While balancing yin and yang is one basic principle of Chinese medicine, balancing methods for combination of meridians and acupoints had been described throughout the history of Chinese medicine. We have identified six historical systems for combinations of acupuncture points in historical writings. All of them represent symmetrical combinations which are defined by the steps in the Chinese Clock. Taking the historical systems as a basis, we calculated the possible combinations that fit into these systems they revealed, leading to a total of 19 systems offering new balancing combinations. Merging the data of these 19 systems, there are 7 combinatorial options for every meridian. On the basis of this data, we calculated 4-meridian combinations with an ideal balance pattern, which is given when all meridians balance each other. We identified 5 of these patterns for every meridian, so we end up with 60 patterns for all the 12 meridians but we find multiple overlapping. Finally, 15 distinct patterns remain. By combining this theoretical concept with the
In Chinese Medicine, disease is understood as a loss of balance between the yin and yang energies [
The most common system is the
Graphical plotting of the historical systems. (a) Interior/exterior; (b) neighbouring channels; (c) 6-stage I; (d) 6-stage II; (e) 6-stage III; (f) opposite clock and one new system; (g) 6-stage IV. Blue: yin meridians, red: yang meridians.
Cross needling originates from Chapter 63 of the Suwen and is called opposite clock needling in modern school [
All historically described systems have in common the fact that they build a symmetrical combination in the CC with a rotation symmetry of 30°, 60° or 120°. Every meridian pairs with only one other and no meridian is left over, so there are always 6 pairs of meridians. A maximum of two alternating steps are used, leading to yin-yang/yang-yin or to yin-yin/yang-yang combinations. They can be described as intrinsic rules of the historical systems, summarized in Table
Intrinsic rules of the historical systems.
Every meridian pairs with only other one |
Rotation symmetry of 30°, 60°, or 120° |
6 pairs of meridian |
Maximum of 2 alternating steps |
6 yin/yang or 3 yin/yin and 3 yang/yang combinations |
Our question was to find out whether there are more systems than historically described and whether any meridians can be excluded as potentially balancing meridians, so we calculated all symmetrical combinatorial possibilities. We did a graph traversal search for further systems, described in detail in our recent paper, available online [
Combinations that follow the intrinsic rules of the historical systems, listed according to steps in the Chinese Clock.
1-step systems | = 2 |
1-step–3-step alternating systems | = 4 |
2-step systems | = 4 |
2-step–6-step alternating systems | = 4 |
3-step systems | = 2 |
5-step systems | = 2 |
6-step systems | = 1 |
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Total number | 19 |
One 2-step–6-step alternating system we want to emphasize, since it combines stages Tai Yang and Jue Yin, Yang Ming and Shao Yin, as well as Shao Yang and Tai Yin. So we named it
There are three more 1-step–3-step alternating systems that lead to additional point combinations not covered by those historically described.
Step 5 provides an additional combinatorial possibility, but has no extensive tradition in Chinese medicine except for concepts connected to the extraordinary vessels. All pairs of Yin extraordinary vessels can be opened by using a 5-step combination which includes the very commonly used technique to combine the master points of the paired extraordinary vessels [
With step 5 distant parts of the body are connected. A combination of step 5 with another step in the Chinese Clock is mathematically not possible, if the intrinsic rules of the historical system are to be observed. As described above this is, however, possible for the 1–3-step and for 2–6-step combinations of two steps for an balance in accord with the intrinsic rules (Table
The possibilities for finding a balanced treatment strategy can be described by the steps that have to be taken in the Chinese clock to combine acupuncture points. Merging the data of all systems, the steps in the Chinese clock showing a possibility for balancing are the following. Steps 1, 2, and 3 are possible so is step 6. Step 4 is not a combinatorial possibility. Step 5 is a combinatorial possibility, but has no tradition in TCM, except in the theory of the extraordinary vessels [
Possible steps in the Chinese clock for balancing a meridian.
1, 2 and 3 are possible | |
4 is not possible | |
5 is possible, but has no tradition in TCM, except in the theory of the extraordinary vessels and might be unbalanced in a multiple point concept | |
6 is possible |
In Table
Systems for combinations of meridians for multimeridian combinations.
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Yellow: historical systems, blue: new systems with additional combinations, and white: new systems without new combinations.
Merging of the combinatorial possibilities (this can be done with every meridian in a similar way).
For a TCM practitioner these 7 options might be mainly understood as energetic relationships. We describe this for the example of the LU-Meridian, plotted on the CC in Figure
Merging of the combinatorial possibilities leads to 7 options for a balanced treatment for every meridian. It might lead to the idea that “everything goes” in acupuncture. This is actually not true. If only two meridians are combined there are these 7 options. Nevertheless, it is very common to combine more than 2 meridians in an acupuncture treatment. For this reason keeping a treatment balanced in accordance with the intrinsic rules of the historical systems becomes complicated. So some acupuncture schools start to describe patterns, usually combining two historical systems treating all four extremities [
So a complete balanced treatment of a meridian combines a left-right yin-yang balance and an up-down yin-yang balance (Figure
Balanced treatment in projection to the body.
Somatotopy is the mapping of touch, vibration, and heat signals coming from different parts of the body to distinct and specific locations in the brain’s primary somatosensory cortex (SI). This somatotopic organization is sometimes described as the homunculus of the brain [
. Somatotopic image and mirror of different body areas.
As a basis for further analysis we took the above described 2-meridian combinations, that follow the intrinsic rules of the historical systems. While the merging of the combinatorial possibilities leads to 7 options for every meridian for a balanced treatment, we were interested in combining more than 2 meridians in a balanced acupuncture procedure. We decided to calculate the mathematical options for combining 4 meridians to gain an ideal balance, because the human body has four extremities. We defined as an ideal balance a combination of meridians, in which every meridian is balanced by all other meridians employed, in accord with the above-described intrinsic rules of the historical systems.
First we calculated all the possible 4-meridian combinations of the 12 meridians in the CC. Second we reduced the number to the above described 7 options. We listed all possibilities. Third we identified and described the patterns that followed our definition of an ideal balance.
Finally we combined the resulting information with the knowledge of the above described
The 12 meridians in the circle were labelled 1, 2, 3, …, 12. There are 6 possible steps in the Chinese clock: 1, 2, 3, 4, 5, and 6. (e.g., step 1 is a connection of two neighbouring meridians, step 2 skips one, combining the first meridian with the third one, etc.). To connect 4 meridian, all solutions can be classified into 3 groups. Every meridian point pairs with other 3 and no meridian is left over.
Then the step of each group was calculated. There are 6 possible steps in the Chinese Clock: 1, 2, 3, 4, 5, 6, as is shown in Figure
An ideal balance pattern for meridian-balancing is given, when all meridians balance each other. So an ideally balanced 4-meridian-pattern is only present, if every meridian is a possible combination (according to one of the 7 options) of every other meridian of this 4-meridian pattern. So we manually evaluated the 4-point combinations according to Table
We listed all possibilities by plotting the combinations on the CC. While there are 12 meridians, there are
First step of the development of 4-meridian patterns. Reduction of 12 × 7 (= 84) of 2-meridian combinations to 42 by deletion of repetitions
Second step of the development of 4-meridian patterns. Potential third balancing meridians of the 2-meridian combinations. Possible 3-meridian combinations and reduction of the 3-meridian combinations by deletion of repetitions
The third step of the development of 4-meridian patterns. Potential 4th balancing meridian of all three-meridian and possible 4-meridian combinations
Fourth step of the development of 4-meridian patterns. Arrangement by meridian patterns and reduction to 15 by deletion of repetitions
These 42 pairs of meridians were evaluated for their common potential balancing meridians. We found 24 times 4 shared balancing meridians for the pairs of meridians, 12 times 3 shared balancing meridians and 6 times 2 shared balancing meridians, leading to 144 options for 3-meridian combinations. We deleted the repetitions and found 48 unique options for 3-meridian combinations.
This second step of the development of 4-meridian patterns is shown in Figure
The 48 3-meridian combinations were evaluated for their common potential balancing meridians. We found 12 times 2 shared balancing meridians of all 3 meridians and 48 times one shared balancing meridian of all 3 meridians, leading to 60 possible 4-meridian combinations. This third step of the development of 4-meridian patterns is shown in Figure
These 60 possible 4-meridian combinations were manually new arranged by the common patterns on the CC and their connection to the 12 meridians. This is shown in Figure
For every meridian five ideally balanced 4-meridian-patterns could be identified. They all had a similar pattern on the CC. This is shown in Table
Possible patterns for an ideal balanced 4-meridian combination.
−1, |
−2, −1, |
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There are always only five ideal balanced options by applying treatment to the three not effected extremities and optionally to the effected meridian itself. So ideal balanced patterns can be plotted similar to Figure
Possible patterns for balancing the LU-meridian.
Graphical plotting of the 5 pattern for balancing the lung meridian on the Chinese Clock.
So every meridian can be balanced by 5 different patterns, but we find multiple overlapping. If we delete all repetitions, 15 patterns remain. This is shown as the fourth step of the development of 4-meridian patterns in Figure
15 ideally balanced patterns.
A graphical plotting, shown in Figure
Graphical plotting on the Chinese Clock of 15 ideally balanced patterns.
Extremities include not only hand and arm or leg and foot, but as well parts of meridians on trunk, neck, or face of the meridian connected to and named by the extremity (hand or foot). The knowledge of finding the right balancing meridians is even more useful, if it is combined with the somatotopic knowledge of the
Research protocol for immediate pain relief in localised pain.
(1) Identify the affected meridian in the region of pain and ask the patient to characterize the pain on a visual analog scale (VAS) from 1 to 10. | |
(2) Decide which unaffected extremity you want to treat first. | |
(3) (a) |
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(4) After the decision on which extremity should be treated and whether yin or yang meridians have to be used, look up in Table |
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(5) (a) Palpate the balancing meridians in a corresponding body region by image or mirror (according to Figure |
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(6) Treat the most painful balancing meridian in the most painful corresponding area. Treat this Ashi area. Insert a needle into the most painful Ashi point. Apply further needles in acupuncture or Ashi points, usually 1-2 proximal the first needle and 1-2 distal the first point on the acupuncture meridian. The number of needles is dependent on the extension of the painful area on the affected meridian. | |
(7) Move the affected joint or palpate the original region for pain and ask the patient about a change of symptoms using VAS. In case of 100% pain reduction, don’t apply further needles. | |
(8) Palpate another non affected extremity on balancing meridians (according to Table |
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(9) See 6. | |
(10) See 7. | |
(11) Palpate the remaining non affected extremity on balancing meridians (according to Table |
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(12) See 6. | |
(13) See 7. | |
(14) If the pain relief is still not sufficient, treatment can also applied to the affected meridian itself. But local treatment of the affected area can often produce discomfort to the patient, so the best choices are points by imaging or mirroring of corresponding areas (according to Figure |
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(15) See 6. | |
(16) See 7. |
Even though possibilities of choice are listed in the protocol, different approaches lead to similar patterns and success rates. For the example of one pattern see the description in Figure
Development of an ideal balance pattern.
A 60-year-old carpenter worked overhead for a full day and developed severe shoulder pain. Pain was prominent on the dorsal head of his shoulder. Pain was increased by lateral lifting of the shoulder and by inward rotation of the arm. Pain could be exaggerated by pressure over the lateral scapula; muscles around this area were tight. The active range of movement of the right shoulder was reduced. The shoulder could only be laterally lifted to 50° due to severe pain.
The patient was asked to estimate the pain on a visual analog scale (VAS) from 1 to 10. He described his pain as 9/10 on VAS.
The area of maximum pain was at point SI-10 (Naoshu) and 2 cun above and below this point. It was decided to start on the legs first and start with a Yang meridian. According to Table
There was no region of pain on the ST-meridian. There were painful Ashi points on the BL-meridian, very mild above and below the knee but severe in the area of the ankle. The pain was much more prominent on the left side.
The maximum area of Ashi was at left Bl-60 (Kunlun). A sterile 0.2
Then we looked at the right leg for a yin meridian that balances the SI- and the BL-meridian. According to Table
The maximum area of Ashi was at left SP-5 (Shangqiu). A sterile 0.2
Then we looked for a yin meridian on the left arm that balances SI, BL and SP. According to Table
We palpated the HT-meridian of the left arm according to Image and Mirror, searching for Ashi points in the area of the shoulder, the wrist and above and below the elbow. The HT-meridian on the shoulder had some mild Ashi points, but the major region of Ashi was around HT-3 (Shaohai). A sterile 0.2
The patient was asked to move his arm. He was able to lift it laterally up to an angle of 180°. Painful areas were palpated again. The patient estimated his pain as 1/10 on VAS.
Finally, the affected meridian itself was palpated according to image and mirror for Ashi points in the area of the wrist and above and below the elbow.
The major region of Ashi was around SI-5 (Yanggu). A sterile 0.2
The patient was asked to move his arm. He was still able to lift it laterally up to an angle of 180°. Painful areas were palpated again. The patient estimated his pain as less than 1/10 on VAS.
The patient was given an appointment for the following day. At this time he reported a relapse in the previous night. He estimated his pain as 4/10 on VAS. A similar treatment was applied. After treatment he again estimated his pain as less than 1/10 on VAS. The next day he had his third appointment. His pain had not returned and was reported as less than 1/10 on VAS. He again got a similar treatment on all non-effected extremities. After this no pain was reported any more. His shoulder showed full active and passive movement in all directions. So no extra treatment on the effected meridian was applied.
The patient stayed pain-free and returned to work.
This paper is based on an analysis of the historically described balancing acupuncture systems found in historical writings and which have been recurrently described in modern textbooks. It uses a mathematical approach to calculate the theoretical options based on the historical systems as a first step. All these historical systems describe combinations of two meridians. They had been determined on the basis of empirical knowledge by generations of experts in Chinese Medicine. But while all the historical systems show a certain symmetry when plotted on the CC and while the order in the CC most likely put a distinct order due to anatomical reasons [
Balancing yin and yang is a basic concept in Chinese medical theory and a basis for acupuncture treatment [
All these approaches, determined by way of a mathematical search for combinatorial possibilities is based on theoretical considerations from historical writings and supported by empirical knowledge.
Our observations do not have to be considered as being the only concept in acupuncture. There are more possibilities like balancing yin and yang meridians on one extremity, applying bilateral treatment of the same meridian, there are microystems like scalp and ear acupuncture, as well as empirically determined point combinations, that do not follow the concept of balancing [
But the concept of of a balanced treatment has a long tradition in TCM and in the historical writings [
The authors’ experience of achievement of immediate effects in pain management by application of this protocol leads to the question of the mechanisms involved. Acupoints on very distant parts of the body, in some cases even with a completely different segmental innervation in the spinal column, can induce a therapeutic effect on local pain. This contradicts the theory that the main effect of acupuncture treatment is due to peripheral or segmental effects [
Interestingly, there are 5 ideally balanced acupuncture patterns for every meridian. Four of them represent a balance that is found in 2 or 3 of the above calculated systems for every meridian pair (Table
In one pattern every balance derives from only one system in Table
Some schools describe rules whereby it is necessary to combine points by one of the above described systems on the contralateral or ipsilateral side, but no explanations are given [
Due to multiple overlapping of the 5 patterns for each meridian there only exist a total of 15 distinct patterns for all meridians. Pattern diagnosis has a long tradition in TCM. Syndromes or patterns are described as Zheng diagnosis [
Modern research on Zheng diagnosis is devoted to the search for a correlation between Zheng patterns and system biology parameters [
Further investigation of the correlation of the described ideally balanced acupuncture patterns and the Zheng patterns might lead to an improvement of clinical treatment. The 5 patterns for every meridian described above and the reduction to 15 patterns for all meridians due to overlapping might explain the overlapping of Zheng patterns, resulting in similar patterns to different diseases as well as different patterns for similar diseases [
Even though pain has been the focus of most clinical research on acupuncture [
Acupuncture treatment based on TCM usually requires an individual diagnosis which leads to an individual treatment strategy [
Our protocol potentially solves this problem because it offers a rational, reproducible procedure independent of examiner experience, but the resulting treatment procedure is an individual. This has many advantages. The necessary acupuncture pattern is developed during examination. The pattern of treatment is not fixed before treatment, so probands of the treatment group are not at risk, to get an ineffective treatment for their condition. While the treatment is developed in a rational examination process, the probands will have a good chance to get a corresponding treatment to their body reaction. This will increase the efficacy of the treatment procedures. Anyhow limitation of this protocol are, that it is only based on theoretical consideration and personal experience of the authors. It has to be further approved in clinical trials.
In addition to the test of the efficacy of acupuncture in pain management, information on patterns can be gained in studies following our research protocol.
This might increase the knowledge as to which acupuncture patterns are most sufficient under which clinical conditions and lead to improved treatment strategies as well as to results that help increase the knowledge on the mechanisms of acupuncture.
With this systematic description of a mathematical model for the calculation of combinatorial possibilities of meridians as well as the calculation of ideally balanced patterns we describe a theoretical model applicable for acupuncture research and treatment. By sharing our protocol for immediate effects in localized pain treatment we offer researchers a protocol for controlled acupuncture trials with an individualized approach based on historical knowledge. Further research has to approve this theoretical approach and might have influence on understanding mechanism of pain relief in acupuncture. By this approach, theoretical and empirical knowledge is organized into a systematic approach.
This study was not supported by any grant.