Dkaraba Introhowacu Ln Tcmwt

TCM Wisdom TubeTM

Intro to How Acupuncture Works: Simplify How You Educate Patients and Colleagues

by David Karaba, OMD, LAc

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Shall not be copied, duplicated, or distributed in any format or be used for teaching without prior written consent from Lotus Institute of Integrative Medicine. 1

Intro to How Acupuncture Works:Simplify How you Educate

Patients & Colleagues

David Karaba, OMD, LAc

Tel: (626) 780-7182 Fax: (626) 609-2929Web: www.elotus.org Email: [email protected]

© Lotus Institute of Integrative Medicine, PO Box 92493, City of Industry, CA 91715Shall not be copied, duplicated, or distributed in any format or be used for teaching without prior written consent from Lotus Institute of Integrative Medicine

Items Covered in this Webinar

Tissue Response– Simplified Explanation– Technical Neuro-endocrine-immune response– Basic Neurological Activation and Response

8 hour course– Detailed Neuro pathways and responses– Effects on Autonomics– Understanding the physiology of Master Tung’s

method of distal pts and how to explain how they work.

– And More… (Reviewed and expanded at conclusion)

Patient Question:

So… How Does Acupuncture Work?– Usually after:

Does It Hurt?

– What I tell my patients…

Puncture Wound

Acupuncture is a Puncture Wound. A puncture wound is a serious threat to the Body.

– It is a breach of the skin barrier systemThe body mounts a major response to neutralize any potential pathogens

– VenomSnake biteInsect bite

– BacteriaAbrasionNail

– PoisonPlant thorn, Animal, etc.

Puncture Wound

The Body responds to investigate and neutralize any Pathogens or Toxins– Vasodilation / Inflammation (initial part of healing)

Allow WBC’s to migrate out of vessels to find any bacteria, venom, or poison.

– Mast cells, basophilsHistamineHeparinLeukotrienesArachidonic AcidProstaglandins

– Immune compliment Chemotaxis (i.e. tells WBC’s where to go)

Puncture Wound

The Body doesn’t find any pathogens or toxins– Only a “Stainless Steel Sterilized - One-Time Use -

Needle”“Investigation” takes some time (~15 min)When the body realizes that it’s a “false alarm”it turns off the inflammation.– It does by creating anti-inflammatory substances

This is natural part of homeostasisOtherwise we would be inflamed all the time.




Puncture WoundThese anti-inflammatory substances circulate in local tissue and reduce inflammation that may be present

Muscle InjuriesArthritisTendonitisEtc.

– Further, sometimes the body forgets or doesn’t “remember” to turn off inflammation (i.e. chronic inflammation)

Chronic pain that is “filtered” (i.e. ignored)Acupuncture (needling) evokes a high enough threshold to “re-investigate”

Puncture WoundFurther still, the body creates natural pain killers (opioids, endorphins, enkephalins, etc.) to turn off the “False Alarm” signal as well.

Puncture Wound

Note:Alternatively -– Occasionally there are pathogens in the body as is

the case when someone is sick with a cold or flu.(Provided the Root is Strong)

– We want to stimulate aggressively and remove needle quickly so the body goes out and seeks pathogens and puts out the “fire”

Leaving needles in situ may calm body to much and allow pathogens to enter further into the body.

Needle Manipulation

Characteristics of treatment controlled by strength of needling, insertion depth, and retention timeStronger stimulation produces more needle induced tissue damage productsLonger needle retention time favors restorative anti-inflammatory response

Muscle Spasms

Injured muscles or joints can result in spasmodic muscles that tighten to reduce movement as one heals (guarding phenomenon).Chronic tightness in muscles (and m. spindle fibers) can hinder rehabilitation.

Muscle Spasms

Needling (puncture wound) is higher priority than guarding phenomenon.Allowing blood flow necessitates relaxation of the muscles – As WBC’s looks for any venom, bacteria, or poison.

Blood flow allows metabolitic build up (i.e. lactic acid, etc.) to be released from m. cellsAnd allows re-supply of oxygen and nutrients to nourish m. cells




Muscle Spasms

Resetting of muscle spindle cells allows stretch and consequent progress towards restoration of full range of motion– Effects can be immediate– Known as quick needle technique– Oblique Acupuncture– Also called trigger point therapy

“Trigger response” or muscle twitch is to resetting of muscle spindle and tendon spindle fibers.

– Known as Gamma Loop Reflex

– HDNJ: Jing Jin treatment: 3 or 2 needles

Muscle Spindlesand Golgi Tendon Organs�It has been calculated that only 1/3 of the fibers of a muscle nerve consists of motor axons connected to the muscle fibers, � While more than an half consists of fibers conveying signals from the neuromuscular spindle to the spinal marrow and vice versa.

Muscle Spindle Fibers

Principles of Anatomy & Physiology, 10th E., Tortora, Grabowski

Spinal Reflexes1. Myotatic (stretch) reflex

MonosynapticMuscle spindle afferents (1A)

Spinal Reflexes

2. Inverse myotatic (tendon organ)

•Golgi tendon organ receptors •Inhibitory input to same muscle•Protects tendon and muscle frominjury due to excessive tension

Spinal Reflexes

3. Gamma-loop reflex

•33% of ventral root axons are from gamma motor neurons •Gamma motor neurons innervate intrafusal muscle fibers•Maintain sensitivity of spindle during contraction of muscle•Increase muscle tone by triggering myotatic reflex contraction of muscles (postural)




Muscle Spindle Afferents

Static load spindle serves as feed back control sensor essential to motor functionDisorders in this system can result in paralysis, stiffness, pain and tendernessStatic load fibers needed to provoke PSSpindle affected by local temperature and pressure which can influence PS

Muscle spindles

It has been calculated that only 1/3 of the fibers of a muscle nerve consists of motoryaxons conducing to the muscle fibers, while more than an half consists of fibers conveying signals from the neuromuscular spindle to the spinal marrow and vice versa.The neuromuscular spindle is richly supplied with nerve fibers and blood vessels.

Puncture WoundHow it works to treat organs– Anti-inflammatory substances may also go to other areas

at the same segmental level (region of the spinal chord)(Enhanced by propagated sensation, PS)

– Organ referred pain concept (viscero-somato effect)Originating from the same segmental level of the spineSomato-Visceral effect:

– Because a puncture wound is serious (high enough threshold), the brain isn’t sure where signal is coming from and sends resources (&/or has specified CNS neurological responses) that effect both regions to produce the desired effect.

– Desired effect is at the discretion of Doctor(i.e. Technique employed and used)

Neuroendocrine Mechanisms of Acupuncture in the Treatment of HypertensionWei Zhou, John C. Longhurst. Evid Based Complement Alternat Med. 2012; 2012: 878673.Published online 2011 December 18.

Organ Referred Pain Patterns

Visceral RelationshipsRecognized in terms of organ referred pain reflecting in certain body regions

Also produce organ traction as noted during surgery

Viscerovisceralrelationships occur as well where function or treatment stimulation of one organ produces autonomic reflexes in another organ

Puncture Wound

Basically, Acupuncture is an ingenious way to trick the body into healing itself by bringing blood flow to the region and related areas– Providing Oxygen, nutrients, defensive substances,

and endocrine substances to these regions

Its all about the blood flow…




How to Explain it to Kids

Fire Alarm analogy– Fire Alarm– Fire Drill at school (or “accidental”)– Everybody moves to designated spaces– Fire fighters come to investigate– Fire fighters don’t find a fire

May find other areas of concern and remedy– Fire alarm turns off– Fire fighters go back to station– Kids and teachers go back to class

Tendency to remember such special (or unusual) daysBasic Concept of Jingluo TheoryBasic Concept of Jingluo Theory

MuscleTissue

Fine Vessels-SunmaiArterioles, Venules

and Capillaries

Collateral Vessels-Luomaiat each Node

Longitudinal DistributionVessels-Jingmai

Connecting-LuomaiBetween Paired Zangfu

Vessels in the Extermetiesand Other Regions of Body

Critical Nodes-Jie

Skin

Arteries

Veins

SuperficialLymphatics

Propagated Sensation Pathway

Dao of Chinese Medicine. Donald Kendall, Oxford University Press, 2002

Defensive Role of Skin

Chinese noted skin has primary defensive role Body evolved efficient defense against pricking injuries, pathogenic assault, insect bites, and animal bitesInvolves many factors of blood coagulation system which then triggers immune complement system

Defensive Role of Skin

Has complex neurovasculoimmune network of cutaneous tissues, fine vessels, immune cells, somatic afferents, and SNS fibersImportant mediators include substance P (NK 1), bradykinin (B1 & B2), and cytokines

Needling Therapy

Needling therapy effects the body first –at the capillary / cellular level– Sun Mai

Second – sensory nerves that affect the CNS

How Does Acupuncture Work?Needle Insertion

Causes the production of Bradykinin via the Blood Coagulation tissue reaction and Immune Compliment system activation

Stimulation of Substance P containing afferent nocioceptive pain fibers activating local, spinal and brainstem restorative processes.

Activates Descending Control from Brain Stem to the spinal cord and finally to trauma site.

•Inhibition of nocioceptive Pain signals•Restoration of blood flow and vascular tone•Relaxation of residual muscular tension (antispasmodic)•Promotes tissue repair




Needling MechanismsHageman Factor XIIDependent Reactants

Kallikrien Kinin GeneratingProtease

Complement AnaphylatoxinC3a, C5a, or C4a

CA++

IGE

IGEReceptors

Mast Cells& Basophils

Granules

NA+

Heparin+

Histamine

C5a

HistamineHeparinECF-ANCF-AArylsulfatase A&B

Selected PhosopholipidsLeukotrine (LT A, B)SRS-A (LT C, D, E)Prostaglandins PGE1 GGE2 PGF2a PGD2 PGI2 - PGF1aThromboxane A2Thromboxane B2Platelet Activating Factor

Dao of Chinese Medicine. Kendall, Oxford University Press, 2002

LTC4

LTD4

LTE4

SelectedPhospholipids

Mast Cellsand Baosophils

Other CellTypes

ArachidonicAcid

Phospholipase A2 orPhospholipase C + Diglyceride Lipase (1)

5 - Lipoxygenase (2) Cyclooxygenase (3)

5-HPETE PGG2

Leukotriene A4

LTB4

Prostaglandin H2

PGI2

PGE2

PGF2

PGD2

Thromboxane A2

5-HETE

Thromboxane B2

Cleaved byArly Sulfatase B

SRS-APathway

1. Blocked by steroidal antiinflamatory drugs2. Blocked by 5-LOX inhibiters3. Blocked by selective and non-selective non-steriodal antiinflamatory drugs (NSAIDs) as COX-1 and COX-2 inhibiters

Modulates motility andpossibly glucose transport

Potentchemotacticagentcomparableto C5A

Causes dissagregationof platelets

Potent broncho andvasodilators that regulatetissue microenviornment

100X 1000X

100X 100X

More potent than histaminein producing bronchospasm

More potent than histamineon vascular permeability

Powerful bronchialconstrictor

Potent vasodilatorpreferently in humanlung

Potent regulatorsof blood coagulationand homeostasis

Aryl


Leukotrienes

LTB4: potent chemotactic agent comparable to C5aLTC4 and LTD4: 100 to 1000 times more potent than histamine in producing bronchospasmLTD4 and LTE4: 100 times more potent than histamine on vascular permeabilityLTC4, LTD4, and LTE4 cleaved by arlysulfatase B from eosinophils

Prostaglandins

PGI2: causes disaggregation of plateletsPGE2: potent broncho and vaso dilators that regulate tissue microenvironmentPGF2: potent bronchial constrictorPGD2: potent vasodilator in human lung

Mast Cell

Are heavily granulated wandering cell found in connective tissue beneath epithelial surfacesGranules contain histamine, heparin, and many proteasesHave IgE receptors and like basophils they degranulate when IgE coated antigens bind to their surfaces




Mast Cell

Also participate in non-specific natural immunity activated by ComplementMarked mast cell degranulation produces allergic reactions and can produce anaphylaxis

Basophil

Also enters tissue and release cytokines and proteinsResemble but are not identical to mast cells, but do contain histamine and heparinParticipate in immediate-type hyper-sensitivityRanges from mild urticaria, rhinitis, and to severe anaphylactic shock

Eosinophil

Have a short half life in circulation and attracted to surface of endothelial cellsLike neutrophils, they release proteins, cytokines, and chemokines producing inflammationCapable of killing off invading organisms

Eosinophil

Abundant in mucosa of gastrointestinal tract to defend against parasitesCirculating eosinophils increased in allergic reactionsIncludes asthma, other respiratory diseases, and gastrointestinal diseases

Platelets

Smallest corpuscular components of human blood (diameter 2-4µm)Have a half life of about 4 daysAbout 300,000/mm³ circulating in blood, and 25% more sequestered in spleenHave primary role in clot formationMembrane have receptors for collagen, ADP, fibrinogen, and vessel von Willebrand factor

Platelets

Cytoplasm contain actin, myosin, glycogen, lysosomes, and two types of granules including serotoninAggregation fostered by platelet activating factor (PAF) secreted by neutrophils, monocytes, and platelets




Nociceptive Activation

Bradykinin B2 from blood coagulation triggers nociceptive fibersThis activates three difference key events that mediate needling response:

1. Activates axon reflex to sustain inflammation2. Sends nociceptive signals to spinal cord and

ascending tracts in spinal cord3. Provokes muscle spindle mediated reflexes

activating propriospinal system

Blood Coagulation System

Needle damage products activate Hageman Factor XIIXIIA simultaneously activates the kinin, fibrinolytic, and coagulation features of blood coagulation systemPrincipal effect is a localized immune defense to needle involving vasodilatation, immune cell egress, nociceptive excitation

Slide Title

Text– Text

Text– Text

Text

Needle Insertion

Damage to Endothelium of SmallBlood Vessels and Capillaries

Collagen, Microfibrilsand Basement Membrane

Hageman Factor XII(Plasma & Tissue Zymogen)

Kinin Proteasefrom Mast Cells

& Basophils

Plasmingen Plasmin

Prothrombin Thrombin

Inhibited by Heparin

XIIa

XIIa

XIIa

Kallikrien

Plasma Kininogen

Bradykinin

Chemotaxis

NociceptiveExcitation

Potent Vasodilation andSmooth Muscle Contraction

Blood CoagulationSystem Provokes

Needling Response


Immune Complement System

Basic defense mechanism that uses at least 30 proteins in circulating blood Named "complement" because system helps antibody kill invaders Marks any cell that does not have certain protective protein coatingsHowever, has an alternative pathway that is activated by minute tissue trauma

Immune Compliment System

Classical Pathway– involves attack by C1 when

antibody bound to antigen in an antigen-antibody complex is encountered




C3

C3b

C3b,B

C3b,Bb

C3

C3bn,Bb Properdin

Factor B

Fractor D

C3bn,P,Bb

C5C6C7C8C9

Immune Complement SystemAlternative Pathway

Chemotaxis

Plasmin

Thrombin

Amplification

Anaphylatoxin

Anaphylatoxin

Lysis, Cytotoxicity

Activated by Plasminto Provoke Immune

Response to Needling

Immune Compliment System

Dao of Chinese Medicine. KendallOxford University Press, 2002

Complement Alternative Pathway

Alternate pathway is activated by the blood coagulation system response to tissue damageDoes not require antibody to function Interacts with blood coagulation system to amplify inflammatory response

C3 activated by Plasminimmediately forms C3b binding with Factor B which then activates more C3 in a feed-forward amplification

Immune Compliment System:Alternative Pathway

Plasmin + =

Complement Alternative Pathway

Plasmin activates C3 provoking the immune complement systemComplement proteins C3 and C5 cause potent vasodilatation by degranulating mast cells and plasma basophilsReleased heparin inhibits thrombin

Combined Action

Blood coagulation system and alternative pathway immune complement system interact to amplify responseC3 causes mast cell and basophilsdegranulation and release of kinin proteaseThis preferentially causes more production of bradykinin to stimulate nociceptive fibers

ImmuneComplement SystemAlternative Pathway

AmplificationLoop

Nociceptive ExcitationVia B2 Receptors

NeedleInsertion

Microfibrils andBasement Membrane

Damage Products

HagemanFactor XII

Factor XIIa

Blood CoagulationSystem

PlasminogenKininogen

PlasminActivates C3

Kinin Protease

Bradykinin

Prothrombin(Inhibited byHeparin fromMast Cells)

C3b,Bb

C3

C3 C5

Mast Cell and Arachidonic Acid

By-products

HistamineHeparin

LT C, D & EPGE2

ECF-ANCF-A

Immune CellAttraction

Potent LocalVasodilation

Dao of Chinese Medicine, Figure 14.1, Oxford University Press © 2002

Needling Mechanisms





Neuroanatomy through Clinical Cases. Blumenfeld, 2002

Sensory Neuron Fiber TypesSpinal Chord

Dorsal Horn– I, II, III, IV, V, VI

Intermediate Zone– VII

Ventral Horn– VIII, IX

Grey Matter (surrounding central canal)– X


A-Delta C-Fiber

Myelinated, Large Non-Myelinated, small

Respond to mechanical stimuliand some to thermal also

Responds to any noxious stimuli.

Receptive fields consist ofcluster of small spots

Receptive field is a single arearather than clusters

May be sensitized May be sensitized.

Resistant to local anestheticsbut susceptible to pressure

Susceptible to local anesthetics

Inactivated with higher temp Inactivated at temp 55°C

Responsible for 1st pain (early,sharp, brief pain) 2nd pain (dull, prolonged pain)


Nocioceptive Fibers Subgroups Nociceptive Fibers

Acupuncture studies have consistently shown both Aδ and C fiber participationTypically more Aδ fibers then C fibersC fibers clearly participate in axon reflexesBoth Aδ fibers and C fibers can activate propriospinal afferents

Nociceptive Fibers

Aδ fibers have a broader area of coverage and wider distribution in spinal cord laminaeAδ fibers provide quick proprioceptiveresponse, especially to pricking injuriesThese features may favor Aδ fibers in mediating propagated sensation and directing descending control responses

Neurogenic Inflammation

C fibers are interconnected with process of inflammation Action potentials in certain branches cause axon reflexesReleases Substance P on capillary bed and mast cell to cause degranulationSympathetic activate axon reflex to constrict deeper veins to enhance cell egress




Somatosensory Pathways

Posterior ColumnMedial LemnisicalPathway – Sensory

VibrationJoint Position

– ProprioceptiveMuscle SpindleGolgi Tendon

Fine Touch– A-alpha, I– A-beta, II


Ascending Pathways

ALT comprised of spinothalamic (STT), spinorecticular (SRT), and spinomesencephalic(SMT) tractsSomatic and visceral nociceptive signals synapse on ALT crossed fibersMajor portion of SRT and SMT fibers project to the pons, midbrain, and medullaA small portion of STT fibers projects to the thalamus, which sends fibers to sensory cortex

Proprioception

Sherrington: defined proprioceptors as sensory receptors for stimuli that "are traceable to actions of the organism itself, and since the stimuli to the receptors are delivered by the organism itself, the deep receptors may be termed proprioceptors...“(1906) Brain 29:467-482

Essential Properties Proprioception

Amount of muscle activity mobilized by proprioceptive inputs is small Adequate stimuli for proprioceptors arise from actions of organism itself System can be stimulated by needling superficial body

Proprioception Receptors

Joint receptors: sensory endings in jointCutaneous receptors: movements and postures cause deformations of skin (mechanoreceptors)Specialized muscles receptors:– Muscle spindles respond to stretch– Golgi tendon organs sensitive to changes in tension

Slide TitleAnterior Lateral Pathways– Sensory

PainTemperatureCrude Touch

– Pressure

– A-delta, III– C, IV





The Yin and Yang of the Spinal Chord

Text– Text

Text– Text

Text


Descending Motor Pathway

CorticospinalTract


Descending Tracts from Primary Motor Cortex85%

CorticospinalCross overpyramidal

decussation to form:

Lateral Corticospinal

Tract. RemainingMake Anterior

CorticospinalTract.


Somatotopic Organization of Spinal Chord

Motor: Descending

Blue:Ant. Cortico -

Red:Rubrio -

Note:Assoc.NeuronsCrossing to opposing sides


Acupuncture and Internal MedicineDescending control from the brain returns to the specific level where activation occurredRestorative processes are activated for both muscles [motor] and internal organs (along with related vessels) [autonomic motor]


(4)

Skin and Superficial

Tissue

Spinal Cord Dorsal Horn

Spinal Cord Ventral Horn

Brain

Muscle

BloodVessels

Internal Organs

Nociceptive (1)

Proprioceptive(2)

Inhibition (9)

Pathways (3)

Response (8)

AutonomicMotor (6)

Motor (5)

AutonomicMotor (7)

VisceralAfferent (10)

NeedleInsertion

GammaLoop

Somatic Afferents

Ascending

Dao of Chinese Medicine, figure 14.4,Oxford University Press © 2002




DescendingInhibition

AfferentSignals

Needle insertion along vessel pathway relativeto location of problem

SegementalLevel

Local andAdjacentNodes

DistalNodes

ProximalNodes

Area Proximal to Problem

Area Distal to Problem

SegementalLevel

Region of Problem

BrainStem

SegementalLevel


Acupuncture and Internal Medicine

Detailed schematic shows specific neural pathways along with specific neurotransmitters

CNS Descending control is shown as separate from stress analgesia which utilizes norepinephrine rather than natural opiates


Node 1

PS

PS

Node 2

Node 3

Needling Sensation &Proprioceptive Signals

DorsalColumns

VentralFuniculi

AntidromicPathway

Tract of Lissauerand DLF

DRR

DRRAntidromicPathway

Spinal CordSegment

THALAMUSPERIAQUEDUCTAL GRAY

DORSAL RAPHE

SENSORY CORTEX

PropriospinalPathways

AnteriorLateralTract

Dorsal Root Ganglia A-δ and C Nociceptive Neurons& Group II Static Load Neurons

NorepinephrineNeurons

EnkephalinInterneuron

SerotonergicNeurons

Skin, Muscle, ConnectiveTissue, Fine Vessels, AfferentNerve Endings, & Intrafusal

Muscle Spindle Fibers


Sensations of “energy”moving up or down the arm (or leg) are properly known as propagated sensation

Automatic reflexes occurring in the spinal cord levels reverse the flow of sensory nerves and activate adjacent areas of skin along the longitudinal pathway of related vessels and nerves

Propagated Sensation PS as Neural Reflex

Result of stimulating high threshold SP nociceptive fibers to activate muscle spindle afferents to produce DRRs the DLFAfferent neural signals enter spinal cord over several segmental levelsThis overlap allows higher and lower levels to be activated if threshold conditions permitProgressive activation of overlapping segments produces PS along nodal pathways

Acupuncture evidence for Restorative Effects in CTS

Acupuncture may benefit CTS patients via both peripheral (e.g. increased blood flow to median n. via vasodilatative peptide release) and central mechanisms (e.g. the cholinergic anti-inflammatory pathway 5 via hypothalamic activity).

Central Processing of Acupuncture Stimuli in Carpal Tunnel SyndromeVitaly Napadow, et al

Saturday Lecture

CNS / Brain pathwaysAcu Mechanisms and pathways – Significance to Tx

HDNJ – (LAPD)

Balance Method / Master Tung’s Points– Proprioception

Embryology

– Cerebellar coordination patterns– Association neurons on midbrain tracts




Saturday Lecture (cont.)

Propagated Sensation (PS)ANS– Sedation and Tonification– Sympathetic activation

Pathogenic responsePredation nerve block

– ParasympatheticRelaxation RestorationChronic conditionsInflammation

PENS Perspectives

Questions /Comments

David Karaba, OMD, LAc– Pacific Center for Optimum Health

250 E. 17th St., #220Costa Mesa, CA 92627

– [email protected]

This webinar is sponsored by:

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