Pain Management by Acupuncture

1. Pain Management by Acupuncture Continue Education Course of @Advanced Acupuncture, Inc. 2007

2. 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

3. Scientific Bases of Acupuncture • Neurohumoral • Morphogenetic • Nerve Reflex Theory • The gate control theory of pain • Endorphin

4. Neuro-humoral Approach • Peripheral nervous system to be crucial in mediating the acupuncture analgesia • Meridian-Cortex-Viscera correlation hypothesis

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

6. 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

7. 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.

8. The Gate Control TheoryDrs 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)

9. Endorphin TheoryDr. 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

10. Therapeutic Mechanisms of Acupuncture

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

12. Acupuncture Pathways

13. 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.

14. 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)

15. 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.

16. 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.

17. 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

18. Effects of acupuncture on the Brain-auditory cortex

19. 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.

20. 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

21. 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.

22. 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

23. 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

24. 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.

25. 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.

26. 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

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

28. HeadachePrinciple acupuncture points • G 20 • Taiyang • Li 4 • GV 20 • Liv 3 • G 8 • T 3

29. 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

30. 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.

31. 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

32. 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

33. 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 Classifications of TN

34. 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

35. 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

36. 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

37. 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

38. TMJ (TMD)

39. TMJ-Etiology 1. Muscle spasm- pain Masseter & temporalis 2. Meniscus-cartilage, buffer between the jaw and skull. Caused “pop”

40. TMJ-Acupuncture points • ST 7 • SI 19 • T 17 • Li 4

41. 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

42. 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: 3:1

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

44. Differential Dx of RA/OA

45. Principle Acupuncture Points for Arthritis

47. 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.

48. Anatomy of CTS

50. Diagnosis of CTS • Numbing pain in the distribution of the median nerve but not limited to it. • Phalen’s sign positive • Tinel’s sign positive • Light touch/vibratory touch positive • Muscle weakness and atrophy • EMG: slowed conduction velocity across the CT.