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Nina Malik, DVMOctober 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 LearnCurriculum in Veterinary MedicineGraduation 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

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

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

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

AbstractEvaluation of electroacupuncture treatment for

thoracolumbar intervertebral disk disease in dogsAyne 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 ArtTheories 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-jingFirst 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 FrameworkYin+

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

MeridiansQi travels in

meridians/channelsAcupuncture points-

locations 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 DifferentiationTCM 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:

HistoryDiagnostic Tests (Radiographs, Bloodwork)Physical ExaminationTongue and Pulse diagnosisLifestyle, 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 ActionEndogenous pain

inhibitory systemSegmental analgesiaLocal inflammatory

effectsAutonomic nervous

system to affect viscera

Relief from trigger points

Review of NociceptorsA-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 InhibitionA 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 PituitaryArcuate nucleus +

pituitary contain all the beta-endorphin cells in the brain

Beta-endorphin release into blood and CSF

Endogenous Pain InhibitionThird 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 AnalgesiaHigh 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

2 minutes-2 weeks

15-30 seconds

10 seconds-2 minutes

PHASES

1.

2.

3.

Time-dependent PhasesVasodilation

Inactivation Nociceptive

of Reaction potentiation

Tissue Repair Chemotaxis

Solubility

Sum Total of Local Tissue EffectsImproved 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 ReflexGeneral 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 PainMcBurney’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 ReflexReverse loop proposedGV 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 ReflexNeedle 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 MuscleDamage to muscle

Calcium release from SR

Actin-myosin interact

Muscle contraction

Decreased perfusion to m.

Decreased ATP locally

Calcium can not return to SRActin-myosin do not

dissociate

Formation of Trigger PointTrauma 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 Sensitize A-delta fibers

Slow transmission to Fast transmission to limbic system parietal lobe

Frontal lobeSharp, short duration

painAfter short delay:

Persistent, dull aching pain, Near or distant to activated trigger pointAbnormally sensitive reflex arc

Types of Trigger PointsActive- causes pain

without manipulationLatent- 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 musclesTendons/Ligaments Joint capsulesPeriosteumSkin (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 NeedlesChina or JapanSingle-use, sterile,

disposable15-25 gauge7-40 mm Seirin J: 0.20 x 30 mm

Seirin D: 0.16-0.20 x 15 mm

Guide tube or withoutMetal handles: EAP/Moxa

Acupuncture ModalitiesDry NeedlesNot painfulDeqi- arrival of QiRetained on average

10-30 minutes depending on pattern treating

Tonifying – shorterSedating – longer

Aquapuncture

Fluid Effect:1.Changes pH2.Displaces tissue to produce pressure3.Changes electrical potential4.Prolonged effect

Electroacupuncture (EAP)Segmental

Analgesia (100 Hz)

Passing of electrical energy through acupuncture points

Attach Accual to needles in place

ElectroacupunctureAdvantages:

1.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

Indications1.Paralysis 2.IVDD3.Severe and chronic

painful conditions4.Surgical analgesia5.Atrophied muscles

Contraindications1.Cardiac Arrhythmias2.Epilepsy3.Shock4.Pregnancy5.Proximal to tumors6.High fever

Electroacupuncture4 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<15): muscle atrophy

Electroacupuncture3 Modes:

1. Continuous- stable frequency; continuous stimulation (tolerance)

2. Dense Disperse- continuous stimulation with alternating high and low frequency bursts (avoids tolerance)

3. Intermittent- stable frequency; stimulation pulsed with rest periods (avoids tolerance)

MoxibustionHeating of

acupuncture pointsArtemesia vulgaris

(mugwort; related chrysanthemum family)

400° F

Indications:“Cold” conditions TCMPainful joints/muscular“Deficient” patients

INDIRECT MOXA

Precautions1.Vicinity of mm or

sensory organs

2.Caudal back/abd in pregnant animals

3.Febrile conditions

4.Burn Fur

Infrared Light TherapyAnother means of using

heat to stimulate acupuncture points

Can use on individual acupuncture points or generalized areas

Mitochondria absorb light - covert to ATP - fuels cellular processes – release of NO- vasodilation(reduce inflammation, improve local circulation, cell replication and repair)

Infrared Light TherapyFDA approved for

specific indications in humans

Human therapy: Carpal tunnel syndrome, arthritis, TMJ

Veterinary Medicine:• Stimulation of

acupuncture point• Needle phobic patients• Hard to reach

acupuncture points• Corneal ulcers, Non-

healing skin wounds, Superficial penetration

• Repetitive Strain Injuries?

Infrared Light Therapy

Disadvantages:Size of diode clusterDurationSuperficial

penetrationUnit costResearch- Equine/

Companion animal optimal settings

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

•Endogenous Pain Inhibition

•Segmental Analgesia

•Local Tissue Effects

•Autonomic Nervous System

•Trigger Point Therapy

Pain ControlMusculoskeletal DiseaseNeurologic Disease

Pain ControlMusculoskeletal DiseaseNeurologic DiseaseDermatologic Disorders

Gastrointestinal DisordersCardiovascular DiseaseRespiratory DiseaseUrogenital Disorders

Pain ControlMusculoskeletal Disease

IndicationsMusculoskeletal DiseasePost-operative

orthopedic surgeryOsteoarthritisTrigger Point TherapyJoint dysplasia

Pain, Range of Motion, Improve Circulation, Promote Healing

IndicationsNeurologic DiseaseIntervertebral Disk

DiseaseFCESeizuresPeripheral

NeuropathiesVestibular DisordersImprove comfort in

Degenerative Myelopathy patients

Indications

Gastrointestinal DisordersNauseaVomitingDiarrheaConstipationAbdominal Pain

PC 6 – Inhibiting frequency of lower esophageal sphincter relaxation (cats)

Indications

Dermatologic Disorders

Allergic DermatitisChronic Skin

DiseaseOtitis ExternaNon-healing skin

wounds (infrared)

IndicationsCardiovascular/

RespiratoryRhinitisSinusitisBronchitisChronic coughingCirculatory DisordersAsthma

IndicationsUrogenital DisordersUrinary incontinenceUrinary tract infectionsChronic kidney disease

Immune Stimulation- Increase in absolute lymphocyte number (21 d)

Behavioral Problems

Oncology Patients

The Forest through the Trees

Course of Therapy

Risks of TherapyOne of the safest therapies availableSide effects are rarePatient may be transiently sleepy or sore for 1-2

daysExpectations: duration of treatment / indicationsDisclose cancerOveruse of injured limbSwallowed needlesEye injury, pneumothorax, infectious arthritisBroken needles

Case Studies10 year old, FS, Lab mix

History of elevated liver enzymes, otherwise clinically normal

Chronic issues: 1.Degenerative

Myelopathy- mild HL ataxia; intermittent dorsal scuffing

2.Blind3.Urinary incontinence

Case StudiesAUS: hepatic massReferred to surgery at

Atlantic Coast Veterinary Specialists:

Left medial liver lobectomy and mass excised from the quadrate lobe

Overnight post-surgery: Ambulatory with hind end sling; lying down in run

Case StudiesReferred for acupuncturePhysical Exam ambulatory without HL sling, but weakHL ataxiaAtrophy bilat HL musculatureDec extension shoulderDec extension bilat hipsTrigger points: Mild L. triceps m.; Bilateral

quadriceps muscles

Case StudiesAcupuncture TreatmentArthritis in shoulders

and hipsTrigger points in L.

triceps and quadricepsUnderlying TCM

patterns contributing to overall condition and HL muscle atrophy

Case Studies

Case Study #22 year old, MN, Basset

HoundDiagnosed with IVDD L1-

L2 and L2-L3Surgical Decompression

Presentation 1 monthPost-op1.Severely paretic in HL2.CP deficits HL3.No deep pain HL

Case Study #2Acupuncture TreatmentCombination of dry

needles and EAP

Lumbar back and distal leg points treated

Thus far: 2 dry needle and 2 EAP treatments

Case Study #2ProgressAfter first couple of txAble to stand up on

own and hold without falling over

After these four txBetter motor HLDeep pain

Case Studies- Other Species

2 year old, FS, DSH•Initial presentation- severe gingivitis

•Dental and medical management

•2 acupuncture tx, 1 month apart

Case Studies- Other Species7 year old, MC, Mini Lop•Chronic head tilt, decreased appetite, decreased activity since a pasteurella ear infection a couple of years ago•Being treated with acupuncture monthly for past 18 months•Activity improved, Appetite improved, Head tilt improved but mild one present

Case Studies- Other Species

Questions?