Periosteal techniques 1963-2018

In July 2018 I gave a workshop on Western medical acupuncture theory and techniques to a group of Chinese Medicine doctors in Lanzhou New District. The workshop lasted a little over 4 days, and the participants did not seem to be familiar with periosteal needling.

I was aware that in other parts of China the use of mini-scalpel acupuncture or acupotomy was used, although I don’t think it is very widely used in practice. The needles are more like tiny chisels than scalpels in appearance, and they are sometimes targeted at soft tissue attachments to bone, but this is not at all like the periosteal needling with filiform acupuncture needles described by Felix Mann.[1–3]

As Western practitioners we often assume that in China acupuncture universally involves very strong needling techniques, but my translator, a doctor trained in integrative medicine (effectively a variety of Chinese medicine), gave me a different impression. She was relatively sensitive to needling herself, so I chose her to demonstrate the technique on me under my guidance. She had never needled onto periosteum before, as you can see from the video…


Felix Mann writes in 2000 that periosteal acupuncture was one of the most important inventions of his medical career.[2] He first started using the technique around 1963, and chose to call it periosteal acupuncture rather than bone acupuncture or osteopuncture because periosteum has a rich innervation and bone does not. So the name reflects the idea that acupuncture is primarily a form of nerve stimulation.

Periosteal acupuncture was one of the most important inventions of my medical career.

Felix Mann [2]

He suggests there is little point in leaving the needles in place, rotating them or stimulating them electrically. He preferred pecking like a woodpecker and immediate removal. Rotation appeared to do nothing on the periosteum in comparison to pecking, and electrical stimulation only appears to excite the more superficial tissues. The latter would be consistent with an insulating effect from embedding the tip of the needle within periosteum. With this in mind I was amused to read the slightly misleading title of a recent trial, which included the phrase ‘periosteal electrical dry needling’.[4] Clinical experience suggests that it is not possible to stimulate periosteum electrically via an acupuncture needle based on the entirely different sensations produced both in terms of the nature and perceived depth of the stimulus by pecking versus electrical stimulation of a needle on periosteum. But this has not stopped trials being performed by a group in the US that claim to do it.[5,6]

They describe:

Periosteal stimulation therapy (PST) is a technique that delivers high-frequency electrical stimulation to periosteum using acupuncture needles.

They continue to explain:

It has been hypothesized that PST exerts its effect primarily by stimulating sympathetic fibers in proximity to the periosteum…

Sympathetic nerve fibres are way too narrow and slowly conducting to sustain a frequency of 100Hz, and as far as I am aware, they exist in cancellous bone rather than periosteum. It’s Interesting that the references supporting the theory of PST are mostly to Felix Mann’s publications, and he did not advise using electrical stimulation.

Sympathetic nerve fibres are way too narrow and slowly conducting to sustain a frequency of 100 Hz

The research on manual periosteal needling is limited, but it seems to support the idea that effects are similar to those of standard manual acupuncture.[7,8]

References

1. Mann F. Reinventing Acupuncture: A New Concept of Ancient Medicine. 1st ed. Oxford: Butterworth Heinemann 1992.

2. Mann F. Reinventing Acupuncture: A New Concept of Ancient Medicine. 2nd ed. Oxford: Butterworth Heinemann 2000.

3. Campbell A. Acupuncture without points. In: Filshie J, White A, Cummings M, eds. Medical Acupuncture – A Western Scientific Approach. London: Elsevier 2016. 125–32.

4. Dunning J, Butts R, Young I, et al.Periosteal Electrical Dry Needling as an Adjunct to Exercise and Manual Therapy for Knee Osteoarthritis: A Multi-Center Randomized Clinical Trial. Clin J Pain Published Online First: 28 May 2018. doi:10.1097/AJP.0000000000000634

5. Weiner DK, Moore CG, Morone NE, et al. Efficacy of periosteal stimulation for chronic pain associated with advanced knee osteoarthritis: a randomized, controlled clinical trial. Clin Ther 2013;35:1703–20.e5. doi:10.1016/j.clinthera.2013.09.025

6. Weiner DK, Rudy TE, Morone N, et al.Efficacy of Periosteal Stimulation Therapy for the Treatment of Osteoarthritis-Associated Chronic Knee Pain: An Initial Controlled Clinical Trial. J Am Geriatr Soc 2007;55:1541–7. doi:10.1111/j.1532-5415.2007.01314.x

7. Hansson Y, Carlsson C, Olsson E. Intramuscular and periosteal acupuncture for anxiety and sleep quality in patients with chronic musculoskeletal pain–an evaluator blind, controlled study. Acupunct Med 2007;25:148–57.

8. Hansson Y, Carlsson C, Olsson E. Intramuscular and periosteal acupuncture in patients suffering from chronic musculoskeletal pain – a controlled trial. Acupunct Med 2008;26:214–23.


Declaration of interests MC