Published: 04.12.2023 Author: Mira Reuter
Background: Acupuncture in the tradition of Chinese medicine has gained more attention in the West, both in its practical application as well as in terms of scientific studies on its effects on the human body. The same applies to fascia and its scientific investigations and applications in sports- and health-related areas. Acupuncture has a great potential to help people heal different diseases. Especially with an ageing society it is of more interest to understand the mechanisms of such a promising treatment. The following studies have investigated the role of fascia in acupuncture and the extent to which they are related to each other.
Results: The studies presented in this paper show, that the fascial system and meridian system follow the same patterns throughout the body and the acupuncture points along the meridians match thicker areas in the fascial tissues. Therefore, the needle that is inserted into acupuncture points automatically stimulates the fascia. The stimulated fascia was observed to arrange itself in spiral patterns around the inserted needle. As a result of this in science called “needle grasp phenomenon” and in traditional Chinese medicine named “de qi” sensation, electrical signals are transmitted by the fascia. Various studies point out the parallels in the functions of the meridian system and of the fascial system within the body.
Conclusion: Many researches come to the conclusion that the fascial system might be the western name and equivalent to the meridian system of traditional Chinese medicine. In terms of this paper it can be stated, that the fascial system plays a crucial role in the application and success of acupuncture treatments.
Acupuncture of traditional Chinese medicine (=TCM) as well as fascia manipulation techniques are known to help many people not only with muscular skeletal problems, but different kind of diseases. The meridian system as well as the fascial system in the body are complex systems who could lead to healing within the body when stimulated in a specific way. Despite this promising effects of fascia stimulation, in-depth scientific investigations on fascia has only been conducted since the late 20th and early 21st centuries. Before, in most medical schools it was still taught that the function of fascia as connective tissue was only to hold the muscles in place and to protect the muscles and was not studied in detail at most medical schools (Stecco, Macchi, Porzionato, Duparc & De Caro, 2011). Now, that research on fascia has deepened due to advances in imaging techniques (ultrasound, MRI) and promote more detailed visualizations of fascial structures, it is know that there are not only multiple different types of fascia in the body, but also many different bodily functions to which the fascia is related to (Bordoni & Zarnier, 2014; Grilley, 2012; Stecco, 2014). The current research of fascia explores the biomechanical, physiological and clinical implications of fascia especially in pain management and movement therapies (Sterling, 2018). While the knowledge of fascia has deepened only since the last decades in the western world, traditional Chinese medicine has been developed a precise knowledge of how to stimulate the meridians and therefore fascia for centuries (Grilley, 2012). Unfortunately, during a very dark time around 800 BC the wisdom of traditional Chinese medicine was abundant, TCM schools were closed and libraries were burned down (Grilley, 2012). The ancient theories of TCM that survived nonetheless and are practiced since then in China and in the last decades increasingly in the West as well, became therefore more of interest for the modern science (Grilley, 2012,). It can be concluded that both, fascia research and the research on acupuncture is still in their beginnings and becomes more and more of interest for the western, modern science. This seminar paper has the aim to summarize research on the topic of how the modern research of fascia is related to the ancient practice of acupuncture.
A general definition of fascia, according to Stecco, Macchi, Porzionato, Duprac and De Caro, is that fascia is a fibrous connective tissue considered in a three dimensional continuity throughout the body, surrounding and supporting muscles, organs and other anatomical structures and therefore providing structural integrity and functionality of the musculoskeletal system, enabling movements of the body and communication within the body (Gatt, Agarwal, Zito, 2023; Stecco et al., 2011). The different types of fascia can be differentiated as superficial fascia, deep fascia, visceral fascia and parietal fascia (Gatt et al., 2023). For the purpose of this paper the superficial fascia and the deep fascia are of interested, since these are the fascia which can be penetrated by the acupuncture needles (Langevin & Yandow; 2002). The superficial fascia is located underneath the skin, retinacula and fat lobules and can be found throughout the entire body (Stecco et al., 2011). In some parts of the superficial facia are muscular fibers located (for example in the neck and face) (Stecco et al., 2011). The arrangement and thickness of the superficial fascia (as well as the superficial and deep adipose layers) varies according to gender, body region and body surface (Stecco et al., 2011). The form of the superficial fascia is made up of membranous layers with loosely packed interwoven collagen and elastic fibers (Gatt, Agarwal, Zito, 2023). The functions of the superficialfascia contain the nourishment and the preserving of the integrity of the skin and the support of the veins and subcutaneous structures (Stecco et al., 2011). Moreover, it enhances mobility and flexibility by enabling the skin to glide over underlying structures (Langevin, Fox, Koptiuch, Badger, Greenan-Naumann, Bouffard, Konofagou, Lee, Triano, & Henry, 2011; Sterling, 2018). The many nerve endings in the superficial fascia are transmitting sensory information to other body parts and therefore enable communication within the body (Langevin et al. 2011; Stecco et al., 2011). The deep fascia consists of a fibrous membrane and is located underneath the skin, a layer of fat lobules and retinacula, the superficial fascia and another layer of fat lobules and retinacula (Stecco et al., 2011). The deep fascia of the limbs has a mean thickness of 1mm (Stecco et al., 2011). It interconnects muscles, bones, vessels and nerves in the body (Stecco, 2014). The deep fascia is only connected through myofascial expansion with the muscles, which can especially be seen around the joints (Stecco et al., 2011). The deep fascia of the limbs consists of two to three layers of collagen fiber bundles, which are separated from each other through thin layers of loose connective tissue (Stecco et al., 2011). Stecco et al. conclude that due to this structure and seen from a mechanical point of view, “each layer may be considered independent and has a specific influence on the function of the tissue” (Stecco et al., 2011, p. 131). When these layers are exercised in different directions, they still contain a strong resistance to traction (Natali, Pavan & Stecco, 2010). The function of the deep fascia differentiates in different body parts (Stecco et al., 2011). Some of the key functions of the complex network of deep fascia in general are compartmentalization of muscle groups, separation of muscles, as well as providence of support and facilitation of their optimal functioning (Stecco 2014). It binds all the structures of muscles, vessels and nerves together into a compact cluster and therefore takes care of containment of bodily structures (Stecco et al., 2011). Thereby, the deep fascia functions as a protective barrier around muscles, nerves and blood vessels to protect them from external forces and possible injuries (Stecco 2014). Moreover, the deep fascia plays an important role in transmitting mechanical forces, which are generated during muscle contractions and thus acts as a medium for force transfer between muscles and other structures of the body to coordinate the movements of the body (Langevin et al., 2011; Matsumoto & Birch, 1988; Stecco et al., 2011). Another function is the neurovascular transport, meaning the provision of a framework for nerves, ensuring their proper positioning and enabling the transport of signals and nutrients within the body (Stecco, 2014). Additionally, the structure of different layers of collagen fiber bundles within the deep fascia, enables the multiple layers to slide and glide over each other and therefore promotes the flexibility and adaptability of muscles and their surrounding structures (Stecco et al., 2011). The fascial gliding itself is therefore crucial for the maintenance of the musculoskeletal function and overall mobility (Langevin et al., 2011; Sterling, 2018). Oschman gets to the heart of the matter by saying: “[t]his matrix determines the overall shape of the organism as well as the detailed architecture of its parts. All movements of the body as a whole, or its smallest parts, are created by tension carried through the connective tissue fabric.” (Oschman, James, L. cited in: Matsumoto & Birch, 1988, p.164). To summarize it can be said that the multifaceted functions of the superficial and deep fascia have an integral role in the stability, protection and dynamic movement of the musculoskeletal system and the communication within the body through mechanical, biochemical and bioelectric signaling.
Acupuncture is a traditional Chinese medical practice that involves the insertion of thin needles into specific locations of the body, named acupuncture points (Langevin & Yandow, 2002). According to Chinese view, a network of multiple energy pathways, known as Meridians, run longitudinally along the entire body (Langevin & Yandow, 2002). The 14 main lines of the meridians contain 361 acupuncture points that can be accessed through the insertion of needles. The names of the meridians are due to their functional areas in the internal organs and body (for example stomach meridian, heart meridian or lung meridian). The meridians are thought to function as channels, in which the Qi flows in (Langevin, Yandow, 2002). Since Qi is very difficult to translate from the Chinese language, many authors state, that there is no western equivalent to the name of Qi. Chinese language is a sign language and Qi has the signs of a rice corn, which is stewed. Similar to an uncooked rice corn that remains indigestible to humans and consequently cannot provide energy to the digestive system, Qi must circulate to impart energy to the body's system. If there is a blockage of Qi, the energy is not flowing anymore and in traditional Chinese medicine this is associated with disease (Langevin & Yandow, 2002). Other authors translate Qi with more than one word, to explain the actual meaning, such as dynamic processes in movement and communication or energy exchange (Langevin & Yandow, 2002). Grilley states, that scientists cannot measure Qi directly and therefore measure electrical and chemical changes in the body and that Qi is the energy force that is responsible for the manifestation of these electrical and chemical changes (Grilley, 2012). If there is a blockage or disruption of the meridian channel network, and therefore disease in the system, accessing the right acupuncture points (dependent on which disease has to be treated) is supposed to access the meridian channels (in which the Qi flows) and to help harmonize the Yin and Yang within the body and system (Langevin & Yandow, 2002). According to TCM all diseases can result from a disbalance of Yin and Yang and can therefore be healed by harmonizing the Yin and Yang energies in the body (for example through acupuncture) (Duffy, 2019; Grilley, 2012).
The superficial and deep fascia, as well es the epimsium (surrounding the muscles) can be penetrated by the acupuncture needles. Which parts of the fascia are exactly stimulated by the needle depends on the acupuncture point as well as the depths of the inserted needle. The acupuncture points are located along fascial planes between muscle and bone or tendon or between muscles (Langevin & Yandow, 2002). If an acupuncture needle is inserted at the site of a connective tissue cleavage plane, it will initially pass through the dermis and subcutaneous tissue before delving into the deep fascia (Langevin & Yandow, 2002). If a needle is inserted away from the connective tissue plane, it will insert through the dermis and subcutaneous tissue before reaching a bone or muscle (Langevin & Yandow, 2002). In the following chapter the role of the fascia in acupuncture is discussed, by explaining different similarities and connections between the fascial system and the meridian system of TCM in the body as well as the effects of acupuncture on the fascia.
Many different studies point out, that the meridian network is anatomically aligned with the fascia planes in the human body (Bai, Wang, Wu, Dai, Sha, Yew, Yuan & Liang, 2011; Finando & Finando, 2011; Langevin & Yandow, 2002; Stecco, 2020). Finando and Finando emphasize, that the needle insertion of acupuncture has an effect on the fascia on every point of the body and that the acupuncture point on the meridian lines and the fascial planes follow a very similar pattern (Finando & Finando, 2011). The anatomical correlation of the meridian lines and fascial planes can easily be seen by mapping them together (Bai et al., 2011, Finando & Finando, 2011; Langevin & Yandow, 2002; Stecco, 2014). Bai, Wang, Wu, Dai, Sha, Yew, Yuan and Liang for example, compared the locations of the triple energizer meridian of hand-shaoyang and the acupuncture points on that meridian (Tianjing, Sanyangluo, Yangchi and Guanchong), as well as the the large intestine meridian of hand-yangming and the acupuncture points placed on it (Quchi, Pianli, Hegu and Shangyang) with a reconstruction of the fascia pathways in the arm (Bai et al., 2011). All the named acupuncture points on the two meridians are placed along the outside of the underarm and on the top of the index finger (large intestine meridian of hand-yangming) and ring finger (triple energizer meridian of hand-shaoyang) (Bai et al., 2011). Scan data of the fascial connective tissue of the human arm matched the location of these meridians and their acupuncture points (Bai et al., 2011). Similar comparisons were done for other body parts and by different authors in multiple studies (Finando & Finando 2011; Stecco, 2014) and all results indicate that the anatomy of the fascia network is consistent with the meridian network pattern according to TCM (Bai et al. 2011, Finando & Finando 2011; Langevin & Yandow, 2002; Stecco, 2014). Furthermore, in 3D fascial reconstructive studies with computed tomography and magnetic resonance imaging (MRI) of living human bodies, the fascia showed line- like structures which are similar, not only in their position within the body but also concerning their form, to the structures of the acupuncture points and meridians (Bai et al., 2011). Langevin and Yandow have tested different acupuncture points and control points (no- acupuncture points) with regard to the fascial planes surrounding their location (Langevin & Yandow, 2002). The results of their study suggest that more than 80% of the acupuncture points and 50% of the meridian intersections of the human arm seem to align with intermuscular or intramuscular fascia planes with a probability that a random point in the section would fall on a fascial plane of 0.083 (Langevin & Yandow, 2002). Their findings also show that some of the acupuncture points (also referred to as „holes“) are placed on deeper fascial layers (than others), where the acupuncture needle accesses greater amounts of the fascia when inserted (Finando & Finando, 2011; Langevin & Yandow, 2002). At those points a greater mechanical stimulus and signaling of the fascia and therefore to better therapeutic effects are given (Langevin & Yandow, 2002).
In traditional acupuncture, the needle is asserted to the body by the TCM doctor and then manipulated manually, either in form of rapid rotation (in one direction or back and forth), and/ or as pistoning (up and down motion) (Langevin & Yandow, 2002). With these methods acupuncturists want to achieve a reaction known as „de qi“ sensation in TCM (Langevin & Yandow, 2002). Patients report that this reaction to the needle feels like a temporary sensation of soreness in the area surrounding the needle insertion, while the acupuncturist describe the experience of a pull on the inserted needle (Bai et al., 2011, Langevin & , 2002). This sensation has been shown to happen when the acupuncture needle physically effects the connective tissue in the fascia and is referred to as needle grasp in modern science (Bai et al., 2011; Fox, Badger, Garra & Krag, 2001; Langevin, Churchill, Wu, Badger, Yandow, Fox & Krag, 2002). When the needle is rotated within the fascia, the connective tissue winds itself around the acupuncture needle and thereby produces a tight mechanical coupling between the connective tissue and the fascia (Langevin & Yandow, 2002). The coupling of the tissue with the needle, enables further movements of the needle (rotation or pistoning), which pulls and forms the connective tissue of the fascia and as a result transfers a mechanical signal into the tissue (Langevin & Yandow 2002). When the acupuncture needle is placed flat onto the subcutaneous tissue surface and rotated it triggers the connective tissue to follow the rotating needle for 180 degrees and after that to rotate itself further, so that it ends up in the formation of a whorl (Langevin & Yandow 2002). Due to this chain reactions, a whorl of the connective tissue around the needle can be produced with only one turn of the needle (Langevin & Yandow 2002). The biomechanical mechanism of needle grasp can be measured with the „pullout force“, the force needed to pull the needle out of the connective tissue (Langevin et al., 2001; Langevin et al., 2002). Langevin, Churchill, Wu, Badger, Yandow, Fox and Krag measured the biomechanical force (pullout force), which is created in the fascia when stimulated by needle rotation of acupuncture needles (Langevin et al., 2001). The results of their study of eight acupuncture points and eight control points in 60 human subjects states an increase in the mean pullout force of 52 percent with the application of an unidirectional and bidirectional needle rotation (by a computer-controlled acupuncture needling instrument) compared to no needle rotation (Langevin et al., 2001). Moreover the pullout force measured in their study was 18 percent higher at the measured acupuncture points than at their control points (with p<0.001). The sensation of “de qi”, also referred to as needle grasp in science, is in TCM believed to be an indication that the goal of the acupuncture has been achieved (Garra, & Krag, 2001; Langevin et al., 2002; Langevin & Yandow, 2002). With the confirmation from numerous studies that the connective tissue of the fascia is the tangible, physical element implicated in the "de qi" sensation/needle grasp phenomenon, it can be affirmed that the fascial system and its biomechanical processes play a crucial role in the outcomes of acupuncture treatments (Bai et al., 2011, Langevin et al., 2001, Langevin et al., 2002, Langevin & Yandow 2002). Langevin and Yandow conclude, that the “phenomenon of needle grasp, therefore, is at the very core of acupuncture’s theoretical construct” (Langevin & Yandow 2002, p. 259). Bai, Wang, Wu, Dai, Sha, Yew, Yuan and Liang sate, that the observation of needle grasp “indicates that the efficacy of acupuncture relies on interaction with the fascia” (Bai et al. 2011).
Several researchers conducted examinations and comparisons between the bodily functions of the traditional Chinese concept of acupuncture, Qi and meridians with the bodily functions of the fascia (Finando & Finando, 2010, Langevin & Yandow, 2002). The practice of acupuncture, which stimulates the Qi flowing through the meridians, as well as the fascial system itself have an influence on the immune function, blood circulation, temperature regulation of the body, the metabolism and digestion, the shape/ structure of the body as well as the ability of movements of the body (Finando & Finando, 2010). Therefore both systems can be described as metasystems of the body, which connect and affect all the other systems within the body (Finando & Finando, 2010, Langevin & Yandow, 2001). As explained in chapter 1.1, the fascial network transmits signals and thereby communicates with the whole body, for example muscles, organism, vessels and nerves (Finando & Finando, 2010). The same is said about the meridian system (Finando & Finando, 2010, Langevin & Yandow, 2001). According to TCM practice, physical dysfunctions in the body can be healed through the stimulation of the Qi in the meridians with acupuncture needles (Finando & Finando, 2010). Manipulating the fascia in therapy can induce changes in cellular physiology, consequently enabling the treatment of physical dysfunctions associated with it (Grilley, 2012; Natali et al., 2010; Stecco, 2014; Sterling, 2018). Luigi Stecco has created a therapy concept called “fascial manipulation”, which is stimulating the fascial planes to excite areas of the central nervous system through reflex pathways (Stecco, 2020). With his fascial manipulation massages he refers to the meridian system of traditional Chinese medicine and the meridians matching with the fascial planes in the body (Stecco, 2014).
Numerous authors assert that unraveling the scientific counterpart to Qi and the meridian system involves comprehending the chain reactions initiated when acupuncture needles stimulate the fascia (Finando & Finando, 2010). Given that both Qi and the fascia have analogous functions within the body, the fascial system might be the scientific equivalent to the meridian system of TCM (Finando & Finando, 2010, Langevin & Yandow, 2001). Grilley states that Qi, being the energy that is manifesting energies itself, cannot be directly measured (Grilley, 2012). However, the measurable aspects lie in the chemical and electrical changes induced by Qi, and they are assessable through the effects observed when acupuncture needles are inserted into the fascia (Grilley, 2012). Langevin and Yandow explain the physiological effects that can be seen due to acupuncture needling in regard to the fascial system (Langevin & Yandow, 2002). They compare the concept of TCM with their purposed anatomical/ physiological equivalents of the fascial system (Langevin & Yandow, 2002). Due to their analogy, the meridian qi has its western equivalent in the biochemical and bioelectrical signaling of the connective tissue/ fascia and a blockage of the Qi is caused by a modified connective tissue matrix composition and therefore a different biochemical and bioelectrical signal transduction (Langevin & Yandow, 2002). As explained in chapter 2.2 the “de qi” sensation at the acupuncture points can be contrasted with the needle grasp phenomenon triggered by the fascia. As a result of altered biochemical and bioelectrical signaling within the fascia and cellular activation triggered by the insertion of needles into the fascia, the restoration of signal transduction and the composition of the connective tissue matrix can occur (Langevin & Yandow, 2002). Finando and Finando reveal the similarities in function, structure and anatomical correlations of the fascial system and meridian system and conclude that “the closest parallel to qi in Western thought is a generative matrix in which all things interact with all other things through the exchange of information” (Finando & Finando, 2011, p. 172). And that generative matrix, which is communicating with the whole body by transferring signals, is called fascial system.
With existing studies on fascia and its role in acupuncture, a new field has been opened that integrates Eastern traditional approaches with Western scientific standards. The current state of studies suggests that the theory and practice of acupuncture relies on the fascial system of the body. This can be explained with the anatomical alignment of the fascial system and the meridian system, the “de qi” sensation/ needle grasp phenomenon in acupuncture, as well as the similarities in their bodily functions, as referred to in the previous chapters. In traditional texts about the originally skilled palpation in order to find the acupuncture points (rather than the later used proportional measurements to find acupuncture points), the sensations are referred to as „holes“ (Finando & Finando, 2010). This description might be a hint to the thicker parts of the fascia (see chapter 2.1), which was not called fascia in the tradition of Chinese medicine, yet might be the same element, referred to with different words in TCM and in the western world (Finando & Finando, 2010). This paper had the aim to explain how fascia is related to the ancient practice of acupuncture in traditional Chinese medicine. In summary it can be stated that the fascial system has a very crucial role in the theory and practice of acupuncture by being responsible for the needle grasp phenomenon/ “de qi” sensation. This “de qi” sensation is thought to be the benchmark, if the acupuncture treatment was successful and therefore the fascia plays a very important role in the effectiveness of acupuncture. As explained in chapter 2.4 the fascia might not only be related to the success of acupuncture, but the fascial system can be assumed to be the western physiological equivalent to the meridian system of TCM. With the connection of the ancient knowledge of TCM with the findings of modern research, the understanding of different cultural practices can be deepened, and a more holistic approach of the body, health and wellbeing can be supported. Therefore, upcoming studies on the involvement of fascia in acupuncture might focus on exploring both, the parallels and distinctions of the perspective of the traditional Chinese medicine and the western approaches to health and wellbeing. Thereby previous and future studies in this field help to understand and acknowledge (in terms of western science) alternative healing methods, that can support many people in their healing journey from different symptoms and diseases.
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