East Meets West Acupuncture Mechanisms PowerPoint Presentation

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Acupuncture MechanismsEast Meets West Thomas Archie, MD, DABFM, DABMA St. Luke’s Wood River Medical Center Integrative Therapies Service

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Objectives Discuss proposed mechanisms of action of acupuncture from two points of view: Western medicine Chinese medicine Applications Complications

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Acupuncture: China to Europe Huang Di Nei Jing “Yellow Emporer’s Inner Classic” Earliest existing major text on AP 3rd-1st Century BCE Europe 1500-1600s Jesuit missionaries gave earliest reports of Chinese Medicine 1683 William Tin Rhijne Dissertation on Arthritis 1671-1686: Three translations of Chinese medical texts Detailed AP names, moxibustion, needle manipulation

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Acupuncture Pre-Research Soulie de Mourant Early to mid 1900s Taught French physicians Published 3 volumes of L’Acuponcture Chinoise in 1939-1955

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Early Acupuncture Research France Mechanism studies beginning in 1940s China Acupuncture pain relief studies started 1965

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Early Electrical Studies 1940-50s Niboyet (France) AP points – decreased electrical resistance relative to surrounding skin Most points w/ decreased electrical resistance corresponded with Chinese AP charts AP pts on classically paired meridians have decreased Elect resistance compared with points on unpaired meridians

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Early Chinese Acupuncture Meridian Chart

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Neurotransmitters Endorphin release by acupuncture Pomeranz 1976 - endorphins (some analgesic effects blocked by Narcan) Clinical effect lasts much longer than blood levels of endorphins Seen in low frequency electroacupuncture

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1979 – LeBarDiffuse Noxious Inhibitory Control Inhibit pain by counter-irritation stimulation Serotonin and Endorphins mediate the response Pain inhibition is directly related to intensity of stimulus Distance between conditioned site and site of stimulation is not important Detailed loop involving spinal tracts, brainstem, and thalamus

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Neurotransmitters Known increase in release during AP treatment Serotonin, NE, Substance P, GABA, dopamine, ACTH Opioid B-endorphins, enkephalin, dynorphin

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fMRI Study Needle placed in foot Acupuncture point associated with stimulation of brain’s visual cortex

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fMRI Study Auditory Complex stimulated by needle placed in AP point on the leg associated with hearing

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91% of Acupuncture Points share this Histology

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Trigger Points 1977 71% correlation between Trigger Points and Acupuncture points

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Meridians Meridians have decreased electrical resistance relative to surrounding skin Qi measured as microelectrical current Flows in a circuit Toes to fingers to head to toes Up on anterior surface of the body Down on posterior surface of the body

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Meridians

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Future Research Central Nervous System (CNS) as a classic example of a nonlinear system Billions of neurons and astrocytes Response to environment is orderly but tends to change with time Functional MRI - change of CNS with time - important for future research of mechanism Future research to look at CNS function as a whole, rather than function of its individual components

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Future Research Outcomes research using Existing research models (“sham” AP vs. “usual care”) Patient-centered, market-based models Interactive modalities (acupuncture, homeopathy, massage, reiki, healing touch) potentially better analyzed by a yet-undeveloped model Problems inherent in applying double-blind, placebo-controlled model

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Dualism vs. Monism Descartes/Newton designed a Dualist model Body and Mind are separate Mind is a product of the Body (esp. Brain) Study components and understand the whole (ex: block breakdown of serotonin and thus increase longevity of serotonin to produce clinical improvement of depressed patient)

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Dualism vs. Monism Dualism: parts make up the whole (body vs. mind/soul) Allopathic Medicine – Descartes, Newton Study components and understand the whole Example: Serotonin enhanced via depression drugs Monism: body, mind, consciousness, universe are continuous and interactive Traditional Chinese Medicine, Ayruveda Example: Weather-related Wind invasion in person with Liver Qi stagnation with Yin or Yang Deficiency as risk factor Cold/Flu vs. Vertigo vs. Autoimmune Disease The individual is reflective of the universal, and vice-versa

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Eastern Mechanisms Rice Vapor Qi

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Eastern Mechanisms Qi (Character with vapor rising above cooking rice) Early 1900s - Soulie de Mourant- Qi = “energy” and Jing = “meridian” Simplified translation of complicated terms “Life Force” made up of air and food transformed by body into blood and body fluids Nei Jing written during 3rd – 1st Century BCE Chinese physicians & cadaveric dissections Using needles of glass, metal and bone to influence neurovascular system

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Meridians Acupuncture points linked together in lines called “meridians” Meridians named for associated Organ Kidney, Heart, Small Intestine, Bladder Liver, Pericardium, Triple Energizer, Gallbladder Spleen, Lung, Large Intestine, Stomach

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Meridians

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Different Acupuncture Models Traditional Chinese Medicine (“TCM”) Eight Principles (Yin/Yang, Damp/Dry, Cold/Heat, Interior/Exterior) Zhang-Fu organ pairings blends Yin-Yang and 5 Element Five Element (Korean) Wood, Fire, Earth, Metal and Water Meridian-based: Japanese, Vietnamese, French Different schools of thought regarding etiology of disease (Kidney versus Spleen/Stomach) Neuroanatomical - CraigPENS, osteopuncture

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Meridian-Based Acupuncture Blockage in meridian flow produces disease Therapeutic action of “unblocking” meridian flow (Relieving Stagnation) Pain Asthma Heavy, Painful, or Irregular Menstrual Periods

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TCM Qi Physiology Stomach separates pure from impure Qi of food Pure Qi to Spleen Impure to Small Intestine (process repeats again) Spleen sends Food Qi to Lung Lung combines it with pure Qi extracted from air Food/Air Qi “heated” by Yuan Qi (ancestral pilot light) provided by Kidney to make “Nutritive Qi” In Heart to make Blood In Meridians

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Five Elements System of Correspondences Fire Wood Water Metal Earth

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Five Element Acupuncture Imbalance between Elements causes Disease Example Chronic overwork/abuse/disease leads to deficiency of Water (fatigue, chronic UTI/stones/incontinence, joint pains, low back pain, fear, low self-esteem) Water controls Fire (Water Def – Fire Excess) Excess Fire symptoms result (anxiety, hot flashes, palpitations, insomnia, inflammation)

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Five Element Acupuncture Patient Evaluation Pattern Recognition Treatment Reassessment for clinical effect

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Patient Evaluation Evaluate history of medical/surgical diagnoses Patterns Sleep, pain, digestion, emotional responses to stressors, self-organization, flavor and color affinities, menstrual patterns, timing of symptoms (24hr, monthly, seasonal variations)

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Pattern Recognition Five Elements Interconnections between Patterns TCM Eight Principles

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Treatment Treat by “Tonifying” deficiencies and “Dispersing” excesses Release excess Fire Tonify deficient Water Use Acupuncture and Chinese Herbs in combination

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Five Elements System of Correspondences Fire Wood Water Metal Earth

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Five Element Correspondences Wood (Liver, Gallbladder) Driven, multiple projects, movement, anger/anxiety, tight traps/lateral neck/IT band, TMJ, migraines, caffeine sensitivity, fibromyalgia, blue/green, sour/citrus, Spring, expansion, insomnia (esp. sleep maintenance 11pm-3am), east Augments Fire, controls Earth, augmented by Water and controlled by Metal Coupled with Fire

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Five Element Correspondences Fire (Heart, Small Intestine, Pericardium, Triple Energizer) Creative, CEO, joy, palpitations, insomnia (esp. sleep initiation), hot flashes, night sweats, cardiac disease, dysrhythmias, mania, red/orange, bitter/roasted, summer, south Augments Earth, Controls Metal, Augmented by Wood, Controlled by Water Coupled with Wood and Water

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Five Element Correspondences Earth (Spleen, Stomach) Nurturing, worry/obsession, GI issues (loose stools, gastritis, bloating, abd pain), sinusitis, cysts, tumors, lumps, dampness, obesity, chronic fatigue(multifactorial), sweet, dampness (cysts, edema), yellow/brown, transitions of seasons, center of compass positions Nurtures Metal, Controls Water, Controlled by Wood Coupled with Metal

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Five Element Correspondences Metal (Lung, Large Intestine) Respiratory, skin disorders (“3rd lung”), constipation, dryness, sense of duty, grief, loss, depression (multifactorial), flavorful/spicy, white/grey/colorless, autumn, west Nurtures Water, Controls Wood, Controlled by Fire Coupled with Earth

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Five Element Correspondences Water (Kidney, Bladder) UTI, Kidney stones, incontinence, joint pain, low back pain, inner chill, abuse, philosopher, music, hearing problems, throat, winter, black, north, salty, motivation/willpower Nurtures Wood, Controls Fire, Controlled by Earth Coupled with Fire

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Eastern Microsystems Holographic/fractal representation of homunculus on skin surface Tongue, Ear, hand, foot, scalp Auricular medicine highly specialized by French Ancient Egyptian paintings depict auricular cautery Nogier (FR) 1950s investigated history of ear cautery for back pain

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Homunculus

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Chinese Diagnostics Tongue Color, size, wetness/“scalloping”, coating, cracks Geographic representations of organs Clinical changes occur slowly (weeks) Pulses Radial artery Organ assessment at certain positions/depths Clinical changes occur quickly (during treatment)

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Kidney Yin Deficiency Excess Heat in Heart Invasion of Wind Long, thin, dry, red body with lateral deviation Dry yellow coat Heart Yin and Blood Deficiency Tongue body pale and tip red and pointed No coat Severe Yin Deficiency Long-standing heat or fire (LR or ST) Red tongue body with black, dry central coat (KI) Yang deficiency Swollen, pale, scalloped, thin clear coat

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Acupuncture Microsystems Auricular points (low electrical resistance) 90% accurate in recognizing past or present organ diseases (gastritis, asthma, past orthopedic surgeries) – Nogier (France) Recent randomized, double blinded, placebo-controlled study on pediatric bed wetting using Korean Hand AP system

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So What Is It Good For?

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Applications Studies of various standards Value of RDBPCT design for interactive modalities dubious Internal Medicine Asthma, nausea, IBS, Crohn’s/UC, anxiety, depression, epilepsy, chronic UTI, eczema, sinusitis, allergies, headache, TMJ, Bell’s Palsy, neuropathy, stroke (scalp acupuncture) Substance abuse - smoking, chewing, opiates, alcohol, craving

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Applications OB/GYN Premenstrual syndrome, (peri)menopausal symptoms, dysmenorrhea, menorrhagia, oligomenorrhea, infertility, labor pain, breech presentation Pain Epicondylitis, plantar fasciitis, arthritis, low back pain, neck pain, pelvic pain, zoster

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Applications Essentially, any medical problem should be accessible with AP Issues are practicality and density of disease Acupuncturist training and experience Role in Cancer Helpful for decreasing side effects of chemo/radiation Especially with herbal therapy Facilitating spiritual transition to interaction with mortality

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Veterinary Acupuncture

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Veterinary Acupuncture

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Clinical Research Examples

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Knee Osteoarthritis Lancet. 2005 Jul 9-15;366(9480):100-1. RCT 294 patients in 28 outpatient centers 12 treatments over 8 weeks 3 groups (AP, sham AP, wait list control) WOMAC index questionairre at 8, 26, 52 weeks Result Pain and joint function improved more with acupuncture than with minimal acupuncture or no acupuncture in patients with osteoarthritis of the knee. However, this benefit decreases over time.

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Low Back Pain JAMA. 1999;281:818-823. 29 men and 31 women with LBP secondary to degenerative disk disease Treated with percutaneous electrical nerve stimulation (PENS), sham-PENS, TENS, and exercise. The PENS group had Significant and larger reductions in VAS scores Decreased drug usage Improved physical activity, quality of sleep, and sense of well-being (P<.05 for each).

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Low Back Pain Pain. 2002 Mar;96(1-2):189-96 RCT with 131 consecutive outpatients with LBP for at least 6 months and a normal neurological examination. Randomization to one of three groups Each group received PT over 12 weeks Plus either acupuncture, sham acupuncture, or no additional treatment. 20 treatments over 12 weeks Acupuncture was superior PT without acupuncture regarding pain intensity (P=0.000), pain disability (P=0.000), and psychological distress (P=0.020) at the end of treatment.

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Chinese Herbal Medicine in Cancer Fu-Zheng pattern (correct predisposing patterns of deficiency and stagnation) Symptom management and increase in survival 197 pts Stage III and IV ENT cancers randomized to radiation with or without TCM herbs (Yi Qi Yang Yin Tang). 3-year survival 67% vs. 33%. Sun. Rec Results in Cancer Research 1988:108:327

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Chinese Herbal Medicine in Cancer 303 patients with Stage III and 63 with Stage IV gastric cancer with chemo randomized to additional Pishen Fang herbal formula or to control group. 5yr survival 53% Stage III with herbs and 10% Stage IV with herbs 10yr survival 47% Stage III with herbs Yu. J Trad Chin Med 1993;13(1):31. 2001 first US FDA-approved clinical study of extract of Coix lachryma-jobi (called Kanglaite) for refractory non-small-cell carcinoma of lung. Phase 2 trial began 2003. Previous Chinese studies show inhibition of mitosis of tumour cells during G2/M phase of the cell cycle, tumor cell apoptosis, increased gene expression of FAS and Apo-1, inhibits angiogenesis

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What does Acupuncture Look Like?

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Complications and Precautions Retained Needle Pneumothorax (any organ puncture) Auricular infections Other skin infections Temporary (24hr) clinical worsening Pregnancy Not a contraindication Theoretical concern of causing contractions Anticoagulation - not a contraindication

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Recommended Readings Between Heaven and Earth, Beinfield and Korngold. Easily read book on Chinese Medicine Alternative Therapies in Health and Medicine. Peer-reviewed journal on integrative medicine. Excellent articles. Inexpensive. 6 issues per year.

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Recommended Readings Vibrational Medicine, Gerber. Very well written on various forms of “energy medicine” - acupuncture, magnets, homeopathy, Bach flower essences, reiki...

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Acupuncture MechanismsEast Meets West Thomas Archie, MD, DABFM, DABMA St. Luke’s Wood River Medical Center Integrative Therapies Service