understanding acupuncture and how it could benefit...
TRANSCRIPT
1/31/16
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Understanding Acupuncture and How It Could Benefit
Your Patients
Ronald B. Koh DVM, MS, CVA, CCRP, CVCH
Assistant Professor, Integrative Medicine
School of Veterinary Medicine Louisiana State University
Integrative Medicine: Acupuncture and its integration into conventional medicine
Outlines
• Background • Science behind
– Analgesia
– Anti-inflammatory
– Nerve regeneration
• Clinical applications
• Case studies
Acupuncture
§ Dates back >2,000 years
§ “Yellow Emperor's Inner Canon” 200 BC
§ Originated in China
§ >> Taiwan, Korea, Japan, Europe, US
§ One of the best known Complementary & Integrative Medicine
§ Proven efficacy in pain management, nerve regeneration, nausea/vomiting, calming effects
Acupuncture in Research
• Research increased exponentially
– Especially in the past 30 years
– 1940s : 1-3/year
– 2000s : >100/year
– 2015: >200/year
• U.S. National Library of Medicine
– PubMed
– 22184 acupuncture references (April, 2015)
– ~500 veterinary references
• 29 RCTs, 17,922 patients
• Back & neck pain, osteoarthritis, chronic headache,
shoulder pain
• ACP is effective for the treatment of chronic pain
• True ACP significantly different from sham ACP
• Chronic Back pain
• Acute pain, dental pain
• Knee osteoarthritis
• Headache
• Fibromyalgia
• Hypertension
• Postoperative/chemotherapy nausea and vomiting
• Improving pregnancy rates undergoing in vitro fertilization
• Arrhythmias
Acupuncture is documented to be effective in
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Insertion on needles into specific points on the body to cause a desired healing effect
Acupoint body
needle
Biological Responses
Endogenous opioids release
Immune circulatory & biochemical effects
Nerve regeneration
Muscle & Nerves
What is Acupoint?
• Shu Xue = “communicating holes”
• Correlate to locations along the nervous system
• Areas under the skin/SQ
• Free nerve endings
• Blood vessels
• Lymphatic ducts
• Mast cells
• Low electrical resistance
• High electrical conductance
Skin surface/SQ
Fascia/Muscle
Acupoint schematic
How Does Acupuncture Works?
• Interactions among: – Nervous system – Endocrine system – Immune system
• Simple in concept, Complex in action
• All take place at once – Local Effects – Spinal Cord Effects – Brainstem Effects
Physiologic Mechanisms
• Local or peripheral • Spinal & Supraspinal
Tissue Microtrauma
Activates local coagulation cascade and complement cascade
Produces plasminogen, protein kinins, prostaglangins
Mast cell degranulation
Releases histamine, heparin, proteases and bradykinin
• Increased blood & lymph flow to the area • Increased local immune responsiveness
• Relaxation of muscles and tissues
Activates Hageman’s factor XII
Harris Gellman, 2002 Anesthesiology. 2014
Physiologic Mechanisms
• Local or peripheral • Spinal & Supraspinal
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Uses enkephalin & dynorphin to block incoming ‘pain’ messages
Pituitary releases β-endorphin into the blood and CSF
Analgesia
Spinal Cord & Brain Effects
Pomeranz, 1990 Harris Gellman, 2002 Anesthesiology. 2014
Activates PAG and Raphe magnus, which inhibit pain transmission
Hypothalamus activates descending analgesia system
Neurochemicals: ß-endorphin Dynorphin Enkephalin Serotonin
Acupuncture Effects: fMRI
• 10 Healthy
Napadow et al. Human Brain Mapping (2007)
• 10 Pain relief after Acp
• 10 CTS pain before Acp
• Somatosensory cortex • Relieve pain • Improve plasticity
Shelby, 2 yr, SF, G. Shepherd
9/14/14 to 10/10/14
• Fungal diskospondylitis (aspergillus) at T8-9 & L4-5
• Voriconazole, Abelcet
• Tramadol, meloxicam, gabapentin, amantadine, fentanyl
• Severe back pain
• Poor appetite, not sleeping well
10/10/14
CSU Pain score 4/4: • Reluctant to rise and walk,
uncomfortable at rest, barely tolerates any touch
• Stuporous, depressed, unresponsive to surroundings
Shelby 10/10/14 to 10/15/15
• Significant less pain • Sleep well
• More involved in surroundings
• Picking up toys
• Eating more
• Still difficulty getting up
10/16/15
• Acute partial paralysis
• X-ray revealed progression of disease
• Humane euthanasia
Sonic Physiologic Mechanisms
• Local or peripheral • Spinal & Supraspinal • Somatovisceral (autonomic) effects
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Autonomic Somatovisceral Effects
• AP converges with visceral efferent
– Causes reflexive interactions with internal organs
• Sympathetic effect:
– GV-26
• Parasympathetic effect:
– PC-6
Napadow et al., 2009; Huang et al., 2012
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Autonomic Effects
GV-26
• é HR, RR, SV, CO, BP
• Mortality of induced shock: – Controls = 100%
– AP-treated = 25%
• Resuscitation for induced Apnea: – Non-AP= 40%
– AP-treated = 88%
• Shorten recovery time from anesthesia (Gemma , 2015)
Schoen, 1990 Still, 1991
• RCT, 222 dogs
• Maropitant:
– Antiemetic
• Acepromazine:
– Antiemetic, anti-nausea, sedation
• Electroacupuncture (PC-6):
– Antiemetic, anti-nausea, sedation
R Koh et al. JAVMA. 2014
Physiologic Mechanisms
• Local or peripheral • Spinal & Supraspinal • Somatovisceral (autonomic) effects • Nerve Regeneration
Doo C. Choi et. al. 2010
§ 10 rats paralyzed by laminectomy T9-T10 paralysis
§ Control and Acu: 5/grp
§ Acu Tx: 30 min, once a day for 2 weeks
Acupuncture on Damaged Nerves
Increases • Neurotropins
• Calcitonin gene-related peptide
• Oligodendrocyte precursor cells
Pain control Functional recovery Bladder dysfundtion
Inhibits
• Microglia and Astroglia
• Proinflammatory factors
Doo C. Choi et. al. 2010
Inhibits
• Microglia and Astroglia
• Proinflammatory factors
– TNF-α – IL-1β, IL-6 – NO synthase – COX-2 – Matrix metalloprotease-9
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� Prospective randomized controlled trials (N=50)
� Group 1: Prednisone + EA weekly or bi-weekly � Group 2: Prednisone
� EA + Prednisolone � ê Time to recover ambulation (10 vs 20 days) � é Regain of deep pain (50% vs 12.5%)
� Overall success rate: 88.5% vs 58.3%
n Hayashi AM and Matera JM. Evaluation of electroacupuncture treatment for thoracolumbar intervertebral disk disease in dogs. Journal of the American Veterinary Medical Association 2007; 231(6):913-918..
Hayashi AM. JAVMA 2007
� Retrospective case series & prospective clinical trial (N=40) � Group 1: DSX � Group 2: EAP � Group 3: DSX+EAP
• Clinical success: Grade 4/5 à Grade 1/2 or normal
Joaquim JG, Luna SP, Brondani JT et al. Comparison of decompressive surgery, electroacupuncture, and decompressive surgery followed by electroacupuncture for the treatment of dogs with intervertebral disk disease with long-standing severe neurologic deficits. Journal of the American Veterinary Medical Association 2010; 36(11):1225-9
Joaquim JG et al. JAVMA 2010
Joaquim JG, et al. JAVMA 236, 1225-1229 June 2010. n Evaluated 40 dogs with clinical signs of IVDD >48 hours n All dogs evaluated were a Grade 4/5 n Re-evaluated after treatment in 6 months n Deemed a success if Grade decreased to 1 or 2
n Return to ambulation
n Success of Treatment groups: n EAP: 15/19 dogs (79%) n Decompressive surgery alone: 4/10 dogs (40%) n EAP and Decompressive surgery: 8/11 dogs (72%) Clinical success when initial grade 4 or 5 was
classified as grade 1 or 2 within 6 months after the end of treatment
Results: � Recovery rate (Grade 4 or 5 becoming Grade 1-2 within 6 months) was
significantly higher for dogs treated with EA alone (15/19 or 78.9%) and EA plus surgery (8/11 or 72.7%) than for dogs that only had surgery (4/10 or 40%).
� The investigators concluded that if early surgical intervention (within 24 hours) was not possible, dogs with Grade 4 or 5 neurological deficits may benefit from tapering doses of prednisone and EA.
n EAP was more effective than DSX for recovery of ambulation and improvement in neurologic deficits in dogs with long-standing severe deficits attributable to thoracolumbar IVDD
n If early surgical intervention (within 24 hours) was not possible, dogs with Grade 4 or 5 neurological deficits may benefit from tapering doses of prednisone and EA
40% 78.9% 72.7%
If early DSX was not possible, dogs with Grade 4/5 may benefit from tapering doses of Pred and EA
Physiologic Mechanisms
• Local effects • Neural (opioid) humoral theory • Neural (non-opioid) segmental gate theory • Somatovisceral (autonomic) effects • Nerve Regeneration • Anti-inflammatory effects
• 12 mice induced sepsis/endotoxemia
• ACP vs Sham:
– >80% survival (vs. <50%)
– For 3 weeks and no late deaths
– ê TNF, MCP1, IL6, INF-ϒ
– ê Fever
– é Dopamine (4X)
• Mediated via vagal modulation
• Control inflammation Septic shock, sepsis, endotoxemia, colitis, pancreatitis
Rafael Torres-Rosas, 2014
Survival was recorded for three weeks and no late deaths were observed,
Given that the vagus nerve inhibits cytokine production in the spleen11,26, and prevents systemic inflammation in endotoxemia
Electroacupuncture controls systemic inflammation in sepsis via the sciatic, the vagus nerves, and catecholamines from the adrenal glands
ACP is effective for reducing elevated BT, and mediated through the suppression of hypothalamic production of pro-inflammatory cytokines
Electroacupuncture increased the levels of DOPA decarboxylase in the adrenal medulla by 4-fold without significantly affecting the levels of Dopamine beta-hydroxylase (Fig.2e,f). Electroacupuncture activated the neuronal network of the adrenal medulla in the proximity of the chromaffin cells overexpressing DOPA decarboxylase
Control inflammation in infectious & inflammatory disorders
Septic shock, sepsis, endotoxemia, colitis, pancreatitis
Dopamine and norepinephrine have generally been considered first-line agents in patients presenting with septic shock; in fact, recent consensus guidelines and expert recommendations have suggested that either agent may be used as a first-choice vasopressor in patients who have septic shock.[2] Epinephrine, vasopressin, and neosynephrine may be useful second-line agents. Inotropic therapy with dobutamine may also be necessary in myocardial dysfunction. Because hypotension may be life-threatening, vasopressors help to maintain adequate blood flow and tissue perfusion despite hypovolemia.[2] Dopamine increases heart rate and stroke volume, leading to an increase in cardiac output and MAP. In contrast, norepinephrine is a vasoconstrictor and thereby increases MAP with little effect on heart rate and stroke volume. While norepinephrine is considered to be more potent and thereby more effective in increasing blood pressure in septic shock, dopamine may be useful in patients with systolic dysfunction, but is also associated with more tachycardia and dysrhythmias. There is also concern regarding adverse effects on the endocrine and immune systems with dopamine. It has also been noted that norepinephrine may potentially decrease cardiac output, oxygen delivery, and blood flow to vulnerable organs despite adequate perfusion pressure..[4]
What Acupuncture Could Help?
§ Acute & Chronic pain
§ MSK disorders
§ Neurological disorders § IVDD, FCE, DM
§ COMS
§ Vestibular syndrome
§ Polyneuropathy
§ Laryngeal paralysis
§ Facial paralysis
§ Seizures
Contraindications: § Shock
§ Pregnancy (specific points)
§ LI4, SP6, BL60, BL40, ST36, BL67
§ Tumors
§ Inflammation or High fever
§ Bone plate
§ Arrhythmias, pacemakers
§ ** Epilepsy
points that are contraindicated in pregnancy are: 1. Points around the abdomen and lumbosacral regions (eg. CV-2/3/4/5/6, Yan-chi, BL23/24/25/26/27/28/52) 2. Others: LI4, SP6, BL60, BL40 ST36, and BL67
Other indications:
• GI issues
• Side effects from drugs, chemotherapy/cancer
• Cognitive dysfunction
• Behavioral disorders
• Sleeping disorders
• Diseases not responsive to conventional Tx
• Peritonitis/sepsis
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When To Use Acupuncture ?
• Integrated with conventional drugs
– Reduce side effects of drugs
– Reduce dosage of drugs
– Reduce recovery time
• Integrated with post-surgery management – Pain control and reduce edema
– Promote tissue healing
• Integrated with rehabilitation
– Pain control
– Improve nerve function and ambulation
What to Expect with Acupuncture?
• Effects may be seen – Immediately – Within a few days or weeks
• Effects are cumulative – Often need multiple treatments – 1-2 per week for 3-5 sessions
• Maintenance treatments: every 1-3 months
• Side effects: tiredness, increased thirst, soreness, minor bleeding, retained needle
» Recover within 24 hours
Zeus, 3 y/o, MN, Dachshund
• Non-ambulatory acute paraparesis
• T12-13 lesion
• Rx: Pred, Tramadol
• A week later, slight improvement
• Grade 3/5
“Zeus”
Lucy Lue, 8 yr, SF, Chihuahua
• Jump off couch à Non-ambulatory Tetraparesis
• Rx: Pred, Methocarb, Tramadol
• After a week, slightly improved remained non-ambulatory
• Pain score 3/4 Stiff neck
Lucy Lue
2 days later
3 days after 2nd Tx
9 days after Tx started (after 4th Tx)
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Daisy, 10 yr, FS, Dachshund
1/16/15
• Acute paraplegia
• Intact deep pain, Grade 4/5
• MRI: L1-2, L2-3 compression
• Left hemilaminectomy
1/20/15
• Remained paraplegia
• Slight-none improvement
• Grade 4/5
1/20/15 • Remained paraplegia
Daisy
1/20/15: Acupuncture and Rehab
2 days later
Daisy
4 days later
7 days later
Mary, 11 yr, SF, Yorksgire Terrier 10/4/15
• Chair fell on her
• Obtunded, tetraparetic, head tilt, ventral strabismus, horizontal nystagmus
• Glasgow coma scale: 4+6+5=15
10/4-10/6:
• Slight improvement
• 10/6: Start acupuncture
10/8 10/9
10/11 10/12
Rosebud, 12 yr, FS, GR 1/20/15
• Acute inability to get up, falling to right side
• Horizontal nystagmus, right head tilt
• CBC, Chem, rads, US
• Dx: Peri. Vestibular disease
• Rx: Maropitant, meclizine
1/21/15
• Slightly better, able to rise, falling to the right
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Rosebud, 12 yr, FS, GR 1/22/15
• Start acupuncture
Marley, 1.5 y/o, FI, Bull Terrier
• 2/26/2014 • Spinning & chasing tail
• Decreased appetite
• Weight lost
• Not sleeping well
• Dx: Compulsive behavior
• Rx: Fluoxetine 20mg q24h
• 3/19 • Mild improvement
• Sleep better
• Inappetence
Marley
• 3/28/2014 • Acupuncture
• 4/8/2014 • >50% improvement
• Sleep much better
• Normal appetite
• Less spinning
• Gained weight
• 4/22/2014 • Continue improving
• Only spin when excited
Toby, 4 yr, MN, Yorkie 4/28/15
• Non-ambulatory Tetraparesis
• Meningoencephalomyelitis of Unknown Aetiology
• Rx: Pred, Cytosar
4/30 & 5/1
• Acupuncture
“7”- 2 yo Brangus Cow
6/29/15
• Ataxia, obturator nerve paralysis and prolapsed uterus
• Use hip riser to lift the cow 2-3 times/day for 20-30 mins
• If no improvement: Euthanasia
7/1/15
• Remained paralysis in the morning
• Started acupuncture at 5pm
6/29/15
• Calving late night. Owner pulled the calf out and she wouldn’t stand up
6/30/15
• Ataxia, paralysis (Obturator nerve paralysis) and prolapsed uterus
• Use hip riser to lift the cow 2- 3 times/day for 20-30 mins
• If no improvement: Euthanasia
Right after 1st ACP
Day 2 after 2nd ACP
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Day 3 after 3rd Acupuncture And they live to see another day…
Take Home Messages
• Multi-mechanisms:
• peripheral, spinal, supraspinal, etc
• Safe and effective
• Pain management
• Neurological conditions
• Inflammatory disease
• Many chronic diseases
• In many species
• Supported by researches
• Integrate with conventional Tx
• Improve outcomes
• Promote quality of life
• Shorten hospitalizations
• Timing is the key!
• Additional tool in pocket
Integrative Medicine
Veterinary Acupuncturists • Ronald Koh, DVM, MS, CVA, CCRP, CVCH, CVFT
• Rebecca McConnico, DVM, PhD, DACVIM, CVA
• Martha Littlefield, DVM, MS, CVA
Rehabilitation Therapists • Ronald Koh, DVM, MS, CVA, CCRP
• Jennifer Bridges, MS, CCRP
Massage Therapist • Maxon Graham, BS, ESMT/CSMT
Technician • Suzie Dauzat, RVT