Transcript Acupuncture Mechanisms East Meets West Thomas Archie, MD, DABFM, DABMA Integrative Therapies Service

Acupuncture Mechanisms
East Meets West
Thomas Archie, MD, DABFM, DABMA
St. Luke’s Wood River Medical Center
Integrative Therapies Service
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
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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
Rice
Qi
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
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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
Heart Yin and Blood
Deficiency
Tongue body pale and
tip red and pointed
No coat
Kidney Yin Deficiency
Excess Heat in Heart
Invasion of Wind
Severe Yin Deficiency
Long-standing heat
or fire (LR or ST)
Red tongue body with
black, dry central coat
Long, thin, dry, red body
with lateral deviation
Dry yellow 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
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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 wellbeing (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 nonsmall-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
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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...
Acupuncture Mechanisms
East Meets West
Thomas Archie, MD, DABFM, DABMA
St. Luke’s Wood River Medical Center
Integrative Therapies Service