2016 AlterMed Robinson Revised 071916
7/19/16 Medical Acupuncture Narda G Robinson, DO, DVM, MS, FAAMA Colorado State University, Department of Clinical Sciences CuraCore.org Narda.Robinson@colostate.edu Learning Objectives 1. Distinguish between the western biological rationale for medical acupuncture and Chinese acupuncture Learning Objectives 2. Compare and contrast diagnostics and treatment approaches from a medical acupuncture versus a TCM perspective 1
7/19/16 Learning Objectives 3. Identify medical conditions treated with acupuncture and resources for referral and further learning Learning Objectives 1. Distinguish between the western biological rationale for medical acupuncture and Chinese acupuncture 2
7/19/16 “Western Medical Acupuncture” A Definition “Western medical acupuncture is a therapeutic modality involving the insertion of fine needles; it is an adaptation of Chinese acupuncture using current knowledge of anatomy, physiology and pathology, and the principles of evidence based medicine.” “Western Medical Acupuncture” A Definition “ While Western medical acupuncture has evolved from Chinese acupuncture, its practitioners no longer adhere to concepts such as Yin/Yang and circulation of qi, and regard acupuncture as part of conventional medicine rather than a complete ‘alternative medical syste m’.” “Western Medical Acupuncture” A Definition “ It acts mainly by stimulating the nervous system, and its known modes of action include local antidromic axon reflexes, segmental and extrasegmental neuromodulation, and other central nervous system effects. Western medical acupuncture is principally used by conventional healthcare practitioners, most commonly in primary care.” 3
7/19/16 “Western Medical Acupuncture” A Definition “ It is mainly used to treat musculoskeletal pain, including myofascial trigger point pain. It is also effective for postoperative pain and nausea. Practitioners of Western medical acupuncture tend to pay less attention than classical acupuncturists to choosing one point over another, though they generally choose classical points as the best places to stimulate the nervous system.” “Western Medical Acupuncture” A Definition “ The design and interpretation of clinical studies is constrained by lack of knowledge of the appropriate dosage of acupuncture, and the likelihood that any form of needling used as a usual control procedure in “placebo controlled” studies may be active. Western medical acupuncture justifies an unbiased evaluation of its role in a modern health service.” Source White A and Editorial Board of Acupuncture in Medicine. Western Medical Acupuncture – A Definition. Acupunct Med 2009;27:3335 doi:10.1136/aim.2008.000372 4
7/19/16 Not All Medical Acupuncturists Practice Scientifically Many MDs and DOs in North America include TCM and other metaphorical approaches Physicians in the United Kingdom and Canada may have a more scientific approach – Neuroanatomic acupuncture Osteopathic physicians tend to include proportionally more myofascial palpation and trigger point deactivation in their treatments American Academy of Medical Acupuncture Primarily a physician acupuncture association – medicalacupuncture.org American Board of Medical Acupuncture confers board certification on eligible MD and DO members who have completed all requirements: DABMA.org Not all courses in medical acupuncture teach strictly scientific medical acupuncture Other Forms of “Medical Acupuncture” French Energetics Traditional Chinese Medicine Auricular acupuncture Five Phases (or Five Elements) Korean Hand Acupuncture Scalp acupuncture 5
7/19/16 Debate between Science and Metaphorical Approaches Ongoing within the medical acupuncture community as well as nonphysician acupuncture groups Some say that approaching acupuncture scientifically and based on anatomy and physiology could rob it of its beauty, elegance, traditional roots This is not true What Are Acupuncture Points? Scientific Medical Acupuncture Acupuncture points are sites through which we can engender neuromodulation and myofascial normalization Neuromodulation impacts neural signaling locally, regionally, and system-wide, leading to physical, psychological, and autonomic nervous system changes 6
7/19/16 Learning Objectives 2. Compare and contrast diagnostics and treatment approaches from a medical acupuncture versus a TCM perspective Traditional Chinese Medicine “[S]kepticism remains about the nature and validity of the concepts that underlie TCM clinical diagnosis and therapeutic decisionmaking.” – O’Brien KA et al. Understanding the reliability of diagnostic variables in a Chinese Medicine examination. J Alt Complement Med. 2009;15(7):727-734. Traditional Chinese Medicine “This skepticism extends to the diagnosis of diseases or disorders on the basis of tongue diagnosis, pulse diagnosis, and other clinical signs and symptoms, the identification of syndromes reflecting underlying patterns of disharmony of a clinical entity or disease and the use of Chinese herbal medicinal formulae to restore the supposedly disrupted balance.” 7
7/19/16 Traditional Chinese Medicine “There are relatively few data available concerning the reproducibility of major TCM diagnostic variables, such as pulse diagnosis and tongue diagnosis, and a distinct lack of information about the reliability of other clinical data gathered in a TCM examination.” Traditional Chinese Medicine “Only a small number of studies have investigated the reproducibility of TCM syndrome diagnosis.” Traditional Chinese Medicine “If the individual diagnostic observations are themselves unreliable, there can be less confidence that the TCM syndrome diagnosed through synthesis of diagnostic observations will be reliable.” 8
7/19/16 Scientific Medical Acupuncture Base treatments on the results of a modern medical examination and myofascial palpation The goals include normalization of nervous function (neuromodulation) and alleviation of myofascial dysfunction Why Anatomy in Acupuncture? Anatomy is factual, rational, and identifiable. Ancient Chinese acupuncturists actually knew a great deal about anatomy. 9
7/19/16 Why Anatomy in Acupuncture? There is no “gap” in the effects of acupuncture that need to be filled by “consciousness”, “Qi”, or “energies”. It’s all real and can be explained. Why Anatomy in Acupuncture? Knowing acupuncture anatomy makes acupuncture safer Anatomy is the basis of medicine and should be the basis of acupuncture as a type of medical practice though others may view the basis as “Qi” and “heat, wind, damp, fire, water, etc.” Interactive Medical Acupuncture Anatomy – Robinson NG – CRC Press – March 2016 10
7/19/16 OUR JOURNEY BEGINS THORACIC LIMB Lung Channel 11
7/19/16 Cephalic vein Early Acupuncture Began as a blood-letting technique, which is why many of the channels follow blood vessels – Epler DC Jr. Bloodletting in early Chinese medicine and its relation to the origin of acupuncture. Bull Hist Med. 1980;54(3):337-367. Early Acupuncture We do not advocate bloodletting – this is only provided for historical context and certainly does not meet CME requirements for care of patients 12
7/19/16 THE OUTCOME OF NEEDLING DEPENDS ON THE STRUCTURES TARGETED LU 5: “Cubit Marsh” What Will You Stimulate? 13
7/19/16 What Will You Stimulate? What Will You Stimulate? ANATOMY DECIDES THE RESULTS 14
7/19/16 CHANNELS FOLLOW NERVES AND VESSELS CHANNELS ARE THE NERVES AND VESSELS Channel Nomenclature Confusing Most refer to organs Many or most of the points on each channel have little to nothing to do with the organ after which the channel is named Some channel names are purely metaphorical – E.g., “Triple Heater” and “Governor Vessel” 15
7/19/16 Channels Nerves and Vessels STRUCTURE DICTATES FUNCTION THE OUTCOME YOU GET DEPENDS ON THE NERVES YOU ACTIVATE 16
7/19/16 Pericardium 6: “Neiguan” “Inner Pass” “Inner Pass” Refers to the passage through the interosseous membrane of the anterior interosseous vessels that supply the dorsal as well as the volar surfaces of the distal antebrachium. What are the local , regional, and systemic effects of needling PC 6? 17
7/19/16 Connective Tissue at PC 6 Interosseous membrane – Longitudinal stability of the antebrachium, or forearm Clinical relevance – High-force compressive trauma can injure the forearm and elbow, tearing the membrane, and causing not only instability but also considerable pain and disability by limiting motion and changing the biomechanics of the wrist Neural Elements at PC 6 Median nerve – Sensory – Motor – Autonomic Medial and lateral antebrachial cutaneous nerves Anterior interosseous nerve 18
7/19/16 Neural Elements at PC 6 Clinical relevance: – Local: Identify and treat sources of nerve entrapment and compression that may mimic carpal tunnel syndrome – Regional: Complex regional pain syndrome (aka reflex sympathetic dystrophy – Systemic: Long loop reflexes to the brain stem and the rostral ventrolateral medulla Large Intestine (LI) Channel Radial Nerve Wrist and Digit Extensors 19
7/19/16 Radial nerve 20
7/19/16 What Makes LI 4 a “Big Point”? LI 4: “Hegu” Needling affects potentially every nerve of the thoracic limb – Radial – Ulnar – Median (with deep needling) – Sympathetic fibers 21
7/19/16 Dorsal View Palmar View 22
7/19/16 PELVIC LIMB Bladder (BL) Sciatic Nerve 23
7/19/16 Left pelvic limb, canine Consider the Spinal Segmental Sources of Peripheral Nerves KI 1 “GUSHING SPRING” TCM: Stabilizes and calms the spirit Descends excess coming from the head Medical Acupuncture: Rich with autonomic fibers “nervi vasorum” 24
7/19/16 HEAD AND NECK 25
7/19/16 Trigeminal Nerve 26
7/19/16 Knowing anatomy makes for a safer acupuncture practice. 27
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7/19/16 ORGAN EFFECTS THROUGH SEGMENTAL STIMULATION Evidence Chen CY et al The possible neuronal mechanism of acupuncture: morphological evidence of the neuronal connection between groin a-shi point and uterus. Evid Based Complement Alternat Med. 2013;2013:429186. Evidence Chang FY et al. Effect of transcutaneous nerve stimulation on esophageal function in normal subjects – evidence for a somatovisceral reflex. Am J Chin Med. 1996;24(2):185-192. 29
7/19/16 Evidence Sato A et al. Neural mechanisms of the reflex inhibition and excitation of gastric motility elicited by acupuncture-like stimulation in anesthetized rats. Neurosci Res. 1993;18(1):53-62. Director of the Experimental Institute of Acupuncture and Moxibustion Therapy “Autonomic Nervous System”, an illustration from Zhu’s New Acupuncture and Moxibustion, indicating her emphasis on Western medical concepts. Somatovisceral Connections 30
7/19/16 Treating Equine Non-Surgical Colic 31
7/19/16 ¡ Somatic afferent nerve stimulation leads to normalization of central, peripheral, and autonomic nervous system function. ¡ Noblett K. § Neuromodulation and female pelvic disorders § Clin Opin Urol. 2016;26(4):321-327. ¡ Yamanishi T et al. § Neuromodulation for the treatment of lower urinary tract symptoms. § Low Urin Tract Symptoms. 2015;7(3):121-132 ¡ Mechanisms for overactive bladder involve: § Reflex inhibition of detrusor contraction by the activation of afferent fibers Activation of the hypogastric nerve Direct inhibition of the pelvic nerve within the sacral cord Supraspinal inhibition of the detrusor reflex 32
7/19/16 ¡ Mechanisms for stress incontinence involve: § Contraction of the pelvic floor muscles through an effect on the muscle fibers § Stimulation of the pudendal nerves ¡ Somatic afferent nerve stimulation leads to normalization of central, peripheral, and autonomic nervous system function. ! BACK AND PELVIS 33
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7/19/16 What are the local, regional, and visceral effects of the pelvic BL points? Thoracolumbar Fascia 35
7/19/16 The Dao of Chinese Medicine According to Donald E. (“Deke”) Kendall’s translation of the “curious meridians”, the Chinese were indicating that these were “singular vessels”, such as the aorta, venae cavae, and the unique venous drainage of the back Azygous and hemi-azygous veins drain the back 36
7/19/16 Continuous with the drainage of the brain 37
7/19/16 Evidence for GV 20 and Circulation to the Brain Learning Objectives 3. Identify medical conditions treated with acupuncture and resources for referral and further learning 38
7/19/16 What Can Acupuncture Treat in Addition to Pain? Digestive disorders: gastritis and hyperacidity, spastic colon, constipation, diarrhea Respiratory disorders: sinusitis, sore throat, bronchitis, asthma, recurrent chest infections Neurological and muscular disorders: headaches, facial tics, neck pain, rib neuritis, frozen shoulder, tennis elbow, various forms of tendinitis, low back pain, sciatica, osteoarthritis Urinary, menstrual, and reproductive problem [From This-Acupuncture-All-About] Systematic Reviews, Meta-Analyses Acute Ischemic Stroke: Acupuncture improves the neurologic score and clinical outcome over conventional approach – Wang Y et al. Scalp acupuncture for acute ischemic stroke: a metaanalysis of randomized controlled trials. Evid Based Complement Alternat Med. 2012; 2012:480950. doi: 10.1155/2012/480950. Co-morbid symptoms among military fighters: Acupuncture effectively treats headaches, anxiety, sleep disturbances, depression and chronic pain as components of the trauma spectrum response – Lee C et al. The effectiveness of acupuncture research across components of the trauma spectrum response (tsr): a systematic review of reviews. Systematic Reviews. 2012;1:46. doi: 10.1186/20464053-1-46. Systematic Reviews, Meta-Analyses Burning Mouth Syndrome: Acupuncture reduces sensation of burning in the oral cavity – Yan Z et al. A systematic review of acupuncture or acupoint injection for management of burning mouth syndrome. Quintessence Int. 2012;43(8):695-701. 39
7/19/16 Systematic Reviews, Meta-Analyses Addictive Behavior: Acupuncture improves smoking cessation rate and reduces the number of cigarettes smoked each day – Cheng HM et al. Systematic review and meta-analysis of the effects of acupoint stimulation on smoking cessation. Am J Chin Med. 2012;40(3):429-442. Postoperative Nausea and Vomiting: Both invasive and non-invasive acupuncture point stimulation prevent post-operative nausea and vomiting with minimal side effects – Holmer Pettersson P et al. Acupuncture prior to surgery to minimize postoperative nausea and vomiting: a systematic review. J Clin Nurs. 2012;21(13-14):1799-1805. Systematic Reviews, Meta-Analyses Acupuncture treats both tension and neurovascular headache – Linde K et al. Acupuncture for tension-type headache. Cochrane Database Syst Rev 2009:CD007587. – Zhao L, Guo Y, Wang W, et al. Systematic review on randomized controlled clinical trials of acupuncture therapy for neurovascular headache. Chin J Integr Med. 2011;17(8):580-586. Systematic Reviews, Meta-Analyses Shoulder Pain after Stroke: Acupuncture treats pain in the shoulder after stroke when combined with exercise – Lee JA et al. Acupuncture for shoulder pain after stroke: a systematic review. J Altern Complement Med. 2012;18(9):818-823. 40
7/19/16 Systematic Reviews, Meta-Analyses Back Pain: Acupuncture may more effectively alleviate the symptoms of acute low back pain than non-steroidal inflammatory drugs – Lee JH et al. Acupuncture for acute low back pain: a systematic review. Clin J Pain. 2013;29(2):172185. – Hutchinson AJ et al. The effectiveness of acupuncture in treating chronic non-specific low back pain: a systematic review of the literature. J Orthop Surg Res. 2012;7:36. Systematic Reviews, Meta-Analyses Pelvic Organ Dysfunction: PTNS improves symptoms, lessens pain and bolsters quality of life by means of percutaneous tibial nerve stimulation – Biemans JMAE et al. Efficacy and effectiveness of percutaneous tibial nerve stimulation in the treatment of pelvic organ disorders: a systematic review. Neuromodulation. 2013;16:25-34. Systematic Reviews, Meta-Analyses Pregnancy Rates in Women Following In-Vitro Fertilization: Acupuncture increases clinical pregnancy rate and live birth rate – Zheng et al. Effects of acupuncture on pregnancy rates in women undergoing in vitro fertilization: a systematic review and meta-analysis. Fertil Steril. 2012;97(3):599-611. Labor Pain: Both acupressure and acupuncture lessened the intensity of pain; acupuncture reduced analgesic drug intake – Smith CA et al. Acupuncture or acupressure for pain management in labour. Cochrane Database Syst Rev. 2011; (7):CD009232. 41
7/19/16 Systematic Reviews, Meta-Analyses Primary Dysmenorrhea: Acupuncture reduces pain in the short term with non-invasive point stimulation – Chung YC et al. Acupoint stimulation intervention for people with primary dysmenorrhea: systematic review and meta-analysis of randomized trials. Complement Ther Med. 2012;20(5):353-363. Chronic Pain: Acupuncture outperforms sham and noacupuncture for the treatment of chronic pain – Vickers AJ et al. Acupuncture for chronic pain: individual patient data meta-analysis. Arch Intern Med. 2012;172(19):1444-1453. Systematic Reviews, Meta-Analyses Osteoarthritis of the Knee and Other Peripheral Joints: Acupuncture outperforms standard care treatment, sham acupuncture and waiting for further treatment in cases of knee pain from osteoarthritis – Manheimer E, Cheng K, Linde K, Lao L, Yoo J, Wieland S, et al. Acupuncture for peripheral joint osteoarthritis. Cochrane Database Syst Rev 2010:CD001977. – Cao L, Zhang XL, Gao YS, et al. Needle acupuncture for osteoarthritis of the knee. A systematic review and updated meta-analysis. Saudi Med J. 2012;33(5):526-532. Systematic Reviews, Meta-Analyses Cancer Care – Acupuncture controls nausea and vomiting Kay Garcia M, McQuade J, Haddad R, et al. Systematic review of acupuncture in cancer care: a synthesis of the evidence. J Clin Oncol. 2013 Mar 1;31(7):952-60. – Acupuncture relieves hiccups Choi T-Y, Lee MS, and Ernst E. Acupuncture for cancer patients suffering from hiccups: a systematic review and meta-analysis. Complementary Therapies in Medicine. 2012;20:447-455. 42
7/19/16 Systematic Reviews, Meta-Analyses Obesity: Acupuncture produced similar efficacy as anti-obesity medication but with fewer adverse effects – Sui Y et al. A systematic review on use of Chinese medicine and acupuncture for treatment of obesity. Obes Rev. 2012;13(5):409-430. Resources for Further Learning American Academy of Medical Acupuncture – Annual symposia – Courses in medical acupuncture – medicalacupuncture.org American Board of Medical Acupuncture – List of approved training programs – dabma.org/programs.asp Referral List American Academy of Medical Acupuncture – medicalacupuncture.org – “Find an Acupuncturist” – Denotes board certified physician acupuncturists (DABMA) as well as Fellows of the American Academy of Medical Acupuncture (FAAMA) 43
7/19/16 Summary Final Thoughts The way acupuncture works is right before our eyes and in our hands It involves neuromodulation and connective tissue treatment Taking a neuroanatomic and connective tissue, medical acupuncture approach does not diminish the wonderment of acupuncture In fact, it heightens it. Final Thoughts Medical acupuncture exemplifies how scientific research and critical inquiry allow us to analyze traditional approaches and to sort fact from myth. Medical acupuncture builds upon, updates, and upgrades ancient approaches such as Chinese Medicine. 44
7/19/16 Final Thoughts As medical acupuncturists, we recognize the important strides that Chinese and other Asian acupuncturists brought to the discipline and the astute observations they made about structure – function relationships These enduring connections provide fertile territory for further explorations Final Thoughts Approaching integrative medicine scientifically facilitates its integration into both primary and specialty care. Additional Reading Robinson N. 4 myths about acupuncture. Veterinary Practice News. 10/27/14. -Acupuncture/ Robinson NG. One Medicine, One Acupuncture. Animals. 2012;2(3):395-414. Accessed at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC 4494296/ Robinson NG. Interactive Medical Acupuncture Anatomy. Teton NewMedia and CRC Press. Published March 2, 2016. 1251 pages. 45
American Academy of Medical Acupuncture Primarily a physician acupuncture association -medicalacupuncture.org American Board of Medical Acupuncture confers board certification on eligible MD and DO members who have completed all requirements: DABMA.org Not all courses in medical acupuncture teach strictly scientificmedical acupuncture
Student Training Manual/Workbook . 5 Law Enforcement/Criminal Justice Use Only Revised 5/23/2016 Revised By: Revised Date: Revised By: Revised Date: Revised By: Revised Date: Revised By: Revised Date: Revised By: Revised Date: Revised By: Revised Date: Revised By: Revised Date: Marie Jernigan Supervisor Training Unit SBI Criminal Information and Identification Section May 23, 2016 Jeannie .
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