Acupuncture Mechanisms East Meets West

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Acupuncture MechanismsEast Meets West

• Thomas Archie, MD, DABFM, DABMA
• St. Lukes Wood River Medical Center
• Integrative Therapies Service

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Objectives

• Discuss proposed mechanisms of action of
  acupuncture from two points of view
• Western medicine
• Chinese medicine
• Applications
• Complications

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Acupuncture China to Europe

• Huang Di Nei Jing
• Yellow Emporers Inner Classic
• Earliest existing major text on AP
• 3rd-1st Century BCE
• Europe
• 1500-1600s Jesuit missionaries gave earliest
  reports of Chinese Medicine
• 1683 William Tin Rhijne
• Dissertation on Arthritis
• 1671-1686 Three translations of Chinese medical
  texts
• Detailed AP names, moxibustion, needle
  manipulation

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Acupuncture Pre-Research

• Soulie de Mourant
• Early to mid 1900s
• Taught French physicians
• Published 3 volumes of LAcuponcture Chinoise in
  1939-1955

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Early Acupuncture Research

• France
• Mechanism studies beginning in 1940s
• China
• Acupuncture pain relief studies started 1965

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Early Electrical Studies

• 1940-50s Niboyet (France)
• AP points decreased electrical resistance
  relative to surrounding skin
• Most points w/ decreased electrical resistance
  corresponded with Chinese AP charts
• AP pts on classically paired meridians have
  decreased Elect resistance compared with points
  on unpaired meridians

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Early Chinese Acupuncture Meridian Chart
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Neurotransmitters

• Endorphin release by acupuncture
• Pomeranz 1976 - endorphins (some analgesic
  effects blocked by Narcan)
• Clinical effect lasts much longer than blood
  levels of endorphins
• Seen in low frequency electroacupuncture

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1979 LeBarDiffuse Noxious Inhibitory Control

• Inhibit pain by counter-irritation stimulation
• Serotonin and Endorphins mediate the response
• Pain inhibition is directly related to intensity
  of stimulus
• Distance between conditioned site and site of
  stimulation is not important
• Detailed loop involving spinal tracts, brainstem,
  and thalamus

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Neurotransmitters

• Known increase in release during AP treatment
• Serotonin, NE, Substance P, GABA, dopamine, ACTH
• Opioid
• B-endorphins, enkephalin, dynorphin

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fMRI Study

• Needle placed in foot Acupuncture point
  associated with stimulation of brains visual
  cortex

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fMRI Study

• Auditory Complex stimulated by needle placed in
  AP point on the leg associated with hearing

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91 of Acupuncture Points share this Histology
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Trigger Points

• 1977
• 71 correlation between Trigger Points and
  Acupuncture points

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Meridians

• Meridians have decreased electrical resistance
  relative to surrounding skin
• Qi measured as microelectrical current
• Flows in a circuit
• Toes to fingers to head to toes
• Up on anterior surface of the body
• Down on posterior surface of the body

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Meridians
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Future Research

• Central Nervous System (CNS) as a classic example
  of a nonlinear system
• Billions of neurons and astrocytes
• Response to environment is orderly but tends to
  change with time
• Functional MRI - change of CNS with time -
  important for future research of mechanism
• Future research to look at CNS function as a
  whole, rather than function of its individual
  components

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Future Research

• Outcomes research using
• Existing research models (sham AP vs. usual
  care)
• Patient-centered, market-based models
• Interactive modalities (acupuncture, homeopathy,
  massage, reiki, healing touch) potentially better
  analyzed by a yet-undeveloped model
• Problems inherent in applying double-blind,
  placebo-controlled model

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Dualism vs. Monism

• Descartes/Newton designed a Dualist model
• Body and Mind are separate
• Mind is a product of the Body (esp. Brain)
• Study components and understand the whole (ex
  block breakdown of serotonin and thus increase
  longevity of serotonin to produce clinical
  improvement of depressed patient)

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Dualism vs. Monism

• Dualism parts make up the whole (body vs.
  mind/soul)
• Allopathic Medicine Descartes, Newton
• Study components and understand the whole
• Example Serotonin enhanced via depression drugs
• Monism body, mind, consciousness, universe are
  continuous and interactive
• Traditional Chinese Medicine, Ayruveda
• Example Weather-related Wind invasion in person
  with Liver Qi stagnation with Yin or Yang
  Deficiency as risk factor
• Cold/Flu vs. Vertigo vs. Autoimmune Disease
• The individual is reflective of the universal,
  and vice-versa

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Eastern Mechanisms
Vapor
Qi
Rice
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Eastern Mechanisms

• Qi (Character with vapor rising above cooking
  rice)
• Early 1900s - Soulie de Mourant- Qi energy
  and Jing meridian
• Simplified translation of complicated terms
• Life Force made up of air and food transformed
  by body into blood and body fluids
• Nei Jing written during 3rd 1st Century BCE
• Chinese physicians cadaveric dissections
• Using needles of glass, metal and bone to
  influence neurovascular system

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Meridians

• Acupuncture points linked together in lines
  called meridians
• Meridians named for associated Organ
• Kidney, Heart, Small Intestine, Bladder
• Liver, Pericardium, Triple Energizer, Gallbladder
• Spleen, Lung, Large Intestine, Stomach

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Meridians
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Different Acupuncture Models

• Traditional Chinese Medicine (TCM)
• Eight Principles (Yin/Yang, Damp/Dry, Cold/Heat,
  Interior/Exterior)
• Zhang-Fu organ pairings blends Yin-Yang and 5
  Element
• Five Element (Korean)
• Wood, Fire, Earth, Metal and Water
• Meridian-based Japanese, Vietnamese, French
• Different schools of thought regarding etiology
  of disease (Kidney versus Spleen/Stomach)
• Neuroanatomical - CraigPENS, osteopuncture

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Meridian-Based Acupuncture

• Blockage in meridian flow produces disease
• Therapeutic action of unblocking meridian flow
  (Relieving Stagnation)
• Pain
• Asthma
• Heavy, Painful, or Irregular Menstrual Periods

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TCM Qi Physiology

• Stomach separates pure from impure Qi of food
• Pure Qi to Spleen
• Impure to Small Intestine (process repeats again)
• Spleen sends Food Qi to Lung
• Lung combines it with pure Qi extracted from air
• Food/Air Qi heated by Yuan Qi (ancestral pilot
  light) provided by Kidney to make Nutritive Qi
• In Heart to make Blood
• In Meridians

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Fire
Five Elements System of Correspondences
Earth
Wood
Water
Metal
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Five Element Acupuncture

• Imbalance between Elements causes Disease
• Example
• Chronic overwork/abuse/disease leads to
  deficiency of Water (fatigue, chronic
  UTI/stones/incontinence, joint pains, low back
  pain, fear, low self-esteem)
• Water controls Fire (Water Def Fire Excess)
• Excess Fire symptoms result (anxiety, hot
  flashes, palpitations, insomnia, inflammation)

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Five Element Acupuncture

• Patient Evaluation
• Pattern Recognition
• Treatment
• Reassessment for clinical effect

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Patient Evaluation

• Evaluate history of medical/surgical diagnoses
• Patterns
• Sleep, pain, digestion, emotional responses to
  stressors, self-organization, flavor and color
  affinities, menstrual patterns, timing of
  symptoms (24hr, monthly, seasonal variations)

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Pattern Recognition

• Five Elements
• Interconnections between
• Patterns
• TCM Eight
• Principles

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Treatment

• Treat by Tonifying deficiencies and
  Dispersing excesses
• Release excess Fire
• Tonify deficient Water
• Use Acupuncture and Chinese Herbs in combination

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Fire
Five Elements System of Correspondences
Earth
Wood
Water
Metal
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Five Element Correspondences

• Wood (Liver, Gallbladder)
• Driven, multiple projects, movement,
  anger/anxiety, tight traps/lateral neck/IT band,
  TMJ, migraines, caffeine sensitivity,
  fibromyalgia, blue/green, sour/citrus, Spring,
  expansion, insomnia (esp. sleep maintenance
  11pm-3am), east
• Augments Fire, controls Earth, augmented by Water
  and controlled by Metal
• Coupled with Fire

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Five Element Correspondences

• Fire (Heart, Small Intestine, Pericardium, Triple
  Energizer)
• Creative, CEO, joy, palpitations, insomnia (esp.
  sleep initiation), hot flashes, night sweats,
  cardiac disease, dysrhythmias, mania, red/orange,
  bitter/roasted, summer, south
• Augments Earth, Controls Metal, Augmented by
  Wood, Controlled by Water
• Coupled with Wood and Water

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Five Element Correspondences

• Earth (Spleen, Stomach)
• Nurturing, worry/obsession, GI issues (loose
  stools, gastritis, bloating, abd pain),
  sinusitis, cysts, tumors, lumps, dampness,
  obesity, chronic fatigue(multifactorial), sweet,
  dampness (cysts, edema), yellow/brown,
  transitions of seasons, center of compass
  positions
• Nurtures Metal, Controls Water, Controlled by
  Wood
• Coupled with Metal

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Five Element Correspondences

• Metal (Lung, Large Intestine)
• Respiratory, skin disorders (3rd lung),
  constipation, dryness, sense of duty, grief,
  loss, depression (multifactorial),
  flavorful/spicy, white/grey/colorless, autumn,
  west
• Nurtures Water, Controls Wood, Controlled by Fire
• Coupled with Earth

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Five Element Correspondences

• Water (Kidney, Bladder)
• UTI, Kidney stones, incontinence, joint pain, low
  back pain, inner chill, abuse, philosopher,
  music, hearing problems, throat, winter, black,
  north, salty, motivation/willpower
• Nurtures Wood, Controls Fire, Controlled by Earth
• Coupled with Fire

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Eastern Microsystems

• Holographic/fractal representation of homunculus
  on skin surface
• Tongue, Ear, hand, foot, scalp
• Auricular medicine highly specialized by French
• Ancient Egyptian paintings depict auricular
  cautery
• Nogier (FR) 1950s investigated history of ear
  cautery for back pain

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Homunculus
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Chinese Diagnostics

• Tongue
• Color, size, wetness/scalloping, coating,
  cracks
• Geographic representations of organs
• Clinical changes occur slowly (weeks)
• Pulses
• Radial artery
• Organ assessment at certain positions/depths
• Clinical changes occur quickly (during treatment)

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(KI) Yang deficiency Swollen, pale, scalloped,
thin clear coat
Kidney Yin Deficiency Excess Heat in
Heart Invasion of Wind Long, thin, dry, red body
with lateral deviation Dry yellow coat
Heart Yin and Blood Deficiency Tongue body pale
and tip red and pointed No coat
Severe Yin Deficiency Long-standing heat or fire
(LR or ST) Red tongue body with black, dry
central coat
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Acupuncture Microsystems

• Auricular points (low electrical resistance) 90
  accurate in recognizing past or present organ
  diseases (gastritis, asthma, past orthopedic
  surgeries) Nogier (France)
• Recent randomized, double blinded,
  placebo-controlled study on pediatric bed wetting
  using Korean Hand AP system

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So What Is It Good For?
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Applications

• Studies of various standards
• Value of RDBPCT design for interactive modalities
  dubious
• Internal Medicine
• Asthma, nausea, IBS, Crohns/UC, anxiety,
  depression, epilepsy, chronic UTI, eczema,
  sinusitis, allergies, headache, TMJ, Bells
  Palsy, neuropathy, stroke (scalp acupuncture)
• Substance abuse - smoking, chewing, opiates,
  alcohol, craving

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Applications

• OB/GYN
• Premenstrual syndrome, (peri)menopausal symptoms,
  dysmenorrhea, menorrhagia, oligomenorrhea,
  infertility, labor pain, breech presentation
• Pain
• Epicondylitis, plantar fasciitis, arthritis, low
  back pain, neck pain, pelvic pain, zoster

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Applications

• Essentially, any medical problem should be
  accessible with AP
• Issues are practicality and density of disease
• Acupuncturist training and experience
• Role in Cancer
• Helpful for decreasing side effects of
  chemo/radiation
• Especially with herbal therapy
• Facilitating spiritual transition to interaction
  with mortality

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Veterinary Acupuncture
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Veterinary Acupuncture
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Clinical Research Examples
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Knee Osteoarthritis

• Lancet. 2005 Jul 9-15366(9480)100-1.
• RCT 294 patients in 28 outpatient centers
• 12 treatments over 8 weeks
• 3 groups (AP, sham AP, wait list control)
• WOMAC index questionairre at 8, 26, 52 weeks
• Result
• Pain and joint function improved more with
  acupuncture than with minimal acupuncture or no
  acupuncture in patients with osteoarthritis of
  the knee. However, this benefit decreases over
  time.

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Low Back Pain

• JAMA. 1999281818-823.
• 29 men and 31 women with LBP secondary to
  degenerative disk disease
• Treated with percutaneous electrical nerve
  stimulation (PENS), sham-PENS, TENS, and
  exercise.
• The PENS group had
• Significant and larger reductions in VAS scores
• Decreased drug usage
• Improved physical activity, quality of sleep, and
  sense of well-being (Plt.05 for each).

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Low Back Pain

• Pain. 2002 Mar96(1-2)189-96
• RCT with 131 consecutive outpatients with LBP for
  at least 6 months and a normal neurological
  examination.
• Randomization to one of three groups
• Each group received PT over 12 weeks
• Plus either acupuncture, sham acupuncture, or no
  additional treatment.
• 20 treatments over 12 weeks
• Acupuncture was superior PT without acupuncture
  regarding pain intensity (P0.000), pain
  disability (P0.000), and psychological distress
  (P0.020) at the end of treatment.

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Chinese Herbal Medicine in Cancer

• Fu-Zheng pattern (correct predisposing patterns
  of deficiency and stagnation)
• Symptom management and increase in survival
• 197 pts Stage III and IV ENT cancers randomized
  to radiation with or without TCM herbs (Yi Qi
  Yang Yin Tang). 3-year survival 67 vs. 33.
• Sun. Rec Results in Cancer Research
  1988108327

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Chinese Herbal Medicine in Cancer

• 303 patients with Stage III and 63 with Stage IV
  gastric cancer with chemo randomized to
  additional Pishen Fang herbal formula or to
  control group.
• 5yr survival 53 Stage III with herbs and 10
  Stage IV with herbs
• 10yr survival 47 Stage III with herbs
• Yu. J Trad Chin Med 199313(1)31.
• 2001 first US FDA-approved clinical study of
  extract of Coix lachryma-jobi (called Kanglaite)
  for refractory non-small-cell carcinoma of lung.
  Phase 2 trial began 2003.
• Previous Chinese studies show inhibition of
  mitosis of tumour cells during G2/M phase of the
  cell cycle, tumor cell apoptosis, increased gene
  expression of FAS and Apo-1, inhibits
  angiogenesis

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What does Acupuncture Look Like?
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Complications and Precautions

• Retained Needle
• Pneumothorax (any organ puncture)
• Auricular infections
• Other skin infections
• Temporary (24hr) clinical worsening
• Pregnancy
• Not a contraindication
• Theoretical concern of causing contractions
• Anticoagulation - not a contraindication

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Recommended Readings

• Between Heaven and Earth, Beinfield and Korngold.
  Easily read book on Chinese Medicine
• Alternative Therapies in Health and Medicine.
  Peer-reviewed journal on integrative medicine.
  Excellent articles. Inexpensive. 6 issues per
  year.

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Recommended Readings

• Vibrational Medicine, Gerber. Very well written
  on various forms of energy medicine -
  acupuncture, magnets, homeopathy, Bach flower
  essences, reiki...

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Acupuncture MechanismsEast Meets West

• Thomas Archie, MD, DABFM, DABMA
• St. Lukes Wood River Medical Center
• Integrative Therapies Service