Nina Malik, DVM October 15, 2008 Atlantic Coast Veterinary Specialists

•History of Acupuncture •Eastern Framework

•Western Framework- Mechanism of Action •Acupuncture Modalities •Indications for Acupuncture •Case Studies

What We Learn Curriculum in Veterinary Medicine Graduation Requirements 

First Year Cr. Fall 5 Principles of Morphology I—B M S 330 6 Biomedical Sciences I—B M S 333 3 Physiological Chemistry—

BBMB 420 1 Clinical Foundations—B M S/V C S 339 1 Clinical Imaging I—V C S 391 1 Case Study I—B M S 345 R Veterinarian in Society I—V C S 311 17 Cr. Spring 4 Principles of Morphology II—B M S 331 6 Biomedical Sciences II—B M S 334 3 Neurobiology—B M S 337 2 Veterinary Immunology—V MPM 380 2 General Pathology—V Pth 342 1 Case Study II—B M S 346 1 Veterinarian in Society II—V C S 312 19

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Second Year Cr. Fall 4 Veterinary Parasitology—V Pth 376 3 Systemic Pathology—V Pth 372 5 Veterinary Microbiology I—V MPM 386 2 Case Study III—V Pth 377 1 Veterinarian in Society III—V C S 313 15 Cr. Spring 3 General Pharmacology—B M S 354 1 Anesthesiology—VCS 398 3 Veterinary Microbiology II—V MPM 387 3 Public Health—V MPM 388 6 Principles of Surgery—V C S 397 2 Case Study IV—V MPM 378 18

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Third Year Cr. Fall 3 Clinical Path—V Pth 425 2 Infert. Diseases—V MPM 436 5 Clinical Medicine I—V C S 444 3 Surgery

Laboratory—V C S 449 4 Disturbances of Reproduction—V C S 450/VDPAM 450 3 Pharmacology and Therapeutics—B M S 443 1 Veterinarian in Society IV—V C S 314 R Introduction to Clinics—V C S 440/VDPAM 440 R Seminar—V C S 385 21 Cr. Spring 4 Special Pathology—V Pth 422 3 Infectious Diseases and Preventive Medicine—V MPM 437 5 Clinical Medicine II—V C S 445/VDPAM 445 3 Veterinary Toxicology—VDPAM 426 2 Radiology—V C S 448 1 Ophthalmology—V C S 399 1 Veterinarian in Society—V C S 315 R Seminar—V C S 385 18

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Fourth Year The fourth year of the veterinary medical curriculum is designed to be flexible and to provide for species

emphasis. Students must complete 38 credits during their fourth year. They must take a required block and at least one option block. The remainder of the fourth year credits are acquired by selecting additional option blocks, Veterinary Teaching Hospital clinical electives, off-campus clinical electives, or other electives. Additional off-campus clinical elective credits can be earned at approved government agencies, research laboratories, veterinary practices, and other university hospitals.

Indications

Applications

Mechanisms of action

Journal of the American Veterinary Medical Association September 15, 2007, Vol. 231, No. 6, Pages 913-918

Abstract Evaluation of electroacupuncture treatment for thoracolumbar intervertebral disk disease in dogs Ayne Murata Hayashi, DVM, MSc, Julia Maria Matera, DVM, PhD, Ana Carolina Brandão de Campos Fonseca Pinto, DVM, PhD Department of Surgery, School of Veterinary Medicine, University of São Paulo, São Paulo-SP, Brazil 05508-900. (Hayashi, Matera, de Campos Fonseca Pinto)

Conclusions and Clinical Relevance—Electroacupuncture combined with standard Western medical treatment was effective and resulted in shorter time to recover ambulation and deep pain perception than did use of Western treatment alone in dogs with signs of thoracolumbar intervertebral disk disease.

What do these athletes have in common?

Ancient Healing Art  Theories of circulation

and pulse character postulated in China 4,000 years before Western medicine  Various nations claimed to be founders  Founders of acupuncture- Northern India or Tibet (Ayurvedic Medicine?)

Huang-de-nei-jing  First written record of    

acupuncture over 2,200 years ago in China Two books- Suwen is the most famous Conversation with Yellow Emperor (3rd millennium B.C.) Physiology, pathology, diagnosis, and prevention of disease Authorship- Yellow Emperor?

History of Veterinary Acupuncture

First Veterinary Acupuncture Textbook

Sun-Yang, 650 B.C.

Lyon, France, 1761

CBS 11:00 p.m. News- 9/24/08

http://wcbstv.com/seenat11

The Eastern Framework Yin + Yang

• Dark •Descends •Cool, moist •Anabolism, rest •Substance- tissues •Ventral and Inner aspects of body

•Light •Expands outwards and upwards •Hot •Metabolism, movement •Head, Back, Outer

Qi •Energy force running through body •Flow of Qi influences health of animal

•Insufficient •Unbalanced •Obstructed

Meridians  Qi travels in

meridians/channels  Acupuncture pointslocations where meridians come to surface/accessible  Needling points= manipulate Qi and restore balance  Allows body to heal itself

Veterinary Acupuncture Points

•Based on transpositional system (human) •Points located via anatomical landmarks and body measurements (cun)

GB 34 and BL 54

Pattern Differentiation  TCM diagnosis is based on pattern differentiation, not on

diagnosis of a particular disease as in Western medicine  One disease entity in Western medicine may have multiple underlying possible TCM patterns.  TCM Patterns are based on a number of different factors: History Diagnostic Tests (Radiographs, Bloodwork) Physical Examination Tongue and Pulse diagnosis Lifestyle, external factors (damp weather), and personality/behavior

The Forest through the Trees

Anatomy of acupuncture points Mechanisms of Action •Effects on the CNS •Endogenous Pain Inhibition •Segmental Analgesia •Local Tissue Effects •Autonomic Nervous System •Trigger Point Therapy

Anatomy of Acupuncture Points  Not random points on the body  Areas of lower electrical skin resistance compared with

the surrounding skin. Normal skin: 200,000-2 million ohms vs. 50,000 ohms  High electrical skin conductance  Many found in palpable depressions on the body

Anatomy of Acupuncture Points

Trigger Points • Hyperirritable locus

within a taut band of skeletal muscle or its associated fascia • Approximately 70% of

acupuncture points correspond to trigger points

Mechanisms of Action  Endogenous pain

inhibitory system  Segmental analgesia  Local inflammatory effects  Autonomic nervous system to affect viscera  Relief from trigger points

Review of Nociceptors A-beta receptors  Large diameter, rapid conduction, myelinated A-delta receptors  Medium diameter, medium conduction, myelinated  Mechanoreceptors; mediate touch/pressure  Skin/fascia  Rapid pain response (“first pain”) C-polymodal receptors  Small diameter, slow conducting, non-myelinated  Activated by thermal, mechanical, chemical stimuli  Mediate slow pain

Effects of Acupuncture on the CNS 3 Regions of CNS Activated 1. Spinal Cord

2. Brainstem 3. Hypothalamus-pituitary

Release of NT (endogenous opiates)

Block Pain Messages

Endogenous Pain Inhibition  A delta fibers carry pain

impulse to lamina I of dorsal horn  Activate neurons of the neospinothalamic tract  Neurons have long axons that cross to opp spinal cord and ascend to the hypothalamus/pituitary by way of the brainstem

Hypothalamus and Pituitary  Arcuate nucleus +

pituitary contain all the beta-endorphin cells in the brain  Beta-endorphin release

into blood and CSF

Endogenous Pain Inhibition  Third CNS region

activated is the brainstem  Input via the A-delta fibers to the dorsal horn of the spinal cord  Via the anterolateral fasciculus of the spinal cord to the brainstem

Activation of the Brainstem •Stimulates descending norepinephrine inhibitory and serotonergic inhibitory fibers •Travel in dorsolateral tract of the spinal cord

•Synapse on dorsal horn interneurons

 Combined result: beta-

endorphin, NE/5-HT3 inhibitory fibers  Release of enkephalin and

dynorphins from segmental interneurons of spinal cord  Bind opiate receptors on pain

afferents  Pre-synaptic inhibition of A-

delta and C fibers (temp, crude touch, aching, burning, chronic pain)

Naloxone reversal  Naloxone reverses

acupuncture analgesia  Evidence that pain

inhibition is mediated through endogenous opioid neural loop

Suppression of substance P from afferent pain axon to inhibit pain impulse transmission to the brain for conscious perception

Anatomy of acupuncture points Mechanisms of Action •Effects on the CNS •Endogenous Pain Inhibition •Segmental Analgesia •Local Tissue Effects •Autonomic Nervous System •Trigger Point Therapy

Segmental Analgesia  High frequency (100 Hz),

low intensity stimulation  Electroacupuncture (EAP)  Localized analgesia, rapid onset, ceases after stimulation has stopped  Brainstem activated

 Stimulates NE and 5HT

inhibitory fibers in brain stem  Dorsal horn of spinal

cord  Mediation by GABA in

the spinal cord

 Activates the

dynorphin synapses in the spinal cord  Relieves chronic pain

possibly by selectively inhibiting input from C fibers

Mechanisms of Action •Effects on the CNS •Endogenous Pain Inhibition •Segmental Analgesia •Local Tissue Effects •Autonomic Nervous System •Trigger Point Therapy

Local Tissue Effects

Local Tissue Effects

Microtrauma

Histology of Acupuncture Point

Vasoactive Effects PHASES 3.

2 minutes-2 weeks

10 seconds-2 minutes 2.

15-30 seconds 1.

Time-dependent Phases Vasodilation Inactivation of Reaction

Nociceptive potentiation

Tissue Repair

Chemotaxis Solubility

Sum Total of Local Tissue Effects  Improved local tissue perfusion  Increased local immune responsiveness  Muscle and tissue relaxation  Pain relief: increased perfusion and cessation of

muscle spasms

Mechanisms of Action •Effects on the CNS •Endogenous Pain Inhibition •Segmental Analgesia •Local Tissue Effects •Autonomic Nervous System •Trigger Point Therapy

Viscerocutaneous Reflex  General mechanism by

which diseased organs are able to refer pain, sensitivity, or muscle contraction to areas of skin often correlating to acupuncture or trigger pt  The pain can be referred to areas that are far away or directly over the painful organ

Referred Pain  McBurney’s point- right

lower abdominal quadrant painful in appendicitis  Heart attack- Left arm, back, neck (not at chest)  “Brain freeze”- ice cream  Diaphragm refers to right shoulder

Cutaneovisceral Reflex  Reverse loop proposed  GV 26- hemorrhagic shock

in dogs: increases cardiac output- blood pressure increases  PC-6 in cats: EAP inhibits frequency of transient lower esophageal sphincter relaxation  ST-36 accelerates colonic motility rats

Cutaneovisceral Reflex Needle in paravertebral muscle at myotome segmental level associated with muscular pain Somatic nerve ending of a muscle stimulated Afferent impulse to dorsal horn Stimulation of contralateral anterior hypothalamus Activation of somato-autonomic reflex Cholinergic vasodilator nerves activated to spastic muscles

Mechanisms of Action •Effects on the CNS •Endogenous Pain Inhibition •Segmental Analgesia •Local Tissue Effects •Autonomic Nervous System •Trigger Point Therapy

Trigger Points • Hyperirritable locus

within a taut band of skeletal muscle or its associated fascia • Approximately 70% of

acupuncture points correspond to trigger points

Taut Bands of Skeletal Muscle Damage to muscle Calcium release from SR Actin-myosin interact Muscle contraction Decreased perfusion to m.

Decreased ATP locally Calcium can not return to SR Actin-myosin do not dissociate

Formation of Trigger Point Trauma to muscle/fascia/tendon via acute injury or chronic strain Release of mediators (bradykinin, PG, histamine) Platelets and mast cells recruited

MPS released into spaces between muscle fibers Fibrocytic nodules expand and stretch surrounding muscle Decreased O2 to muscle Local Acidity Sensitized muscle nociceptors and converted to trigger points

Pain Activation of Trigger Points Trauma to muscle/fascia/tendon via acute injury or chronic strain Release of mediators (bradykinin, PG, histamine, etc) Sensitize C-Fibers

Slow transmission to limbic system

Sensitize A-delta fibers

Fast transmission to parietal lobe

Frontal lobe

Sharp, short duration pain After short delay: Persistent, dull aching pain, Near or distant to activated trigger point Abnormally sensitive reflex arc

Types of Trigger Points  Active- causes pain

without manipulation  Latent- not obviously painful to patient. May be painful on palpation. May cause restriction of movement and eventual weakness.  Often refer pain to specific area depending on location of trigger point. (GB 21)

Structures Affected:  Skeletal muscles  Tendons/Ligaments  Joint capsules  Periosteum  Skin (esp. scar-associated)

Treatment  Needling trigger point

disrupts the abnormally contractile elements or nerve ending  Stops feedback loop

 Dry needling  Aquapuncture

•History of Acupuncture •Eastern Framework

•Western Framework- Mechanism of Action •Acupuncture Modalities •Indications for Acupuncture •Case Studies

Acupuncture Modalities       

Dry Needles China or Japan Single-use, sterile, disposable 15-25 gauge 7-40 mm Seirin J: 0.20 x 30 mm Seirin D: 0.16-0.20 x 15 mm Guide tube or without Metal handles: EAP/Moxa

Acupuncture Modalities Dry Needles  Not painful  Deqi- arrival of Qi  Retained on average 1030 minutes depending on pattern treating  Tonifying – shorter  Sedating – longer

Aquapuncture

Fluid Effect: 1. Changes pH 2. Displaces tissue to produce pressure 3. Changes electrical potential 4. Prolonged effect

Electroacupuncture (EAP)  Segmental

Analgesia (100 Hz)  Passing of electrical

energy through acupuncture points  Attach Accual to

needles in place

Electroacupuncture 1.

Advantages: Avoid manual manipulation of needles

2.

Amount and quality of stimulation to needles: accurate and uniform

3.

Higher and more continuous level of stimulation than manual

Electroacupuncture 1. 2.

3. 4.

5.

Indications Paralysis IVDD Severe and chronic painful conditions Surgical analgesia Atrophied muscles

1. 2.

3. 4. 5.

6.

Contraindications Cardiac Arrhythmias Epilepsy Shock Pregnancy Proximal to tumors High fever

Electroacupuncture  4 outputs; each with 2

needle clip leads  AC- alternates between

positive and negative polarity (deep tissue penetration)  Amplitude adjustment  Frequency (Hz): pulses per

second (high >15): sedate pain vs. (low