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MedicalAcupuncture

NardaGRobinson,DO,DVM,MS,FAAMAColoradoStateUniversity,DepartmentofClinicalSciences

CuraCore.orgNarda.Robinson@colostate.edu

LearningObjectives

1. DistinguishbetweenthewesternbiologicalrationaleformedicalacupunctureandChineseacupuncture

LearningObjectives

2. CompareandcontrastdiagnosticsandtreatmentapproachesfromamedicalacupunctureversusaTCMperspective

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LearningObjectives

3. Identifymedicalconditionstreatedwithacupunctureandresourcesforreferralandfurtherlearning

LearningObjectives

1. DistinguishbetweenthewesternbiologicalrationaleformedicalacupunctureandChineseacupuncture

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“WesternMedicalAcupuncture”ADefinition

• “Westernmedicalacupunctureisatherapeuticmodalityinvolvingtheinsertionoffineneedles;itisanadaptationofChineseacupunctureusingcurrentknowledgeofanatomy,physiologyandpathology,andtheprinciplesofevidencebasedmedicine.”

“WesternMedicalAcupuncture”ADefinition

• “…WhileWesternmedicalacupuncturehasevolvedfromChineseacupuncture,itspractitionersnolongeradheretoconceptssuchasYin/Yang andcirculationof qi,andregardacupunctureaspartofconventionalmedicineratherthanacomplete‘alternativemedicalsystem’.”

“WesternMedicalAcupuncture”ADefinition

• “…Itactsmainlybystimulatingthenervoussystem,anditsknownmodesofactionincludelocalantidromicaxonreflexes,segmentalandextrasegmentalneuromodulation,andothercentralnervoussystemeffects.Westernmedicalacupunctureisprincipallyusedbyconventionalhealthcarepractitioners,mostcommonlyinprimarycare.”

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“WesternMedicalAcupuncture”ADefinition

• “…Itismainlyusedtotreatmusculoskeletalpain,includingmyofascialtriggerpointpain.Itisalsoeffectiveforpostoperativepainandnausea.PractitionersofWesternmedicalacupuncturetendtopaylessattentionthanclassicalacupuncturiststochoosingonepointoveranother,thoughtheygenerallychooseclassicalpointsasthebestplacestostimulatethenervoussystem.”

“WesternMedicalAcupuncture”ADefinition

• “…Thedesignandinterpretationofclinicalstudiesisconstrainedbylackofknowledgeoftheappropriatedosageofacupuncture,andthelikelihoodthatanyformofneedlingusedasausualcontrolprocedurein“placebocontrolled”studiesmaybeactive.Westernmedicalacupuncturejustifiesanunbiasedevaluationofitsroleinamodernhealthservice.”

Source

• WhiteAandEditorialBoardofAcupunctureinMedicine.WesternMedicalAcupuncture– ADefinition.AcupunctMed 2009;27:33-35 doi:10.1136/aim.2008.000372

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NotAllMedicalAcupuncturistsPracticeScientifically

• ManyMDsandDOsinNorthAmericaincludeTCMandothermetaphoricalapproaches

• PhysiciansintheUnitedKingdomandCanadamayhaveamorescientificapproach– Neuroanatomicacupuncture

• Osteopathicphysicianstendtoincludeproportionallymoremyofascialpalpationandtriggerpointdeactivationintheirtreatments

AmericanAcademyofMedicalAcupuncture

• Primarilyaphysicianacupunctureassociation– medicalacupuncture.org

• AmericanBoardofMedicalAcupunctureconfersboardcertificationoneligibleMDandDOmemberswhohavecompletedallrequirements:DABMA.org

• Notallcoursesinmedicalacupunctureteachstrictlyscientific medicalacupuncture

OtherFormsof“MedicalAcupuncture”

• FrenchEnergetics• TraditionalChineseMedicine• Auricularacupuncture• FivePhases(orFiveElements)• KoreanHandAcupuncture• Scalpacupuncture

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DebatebetweenScienceandMetaphoricalApproaches

• Ongoingwithinthemedicalacupuncturecommunityaswellasnonphysicianacupuncturegroups

• Somesaythatapproachingacupuncturescientificallyandbasedonanatomyandphysiologycouldrobitofitsbeauty,elegance,traditionalroots

• Thisisnottrue

WhatAreAcupuncture

Points?

ScientificMedicalAcupuncture

• Acupuncturepointsaresitesthroughwhichwecanengenderneuromodulationandmyofascialnormalization

• Neuromodulationimpactsneuralsignalinglocally,regionally,andsystem-wide,leadingtophysical,psychological,andautonomicnervoussystemchanges

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LearningObjectives

2. CompareandcontrastdiagnosticsandtreatmentapproachesfromamedicalacupunctureversusaTCMperspective

TraditionalChineseMedicine

• “[S]kepticismremainsaboutthenatureandvalidityoftheconceptsthatunderlieTCMclinicaldiagnosisandtherapeuticdecision-making..”– O’BrienKAetal.UnderstandingthereliabilityofdiagnosticvariablesinaChineseMedicineexamination.JAltComplementMed. 2009;15(7):727-734.

TraditionalChineseMedicine

• “Thisskepticismextendstothediagnosisofdiseasesordisordersonthebasisoftonguediagnosis,pulsediagnosis,andotherclinicalsignsandsymptoms,theidentificationofsyndromesreflectingunderlyingpatternsofdisharmonyofaclinicalentityordiseaseandtheuseofChineseherbalmedicinalformulaetorestorethesupposedlydisruptedbalance.”

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TraditionalChineseMedicine

• “TherearerelativelyfewdataavailableconcerningthereproducibilityofmajorTCMdiagnosticvariables,suchaspulsediagnosisandtonguediagnosis,andadistinctlackofinformationaboutthereliabilityofotherclinicaldatagatheredinaTCMexamination.”

TraditionalChineseMedicine

• “OnlyasmallnumberofstudieshaveinvestigatedthereproducibilityofTCMsyndromediagnosis.”

TraditionalChineseMedicine

• “Iftheindividualdiagnosticobservationsarethemselvesunreliable,therecanbelessconfidencethattheTCMsyndromediagnosedthroughsynthesisofdiagnosticobservationswillbereliable.”

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ScientificMedicalAcupuncture

• Basetreatmentsontheresultsofamodernmedicalexaminationandmyofascialpalpation

• Thegoalsincludenormalizationofnervousfunction(neuromodulation)andalleviationofmyofascialdysfunction

WhyAnatomyinAcupuncture?

• Anatomyisfactual,rational,andidentifiable.• AncientChineseacupuncturistsactuallyknewagreatdealaboutanatomy.

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WhyAnatomyinAcupuncture?

• Thereisno“gap”intheeffectsofacupuncturethatneedtobefilledby“consciousness”,“Qi”,or“energies”.It’sallrealandcanbeexplained.

WhyAnatomyinAcupuncture?

• Knowingacupunctureanatomymakesacupuncturesafer

• Anatomyisthebasisofmedicineandshouldbethebasisofacupunctureasatypeofmedicalpracticethoughothersmayviewthebasisas“Qi”and“heat,wind,damp,fire,water,etc.”

• InteractiveMedicalAcupunctureAnatomy– RobinsonNG– CRCPress–March2016

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OURJOURNEYBEGINS

THORACICLIMB

LungChannel

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Cephalicvein

EarlyAcupuncture

• Beganasablood-lettingtechnique,whichiswhymanyofthechannelsfollowbloodvessels– EplerDCJr.BloodlettinginearlyChinesemedicineanditsrelationtotheoriginofacupuncture.BullHistMed. 1980;54(3):337-367.

EarlyAcupuncture

• Wedonotadvocatebloodletting– thisisonlyprovidedforhistoricalcontextandcertainlydoesnotmeetCMErequirementsforcareofpatients

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THEOUTCOMEOFNEEDLINGDEPENDSONTHESTRUCTURESTARGETED

LU5:“CubitMarsh”

WhatWillYouStimulate?

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WhatWillYouStimulate?

WhatWillYouStimulate?

ANATOMYDECIDESTHERESULTS

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CHANNELSFOLLOWNERVESANDVESSELS

CHANNELSARETHENERVESANDVESSELS

ChannelNomenclature

• Confusing• Mostrefertoorgans• Manyormostofthepointsoneachchannelhavelittletonothingtodowiththeorganafterwhichthechannelisnamed

• Somechannelnamesarepurelymetaphorical– E.g.,“TripleHeater”and“GovernorVessel”

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Channels=NervesandVessels

STRUCTUREDICTATESFUNCTION

THEOUTCOMEYOUGETDEPENDSONTHENERVESYOUACTIVATE

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Pericardium6:“Neiguan”“InnerPass”

“InnerPass”

• Referstothepassagethroughtheinterosseousmembraneoftheanteriorinterosseousvesselsthatsupplythedorsalaswellasthevolarsurfacesofthedistalantebrachium.

Whatarethelocal,regional,and

systemiceffectsofneedlingPC6?

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ConnectiveTissueatPC6

• Interosseousmembrane– Longitudinalstabilityoftheantebrachium,orforearm

• Clinicalrelevance– High-forcecompressivetraumacaninjuretheforearmandelbow,tearingthemembrane,andcausingnotonlyinstabilitybutalsoconsiderablepainanddisabilitybylimitingmotionandchangingthebiomechanicsofthewrist

NeuralElementsatPC6

• Mediannerve– Sensory–Motor– Autonomic

• Medialandlateralantebrachialcutaneousnerves

• Anteriorinterosseousnerve

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NeuralElementsatPC6

• Clinicalrelevance:– Local:Identifyandtreatsourcesofnerveentrapmentandcompressionthatmaymimiccarpaltunnelsyndrome

– Regional:Complexregionalpainsyndrome(akareflexsympatheticdystrophy

– Systemic:Longloopreflexestothebrainstemandtherostralventrolateralmedulla

LargeIntestine(LI)Channel

RadialNerve WristandDigitExtensors

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Radialnerve

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WhatMakesLI4a“BigPoint”?

LI4:“Hegu”

• Needlingaffectspotentiallyeverynerveofthethoraciclimb– Radial– Ulnar–Median(withdeepneedling)– Sympatheticfibers

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DorsalView PalmarView

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PELVICLIMB

Bladder(BL)

SciaticNerve

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Leftpelviclimb,canine

ConsidertheSpinalSegmentalSourcesofPeripheralNerves

KI1“GUSHINGSPRING”

TCM:

Stabilizesandcalmsthespirit

Descendsexcesscomingfromthehead

MedicalAcupuncture:

Richwithautonomicfibers“nervivasorum”

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HEADANDNECK

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TrigeminalNerve

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Knowinganatomymakesforasaferacupuncturepractice.

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ORGANEFFECTSTHROUGHSEGMENTALSTIMULATION

Evidence

• ChenCYetal• Thepossibleneuronalmechanismofacupuncture:morphologicalevidenceoftheneuronalconnectionbetweengroina-shipointanduterus.EvidBasedComplementAlternatMed. 2013;2013:429186.

Evidence

• ChangFYetal.• Effectoftranscutaneousnervestimulationonesophagealfunctioninnormalsubjects–evidenceforasomatovisceralreflex.AmJChinMed. 1996;24(2):185-192.

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Evidence

• SatoAetal.• Neuralmechanismsofthereflexinhibitionandexcitationofgastricmotilityelicitedbyacupuncture-likestimulationinanesthetizedrats.NeurosciRes.1993;18(1):53-62.

Director of the Experimental Institute of

Acupuncture and Moxibustion Therapy

“Autonomic Nervous System”, an illustration from Zhu’s New Acupuncture and Moxibustion, indicating her emphasis on Western

medical concepts.

SomatovisceralConnections

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TreatingEquineNon-SurgicalColic

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¡ Somatic afferent nerve stimulation leads to normalization of central, peripheral, and autonomic nervous system function.

¡ Noblett K.§ Neuromodulation and female pelvic disorders§ Clin Opin Urol. 2016;26(4):321-327.

¡ Yamanishi T et al.§ Neuromodulation for the treatment of lower

urinary tract symptoms. § Low Urin Tract Symptoms. 2015;7(3):121-132

¡ Mechanisms for overactive bladder involve:§ Reflex inhibition of detrusor contraction by the

activation of afferent fibers▪ Activation of the hypogastric nerve▪ Direct inhibition of the pelvic nerve within the sacral

cord▪ Supraspinal inhibition of the detrusor reflex

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¡ Mechanisms for stress incontinence involve:§ Contraction of the pelvic floor muscles through an

effect on the muscle fibers§ Stimulation of the pudendal nerves

¡ Somatic afferent nerve stimulation leads to normalization of central, peripheral, and autonomic nervous system function.

!

BACKANDPELVIS

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Whatarethelocal,regional,andvisceraleffectsofthepelvicBLpoints?

ThoracolumbarFascia

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TheDaoofChineseMedicine

• AccordingtoDonaldE.(“Deke”)Kendall’stranslationofthe“curiousmeridians”,theChinesewereindicatingthatthesewere“singularvessels”,suchastheaorta,venaecavae,andtheuniquevenousdrainageoftheback

Azygousandhemi-azygousveinsdraintheback

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Continuouswiththe

drainageofthebrain

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EvidenceforGV20andCirculationtotheBrain

LearningObjectives

3. Identifymedicalconditionstreatedwithacupunctureandresourcesforreferralandfurtherlearning

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WhatCanAcupunctureTreatinAdditiontoPain?

• Digestivedisorders:gastritisandhyperacidity,spasticcolon,constipation,diarrhea

• Respiratorydisorders:sinusitis,sorethroat,bronchitis,asthma,recurrentchestinfections

• Neurologicalandmusculardisorders:headaches,facialtics,neckpain,ribneuritis,frozenshoulder,tenniselbow,variousformsoftendinitis,lowbackpain,sciatica,osteoarthritis

• Urinary,menstrual,andreproductiveproblem[Fromhttp://www.medicalacupuncture.org/For-Patients/Articles-By-Physicians-About-Acupuncture/Doctor-Whats-This-Acupuncture-All-About]

SystematicReviews,Meta-Analyses• AcuteIschemicStroke:Acupunctureimprovestheneurologicscoreand

clinicaloutcomeoverconventionalapproach– WangYetal.Scalpacupunctureforacuteischemicstroke:ameta-

analysisofrandomizedcontrolledtrials.EvidBasedComplementAlternatMed.2012;2012:480950.doi:10.1155/2012/480950.

• Co-morbidsymptomsamongmilitaryfighters:Acupunctureeffectivelytreatsheadaches,anxiety,sleepdisturbances,depressionand chronicpain ascomponentsofthetraumaspectrumresponse– LeeCetal.Theeffectivenessofacupunctureresearchacross

componentsofthetraumaspectrumresponse(tsr):asystematicreviewofreviews.SystematicReviews.2012;1:46.doi:10.1186/2046-4053-1-46.

SystematicReviews,Meta-Analyses

• BurningMouthSyndrome:Acupuncturereducessensationofburningintheoralcavity– YanZetal.Asystematicreviewofacupunctureoracupointinjectionformanagementofburningmouthsyndrome.QuintessenceInt.2012;43(8):695-701.

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SystematicReviews,Meta-Analyses• AddictiveBehavior:Acupunctureimprovessmokingcessationrateandreducesthenumberofcigarettessmokedeachday– ChengHMetal.Systematicreviewandmeta-analysisoftheeffectsofacupointstimulationonsmokingcessation.AmJChinMed.2012;40(3):429-442.

• PostoperativeNauseaandVomiting:Bothinvasiveandnon-invasiveacupuncturepointstimulationpreventpost-operativenauseaandvomitingwithminimalsideeffects– HolmerPetterssonPetal.Acupuncturepriortosurgerytominimizepostoperativenauseaandvomiting:asystematicreview.JClinNurs.2012;21(13-14):1799-1805.

SystematicReviews,Meta-Analyses

• Acupuncturetreatsbothtensionandneurovascularheadache– LindeK etal.Acupuncturefortension-typeheadache.CochraneDatabaseSystRev2009:CD007587.

– ZhaoL,GuoY,WangW,etal.Systematicreviewonrandomizedcontrolledclinicaltrialsofacupuncturetherapyforneurovascularheadache.ChinJIntegrMed.2011;17(8):580-586.

SystematicReviews,Meta-Analyses

• ShoulderPainafterStroke:Acupuncturetreatspainintheshoulderafterstrokewhencombinedwithexercise– LeeJAetal.Acupunctureforshoulderpainafterstroke:asystematicreview.JAlternComplementMed.2012;18(9):818-823.

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SystematicReviews,Meta-Analyses

• BackPain:Acupuncturemaymoreeffectivelyalleviatethesymptomsofacutelowbackpainthannon-steroidalinflammatorydrugs– LeeJHetal.Acupunctureforacutelowbackpain:asystematicreview.ClinJPain.2013;29(2):172-185.

– HutchinsonAJetal.Theeffectivenessofacupunctureintreatingchronicnon-specificlowbackpain:asystematicreviewoftheliterature.JOrthopSurgRes.2012;7:36.

SystematicReviews,Meta-Analyses

• PelvicOrganDysfunction:PTNSimprovessymptoms,lessenspainandbolstersqualityoflifebymeansofpercutaneoustibialnervestimulation– BiemansJMAEetal.Efficacyandeffectivenessofpercutaneoustibialnervestimulationinthetreatmentofpelvicorgandisorders:asystematicreview. Neuromodulation.2013;16:25-34.

SystematicReviews,Meta-Analyses• PregnancyRatesinWomenFollowingIn-VitroFertilization:Acupunctureincreasesclinicalpregnancyrateandlivebirthrate– Zhengetal.Effectsofacupunctureonpregnancyratesinwomenundergoinginvitrofertilization:asystematicreviewandmeta-analysis.FertilSteril.2012;97(3):599-611.

• LaborPain:Bothacupressureandacupuncturelessenedtheintensityofpain;acupuncturereducedanalgesicdrugintake– SmithCAetal.Acupunctureoracupressureforpainmanagementinlabour.CochraneDatabaseSystRev.2011;(7):CD009232.

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SystematicReviews,Meta-Analyses• PrimaryDysmenorrhea:Acupuncturereducespainintheshorttermwithnon-invasivepointstimulation– ChungYCetal.Acupointstimulationinterventionforpeoplewithprimarydysmenorrhea:systematicreviewandmeta-analysisofrandomizedtrials.ComplementTher Med.2012;20(5):353-363.

• ChronicPain:Acupunctureoutperformsshamandno-acupunctureforthetreatmentofchronicpain– VickersAJetal.Acupunctureforchronicpain:individualpatientdatameta-analysis.ArchInternMed.2012;172(19):1444-1453.

SystematicReviews,Meta-Analyses• OsteoarthritisoftheKneeandOtherPeripheralJoints:Acupunctureoutperformsstandardcaretreatment,shamacupunctureandwaitingforfurthertreatmentincasesofkneepainfromosteoarthritis– ManheimerE,ChengK,LindeK,LaoL,Yoo J,WielandS,etal.Acupunctureforperipheraljointosteoarthritis.CochraneDatabaseSystRev2010:CD001977.

– CaoL,ZhangXL,GaoYS,etal.Needleacupunctureforosteoarthritisoftheknee.Asystematicreviewandupdatedmeta-analysis.SaudiMedJ.2012;33(5):526-532.

SystematicReviews,Meta-Analyses

• CancerCare– Acupuncturecontrolsnauseaandvomiting• KayGarciaM,McQuadeJ,HaddadR,etal.Systematicreviewofacupunctureincancercare:asynthesisoftheevidence.JClinOncol.2013Mar1;31(7):952-60.

– Acupuncturerelieveshiccups• ChoiT-Y,LeeMS,andErnstE.Acupunctureforcancerpatientssufferingfromhiccups:asystematicreviewandmeta-analysis.ComplementaryTherapiesinMedicine. 2012;20:447-455.

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SystematicReviews,Meta-Analyses

• Obesity:Acupunctureproducedsimilarefficacyasanti-obesity medicationbutwithfeweradverseeffects– SuiYetal.AsystematicreviewonuseofChinesemedicineandacupuncturefortreatmentofobesity.ObesRev.2012;13(5):409-430.

ResourcesforFurtherLearning

• AmericanAcademyofMedicalAcupuncture– Annualsymposia– Coursesinmedicalacupuncture– medicalacupuncture.org

• AmericanBoardofMedicalAcupuncture– Listofapprovedtrainingprograms– dabma.org/programs.asp

ReferralList

• AmericanAcademyofMedicalAcupuncture– medicalacupuncture.org– “FindanAcupuncturist”– Denotesboardcertifiedphysicianacupuncturists(DABMA)aswellasFellowsoftheAmericanAcademyofMedicalAcupuncture(FAAMA)

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Summary

FinalThoughts

• Thewayacupunctureworksisrightbeforeoureyesandinourhands

• Itinvolvesneuromodulationandconnectivetissuetreatment

• Takinganeuroanatomicandconnectivetissue,medicalacupunctureapproachdoesnotdiminishthewondermentofacupuncture

• Infact,itheightensit.

FinalThoughts…

• Medicalacupunctureexemplifieshowscientificresearchandcriticalinquiryallowustoanalyzetraditionalapproachesandtosortfactfrommyth.

• Medicalacupuncturebuildsupon,updates,andupgradesancientapproachessuchasChineseMedicine.

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FinalThoughts…

• Asmedicalacupuncturists,werecognizetheimportantstridesthatChineseandotherAsianacupuncturistsbroughttothedisciplineandtheastuteobservationstheymadeaboutstructure– functionrelationships

• Theseenduringconnectionsprovidefertileterritoryforfurtherexplorations

FinalThoughts…

• Approachingintegrativemedicinescientificallyfacilitatesitsintegrationintobothprimaryandspecialtycare.

AdditionalReading• RobinsonN.4mythsaboutacupuncture.VeterinaryPracticeNews. 10/27/14.http://www.veterinarypracticenews.com/4-Myths-About-Acupuncture/

• RobinsonNG.OneMedicine,OneAcupuncture.Animals. 2012;2(3):395-414.Accessedathttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC4494296/

• RobinsonNG.InteractiveMedicalAcupunctureAnatomy.TetonNewMediaandCRCPress.PublishedMarch2,2016.1251pages.