medical acupuncture review course...section 2 - musculoskeletal / neuroanatomic acupuncture this...
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Medical Acupuncture Review Course
Review Course Faculty
Bradley T. Lawrence, MD, FAAMA
Phoenix, AZ
Mitchell Elkiss, DO, FAAMA
Farmington Hills, MI
Tate Kauffman, MD
Newville, PA
Joseph Walker III, MD, DABMA
Farmington, CT
American Academy of Medical Acupuncture
COURSE SECTIONSScientific Basis and History of Medical Acupuncture1
Musculoskeletal / Neuroanatomic Acupuncture2
Circulation of Energy3
TCM Classical Evaluation and Therapy4
Microsystems in Acupuncture5
Energetics6
The 5 Phases in the Regulation of Qi7
Point Groupings8
MUSCULOSKELETAL/
NEUROANATOMIC
ACUPUNCTURE
SECTION 2
Section 2 - Musculoskeletal / Neuroanatomic Acupuncture
This section is designed to review various musculoskeletal and
neuroanatomic acupuncture techniques.
After completing Section 2, participants will be able to:
1. Compare different levels (superficial to deep) of musculoskeletal
acupuncture treatments.
2. Identify the neuroanatomical targets of each level of treatment.
3. Design treatments for common musculoskeletal pain problems.
Financial Disclosure
In order to comply with the ACCME’s Updated Standards for Commercial Support, The American
Academy of Medical Acupuncture has implemented a disclosure process to ensure that anyone in a
position to control the content of an educational activity has disclosed all relevant financial
relationships with any commercial interest. Per these updated standards. The faculty presenters
were required to disclose all financial relationships. The ACCME defines a “commercial interest” as
any proprietary entity producing health care goods or services consumed by or used on patients. It
does not consider providers of clinical service directly to patients to be commercial interests. The
ACCME considers “relevant” financial relationships as financial transactions (in any amount) that
may create a conflict of interest and occur within the 12 months preceding the time that the individual
is being asked to assume a role controlling content of the educational activity.
Disclosure Information:
Presenters have nothing to disclose.
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Musculoskeletal/Neuroanatomic Acupuncture
• Surface
• Myofascial
• Neuromuscular
• Periosteal
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Neuroanatomic Basis of Acupuncture Effect of Local Needles
Local mechanical effects
▪ Release of spasm
▪ Breakup of fibrosis
▪ Stimulation of blood flow
▪ Current of injury
▪ Diffuse noxious inhibitory control
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Musculoskeletal/Neuroanatomic Acupuncture-Surface
• Kori (Seem)
• Cupping and Scraping
• Surface Release Technique-SRT (Helms)
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Combined Neurodermatomal and Classical Techniques
Mark Seem, PhD, LAc
• Surface Energetics
o Superficial nontender "kori" bands, nodules
o Superficial "Ashi" points
o Body-Zone
• Body-zone appropriate meridian points
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Cupping
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Cupping
• Suction
• Pulls to the surface
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(Scraping) Gua Sha
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Gua Sha
➢ Scraping to mobilize
circulation, release fibrosis➢ Cover up/ warm afterwards
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Surface Release Techniques (SRT)
• Applied to loose connective tissue
• Helps underlying muscles
• Treats surface layer directly and provides avenues for
release of deeper pathology
• From the deeper Principal Meridians to the Surface,
there are Luo vessels or connections that link the
surface with the depth
• Helps avoid deeper penetration of pathology
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• Connective tissue surrounds arteries, veins, lymphatics, nerves
• Connective tissue can regulate its own tension level
• Structure implies function(tension)
• Slow process
Surface Release Techniques (SRT)
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Musculoskeletal/Neuroanatomic Acupuncture-Myofascial
• Trigger Points (Travell)
• Trigger Point Deactivation
• 4 Quadrant Technique
• Two Needle Technique-TNT (Elorriaga-Claraco)
• Daisy Chain
• Scar Deactivation
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Acupuncture and the Myofascial System Symptoms
• Spontaneous pain
o Burning
o Atypical
• Abnormal responses to stimuli
• Vasomotor abnormalities
• Trophic changes
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Trigger Points
• Travell and Simons
• Myofascial Pain and Dysfunction
• Trigger Point Deactivation
• Spray and Stretch
• 4 Quadrant Deactivation
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Acupuncture and the Myofascial System Trigger Points
• Travell's Diagnostic Criteria
o Localized tenderness
o Palpable firm bands
o Referral patterns
o Reproducible pain on
palpation, jump sign
o Differentiate active and latent
points
• Early Inflammatory Phase
o Microscopy: fibers and
cells
o Biochemistry: mediators
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Acupuncture and the Myofascial System Trigger Points
• Late dystrophic phase
o Neuropathy with negative evaluation
▪ Autonomic
▪ Sensory
▪ Motor
o Secondary myofascial strain Pain cycle
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Acupuncture and the Myofascial System Trigger Point Referral Patterns
• Deceptive and non-dermatomal
• Predictable
• Diagram: typical head and neck trigger points
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Two Needle Technique (TNT)
• Two needles convergently aimed at a deep muscle knot
• Stimulation at 10 hz.
• Anode and cathode target same spot
• Post-tetanic relaxation
• Best technique to get rid of a stubborn muscle knot
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Two Needle Technique
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Daisy Chain
• Electrical stimulation at 15 Hz
• In series linking to multiple trigger points
• Black-Red-Black-Red-Black-Red, etc.
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Scar Treatment
• Scars form as fibroblasts convert to myofibroblasts and
pull wound edges together
• In the process they may entrap fascia, nerves, venules,
capillaries, arteries, lymphatics
• Surround with needles
• Electrify the needles
• Infiltrate, hydro-dissect
• Soapbox….scars are forever
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Wound Healing Fibrosis
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Scar Deactivation
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Musculoskeletal/Neuroanatomic Acupuncture-Neuromuscular
• One Needle Technique (Wong)
• Percutaneous Electrical Nerve Stimulation-PENS (Craig)
• KB1, KB2 (Bishop, Berry)
• Intramuscular Stimulation/Neuropathic Theory (Gunn)
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One Needle Technique (ONT)
• Localized diagnosis
• Muscle, tendon, ligament, nerve
• Functional anatomy, neuroanatomy, pathology
• Neurofunctional Anatomic Exam (Elorriaga-Claraco)
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One Needle Technique (ONT)
• Good for neuromusculoskeletal problems
• Anatomic diagnosis by History & Physical, Functional
exam
• Consider neural elements and their hierarchy
• Apply one needle
• Did it work?
• No, go back to beginning
• Reconsider anatomic diagnosis, neural hierarchy
• Series of ONT
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One Needle Technique (ONT)
• Accurate diagnosis
• Point selection
• Hierarchy
• Needle placement
• Needle stimulation
• Immediate effects
• If no effect, reconsider
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• Midline medial branch, dorsal ramus facet pain
• Inner Bladder line lateral branch, dorsal ramus segmental muscles
• Outer Bladder line aimed medially ventral roots
One Needle Techniques (ONT)
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Myotendinous Shoulder Pain (ONT)
MOTOR POINT, MYOTENDINOUS, SUPRATENDINOUS, PERIPHERAL N, +/-AUTONOMIC SWITCHES
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• 38 y.o. 6 weeks sciatica
• Normal neurologic, (+) SLR, tender sciatic notch
• X-ray-mild spondylosis @ L4-5, L5-S1
• Tx: GB.30Bl.40, BL.60 interspinal L4-5-S1
Low Back Pain (ONT)
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Percutaneous Electrical Needle Stimulation (PENS)
William Craig, MD
• Stimulation to engage myotomes, dermatomes,
sclerotomes, autonomotomes
• Central modules
• Peripheral modules
• Variable frequencies
• Variable effects on neurotransmitters
• 2, 4, 15, 30, 90, 150, 300
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Dermatomes, Myotomes, and Sclerotomes
• Needle insertion through multiple tissue layers
• Strategically selected points
• Simultaneous central & peripheral activation
• Augmentation via electrical stimulation at selected
frequencies
• Supported by significant research in recent years
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Neurodermal Electrical Stimulation Sympathetic Activation
• T1 - head
• T1, T2 - neck
• T3, T4 - shoulder, arm
• T4, T5, T6 - thorax
• T7 - T11 - abdomen
• T10 - lumbar
• T10, T11 - gluteal
• T12, L1, L2 - leg
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Lumbar PENS• The central module is
stimulated at 4 Hz.
• The periosteal module from the
PSIS to the hip is optional and
added if the patient's symptoms
and physical examination
indicate. This module is
stimulated at 30 Hz. Increase
the intensity of stimulation if
accommodation occurs.
• The PENS and periosteal
treatments run for 20 minutes.
• For improved results include
and appropriate N n+1
energy-moving input at 2 to 4
Hz for 10 to 12 minutes at
some point during your
patient's visit.
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Cervical-Thoracic PENS
• Outer module optional,
depending on symptoms and
palpation findings.
• 4 Hz frequency may be
traded for 15 Hz if patient is
uncomfortable with thumping
in the cervical region.
• Include an appropriate
energy-moving input using
peripheral points and
possibly 2 Hz electrical
stimulation.
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KB1 and KB2
• Treatments that pierce the interosseous membranes
• KB.1 Forearm
• KB.2 Foreleg
• Interosseous membranes richly innervated by
sympathetic nervous system (SNS)
• Pain problems of extremities can be maintained by deep
interosseous changes
• Structure Function
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KB2
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• Neuropathic Theory (GUNN)
• Compression of Adjacent Structures
• Pseudoradiculopathy
• Joint Distortion
• Tendinous/Ligamentous Distortion
• Bursa Compression
• Intramuscular Stimulation for Pain of Radicular Origin
• Intramuscular Stimulation to Release Spasm/Fibrosis
Acupuncture and the Myofascial System
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• To treat pain and
tenderness over the
medial epicondylar
region.
• Needle the flexor muscles
on the front of forearm:
Pronator teres, flexor
carpi radialis, palmaris
longus, flexor digitorum
sublimis, and flexor carpi
ulnaris and their common
origin.
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Neuropathic Theory (GUNN)
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Musculoskeletal/Neuroanatomic Acupuncture-Periosteal
• Osteopuncture
• Periosteal Stimulation
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Acupuncture and Bone: Osteopuncture
Ronald Lawrence, MD; Felix Mann, MD
• Periosteum rich in sympathetics
• Increase blood flow and modulate autonomic nervous
system pain
• C-fibers slow link to thalamic nuclei
• Activation by manual and electric stimulation
• Selected points may be acupuncture points
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Acupuncture and Bone: OsteopunctureTechnique
• Insert 1-2 mm into periosteum
• 100-200 Hz (-) to bone needle, (+) to muscle needle(s)
• 15-45 min, q week x 4-6 treatments, increase current to
avoid accommodation
• Can use as local treatment during other acupuncture
circuitry
• Moxa where appropriate
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Periosteal Stimulation
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• Point Groupings
Barrier Points
Huato Jia Ji Points
• References
Acupuncture Energetics, Helms
Neuroanatomical Acupuncture, Wong, Vol 1 & 2
• Questions
1. Ways to deactivate trigger points?
2. How to set up a lumbar PENS treatment?
Musculoskeletal/Neuroanatomic
Acupuncture Summary
Conclusion of Section 2
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