1471-2342/7/4 References 1. Shen J: Research on the neurophysiological mechanisms of acupuncture: review of selected studies and methodological issues. J Altern Complement Med 2001, 7 Suppl 1:S121-S127. 2. Lewith GT, White PJ, Pariente J: Investigating acupuncture using brain imaging techniques: the current state of play. Evid Based Complement Alternat Med 2005, 2:315-319. 3. 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Moncayo R, Moncayo H: A musculoskeletal model of low grade connective tissue inflammation in patients with thyroid asso- ciated ophthalmopathy (TAO): the WOMED concept of lat- eral tension and its general implications in disease. BMC Musculoskelet Disord 2007, 8:17. Pre-publication history The pre-publication history for this paper can be accessed here: http://www.biomedcentral.com/1471-2342/7/4/prepub Publish with Bio Med Central and every scientist can read your work free of charge "BioMed Central will be the most significant development for disseminating the results of biomedical researc h in our lifetime." 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BMC Medical Imaging – Springer Journals
Published: Mar 14, 2007
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