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Pain Management by Acupuncture

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Pain Management by Acupuncture

  1. 1. Pain Management by Acupuncture Continue Education Course of @Advanced Acupuncture, Inc. 2007
  2. 2. Acupuncture Pain Management <ul><li>Part I: Theory </li></ul><ul><li>Overview of scientific bases of acupuncture </li></ul><ul><li>Mechanisms of pain management </li></ul><ul><li>Current researches and clinical trials </li></ul><ul><li>Pain Scores and evaluation methods </li></ul>
  3. 3. Scientific Bases of Acupuncture <ul><li>Neurohumoral </li></ul><ul><li>Morphogenetic </li></ul><ul><li>Nerve Reflex Theory </li></ul><ul><li>The gate control theory of pain </li></ul><ul><li>Endorphin </li></ul>
  4. 4. Neuro-humoral Approach <ul><li>Peripheral nervous system to be crucial in mediating the acupuncture analgesia </li></ul><ul><li>Meridian-Cortex-Viscera correlation hypothesis </li></ul>
  5. 5. Neurohumoral Approach <ul><li>Acupoint-brain-organ </li></ul><ul><li>Acupuncture stimulates to brain cortex and nerve system, then control the chemical or hormone release to the disordered organs. </li></ul>
  6. 6. Morphogenetic Theory Shang C. China, 1989 <ul><li>Acupuncture points are singular points in surface bioelectric field </li></ul><ul><li>The role of electric field in growth control and morphogenesis </li></ul><ul><li>Organizing centers have high electric conductance </li></ul><ul><li>Acupuncture points originate from organizing centers </li></ul>
  7. 7. Nerve Reflex Theory -Ishikawa and Fujita et al, Japan, 1950s <ul><li>Autonomic nervous system extending thru the internal organs </li></ul><ul><li>Viscera-mutinous reflex </li></ul><ul><li>Cutanous –Viscera reflex </li></ul><ul><li>Acupuncture utilize these reflexes for restoring the homeostasis of the body and acceralate the healing process. </li></ul>
  8. 8. The Gate Control Theory Drs Melzack and Wall, 1965 <ul><li>Model for acupuncture pain relief </li></ul><ul><li>Specific nerve fibers that transmit pain to the spinal cord (substantia gelatinous) </li></ul><ul><li>Balance between Stimulation & inhibitory fibers </li></ul><ul><li>Short term block pain by acupuncture ( did not explain the prolong effect) </li></ul>
  9. 9. Endorphin Theory Dr. Pomeranz, Canada, 1996 <ul><li>Natural Morphine </li></ul><ul><li>Acupuncture trigger the release of endorphin into the central nervous system </li></ul><ul><li>Only deal with pain </li></ul><ul><li>Corticoids and Substance P also released along with endorphin </li></ul>
  10. 10. Therapeutic Mechanisms of Acupuncture
  11. 11. Acupuncture Mechanisms of Action <ul><li>Conduction of electromagnetic signals </li></ul><ul><li>Activation of opioids systems </li></ul><ul><li>Changes in brain chemistry-release of neurotransmitters and neurohormones. </li></ul>
  12. 12. Acupuncture Pathways
  13. 13. Meridian-Cortex-Viscera Correlation Hypothesis <ul><li>1. The meridian system is and connected the nervous system to the cerebral cortex. </li></ul><ul><li>2. It acts through neurohumoral mechanisms </li></ul><ul><li>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. </li></ul>
  14. 14. Morphogenetic Singularity Theory <ul><li>Acupuncture points are singular points in surface bioelectric field </li></ul><ul><li>Converging points of surface current for change in electric current flow. </li></ul><ul><li>Abrupt transition from one state to another. </li></ul><ul><li>Eg: BaiHui (Du 20) </li></ul>
  15. 15. Physical characteristics of the acupuncture points-WHO <ul><li>Points are corresponds to the high electrical conductance points on the body surface </li></ul><ul><li>High density of gap junctions at the epithelia of the acupuncture points. </li></ul><ul><li>Gap junctions are hexagonal proteins that facilitate intercellular communication and increase electric conductivity. </li></ul>
  16. 16. Research on Auricular points <ul><li>WHO found 43 points have proven therapeutic value </li></ul><ul><li>Therapeutic effect can be achieved by needling, temperature variation, laser, ultrasound, and pressure. </li></ul>
  17. 17. Effects of Acupuncture on the Brain <ul><li>UCI-Use functional MRI to investigate the mechanisms of acupuncture analgesia </li></ul><ul><li>Stimulates Li 4 revealed activation of visual cortex. </li></ul><ul><li>Needling Tin Hui revealed auditory cortex activation </li></ul>
  18. 18. Effects of acupuncture on the Brain-auditory cortex
  19. 19. Why acupuncture has fewer side effects? <ul><li>May indirect adjust the process and restore normal function by activating the network of organizing centers in the organism </li></ul><ul><li>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. </li></ul>
  20. 20. The role of electric field in growth control and morphogenesis <ul><li>Enhanced cell growth toward cathode and reduced cell growth toward anode in electric fields of physiological strength </li></ul><ul><li>Fast growing cells tend to have relative negativity polarity. </li></ul><ul><li>The polarity is due to the increased negative membrane potential generated by mitochondria at high rate of energy metabolism </li></ul>
  21. 21. Efficacy, effective, safety and costs of acupuncture for chronic pain <ul><li>Evaluated 304,674 patients over 10,000 physicians and received 10+ acupuncture for pain </li></ul><ul><li>Results: acupuncture was an effective and safe treatment </li></ul><ul><li>The effects attributed to specific or nonspecific mechanisms and depend on the diagnosis-results a large research initiative. </li></ul>
  22. 22. Mechanisms of acupuncture for Pain relief <ul><li>Polymodal receptors </li></ul><ul><li>(PMRs) in the acupuncture points are sensitized for the immediate action. </li></ul><ul><li>Action mediated by endogenous opioids </li></ul><ul><li>Potent stimulus for activating the analgesic systems </li></ul>
  23. 23. Therapeutic Mechanisms of Acupuncture -Dr.D. Kendall, 1980 <ul><li>Inserting a needle provokes an acute defensive inflammatory response </li></ul><ul><li>Afferent nociceptive (pain) neurons distribute to the dorsal horn of the spinal cord </li></ul><ul><li>Trigger the gamma loop efferent in the ventral horn and activate neurons that cross over the spinal cord to the brain </li></ul><ul><li>Activate somatic motor nerves </li></ul><ul><li>To muscles, and autonomic motor nerves to peripheral blood vessels and to the internal organs </li></ul>
  24. 24. Acupuncture Pain Management <ul><li>Part II: Clinical applications </li></ul><ul><li>Differential diagnosis and treatment for </li></ul><ul><li>Headache & migraines, Trigeminal neuralgia, </li></ul><ul><li>Carpal Tunnel Syndromes, Arthritis, Neck </li></ul><ul><li>pain, Fibromyalgia, lumbago and sciatic </li></ul><ul><li>neuralgia. </li></ul>
  25. 25. Etiology of Headache <ul><li>Blood Vessels that become dilated enlarged or constricted </li></ul><ul><li>Muscles in the neck and head become tight or tense </li></ul><ul><li>Muscles around the eyes the become strained due to overwork </li></ul><ul><li>Sinuses became swollen due to allergies or infections </li></ul><ul><li>Nerves that transmit abnormal pain signals </li></ul><ul><li>Joints in the jaw and neck are overused or damaged. </li></ul>
  26. 26. Types of Headache - Western Medicine <ul><li>Vascular headache (Migraines) </li></ul><ul><li>Muscle contraction headache </li></ul><ul><li>Combined vascular & muscle contraction headache </li></ul><ul><li>Headache of nasal vasomotor reactions </li></ul><ul><li>Headache of delusional conversion or hypochondriacal states </li></ul>
  27. 27. Migraine Headache <ul><li>Classic Migraine </li></ul><ul><li>Common migraine </li></ul><ul><li>Cluster headache </li></ul><ul><li>Hemiplegic and ophthalmoplegic migraine </li></ul><ul><li>Lower half headache </li></ul>
  28. 28. Headache Principle acupuncture points <ul><li>G 20 </li></ul><ul><li>Taiyang </li></ul><ul><li>Li 4 </li></ul><ul><li>GV 20 </li></ul><ul><li>Liv 3 </li></ul><ul><li>G 8 </li></ul><ul><li>T 3 </li></ul>
  29. 29. TCM Classification of headache <ul><li>Headache due to invasion of pathogenic wind into the channels and collateral: </li></ul><ul><li>Headache occurs often, especially on exposure to wind. </li></ul><ul><li>The pain may extend to the nape of the neck and back region. </li></ul><ul><li>Tongue white coating, pulse floating </li></ul>
  30. 30. TCM Classification of headache <ul><li>2. Headache due to upsurge of liver-yang: </li></ul><ul><li>Headache distension of the head, irritability, hot temper, dizziness, blurred vision, </li></ul><ul><li>Tongue red with thin and yellow coating </li></ul><ul><li>Pulse thin wiry and rapid. </li></ul>
  31. 31. TCM Classification of headache <ul><li>3. Headache due to deficiency of qi and blood: </li></ul><ul><li>Lingering headache, dizziness, blurred vision, lassitude, pale complexion </li></ul><ul><li>Tongue pale with thin white coating’ </li></ul><ul><li>Pulse thin and thread </li></ul>
  32. 32. Trigeminal Neuralgia (TN) <ul><li>Causation:-blood vessels compressing the Trigeminal nerve root as it enters the brain stem </li></ul><ul><li>Peripheral pathology-neurovas compression </li></ul><ul><li>Central pathology- hyperactivity of the trigeminal nerve nucleus </li></ul>
  33. 33. Classifications of TN <ul><li>Western Medicine: </li></ul><ul><li>Typical </li></ul><ul><li>Atypical </li></ul><ul><li>Pre-TN </li></ul><ul><li>MS-related TN </li></ul><ul><li>Secondary or tumor related </li></ul><ul><li>TN neuropathy </li></ul><ul><li>Post traumatic TN </li></ul><ul><li>Eastern Medicine </li></ul><ul><li>Pathogenic wind and cold </li></ul><ul><li>Ascending of Liver and stomach fire </li></ul><ul><li>Deficiency heat due to liver yin deplete </li></ul><ul><li>Damp/heat or damp cold accumulation </li></ul>
  34. 34. TN-Pathogenic Wind & Cold <ul><li>Clinical manifestation: </li></ul><ul><li>Acute onset </li></ul><ul><li>Usually affects V1 sensory </li></ul><ul><li>Aversion of wind & cold or aggravated by </li></ul><ul><li>Pain like cutting, boring and electric shock but transient ( few minutes)s </li></ul><ul><li>Wind cold or wind heat symptoms </li></ul>
  35. 35. Tx-TN Pathogenic wind & cold <ul><li>Acupuncture: </li></ul><ul><li>Yang bai, (GB14) </li></ul><ul><li>Taiyang, (extra) </li></ul><ul><li>Zan Zhu (Bl 2) </li></ul><ul><li>Wai guan (SJ5) </li></ul><ul><li>He Gu (Li 4) </li></ul><ul><li>Herbal formula: </li></ul><ul><li>Jin Fang Bai du San plus Ginger </li></ul>
  36. 36. TMJ-Tempro mandibular joint Dysfunction syndrome <ul><li>Symptoms: </li></ul><ul><li>Grinding teeth, </li></ul><ul><li>Joint pain, </li></ul><ul><li>Headache </li></ul><ul><li>Ringing in the ears </li></ul><ul><li>Unable to open his or her month wide or hear a “pop” upon opening </li></ul>
  37. 37. TN-acupuncture treatment <ul><li>Li 3 or Li 4 plus </li></ul><ul><li>Temporal branch: </li></ul><ul><li>Taiyang, G 3 & G 14 </li></ul><ul><li>Maxillary branch: </li></ul><ul><li>G1, St2, SI18, and ST3 </li></ul><ul><li>Mandibular branch: </li></ul><ul><li>St6, St 5, and G2 </li></ul>
  38. 38. TMJ (TMD)
  39. 39. TMJ-Etiology <ul><li>1. Muscle spasm- pain </li></ul><ul><li>Masseter & temporalis </li></ul><ul><li>2. Meniscus-cartilage, buffer between the jaw and skull. Caused “pop” </li></ul>
  40. 40. TMJ-Acupuncture points <ul><li>ST 7 </li></ul><ul><li>SI 19 </li></ul><ul><li>T 17 </li></ul><ul><li>Li 4 </li></ul>
  41. 41. Osteoarthritis <ul><li>Arthritis due to destruction of the cartilage, bone and ligaments </li></ul><ul><li>Causing deformity of the joints </li></ul><ul><li>Damage to the joints can occur early in the disease and be progressive </li></ul>
  42. 42. Rheumatoid Arthritis <ul><li>Auto-immune disease </li></ul><ul><li>Chronic inflammation of the tissue around joints , organ and body </li></ul><ul><li>Body tissues attacked by own antibodies in the blood level which causes inflammation. </li></ul><ul><li>Women to men: 3:1 </li></ul>
  43. 43. Osteoarthritis <ul><li>90% of arthritis </li></ul><ul><li>Destruction of the cartilage, bone and ligaments causing deformity of the joints </li></ul><ul><li>Damage to the joints can be progressive </li></ul>
  44. 44. Differential Dx of RA/OA
  45. 45. Principle Acupuncture Points for Arthritis Metatarsophala-ngeal joints : Sp 4, B 65, G 38, Sp 5 Ankle joints: ST 41, T 40, K3, B50, G 35 K8 Knee joints: St 34,St 36, Sp 9, G 34 Hip joints: G30, G 29, G34, G39 Hip joints: G 30, G 29, G34, G39 Sacroiliac Joints: B 27, B28 Lumbosacra Joints: GV3, B30, B 25, B40 B 60 Lumbar spinal joints: Huatuoparaspinal acupoints, UB37 and UB 40 Wrist & joints: T5, Li 10., LI. 4 Elbow joints: Li 11, T10, Li 4 Shoulder joints: LI 15, T14, SI 11, T3,G 34 Temporo-mandibular ST7, SI 19, T 17, Li 4
  46. 47. Causation of Carpal Tunnel Syndrome <ul><li>Painful neuropathies of the hand and wrist are from nerve compression, most often compression of the median nerve in the carpal tunnel. </li></ul>
  47. 48. Anatomy of CTS
  48. 50. Diagnosis of CTS <ul><li>Numbing pain in the distribution of the median nerve but not limited to it. </li></ul><ul><li>Phalen’s sign positive </li></ul><ul><li>Tinel’s sign positive </li></ul><ul><li>Light touch/vibratory touch positive </li></ul><ul><li>Muscle weakness and atrophy </li></ul><ul><li>EMG: slowed conduction velocity across the CT. </li></ul>
  49. 51. Etiology of CTS <ul><li>Median nerve compression by tendonitis </li></ul><ul><li>Usually due to repetitive motion of the wrist and hands. </li></ul>
  50. 52. Carpal Tunnel Release <ul><li>Surgery: </li></ul>
  51. 53. Carpal Tunnel Syndrome Principle acupuncture points <ul><li>P 6 </li></ul><ul><li>P 5 </li></ul><ul><li>T 4 </li></ul><ul><li>T 5 </li></ul>
  52. 54. Cervical Spondylosis Principle acupuncture points <ul><li>SI 3 </li></ul><ul><li>G 39 </li></ul><ul><li>B 64 </li></ul><ul><li>B 11 </li></ul><ul><li>G 21 </li></ul><ul><li>GV 16 </li></ul><ul><li>T 10 </li></ul><ul><li>B 10 </li></ul>
  53. 55. Rotator Cuff Syndrome Principle acupuncture points <ul><li>Li15 </li></ul><ul><li>Si 11 </li></ul><ul><li>T14 </li></ul><ul><li>Li 16 </li></ul><ul><li>Li12 </li></ul><ul><li>Li4 </li></ul><ul><li>L 7 </li></ul><ul><li>L 9 </li></ul><ul><li>T 9 </li></ul><ul><li>T 4 </li></ul>
  54. 56. DX of Lateral Epicondylitis (Tennis elbow) <ul><li>History of tennis elbow use </li></ul><ul><li>Pain just distal to the prominence of the lateral epicondyle </li></ul><ul><li>Radiological study negative </li></ul>
  55. 57. Knee Tendonitis <ul><li>Patellar Tendonitis </li></ul>
  56. 58. Achilles Tendonitis <ul><li>Runner’s injury </li></ul>
  57. 59. Lower back pain-Etiology <ul><li>Herniated Disk (bulging) </li></ul><ul><li>Facet joint syndrome </li></ul><ul><li>Sacroilliac joint syndrome </li></ul><ul><li>Myofascial syndrome </li></ul>
  58. 60. Low Back Pain-diagnosis <ul><li>Clinical history </li></ul><ul><li>Physical examination </li></ul><ul><li>Pain sensitive structures </li></ul><ul><li>Pain generators </li></ul><ul><li>Radiological studies </li></ul>
  59. 61. Low Back Pain-X-ray
  60. 62. Low Back Pain-MRI <ul><li>Imaging study to evaluate the entire lumbar bones, discs, soft tissues and nerves. </li></ul><ul><li>CT, myelography, and discography use to complement MRI </li></ul>
  61. 63. Referred and Interactive Low Back Pain
  62. 64. Referred and Interactive Low Back Pain <ul><li>The frequent referral of “ somatic pain into the limbs </li></ul><ul><li>Cause of the cause: Identify the source of symptoms. </li></ul><ul><li>Make realistic prognosis based on the stage, severity, stability and irritability of the dysfunction </li></ul>
  63. 65. Referred and interactive- Low Back Pain
  64. 66. Low back pain Principle acupuncture points <ul><li>B 40 & K2 (basic) </li></ul><ul><li>L5, B 40, G34, B 65, B 60, B 34, K7, L 5, Li 11, Li 4, Sp6, Liv. 2, Li 10. </li></ul>
  65. 67. Sciatic Neuralgia Principle acupuncture points <ul><li>B 23 </li></ul><ul><li>B 30 </li></ul><ul><li>G 30 </li></ul><ul><li>B 36 </li></ul><ul><li>B 37 </li></ul><ul><li>B 40 </li></ul><ul><li>G 34 </li></ul>
  66. 68. Traumatic Injury-Brain-TBI <ul><li>Clinical manifestations: </li></ul><ul><li>Altered mental status </li></ul><ul><li>Communication disorders </li></ul><ul><li>Emotional and psychitric disorders </li></ul><ul><li>Related paralysis or paresthesia </li></ul><ul><li>Dx: Refer to physician for further investigation. </li></ul>
  67. 69. Cause of Neck Pain
  68. 70. Radiological Findings of Neck Pain
  69. 72. Diagnosis of Fibromyalgia <ul><li>Widespread aching > 3 months </li></ul><ul><li>Skin roll tenderness & hyperemia </li></ul><ul><li>Disturbed sleep with morning fatigue and stiffness </li></ul><ul><li>Absence of lab. Evidence of inflammation or muscle damage </li></ul><ul><li>Bilateral tender points in at least 6 areas. </li></ul>

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