Pain Management by Acupuncture

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Pain Management by Acupuncture

• Continue Education Course of
• _at_Advanced Acupuncture, Inc.
• 2007

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Acupuncture Pain Management

• Part I Theory
• Overview of scientific bases of acupuncture
• Mechanisms of pain management
• Current researches and clinical trials
• Pain Scores and evaluation methods

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Scientific Bases of Acupuncture

• Neurohumoral
• Morphogenetic
• Nerve Reflex Theory
• The gate control theory of pain
• Endorphin

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Neuro-humoral Approach

• Peripheral nervous system to be crucial in
  mediating the acupuncture analgesia
• Meridian-Cortex-Viscera correlation hypothesis

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Neurohumoral Approach

• Acupoint-brain-organ
• Acupuncture stimulates to brain cortex and nerve
  system, then control the chemical or hormone
  release to the disordered organs.

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Morphogenetic Theory Shang C. China, 1989

• Acupuncture points are singular points in surface
  bioelectric field
• The role of electric field in growth control and
  morphogenesis
• Organizing centers have high electric conductance
• Acupuncture points originate from organizing
  centers

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Nerve Reflex Theory -Ishikawa and Fujita
et al, Japan, 1950s

• Autonomic nervous system extending thru the
  internal organs
• Viscera-mutinous reflex
• Cutanous Viscera reflex
• Acupuncture utilize these reflexes for restoring
  the homeostasis of the body and acceralate the
  healing process.

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The Gate Control Theory Drs Melzack and
Wall, 1965

• Model for acupuncture pain relief
• Specific nerve fibers that transmit pain to the
  spinal cord (substantia gelatinous)
• Balance between Stimulation inhibitory fibers
• Short term block pain by acupuncture ( did not
  explain the prolong effect)

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Endorphin Theory Dr. Pomeranz, Canada, 1996

• Natural Morphine
• Acupuncture trigger the release of endorphin into
  the central nervous system
• Only deal with pain
• Corticoids and Substance P also released along
  with endorphin

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Therapeutic Mechanisms of Acupuncture
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Acupuncture Mechanisms of Action

• Conduction of electromagnetic signals
• Activation of opioids systems
• Changes in brain chemistry-release of
  neurotransmitters and neurohormones.

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Acupuncture Pathways
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Meridian-Cortex-Viscera Correlation Hypothesis

• 1. The meridian system is and connected the
  nervous system to the cerebral cortex.
• 2. It acts through neurohumoral mechanisms
• 3. Acu-point-Brain-organ model stimulates the
  brain cortex/nervous system, then controlling the
  chemical or hormone release to the disordered
  organs for treatment.

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Morphogenetic Singularity Theory

• Acupuncture points are singular points in surface
  bioelectric field
• Converging points of surface current for change
  in electric current flow.
• Abrupt transition from one state to another.
• Eg BaiHui (Du 20)

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Physical characteristics of the acupuncture
points-WHO

• Points are corresponds to the high electrical
  conductance points on the body surface
• High density of gap junctions at the epithelia of
  the acupuncture points.
• Gap junctions are hexagonal proteins that
  facilitate intercellular communication and
  increase electric conductivity.

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Research on Auricular points

• WHO found 43 points have proven therapeutic value
• Therapeutic effect can be achieved by needling,
  temperature variation, laser, ultrasound, and
  pressure.

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Effects of Acupuncture on the Brain

• UCI-Use functional MRI to investigate the
  mechanisms of acupuncture analgesia
• Stimulates Li 4 revealed activation of visual
  cortex.
• Needling Tin Hui revealed auditory cortex
  activation

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Effects of acupuncture on the Brain-auditory
cortex
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Why acupuncture has fewer side effects?

• May indirect adjust the process and restore
  normal function by activating the network of
  organizing centers in the organism
• The activation of the self-organizing activity is
  less likely to cause the side effects resulted
  from directly antagonizing a pathological
  process which often overlap with other normal and
  beneficial physiological processes.

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The role of electric field in growth control and
morphogenesis

• Enhanced cell growth toward cathode and reduced
  cell growth toward anode in electric fields of
  physiological strength
• Fast growing cells tend to have relative
  negativity polarity.
• The polarity is due to the increased negative
  membrane potential generated by mitochondria at
  high rate of energy metabolism

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Efficacy, effective, safety and costs of
acupuncture for chronic pain

• Evaluated 304,674 patients over 10,000 physicians
  and received 10 acupuncture for pain
• Results acupuncture was an effective and safe
  treatment
• The effects attributed to specific or nonspecific
  mechanisms and depend on the diagnosis-results a
  large research initiative.

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Mechanisms of acupuncture for Pain relief

• Polymodal receptors
• (PMRs) in the acupuncture points are
  sensitized for the immediate action.
• Action mediated by endogenous opioids
• Potent stimulus for activating the analgesic
  systems

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Therapeutic Mechanisms of Acupuncture -Dr.D.
Kendall, 1980

• Inserting a needle provokes an acute defensive
  inflammatory response
• Afferent nociceptive (pain) neurons distribute to
  the dorsal horn of the spinal cord
• Trigger the gamma loop efferent in the ventral
  horn and activate neurons that cross over the
  spinal cord to the brain
• Activate somatic motor nerves
• To muscles, and autonomic motor nerves to
  peripheral blood vessels and to the internal
  organs

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Acupuncture Pain Management

• Part II Clinical applications
• Differential diagnosis and treatment for
• Headache migraines, Trigeminal neuralgia,
• Carpal Tunnel Syndromes, Arthritis, Neck
• pain, Fibromyalgia, lumbago and sciatic
• neuralgia.

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Etiology of Headache

• Blood Vessels that become dilated enlarged or
  constricted
• Muscles in the neck and head become tight or
  tense
• Muscles around the eyes the become strained due
  to overwork
• Sinuses became swollen due to allergies or
  infections
• Nerves that transmit abnormal pain signals
• Joints in the jaw and neck are overused or
  damaged.

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Types of Headache -Western Medicine

• Vascular headache (Migraines)
• Muscle contraction headache
• Combined vascular muscle contraction headache
• Headache of nasal vasomotor reactions
• Headache of delusional conversion or
  hypochondriacal states

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Migraine Headache

• Classic Migraine
• Common migraine
• Cluster headache
• Hemiplegic and ophthalmoplegic migraine
• Lower half headache

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HeadachePrinciple acupuncture points

• G 20
• Taiyang
• Li 4
• GV 20
• Liv 3
• G 8
• T 3

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TCM Classification of headache

• Headache due to invasion of pathogenic wind into
  the channels and collateral
• Headache occurs often, especially on exposure to
  wind.
• The pain may extend to the nape of the neck and
  back region.
• Tongue white coating, pulse floating

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TCM Classification of headache

• 2. Headache due to upsurge of liver-yang
• Headache distension of the head, irritability,
  hot temper, dizziness, blurred vision,
• Tongue red with thin and yellow coating
• Pulse thin wiry and rapid.

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TCM Classification of headache

• 3. Headache due to deficiency of qi and blood
• Lingering headache, dizziness, blurred vision,
  lassitude, pale complexion
• Tongue pale with thin white coating
• Pulse thin and thread

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Trigeminal Neuralgia (TN)

• Causation-blood vessels compressing the
  Trigeminal nerve root as it enters the brain stem
• Peripheral pathology-neurovas compression
• Central pathology- hyperactivity of the
  trigeminal nerve nucleus

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Classifications of TN

• Western Medicine
• Typical
• Atypical
• Pre-TN
• MS-related TN
• Secondary or tumor related
• TN neuropathy
• Post traumatic TN

• Eastern Medicine
• Pathogenic wind and cold
• Ascending of Liver and stomach fire
• Deficiency heat due to liver yin deplete
• Damp/heat or damp cold accumulation

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TN-Pathogenic Wind Cold

• Clinical manifestation
• Acute onset
• Usually affects V1 sensory
• Aversion of wind cold or aggravated by
• Pain like cutting, boring and electric shock but
  transient ( few minutes)s
• Wind cold or wind heat symptoms

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Tx-TN Pathogenic wind cold

• Acupuncture
• Yang bai, (GB14)
• Taiyang, (extra)
• Zan Zhu (Bl 2)
• Wai guan (SJ5)
• He Gu (Li 4)
• Herbal formula
• Jin Fang Bai du San plus Ginger

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TMJ-Tempro mandibular jointDysfunction syndrome

• Symptoms
• Grinding teeth,
• Joint pain,
• Headache
• Ringing in the ears
• Unable to open his or her month wide or hear a
  pop upon opening

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TN-acupuncture treatment

• Li 3 or Li 4 plus
• Temporal branch
• Taiyang, G 3 G 14
• Maxillary branch
• G1, St2, SI18, and ST3
• Mandibular branch
• St6, St 5, and G2

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TMJ (TMD)
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TMJ-Etiology

• 1. Muscle spasm- pain
• Masseter temporalis
• 2. Meniscus-cartilage, buffer between the jaw
  and skull. Caused pop

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TMJ-Acupuncture points

• ST 7
• SI 19
• T 17
• Li 4

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Osteoarthritis

• Arthritis due to destruction of the cartilage,
  bone and ligaments
• Causing deformity of the joints
• Damage to the joints can occur early in the
  disease and be progressive

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Rheumatoid Arthritis

• Auto-immune disease
• Chronic inflammation of the tissue around joints
  , organ and body
• Body tissues attacked by own antibodies in the
  blood level which causes inflammation.
• Women to men 31

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Osteoarthritis

• 90 of arthritis
• Destruction of the cartilage, bone and ligaments
  causing deformity of the joints
• Damage to the joints can be progressive

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Differential Dx of RA/OA
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Principle Acupuncture Points for Arthritis
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Causation of Carpal Tunnel Syndrome

• Painful neuropathies of the hand and wrist are
  from nerve compression, most often compression of
  the median nerve in the carpal tunnel.

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Anatomy of CTS
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Diagnosis of CTS

• Numbing pain in the distribution of the median
  nerve but not limited to it.
• Phalens sign positive
• Tinels sign positive
• Light touch/vibratory touch positive
• Muscle weakness and atrophy
• EMG slowed conduction velocity across the CT.

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Etiology of CTS

• Median nerve compression by tendonitis
• Usually due to repetitive motion of the wrist and
  hands.

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Carpal Tunnel Release

• Surgery

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Carpal Tunnel SyndromePrinciple acupuncture
points

• P 6
• P 5
• T 4
• T 5

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Cervical SpondylosisPrinciple acupuncture
points

• SI 3
• G 39
• B 64
• B 11
• G 21
• GV 16
• T 10
• B 10

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Rotator Cuff SyndromePrinciple acupuncture points

• Li15
• Si 11
• T14
• Li 16
• Li12
• Li4
• L 7
• L 9
• T 9
• T 4

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DX of Lateral Epicondylitis (Tennis
elbow)

• History of tennis elbow use
• Pain just distal to the prominence of the lateral
  epicondyle
• Radiological study negative

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Knee Tendonitis

• Patellar Tendonitis

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Achilles Tendonitis

• Runners injury

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Lower back pain-Etiology

• Herniated Disk (bulging)
• Facet joint syndrome
• Sacroilliac joint syndrome
• Myofascial syndrome

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Low Back Pain-diagnosis

• Clinical history
• Physical examination
• Pain sensitive structures
• Pain generators
• Radiological studies

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Low Back Pain-X-ray
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Low Back Pain-MRI

• Imaging study to evaluate the entire lumbar
  bones, discs, soft tissues and nerves.
• CT, myelography, and discography use to
  complement MRI

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Referred and Interactive Low Back Pain
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Referred and Interactive Low Back Pain

• The frequent referral of somatic pain into the
  limbs
• Cause of the cause Identify the source of
  symptoms.
• Make realistic prognosis based on the stage,
  severity, stability and irritability of the
  dysfunction

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Referred and interactive- Low Back Pain
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Low back painPrinciple acupuncture points

• B 40 K2 (basic)
• L5, B 40, G34, B 65, B 60, B 34, K7, L 5, Li 11,
  Li 4, Sp6, Liv. 2, Li 10.

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Sciatic NeuralgiaPrinciple acupuncture points

• B 23
• B 30
• G 30
• B 36
• B 37
• B 40
• G 34

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Traumatic Injury-Brain-TBI

• Clinical manifestations
• Altered mental status
• Communication disorders
• Emotional and psychitric disorders
• Related paralysis or paresthesia
• Dx Refer to physician for further
  investigation.

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Cause of Neck Pain
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Radiological Findings of Neck Pain
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Diagnosis of Fibromyalgia

• Widespread aching gt 3 months
• Skin roll tenderness hyperemia
• Disturbed sleep with morning fatigue and
  stiffness
• Absence of lab. Evidence of inflammation or
  muscle damage
• Bilateral tender points in at least 6 areas.