1 Acupuncture Part 1 Modernization of Ancient Wisdom

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Acupuncture Acupuncture Part 1Part 1

Modernization of Ancient Modernization of Ancient WisdomWisdom

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Comparison of East & Comparison of East & WestWest

Empirical Empirical Observations Observations over Thousands over Thousands of Yearsof Years

Scientific Scientific Method & Case-Method & Case-Based MedicineBased Medicine

EasEastt

WestWest

Art of MedicineArt of Medicine Holistic ViewHolistic View Circular LogicCircular Logic EnergeticEnergetic

Technology of Technology of MedicineMedicine

Molecular and Molecular and Organ ViewOrgan View

Linear LogicLinear Logic MechanisticMechanistic

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What is Acupuncture?What is Acupuncture?

AcusAcus meaning needle meaning needle PungarePungare meaing to meaing to

piercepierce ZhenjiuZhenjiu meaning meaning

needle (needle (zhenzhen) and ) and moxabustion (moxabustion (jiujiu))

Manipulating body Manipulating body balance through balance through regulating flow of Qiregulating flow of Qi

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MoxabustionMoxabustion

Applied either Applied either moxa or heated moxa or heated element (1500° element (1500° F) to arthritic F) to arthritic jointsjoints• Moxa burned in Moxa burned in

roomroom

Moxa was better Moxa was better & longer lasting& longer lasting

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Scientific Evidence ?Scientific Evidence ?

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What Scientific What Scientific Evidence Exists?Evidence Exists?

Total Medline Cites for Total Medline Cites for AcupunctureAcupuncture to Date Represents 7107 Publicationsto Date Represents 7107 Publications

62 Double-Blind Studies62 Double-Blind Studies

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100

200

300

400

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Animal Acupuncture Animal Acupuncture StudiesStudies

Represent 1/10th of all CitesRepresent 1/10th of all Cites Parallel Human Acupuncture Parallel Human Acupuncture

Studies in FrequencyStudies in Frequency No Double-Blind StudiesNo Double-Blind Studies

0

500

1000

1500

2000

1966-70

1971-75

1976-80

1981-85

1986-90

1991-95

1996-2000

0102030405060

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Placebo EffectPlacebo Effect

Study showed Study showed that, if something that, if something specific is specific is measured, then measured, then there is no placebo there is no placebo effect. Only if the effect. Only if the measure is measure is subjective.subjective.

So, “blindness” So, “blindness” may not be valid in may not be valid in all cases. all cases.

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NIH ‘97 Consensus on NIH ‘97 Consensus on APAP

Effective for Osteoarthritis and Effective for Osteoarthritis and Musculoskeletal PainMusculoskeletal Pain

Effective for many GI ProblemsEffective for many GI Problems• IBD, diarrhea, ulcerative colitis, IBD, diarrhea, ulcerative colitis,

peptic ulcers, dyspepsia, abdominal peptic ulcers, dyspepsia, abdominal pain, nausea and vomitingpain, nausea and vomiting

Effective for Pulmonary diseaseEffective for Pulmonary disease• asthma, coldsasthma, colds

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NIH ‘97 Consensus on NIH ‘97 Consensus on APAP

Effective for Effective for ImmunomodulationImmunomodulation• reduces inflammation, elevates reduces inflammation, elevates

WBC, WBC, interleukin-2 production interleukin-2 production Effective for Reproductive Effective for Reproductive

DisordersDisorders uterine bleeding, ovulationuterine bleeding, ovulation

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How Does AP Work?How Does AP Work?

The physiologic effects of The physiologic effects of acupuncture therapy cannot be acupuncture therapy cannot be explained by a single explained by a single mechanism, but rather a series mechanism, but rather a series of interactions among theof interactions among the• Nervous SystemNervous System• Endocrine SystemEndocrine System• Immune SystemImmune System

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AP EventsAP Events

Simple in Simple in concept, complex concept, complex in actionin action

Starts from Local Starts from Local EffectsEffects

Expands to Expands to involve the entire involve the entire Neural AxisNeural Axis

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AP EventsAP Events

Local effectsLocal effects Segmental Segmental

effectseffects• Pain controlPain control• Organ effectsOrgan effects

Central effectsCentral effects

All take place at All take place at onceonce

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Basic Tenets of APBasic Tenets of AP

Based upon the Based upon the AP point selectedAP point selected

Based upon the Based upon the method of method of stimulationstimulation• Dry needlesDry needles• Electrical APElectrical AP• AquapunctureAquapuncture• HemoacupunctureHemoacupuncture

Based upon the Based upon the length of length of stimulationstimulation

Low-rate, twisting Low-rate, twisting stimulation of GV26 stimulation of GV26 leads to endorphin leads to endorphin response, while response, while high-frequency high-frequency needling of GV26 needling of GV26 leads to epinephrine leads to epinephrine responseresponse

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Effects of AcupunctureEffects of Acupuncture

Using manganese-Using manganese-enhanced fMRI enhanced fMRI (functional (functional magnetic magnetic resonance resonance imaging), visual imaging), visual effects can be seen effects can be seen in human and in human and animal neural animal neural tissuestissues

BaselineBaseline MannitoMannitoll

Mn InfusionMn Infusion EA GB34EA GB34

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Activation of Activation of cortex is site cortex is site specificspecific

Leads initially Leads initially to specific to specific effectseffects

GB34GB34 ST36ST36

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Activation has Activation has temporal effectstemporal effects

Longer Longer stimulation stimulation activates more activates more cortical structurescortical structures

Leads to broader Leads to broader effectseffects

5 minutes5 minutes 20 minutes20 minutes

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In separate study, In separate study, analgesic AP points analgesic AP points were compared to were compared to non-analgesic pointsnon-analgesic points• Analgesic AP altered Analgesic AP altered

brain regions brain regions involved in pain involved in pain modulationmodulation– PAG, MnR, PAG, MnR,

hypothalamus, hypothalamus, thalamusthalamus

• Non-Analgesic AP did Non-Analgesic AP did not activate same not activate same areasareas

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Method of StimulationMethod of Stimulation

Stimulation of BL-20 Stimulation of BL-20 (the SP association (the SP association point) in horses led point) in horses led to analgesia using to analgesia using dry needles or dry needles or electrical AP.electrical AP.

Only EA increased Only EA increased release of release of endrophins into the endrophins into the blood.blood.

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Medication Timing & Medication Timing & TCM 24-hour ClockTCM 24-hour Clock

GB 11- 1AM

TH 9- 11 PM

PC 7- 9 PM

KID 5- 7 PM

BL 3- 5 PM SI 1- 3 PM

HT 11- 1 PM

SP 9- 11 AM

ST 7- 9 AM

LI 5- 7 AM

LU 3- 5 AMLIV 1- 3 AM

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Anatomical Anatomical ConsiderationsConsiderations

Acupuncture pointAcupuncture point

MeridiansMeridians

Reflex ConnectionsReflex Connections

Central Central ConnectionsConnections

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Shu Xue Shu Xue (communication (communication outlet)outlet)

Electrical Electrical resistance resistance

Electrical Electrical conductivityconductivity

High density ofHigh density of• free nerve endingsfree nerve endings• arteriolesarterioles• lymphatic vesselslymphatic vessels• mast cellsmast cells

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AP PointsAP Points

Points where Points where neurovasculaneurovascular bundles r bundles where nerves where nerves penetrate penetrate the body the body fasciafascia

Points where Points where nerves nerves bifurcatebifurcate

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AP PointsAP Points

Inner and Inner and Outer Outer Bladder Bladder Meridian Meridian PointsPoints

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Acupuncture points: Acupuncture points: IV IV typestypes

Type I: motor point; 67% of all the Type I: motor point; 67% of all the pointspoints• maximal contraction with minimal maximal contraction with minimal

intensity of stimulationintensity of stimulation• the nerve enters the muscle the nerve enters the muscle • LI-4 ( He-gu)LI-4 ( He-gu)

Type II: dorsal & ventral midlineType II: dorsal & ventral midline• superficial nerves in the sagittal planesuperficial nerves in the sagittal plane• #68 (Bai-hui)#68 (Bai-hui)

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Acupuncture points: Acupuncture points: IV IV typestypes

Type III: superficial nerves / nerve Type III: superficial nerves / nerve plexusesplexuses• GB-34: common peroneal nerve (deep GB-34: common peroneal nerve (deep

& superficial branches)& superficial branches)• PC-6: over the median nervePC-6: over the median nerve

Type IV: Muscle tendon junctionsType IV: Muscle tendon junctions• Golgi tendon organGolgi tendon organ• BL-57: gastrocnemiusBL-57: gastrocnemius

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HemoAcupuncture HemoAcupuncture PointsPoints

Most AP points Most AP points are associated are associated with vascular with vascular elements elements (veins)(veins)

Blood vessel Blood vessel walls (veins) walls (veins) appear to appear to have AP points have AP points directly on or directly on or in themin them

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MeridiansMeridians



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Meridians: Meridians: Myth or Myth or Reality?Reality?

Close correlation betweenClose correlation between• AP MeridianAP Meridian• Peripheral Nerve PathwaysPeripheral Nerve Pathways

Meridians appear to possess Meridians appear to possess bioelectric function similar to PNbioelectric function similar to PN

Meridians follow PNMeridians follow PN• Lung (LU) = Musculocutaneous NLung (LU) = Musculocutaneous N• Pericardium (PC) = Median NPericardium (PC) = Median N

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Meridian ResearchMeridian Research

Stimulation of AP Stimulation of AP points on points on meridian lower meridian lower resistance at resistance at other meridian other meridian pointspoints

Injection of radio-Injection of radio-isotopes into one isotopes into one point gradually point gradually accumulates at accumulates at other pointsother points

Radio signals Radio signals places over one places over one AP point can be AP point can be picked up at picked up at other AP points other AP points along the along the meridianmeridian

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14 Major Meridians14 Major Meridians

Lung Meridian: LULung Meridian: LU Heart Meridian: HTHeart Meridian: HT Pericardium M.: PCPericardium M.: PC Spleen Meridian: SPSpleen Meridian: SP Liver Meridian: LIVLiver Meridian: LIV Kidney Meridian: KIDKidney Meridian: KID Conception Vessels: Conception Vessels:

CVCV

Large Intestines M.: LILarge Intestines M.: LI Small Intestines M.: SISmall Intestines M.: SI Triple Heater M.: THTriple Heater M.: TH Stomach Meridian: STStomach Meridian: ST Gallbladder M.: GBGallbladder M.: GB Bladder Meridian: BLBladder Meridian: BL Governing Vessels M.: Governing Vessels M.:

GVGV

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MeridiansMeridians

Energy flow systemEnergy flow system Chi (Qi): energy flowChi (Qi): energy flow AP points on 14 major meridiansAP points on 14 major meridians Normal: Energy flow all the time Normal: Energy flow all the time

on all the meridians from one on all the meridians from one acupuncture point to anotheracupuncture point to another

LU->LI->ST->SP->HT->SI->BL->KID->PC->TB->GB-LU->LI->ST->SP->HT->SI->BL->KID->PC->TB->GB->LIV>LIV

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MeridiansMeridians

Where there is no free flow, there is pain.Where there is no free flow, there is pain.

MeridianMeridian

No free flowNo free flowPainPain

Pathogenic Pathogenic factorsfactors

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Where there is free flow, there is no pain.Where there is free flow, there is no pain.

MeridianMeridian

No free flowNo free flowPainPain

Pathogenic Pathogenic factorsfactors

MeridianMeridian

Eliminating Eliminating

NormalNormal

MeridiansMeridians

Acupuncture StimulationAcupuncture Stimulation

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MeridiansMeridians



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AP EffectsAP Effects

Needle insertion stimulates Needle insertion stimulates afferent A-delta nociceptive afferent A-delta nociceptive fibers which leads tofibers which leads to• Local EffectsLocal Effects• Spinal Cord EffectsSpinal Cord Effects• Brainstem EffectsBrainstem Effects

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Acupuncture PathwayAcupuncture Pathway

AP Stimulus is carried by AP Stimulus is carried by afferent peripheral nerveafferent peripheral nerve• Can be blocked by ProcaineCan be blocked by Procaine• No AP analgesia on paralyzed No AP analgesia on paralyzed

limbs (somatosensory paralysis)limbs (somatosensory paralysis)• Most profound AP analgesia is Most profound AP analgesia is

from points overlying major from points overlying major peripheral nervesperipheral nerves

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Acupuncture PathwayAcupuncture Pathway

Stimulus enters Stimulus enters the spinal cordthe spinal cord

Integrated Integrated information information ascends the ascends the spinal cord to spinal cord to the brainstem, the brainstem, thalamus and thalamus and cerebral cortexcerebral cortex

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Acupuncture & PainAcupuncture & Pain

Responses to Responses to • heatheat• electricityelectricity• pinprick pinprick • pinchpinch PTPT AnalgesiaAnalgesia

APAP

NaloxoneNaloxone

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EA: EA: Effect of Increasing Effect of Increasing FrequencyFrequency

200 Hz200 Hz

4 Hz4 Hz

0.2 0.2 HzHz

Electrical AcupunctureElectrical Acupuncture

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EA: EA: Low Frequency ± NaloxoneLow Frequency ± Naloxone

Electro-Electro-acupuncture acupuncture

4 Hz + saline4 Hz + saline

4 Hz + 4 Hz + NaloxoneNaloxone

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Electro-Electro-acupuncture acupuncture

200 Hz + saline200 Hz + saline

200 Hz + naloxone200 Hz + naloxone

EA:EA: High Frequency ± Naloxone High Frequency ± Naloxone

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Acupuncture AnalgesiaAcupuncture Analgesia

Enkephalins & Dynorphins Enkephalins & Dynorphins Spinal Cord Spinal Cord (Substantia Gelatinosa)(Substantia Gelatinosa)

Endorphins Endorphins Brainstem Brainstem (Periaqueductal Gray Matter)(Periaqueductal Gray Matter)

5HT 5HT Brainstem Brainstem (Raphe Nuclei)(Raphe Nuclei)

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AP AnalgesiaAP Analgesia

Varies among Varies among patients (species patients (species specific)specific)

Varies from Varies from location of AP location of AP pointpoint

Varies with Varies with proximity to AP proximity to AP pointpoint

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0.5

1

1.5

2

2.5

Pain

Thr

esho

ld

baseline horses mules cattle

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1 Acupuncture Part 1 Modernization of Ancient Wisdom