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Quite a few people, especially those getting on a bit, tend to find themselves taking medication to reduce their blood pressure. But since these medications can sometimes have unwelcome side effects, (such as headaches, or a dry cough) any means of reducing blood pressure without recourse to the products of the pharmaceutical industry are to be welcomed (except, perhaps, by the pharmaceutical industry.) Can acupuncture be such a means?

Of course, since high blood pressure, aka hypertension, may often be caused by the seemingly all-pervading stresses and strains of modern living, and since acupuncture treatment is for most people a surprisingly relaxing experience, it can certainly help. But can acupuncture have a direct effect on blood pressure itself?

Most cases of high blood pressure are classified as essential hypertension, which means that there is no obvious reason as to why the blood pressure is high. It just is. (I suppose ‘essential hypertension’ sounds more impressive than ‘unexplained hypertension’, and the suggestion that no one actually knows why your blood pressure is high might send it even higher! No one likes uncertainty.) And the issue with hypertension, whether essential or otherwise, is that it is often asymptomatic. Raised blood pressure, the silent killer. You feel fine, and then suddenly you drop dead, or at least have a stroke or a heart attack.

This lack of symptoms is potentially problematical for traditional acupuncturists, at least if we want to treat the essential version, since we tend to rely on signs and symptoms to guide our traditionally framed diagnosis and consequent treatment. (Signs being things we can observe about the patient, such as their complexion or the way they walk; symptoms being what they tell us about their condtion.) Blood pressure is not part of that traditional framework. Traditional Chinese doctors noticed all sorts of things about their patients, from the colour of their tongue to the brightness, or otherwise, of their eyes, and they certainly paid a lot of attention to their pulse. But measuring blood pressure was not part of their world. Hypertension does not feature as a potential symptom of any traditional Chinese diagnostic category.

Of course there have been recent attempts to integrate blood pressure into the signs and symptoms traditional Chinese doctors and acupuncturists interpreted. How successful these attempts have been so far is perhaps a moot point, which may leave us with a bit of a quandary. How do we treat someone for their high blood pressure if there are no symptoms to go on (other than their high blood pressure.) How do we treat someone who is apparently in perfect health, blood pressure readings aside?

Fortunately, though, perfectly healthy people do not exist. At least, I have not met one yet Ask the right questions, in the right kind of way, and you soon find out that the perfectly healthy person does, actually, occasionally have a headache. Not very often, perhaps, really quite mild.  Or, they do occasionally have a little trouble getting off to sleep. Or, perhaps, their hands and feet do tend to get cold quite easily. And then there is the pulse. Traditional acupuncturists like a bit of pulse taking, and sometimes the pulse can give a few little hints. Maybe it feels just a little too tight or tense. Maybe it feels a little on the thin side. Maybe, even, it is a bit ‘slippery’. (You can’t, though, tell anything about someone’s blood pressure from taking their pulse, as far as I know anyway.)

So, look hard enough at the perfectly healthy person and you will find some small, subtle, imbalance, some area of potential weakness, some hint that their Yin and Yang is not quite in perfect equilibrium, some suggestion that their Qi is not as abundant and free flowing throughout every organ system as it should be. (From this perspective, hypertension is not so much as silent killer as one who is really quite quiet.)

So we can make a diagnosis based on these little imperfections and hints, and treat accordingly.

For example:  it may be that their occasional headache, cold extremities, and tense pulse lead us to believe that they are suffering from a little bit of Liver Qi Stagnation. So, we treat their Liver Qi Stagnation with acupuncture. And maybe their blood pressure comes down. If it doesn’t, maybe we have to look again, maybe even more carefully, listen even more attentively to the pulse. Maybe there is something underlying the Liver Qi Stagnation, Kidney Yin deficiency perhaps. Surely, somewhere inside, something is going on which results in the blood pressure being raised. As Einstein put it, God doesn’t play dice with the universe - meaning things don’t just happen at random. You don’t get abnormally high blood pressure just through bad luck. (Although there is an issue here about just what constitutes “abnormally high”. Is it the same for everybody? If my blood pressure has been on the low side all my life, and now it is ‘normal’, is that, for me, high?)

There is certainly evidence to support acupuncture as a treatment for hypertension. For instance, a recent Chinese trial using just a couple of acupuncture points on the foot and ankle, and utilising MRI scans of the brain during treatment found positive and long lasting effects on reducing blood pressure in patients with hypertension, along with activation of the parts of the brain involved in blood pressure regulation.1

​This tends to support the idea that acupuncture is a moderating kind of treatment modality. If something (blood pressure, stress levels, muscle tension etc.), acupuncture helps reduce it; if something (blood pressure, energy levels, mood etc.) is too low, it helps raise it In western medical parlance, it promotes homeostasis.
So to go back to the original question as to whether acupuncture can treat hypertension, I think we can answer that it can, but not necessarily directly. That is to say, it can treat the underlying disharmonies in a patient’s body-mind which are behind the raised blood pressure, whether these disharmonies are Liver Qi Stagnation, Kidney Yin deficiency, or something else. It can promote homeostasis. It can help restore a patient to how nature intended them, so to speak.
 
 
1.  Acupuncture at LR3 and KI3 shows a control effect on essential hypertension and targeted action on cerebral regions related to blood pressure regulation: a resting state functional magnetic resonance imaging study  Zhang et al 2020  Acupuncture in Medicine  39,1
 
 

 
Sometimes people assume that acupuncture treatment will involves putting needles where the problem is – in the knee if the problem is a painful knee, in the head to treat dizziness, and so on. But this isn’t always how it works.

The traditional Chinese understanding of acupuncture involves a fairly sophisticated system of about 360 acupuncture points distributed all over the body, from the top of the head to the sole of the foot. Many of these points have a number of functions, not all of which are obviously related to the actual location of the acupuncture point. But we can also invoke a western scientific understanding of the various effects the insertion of an acupuncture needle has to help us understand why needles go where they do - and not always in the location of the problem.

i) GENERAL EFFECTS

Our skin and muscles contain many different kinds of nerve endings or receptors, which respond to different kinds of stimulation. For instance, there are receptors which detect heat and ones that detect pressure – so that we can become aware for example of hot objects on or near our skin, or of something pressing against our skin. One of the most important kinds of nerve which seems to be involved in acupuncture treatment are called Aδ nerves (or type II/III nerves in muscles), which amongst other things convey a feeling of heaviness which will perhaps be familiar to acupuncture patients.

Once an Aδ nerve has been stimulated by an acupuncture needle entering the skin in its vicinity, information travels along the nerve to the spinal cord, and from there up towards the brain, where it can initiate a number of different subtle changes in the almost infinitely complex activity within the various parts of the brain. One of these changes involves triggering a number of ‘descending inhibitory pathways’. These refer to different pain relieving substances which are released from the brain and descend down the spinal cord (and in some cases also pass into the blood stream) to inhibit or block pain signals from any part of the body. One such substance is called β-endorphin, somewhat similar to morphine, which is released from the pituitary gland within the brain into the blood stream, and from the hypothalamus, another part of the brain, into and down the spinal cord.  In other words, the needles cause the brain to trigger some of the body’s own built in pain relieving systems.

Hence acupuncture in the hands and feet, where it is usually easy to stimulate the Aδ nerves, can result in a generalised pain relief, not just in the hands and feet, but throughout the body.

Another part of the brain which is reached by the signals travelling along the Aδ nerves is the limbic system, which seems to be crucially involved in emotion. These signals tend to deactivate the limbic system and, as far as pain is concerned, this may reduce the emotional component of that pain, so that we are less bothered by it.

These kinds of effects are not thought to be particularly dependent on where the needles are placed as long as there is a reasonably strong stimulation of the Aδ nerves. (Traditional acupuncturists would demur a bit here: whilst many traditional acupuncture points are considered to trigger numerous general effects throughout the body-mind, these points are considered to be in need of precise location.)

ii) SEGMENTAL EFFECTS

But some effects of acupuncture, whilst not confined to the exact vicinity of the needle, are nevertheless particular to one section of the body. Or rather, to one segment. A segment in this context refers to that part of the body served by nerves which enter and leave the spinal cord at one particular level.

So, for instance, nerves entering and leaving the spinal cord at the level of the fifth lumbar vertebra (L5) in the lower back serve amongst other things, some of the main buttock muscles, as well as the tibialis anterior muscle just outside the shin bone and the muscle which is used to lift up the big toe; and also a band of skin running across the buttock and down the side of the leg and including the top of the foot.

Acupuncture needles inserted into points within this segment may of course trigger the kind of systemic or general effects mentioned above, but they can also have effects particular to the segment in which they lie. One of these is segmental analgesia, whereby pain which has its origin in any part of the segment is relieved by needles placed somewhere within that segment. So if we wanted to treat pain associated with the tibialis anterior muscle we could choose to place needles somewhere in the area innervated by the L5 segment  - for example on the top of the foot, or in the lower back adjacent to the L5 vertebra, knowing that the pain relief we are generating will include the tibialis anterior.

One explanation for this segmental pain relief is called gate control theory. In simple terms, once the signal from an Aδ nerve stimulated by an acupuncture needle somewhere –anywhere – in the segment reaches the spinal cord at the L5 level, say, it blocks (or closes the gate to) any pain signals arriving at that level from pain transmitting nerves in the segment, so that these pain signals cannot travel up the spinal cord to the brain, and so we do not feel pain.. So, to reiterate, we can treat pain arising from a specific part of the body by identifying which segment that part lies in, and inserting acupuncture needles at a place within that segment. 

Of course we might choose to use acupuncture points at or near the site of the pain, which will obviously lie in the correct segment, but sometimes that may not be possible or appropriate. In the case of a recent injury, for instance, where the tissue around the injury is painful and inflamed, we may think that it is best to avoid acupuncture in and around that painful area, but we can still have a pain killing effect by needling other points in the segment which are at a distance from the painful place.

iii)  REFERRED PAIN AND TRIGGER POINTS

Referred pain is pain which is felt at some distance from the part of the body which is damaged or problematic. One type of referred pain which acupuncture is a useful treatment for is pain which is caused by trigger points, which are small knots within muscles that have become tense. The pain caused by a trigger point, either when it is pressed or when the muscle itself is stretched, is usually felt some way away from the trigger point. For instance, a trigger in the trapezius muscle in the shoulder, just to the side of the neck, commonly causes pain which radiates around the side of the head to the temple.

Trigger points can and do appear in many of the muscles in the body; fortunately the location of the pain a particular trigger point causes is fairly predictable, so that if we have reason to believe that a pain may have, at least in part, a muscular origin, we can quickly identify which muscle may be causing the pain and examine that muscle for trigger points, which are easily located by someone trained to use their hands properly. Pressing on the trigger point for a few seconds will often lead the patient to say that that is just the pain they are complaining of.

So in this case we need to treat the trigger point, not the place where the pain is; in the example above, we need to release the muscle in the shoulder, either with acupuncture of massage, so as to make the pain in the side of the head go away. Incidentally, migraine sufferers often identify the temple as the place where the throbbing, pounding pain of a migraine is felt; such people are often found to have an active trigger in the trapezius which, if not entirely responsible for the migraine, is at least part of the problem.

iv) LOCAL TREATMENT

Despite all the above, however, it is still often useful to use acupuncture points in the place where the problem is. One of the localised effects of acupuncture, for instance, is an increase in blood flow around the site of the needle. (This increased perfusion of blood is triggered once again by the Aδ nerves which cause local blood vessels to dilate.) This is often observable as a reddening of the skin around the needle, and can be useful for a number of reasons, such as the fact that it supports the body’s own healing systems, which use the blood to bring the necessary nutrients to the site. Another local effect involves the build-up of endorphins in the vicinity of the needle, peaking at around 24 hours after the treatment, which is perhaps why some of the beneficial effects of acupuncture are often felt a day or two after treatment.

Sometimes people enquiring about acupuncture ask whether you have to believe in it for it to work. What often lies behind this question is the belief that alternative medicine does not have any tangible, physical benefits and any success it may have must be due to the patient believing, or wanting to believe, that they are feeling better;  alternative medicine is ‘airy fairy’. If you don’t have faith, perhaps even if you are not gullible enough, nothing will happen. This belief, like most of our beliefs perhaps, is not usually the result of clear thinking and sifting of the evidence; whilst it is true that some people have a more or less blind faith in alternative medicine, or in some branch of it, more common is this, a more or less blind faith that if something is classed as alternative medicine, it must be some kind of airy fairy mumbo-jumbo.

To begin with, the idea that you can lump together all manner of treatments and therapies under the banner of ‘alternative medicine’ and say something meaningful of them as a group, is highly questionable. What they have in common is that they are not generally considered part of mainstream medicine (although that is not entirely true of acupuncture). Whether they have anything else in common is open to question. Knowing something about Alexander technique does not mean you know anything about crystal healing. Knowing something about homeopathy does not tell you anything about acupuncture. Can some kind of vague new-age treatment dreamt up yesterday by someone in need of a quick buck really be classed alongside something like traditional Chinese medicine, an integral part of Chinese culture and civilisation with a history going back 2,000 years or more and providing effective treatments right now in hundreds of hospitals across China? Yet they might both be considered, at least in the west, ‘alternative medicine’.

So the idea that you can bunch all these various treatments together and say they depend on the patient’s faith or gullibility is a non-starter. It may very well be true that some of them do depend heavily on the patient having faith, but I at any rate am not in a position to say. All I can talk about is acupuncture.

As far as acupuncture goes, there are obvious physical measurable results from correctly inserting an acupuncture needle into an appropriate place on the body. To mention only a few, blood flow in the vicinity of the needle increases, certain kinds of nerve endings get stimulated, occasionally a muscle will twitch. It is true that, in the hands of a capable clinician, acupuncture treatment can be, when it needs to be, quite subtle; but it can also be a very vigorous kind of intervention indeed.  In the latter case at least, there is nothing airy fairy about it; you don’t have to have faith that something is happening, because you can feel it happening. Of course that you can feel that something tangible is going on doesn’t in itself tell you anything about whether it is an effective treatment (although I think often patients can sense that an intervention is beneficial.) But at least we can be clear that it is, when it needs to be, working on a very physical level, and it is working on that level more or less independently of whether you believe it is going to work or not.

More or less. But in truth it does seem to be that patient expectations play an important part in many medical treatments – alternative, conventional or whatever. If you have a positive expectation that acupuncture will alleviate your symptoms, it is a bit more likely that they will. But it is also the case, for example, that if you have a positive expectation that having an operation(1) will alleviate your symptoms, it is more likely that it will. If you have a positive expectation that the drug diazepam(2) (used to treat anxiety, muscle spasms and seizures) will alleviate your symptoms, it is more likely that it will. And the same for anything from analgesic skin cream(3) to deep brain stimulation(2). (And indeed there is some evidence that if the person treating you has a positive expectation of the treatment, it is also more effective(4).)

This is the placebo effect. Conversely there is also the nocebo effect – if you have an expectation that any given treatment will be ineffective, or perhaps that it will involve some unwelcome side effects, these things become more likely to happen.
It is not that these things, placebo and nocebo, are ‘all in the mind’. If the problem you have is pain, the placebo effect encompasses a measurable increase in endogenous opioids, part of the body’s built in pain relief system(5). Something is happening in your body. Patients with the common cold who perceive their doctor is empathetic show reduced objective markers of inflammation in their blood stream as compared with ones who don’t get the impression their doctor is much bothered.(6) These patients aren’t just imaging they feel better; there are measurable improvement in their bodies.

There is though also the question of how we interpret our experience. A patient who insists that a form of treatment will be ineffective, but who is persuaded to try it anyway, is perhaps likely to undervalue any improvement in their symptoms, or perhaps to ascribe them to some other cause. It’s generally easier to say, if only to oneself, “I told you so” than it is to say “maybe I was mistaken”. Occasionally a patient will come into clinic for their second acupuncture appointment and say something like, “I have to admit my back feels a lot better”. As if in some ways they would rather it wasn’t better! No one likes to eat humble pie.

Another patient, say one who tends to favour alternative medicine, will have something invested in the treatment working, apart from the obvious desire to get better. They are likely to overvalue any improvement in their symptoms, although as we have already seen their positive expectation may make it a bit more likely they will be improving. But even if this improvement is slight, they will tend to make as much of it as they can.

A theme running through this question is that of the relation of mind and body. In the west we are inclined, for historical reasons usually laid at the door of the French philosopher Rene Descartes, to believe that mind and body are separate entities. But it is clear from the above that they are not. Someone with a positive expectation (in their mind, presumably) that their knee pain will improve with treatment may have a greater presence of those enogenous opiods in their body than someone who is more pessimistic. The mind and the body are deeply inter-related; what happens in the mind manifests in the body, what happens in the body triggers effects in the mind. Any slight change in what is going on in the body impacts on the mind; any passing mood or train of thought is associated with subtle changes in the body. And after all, what is mind? Does anyone really know?

So to sum up, the answer to the question is that you don’t have to believe in it for it to work, but on the other hand you are likely to get extra benefit from treatment if you have a positive expectation that it will work. And if you want to try to figure out how much of the benefit you have got from the treatment is ‘in your mind’, and how much of it is ‘in your body’….good luck!
 

1. Wartolowska K, Judge A, Hopewell S, et al Use of placebo controls in the evaluation of surgery: systematic review. BMJ 2014; 348:g3253
2. Colloca L, Lopiano L, Lamotte M, Benedetti F. Overt versus covert treatment for pain, anxiety and Parkinson’s disease. Lancet Neurol 2004:3: 679-84
3. Petersen GL, Finnerup NB , Grosen K, et al. Expectations and positive emotional feelings accompany reductions in ongoing and evolved neuropathic pain following placebo interventions. Pain 2014;155:2687-98
4. Gracely RH, Dubaer R, Deeter WR, Wolskee PJ Clinician’s expectations influence placebo analgesia. Lancet 1985;1:43
5. Amanzio M, Benedetti F Neuropharmacological dissection of placebo analgesia: expectation-activated opioid systems versus conditioning-activated specific sub-system. J Neurosci 1999;19:484-94
6. Rakel D, Barrett B, Zhong Z, et al  Perception of empathy in the therapeutic encounter: effects on the common cold Patient Educ Couns 2011;85:390-7

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Cupping is a form of treatment often used alongside acupuncture as part of Traditional Chinese Medicine, as well as being widespread across traditional cultures in Asia, the Middle East and North Africa. It involves first of all applying a massage oil or other suitable lubricant to the part of the body to be treated and then a special cup in which the pressure has been temporarily lowered, either by briefly introducing a flame inside the cup (the traditional method) or with modern cupping devices using a suction pump. It is a little like reverse massage - rather than someone applying pressure to your body, they are reducing the pressure. The immediate effect is that the tissue on which the cup is placed is drawn up into the cup.

If you've not seen it before, it can look a little alarming, but actually it just feels slightly tight and not at all painful - in fact it is sometimes a useful form of treatment for people who might benefit from acupuncture but whose severe needle phobia puts them off. Once the cups are removed, a circular mark will remain on the skin, perhaps for a few days in some cases, which may be inconvenient if you are a fashion model for instance.

One of the most immediate benefits of cupping is that it stretches the tissue under the cup, which makes it a useful treatment for problems involving overly tense muscles. A recent meta-analysis of research into cupping for neck pain, for example, showed significant reduction in pain and corresponding improvement in function (i.e. the ability to turn your head); unwelcome side effects were infrequent, mild and temporary.* Since a lot of neck pain is at least partly due to muscle tension in the neck and shoulders, that cupping should be helpful is not surprising.

Another effect of cupping is to increase blood flow through the area being cupped and its surroundings - often the area will flush red because of this. Again this helps with tight muscles and facilitates tissue healing, which makes it useful in the treatment of ligaments and tendons, which tend to heal slowly because of their limited blood supply. 

*  Is Cupping Therapy Effective in Patients with Neck Pain? A Systematic Review and Meta-Analysis MJ Open. 2018 Nov 5;8(11):e021070.