1. Pain Management by Acupuncture
Borjis Holistic Health Clinic
Dr. Ansari

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 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)

9. 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

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. Headache Principle 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. Classifications of TN Western Medicine: Eastern 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

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 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

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
Temporo-mandibular
ST7, SI 19, T 17, Li 4
Shoulder joints:
LI 15, T14, SI 11, T3,G 34
Elbow joints:
Li 11, T10, Li 4
Wrist & joints:
T5, Li 10., LI. 4
Lumbar spinal joints:
Huatuoparaspinal acupoints, UB37 and UB 40
Lumbosacra
Joints:
GV3, B30, B 25, B40 B 60
Sacroiliac Joints:
B 27, B28
Hip joints:
G 30, G 29, G34, G39
G30, G 29, G34, G39
Knee joints:
St 34,St 36, Sp 9,
G 34
Ankle joints:
ST 41, T 40, K3, B50, G 35 K8
Metatarsophala-ngeal joints:
Sp 4, B 65, G 38, Sp 5

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.

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

52. Carpal Tunnel Release
Surgery:

53. Carpal Tunnel Syndrome Principle acupuncture points

54. Cervical Spondylosis Principle acupuncture points
G 39
B 64
B 11
G 21
GV 16
T 10
B 10

55. Rotator Cuff Syndrome Principle acupuncture points
Li15
Si 11
T14
Li 16
Li12
Li4
L 7
L 9
T 9
T 4

56. DX of Lateral Epicondylitis (Tennis elbow)
History of tennis elbow use
Pain just distal to the prominence of the lateral epicondyle
Radiological study negative

57. Knee Tendonitis
Patellar Tendonitis

58. Achilles Tendonitis
Runner’s injury

59. Lower back pain-Etiology
Herniated Disk (bulging)
Facet joint syndrome
Sacroilliac joint syndrome
Myofascial syndrome

60. Low Back Pain-diagnosis
Clinical history
Physical examination
Pain sensitive structures
Pain generators
Radiological studies

61. Low Back Pain-X-ray

62. 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

63. Referred and Interactive Low Back Pain

64. 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

65. Referred and interactive- Low Back Pain

66. 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.

67. Sciatic Neuralgia Principle acupuncture points
B 23
B 30
G 30
B 36
B 37
B 40
G 34

68. Traumatic Injury-Brain-TBI
Clinical manifestations:
Altered mental status
Communication disorders
Emotional and psychitric disorders
Related paralysis or paresthesia
Dx: Refer to physician for further investigation.

69. Cause of Neck Pain

70. Radiological Findings of Neck Pain

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