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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?