The history of holistic therapy
Holistic therapy means treating the root by harmonizing the five viscera and six bowels. At the beginning of the 20th century, a Japanese acupuncturist, Sawada, developed the first holistic therapy, which is called “Sawada-style holistic therapy”. This therapy consists of moxibustion on the eleven fundamental meridian points that regulate the whole body and that are essential for every patient and additional points for the individual patient’s status [
7].
The disorders susceptible to this therapy include nervous exhaustion and disorders for which occidental medicine is not sufficiently effective, such as daytime somnolence, tinnitus, and nocturnal perspiration. In China, acupuncture was virtually abolished in 1822 and remained disregarded until 1954. During this period, the Sawada-style was introduced to China and helped Chinese acupuncture continue its existence [
8]. The essence of Sawada-style was published by Sawada’s disciple, Shirota [
9,
10]. This book functions as a bible for Japanese acupuncturists and moxa-cauterizers [
11]. It is possible that this therapy involves the central nervous system. Unfortunately, no direct evidence for Sawada-style holistic therapy has been published.
Apart from Sawada-style holistic therapy, Kurono developed his own holistic therapy. He selected the fundamental meridian points according to the statistics on the previous frequency of his own usage, which are partially the same with those of the Sawada-style [
12].
The effects of fundamental meridian points for holistic therapies according to modern medicine
According to traditional Chinese theory, the 20 fundamental points for the Sawada-style or Kurono-style mentioned above have various physiological actions that are regarded according to modern medicine as actions on the central nervous, immune, endocrine, and metabolic systems, as shown in Table
2[
13]. Shirota considered the principle of his holistic therapy, which was seven times of moxibustion per meridian point over the long term as a supplementary stimulation [
9]. Kurono et al. employed acupuncture with relatively slight pressure, 20 g, which appeared to hardly raise habituation in a pilot study, while acupuncture with pressure of 60 g tended to raise habituation. Therefore, it would be useful to refer to reports on the physiological effects of supplementary acupuncture or moxibustion in understanding the mechanism of the action of holistic therapies. In the reports cited below, supplementary stimulations are mainly used such as electroacupuncture of 2 Hz [
14,
15], or 2–10 Hz [
16].
Table 2
The effects of fundamental meridian points for the Sawada-style and Kurono-style holistic therapies on the central nervous, immune, endocrine, and metabolic systems
Sawada-style fundamental meridian points | | | | | ○ | ○ | ○ | | ○ | ○ | ○ | | | ○ | ○ | ○ | | | ○ | ○ |
Kurono-style fundamental meridian points | ○ | ○ | ○ | ○ | | ○ | ○ | ○ | | ○ | ○ | ○ | ○ | | | | ○ | ○ | | |
Effects on the autonomic nervous system | Vagal nerve activity | | | | | | | | | | ↑ | | | | | | | | | ↑ | |
Sympathetic nerve activity | | | ↓ | | | | | | | | | | ↑ | | | ↑ | | | | |
Heart rate | | | | | | | | | ↑* | | | | | | | | | | | |
Effects on the immune, endocrine and metabolic system | Anti-inflammatory effect | | + | + | | + | + ** | + | | | + | | + | | | + | ++ *** | | | + | + |
Reinforcing immunological resistance | | | + | | | + | + | | | | + | | | | | | + | | + | |
Promoting oxygen intake and alimentation,and regulating body temperature | | | | | | | + | + | | + | + | | | | | | + | | | ++ |
Effects on the central nervous system | Anxiolytic effect | + | | | | + | | | | | ++ | + | + | | ++ | ++ | + | | | + | |
Antidepressive effect | | | | | ++ | | | | | + | | + | + | | | | + | | + | |
Analgesia | + | + | | + | | | | + | | | | + | + | | | + | | + | + | + |
The effects of fundamental meridian points for holistic therapies on the autonomic nervous system
It was recently reported that some of these meridian points have effects on the autonomic nervous system. For example, CV12 [
17] and ST36 [
18] increase parasympathetic nerve activity. In addition, some of the meridian points have opposite effects, which are contrary to other points. LI11 [
14] and GB21 [
19] increase sympathetic nerve activity, while BL13 decreases it [
20]. Since the point combinations in the holistic therapies include meridian points with bi-directional regulation of the autonomic balance, they can be applied to various pathological conditions in a balanced manner. Therefore, the holistic therapies can also be applied to chronic anxiety disorders [
21] or severe depression [
22,
23], in which both sympathetic and parasympathetic nerve activities are reduced. BL32 reduces heart rate without an effect on heart rate variability [
17], which might be effective for patients with palpitations without heart rate variability abnormalities.
The effects of fundamental meridian points for holistic therapies on the immune, endocrine, and metabolic systems
BL18, BL20, CV12, KI6, LI11, ST36, and TE4 have an anti-inflammatory effect on the immune system, while BL20, BL23, CV6, ST36, BL13, and LR14 reinforce the immune system according to traditional Chinese theory [
13]. Stimulation of BL23, the dorsal transport point of the kidney meridian, promoted the secretion of adrenal steroid hormones [
24,
25]; this is quite reasonable, since the organ called the kidney in traditional Chinese theory includes the adrenal gland. If the hypothalamo-pituitary adrenal axis (HPA axis) is activated by acupuncture, cortisol is released, and this relieves the inflammation of arthritis or bronchial asthma. In fact, this meridian point has an anti-inflammatory effect on the five viscera according to traditional Chinese theory [
9,
14]. On the other hand, Toriizuka et al. reported that subcutaneous needles at BL23 increased norepinephrine and dopamine in the brain and prevented the decrease in the immune responses accompanying aging or menopause [
26]. ST32 in addition to Extra37 also improved immune suppression after surgical stress [
27].
Sawada laid weight on the triple energizer meridian, which was considered to promote oxygen intake and alimentation to regulate anabolism, catabolism, and body temperature [
7,
9,
10,
28]. Unfortunately, direct evidence that supports this theory was not found. The only evidence is a report that acupuncture including TE5 decreased vasomotor symptoms in cancer patients, probably due to raising the serotonin level to alter the body temperature set point [
29].
The effects of fundamental meridian points for holistic therapies on mental status
BL10, BL18, CV6, CV12, GB20, GV12, KI6, LI11 and ST36 have an anxiolytic effect according to traditional Chinese theory [
13]. There is evidence for some of these. For example, acupuncture for ST36 decreased anxiety-related behavior, the serum corticosterone level, and tyrosine hydroxylase-immunoreactive expression of rats under immobilization stress [
15].
BL18, CV12, ST36, GB20, GB21 LR14, and ST36 have an antidepressive effect according to traditional Chinese theory. Among these meridian points, electroacupuncture at ST36 and GB20 reduced the Beck Depression Inventory scales in subjects with psychosomatic or psychiatric disorders such as fibromyalgia, irritable bowel syndrome, chronic fatigue syndrome, primary insomnia, and obsessive-compulsive disorder, probably by enhancing the intracephalic release of serotonin [
16].
The effects of fundamental meridian points for holistic therapies on nociception
The fundamental points for holistic therapies include such meridian points as BL10, BL11, BL14, BL25, GB20, GB21, LI11, ST25, ST36 and TE4, which are also used for acupuncture analgesia, shown as “analgesia” in Table
2[
30]. It has been reported that midbrain monoamines, especially serotonin and norepinephrine, are involved in acupuncture analgesia, not for surgical procedures but for the treatment of chronic pain [
31]. There have been many reports indicating that these monoamine neurotransmitters released from the descending inhibition systems are involved in the effects of these meridian points. Increases in the synthesis and utilization of serotonin during acupuncture are supported by a double-blind study that showed that acupuncture analgesia was facilitated in patients who had been given a serotonin reuptake inhibitor [
32]. This indicates that acupuncture has a synergistic action with serotonin reuptake inhibitors, which are commonly administered for psychosomatic or psychiatric disorders such as pain disorders and functional gastrointestinal disorders with a decreased visceral pain threshold or depression. In fact, Zhang et al. reported that a combination of weekly electroacupuncture for six weeks and paroxetine provided more effective treatment for depression than paroxetine alone [
33]. The stimulation method is different between Sawada-style and acupuncture analgesia. Moreover, it is unclear whether Sawada selected the fundamental points in consideration of these detailed physiological effects. However, it is possible that the brain monoamine system is facilitated by holistic therapies, since Shirota reported that the Sawada-style was effective in treating many cases with depression or obsessive-compulsive disorder [
10], for which monoamine reuptake inhibitors are given.
The effects of fundamental meridian points for holistic therapies on the mind-body correlation
Apart from the central nervous system, acupuncture at ST25 and ST37 relieved chronic visceral hypersensitivity in rats with irritable bowel syndrome [
34]. In this study, changes in serotonin metabolism in the colon tissue were observed. ST25 also prevented chronic stress-induced increases in the sympathetic peptide, neuropeptide Y [
35].
The effects of fundamental meridian points for holistic therapies according to Qi, blood, and water theory
In Japan, an original scoring system was developed by Terasawa et al., which makes quantification of patterns possible (Table
3) [
36,
37]. This is quite helpful in clinical diagnosis and research, which is not the case in other countries. In this system, the scores for Qi deficiency, Qi stagnation, Qi counterflow, blood deficiency, blood stagnation, and water retention can be calculated. It is characteristic of Japanese oriental medicine to place weight on water retention instead of phlegm. Phlegm is generated when stagnant water loses its ability to flow and is more serous than water retention. This difference in the main pattern may be attributed to the differences in the climate between the dry continental climate of China and the wet monsoon climate of Japan [
38].
Table 3
Terasawa’s Qi, blood, and water scoring system
General fatigue | 10 | Depressive mood | 18 | Cold constitution and hot flush | 14 | Retardation of thought | 6 | Heaviness of body | 3 |
Hypobulia | 10 | Heavy-headed feeling | 8 | Palpitation attack | 8 | Early-morning awakening | 6 | Systaltic headache | 4 |
Easy fatigability | 10 | Unpleasant sensation of laryngopharynx | 12 | Sporadic headache | 8 | Asthenopia | 12 | Heavy-headed feeling | 3 |
Hypersomnia | 6 | Chest oppression | 8 | Vomit | 8 | Dizziness | 8 | Carsickness | 5 |
Anorexia | 4 | Hypochondrial oppression | 8 | Cough | 10 | Cramp | 10 | Dizziness | 5 |
Vulnerability to cold | 8 | Abdominal fullness | 8 | Abrupt abdominal pain | 6 | Slight menorrhea | 6 | Dizzy feeling on standing up | 5 |
Scariness | 4 | Counterchanging of symptoms | 8 | Scariness | 6 | Pale complexion | 10 | Watery rhinorrhea | 3 |
Objective hollow voice | 6 | Difficulty in uprising | 8 | Impatience | 8 | Alopecia | 8 | Ptyalism | 3 |
Pale tongue | 8 | Abdominal wind | 6 | Flush | 10 | Xeroderma | 14 | Foamy sputum | 4 |
Vacuous pulse | 8 | Burping | 4 | Palpations above the umbilicus | 14 | Ungual incisure | 8 | Nausea | 3 |
Flaccid abdomen | 8 | Sense of residual urine | 4 | Crural chills | 4 | Paresthesia | 6 | Rugitus | 3 |
Uterine prolapse | 10 | Tympanicity | 8 | Palmar and plantar diaphoresis | 4 | Rectus abdominis spasm | 6 | Arthral tightening | 7 |
Lower abdominal numbness | 6 | | | | | | | Edema | 15 |
Diarrhea | 4 | | | | | | | Effusion | 15 |
| | | | | | | | Palpations above the umbilicus | 5 |
| | | | | | | | Watery diarrhea | 5 |
| | | | | | | | Oliguria | 7 |
| | | | | | | | Polyuria | 5 |
For example, a diagnostic criterion, the Qi-deficiency score, was devised as follows. First, the author Terasawa observed the patients’ subjective symptoms and objective findings to achieve synthesis. The severity of Qi-deficiency, assessed by observation, was graded into four levels as an “overall scale” based on the author’s empirical knowledge. Second, the prevalence of the symptoms and signs related to Qi-deficiency in previous studies was ordered into four levels. The weight assigned to each symptom or sign with respect to the overall scale was estimated by multiple regression analysis, and this was used to create the Qi-deficiency score. In addition, Qi-stagnation, Qi-flowback, blood deficiency, blood stagnation, and water retention scores are calculated according to this system [
37].
The fundamental meridian points for holistic therapies consist of meridian points with effects on these six Qi, blood, and water patterns in a balanced manner. This is why it is called a holistic therapy. These effects, in addition to their effects on yin deficiency patterns, and the corresponding therapeutic principles are listed in Table
4.
Table 4
The effects of fundamental meridian points for holistic therapies on Qi, blood, and water patterns
Qi deficiency | Mood disorders and major depression | Tonifying Qi | | | + | | | + | + | | | | + | | | + | | | + | | + | |
Qi stagnation | Soothing the liver and regulating Qi | | | + | + | + | | | | + | + | + | | | | | | + | | + | |
Qi counterflow | Anxiety disorders, generalized anxiety disorder and somatoform disorder in females | Downbearing Qi counterflow | | | | + | | + | | | | + | | | | + | | + | + | | + | |
Blood deficiency | Generalized anxiety disorder in males and somatoform disorder in females | Tonifying blood | | | | | + | + | | | | | | | | | | | | | + | |
Blood stagnation | | Activating blood | | | | + | | | | | + | + | | + | + | | | + | + | + | | |
Water retention | Eating disorder in females | Dispelling edema | | | | | | | + | | | | | | + | | + | + | | + | ++ | + |
Diuresis | | | | | | + | + | | | | | | | | + | | | | + | |
Yin deficiency | | Tonifying yin | | | | | + | | + | | | | | | | | ++ | | | | | + |
According to this system, the patterns associated with psychiatric and psychosomatic disorders were investigated in detail, in which Qi stagnation scores were associated with mood disorders and major depression [
39]. This result is consistent with the notion that “Qi stagnation” consists of depressive mood, loss of interest, heavy-headed feeling, unpleasant sensation of the laryngopharynx, circadian rhythm of the symptoms, burping, and abdominal gas [
36], which corresponds to the masked depression or “somatic anxiety” described in Hamilton’s rating scale for depression. In both sexes, high Qi deficiency scores were also associated with mood disorders and major depression and inversely associated with depressive disorder not otherwise specified [
39]. For women, high Qi counterflow scores were associated with anxiety disorders, generalized anxiety disorder, and somatoform disorders [
39]. On the other hand, high blood deficiency scores were associated with generalized anxiety disorder in men [
39]. For women, high water retention scores were associated with eating disorders [
39]. High Qi counterflow and blood deficiency scores for women and low water retention scores for both sexes were associated with somatoform disorders [
39]. The associations of these disorders with the Qi, blood, and water patterns are also listed in Table
4.
Although Terasawa established no scoring system, yin deficiency listed in Table
4 is quite important. We previously reported three patterns of the depressive state, based on principal component analysis of the results of four examinations given to outpatients [
40]. Of the three patterns, two yin deficiency patterns were accompanied by suicidal feelings or planning of suicide, while the depressive state of Qi deficiency pattern was not. This indicates that subjects with the heart yin deficiency-type depressive state are at risk of committing suicide. In this pattern, subjective and objective irritability, which are characteristic of heart yin deficiency, were considered associated with suicidal feelings or the planning of suicide.
In summary, the holistic therapies have physiological effects that correspond to therapeutic principles for mood, anxiety, somatoform, and eating disorders. In fact, a Japanese acupuncturist [
41] reported a patient with a specific phobia treated with Sawada-style meridian points. At pain clinics, the Sawada-style is often used to treat chronic pain, which is often accompanied by indefinite complaints [
3]. Regretfully, the Sawada-style has seldom been introduced abroad, and the reports mentioned below are not on the Sawada-style. However, its fixed protocol would be suitable for large-scale, randomized, controlled studies in the future.
The total effectiveness of holistic therapies
It is a principle of Sawada-style holistic therapy to use not acupuncture but moxibustion. This is consistent with a report that acupuncture shows quick effects, while moxibustion is recommended for cases for which acupuncture is not sufficiently effective [
42].
A randomized controlled trial using holistic therapy and placebo acupuncture for lumbago was done [
43]. In this study, use of the thirteen fundamental meridian points for Kurono-style holistic therapy alone was more effective than placebo acupuncture, and as effective as the combination of the fundamental meridian points and electroacupuncture at BL23 and BL40 which are often used for lumbago. These results indicate that holistic therapy alone has a sufficient effect on lumbago, probably owing to adjustment of the whole body. Since this study was of parallel design with placebo acupuncture combined with a crossover design, the non-specific effects of the holistic therapy or electroacupuncture deriving from insertion of needles into the derma including non-meridian points could not be excluded.
Ishigami et al. reported that the Kurono-style fundamental meridian points significantly decreased the indefinite complaints in combination with ST36, which is one of Sawada’s, not Kurono’s fundamental meridian points, and CV17 [
44], although it was not a controlled study.