This article is loosely based on a talk given to a meeting of the
British Medical Acupuncture Society in 1999 (Acupunct Med 1999;17:2
113-117). Naturally my view of acupuncture has evolved in the
intervening decades (I'd be worried if it hadn't!), and this is
therefore a pretty radical revision of the original article. But
I've preserved the title of the piece, along with some of the
original text, because it still covers the same territory although
in a different way.
I. Where to needle?
Newcomers to acupuncture generally spend a lot of time asking where
they should place the needles. They often yearn for firm
instructions; they want to be told that in disorder A you should put
the needles in points x, y, and z, while in disorder B you should
put them in points p, q, and r, and that provided you do this you
should get the hoped-for results. There are numerous 'cook books'
which purport to give this information. If you attend an
introductory acupuncture course you may get the impression that
there is a firmly established body of rather arcane knowledge which
must be gradually acquired, so that becoming an expert acupuncturist
is partly a matter of learning more and more acupuncture points with
their specific properties and effects.
As time goes by, however, you are likely to find that this rather
simplistic view of the matter doesn't correspond to reality.
Different teachers of acupuncture have quite divergent ideas about
how to choose which points to needle, as well as about the duration
and intensity of needling and other matters. This can be
confusing. But I think it is possible to clarify
things if we think systematically about the various options that
Here I briefly summarise the main methods of choosing where
to needle and then propose a composite view which, I suggest,
represents a satisfactory compromise among all of them.
TCM theory postulates the existence of numerous acupuncture points
with specific effects, but the research evidence for point
specificity is thin. Most randomised controlled trials in the West
have found little if any difference between so-called real and sham
acupuncture. For this reason many modern acupuncturists are more or
less sceptical about the existence of acupuncture points as usually
understood. (An interesting paper by Cheng1 may offer
the point concept a modified kind of validity. See Note 1 below.)
I use the expression 'neo-TCM' to refer to a rather heterogeneous
collection of treatments that have some kind of affinity with the
traditional system but depart from it in various ways. Examples
include systems based on proposed localised body maps, such as ear
acupuncture (auriculotherapy) and scalp acupuncture. These generally
retain the concept of 'points' in some form and suffer from the same
drawback as TCM, being unsupported by good scientific evidence for
their efficacy and basic assumptions.
B. Non-traditional methods
The remaining methods of choosing where to needle are modern; they
seek to reinterpret acupuncture on the basis of current ideas of
neuroanatomy and neurophysiology. In principle, they ought to
provide acupuncture students with rational ways of choosing where to
needle that are easier to accommodate within a scientific world view
than those offered by TCM, and to quite a large extent this is the
case. The methods described include (1) acupuncture based on body
segments (dermatomes, myotomes, sclerotomes, viscerotomes), which is
mainly used to treat inaccessible structures such as viscera; and
(2) needling myofascial trigger points (MTrPs), especially for the
treatment of musculoskeletal pain. (For a useful review of these
methods, see Cummings2.)
However, our current knowledge cannot explain all the
acupuncture effects that are seen clinically, and a good deal of the
treatment still has to be empirical. It works but we don't (yet) know
why. So I prefer to use a purely descriptive approach, which works
well in practice and can accommodate all the modern ideas that are
current today. It can also accommodate those practitioners who wish
to retain at least some traditional points, as quite a number do,
provided they are willing to accept that we need to think in terms
of areas rather than small localised 'points'.
I suggest that acupuncture treatments can be categorised under
four methods which we can use to decide where to needle3.
I describe these as the four principles of acupuncture.
C. The four principles of acupuncture
Method 1. Needle the site of pain
This is the simplest form of acupuncture and is often all that is
required. Insert one or more needles in the painful area itself. For
example, widespread back pain, due perhaps to ankylosing
spondylitis or osteoporosis, can be treated by needling the
paraspinal muscles. A localised area of pain in the chest wall can be
treated by inserting a few needles subcutaneously over the painful
Method 2. Needle a remote site to influence the site of pain
This depends on the phenomenon of referred pain and covers both
MTrPs and segmental acupuncture but is not confined to these. One
example would be needling the ulnar side of the hand at the site
known to TCM as Small Intestine 3 (C8/T1 dermatomes) for upper
thoracic pain. Another is pain in the dorsum of the wrist which can
be treated by needling a MTrP helow the elbow, in extensor
Method 3. Needle the periosteum
Needling the periosteum seems to have been introduced by
Mann4; it figures little or not at all in the traditional
system. It is most commonly used to treat intrinsic joint pain such
as that due to osteoarthritis, but can also act on wide areas of the
body. For example, periosteal needling of the articular pillar in
the neck can influence symptoms in the upper half of the body, and
needling the pelvic periosteum in the region of the sacroiliac joint
can do the same for the lower half.
Method 4. Needle for generalised (central) effect
In some cases acupuncture produces widespread and quite profound
generalised effects. This appears to be a central phenomenon,
probably mediated at least in part by limbic system structures.
Responses of this kind can occur no matter where the needles are
inserted but the hands and feet seem to be most effective. This can
be used either on its own, e.g. for allergies, or to reinforce
treatments using the other methods.
I think that these four principles make acupuncture 'simple but not too
simple'. But please note the following.
1. The headings are guides, not rules. They suggest how to think
about treatment but they don't say what you must do. They
are meant to help you shape your thinking but not to limit it.
2. The methods are not mutually exclusive. They can be combined
and often are. For example, Method 4 (central effect) can be used
along with any of the other methods.
3. Some treatments could be described under more than one heading.
For example, many local treatments (Method 1) may also have
central effects (Method 4).
4. The scheme is theory-neutral; it does not imply anything about
how acupuncture works. It merely describes the possible treatment
options that exist.
Most traditionalists, and some modernists, leave needles in place
for at least 20 minutes, often with intermittent manual or
electrical stimulation. My own practice is different: I favour brief
needling, which means about 2 minutes maximum per needle, often
less. At the extreme, this becomes minimalist (micro) acupuncture,
in which needles are inserted for only a few seconds, with little or
no stimulation. Periosteal acupuncture is always very brief.
The use of brief needling may be counter-intuitive but it works in
practice and is less likely to cause aggravations than more
prolonged needling. The following considerations may make this
method appear less counter-intuitive.
1. The nervous system habituates very quickly to a new stimulus.
What it notices is change in intensity. For example, if
you are exposed to a continuous noise, such as a distant car alarm,
you notice it at first but cease to do so after a few minutes; you
only become conscious of it again when it stops. What the system
registers is 'news of a difference'*.
2. I think of acupuncture as a means of switching patterns
of activity in the nervous system. The operative word is
'switching'; you don't keep your finger on the light switch for 20
3. Even though the needle is withdrawn it has created an area of
disturbance in the tissues and this, presumably, will continue to
modulate the nervous system for hours or even days.
4. Anyway, it works in practice!
*Gregory Bateson, Steps to an Ecology of Mind, 1972
Instead of looking at individual points and their alleged effects,
we could consider them in groups and hence as areas rather than
points. This has been done by Cheng1 in a very
interesting paper. His conclusions
are as follows.
(1) The acupuncture points in the trunk and their stated effects on the
internal organs in the trunk have a segmental relationship—that is,
acupuncture points within certain spinal segments in the trunk
affect the functioning of the organs that receive autonomic
innervation from the same spinal segments. This is consistent with
the concept of segmental acupuncture and the idea that acupuncture
may act via the somatic sympathetic reflex with a spinal pathway to
affect the trunk organs.
(2) The acupuncture points in the trunk and
extremities have a musculoskeletal effect that is local or regional,
but not distal. This is consistent with some of the models of
acupuncture mechanisms on musculoskeletal effects in the Western
medical acupuncture approach.
(3) The acupuncture points on the head
and neck preferentially affect the nearest organ. This presumably
reflects the belief in TCM that acupuncture can somehow regulate the
functioning of the proximal organ. No clear relationship can be
identified between the myotome level of the acupuncture points in
the extremities and their non-musculoskeletal clinical indications.
This research seems to offer a partial reconciliation between TCM
acupuncture and the modern approach.
1. Cheng KJ. Neuroanatomical characteristics of acupuncture points:
relationship between their anatomical locations and traditional
clinical indications Acupuncture in Medicine Dec 2011, 29 (4)
289-294; DOI: 10.1136/acupmed.2011.010056
2. Cummings M. Western medical acupuncture—the approach to
treatment. In: Filshie J, White A, Cummings C. Western medical
acupuncture: a western scientific approach (second edition).
Elsevier, London 2018:100–124.o
3. Campbell A. Acupuncture without points. In: Filshie J, White A,
Cummings C (editors): Western medical acupuncture: a western
scienrific approach (second edition). Elsevier, London
4. Mann F. Reinventing acupuncture: a new concept of ancient
medicine. Oxford: Butterworth Heinemann; 1992.