Pain Management by Acupuncture

Continue Education Course of @Advanced Acupuncture, Inc. 2007

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

Scientific Bases of Acupuncture

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

Neuro-humoral Approach
Peripheral nervous system to be crucial in mediating the acupuncture analgesia Meridian-CortexViscera correlation hypothesis

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

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

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.

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)

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

Therapeutic Mechanisms of Acupuncture

Acupuncture Mechanisms of Action

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

Acupuncture Pathways

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.

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)

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.

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.

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

Effects of acupuncture on the Brain-auditory cortex

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 selforganizing 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.

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

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.

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

Therapeutic Mechanisms of Acupuncture

-Dr.D. Kendall, 1980

1. 2. 3. 4. 5.

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

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.

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.

Types of Headache -Western Medicine

I. Vascular headache (Migraines) II. Muscle contraction headache III. Combined vascular & muscle contraction headache IV. Headache of nasal vasomotor reactions V. Headache of delusional conversion or hypochondriacal states

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

Headache Principle acupuncture points

G 20 Taiyang Li 4 GV 20 Liv 3 G8 T3

TCM Classification of headache

1. 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

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.

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

Trigeminal Neuralgia (TN)

Causation:-blood vessels compressing the Trigeminal nerve root as it enters the brain stem Peripheral pathologyneurovas compression Central pathologyhyperactivity of the trigeminal nerve nucleus

Classifications of TN
Western Medicine:
1. 2. 3. 4. 5. 6. 7. Typical Atypical Pre-TN MS-related TN Secondary or tumor related TN neuropathy Post traumatic TN

Eastern Medicine
1. 2. 3. 4. Pathogenic wind and cold Ascending of Liver and stomach fire Deficiency heat due to liver yin deplete Damp/heat or damp cold accumulation

TN-Pathogenic Wind & Cold

Clinical manifestation:
1. 2. 3. 4. 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

5.

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

TMJ-Tempro mandibular joint Dysfunction 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

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

TMJ (TMD)

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

TMJ-Acupuncture points

ST 7 SI 19 T 17 Li 4

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

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

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

Differential Dx of RA/OA

Principle Acupuncture Points for Arthritis

Temporomandibular
ST7, SI 19, T 17, Li 4

Shoulder joints: Elbow joints: LI 15, T14, SI Li 11, T10, Li 4 11, T3,G 34 Lumbosacra Joints: GV3, B30, B 25, B40 B 60 Sacroiliac Joints: B 27, B28

Wrist & joints: T5, Li 10., LI. 4

Lumbar spinal joints: Huatuoparaspinal acupoints, UB37 and UB 40 Hip joints: G30, G 29, G34, G39

Hip joints: G 30, G 29, G34, G39

Knee joints: Ankle joints: St 34,St 36, Sp 9, ST 41, T 40, K3, B50, G 35 K8 G 34

Metatarsophalangeal joints: Sp 4, B 65, G 38, Sp 5

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.

Anatomy of CTS

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.

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

Carpal Tunnel Release

Surgery:

Carpal Tunnel Syndrome Principle acupuncture points

P6 P5 T4 T5

Cervical Spondylosis Principle acupuncture points

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

Rotator Cuff Syndrome Principle acupuncture points

Li15 Si 11 T14 Li 16 Li12 Li4 L7 L9 T9 T4

DX of Lateral Epicondylitis (Tennis elbow)

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

Knee Tendonitis
Patellar Tendonitis

Achilles Tendonitis
Runners injury

Lower back pain-Etiology

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

Low Back Pain-diagnosis

Clinical history Physical examination Pain sensitive structures Pain generators Radiological studies

Low Back Pain-X-ray

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

Referred and Interactive Low Back Pain

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

Referred and interactiveLow Back Pain

Low back pain Principle 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.

Sciatic Neuralgia Principle acupuncture points

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

Traumatic Injury-Brain-TBI
Clinical manifestations:
1. 2. 3. 4. Altered mental status Communication disorders Emotional and psychitric disorders Related paralysis or paresthesia

Dx: Refer to physician for further investigation.

Cause of Neck Pain

Radiological Findings of Neck Pain

Diagnosis of Fibromyalgia
1. Widespread aching > 3 months 2. Skin roll tenderness & hyperemia 3. Disturbed sleep with morning fatigue and stiffness 4. Absence of lab. Evidence of inflammation or muscle damage 5. Bilateral tender points in at least 6 areas.