Acupuncture in Geriatric Medicine

1
Acupuncture in (Geriatric) Medicine

• Stevan A. Walkowski, DO
• 17 March, 2008

2
Whats the Point?

• Put acupuncture in a historical context
• Put acupuncture in a scientific context
• Put acupuncture in a clinical context

3
History of Acupuncture-China

• rooted in Taoist philosophy (2000BC) Xia Dynasty
  
• stone needles (500BC)
• early writings (200 AD) Huang Di Nei
  Jing--gold/iron acupuncture needles
• 1822--acupuncture banned from medical colleges
• 1949--barefoot doctors

4
History of Acupuncture-European

• Jesuit priests--16th-17th Centuries
• French practice--1774 Histoire de la Chirurgie
• Soulie De Morant--1939,1941,1955

5
History of Acupuncture-United States

• 1892-Osler-sciatica
• 1971-James Reston--New York Times
• 1982-UCLA--Joseph Helms, MD
• 1987-American Academy of Medical Acupuncture

6
Styles of Acupuncture

• Traditional Chinese Medicine
• Formula
• French Energetic
• Japanese
• Five Element
• Microsystem
• hand, scalp, new scalp, auricular,

7
Physiology of Acupuncture

• Acupuncture points
• Neurophysiology and location of action

8
Nature of Acupuncture Points

• Meridians as fascial cleavage planes between
  muscles
• Stimulation of acupoints activate Type II and III
  fibers

9
Anatomical Relationships to Acupoints

• 71 overlap with trigger points--Melzak
• Overlap with Jones counterstrain points
• 350 named points plus ah shi points

10
Anatomical Structures Near Acupoints

• Large peripheral nerves
• Nerves emerging from deep to superficial
• Cutaneous nerves from deep fascia
• Nerves emerging from bony foramina
• Motor points of neuromuscular attachments

11
Anatomical Structures Near Acupoints (contd)

• Blood vessels near neuromuscular attachments
• Along a nerve composed of fibers of various
  diameters
• Bifurcation point of peripheral nerve
• Ligaments
• Suture lines of the skull

12
NEUROHUMORAL EFFECTS OF ELECTRO-ACUPUNCTURE
13
Physiology of Nerve Fibers

• Various afferent nerve fibers are involved in
  transmitting pain impulses
• Large myelinated nerves
• A- Beta (skin) carry touch
• Type I (muscle) carry proprioception
• Small myelinated nerves carry pain
• A-delta (skin)
• Type II and III (muscle)
• Type II, III, IV and C carry nonpainful messages

14
(No Transcript)
15
(No Transcript)
16
(No Transcript)
17
(No Transcript)
18
Nine Lines of Endorphin Research

• Four different opiate antagonists block AA
• Naloxone as a stereospecific effect
• Microinjection of naloxone blocks AA only if
  given into analgesic sites
• Rats deficient in endorphin show poor AA

19
Nine Lines of Endorphin Research

• Endorphin levels rise in blood CSF during AA, and
  fall in specific brain regions during AA
• AA is enhanced by protecting endorphins from
  enzyme degradation
• AA can be transmitted to a second animal by CSF
  transfer or by cross circulation and this effect
  is blocked by naloxone
• Reduction of pituitary endorphins supressess AA

20
Sites of Action of Acupuncture

• Tissue
• Spinal
• Cortical/Midbrain
• Neurohumoral

21
Sites of Action Tissue

• Local immediate release when needles are
  introduced to trigger points
• Probably complex response both fascially and from
  stimulating larger faster myelinated
  somatosensory fibers with local spinal inhibition
• Dry needling of trigger points

22
Sites of Action

• Spinal
• enkephalin, dynorphin
• Midbrain
• enkephalin to activate the raphe descending
  system
• uses monamine serotonin, norepinephrine
• Hypothalamus-Pituitary
• beta endorphin into the blood and CSF

23
Sites of Action

• Neurohumoral
• Beta Endorphin and ACTH are released in equimolar
  amounts from the pituitary hypothalamus
• Thought to be the mechanism for the
  anti-inflammatory action of acupuncture

24
NIH Consensus Conference (1997)

• http//consensus.nih.gov/1997/1997Acupuncture107ht
  ml.htm
• Non-Federal, nonadvocate, 12 member panel,
  diverse clinical and research background reviewed
  25 expert presentations before a conference of
  1200

25
NIH Consensus Conference (1997)

• clear evidence that acupuncture is effective
  for adult postoperative and chemotherapy nausea
  and vomiting and probably nausea of pregnancy
• evidence of efficacy for postoperative dental
  pain

26
NIH Consensus Conference (1997)

• reasonable studies showing relief of pain for
  menstrual cramps, tennis elbow, and fibromyalgia
• Other conditions where the research suggests
  efficacy but the quality and quantity of the
  research is not sufficient

27
Other Evidence

• www.cochrane.org
• The Cochrane Collaboration
• Search acupuncture
• 129 review citations some in progress, some
  positive, some negative, some neutral

28
More Evidence

• Berman BM, Lao L, Langenberg P, Lee WL, Gilpin
  AMK, Hochberg MC. Effectiveness of Acupuncture as
  Adjunctive Therapy in Osteoarthritis of the Knee
  A Randomized, Controlled Trial. Annals of
  Internal Medicine. 2004 141(12)901-910.

29
More Evidence

• 570 patients over 50y/o with OA knee
• Randomized to three groups acupuncture, sham,
  and arthritis education (24 treatments over 26
  weeks)
• Measured with WOMAC (Western Ontario McMasters
  Osteoarthritis Index) at wk 4,8,14, 24

30
More Evidence

• By week 8, acupuncture group shows significant
  increase in function
• By week 14, a significant decrease in pain
• Held through week 26
• http//nccam.nih.gov/news/2004/acu-osteo/pressrele
  ase.htm

31
Acupuncture Research

• Acupuncture for Back Pain (Archives of Internal
  Medicine 9 Nov 1998 1582235-2241)
• Meta-analysis of 9 studies (1976-1994)any form of
  acupuncture for any type of back pain
• Conclusion Acupuncture superior to control
  intervention, insufficient evidence to state
  whether it is superior to placebo.

32
Acupuncture Research

• Is Acupuncture Effective in the Treatment of
  Fibromyalgia (Journal of Family Practice, Mar
  1999, (48)3 213-218)
• seven studies, one of high methodological quality
  suggest real acupuncture is more effective than
  sham acupuncture for pain relief, increasing pain
  thresholds, improving global ratings, reducing
  morning stiffness duration of relief unknown

33
Acupuncture Research

• Percutaneous Electrical Nerve Stimulation for Low
  Back Pain (JAMA, 3 Mar 99, (281)9 818-823)
• randomized, single-blind sham-controlled
  crossover study n60, degenerative disc disease
• PENS significantly more effective than sham-PENS,
  TENS, and exercise therapies

34
Acupuncture Research

• A randomized comparative trial of acupuncture
  versus transcutaneous electrical nerve
  stimulation for chronic back pain in the elderly
  (Pain 199982,9-13) n60
• VAS, NHP, analgesic tablets consumed, all
  improved in both groups, slightly moreso in
  acupuncture
• acupuncture statistical improvement in spinal
  flexion

35
Acupuncture Research

• Clinical trial of electrical acupuncture on
  hemiplegic stroke patients (AmJ PMR (78)2
  117-122)randomized n128
• stroke patients treated with electrical
  acupuncture had shorter duration of hospital
  stay,
• better neurological and functional outcomes
• significant difference for self-care and
  locomotion

36
Why Use Acupuncture?

• Pain
• Pain
• Pain

37
Why Use Acupuncture?

• Tremendous opportunity to get to know someone and
  help them to express themselves in as full a way
  as is possible.
• Listening in the history for elements not covered
  in traditional medical history, nuances, word
  choices.
• Take into account manners of dress, appearance,
  food preferences
• How they live life

38
Why Use Acupuncture?

• Diagnostically, an osteopath has the opportunity
  to be the best acupuncturist because of our keen
  palpatory skills
• Additionally, palpating for subtleties within the
  pulse and noting changes in the tongue

39
Training for Physicians

• www.hmieducation.com
• Annual course taught twice a year
• Combination of 3-5 days on-site with 4-6 months
  of home study and video review
• 10 days on-site clinical integration

40
Professional Organization

• American Academy of Medical Acupuncture
• www.medicalacupuncture.org
• CME
• Patient information
• Research
• Online forums

41
What was the point?

• Acupuncture is another method of accessing the
  bodys inherent homeostatic healing tendencies
• The acupuncture interview puts our patients into
  a larger universe of the interrelatedness of
  mind-body, structure-function, as above-so below

42
What was the point?

• The science of acupuncture is clear about
  efficacy in some conditions, presents a strong
  argument for its physiologic mechanisms but
  requires more research
• Osteopathy and acupuncture flow seamlessly. The
  job of the physician is to find health. Anyone
  can find disease.