Medical Acupuncture Review Course

Review Course Faculty

Bradley T. Lawrence, MD, FAAMA

Phoenix, AZ

Mitchell Elkiss, DO, FAAMA

Farmington Hills, MI

Tate Kauffman, MD

Newville, PA

Joseph Walker III, MD, DABMA

Farmington, CT

American Academy of Medical Acupuncture

Financial Disclosure

In order to comply with the ACCME’s Updated Standards for Commercial Support, The American

Academy of Medical Acupuncture has implemented a disclosure process to ensure that anyone in a

position to control the content of an educational activity has disclosed all relevant financial

relationships with any commercial interest. Per these updated standards. The faculty presenters

were required to disclose all financial relationships. The ACCME defines a “commercial interest” as

any proprietary entity producing health care goods or services consumed by or used on patients. It

does not consider providers of clinical service directly to patients to be commercial interests. The

ACCME considers “relevant” financial relationships as financial transactions (in any amount) that

may create a conflict of interest and occur within the 12 months preceding the time that the individual

is being asked to assume a role controlling content of the educational activity.

Disclosure Information:

Presenters have nothing to disclose.

COURSE SECTIONSScientific Basis and History of Medical Acupuncture1

Musculoskeletal / Neuroanatomic Acupuncture2

Circulation of Energy3

TCM Classical Evaluation and Therapy4

Microsystems in Acupuncture5

Energetics6

The 5 Phases in the Regulation of Qi7

Point Groupings8

Scientific Basis and

History of Medical

Acupuncture

SECTION 1

Section 1 - Scientific Basis of Acupuncture

This section is designed to review the scientific basis of acupuncture.

After completing Section 1, participants will be able to:

1. Describe typical anatomical features of acupuncture points.

2. Summarize the neurophysiology of pain, including relevant

structures and neurotransmitters.

3. Explain the neurophysiologic effects of acupuncture with high- and

low-frequency stimulation.

7American Academy of Medical Acupuncture

Scientific Basis of Medical Acupuncture Chronology

• Anatomy of Acupuncture Points

• Stimulation of Nerves in Muscle

• Neurochemical Basis of Acupuncture

• Neurologic Basis of De Qi

• Gate Theory of Pain

• Neurophysiology of Acupuncture with

Stimulation

• Acupuncture and Fascia

• Neuroimaging and Acupuncture


• Artery

• Vein

• Nerve

• Lymphatic

Anatomy of Typical Acupuncture Point


Acupuncture Points

• High conductance, low resistance

• High density of gap junctions

• Associated with nerve, artery, vein, lymphatic clusters

• Palpable depressions on muscle, bone, tendon, ligaments

• Tender points on and off of channels

• Overlap with motor, trigger, Chapman’s points

10 American Academy of Medical Acupuncture

Bioelectrical Properties of

Acupuncture Points

• Low resistance

• High conduction

• High density of gap junctions

• Charles Shang, MD Emory University


Acupuncture Points

• Topological

• Palpable

• Resist needle withdrawal compared to

surround

• Along fascial planes


Anatomy of Acupuncture Points

Relation to:

• Nerves

• Vessels

• Bone

• Connective Tissue



Relation to nerves:

• Large peripheral nerves

• Motor points

• Areas of emergence from deep to

superficial

• Bony foramina

• Peripheral nerve bifurcation points



Relation to vessels:

• Vessels near neuromuscular attachments

• Vasa nervorum, especially muscular

15

Nerves and Arteries

16

Nerves and Arteries


Scientific Basis of Acupuncture

Stimulation of nerves in muscle

• Touch A-B

• Skin injury - A-d, I, II, III, IV, C


Neurologic Basis of De Qi Muscle Afferents

Acupuncture Analgesia blocked by intra-muscular procaine, but

not subcutaneous

Type II* - numbness

Type III - distension, heaviness, aching

Type IV - soreness

*Fibers required for acupuncture analgesia

19

Neurotransmitters Affected by Acupuncture

• Beta Endorphin

• Enkephalin

• Dynorphin

• Serotonin

• Norepinephrine

• Adenosine

• Anandamide

• Glycine

• Somatostatin

• Acetylcholine

• Dopamine

• GABA

• Substance P

• Glutamate

• Vasoactive intestinal polypeptide

(VIP)

• Histamine

• Nitric oxide


Yin and Yang of the Neurochemical

Basis of Acupuncture

Inhibition and Excitation


SG - substantia gelatinosa

T - central transmission cell

L - large diameter

S - small diameter

Melzack and Wall, 1963

Gate Theory of Pain I

Schematic of the gate-control theory of pain

22

Nervous System Effects of Electro-Acupuncture (EA)

23

Skin

1

2

7

6

Muscle

Spinal Cord5

Painful

Stimulus

Acu

Needle

3 4

9

11

10

8

Mid

Brain

Thalamus Cortex

14

1312

Pituitary

Hypothal

Blood

Vessel

Acupuncture

Needle

LegendPainful

Stimulus

Direction of

impulses

Nerve Cell

Excitatory Synapse

Inhibitory Synapse

Sensory

Nerve

Sensory

Receptor

STT = Spinothalamic Tract

Blood

Vessel

Overall Pain Pathway Schematic

Graphic courtesy of Joey Walker, MD, DABMA

24

Skin

1

2

7

6

Muscle

Spinal Cord5

Painful

Stimulus

3 4

9

11

10

8

Mid

Brain

Thalamus Cortex

14

1312

Pituitary

Hypothal

Blood

Vessel Blood

Vessel

Acupuncture

Needle

Legend

Painful Stimulus

Direction of

impulses

Nerve Cell

Excitatory Synapse

Inhibitory Synapse

Sensory

Nerve

Sensory

Receptor

STT = Spinothalamic Tract DLT = Dorsolateral Tract

ALT = Anterolateral Tract M = Monoamines

E = Endorphins

ST

T

ALT

M

M

DLT

E

E

E

E

Acu

Needle

Low Frequency Electroacupuncture Stimulation Pain Pathway Schematic

<10 Hz



Neuroanatomic Basis of Acupuncture

Hypothalamus/Pituitary

Low frequency stimulation

-Betalipotropin Beta-endorphin & ACTH

• To circulation distant analgesia

• To CSF periaqueductal gray

• Long Axons Midbrain raphe descending

system

26

Skin

1

2

7

6

Muscle

Spinal Cord5

Painful

Stimulus

Acu

Needle

3 4

9

11

10

8

Mid

Brain

Thalamus Cortex

14

1312

Pituitary

Hypothal

Blood

VesselBlood

Vessel

Acupuncture

Needle

Legend

Painful Stimulus

Direction of

impulses

Nerve Cell

Excitatory Synapse

Inhibitory Synapse

Sensory

Nerve

Sensory

Receptor

STT = Spinothalamic Tract DLT = Dorsolateral Tract

ALT = Anterolateral Tract M = Monoamines

E = Endorphins

STT

ALT

MDLT

E

E

High Frequency Electroacupuncture Stimulation Pain Pathway Schematic

>80 Hz




Spinal Cord

Low frequency stimulation enkephalin, dynorphin

enkephalin decrease calcium inflow decrease, substance P

release

High frequency stimulation GABA



Midbrain

Low frequency stimulation enkephalin

• Secondary action on cord via raphe descending system

(dorsolateral tract)

High frequency stimulation bypasses enkephalin system

• synergistic cord inhibition by monoamines seratonin,

norepinephrine effect

• enhanced by tryptophan

29

Electro-Acupuncture (EA) Low Frequency, High Frequency

• Slow onset of analgesia

• Generalized effect

• Continues after

stimulation

• Cumulative effect

• Endorphin dependent

• Rapid onset of analgesia

• Segmental effect

• Active during stimulation

• No cumulative effect

• Monoamine dependent


• James Ochsman, MD

• DC currents conducted along

perineural transmission network

• Role of glial cells, 90% of cells in

central nervous system (CNS)

• Astrocytes, Microglia

• Oligodendrocytes

Perineural Transmission Network


• Organized by connective tissue

• Fascial planes, between muscles, bone and muscle, etc.

• Mechanical effect on nerves, vessels,

• Chemical effect on connective tissue afferents

Acupuncture Meridians and Fascia


Acupuncture Meridians

• Channel propagation

• Radiations from the deep

• Isotope studies (Tch99)

• Fascial planes

• Bioelectric morphogenesis: Erich

Bleckschmidt - metabolic, mechanical, and

field effects in embryologic development

33

Biodynamic Embryology

34

Isotope Scan of Acupuncture vs. Non-Acupuncture Point

35

Loose Connective Tissue


• Helene Langevin, MD

• Twirling the needle deforms connective tissue

• This results in a myofascial deformation signal

• Needle withdrawal resistance

Fascia, Microtubules, and Cytoskeletal Transmission


• Mechano-transduction

• Purinergic signaling

• Peripheral sensory modulation via

Adenosine

Acupuncture and the Connective Tissue Matrix


• Connective tissue matrix includes the extracellular matrix (ECM), fibroblasts, immune cells

• Whole body organ

• Needle rotation with increased grasp, correlates with collagen wrapping

• Collagenase blocks the effects of manual acupuncture (MA)

Acupuncture and the Connective Tissue Matrix


• Acupuncture affects fibroblasts several cm. away

• Reorganize their cytoskeleton, change shape

• Become larger and flatter

• Similar with sustained stretch(30 min.)

Mechanotransduction


• Change of fibroblast shape

associated with release of ATP

Purinergic Signaling


Peripheral Sensory Modulation

• ATP Adenosine Peripheral Sensory Modulation

• Adenosine endogenous neuromodulator in the peripheral and

central nervous system

• Inhibits pain signals by hyperpolarizing neuronal membranes


Acupuncture Pain Neuroimaging

• Vitaly Napadow, PhD, LAc

• FM vs. healthy, resting connectivity of DMN with S2 and insula

is increased with FM

• Amount of pain, more pain, more connected to the insula. If

SLR causes pain, insula connectivity increases


• NEJM March 2013, DMN

plus Insula

• Pain Biomarker

Pain Signature (f-MRI) Biomarker



• Richard Harris, PhD

• Connectivity in Fibromyalgia (FM), Insula highly connected to

DMN, not in controls, correlates with clinical report, also seen

in neuropathic pain, LBP, TMD

• Can acupuncture affect this?

• FM with acupuncture, decrease Insula connectivity to DMN,

correlates with decreased pain.



• After acupuncture in FM, decreased pain, decreased

connectivity to the Insula

• Insula, stimulus salience, integrates subcortical homeostatic

information into action, cognition, and affect. Substrate for

clinical pain? Surrogate? Predictive?


Pain/Acupuncture/f-MRI

Zang Hee Cho

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• Point Groupings

Shock Points, Nausea Points

Ba Feng, Ba Xie

GV20, GV24.5

• References

Acupuncture Energetics, Helms

• Questionso Differences between manual and electrical stimulation?

o Differences between low freq and high freq EA?

Scientific Basis and History of Medical

Acupuncture Summary

Conclusion of Section 1

Medical Acupuncture Review Course

Documents

Transcript of Medical Acupuncture Review Course