Acupuncture Mechanisms - East Meets West

							Acupuncture Mechanisms
   East Meets West
               Objectives
• Discuss proposed mechanisms of action of
  acupuncture from two points of view:
  – Western medicine
  – Chinese medicine
• Applications
• Complications
  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
    Acupuncture Pre-Research
• Soulie de Mourant
  – Early to mid 1900s
  – Taught French physicians
  – Published 3 volumes of L’Acuponcture
    Chinoise in 1939-1955
   Early Acupuncture Research
• France
  – Mechanism studies beginning in 1940s


• China
  – Acupuncture pain relief studies started 1965
        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
Early Chinese
Acupuncture
  Meridian
   Chart
          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
           1979 – LeBar
 Diffuse 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
           Neurotransmitters
• Known increase in release during AP
  treatment
  – Serotonin, NE, Substance P, GABA, dopamine,
    ACTH
• Opioid
  – B-endorphins, enkephalin, dynorphin
               fMRI Study
• Needle placed in foot Acupuncture point
  associated with stimulation of brain’s visual
  cortex
              fMRI Study
• Auditory Complex stimulated by needle
  placed in AP point on the leg associated
  with hearing
91% of Acupuncture Points share
        this Histology
             Trigger Points
• 1977
  – 71% correlation between Trigger Points and
    Acupuncture points
                  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
Meridians
              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
              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
         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)
            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
       Eastern Mechanisms



        Vapor




                      Qi
Rice
           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
                 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
Meridians
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
  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
           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
            Fire

Wood                     Earth
        Five Elements
          System of
       Correspondences
  Water              Metal
    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)
      Five Element Acupuncture
•   Patient Evaluation
•   Pattern Recognition
•   Treatment
•   Reassessment for clinical effect
          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)
Pattern Recognition
 • Five Elements


 • Interconnections between
   Patterns


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

Wood                     Earth
        Five Elements
          System of
       Correspondences
  Water              Metal
 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
 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
  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
 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
 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
        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
Homunculus
           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)
                         (KI) Yang deficiency

                        Swollen, pale, scalloped,
                             thin clear coat




                                                    Kidney Yin Deficiency
                                                    Excess Heat in Heart
Heart Yin and Blood                                   Invasion of Wind
    Deficiency
                        Severe Yin Deficiency
                                                    Long, thin, dry, red body
Tongue body pale and     Long-standing heat          with lateral deviation
  tip red and pointed     or fire (LR or ST)            Dry yellow coat
        No coat
                          Red tongue body with
                          black, dry central coat
    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
So What Is It Good For?
                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
                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
                   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
Veterinary Acupuncture
Veterinary Acupuncture
Clinical Research Examples
              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.
                  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).
                  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.
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
 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
What does Acupuncture Look
           Like?
    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
      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.
      Recommended Readings
• Vibrational Medicine, Gerber. Very well
  written on various forms of “energy
  medicine” - acupuncture, magnets,
  homeopathy, Bach flower essences, reiki...