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Acupuncture and Chinese herbal medicine for treating horses

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Acupuncture and Chinese Herbal
Medicine for Treating Horses
Justin Shmalberg, DVM, CVA
Huisheng Xie, DVM, PhD*
University of Florida

Abstract: Acupuncture exerts diffuse analgesic effects through the release of endogenous opioids and other locally and centrally acting
mediators. Successful therapeutic interventions for various musculoskeletal conditions in horses are well documented, and acupuncture
may significantly enhance performance. The use of acupuncture is specifically supported in treating nonsurgical gastrointestinal
disorders, in which specific techniques can alter motility and contribute to visceral analgesia. This article describes the use of
acupuncture and Chinese herbal medicine for equine reproductive management and for treating respiratory disease. A careful review
of available data and ongoing efforts to enhance unbiased research should continue to guide practitioners of evidence-based medicine
in refining the most useful applications of acupuncture and Chinese herbal medicine.

T
he increasing popularity of acupuncture and integrative by extrapolation of the human acupoint system (which typically
therapies has brought awareness of the need for research and recognizes more than 300 acupoints) to horses, for which the Yuan
enhanced training in these emerging fields.1 Equine practi- Heng Liaoma Ji described 159 acupoints in the year 1608.6 However,
tioners face a barrage of information from owner experience, lay some veterinary acupoints have recently been refined7 to reflect
and scientific literature, colleague experience with unconventional the neurovascular components, and the use of these acupoints
modalities, and public interest in the philosophies of healing. should be encouraged to mold traditional acupuncture into a
This review of the available, pertinent literature—both experience- modern, informed, and physiologically sound treatment modality.
and evidence-based—highlights the reported strengths of acu- Mechanistic research into acupuncture has largely focused on
puncture and related herbal therapy while offering insight into widespread recognition of its perceived benefits in ameliorating
areas requiring further research and refinement before they are pain. Reviews of the pathophysiology and pathways of pain high-
integrated into conventional practice. light the complex interplay between local mediators, peripheral
and central neurotransmitters, spinal control, higher centers, and
Acupuncture: Demystifying the Effects descending pathways. Because broad reviews of the acupuncture
Early Chinese medicine texts, including Yellow Emperor’s Classic literature have highlighted the role of acupuncture in all segments
of Medicine by Huang Di Nei Jing, describe the locations of acupoints of the pain pathway,8 a short primer on the mechanism is critical
(acupuncture points), the channels or meridians on which acu- to objective understanding.
points are often placed, and general guidelines for treatment. Sensory fibers form the foundation of nociception; traditionally,
One early author stated that the practitioner must focus on myriad these fibers have been labeled Aβ, Aδ, or C. Aβ fibers have large
historical and clinical factors in recognition that “healing actually diameters, low activation thresholds, and high levels of myelina-
comes from within.”2 Researchers have been standardizing the tion, making them adept at quickly transmitting common stimuli.
previously diverse treatment approaches to elucidate the mechanisms Aδ fibers have a smaller diameter, less myelination, and a higher
behind acupuncture stimulation and the observed “healing.” The stimulation threshold. Information regarding thermal and me-
acupoints, which were previously thought to represent arbitrary chanical inputs is propagated more slowly in Aδ fibers than in Aβ
anatomic landmarks, indicate larger concentrations of neurovascular fibers. C fibers are the smallest and slowest of the afferent fibers
components, including mast cells, the Golgi tendon apparatus, because of their unmyelinated axons. C fibers have the highest
and free nerve endings.3–5 These findings have been complicated activation threshold. C fibers and Aδ fibers are capable of trans-
mitting various nociceptive signals that end in the superficial
*Dr. Xie discloses that he has ownership interests in the Chi Institute, a provider of Chinese veterinary
medical training, and in Jing Tang Herbal, a supplier of veterinary herbal formulations. Chi Institute aspect of the dorsal horn of the spinal cord.9 At the level of the
has donated funds to the nutrition service at the University of Florida (the authors’ employer). spinal cord, nociceptive-specific cells fire only when painful

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 Acupuncture and Chinese Herbal Medicine for Treating Horses

Figure 1. Acupuncture: potential mechanisms and mediators. ACTH = adrenocorticotropic hormone; CGRP = calcitonin gene-related peptide; NMDA = N-methyl-
D-aspartate; VIP = vasoactive intestinal polypeptide.

stimuli are detected, thus maintaining synapses with only Aδ and generated considerable attention from acupuncture researchers. In
C fibers.10 Wide dynamic-range neurons also participate in transmis- this system, electroacupuncture (the use of electrical current across
sion of pain. They collect information from all fiber types and pro- acupoints) stimulation of Aβ fibers is thought to “close” the “gate” for
duce a response compatible with the level of stimulation. These pain input at the substantia gelatinosa in the superficial dorsal horn
neurons are chiefly responsible for the windup phenomenon.11 of the spinal cord, which, otherwise, would be “opened” by the larger
Multiple factors contribute to windup, in which the neuronal nociceptive fibers.15 The second chief area of interest is the descend-
response is augmented in level and duration. Transmitters such ing pain pathway, as described above, which may further alter the
as calcitonin gene-related peptide (CGRP), substance P, and glu- activities of cells within the dorsal horn through interplay between
tamate may have a role in activating the N-methyl-d-aspartate serotonin, endogenous opioids, and noradrenergic transmitters.
receptor, which chiefly mediates the windup response.12 This Longer clinical effects may be explained by neuroplasticity—the
response from the spinal cord is influenced by higher processing theory that the functional relationships and structural components of
centers and vice versa. Descending pathways can enhance or the nervous system may be reorganized according to new inputs.16
diminish nociceptive activity; serotonin, via the 5-HT3 receptor, Most acupuncture research has employed electroacupuncture
is likely facilitatory, while noradrenergic input is inhibitory. This because of its profound effect on endogenous opioids and, by
complex interplay between pain-processing and feedback systems extension, descending pathways of pain inhibition. Professor
provides various therapeutic targets and mirrors the diversity of Han of the Beijing Medical University authored pioneering work
neurophysiologic research on the basis for acupuncture. on the mechanisms of electroacupuncture and manual acupuncture.
The veterinary literature suggests that acupuncture (1) has wide- His studies established that (1) electroacupuncture-tolerant rats
ranging influence on descending pathways and (2) influences sero- were also tolerant of morphine analgesia, (2) acupuncture analgesia
tonin, endogenous opiates, neurotransmitter receptors, inflammatory could be transmitted between rabbits through cerebrospinal fluid
responses, and the autonomic nervous system13 (FIGURE 1). The transfer, and (3) the opioid receptor was responsible for acupuncture
gate-control theory of pain, espoused by Melzack and Wall,14 has analgesia via attenuation of effects by naloxone.17

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 Acupuncture and Chinese Herbal Medicine for Treating Horses

The contribution of endogenous opioids was further refined d-aspartate antagonism, meaning that C fibers are persistently
by receptor type and electroacupuncture frequency. Stimulation at less active after treatment and that windup is prevented.30 This
2 Hz promotes the release of endomorphin, which serves primarily spinal plasticity may be mediated by a number of substances that
as a µ-receptor agonist, along with enkephalin and β-endorphin encourage the development of new interactions among neurons
(mixed µ and δ agonists). Stimulation at 100 Hz promotes release in damaged and undamaged spinal cords.31 More broadly, elec-
of dynorphins with selective κ-receptor activity.18 Stimulation at troacupuncture stimulates distinct brain centers,32 which con-
15 Hz appears to stimulate all opioids, thereby affecting all recep- tributes to the development of new neural connections in animals
tor types. Clinical use of acupuncture can therefore be informed with neurologic dysfunction or chronic pain. The amount of
by knowledge of stimulation intensity and subsequent receptor stimulation varies according to the frequency of application.33
activity. Concurrent administration of opiates (e.g., morphine, To date, acupuncture-related laboratory research specific to
butorphanol, fentanyl, hydromorphone) should be considered horses has been more rudimentary than human and laboratory
when selecting frequency of treatment. animal investigations. In horses, the research has focused on the
While opioids have a relatively defined role in inhibiting pain model of acupuncture analgesia that emphasizes β-endorphins,
transmission via descending pathways, the role of serotonin (5-HT) cortisol, and adrenocorticotropic hormone. Early studies sug-
is less clear. Acupuncture appears to generally increase the serotonin gested that electroacupuncture releases cortisol and β-endorphins,
level, contributing to a combined analgesic effect with endogenous although the findings did not correlate to the degree of analgesia
opioids.19 However, the prevalence of multiple subtypes of receptors observed in the study.34 However, a similar study35 that docu-
with competing actions suggests a complexity to serotonergic mented elevations in β-endorphin showed an effect on cutaneous
effects.20 A study of rabbits supported this theory; electroacu- analgesia. Thermal pain threshold studies demonstrated rising
puncture analgesia was facilitated by 5-HT1, 5-HT2, and 5-HT3 endorphin levels, which varied according to selected acupoints
subtypes, with the exclusion of 5-HT1A and 5-HT2A, which sup- and correlated to the degree of analgesia measured.36 In a small
pressed analgesia.21 Further studies are needed to fully under- (n = 8), randomized, crossover study of mares, acupuncture and
stand how serotonin contributes to acupuncture analgesia. electroacupuncture increased cutaneous and visceral pain toler-
The local and central effects of acupuncture needle insertion ance.37 Analgesia was believed to correlate with measurable rises
may influence the release and activity of substance P, a potent in met-enkephalin and dynorphins after electroacupuncture (2 to
neurotransmitter involved in nociception locally and at the 100 Hz, variable frequency), although only enkephalin increases
spinal cord. Higher levels of substance P in the tissue of canine were statistically significant. These findings largely explain the
acupoints have been reported, suggesting another neurovascular short-term model of acupuncture analgesia. Long-term effects
feature unique to acupoints versus nonacupoints.22 In clinical have not been substantially elucidated in horses.
application, electroacupuncture appears uniformly able to reduce
local and plasma levels of substance P,23,24 while spinal effects Acupuncture: Materials and Methods
vary with the frequency of stimulation.25 Receptor-level research The location of many acupoints is based on the Chinese notion of
has refined the understanding of the effects of substance P at the meridians, or channels. According to classic Chinese texts, these
dorsal horn. Persistent inflammation appears to upregulate the lines transmit Qi (pronounced “chee”) in the subcutaneous space
neurokinin-1/substance P receptor, which, when activated by where the needle penetrates, thereby establishing communication
substance P, produces enhanced nociception and hyperalgesia. with other points and areas of the body. This concept has not
This effect was suppressed by electroacupuncture at 10 Hz; the been scientifically defined, and the diffuse effects of acupuncture
study26 authors also highlighted other work suggesting that acti- may be largely explained by the aforementioned complex neural
vated opioid receptors (µ and δ) decrease substance P release and pathways and mediators. Many researchers have debated and
expression of neurokinin-1. Local injury may prompt release of studied the existence of acupuncture meridians,38 and several articles
nerve growth factor, which increases the synthesis and trafficking have questioned the validity of confirmatory tests involving radio-
of substance P in the dorsal horn, thereby contributing to pain. isotope studies,39 thermal imaging,40 and electrical conductance.41
One study27 suggests that electroacupuncture decreases the negative However, recent investigation using novel methodology is reig-
effect of nerve growth factor in rats. Substance P will likely be- niting the debate on the existence and function of acupuncture
come a target for novel pharmacologic interventions, and clinical meridians.
knowledge of electroacupuncture may prove beneficial in reducing Injection of tracer into human acupoints has identified sub-
the role of the compound in chronic pain. cutaneous channels that were differentiated from lymphatic or
In addition to how acupuncture controls neurotransmitters vascular flow by angiography and that appeared only after
and receptor expression, recent human research has sought to administration of tracer at specific acupoints.42 In sheep, acoustic
explain gradual clinical improvement in patients over multiple emission signals have been measured and propagated along me-
treatments, referred to by some as therapeutic acupuncture.28,29 In ridians.43 Within this model, the 14 major meridians were tested
chronic pain, synaptic plasticity may contribute to this observa- using 84 acupoints. Researchers found significant signal-strength
tion. Low-frequency (2 Hz) electroacupuncture contributes to increases over baseline in 85% of acupoints and only 28% of
long-term depression of C-fiber action potentials via N-methyl- control points (P < .01), suggesting preferential communication

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 Acupuncture and Chinese Herbal Medicine for Treating Horses

Table 1. The Most Common Methods of Equine Acupuncture

Method Technique Indications Contraindications Advantages Disadvantages

Dry needling Smooth, rapid insertion Most conditions and Insertion into Relatively inexpensive; Lower stimulation
(white needle; of a filiform 28- to almost all acupoints neoplasia, scar tissue, requires no electronic than that provided by
the traditional 32-gauge acupuncture or areas of infection equipment; suited to electroacupuncture;
acupuncture needle (13–100 mm in various conditions requires more frequent
needling technique) length) at a depth and treatments
angle directed by the
location of each acupoint
Electroacupuncture Needle insertion Neuromuscular Cardiac arrhythmias; Increased stimulation; Equipment is required;
followed by placement stimulation; paralysis; shock; epilepsy; solid scientific data 20–30 min required;
of electrical leads severe pain; induction pacemaker; dermatitis; supporting use leads may be difficult
using machines; of adjunctive surgical pregnancy (electroacu- to keep on certain
common frequencies analgesia puncture not horses
include low (2 Hz; recommended near the
endorphins, enkepha- ventral abdomen);
lins), middle (100 Hz; neoplasia (electrical
dynorphins), and high leads should never
(200 Hz; serotonin) cross a mass)
Aquapuncture Insertion of a Conditions associated Some dermatitis cases Inexpensive; less May be less effective
(acupoint injection) hypodermic needle with pain; muscle time-consuming when used alone
(appropriately sized for atrophy; internal compared with versus traditional
the horse) and injection conditions; when traditional needle techniques or
of fluid (generally traditional acupuncture placement or electroacupuncture
vitamin B12 or saline; is unavailable; may be electroacupuncture
2–10 mL per site) used as an adjunct
treatment
Hemoacupuncture A hypodermic needle is Conditions associated General weakness; Quick; inexpensive May cause excessive
(red needle) used to puncture a with acute-onset anemia; pregnancy; bleeding if the needle
blood vessel to draw inflammation or fever dehydration; weakness; is too large for the
blood (5–20 mL per during winter or in cold particular point or if the
acupoint) environments horse has an underlying
coagulopathy
Moxibustion A moxa stick (made of Cold environment; During summer or in Can be conveniently May cause smoke and
Artemisia leaves) is local swelling; pain hot environments used by horse owners an unpleasant odor
burned near acupoints

between same-meridian points. On functional magnetic resolution on these neural connections. A combination of meridian and
imaging studies, rabbits showed specific activation of neural centers back-shu points is often used to achieve a clinical result.
at different acupoints, and related work in humans suggests that Multiple methods of acupoint stimulation are available, including
stimulation of acupoints on the same meridian activates similar traditional methods and modern adaptations (e.g., electroacu-
brain centers.44,45 Despite the lack of conclusive clinical correlates puncture). These methods include traditional needle stimulation
from meridian studies, meridians, as presently established, pro- with a small (28- to 32-gauge), usually stainless-steel, filiform
vide useful anatomic locations and nomenclature for acupoint or round-sharp needle; the injection of sterile saline or vitamin
selection by practitioners. B12 solution into the acupoint (aquapuncture); drawing blood
Another important concept is that of organ-associated, or (hemoacupuncture); the introduction of air (pneumoacupunc-
back-shu, acupoints, which allow practitioners to treat internal ture); laser stimulation; or the application of heat by burning an
organ pathology via stimulation of areas on the epaxial musculature herb (moxa) on the needle’s handle or point48 (moxibustion;
of horses. Although the concept may appear implausible, evidence TABLE 1).
suggests that acupuncture at superficial sites may alter blood flow Clinical efficacy has been reported for all of the above methods
to internal organs.46 This may be mediated, in part, by neural in humans; however, most research in horses, as in humans, has
somaticovisceral reflexes, which have been described in humans focused on the use of electroacupuncture. Protocols for the duration
and laboratory animals.47 The proximity of back-shu points to and electrical frequency vary; however, 15 minutes of stimulation
the dorsal horn of the spinal cord and to the internal organ they is likely adequate for clinical effect, and bilateral stimulation
are said to represent could allow empiric therapy that capitalizes appears to be more efficacious than unilateral application.49,50

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 Acupuncture and Chinese Herbal Medicine for Treating Horses

acupoints using a blunt probe. Specific acupoints are thought to

Table 2. Acupoints for Treating Laryngeal Hemiplegiaa
be associated with primary sites of lameness. For example, when a
Acupoint Anatomic Location horse reacts to LI-18 in the cervical region (TABLE 2), imbalance
or pain in the distal joints of the ipsilateral forelimb is suspected.54
CV-23 On the ventral midline of the neck, just cranial to the larynx
This acupoint sensitivity may result from altered muscle com-
GB-21 In a depression located halfway along the cranial margin of the pensation associated with lameness and the formation of myo-
scapula fascial trigger points, which have recently been described in
horses.55 Beyond the musculoskeletal uses of acupuncture in horses,
Hou-bi Caudal to the mandible, 6 cm dorsal and cranial to Hou-men
(on the jugular vein, 3 cm caudal to the larynx) diagnostic acupoints have been described for other conditions,
mainly infectious diseases with neural or muscular manifestations,
Hou-shu On the ventral midline at the third tracheal ring although limited clinical trials have not provided confirmation.56
Whether the lameness examination involves conventional,
LI-15 Immediately cranial to the point of the shoulder (greater
tubercle) Chinese medical, or, ideally, integrative diagnostics, the acu-
puncture treatment is tailored to the individual and includes
LI-17 On the brachiocephalicus muscle, 6 cm craniodorsal to the multiple acupoints adjacent to the localized cause. Studies evalu-
point one-third the distance from the shoulder joint along the ating this approach have varied widely in experimental rigor,
cranial scapular margin
methodology, and results. Early studies on chronic laminitis (n =
LI-18 The depression just above the jugular groove, found by 10) and navicular disease (n = 10) in small populations showed
following the ventral mandible with the head extended no significant difference between groups regarding stride length
and force-plate analysis.57 Chronic back pain responded positively
SI-17 Just caudal to the mandibular ramus, exactly halfway between
the dorsal and ventral margins of the ramus
to various stimulation techniques in multiple studies involving
200 horses, but these studies did not include control groups.58–61
ST-9 In the depression caudal to the angle of the mandible In a more recent prospective study, three electroacupuncture
a
Some references and practitioners use a unit of measurement known as the cun, which is based on a treatments sufficiently ameliorated uncomplicated chronic tho-
traditional scaled measuring system that varies depending on the total area of the body segment on which racolumbar pain in 15 horses.62
the point is located. In general, most points were discovered because of a palpable depression at the site. In a randomized, double-blind, controlled trial involving a
treatment group of 16 Thai sport horses, control horses with
For basic “dry” needle insertion, small-gauge needles are chronic back pain for 3 months or longer received sham acu-
used, ranging in length from 13 mm for acupoints just proximal puncture and were rested for 15 days.63 The treatment group
to the coronary band to 75 mm for acupoints adjacent to the cox- received electroacupuncture in local acupoints and was rested
ofemoral joints. Although needle depth largely depends on the for a similar amount of time. The pain threshold was quantified
practitioner’s preference, recent research using functional mag- with pressure algometry to avoid more subjective pain scoring
netic resonance imaging in humans highlighted similar findings systems, and the results revealed statistically significant differ-
between superficial (Japanese) and deep (Chinese) needling.51 ences, although no correlation was made to clinical or owner-
Aquapuncture, another common stimulation method, is thought based observations.64
to provide longer stimulation of the acupoint until the fluid, saline, There has been considerable interest in the possible use of
or vitamin B12 is absorbed. Injection at the acupoint produces phys- acupuncture for pain reduction and detection of subclinical
iologic responses similar to those of fine-gauge needle insertion.52 lameness in racing Thoroughbreds; therefore, many large equine
In China, various sterilized substances are used in aquapuncture. training facilities integrate acupuncture into their treatment and
Injectable herbs are not available in the United States, so vitamin B12 preventive care regimens. Despite this large equine population,
and saline are used most often. Further research is necessary to few studies have documented the effect of acupuncture on spe-
evaluate the response rate of horses to this technique. cific performance parameters. A study of aquapuncture analyzed
cardiovascular and metabolic parameters in 18 Thoroughbred
Lameness: An Integrative Approach racehorses.65 Chinese diagnostic methods were used to classify
Most equine practitioners who consider using acupuncture focus horses according to endocrine, gastric, stifle, hock, and coxofemoral
on its clinical applications for treating lameness and associated abnormalities. Therefore, acupoint selection varied between
musculoskeletal disorders, and these applications appear to be horses based on their diagnostic sensitivity. The only parameter
strongly supported by the current model of acupuncture analgesia. that showed statistically significant improvement was blood lactate,
Human and veterinary clinicians find acupuncture to be well but the performance correlation of the measured differences
suited to restoring normal activity and function after musculo­ remains unclear. The authors note that five of six horses won
skeletal problems, with the caveat that conformational challenges races after treatment, whereas none had won before treatment.
may complicate or lengthen treatment.53 This anecdotal support is similar to that from trainers and owners
From a modern Chinese medical perspective, the cornerstone who continue acupuncture therapy solely because of an apparent
of the equine lameness evaluation is palpation, or scanning, of correlation to performance enhancement.

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 Acupuncture and Chinese Herbal Medicine for Treating Horses

Despite the inadequacies of studies regarding veterinary acu- left Hou-shu to right Hou-shu, bilateral ST-9 to Hou-bi, and
puncture and the lack of standardized treatment due to practitioner bilateral SI-17 to LI-15 (TABLE 2). The preliminary data appear
preference and tailoring of acupuncture to individual patients, promising; future studies should focus on response rates within
studies on using acupuncture to treat lameness due to various grades, persistent observational changes in laryngeal function,
causes have shown promising results. A simplified statistical and differences between reported acupuncture protocols. Given
review of English- and Chinese-language studies on this topic the benefits and benign nature of electroacupuncture, increased
found acupuncture to have a >80% efficacy in resolving or im- use of it for laryngeal hemiplegia is warranted.
proving lameness due to back pain, shoulder pathology, fetlock
injury, laminitis, and paresis or paralysis.66 Exact acupuncture Gastrointestinal Effects of Acupuncture and
protocols varied in each study because practitioners select acu- Chinese Herbal Formulations
points based on experience and then modify them based on Research and anecdotal evidence support the use of acupuncture for
clinical response. treating conditions other than musculoskeletal and performance-
related pathologies. For example, treatment of colic by integra-
Laryngeal Hemiplegia: a Noninvasive Alternative tive management of medical gastrointestinal (GI) disorders or by
Neural stimulation and regeneration are classic applications of adjunctive postsurgical care has been described.
electroacupuncture. Experimental models using rabbits and rats Experimental models have sought to evaluate the observed
have demonstrated dramatic improvements in crushing injuries67 visceral analgesic effect of electroacupuncture. A rectal distention
or complete transections of the sciatic nerve,68 and electroacu- model of colic pain in mares using multiple acupoints found
puncture appears capable of regenerating multiple fiber types in “useful” rectal analgesia.75 However, acupuncture limited to one
these injuries.69 In less severe pathology, electroacupuncture has acupoint, BL-21 or Guan-yuan-shu, did not alleviate discomfort
shown clinical efficacy in humans. In a nonrandomized, retro- associated with experimental small intestinal distention.76 The
spective pilot study of polyneuropathy of unknown cause, 16 of results of these two contrasting studies show the inherent chal-
21 (76%) patients improved in subjective scoring and in nerve lenges in standardizing treatment protocols and experimental
conduction studies.70 models to provide meaningful data. The following could be deduced
These studies are most relevant to the role of electroacupuncture regarding acupuncture: BL-21 is ineffective, multiple points are
in treating laryngeal hemiplegia, which generally has an idiopathic necessary, small intestinal pain cannot be relieved, electroacu-
origin, whereby large myelinated fiber dysfunction contributes to puncture frequencies play a role in the differences between results,
secondary mechanically induced complications such as exercise and acupuncture for GI analgesia in horses is unreliable given
intolerance, inspiratory noise, airway resistance, and diminished the available data. Despite isolated case reports that support this
airflow.71 Surgical approaches to overcome adduction of the use of acupuncture,77 there are no conclusive scientific data in
arytenoid cartilages are well described, and each has its own English-language journals from which to propose a complete
complications and reported success rate. Regardless of predicted mechanism for the reported success of acupuncture for GI anal-
surgical outcomes, the comparatively noninvasive approach of gesia in horses.
acupuncture is promising for pragmatic reasons and for its lack In addition to acupuncture providing some degree of visceral
of complications compared with other approaches. analgesia, a motility-modifying effect likely explains the reported
Early human reports suggested that treatment of laryngeal clinical achievements associated with acupuncture. Studies in
nerve pathology using a mixed-modality approach, including other species show profound GI effects from acupoints traditionally
acupuncture, in a small number of patients (n = 14) resulted in associated with the treatment of GI disorders. For example, in
clinical recovery.72 Data from canine nerve transection followed rats, ST-36 promotes distal colon contractility mediated through
by electrical nerve stimulation via an implanted device, unrelated to a cholinergic mechanism.78 In cats, the same acupoint affects
acupuncture principles, showed histologic evidence of regeneration esophageal motility, gastrin, motilin, and vasoactive peptide,
along with maintenance of functional laryngeal musculature.73 suggesting wide-ranging GI effects that likely have a neurochemical
Clinical reports of responses in horses are becoming more common. origin.79 GV-1, an acupoint frequently used for treating diarrhea,
In a recent retrospective study of 18 horses treated by the suppressed proximal colonic motility in dogs by decreasing the
University of Florida acupuncture service, promising outcome data frequency and duration of colonic contractions; acupoints that
emerged. In all cases, the standing endoscopic grade improved.74 are not typically associated with treating diarrhea had no effect.80
Because the study was retrospective, neither stratification nor After stimulation of BL-21 (the stomach-associated back-shu
controls were present. Pretreatment grading ranged from IIa to IIIb, acupoint), gastric motility increased in dogs.81 The effects of
with outcomes ranging from normal to IIb, using the common specific acupoints in horses are currently being investigated;
grading nomenclature for describing the degree and maintenance additional research is needed to evaluate the use of acupuncture
of arytenoid abduction. In this study, a combination of low-frequency in treating colic.
(10 minutes at 20 Hz) and high-frequency (10 minutes at 80 to The therapeutic goals of acupuncture for GI disorders are to
120 Hz) stimulation was reported. The electroacupuncture approach alleviate or reduce visceral pain while normalizing GI motility.
was standardized: CV-23 to left GB-21, left LI-18 to left LI-17, In China, the traditional “pattern diagnosis” system is generally

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 Acupuncture and Chinese Herbal Medicine for Treating Horses

Table 3. Common Acupoints for Treating Table 4. Common Acupoints for Treating
Gastrointestinal Disorders Reproductive Disorders
Acupoint Anatomic Location Acupoint Anatomic Location

GV-1 In the depression between the anus and the ventral aspect of the GV-3 On the dorsal midline overlying the intervertebral space between
base of the tail L4 and L5
ST-36 6 cm below the patella, 1.5 cm lateral to the cranial aspect of the GV-4 On the dorsal midline overlying the intervertebral space between
tibia, in the cranial tibialis muscle L2 and L3
SP-6 6 cm proximal to the medial malleolus, just caudal to the tibial Bai-hui On the dorsal midline at the lumbosacral space
border, and 1.5 cm caudal to the saphenous vein
Yan-chi One-half the distance between the proximal border of the tuber
Bai-hui On dorsal midline at the lumbosacral space coxa and Sheng-peng (the point located 6 cm from the dorsal
midline at the center of L6)
BL-20 At the 17th intercostal space, 9 cm lateral to the dorsal midline
Shen-shu 6 cm lateral to the dorsal midline at the lumbosacral space
BL-21 Caudal to the 18th rib, 9 cm lateral to the dorsal midline (Bai-hui)

BL-23 9 cm lateral to the dorsal midline at the second lumbar

employed to guide treatment, but acupoints with a diffuse array intervertebral space (L2-L3)
of effects can be chosen. Frequently selected acupoints include
GV-1 (especially for treating diarrhea), ST-36, SP-6, Bai-hui, and
acupoints on the back that are associated with the GI tract, a survey of data on multiple species, acupuncture showed efficacy
namely BL-20 and BL-2182 (TABLE 3). At these acupoints, elec- in normalizing the hypophyseal–pituitary–gonadal axis,90 aug-
troacupuncture is useful at a recommended combination of low menting sperm counts,91 inducing estrus,92 treating infertility
and high frequencies. Dry needling and aquapuncture are also among dairy cattle,93 and improving the success of human in
appropriate. vitro fertilization.94 Equine reports include conflicting findings
Herbal formulations are commonly used in the integrative regarding prostaglandin administration at acupoint Bai-hui (at
treatment of GI disorders. Equine patterns of diarrhea and sub- the lumbosacral junction); current research shows no advantage
sequent herbal selections have been described.83 The herbs in these over using a nonacupoint despite previous reports that suggested
formulations have a plethora of functions, including antispasmodic enhanced effects of using Bai-hui, which has traditionally been
effects,84 immunomodulation,85 and alteration of biochemical associated with treating fertility disorders.95
and bacterial parameters.86 A review of equine reproduction provided strong anecdotal
In the absence of precise data governing herbal pharmacokinetics support for the use of Chinese medical therapies, including acu-
and activities, there have been multiple Chinese studies on herbal puncture, as adjuncts to conventional interventions.96 However,
formulations, typically comprising multiple herbs that are said to the author suggested that it was difficult to predict the hormonal
work in conjunction; however, these studies have generally been response to treatment. Despite these ongoing challenges, clinical
performed without a rigorous experimental design. In one labo- studies in China highlight the promising role of herbal formulations
ratory study, experimental diarrhea in mice was treated with Bai for treating reproductive disorders. In one example, an herbal
Tou Weng Tang (a combination of pulsatilla, phellodendron, formulation was given to infertile mares with anestrous or ano-
coptis, and fraxinus) or each herb alone; the classic clinical vulatory follicles. After two to six treatments, 685 of 734 mares
formulation resolved diarrhea faster, but each herb alone had had normal estrus and eventually conceived.97 In a retrospective
stronger antibacterial action than the formulation.87 The same study on goats with endometritis, the condition resolved in most
formula has shown efficacy (i.e., clinical resolution in 3 days) in (53 of 57) subjects after 6 days of therapy with a formula based on
an outbreak of acute hemorrhagic calf diarrhea of unknown the Chinese pattern associated with endometritis.98
cause.88 In a review of the use of Ping Wei San in horses, the Common acupoints for managing a range of reproductive
formulation was associated with positive clinical outcomes of disorders include Bai-hui, GV-3, GV-4, Yan-chi, Shen-shu, and
chronic GI conditions, including pica and gas colic.89 Although many BL-23 (TABLE 4). Caution should be exercised in using acupuncture
of these retrospective studies lack the design required to apply to treat pregnant mares: ideally, only clinicians with specialty
their results broadly, they provide a foundation for independent training should treat pregnant mares because of the risk for iat-
clinical investigation to verify the Chinese literature. rogenic induction of abortion, despite little evidence definitively
linking acupuncture and abortion.
Reproduction: Integrative Management
While GI disorders largely manifest as acute indications for acu- Equine Respiratory Disease: Can Herbs Help?
puncture, there is considerable interest in using acupuncture in Clinicians who are not comfortable with using acupuncture are
the ongoing, integrative management of equine reproduction. In often hesitant to use herbal formulations, especially given the

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 Acupuncture and Chinese Herbal Medicine for Treating Horses

relatively basic pharma- Despite the lack of in vivo clinical trials involving herbs, the
Critical Points cokinetic and drug interac- Chinese polypharmacy for respiratory conditions has attracted
tion studies performed to considerable interest. Multiple case studies have suggested success
• The classic model of acupuncture date. Herbal selections are in treating acute and chronic equine respiratory conditions with
analgesia based on endogenous based on classic anteced- herbal formulations such as modified Bai He Gu Jin Tang, Ge Jie
opioid release is well supported in ents or formulations from San, and Si Jun Zi Tang.104,105 In a pilot study involving six horses
horses. Research in other species early texts of human and with recurrent airway obstruction, treatment with a proprietary
suggests that other mediators are veterinary Chinese medi- Western herb blend (including some of the same herbs in many
responsible for long-term clinical cine. These botanical treat- classic Chinese formulations) significantly decreased the horses’
effects. ments and their subsequent respiratory rates.106 In a review of Chinese herbal formulations
modifications represent for treating equine respiratory disease, including a laboratory
• Various acupoint stimulation
experience-based pharma- investigation of the constituent herbs, evidence supported the
methods are available to practitioners.
cology, just as acupuncture use of the formulations for the following: expectoration, reduction
Most of these methods are appropriate
stems from experience- in smooth muscle contraction, antimicrobial effects, T-helper
for treating musculoskeletal
based physiologic responses immunomodulation, macrophage stimulation, antioxidant prop-
disorders—the classic indication
to needling. erties, inflammatory cytokine downregulation, antiinflammatory
for acupuncture, and the most widely
Although no veterinary effects, antihistaminic properties, and antitussive properties.107
studied area in horses.
case reports regarding The literature from China demonstrates the potential broad
• As an adjunctive treatment of surgical herb–drug interactions or applications of herbal prescriptions for treating many conditions
colic or a stand-alone therapy for toxicities have been pub- in veterinary medicine. Four reports highlight the promising
medical colic, acupuncture or herbal lished, human cases and role of Xin Yi San for treating chronic sinusitis in horses.108–111 In
medicine may alter visceral pain concerns have been docu- a clinical trial in which Zhi Sou San was used to treat chronic
thresholds, regulate GI motility, and mented.99 Adverse events coughing in 50 horses, clinical signs resolved in 90% of the horses.112
alter regional blood flow. are generally categorized A similar response rate was reported when Wei Jing Tang (aqueous
as follows: an unpredict- extract) was used to treat pneumonia: 19 of 23 mixed animal
• Some herbal formulas show promising
able and likely unavoidable cases, including 14 horses, responded to 6 days of high-dose
results in laboratory investigations and
adverse event due to pa- administration of the herbal formulation, although the primary
clinical reports. These formulas may
tient allergy or reactivity, causative agents were not reported.113 Further double-blind,
prove valuable in treating chronic
improper use (e.g., when randomized trials are required to objectively evaluate the consis-
respiratory disease and reproductive
ephedra was used at supra- tency and clinical effect of herbs in practice.
disorders when more clinical data are
clinical doses for an unin-
available.
tended purpose), contami- Equine Acupuncture and Herbal Medicine in Practice:
nation during production or Prospects and Challenges
processing, misidentification A superior doctor is able to gather all techniques and use them
of a medical plant, and herb–drug interactions.100 either together or separately … and to consider the many variables
Knowledgeable and appropriately trained practitioners generally in the treatment of a condition. Thus, it is understood that even
avoid using herbs at high doses, reducing the risk of an adverse event. though treatment methods are different, all can succeed in healing
Because of increased scrutiny, many herbal suppliers are providing a condition.
more information about their sources and the processing of herbal This statement, which is from a foundational text of Chinese
formulations. Some medicinal ingredients have undergone scientific medicine from the second century BCE,2 highlights the approach
review. Cinnabar, which contains mercury sulfide, has been used in of acupuncture and its related modalities. Traditional Chinese
multiple herbal formulations; despite its relatively low oral toxicity, it medicine adopted a philosophical framework for evaluation
is not used in veterinary formulations in the United States.101 based on observation of clinical signs and their relationship to
Herb–drug interactions have become a primary focus of inte- perceived organ systems. This framework was rooted in the goal
grative medicine research. Given the broad pharmacologic activity of establishing a “pattern” diagnosis: a collection of environmental,
of herbs and their likely lower levels of active constituents com- historical, biologic, and observational factors suggestive of an
pared with pharmaceuticals, evaluating traditional pharmaceuticals underlying disorder in the body.114 Western diagnoses, which
against representative herbs may prove beneficial.102 Because the dominate current practice paradigms, often fail to neatly translate
regulation of herbs has increased in Europe,103 it is plausible that into a comparable Chinese medicine pattern. For example, in
manufacturing and quality-control regulations will increase in Chinese medicine, degenerative joint disease may be expressed in
the United States. However, because of the expense and breadth four or more different patterns, depending on factors unrelated
of the herbal formulary, it is unlikely that costly pharmacokinetic to the rigid conventional diagnosis and the relevant clinical signs.
studies will match those of conventional drugs, which generally Over thousands of years, these patterns were refined and
have more narrow pharmacokinetic activities. subsequent treatments devised to address the corresponding

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 Acupuncture and Chinese Herbal Medicine for Treating Horses

imbalance or disease. Modern scientific evaluation of these mo- Support Palliat Care 2008;2(2):133-139.
11. Coste J, Voisin DL, Luccarini P, Dallel R. A role for wind-up in trigeminal sensory pro-
dalities is a relatively recent phenomenon, often complicated by
cessing: intensity coding of nociceptive stimuli in the rat. Cephalalgia 2008;28(6):631-639.
the lack of rigid, controlled trials and by inherent differences in 12. Budai D, Larson AA. Role of substance P in the modulation of C-fiber-evoked re-
therapeutic approach, which varies with each patient. The confidence sponses of spinal dorsal horn neurons. Brain Res 1996;710(1-2):197-203.
that acupuncture practitioners have placed in “experience-based” 13. Lin JG, Chen WL. Acupuncture analgesia: a review of its mechanisms of actions. Am
medicine has been challenged by clinical veterinarians who cite the J Chin Med 2008;36(4):635-645.
14. Melzack R, Wall PD. Pain mechanisms: a new theory. Science 1965;150(699):971-979.
lack of proper experimental controls and treatment conformity.115
15. Pyne D, Shenker NG. Demystifying acupuncture. Rheumatology 2008;47:1132-1136.
Consequently, a recent meta-analysis of acupuncture in veterinary 16. Chakraborty R, Chatterjee A, Choudhary S, Chakraborty PK. Neuroplasticity—a
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pelling” evidence to recommend or reject acupuncture at this 17. Ulett GA, Han S, Han JS. Electroacupuncture: mechanisms and clinical applications.
time.116 Opponents of acupuncture have suggested that current Biol Psychiatry 1998;44:129-138.
research “does not favor the use of this technique.”117 Nonetheless, 18. Han JS. Acupuncture and endorphins. Neurosci Lett 2004;361:258-261.
19. Chang YH, Hsieh MT, Cheng JT. Increase of locomotor activity by acupuncture on
the physiologic insights into the effects of acupuncture, coupled Bai-hui in rats. Neurosci Lett 1996;211(2):121-124.
with clinical information regarding its indications, should en- 20. Zhang YQ, Wu GC. Endogenous descending inhibitory/facilitatory system and se-
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relative to its minimal adverse effects while recognizing the need Jin Zhan 2000;31(3):211-216.
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cal acupuncture. Jpn J Pharmacol 1998;78(4):511-514.
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