Qi,Acupuncture,and the Fascia: A Reconsideration of the Fundamental Principles of Acupuncture

Introduction

Q i is a philosophical principle that has been difficult to embrace and assimilate into Western culture in part due to cross-cultural differences. It is a concept that may be applied to everything and as such can readily be employed as a construct in the understanding of human health. When applied to acupuncture, the qi principle requires discussion in order to consider the means by which the stimulation of points along acupuncture channels may produce a wide range of physiologic effects.

Three (3) relatively new areas of research offer previously unavailable information that provides support for understanding both the qi principle as applied to acupuncture and the connection between acupuncture and the fascia. The first such area involves several meta-analyses of clinical acupuncture studies that have consistently failed to demonstrate significant differences between acupuncture treatment and control. A meta-analysis by Moffet ¹ suggests that the fundamental principles of acupuncture be reconsidered. The second, most crucial area considers the numerous studies of the fascia that have shed new light on its form and functions. Finally, there have been a number of studies that have provided new insights into cellular biology, expanding our fundamental understanding of human physiology.

The complexity of qi requires a multidisciplinary discussion and includes cross-cultural, philosophical, scientific, and historical perspectives. The purpose of this discussion is to stimulate thinking about a term that is frequently used but often poorly understood.

Cross-Cultural Communication and Understanding Qi

Western culture has had difficulty unraveling the concept of qi. O'Connor and Bensky ² consider qi to be untranslatable. Kaptchuk ³ concurs, stating that no English phrase can capture its meaning. Unschuld ⁴ goes further and states that the customary translation of qi as “energy” is a basic misconception. While such difficulty is connected to both philosophical complexity and linguistic differences, cross-cultural issues focus on the difficulty of introducing the qi principle to Western minds.

In an extensive review of the literature by Nisbett et al., ⁵ arguments are made that the considerable social differences that exist between cultures affect the nature of cognitive processes of individuals raised within such cultures. Nisbett's review offers evidence that societies differ markedly in their systems of thought, characterizing Eastern thinking as holistic, and Western as analytic. Holistic thought is defined as an orientation to the context or field as a whole, with attention to the relationships between a focal object and the field in which it is located, and a preference for explaining and predicting events based on such relationships. Analytic thought involves the detachment of the object from its context, a tendency to focus on attributes of the object in order to assign it to categories, and a preference for using rules about the categories to explain and predict the object's behavior.

Research supports the existence of these differences. ^6,7 One such study presented animated scenes of fish and other underwater objects to groups of Japanese and Americans and then asked them to report on what they had seen. ⁷ The Americans' responses were almost completely about a focal fish, while the Japanese responses were overwhelmingly connected to both the fish and the background environment. Subsequently, both groups were asked to perform a fish recognition task where the previously shown fish were placed in a different background. The performance of the Japanese group suffered, indicating that for them the object had been bound to its relationship to the background. The American group's ability to recognize the fish was unaffected by the different background.

What we see here is that despite the globalization of the world, there are basic differences in the cognitive processes between cultures, representing fundamental disparities in the way each culture views the world. The Eastern mind sees a world of complex relationships, interdependency, and interconnectedness. The Western mind tends toward individualism, categorization, reductionism, and logical analysis that differentiate objects into discrete entities. Such differences are important to the discussion of the philosophical basis of qi.

What is qi?

Qi is a principle that is deeply rooted in Eastern philosophy. It is connected to a worldview that is bound to relationships and the relativity of all things and as such is difficult for Western cognitive processes to conceptualize and integrate. The idea of qi as “energy” is a completely modern idea, most likely derived from Soulie de Morant at the beginning of the 20th century, in an effort to provide a “scientific” explanation to a skeptical West. ⁸ An energy explanation was understandable in the context of then-recent scientific discoveries about atomic structure. ⁹ While the idea that qi is energy may have helped to disseminate acupuncture to the West, it may also have left a legacy of confusion surrounding qi. As a result of the conception of qi as some “thing” in the form of a vital energy, modern scientists have set forth on a futile hunt to discover some “insubstantial substance.” The idea of qi as some sort of measurable energy is comfortable to the Western mind, but is not in accord with Eastern cultural tradition surrounding the qi principle.

Qi is a fundamental philosophical concept that represents the quality or nature of whatever it is applied to. The concept of qi is so rich with meaning, that philosophers have spent lifetimes contemplating the idea. It is an idea that is ubiquitous in the East and relates to all that exists. For the purposes of this discussion we will focus upon two fundamental aspects of the qi principle: movement or activity, and relationship or relativity. It must be understood that activity and relativity are inseparable concepts, but difficult to discuss as a singular idea. Therefore, they will be considered separately, while understanding the artificiality of such separation.

Insight into the qi principle must begin with an examination of its roots in Taoist cosmology, where it is the first principle of the material world. Cosmology is an effort to explain the nature and order of the universe. Taoist cosmology, like many other philosophical systems, begins with creation, similar to modern science's description of the “Big Bang.” In Taoism, the beginning is “The Void” or “Nothingness;” it is an idea comparable to the state prior to the Big Bang. In Taoism this state is called Wu Qi, symbolically represented by an empty circle. It is the state of “no qi,” quiescence. What follows is the beginning of existence, the Tai Qi, or the “Ultimate Qi,” symbolically represented by the familiar Yin/Yang. The evolution of all that exists then proceeds through a process of increasing complexity and interrelationships, symbolized first by the Six Energies, leading to the Five Elements, then the Eight Trigrams, the Sixty-Four Hexagrams, and finally, the whole of the material universe, euphemistically described as the 10,000 Things (Fig. 1). It is important to note that each phase of creation contains and is governed by all principles preceding it. Thus, the material universe, everything that is—the 10,000 Things—is governed by all universal principles preceding it in the cosmology. The “first” principle, however, is Tai Qi, the beginning of existence.

OPEN IN VIEWER

FIG. 1.

The Descent of Being as outlined in Taoist cosmology.

A full consideration of Taoist cosmology is beyond the scope of this discussion, but focusing upon the earliest stages of creation, from Wu Qi to Tai Qi, may provide some insight into the concept of qi. There are three important ideas about this first step from “no qi” to the “ultimate qi.” First, creation is marked by a change from oneness and quiescence to duality and activity. The progression from Wu Qi to Tai Qi begins with movement—something moves; there is activity. Second, inherent in the notion of movement is relativity. Movement cannot exist unless that movement is relative to something else. Thus, movement implies duality, the beginning of existence. Third, the interplay that we see within the Tai Qi symbol reflects both the dynamic of movement and the relationships that result from that dynamic. It represents opposing forces engaged in an ongoing activity, seeking unattainable equilibrium. The Tai Qi is reflected in the pairs of opposites that define this world. Hot/cold, up/down, black/white: apparent opposites, each connected and unknowable without the other. Contained within the Tai Qi, then, is both the fundamental, underlying nature of all that is and the dynamic relationships that define it. Qi then can be understood as a principle that describes the nature, dynamic, and relationships of that which exists.

We now can see how this concept may be applied to everything. It is a statement of essence, the fundamental nature of that which exists. Everything is but one aspect of a dynamic whole in which everything affects and is affected by everything else. This is the environment to which the Taoist refers when speaking about the interrelationships of the Ten Thousand Things. A change in the qi, the nature and dynamic, of any one thing affects everything in and around its environment. The sets of interrelationships are innumerable. It implies that in reality there is no one thing that is separate from any other. In fact, to the enlightened Taoist, “environment” is simply a concept of convenience. There is no environment. Everything is connected in a complex, ever changing, interactive reality.

Qi, when applied generally to a human being, refers to far more than physical health. It applies to who and what they are, their relationships with others and the world around them, the order of their life, their being. It is the totality of these things that define and reflect the essence of a person. The same notion holds true for every thing: a mountain, a tree, a river, the earth, and the objects that we create. For example, the qi of a sword speaks to everything about its nature: its tensile strength, stability, flexibility, balance, sharpness, grip, its ease of use, that is, its relationship to the swordsman—everything that makes it a sword.

The late eminent physicist Richard Feynman unintentionally provided an elegant example of qi when he wrote that the atomic hypothesis is the single most important statement of scientific knowledge. ¹⁰ Simply put, this hypothesis sets forth that all things are made of atoms, particles that move around in perpetual motion, attracting or repelling each other, based upon their relationships of distance to each other. Feynman is describing the fabric of existence in terms of movement and interaction. He may well be describing the Tai Qi: “the fundamental, underlying nature of all that is and the dynamic relationships that define it.” Feynman tells us that there is enormous information here, if a little imagination is applied to it.

To the Eastern mind, qi is an idea that is self-evident and fundamental. It is an expression of the basic reality experienced by cognitive process. To the Western mind, it is difficult to embrace and incomprehensible in a world that is seen through the lens of individuation, separation, and categories. Yet with a little imagination and thought, new perspectives about the world can be revealed.

Cellular Biology

Just as recent research has transformed perception of the fascia, the structure and physiology of the human cell has been transformed as well. New insights into the functions of subcellular structure have shed light on the cell as a structure of enormous complexity. Of particular importance to this discussion is the research into the cellular membrane, the structure fundamental to the interaction between the cell and its environment. The extracellular matrix (ECM) is the environment that is most immediate to the human cell. Its functions include nutrient transfer, nerve signal transduction, regulation of intercellular communication, and transmission of mechanical stresses exerted on the cytoskeleton. Oschman states: “Every function and every process of the living body involves the matrix in one way or the other. The reason for this is that every cell in the body is nourished via the matrix, and all waste products of cellular metabolism likewise pass through the ground substance, which is the actual milieu. The matrix is also the terrain in which all immune responses and tissue repair processes take place.” ²¹ The ECM is a fundamental component of the fascia.

Chen and Ingber have studied cellular structure and describe a cytoskeleton that is under continuous tension, making it capable of transmitting mechanical forces through the system. ²² They have called this the tensegrity model and suggest that pressure and tension transmitted to the cell through the system can produce biochemical effects through mechanochemical transduction. Research has demonstrated that acupuncture is capable of exerting such an effect. ^23,24

Human physiology may be understood as a complex of dynamic interactions, effectively described by the concept of qi. The fascia affects immune function, metabolism, circulation, organ function, and virtually every aspect of human physiology. As subcellular mechanisms are revealed, its role as the cellular environment is demonstrating an even more fundamental role in human physiology.

The Placebo Problem

Recently there have been a number of meta-analyses of clinical acupuncture studies, many of which have failed to find significant differences between the independent variable (acupuncture) and the control. ^1,11,12,25 This has led to some speculation that the effects of acupuncture may be explained as a placebo effect. While any therapeutic intervention may have a placebo component, this explanation alone is highly unlikely. Placebo does not explain the results of acupuncture in animal studies, where a wide range of physiologic effects have been demonstrated. ^{26 –30}

The issue of the placebo effect might be clarified by an examination of the methods of experimental control. Lao examined various methods of experimental control in a number of clinical acupuncture trials. ³¹ In studies where there was no tissue needling or stimulation of the control groups, there were significant differences between control and acupuncture in virtually every study. Where some type of tissue needling was employed as a control, or “sham acupuncture,” the studies revealed no significant differences between acupuncture and control in all but one study. However, when compared to no treatment or conventional medical approaches, the acupuncture and sham acupuncture groups both demonstrated significant effects. For example, Scharf et al. found that both acupuncture and sham acupuncture groups demonstrated double the improvement when compared to the conventional medical treatment group. ³²

Pirog describes the treatment of pain employing meridian-style acupuncture. ³³ He states that when there are surface anomalies and constrictions near the pain, or near the point selected for treatment, it is the constrictions that should be needled, rather than local acupuncture points. Clinical observations suggest that charted acupuncture points need not be used to obtain a therapeutic effect. Careful palpation near and along fascial planes followed by needling densifications within the fascia appear to produce extremely effective treatment outcomes. This observation is significant because specific charted acupuncture points are used in much, if not all, of the clinical research of acupuncture for pain control, and it is unclear whether acupuncturists reliably needle acupuncture points as charted. ^34,35

From a behavioral perspective, acupuncture involves the placement of needles into the skin, fascia, and occasionally muscles. There is always needle contact with the fascia. The only accurate statement that can be made regarding “acupuncture” and “sham acupuncture” is that both stimulate fascia. Understanding acupuncture as the stimulation of the fascia, it is impossible to have “sham” acupuncture treatment. Some acupuncture treatments may be more effective than others, but the moment the fascia is stimulated, some physiologic effect is occurring. This applies to acupuncture, where patterned needling provides complex areas of stimulation, as well as other ancillary channel therapies. Tui na, shiatsu and amma, moxibustion, gua sha, cupping, laser and electrical stimulation, tai qi chuan, and qigong also affect the fascia. The results of the meta-analyses of clinical acupuncture studies may well be explained in part by the fascia acupuncture hypothesis.

The research regarding the fascia, cellular biology and sham acupuncture all support the hypothesis that the qi of the channels, manipulated by the acupuncturist, refers to maintaining the activity and relationships of the fascia. The qi principle has generally been applied to comprehensible realities. Yet when the qi principle was applied to the practice of acupuncture in the West, there was a conceptual shift that was inconsistent with other applications of this principle. Rather than referring to an existent reality, acupuncture channels were conceived to be invisible conduits (meridians) for a scientifically undetectable vital energy. Understanding the qi principle as it is applied to acupuncture channels as the activity and interrelationships of the fascia, the qi principle is returned to a position that is consistent with other conceptions and uses of the term qi.

Historical Perspective

Some key points in the history of acupuncture may help to clarify the diverse and often contradictory concepts of modern acupuncture practices. Qi, as a concept, was applied to acupuncture at least as early as the Nei Ching, circa 200 bc. According to O'Connor and Bensky ² and Birch and Felt, ⁹ acupuncture was originally a technique that relied on whole-body palpation. The fascia was known to have an important role in human function. The earliest classics describe “fatty, greasy” tissues and connecting membranes. Channels were located in the body lining and are described as keeping the bones and sinews moistened and the joints lubricated. ³⁶ This provides some indication that the fascia was recognized as a structure that had physiologic purpose. Diagnosis of disease was based on observation and palpation of tender or painful areas along the pathways of the channels. It was theorized that the channels were connections between the body's surface and the internal organs. ² Acupuncture points were chosen for use by skilled palpation and treated with the aim of affecting qi throughout the channel system. It was not until the seventh century that the standard measurement system for point location was developed. ⁹ This suggests that for 1000 years, charts were used for approximation and points were chosen for use by palpation, rather than standardized measurement. It is therefore possible that acupuncture had its roots in a fascia-based system that used palpation as the means of diagnosis and needle stimulation as treatment.

The early development of acupuncture, arising from roots in demonology and magic in the middle Zhou period (approximately 772–480 bce), was paralleled by the rise of Confucianism. Confucian morality sought to minimize exposure of the body. There was a concurrent transformation of the practice of acupuncture, moving from whole-body palpation to the palpation of the pulses, with greater reliance on interrogation and pattern diagnosis. In Japan, where Confucian influence was less pervasive, a strong reliance on palpation continued. ⁹ Thus, religious and moral issues began to transform acupuncture from a palpation-based, tissue-oriented system to one that minimized palpation.

A major shift in acupuncture practice occurred in the last century. Today, many practitioners and lay public commonly refer to acupuncture as Traditional Chinese Medicine (TCM). What we call TCM represents an acupuncture that is primarily the result of political, social, and economic influences. “TCM” is capitalized to indicate a specific product of the Cultural Revolution rather than the broad array of ancient traditions of classical Chinese medicine. Birch and Felt refer to TCM as “modern” acupuncture because it is a specific creation of the People's Republic of China (PRC), beginning sometime around 1950. ⁹ TCM was a development of a new political structure that faced a major health crisis, and needed health care for a massive population. The development of TCM was dependent on meeting a number of criteria that were set forth by the PRC leadership. First, acupuncture and herbal practice were to be integrated under a single set of principles. This was a political decision, not a medical one. Acupuncture and herbs were traditionally practiced using quite different, but related principles. Pirog refers to TCM as “herbalized” acupuncture for this reason. ³³ Second, the teaching of TCM had to be amenable to large classroom training, rather than by traditional apprenticeship, since there was a need for rapid, uniform training. Therefore, the possibility of careful training in palpation was virtually eliminated. Third, the diagnosis of disease was to be connected to modern biomedical concepts. Pattern diagnoses were connected to Western-defined diseases, and textbooks began to provide treatments for arthritis, gastritis, and other such Western-defined pathologies. TCM became the only permitted acupuncture practice in the PRC. An historical review by Taylor describes TCM as a simplification of Chinese medicine into one easy-access nutshell, which compromises every level of the physician's encounter with the patient, and is a medicine taught in an increasingly formulaic manner. ³⁷

TCM has become the most commonly used acupuncture practice worldwide, certainly among Western practitioners. It is also the most commonly employed approach in acupuncture clinical research, becoming the de facto definition of the independent variable. Most of what is known scientifically about the clinical effects of acupuncture is based upon the study of TCM, rather than the palpation approaches that still survive in a minority of practitioners. TCM marks a significant movement away from an acupuncture that was based upon careful attention to the body, toward a more formulaic approach where charted acupuncture points are designated for use. It has replaced attention to the “terrain” with a prescribed use of the “map.”

Implications

The role of the fascia in human physiology and pathology has yet to be fully defined. However, there appears to be a confluence of information in support of the fascia hypothesis. The fascia as the mechanism of acupuncture opens a new world of possibilities for future research. High-resolution ultrasound imaging might be used to evaluate the effects of needle stimulation on the fascia as well as the effects of such stimulation upon physiologic processes. Research is needed to assess the effects of needle insertion on fascial planes. Effects may include local mechanical stimulation, mechanical stimulation generated along fascial planes, and local and systemic immune responses. Research may also help to shed light on the possible effects of superficial needle stimulation on organ processes associated with specific channels.

The implications for research point to a reconsideration of the operational definition of acupuncture, no longer defining it in terms of TCM simply because of its ubiquity.

The current model for acupuncture education may also need re-evaluation. Acupuncture programs often lack training in the anatomy, physiology, and palpation of the fascia. In the United States and elsewhere, the cyclical interdependency of acupuncture college curricula, accreditation standards, and certification standards should be part of such re-evaluation.

Most important are the implications for health care. As greater understanding of the role of the fascia in human health emerges, new approaches to health maintenance, prevention, and treatment may evolve as well.

Conclusions

Modern acupuncture is an amalgam of ancient principles shaped by political, religious, economic, cultural, and biomedical influences. There is clearly a need for reconsideration of currently held acupuncture principles described by Unschuld as “mutually contradictory, antagonistic and exclusive.” ³⁸ Theories are replaced as new theories demonstrate greater ability to explain and predict phenomena. The fascia acupuncture hypothesis within the context of understanding qi as a philosophical principle may explain acupuncture's effectiveness in treating a wide range of conditions and why varying approaches to acupuncture may all be effective to varying degrees. It provides a possible contributing factor regarding the placebo issue arising from meta-analyses of clinical acupuncture research. The fascia acupuncture hypothesis is in accord with recent research explaining the form and functions of the fascia and cellular biology and it is scientifically testable, through both laboratory and clinical studies.

Reconsideration of an acupuncture that manipulates some yet unknown energy, accomplished by the dogmas of various styles of treatment, is necessary for the future development of the field. The meta-analyses that challenge the effectiveness of acupuncture may serve as stimuli for renewed evaluation of acupuncture, perhaps leading to a renewed understanding as well. This requires openness to scientific scrutiny regarding what acupuncturists do and the means by which it is done. Future clinical research must therefore include reconsideration of the operational definition of the independent variable (acupuncture). The application of Western cognitive processes to acupuncture, including critical logical analysis, reductionism, and categorization can help clarify and evolve objective knowledge without replacing the root holistic principles of this ancient practice. The result may be the development of a broader understanding of acupuncture in a modern scientific context.