Lesley Pattenden
Biography
Lesley qualified as a physiotherapist from Bristol School of Physiotherapy in the early 1980rsquos Since then she has worked in both the NHS and privately within the field of musculo-skeletal out-patients and is currently the Orthopaedic Team Lead at Weston Super Mare General Hospital (NHS) Her
acupuncture career began with various short courses in 1992 leading to a Diploma in Acupuncture from Coventry University in 2006 After securing a teaching qualification she has been an
experienced AACP tutor for 7 years She is also Vice- Chair and Director of AACP and has represented AACP at many events including various NICE guideline groups and the Acupuncture
Stakeholders Group Her aim is to continue to promote the use of acupuncture by physiotherapists and maintain this useful modality within the NHS
AACP Still Pointing the Way after 30 Years
Low back pain practice makes perfect
Lesley Pattenden
AACP Still Pointing the Way after 30 Years
Abstract
The use of acupuncture within physiotherapy particularly for the treatment of musculo-skeletal conditions and particularly LBP is common This presentation aims to explore the many variables
that need to be considered as part of ldquodosagerdquo and relate these to the current evidence base in order to make interventions for LBP more efficacious The presentation will include a demonstration of some of the acupuncture techniques used in the Lumbar Spine and opportunity will be given to
discuss the implications of such techniques
AACP Still Pointing the Way after 30 Years
Learning Outcomes
Title Low Back Pain Practice makes perfect Theoretical Learning Outcomes
1 Understand the current evidence base related to the specific
variables of dosage 2 Acknowledge how various pain presentations can affect
outcomes of interventions with reference to Low Back Pain
Skills to be communicated
Application of clinical reasoning based on Western Medical Approaches to various clinical presentations encountered in the Outpatient department
Information on practical application of information
Various acupuncture techniques on the Lumbar spine and other areas will be demonstrated and discussed
Areas of further learning which may benefit the delegate
Pain mechanisms for example peripheralcentral sensitisation processes
Summarise key points with emphasis on clinical application
Acupuncture Association of Chartered Physiotherapists Limited Registered in England and Wales Registration No 5680004
Registered Office- Southgate House Southgate Park Bakewell Road Orton Southgate Perterborough PE2 6YS
CPD REGISTRATION FORM
Membership of the AACP is open to Chartered Physiotherapists practising Acupuncture
Surname CSP registration no
First Name HPC registration no
AACP membership no
CPD Activity
Date
CPD Hours
Learning Objectives
Learning Outcomes
23052014
1
Qmarketinginsignia guidelines
wwwaacpukcom
AACP
Conference 2014
Coventry
LBP- Practice makes perfect Lesley Pattenden MCSP lesleypattendenhotmailcom
Qmarketinginsignia guidelines
wwwaacpukcom
Lessons to be learned
What is ldquoAdvancedrdquo acupuncture after
Foundation Course completion
What do you want from your needle
Qmarketinginsignia guidelines
Aims of the session
1 Explore your current knowledge of acupuncture
and LBP
2 To examine the current evidence base and
review current guidelines concerning LBP
3 To review the clinical reasoning process and
relate it to LBP
4 To Review the various techniques associated
with acupuncture for LBP
How can you make your practice
more effective
UK population
- lifetime prevalence 70
- annual prevalence 40
Recurrences are common and prevalence of LBP has
not changed
90 of acute attacks that present for healthcare settle
sufficiently to prevent further intervention and return to
work within 6 weeks
7 of adults have persisting LBP which restricts
function
1 in 15 of the population will consult their GP for LBP
LBP accounts for between 25 and 45 of PT case
load
(NICE 2009 Yuan et al 2008 Kent and Keating 2005)
The scale of the problem
1 Consider offering a course of manual therapy including
spinal manipulation of up to 9 sessions over 12 weeks
2 Consider offering a course of Acupuncture up to
10 sessions over 12 weeks (pg 180)
3 Do not offer injections of therapeutic substances into
the back
4 Do not offer stand alone formal education programmes
5 Do not offer laserIFTherapeutic US or TENS
routinely
NICE (2009) Guidelines
Recommendations Research
Systematic Review
bull Furlan et al (2005) Acupuncture and Dry-Needling
for LBP Cochrane Database Syst Rev 2005 Jan 25(1)CD001351
RCTrsquos (4)
bull Brinkhaus et al (2006) Acupuncture in patients with
CLBP An RCT Arch Intern Med 2006 Feb 27166(4)450-7
bull Haake et al (2007) GERAC Trials for LBP Arch Intern Med
2007 Sep 24167(17)1892-8
bull Witt (2006) Pragmatic RCT for clinical and cost-
effectiveness for CLBP Am J Epidemiol 2006 Sep 1164(5)487-96
bull Thomas et al (2005) Longer term clinical and
economical benefits of AP and LBP Health Technol
Assess Aug9(32)iii-iv ix-x 1-109
23052014
2
NICE 2013 Review (Due 2016)
How may these affect us
Scope- what does this suggest
Low Back Pain and Sciatica Management
of non-specific LBP and Sciatica Pulse Article (2010) - non adherence to guideline
Of -127 PCTrsquos- frac12 provided funding and 15 offered AP in
GP practices
What Research is NICE likely to consider
Acupuncture Trialist Collaboration
Aim- To determine effect sizes of AP in 4 common
conditions with chronic pain states
Data- 29 trials data- 17922 patients
Outcome- Superior to sham and no control
ldquo reasonable referral option for effectrdquo
ldquostatistical significance between true AP and shamrdquo
ldquoindicate effect is more than placebo but other factors for effect are important contributorsrdquo
Vickers et al (2012)
STRICTA GUIDELINES Standards for reporting Interventions in
Clinical Trials of Acupuncture
2001 2002 revised 2010 H MacPherson D G Altman R Hammerschlag et al ldquoRevised standards for reporting interventions in clinical
trials of acupuncture (STRICTA) extending the consort statementrdquo Acupuncture in Medicine vol 28 no 2 pp 83ndash
93 2010
1 Acupuncture Rationale
2 Details of needling
I Number of needles
II Nameslocation
III Depth of insertion
IV Response sought
V Needle Stimulation
VI Time
VIINeedle diameterlengthtype
3 Treatment Regimen
4 Other components
5 Practitioner Background
6 Control
Session
Date
Points
Needle Size
(Angle)
De Qi
Further Stim
Treatment Duration
Adverse Effects
Outcome Measure
121013
Session1
BL252627 (bilaterally) BL54 BL57 GV43 GB30 GB31 ST36
40mm (perp)
40mm (perp) 40mm (perp) 25mm (perp) 70mm (obliq) 40mm (perp) 25mm (perp)
Achieved all
points except GB30
Further
stimulation all points x2
20 mins (all needles)
Slight anxiety with
first few needles ndash settled
VRS- 610
151013 Session 2
BL252627 (bilaterally) BL54 BL57 GV43 GB30 GB31 ST36
40mm (perp)
40mm (perp) 40mm (perp) 25mm (perp) 70mm (obliq) 40mm (perp) 25mm (perp)
De Qi on all points
Further stim X 2
20 mins (all needles)
None
VRS- 610
201013
Session 3
BL252627 (bilaterally) BL54 BL57 GV43 GB30 GB31 ST36
40mm (perp)
40mm (perp) 40mm (perp) 25mm (perp) 70mm (obliq) 40mm (perp) 25mm (perp)
De Qi on all points
Further stim
X 3
20 mins (all needles)
None
VRS- 410
Pt reports
less leg pain-more
into back
251013 Session 4
BL252627 (bilaterally) (HJJ pts adjacent to BL pts) LI4
40mm (perp)
25mm (obliq)
25mm (perp)
De Qi on all points
Further stim
X 3
25 mins (all needles)
Had to re position LI4 as it was too painful for
pt
VRS- 2-310
(Isolated to back
onlyoccasional buttock)
How do you choose your points
Recipesprotocols
Points you are familiar with
TCM associations
Western Scientific theory- and
what do we mean by this
Clinical Reasoning v Technical Operation
23052014
3
Questions to ask
yourself
What structures will the needle penetrate
What is the state of the tissues Do you want to needle
locally Or should you just use distal points
What stimulation are you wanting to perform
What indications does your patient give you regarding
needling
Why Why Why do we do anything
bull Peripheral effects
bull Segmentalspinal effects
bull Add a layer
bull Supraspinal effects
bull Sympathetic Outflow
bull Central Sympathetic effects
bull Immune effects
Bradnam (2007)
bull ldquomultisensory pain modulationrdquo
Campbell (2013)
Layering technique
Downs M Laporte C (2011) Conflicting Dermatome maps
Educational and Clinical Implications JOSPT Vol 41(6) 434
doi102519jospt20113506
)
Points (dermatomes myotomes sclerotomes)
Point Dermatom
e
Myotome Sclerotome Peripheral nerve
(motor)
ST 36 L45 L45 L45 Deep Peroneal
LR 3 L45 L5S1 or S2S3 L5S1 Medial Lateral
Plantar Nerve
GB 30 L2L3S2 L5S1S2 L4L5S1 Inferior Gluteal
NerveObturator
GB 39 L4L5S1 L4L5S1 L4L5S1 Superficial
Peroneal (PLPB)
Deep Peroneal
(PT)
BL 23 L2L3 L23 L23 Local Segmental
(dorsal rami)
BL 52 L23 L23 L23 Local Segmental
(dorsal rami)
Lumbar Spine Points- examples
Level Dermatome Myotome Sclerotome
L1 BL 2122 BL 2122
L2 BL 23 BL 25 GV 4 HJJ BL 23GV 4
L3 SP 9LR 3 SP 10 SP 9
L4 ST 36SP 6SP
9KI 3LR 3
BL 25ST 36 SP 10 GV 3 BL 25
L5 ST 36 LR 3 ST 36 BL 54 ST 36 LR 3
S1 SP 6BL 40 SP 6SP 9KI 3 LR 3
S2 SP 6 KI 3BL 40 SP 6SP 9KI 3 L 3 KI 3
Examples of Points related to spinal segments (White 2008)
Neural Anatomical Unit
Key issue Discussing the metaphysical
concepts of points and meridians in the
framework of modern scientific language
httpwwwhindawicomjournalsecam2012429412
NAU (Zhang 2012)
Classification Location
Muscle Spindle rich Around 60 of acupuncture
points are located in muscle
Cutaneous receptor rich Hands Face Feet (sensory
homonculus
Tendon Organ Rich Around joints
wristelbowknees
23052014
4
M receptors
Prostaglandins
Dynorphin
Allodynia
nociceptio
n
Spinoreticular
tract
Long Term
potentiation
serotonin
Inflammatory
mediators
PAIN PATHWAY
Peripheral Sensitisation
Inflammation
Interleukins
Tumor necrosis
factor
Serotonin (5-HT)
Hydrogen ions
High-threshold
nociception
Tissue damage Sympathetic Afferents
Low-threshold
nociception
Histamine
Potassium ions
Prostanoids
Purines
Norepinephine
Bradykinin
Neuropeptides
Leukotrienes
(Hudspith Munglani amp Siddall 2006) Kavoussi and Ross (2007) The neuroimmune basis of anti-inflammatory
acupuncture Integ Canc Therap 6251-257
CENTRAL SENSITISATION
bull Increased synaptic activity causing sub threshold
stimulus to produce response
bull Reflects functional states of circuits in the CNS
bull CNS distortamplify degree duration extent of
pain
bull Stimulus pain in segmentally related TPrsquos
(Woolf 2011)
ldquoOpening or Shutting the pharmaceutical box in the brainrdquo
bull Helen Langevin- connective tissue effects
bull Tom Myers- Anatomy Trains
bull Gil Hadley-Fuzz- ldquostrolling under the skinrdquo
bull MfTPrsquos
Structural
23052014
5
DEFINING DOSAGEDefining an adequate dose of
acupuncture using a neurophysiological approach--a
narrative review of the literature (2008) White A et al
Acupunct Med Jun26(2)111-20
Physical Procedure De QiTechnique
1+ needles Selection of Points
Consider patients perception
of pain
Sensory Affective
May be affected by the state
of the patient
Nervous immune-
suppressed etc
DIFFERENT CONDITIONS (in WM) MAY REQUIRE
DIFFERENT DOSES AS EFFECT MAY RELY ON
MANY MECHANISMS
(localsegmentalextrasegmentalcentralimmune
effects)
Think THRESHOLD v TOLERANCE
Evidence for 1 Number of needles- Ceccherelli et al (2010) ndash
Bradnam (200)- ldquoLayering theoryrdquo
2 Needle Retention time- Lewis and Abdi (2010) Yuan (2008)
3 Frequency of sessions- Sherman (2009)
4 Total number of sessions- Ezzo (2000) MacPherson (2004)
5 De Qi- Lundeberg et al (2012) White (2008)
6 LengthGauge of needles- Bradnam (2007) Zhang (2012)
7 Other Factors
Pariente et al (2005) + Wasan (2010) ndash Effect of expectation Witt (2011)- being female living in a multi person household
failure of other therapies before study former positive experience
Witt (2010) Therapeutic relationship (not training or length of qualification)
Harris (2009) Genetics ndasheffect of mu receptors and difference in opioid metabolism
Pearce (2006) Acupuncture time line model
Letrsquos review a pointBL 25
(40mm needle angled obliquely
towards spinous process)
bull Location 15 lateral to the lower border of L4
bull Skin
bull Thoracolumbar fascia
bull Muscles multifidus iliocostalis lumborum
bull longissimus thoracicis
bull fibresthoracolumbar fascia Lat Dorsi
bull Quadratus Lumborum
bull Bone
BL 25
BL 23 Cadaver
Qmarketinginsignia guidelines
LI 4 Cadaver
23052014
6
LR 3 Cadaver
Qmarketinginsignia guidelines
GB 30 Cadaver
Qmarketinginsignia guidelines
ST 36 Cadaver
Local ndash BL 20-35 BL 48-54 Ah Shi Extra points- HJJ Yao Yi Yuo Yan
Segmental- L5S1- GB 30 GB 31 GB 34 GB 41 GB 43 BL 60-67
Extra Segmental- KI channelSP channel LR channel AND all channels in arms head GV 20
Sympathetic- HT 7 PC 6 LU 9
LSP Points
Qmarketinginsignia guidelines
23052014
7
Acupuncture and the Emerging Evidence
base Contrived Controversy and
Rational Debate
3 areas of Research
1)Safety and the risk of serious adverse
events
2) Clinical Efficacy and Effectiveness
3)Physiologic Action
MacPherson Hammerschlag
(2012)
bull AACP website (must be on aacporguk)
bull (usernamepassword)
bull On-line databases
bull Access to AIM
bull Choose article-abstract- ldquofull textrdquo
bull Then look at references- it will denote
what is freeon Google scholar
References
Qmarketinginsignia guidelines wwwaacpukcom
Thank You for
listening
White A Cummings M and Filshie J (2008) An Introduction to Western Medical Acupuncture Philadelphia Churchill Livingstone Haker E Egekvist H and Bjerring P (2000) lsquoEffect of sensory stimulation (acupuncture) on sympathetic and parasympathetic activities in healthy subjectsrsquo Journal of the autonomic nervous system vol 79 no 1 February pp 52-59 Sandberg M Lundeberg T Lindberg LG and Gerdle B (2003) lsquoEffects of acupuncture on skin and muscle blood flow in healthy subjectsrsquo European Journal of Applied Physiology vol 90 no 1-2 September pp 114-9 Sandkuumlhler J Chen JG Cheng G and Randić M (1997) lsquoLow-frequency stimulation of afferent Adelta-fibers induces long-term depression at primary afferent synapses with substantia gelatinosa neurons in the ratrsquo Journal of neuroscience vol 17 no 16 August pp 6483-6491 Stein C Machelska H Binder W and Schaumlfer M (2001) lsquoPeripheral opioid analgesiarsquoCurrent Opinion in Pharmacology vol 1 no 1 February pp 62-65 Vas J and White A (2007) lsquoEvidence from RCTs on optimal acupuncture treatment for knee osteoarthritis--an exploratory reviewrsquo Acupuncture in medicine vol 25 no 1-2 June pp 29-35 White A Cummings M Barlas P Cardini F Filshie J Foster NE Lundeberg T Stener-Victorin E and Witt C (2008) lsquoDefining an adequate dose of acupuncture using a neurophysiological approach--a narrative review of the literaturersquo Acupuncture in Medicine vol 26 no 2 June pp 111-120 White A Foster NE Cummings M and Barlas P (2007) lsquoAcupuncture treatment for chronic knee pain a systematic reviewrsquo Rheumatology vol 46 no 3 March pp 384-390
AACP Still Pointing the Way after 30 Years
Low back pain practice makes perfect
Lesley Pattenden
AACP Still Pointing the Way after 30 Years
Abstract
The use of acupuncture within physiotherapy particularly for the treatment of musculo-skeletal conditions and particularly LBP is common This presentation aims to explore the many variables
that need to be considered as part of ldquodosagerdquo and relate these to the current evidence base in order to make interventions for LBP more efficacious The presentation will include a demonstration of some of the acupuncture techniques used in the Lumbar Spine and opportunity will be given to
discuss the implications of such techniques
AACP Still Pointing the Way after 30 Years
Learning Outcomes
Title Low Back Pain Practice makes perfect Theoretical Learning Outcomes
1 Understand the current evidence base related to the specific
variables of dosage 2 Acknowledge how various pain presentations can affect
outcomes of interventions with reference to Low Back Pain
Skills to be communicated
Application of clinical reasoning based on Western Medical Approaches to various clinical presentations encountered in the Outpatient department
Information on practical application of information
Various acupuncture techniques on the Lumbar spine and other areas will be demonstrated and discussed
Areas of further learning which may benefit the delegate
Pain mechanisms for example peripheralcentral sensitisation processes
Summarise key points with emphasis on clinical application
Acupuncture Association of Chartered Physiotherapists Limited Registered in England and Wales Registration No 5680004
Registered Office- Southgate House Southgate Park Bakewell Road Orton Southgate Perterborough PE2 6YS
CPD REGISTRATION FORM
Membership of the AACP is open to Chartered Physiotherapists practising Acupuncture
Surname CSP registration no
First Name HPC registration no
AACP membership no
CPD Activity
Date
CPD Hours
Learning Objectives
Learning Outcomes
23052014
1
Qmarketinginsignia guidelines
wwwaacpukcom
AACP
Conference 2014
Coventry
LBP- Practice makes perfect Lesley Pattenden MCSP lesleypattendenhotmailcom
Qmarketinginsignia guidelines
wwwaacpukcom
Lessons to be learned
What is ldquoAdvancedrdquo acupuncture after
Foundation Course completion
What do you want from your needle
Qmarketinginsignia guidelines
Aims of the session
1 Explore your current knowledge of acupuncture
and LBP
2 To examine the current evidence base and
review current guidelines concerning LBP
3 To review the clinical reasoning process and
relate it to LBP
4 To Review the various techniques associated
with acupuncture for LBP
How can you make your practice
more effective
UK population
- lifetime prevalence 70
- annual prevalence 40
Recurrences are common and prevalence of LBP has
not changed
90 of acute attacks that present for healthcare settle
sufficiently to prevent further intervention and return to
work within 6 weeks
7 of adults have persisting LBP which restricts
function
1 in 15 of the population will consult their GP for LBP
LBP accounts for between 25 and 45 of PT case
load
(NICE 2009 Yuan et al 2008 Kent and Keating 2005)
The scale of the problem
1 Consider offering a course of manual therapy including
spinal manipulation of up to 9 sessions over 12 weeks
2 Consider offering a course of Acupuncture up to
10 sessions over 12 weeks (pg 180)
3 Do not offer injections of therapeutic substances into
the back
4 Do not offer stand alone formal education programmes
5 Do not offer laserIFTherapeutic US or TENS
routinely
NICE (2009) Guidelines
Recommendations Research
Systematic Review
bull Furlan et al (2005) Acupuncture and Dry-Needling
for LBP Cochrane Database Syst Rev 2005 Jan 25(1)CD001351
RCTrsquos (4)
bull Brinkhaus et al (2006) Acupuncture in patients with
CLBP An RCT Arch Intern Med 2006 Feb 27166(4)450-7
bull Haake et al (2007) GERAC Trials for LBP Arch Intern Med
2007 Sep 24167(17)1892-8
bull Witt (2006) Pragmatic RCT for clinical and cost-
effectiveness for CLBP Am J Epidemiol 2006 Sep 1164(5)487-96
bull Thomas et al (2005) Longer term clinical and
economical benefits of AP and LBP Health Technol
Assess Aug9(32)iii-iv ix-x 1-109
23052014
2
NICE 2013 Review (Due 2016)
How may these affect us
Scope- what does this suggest
Low Back Pain and Sciatica Management
of non-specific LBP and Sciatica Pulse Article (2010) - non adherence to guideline
Of -127 PCTrsquos- frac12 provided funding and 15 offered AP in
GP practices
What Research is NICE likely to consider
Acupuncture Trialist Collaboration
Aim- To determine effect sizes of AP in 4 common
conditions with chronic pain states
Data- 29 trials data- 17922 patients
Outcome- Superior to sham and no control
ldquo reasonable referral option for effectrdquo
ldquostatistical significance between true AP and shamrdquo
ldquoindicate effect is more than placebo but other factors for effect are important contributorsrdquo
Vickers et al (2012)
STRICTA GUIDELINES Standards for reporting Interventions in
Clinical Trials of Acupuncture
2001 2002 revised 2010 H MacPherson D G Altman R Hammerschlag et al ldquoRevised standards for reporting interventions in clinical
trials of acupuncture (STRICTA) extending the consort statementrdquo Acupuncture in Medicine vol 28 no 2 pp 83ndash
93 2010
1 Acupuncture Rationale
2 Details of needling
I Number of needles
II Nameslocation
III Depth of insertion
IV Response sought
V Needle Stimulation
VI Time
VIINeedle diameterlengthtype
3 Treatment Regimen
4 Other components
5 Practitioner Background
6 Control
Session
Date
Points
Needle Size
(Angle)
De Qi
Further Stim
Treatment Duration
Adverse Effects
Outcome Measure
121013
Session1
BL252627 (bilaterally) BL54 BL57 GV43 GB30 GB31 ST36
40mm (perp)
40mm (perp) 40mm (perp) 25mm (perp) 70mm (obliq) 40mm (perp) 25mm (perp)
Achieved all
points except GB30
Further
stimulation all points x2
20 mins (all needles)
Slight anxiety with
first few needles ndash settled
VRS- 610
151013 Session 2
BL252627 (bilaterally) BL54 BL57 GV43 GB30 GB31 ST36
40mm (perp)
40mm (perp) 40mm (perp) 25mm (perp) 70mm (obliq) 40mm (perp) 25mm (perp)
De Qi on all points
Further stim X 2
20 mins (all needles)
None
VRS- 610
201013
Session 3
BL252627 (bilaterally) BL54 BL57 GV43 GB30 GB31 ST36
40mm (perp)
40mm (perp) 40mm (perp) 25mm (perp) 70mm (obliq) 40mm (perp) 25mm (perp)
De Qi on all points
Further stim
X 3
20 mins (all needles)
None
VRS- 410
Pt reports
less leg pain-more
into back
251013 Session 4
BL252627 (bilaterally) (HJJ pts adjacent to BL pts) LI4
40mm (perp)
25mm (obliq)
25mm (perp)
De Qi on all points
Further stim
X 3
25 mins (all needles)
Had to re position LI4 as it was too painful for
pt
VRS- 2-310
(Isolated to back
onlyoccasional buttock)
How do you choose your points
Recipesprotocols
Points you are familiar with
TCM associations
Western Scientific theory- and
what do we mean by this
Clinical Reasoning v Technical Operation
23052014
3
Questions to ask
yourself
What structures will the needle penetrate
What is the state of the tissues Do you want to needle
locally Or should you just use distal points
What stimulation are you wanting to perform
What indications does your patient give you regarding
needling
Why Why Why do we do anything
bull Peripheral effects
bull Segmentalspinal effects
bull Add a layer
bull Supraspinal effects
bull Sympathetic Outflow
bull Central Sympathetic effects
bull Immune effects
Bradnam (2007)
bull ldquomultisensory pain modulationrdquo
Campbell (2013)
Layering technique
Downs M Laporte C (2011) Conflicting Dermatome maps
Educational and Clinical Implications JOSPT Vol 41(6) 434
doi102519jospt20113506
)
Points (dermatomes myotomes sclerotomes)
Point Dermatom
e
Myotome Sclerotome Peripheral nerve
(motor)
ST 36 L45 L45 L45 Deep Peroneal
LR 3 L45 L5S1 or S2S3 L5S1 Medial Lateral
Plantar Nerve
GB 30 L2L3S2 L5S1S2 L4L5S1 Inferior Gluteal
NerveObturator
GB 39 L4L5S1 L4L5S1 L4L5S1 Superficial
Peroneal (PLPB)
Deep Peroneal
(PT)
BL 23 L2L3 L23 L23 Local Segmental
(dorsal rami)
BL 52 L23 L23 L23 Local Segmental
(dorsal rami)
Lumbar Spine Points- examples
Level Dermatome Myotome Sclerotome
L1 BL 2122 BL 2122
L2 BL 23 BL 25 GV 4 HJJ BL 23GV 4
L3 SP 9LR 3 SP 10 SP 9
L4 ST 36SP 6SP
9KI 3LR 3
BL 25ST 36 SP 10 GV 3 BL 25
L5 ST 36 LR 3 ST 36 BL 54 ST 36 LR 3
S1 SP 6BL 40 SP 6SP 9KI 3 LR 3
S2 SP 6 KI 3BL 40 SP 6SP 9KI 3 L 3 KI 3
Examples of Points related to spinal segments (White 2008)
Neural Anatomical Unit
Key issue Discussing the metaphysical
concepts of points and meridians in the
framework of modern scientific language
httpwwwhindawicomjournalsecam2012429412
NAU (Zhang 2012)
Classification Location
Muscle Spindle rich Around 60 of acupuncture
points are located in muscle
Cutaneous receptor rich Hands Face Feet (sensory
homonculus
Tendon Organ Rich Around joints
wristelbowknees
23052014
4
M receptors
Prostaglandins
Dynorphin
Allodynia
nociceptio
n
Spinoreticular
tract
Long Term
potentiation
serotonin
Inflammatory
mediators
PAIN PATHWAY
Peripheral Sensitisation
Inflammation
Interleukins
Tumor necrosis
factor
Serotonin (5-HT)
Hydrogen ions
High-threshold
nociception
Tissue damage Sympathetic Afferents
Low-threshold
nociception
Histamine
Potassium ions
Prostanoids
Purines
Norepinephine
Bradykinin
Neuropeptides
Leukotrienes
(Hudspith Munglani amp Siddall 2006) Kavoussi and Ross (2007) The neuroimmune basis of anti-inflammatory
acupuncture Integ Canc Therap 6251-257
CENTRAL SENSITISATION
bull Increased synaptic activity causing sub threshold
stimulus to produce response
bull Reflects functional states of circuits in the CNS
bull CNS distortamplify degree duration extent of
pain
bull Stimulus pain in segmentally related TPrsquos
(Woolf 2011)
ldquoOpening or Shutting the pharmaceutical box in the brainrdquo
bull Helen Langevin- connective tissue effects
bull Tom Myers- Anatomy Trains
bull Gil Hadley-Fuzz- ldquostrolling under the skinrdquo
bull MfTPrsquos
Structural
23052014
5
DEFINING DOSAGEDefining an adequate dose of
acupuncture using a neurophysiological approach--a
narrative review of the literature (2008) White A et al
Acupunct Med Jun26(2)111-20
Physical Procedure De QiTechnique
1+ needles Selection of Points
Consider patients perception
of pain
Sensory Affective
May be affected by the state
of the patient
Nervous immune-
suppressed etc
DIFFERENT CONDITIONS (in WM) MAY REQUIRE
DIFFERENT DOSES AS EFFECT MAY RELY ON
MANY MECHANISMS
(localsegmentalextrasegmentalcentralimmune
effects)
Think THRESHOLD v TOLERANCE
Evidence for 1 Number of needles- Ceccherelli et al (2010) ndash
Bradnam (200)- ldquoLayering theoryrdquo
2 Needle Retention time- Lewis and Abdi (2010) Yuan (2008)
3 Frequency of sessions- Sherman (2009)
4 Total number of sessions- Ezzo (2000) MacPherson (2004)
5 De Qi- Lundeberg et al (2012) White (2008)
6 LengthGauge of needles- Bradnam (2007) Zhang (2012)
7 Other Factors
Pariente et al (2005) + Wasan (2010) ndash Effect of expectation Witt (2011)- being female living in a multi person household
failure of other therapies before study former positive experience
Witt (2010) Therapeutic relationship (not training or length of qualification)
Harris (2009) Genetics ndasheffect of mu receptors and difference in opioid metabolism
Pearce (2006) Acupuncture time line model
Letrsquos review a pointBL 25
(40mm needle angled obliquely
towards spinous process)
bull Location 15 lateral to the lower border of L4
bull Skin
bull Thoracolumbar fascia
bull Muscles multifidus iliocostalis lumborum
bull longissimus thoracicis
bull fibresthoracolumbar fascia Lat Dorsi
bull Quadratus Lumborum
bull Bone
BL 25
BL 23 Cadaver
Qmarketinginsignia guidelines
LI 4 Cadaver
23052014
6
LR 3 Cadaver
Qmarketinginsignia guidelines
GB 30 Cadaver
Qmarketinginsignia guidelines
ST 36 Cadaver
Local ndash BL 20-35 BL 48-54 Ah Shi Extra points- HJJ Yao Yi Yuo Yan
Segmental- L5S1- GB 30 GB 31 GB 34 GB 41 GB 43 BL 60-67
Extra Segmental- KI channelSP channel LR channel AND all channels in arms head GV 20
Sympathetic- HT 7 PC 6 LU 9
LSP Points
Qmarketinginsignia guidelines
23052014
7
Acupuncture and the Emerging Evidence
base Contrived Controversy and
Rational Debate
3 areas of Research
1)Safety and the risk of serious adverse
events
2) Clinical Efficacy and Effectiveness
3)Physiologic Action
MacPherson Hammerschlag
(2012)
bull AACP website (must be on aacporguk)
bull (usernamepassword)
bull On-line databases
bull Access to AIM
bull Choose article-abstract- ldquofull textrdquo
bull Then look at references- it will denote
what is freeon Google scholar
References
Qmarketinginsignia guidelines wwwaacpukcom
Thank You for
listening
White A Cummings M and Filshie J (2008) An Introduction to Western Medical Acupuncture Philadelphia Churchill Livingstone Haker E Egekvist H and Bjerring P (2000) lsquoEffect of sensory stimulation (acupuncture) on sympathetic and parasympathetic activities in healthy subjectsrsquo Journal of the autonomic nervous system vol 79 no 1 February pp 52-59 Sandberg M Lundeberg T Lindberg LG and Gerdle B (2003) lsquoEffects of acupuncture on skin and muscle blood flow in healthy subjectsrsquo European Journal of Applied Physiology vol 90 no 1-2 September pp 114-9 Sandkuumlhler J Chen JG Cheng G and Randić M (1997) lsquoLow-frequency stimulation of afferent Adelta-fibers induces long-term depression at primary afferent synapses with substantia gelatinosa neurons in the ratrsquo Journal of neuroscience vol 17 no 16 August pp 6483-6491 Stein C Machelska H Binder W and Schaumlfer M (2001) lsquoPeripheral opioid analgesiarsquoCurrent Opinion in Pharmacology vol 1 no 1 February pp 62-65 Vas J and White A (2007) lsquoEvidence from RCTs on optimal acupuncture treatment for knee osteoarthritis--an exploratory reviewrsquo Acupuncture in medicine vol 25 no 1-2 June pp 29-35 White A Cummings M Barlas P Cardini F Filshie J Foster NE Lundeberg T Stener-Victorin E and Witt C (2008) lsquoDefining an adequate dose of acupuncture using a neurophysiological approach--a narrative review of the literaturersquo Acupuncture in Medicine vol 26 no 2 June pp 111-120 White A Foster NE Cummings M and Barlas P (2007) lsquoAcupuncture treatment for chronic knee pain a systematic reviewrsquo Rheumatology vol 46 no 3 March pp 384-390
AACP Still Pointing the Way after 30 Years
Abstract
The use of acupuncture within physiotherapy particularly for the treatment of musculo-skeletal conditions and particularly LBP is common This presentation aims to explore the many variables
that need to be considered as part of ldquodosagerdquo and relate these to the current evidence base in order to make interventions for LBP more efficacious The presentation will include a demonstration of some of the acupuncture techniques used in the Lumbar Spine and opportunity will be given to
discuss the implications of such techniques
AACP Still Pointing the Way after 30 Years
Learning Outcomes
Title Low Back Pain Practice makes perfect Theoretical Learning Outcomes
1 Understand the current evidence base related to the specific
variables of dosage 2 Acknowledge how various pain presentations can affect
outcomes of interventions with reference to Low Back Pain
Skills to be communicated
Application of clinical reasoning based on Western Medical Approaches to various clinical presentations encountered in the Outpatient department
Information on practical application of information
Various acupuncture techniques on the Lumbar spine and other areas will be demonstrated and discussed
Areas of further learning which may benefit the delegate
Pain mechanisms for example peripheralcentral sensitisation processes
Summarise key points with emphasis on clinical application
Acupuncture Association of Chartered Physiotherapists Limited Registered in England and Wales Registration No 5680004
Registered Office- Southgate House Southgate Park Bakewell Road Orton Southgate Perterborough PE2 6YS
CPD REGISTRATION FORM
Membership of the AACP is open to Chartered Physiotherapists practising Acupuncture
Surname CSP registration no
First Name HPC registration no
AACP membership no
CPD Activity
Date
CPD Hours
Learning Objectives
Learning Outcomes
23052014
1
Qmarketinginsignia guidelines
wwwaacpukcom
AACP
Conference 2014
Coventry
LBP- Practice makes perfect Lesley Pattenden MCSP lesleypattendenhotmailcom
Qmarketinginsignia guidelines
wwwaacpukcom
Lessons to be learned
What is ldquoAdvancedrdquo acupuncture after
Foundation Course completion
What do you want from your needle
Qmarketinginsignia guidelines
Aims of the session
1 Explore your current knowledge of acupuncture
and LBP
2 To examine the current evidence base and
review current guidelines concerning LBP
3 To review the clinical reasoning process and
relate it to LBP
4 To Review the various techniques associated
with acupuncture for LBP
How can you make your practice
more effective
UK population
- lifetime prevalence 70
- annual prevalence 40
Recurrences are common and prevalence of LBP has
not changed
90 of acute attacks that present for healthcare settle
sufficiently to prevent further intervention and return to
work within 6 weeks
7 of adults have persisting LBP which restricts
function
1 in 15 of the population will consult their GP for LBP
LBP accounts for between 25 and 45 of PT case
load
(NICE 2009 Yuan et al 2008 Kent and Keating 2005)
The scale of the problem
1 Consider offering a course of manual therapy including
spinal manipulation of up to 9 sessions over 12 weeks
2 Consider offering a course of Acupuncture up to
10 sessions over 12 weeks (pg 180)
3 Do not offer injections of therapeutic substances into
the back
4 Do not offer stand alone formal education programmes
5 Do not offer laserIFTherapeutic US or TENS
routinely
NICE (2009) Guidelines
Recommendations Research
Systematic Review
bull Furlan et al (2005) Acupuncture and Dry-Needling
for LBP Cochrane Database Syst Rev 2005 Jan 25(1)CD001351
RCTrsquos (4)
bull Brinkhaus et al (2006) Acupuncture in patients with
CLBP An RCT Arch Intern Med 2006 Feb 27166(4)450-7
bull Haake et al (2007) GERAC Trials for LBP Arch Intern Med
2007 Sep 24167(17)1892-8
bull Witt (2006) Pragmatic RCT for clinical and cost-
effectiveness for CLBP Am J Epidemiol 2006 Sep 1164(5)487-96
bull Thomas et al (2005) Longer term clinical and
economical benefits of AP and LBP Health Technol
Assess Aug9(32)iii-iv ix-x 1-109
23052014
2
NICE 2013 Review (Due 2016)
How may these affect us
Scope- what does this suggest
Low Back Pain and Sciatica Management
of non-specific LBP and Sciatica Pulse Article (2010) - non adherence to guideline
Of -127 PCTrsquos- frac12 provided funding and 15 offered AP in
GP practices
What Research is NICE likely to consider
Acupuncture Trialist Collaboration
Aim- To determine effect sizes of AP in 4 common
conditions with chronic pain states
Data- 29 trials data- 17922 patients
Outcome- Superior to sham and no control
ldquo reasonable referral option for effectrdquo
ldquostatistical significance between true AP and shamrdquo
ldquoindicate effect is more than placebo but other factors for effect are important contributorsrdquo
Vickers et al (2012)
STRICTA GUIDELINES Standards for reporting Interventions in
Clinical Trials of Acupuncture
2001 2002 revised 2010 H MacPherson D G Altman R Hammerschlag et al ldquoRevised standards for reporting interventions in clinical
trials of acupuncture (STRICTA) extending the consort statementrdquo Acupuncture in Medicine vol 28 no 2 pp 83ndash
93 2010
1 Acupuncture Rationale
2 Details of needling
I Number of needles
II Nameslocation
III Depth of insertion
IV Response sought
V Needle Stimulation
VI Time
VIINeedle diameterlengthtype
3 Treatment Regimen
4 Other components
5 Practitioner Background
6 Control
Session
Date
Points
Needle Size
(Angle)
De Qi
Further Stim
Treatment Duration
Adverse Effects
Outcome Measure
121013
Session1
BL252627 (bilaterally) BL54 BL57 GV43 GB30 GB31 ST36
40mm (perp)
40mm (perp) 40mm (perp) 25mm (perp) 70mm (obliq) 40mm (perp) 25mm (perp)
Achieved all
points except GB30
Further
stimulation all points x2
20 mins (all needles)
Slight anxiety with
first few needles ndash settled
VRS- 610
151013 Session 2
BL252627 (bilaterally) BL54 BL57 GV43 GB30 GB31 ST36
40mm (perp)
40mm (perp) 40mm (perp) 25mm (perp) 70mm (obliq) 40mm (perp) 25mm (perp)
De Qi on all points
Further stim X 2
20 mins (all needles)
None
VRS- 610
201013
Session 3
BL252627 (bilaterally) BL54 BL57 GV43 GB30 GB31 ST36
40mm (perp)
40mm (perp) 40mm (perp) 25mm (perp) 70mm (obliq) 40mm (perp) 25mm (perp)
De Qi on all points
Further stim
X 3
20 mins (all needles)
None
VRS- 410
Pt reports
less leg pain-more
into back
251013 Session 4
BL252627 (bilaterally) (HJJ pts adjacent to BL pts) LI4
40mm (perp)
25mm (obliq)
25mm (perp)
De Qi on all points
Further stim
X 3
25 mins (all needles)
Had to re position LI4 as it was too painful for
pt
VRS- 2-310
(Isolated to back
onlyoccasional buttock)
How do you choose your points
Recipesprotocols
Points you are familiar with
TCM associations
Western Scientific theory- and
what do we mean by this
Clinical Reasoning v Technical Operation
23052014
3
Questions to ask
yourself
What structures will the needle penetrate
What is the state of the tissues Do you want to needle
locally Or should you just use distal points
What stimulation are you wanting to perform
What indications does your patient give you regarding
needling
Why Why Why do we do anything
bull Peripheral effects
bull Segmentalspinal effects
bull Add a layer
bull Supraspinal effects
bull Sympathetic Outflow
bull Central Sympathetic effects
bull Immune effects
Bradnam (2007)
bull ldquomultisensory pain modulationrdquo
Campbell (2013)
Layering technique
Downs M Laporte C (2011) Conflicting Dermatome maps
Educational and Clinical Implications JOSPT Vol 41(6) 434
doi102519jospt20113506
)
Points (dermatomes myotomes sclerotomes)
Point Dermatom
e
Myotome Sclerotome Peripheral nerve
(motor)
ST 36 L45 L45 L45 Deep Peroneal
LR 3 L45 L5S1 or S2S3 L5S1 Medial Lateral
Plantar Nerve
GB 30 L2L3S2 L5S1S2 L4L5S1 Inferior Gluteal
NerveObturator
GB 39 L4L5S1 L4L5S1 L4L5S1 Superficial
Peroneal (PLPB)
Deep Peroneal
(PT)
BL 23 L2L3 L23 L23 Local Segmental
(dorsal rami)
BL 52 L23 L23 L23 Local Segmental
(dorsal rami)
Lumbar Spine Points- examples
Level Dermatome Myotome Sclerotome
L1 BL 2122 BL 2122
L2 BL 23 BL 25 GV 4 HJJ BL 23GV 4
L3 SP 9LR 3 SP 10 SP 9
L4 ST 36SP 6SP
9KI 3LR 3
BL 25ST 36 SP 10 GV 3 BL 25
L5 ST 36 LR 3 ST 36 BL 54 ST 36 LR 3
S1 SP 6BL 40 SP 6SP 9KI 3 LR 3
S2 SP 6 KI 3BL 40 SP 6SP 9KI 3 L 3 KI 3
Examples of Points related to spinal segments (White 2008)
Neural Anatomical Unit
Key issue Discussing the metaphysical
concepts of points and meridians in the
framework of modern scientific language
httpwwwhindawicomjournalsecam2012429412
NAU (Zhang 2012)
Classification Location
Muscle Spindle rich Around 60 of acupuncture
points are located in muscle
Cutaneous receptor rich Hands Face Feet (sensory
homonculus
Tendon Organ Rich Around joints
wristelbowknees
23052014
4
M receptors
Prostaglandins
Dynorphin
Allodynia
nociceptio
n
Spinoreticular
tract
Long Term
potentiation
serotonin
Inflammatory
mediators
PAIN PATHWAY
Peripheral Sensitisation
Inflammation
Interleukins
Tumor necrosis
factor
Serotonin (5-HT)
Hydrogen ions
High-threshold
nociception
Tissue damage Sympathetic Afferents
Low-threshold
nociception
Histamine
Potassium ions
Prostanoids
Purines
Norepinephine
Bradykinin
Neuropeptides
Leukotrienes
(Hudspith Munglani amp Siddall 2006) Kavoussi and Ross (2007) The neuroimmune basis of anti-inflammatory
acupuncture Integ Canc Therap 6251-257
CENTRAL SENSITISATION
bull Increased synaptic activity causing sub threshold
stimulus to produce response
bull Reflects functional states of circuits in the CNS
bull CNS distortamplify degree duration extent of
pain
bull Stimulus pain in segmentally related TPrsquos
(Woolf 2011)
ldquoOpening or Shutting the pharmaceutical box in the brainrdquo
bull Helen Langevin- connective tissue effects
bull Tom Myers- Anatomy Trains
bull Gil Hadley-Fuzz- ldquostrolling under the skinrdquo
bull MfTPrsquos
Structural
23052014
5
DEFINING DOSAGEDefining an adequate dose of
acupuncture using a neurophysiological approach--a
narrative review of the literature (2008) White A et al
Acupunct Med Jun26(2)111-20
Physical Procedure De QiTechnique
1+ needles Selection of Points
Consider patients perception
of pain
Sensory Affective
May be affected by the state
of the patient
Nervous immune-
suppressed etc
DIFFERENT CONDITIONS (in WM) MAY REQUIRE
DIFFERENT DOSES AS EFFECT MAY RELY ON
MANY MECHANISMS
(localsegmentalextrasegmentalcentralimmune
effects)
Think THRESHOLD v TOLERANCE
Evidence for 1 Number of needles- Ceccherelli et al (2010) ndash
Bradnam (200)- ldquoLayering theoryrdquo
2 Needle Retention time- Lewis and Abdi (2010) Yuan (2008)
3 Frequency of sessions- Sherman (2009)
4 Total number of sessions- Ezzo (2000) MacPherson (2004)
5 De Qi- Lundeberg et al (2012) White (2008)
6 LengthGauge of needles- Bradnam (2007) Zhang (2012)
7 Other Factors
Pariente et al (2005) + Wasan (2010) ndash Effect of expectation Witt (2011)- being female living in a multi person household
failure of other therapies before study former positive experience
Witt (2010) Therapeutic relationship (not training or length of qualification)
Harris (2009) Genetics ndasheffect of mu receptors and difference in opioid metabolism
Pearce (2006) Acupuncture time line model
Letrsquos review a pointBL 25
(40mm needle angled obliquely
towards spinous process)
bull Location 15 lateral to the lower border of L4
bull Skin
bull Thoracolumbar fascia
bull Muscles multifidus iliocostalis lumborum
bull longissimus thoracicis
bull fibresthoracolumbar fascia Lat Dorsi
bull Quadratus Lumborum
bull Bone
BL 25
BL 23 Cadaver
Qmarketinginsignia guidelines
LI 4 Cadaver
23052014
6
LR 3 Cadaver
Qmarketinginsignia guidelines
GB 30 Cadaver
Qmarketinginsignia guidelines
ST 36 Cadaver
Local ndash BL 20-35 BL 48-54 Ah Shi Extra points- HJJ Yao Yi Yuo Yan
Segmental- L5S1- GB 30 GB 31 GB 34 GB 41 GB 43 BL 60-67
Extra Segmental- KI channelSP channel LR channel AND all channels in arms head GV 20
Sympathetic- HT 7 PC 6 LU 9
LSP Points
Qmarketinginsignia guidelines
23052014
7
Acupuncture and the Emerging Evidence
base Contrived Controversy and
Rational Debate
3 areas of Research
1)Safety and the risk of serious adverse
events
2) Clinical Efficacy and Effectiveness
3)Physiologic Action
MacPherson Hammerschlag
(2012)
bull AACP website (must be on aacporguk)
bull (usernamepassword)
bull On-line databases
bull Access to AIM
bull Choose article-abstract- ldquofull textrdquo
bull Then look at references- it will denote
what is freeon Google scholar
References
Qmarketinginsignia guidelines wwwaacpukcom
Thank You for
listening
White A Cummings M and Filshie J (2008) An Introduction to Western Medical Acupuncture Philadelphia Churchill Livingstone Haker E Egekvist H and Bjerring P (2000) lsquoEffect of sensory stimulation (acupuncture) on sympathetic and parasympathetic activities in healthy subjectsrsquo Journal of the autonomic nervous system vol 79 no 1 February pp 52-59 Sandberg M Lundeberg T Lindberg LG and Gerdle B (2003) lsquoEffects of acupuncture on skin and muscle blood flow in healthy subjectsrsquo European Journal of Applied Physiology vol 90 no 1-2 September pp 114-9 Sandkuumlhler J Chen JG Cheng G and Randić M (1997) lsquoLow-frequency stimulation of afferent Adelta-fibers induces long-term depression at primary afferent synapses with substantia gelatinosa neurons in the ratrsquo Journal of neuroscience vol 17 no 16 August pp 6483-6491 Stein C Machelska H Binder W and Schaumlfer M (2001) lsquoPeripheral opioid analgesiarsquoCurrent Opinion in Pharmacology vol 1 no 1 February pp 62-65 Vas J and White A (2007) lsquoEvidence from RCTs on optimal acupuncture treatment for knee osteoarthritis--an exploratory reviewrsquo Acupuncture in medicine vol 25 no 1-2 June pp 29-35 White A Cummings M Barlas P Cardini F Filshie J Foster NE Lundeberg T Stener-Victorin E and Witt C (2008) lsquoDefining an adequate dose of acupuncture using a neurophysiological approach--a narrative review of the literaturersquo Acupuncture in Medicine vol 26 no 2 June pp 111-120 White A Foster NE Cummings M and Barlas P (2007) lsquoAcupuncture treatment for chronic knee pain a systematic reviewrsquo Rheumatology vol 46 no 3 March pp 384-390
AACP Still Pointing the Way after 30 Years
Learning Outcomes
Title Low Back Pain Practice makes perfect Theoretical Learning Outcomes
1 Understand the current evidence base related to the specific
variables of dosage 2 Acknowledge how various pain presentations can affect
outcomes of interventions with reference to Low Back Pain
Skills to be communicated
Application of clinical reasoning based on Western Medical Approaches to various clinical presentations encountered in the Outpatient department
Information on practical application of information
Various acupuncture techniques on the Lumbar spine and other areas will be demonstrated and discussed
Areas of further learning which may benefit the delegate
Pain mechanisms for example peripheralcentral sensitisation processes
Summarise key points with emphasis on clinical application
Acupuncture Association of Chartered Physiotherapists Limited Registered in England and Wales Registration No 5680004
Registered Office- Southgate House Southgate Park Bakewell Road Orton Southgate Perterborough PE2 6YS
CPD REGISTRATION FORM
Membership of the AACP is open to Chartered Physiotherapists practising Acupuncture
Surname CSP registration no
First Name HPC registration no
AACP membership no
CPD Activity
Date
CPD Hours
Learning Objectives
Learning Outcomes
23052014
1
Qmarketinginsignia guidelines
wwwaacpukcom
AACP
Conference 2014
Coventry
LBP- Practice makes perfect Lesley Pattenden MCSP lesleypattendenhotmailcom
Qmarketinginsignia guidelines
wwwaacpukcom
Lessons to be learned
What is ldquoAdvancedrdquo acupuncture after
Foundation Course completion
What do you want from your needle
Qmarketinginsignia guidelines
Aims of the session
1 Explore your current knowledge of acupuncture
and LBP
2 To examine the current evidence base and
review current guidelines concerning LBP
3 To review the clinical reasoning process and
relate it to LBP
4 To Review the various techniques associated
with acupuncture for LBP
How can you make your practice
more effective
UK population
- lifetime prevalence 70
- annual prevalence 40
Recurrences are common and prevalence of LBP has
not changed
90 of acute attacks that present for healthcare settle
sufficiently to prevent further intervention and return to
work within 6 weeks
7 of adults have persisting LBP which restricts
function
1 in 15 of the population will consult their GP for LBP
LBP accounts for between 25 and 45 of PT case
load
(NICE 2009 Yuan et al 2008 Kent and Keating 2005)
The scale of the problem
1 Consider offering a course of manual therapy including
spinal manipulation of up to 9 sessions over 12 weeks
2 Consider offering a course of Acupuncture up to
10 sessions over 12 weeks (pg 180)
3 Do not offer injections of therapeutic substances into
the back
4 Do not offer stand alone formal education programmes
5 Do not offer laserIFTherapeutic US or TENS
routinely
NICE (2009) Guidelines
Recommendations Research
Systematic Review
bull Furlan et al (2005) Acupuncture and Dry-Needling
for LBP Cochrane Database Syst Rev 2005 Jan 25(1)CD001351
RCTrsquos (4)
bull Brinkhaus et al (2006) Acupuncture in patients with
CLBP An RCT Arch Intern Med 2006 Feb 27166(4)450-7
bull Haake et al (2007) GERAC Trials for LBP Arch Intern Med
2007 Sep 24167(17)1892-8
bull Witt (2006) Pragmatic RCT for clinical and cost-
effectiveness for CLBP Am J Epidemiol 2006 Sep 1164(5)487-96
bull Thomas et al (2005) Longer term clinical and
economical benefits of AP and LBP Health Technol
Assess Aug9(32)iii-iv ix-x 1-109
23052014
2
NICE 2013 Review (Due 2016)
How may these affect us
Scope- what does this suggest
Low Back Pain and Sciatica Management
of non-specific LBP and Sciatica Pulse Article (2010) - non adherence to guideline
Of -127 PCTrsquos- frac12 provided funding and 15 offered AP in
GP practices
What Research is NICE likely to consider
Acupuncture Trialist Collaboration
Aim- To determine effect sizes of AP in 4 common
conditions with chronic pain states
Data- 29 trials data- 17922 patients
Outcome- Superior to sham and no control
ldquo reasonable referral option for effectrdquo
ldquostatistical significance between true AP and shamrdquo
ldquoindicate effect is more than placebo but other factors for effect are important contributorsrdquo
Vickers et al (2012)
STRICTA GUIDELINES Standards for reporting Interventions in
Clinical Trials of Acupuncture
2001 2002 revised 2010 H MacPherson D G Altman R Hammerschlag et al ldquoRevised standards for reporting interventions in clinical
trials of acupuncture (STRICTA) extending the consort statementrdquo Acupuncture in Medicine vol 28 no 2 pp 83ndash
93 2010
1 Acupuncture Rationale
2 Details of needling
I Number of needles
II Nameslocation
III Depth of insertion
IV Response sought
V Needle Stimulation
VI Time
VIINeedle diameterlengthtype
3 Treatment Regimen
4 Other components
5 Practitioner Background
6 Control
Session
Date
Points
Needle Size
(Angle)
De Qi
Further Stim
Treatment Duration
Adverse Effects
Outcome Measure
121013
Session1
BL252627 (bilaterally) BL54 BL57 GV43 GB30 GB31 ST36
40mm (perp)
40mm (perp) 40mm (perp) 25mm (perp) 70mm (obliq) 40mm (perp) 25mm (perp)
Achieved all
points except GB30
Further
stimulation all points x2
20 mins (all needles)
Slight anxiety with
first few needles ndash settled
VRS- 610
151013 Session 2
BL252627 (bilaterally) BL54 BL57 GV43 GB30 GB31 ST36
40mm (perp)
40mm (perp) 40mm (perp) 25mm (perp) 70mm (obliq) 40mm (perp) 25mm (perp)
De Qi on all points
Further stim X 2
20 mins (all needles)
None
VRS- 610
201013
Session 3
BL252627 (bilaterally) BL54 BL57 GV43 GB30 GB31 ST36
40mm (perp)
40mm (perp) 40mm (perp) 25mm (perp) 70mm (obliq) 40mm (perp) 25mm (perp)
De Qi on all points
Further stim
X 3
20 mins (all needles)
None
VRS- 410
Pt reports
less leg pain-more
into back
251013 Session 4
BL252627 (bilaterally) (HJJ pts adjacent to BL pts) LI4
40mm (perp)
25mm (obliq)
25mm (perp)
De Qi on all points
Further stim
X 3
25 mins (all needles)
Had to re position LI4 as it was too painful for
pt
VRS- 2-310
(Isolated to back
onlyoccasional buttock)
How do you choose your points
Recipesprotocols
Points you are familiar with
TCM associations
Western Scientific theory- and
what do we mean by this
Clinical Reasoning v Technical Operation
23052014
3
Questions to ask
yourself
What structures will the needle penetrate
What is the state of the tissues Do you want to needle
locally Or should you just use distal points
What stimulation are you wanting to perform
What indications does your patient give you regarding
needling
Why Why Why do we do anything
bull Peripheral effects
bull Segmentalspinal effects
bull Add a layer
bull Supraspinal effects
bull Sympathetic Outflow
bull Central Sympathetic effects
bull Immune effects
Bradnam (2007)
bull ldquomultisensory pain modulationrdquo
Campbell (2013)
Layering technique
Downs M Laporte C (2011) Conflicting Dermatome maps
Educational and Clinical Implications JOSPT Vol 41(6) 434
doi102519jospt20113506
)
Points (dermatomes myotomes sclerotomes)
Point Dermatom
e
Myotome Sclerotome Peripheral nerve
(motor)
ST 36 L45 L45 L45 Deep Peroneal
LR 3 L45 L5S1 or S2S3 L5S1 Medial Lateral
Plantar Nerve
GB 30 L2L3S2 L5S1S2 L4L5S1 Inferior Gluteal
NerveObturator
GB 39 L4L5S1 L4L5S1 L4L5S1 Superficial
Peroneal (PLPB)
Deep Peroneal
(PT)
BL 23 L2L3 L23 L23 Local Segmental
(dorsal rami)
BL 52 L23 L23 L23 Local Segmental
(dorsal rami)
Lumbar Spine Points- examples
Level Dermatome Myotome Sclerotome
L1 BL 2122 BL 2122
L2 BL 23 BL 25 GV 4 HJJ BL 23GV 4
L3 SP 9LR 3 SP 10 SP 9
L4 ST 36SP 6SP
9KI 3LR 3
BL 25ST 36 SP 10 GV 3 BL 25
L5 ST 36 LR 3 ST 36 BL 54 ST 36 LR 3
S1 SP 6BL 40 SP 6SP 9KI 3 LR 3
S2 SP 6 KI 3BL 40 SP 6SP 9KI 3 L 3 KI 3
Examples of Points related to spinal segments (White 2008)
Neural Anatomical Unit
Key issue Discussing the metaphysical
concepts of points and meridians in the
framework of modern scientific language
httpwwwhindawicomjournalsecam2012429412
NAU (Zhang 2012)
Classification Location
Muscle Spindle rich Around 60 of acupuncture
points are located in muscle
Cutaneous receptor rich Hands Face Feet (sensory
homonculus
Tendon Organ Rich Around joints
wristelbowknees
23052014
4
M receptors
Prostaglandins
Dynorphin
Allodynia
nociceptio
n
Spinoreticular
tract
Long Term
potentiation
serotonin
Inflammatory
mediators
PAIN PATHWAY
Peripheral Sensitisation
Inflammation
Interleukins
Tumor necrosis
factor
Serotonin (5-HT)
Hydrogen ions
High-threshold
nociception
Tissue damage Sympathetic Afferents
Low-threshold
nociception
Histamine
Potassium ions
Prostanoids
Purines
Norepinephine
Bradykinin
Neuropeptides
Leukotrienes
(Hudspith Munglani amp Siddall 2006) Kavoussi and Ross (2007) The neuroimmune basis of anti-inflammatory
acupuncture Integ Canc Therap 6251-257
CENTRAL SENSITISATION
bull Increased synaptic activity causing sub threshold
stimulus to produce response
bull Reflects functional states of circuits in the CNS
bull CNS distortamplify degree duration extent of
pain
bull Stimulus pain in segmentally related TPrsquos
(Woolf 2011)
ldquoOpening or Shutting the pharmaceutical box in the brainrdquo
bull Helen Langevin- connective tissue effects
bull Tom Myers- Anatomy Trains
bull Gil Hadley-Fuzz- ldquostrolling under the skinrdquo
bull MfTPrsquos
Structural
23052014
5
DEFINING DOSAGEDefining an adequate dose of
acupuncture using a neurophysiological approach--a
narrative review of the literature (2008) White A et al
Acupunct Med Jun26(2)111-20
Physical Procedure De QiTechnique
1+ needles Selection of Points
Consider patients perception
of pain
Sensory Affective
May be affected by the state
of the patient
Nervous immune-
suppressed etc
DIFFERENT CONDITIONS (in WM) MAY REQUIRE
DIFFERENT DOSES AS EFFECT MAY RELY ON
MANY MECHANISMS
(localsegmentalextrasegmentalcentralimmune
effects)
Think THRESHOLD v TOLERANCE
Evidence for 1 Number of needles- Ceccherelli et al (2010) ndash
Bradnam (200)- ldquoLayering theoryrdquo
2 Needle Retention time- Lewis and Abdi (2010) Yuan (2008)
3 Frequency of sessions- Sherman (2009)
4 Total number of sessions- Ezzo (2000) MacPherson (2004)
5 De Qi- Lundeberg et al (2012) White (2008)
6 LengthGauge of needles- Bradnam (2007) Zhang (2012)
7 Other Factors
Pariente et al (2005) + Wasan (2010) ndash Effect of expectation Witt (2011)- being female living in a multi person household
failure of other therapies before study former positive experience
Witt (2010) Therapeutic relationship (not training or length of qualification)
Harris (2009) Genetics ndasheffect of mu receptors and difference in opioid metabolism
Pearce (2006) Acupuncture time line model
Letrsquos review a pointBL 25
(40mm needle angled obliquely
towards spinous process)
bull Location 15 lateral to the lower border of L4
bull Skin
bull Thoracolumbar fascia
bull Muscles multifidus iliocostalis lumborum
bull longissimus thoracicis
bull fibresthoracolumbar fascia Lat Dorsi
bull Quadratus Lumborum
bull Bone
BL 25
BL 23 Cadaver
Qmarketinginsignia guidelines
LI 4 Cadaver
23052014
6
LR 3 Cadaver
Qmarketinginsignia guidelines
GB 30 Cadaver
Qmarketinginsignia guidelines
ST 36 Cadaver
Local ndash BL 20-35 BL 48-54 Ah Shi Extra points- HJJ Yao Yi Yuo Yan
Segmental- L5S1- GB 30 GB 31 GB 34 GB 41 GB 43 BL 60-67
Extra Segmental- KI channelSP channel LR channel AND all channels in arms head GV 20
Sympathetic- HT 7 PC 6 LU 9
LSP Points
Qmarketinginsignia guidelines
23052014
7
Acupuncture and the Emerging Evidence
base Contrived Controversy and
Rational Debate
3 areas of Research
1)Safety and the risk of serious adverse
events
2) Clinical Efficacy and Effectiveness
3)Physiologic Action
MacPherson Hammerschlag
(2012)
bull AACP website (must be on aacporguk)
bull (usernamepassword)
bull On-line databases
bull Access to AIM
bull Choose article-abstract- ldquofull textrdquo
bull Then look at references- it will denote
what is freeon Google scholar
References
Qmarketinginsignia guidelines wwwaacpukcom
Thank You for
listening
White A Cummings M and Filshie J (2008) An Introduction to Western Medical Acupuncture Philadelphia Churchill Livingstone Haker E Egekvist H and Bjerring P (2000) lsquoEffect of sensory stimulation (acupuncture) on sympathetic and parasympathetic activities in healthy subjectsrsquo Journal of the autonomic nervous system vol 79 no 1 February pp 52-59 Sandberg M Lundeberg T Lindberg LG and Gerdle B (2003) lsquoEffects of acupuncture on skin and muscle blood flow in healthy subjectsrsquo European Journal of Applied Physiology vol 90 no 1-2 September pp 114-9 Sandkuumlhler J Chen JG Cheng G and Randić M (1997) lsquoLow-frequency stimulation of afferent Adelta-fibers induces long-term depression at primary afferent synapses with substantia gelatinosa neurons in the ratrsquo Journal of neuroscience vol 17 no 16 August pp 6483-6491 Stein C Machelska H Binder W and Schaumlfer M (2001) lsquoPeripheral opioid analgesiarsquoCurrent Opinion in Pharmacology vol 1 no 1 February pp 62-65 Vas J and White A (2007) lsquoEvidence from RCTs on optimal acupuncture treatment for knee osteoarthritis--an exploratory reviewrsquo Acupuncture in medicine vol 25 no 1-2 June pp 29-35 White A Cummings M Barlas P Cardini F Filshie J Foster NE Lundeberg T Stener-Victorin E and Witt C (2008) lsquoDefining an adequate dose of acupuncture using a neurophysiological approach--a narrative review of the literaturersquo Acupuncture in Medicine vol 26 no 2 June pp 111-120 White A Foster NE Cummings M and Barlas P (2007) lsquoAcupuncture treatment for chronic knee pain a systematic reviewrsquo Rheumatology vol 46 no 3 March pp 384-390
Acupuncture Association of Chartered Physiotherapists Limited Registered in England and Wales Registration No 5680004
Registered Office- Southgate House Southgate Park Bakewell Road Orton Southgate Perterborough PE2 6YS
CPD REGISTRATION FORM
Membership of the AACP is open to Chartered Physiotherapists practising Acupuncture
Surname CSP registration no
First Name HPC registration no
AACP membership no
CPD Activity
Date
CPD Hours
Learning Objectives
Learning Outcomes
23052014
1
Qmarketinginsignia guidelines
wwwaacpukcom
AACP
Conference 2014
Coventry
LBP- Practice makes perfect Lesley Pattenden MCSP lesleypattendenhotmailcom
Qmarketinginsignia guidelines
wwwaacpukcom
Lessons to be learned
What is ldquoAdvancedrdquo acupuncture after
Foundation Course completion
What do you want from your needle
Qmarketinginsignia guidelines
Aims of the session
1 Explore your current knowledge of acupuncture
and LBP
2 To examine the current evidence base and
review current guidelines concerning LBP
3 To review the clinical reasoning process and
relate it to LBP
4 To Review the various techniques associated
with acupuncture for LBP
How can you make your practice
more effective
UK population
- lifetime prevalence 70
- annual prevalence 40
Recurrences are common and prevalence of LBP has
not changed
90 of acute attacks that present for healthcare settle
sufficiently to prevent further intervention and return to
work within 6 weeks
7 of adults have persisting LBP which restricts
function
1 in 15 of the population will consult their GP for LBP
LBP accounts for between 25 and 45 of PT case
load
(NICE 2009 Yuan et al 2008 Kent and Keating 2005)
The scale of the problem
1 Consider offering a course of manual therapy including
spinal manipulation of up to 9 sessions over 12 weeks
2 Consider offering a course of Acupuncture up to
10 sessions over 12 weeks (pg 180)
3 Do not offer injections of therapeutic substances into
the back
4 Do not offer stand alone formal education programmes
5 Do not offer laserIFTherapeutic US or TENS
routinely
NICE (2009) Guidelines
Recommendations Research
Systematic Review
bull Furlan et al (2005) Acupuncture and Dry-Needling
for LBP Cochrane Database Syst Rev 2005 Jan 25(1)CD001351
RCTrsquos (4)
bull Brinkhaus et al (2006) Acupuncture in patients with
CLBP An RCT Arch Intern Med 2006 Feb 27166(4)450-7
bull Haake et al (2007) GERAC Trials for LBP Arch Intern Med
2007 Sep 24167(17)1892-8
bull Witt (2006) Pragmatic RCT for clinical and cost-
effectiveness for CLBP Am J Epidemiol 2006 Sep 1164(5)487-96
bull Thomas et al (2005) Longer term clinical and
economical benefits of AP and LBP Health Technol
Assess Aug9(32)iii-iv ix-x 1-109
23052014
2
NICE 2013 Review (Due 2016)
How may these affect us
Scope- what does this suggest
Low Back Pain and Sciatica Management
of non-specific LBP and Sciatica Pulse Article (2010) - non adherence to guideline
Of -127 PCTrsquos- frac12 provided funding and 15 offered AP in
GP practices
What Research is NICE likely to consider
Acupuncture Trialist Collaboration
Aim- To determine effect sizes of AP in 4 common
conditions with chronic pain states
Data- 29 trials data- 17922 patients
Outcome- Superior to sham and no control
ldquo reasonable referral option for effectrdquo
ldquostatistical significance between true AP and shamrdquo
ldquoindicate effect is more than placebo but other factors for effect are important contributorsrdquo
Vickers et al (2012)
STRICTA GUIDELINES Standards for reporting Interventions in
Clinical Trials of Acupuncture
2001 2002 revised 2010 H MacPherson D G Altman R Hammerschlag et al ldquoRevised standards for reporting interventions in clinical
trials of acupuncture (STRICTA) extending the consort statementrdquo Acupuncture in Medicine vol 28 no 2 pp 83ndash
93 2010
1 Acupuncture Rationale
2 Details of needling
I Number of needles
II Nameslocation
III Depth of insertion
IV Response sought
V Needle Stimulation
VI Time
VIINeedle diameterlengthtype
3 Treatment Regimen
4 Other components
5 Practitioner Background
6 Control
Session
Date
Points
Needle Size
(Angle)
De Qi
Further Stim
Treatment Duration
Adverse Effects
Outcome Measure
121013
Session1
BL252627 (bilaterally) BL54 BL57 GV43 GB30 GB31 ST36
40mm (perp)
40mm (perp) 40mm (perp) 25mm (perp) 70mm (obliq) 40mm (perp) 25mm (perp)
Achieved all
points except GB30
Further
stimulation all points x2
20 mins (all needles)
Slight anxiety with
first few needles ndash settled
VRS- 610
151013 Session 2
BL252627 (bilaterally) BL54 BL57 GV43 GB30 GB31 ST36
40mm (perp)
40mm (perp) 40mm (perp) 25mm (perp) 70mm (obliq) 40mm (perp) 25mm (perp)
De Qi on all points
Further stim X 2
20 mins (all needles)
None
VRS- 610
201013
Session 3
BL252627 (bilaterally) BL54 BL57 GV43 GB30 GB31 ST36
40mm (perp)
40mm (perp) 40mm (perp) 25mm (perp) 70mm (obliq) 40mm (perp) 25mm (perp)
De Qi on all points
Further stim
X 3
20 mins (all needles)
None
VRS- 410
Pt reports
less leg pain-more
into back
251013 Session 4
BL252627 (bilaterally) (HJJ pts adjacent to BL pts) LI4
40mm (perp)
25mm (obliq)
25mm (perp)
De Qi on all points
Further stim
X 3
25 mins (all needles)
Had to re position LI4 as it was too painful for
pt
VRS- 2-310
(Isolated to back
onlyoccasional buttock)
How do you choose your points
Recipesprotocols
Points you are familiar with
TCM associations
Western Scientific theory- and
what do we mean by this
Clinical Reasoning v Technical Operation
23052014
3
Questions to ask
yourself
What structures will the needle penetrate
What is the state of the tissues Do you want to needle
locally Or should you just use distal points
What stimulation are you wanting to perform
What indications does your patient give you regarding
needling
Why Why Why do we do anything
bull Peripheral effects
bull Segmentalspinal effects
bull Add a layer
bull Supraspinal effects
bull Sympathetic Outflow
bull Central Sympathetic effects
bull Immune effects
Bradnam (2007)
bull ldquomultisensory pain modulationrdquo
Campbell (2013)
Layering technique
Downs M Laporte C (2011) Conflicting Dermatome maps
Educational and Clinical Implications JOSPT Vol 41(6) 434
doi102519jospt20113506
)
Points (dermatomes myotomes sclerotomes)
Point Dermatom
e
Myotome Sclerotome Peripheral nerve
(motor)
ST 36 L45 L45 L45 Deep Peroneal
LR 3 L45 L5S1 or S2S3 L5S1 Medial Lateral
Plantar Nerve
GB 30 L2L3S2 L5S1S2 L4L5S1 Inferior Gluteal
NerveObturator
GB 39 L4L5S1 L4L5S1 L4L5S1 Superficial
Peroneal (PLPB)
Deep Peroneal
(PT)
BL 23 L2L3 L23 L23 Local Segmental
(dorsal rami)
BL 52 L23 L23 L23 Local Segmental
(dorsal rami)
Lumbar Spine Points- examples
Level Dermatome Myotome Sclerotome
L1 BL 2122 BL 2122
L2 BL 23 BL 25 GV 4 HJJ BL 23GV 4
L3 SP 9LR 3 SP 10 SP 9
L4 ST 36SP 6SP
9KI 3LR 3
BL 25ST 36 SP 10 GV 3 BL 25
L5 ST 36 LR 3 ST 36 BL 54 ST 36 LR 3
S1 SP 6BL 40 SP 6SP 9KI 3 LR 3
S2 SP 6 KI 3BL 40 SP 6SP 9KI 3 L 3 KI 3
Examples of Points related to spinal segments (White 2008)
Neural Anatomical Unit
Key issue Discussing the metaphysical
concepts of points and meridians in the
framework of modern scientific language
httpwwwhindawicomjournalsecam2012429412
NAU (Zhang 2012)
Classification Location
Muscle Spindle rich Around 60 of acupuncture
points are located in muscle
Cutaneous receptor rich Hands Face Feet (sensory
homonculus
Tendon Organ Rich Around joints
wristelbowknees
23052014
4
M receptors
Prostaglandins
Dynorphin
Allodynia
nociceptio
n
Spinoreticular
tract
Long Term
potentiation
serotonin
Inflammatory
mediators
PAIN PATHWAY
Peripheral Sensitisation
Inflammation
Interleukins
Tumor necrosis
factor
Serotonin (5-HT)
Hydrogen ions
High-threshold
nociception
Tissue damage Sympathetic Afferents
Low-threshold
nociception
Histamine
Potassium ions
Prostanoids
Purines
Norepinephine
Bradykinin
Neuropeptides
Leukotrienes
(Hudspith Munglani amp Siddall 2006) Kavoussi and Ross (2007) The neuroimmune basis of anti-inflammatory
acupuncture Integ Canc Therap 6251-257
CENTRAL SENSITISATION
bull Increased synaptic activity causing sub threshold
stimulus to produce response
bull Reflects functional states of circuits in the CNS
bull CNS distortamplify degree duration extent of
pain
bull Stimulus pain in segmentally related TPrsquos
(Woolf 2011)
ldquoOpening or Shutting the pharmaceutical box in the brainrdquo
bull Helen Langevin- connective tissue effects
bull Tom Myers- Anatomy Trains
bull Gil Hadley-Fuzz- ldquostrolling under the skinrdquo
bull MfTPrsquos
Structural
23052014
5
DEFINING DOSAGEDefining an adequate dose of
acupuncture using a neurophysiological approach--a
narrative review of the literature (2008) White A et al
Acupunct Med Jun26(2)111-20
Physical Procedure De QiTechnique
1+ needles Selection of Points
Consider patients perception
of pain
Sensory Affective
May be affected by the state
of the patient
Nervous immune-
suppressed etc
DIFFERENT CONDITIONS (in WM) MAY REQUIRE
DIFFERENT DOSES AS EFFECT MAY RELY ON
MANY MECHANISMS
(localsegmentalextrasegmentalcentralimmune
effects)
Think THRESHOLD v TOLERANCE
Evidence for 1 Number of needles- Ceccherelli et al (2010) ndash
Bradnam (200)- ldquoLayering theoryrdquo
2 Needle Retention time- Lewis and Abdi (2010) Yuan (2008)
3 Frequency of sessions- Sherman (2009)
4 Total number of sessions- Ezzo (2000) MacPherson (2004)
5 De Qi- Lundeberg et al (2012) White (2008)
6 LengthGauge of needles- Bradnam (2007) Zhang (2012)
7 Other Factors
Pariente et al (2005) + Wasan (2010) ndash Effect of expectation Witt (2011)- being female living in a multi person household
failure of other therapies before study former positive experience
Witt (2010) Therapeutic relationship (not training or length of qualification)
Harris (2009) Genetics ndasheffect of mu receptors and difference in opioid metabolism
Pearce (2006) Acupuncture time line model
Letrsquos review a pointBL 25
(40mm needle angled obliquely
towards spinous process)
bull Location 15 lateral to the lower border of L4
bull Skin
bull Thoracolumbar fascia
bull Muscles multifidus iliocostalis lumborum
bull longissimus thoracicis
bull fibresthoracolumbar fascia Lat Dorsi
bull Quadratus Lumborum
bull Bone
BL 25
BL 23 Cadaver
Qmarketinginsignia guidelines
LI 4 Cadaver
23052014
6
LR 3 Cadaver
Qmarketinginsignia guidelines
GB 30 Cadaver
Qmarketinginsignia guidelines
ST 36 Cadaver
Local ndash BL 20-35 BL 48-54 Ah Shi Extra points- HJJ Yao Yi Yuo Yan
Segmental- L5S1- GB 30 GB 31 GB 34 GB 41 GB 43 BL 60-67
Extra Segmental- KI channelSP channel LR channel AND all channels in arms head GV 20
Sympathetic- HT 7 PC 6 LU 9
LSP Points
Qmarketinginsignia guidelines
23052014
7
Acupuncture and the Emerging Evidence
base Contrived Controversy and
Rational Debate
3 areas of Research
1)Safety and the risk of serious adverse
events
2) Clinical Efficacy and Effectiveness
3)Physiologic Action
MacPherson Hammerschlag
(2012)
bull AACP website (must be on aacporguk)
bull (usernamepassword)
bull On-line databases
bull Access to AIM
bull Choose article-abstract- ldquofull textrdquo
bull Then look at references- it will denote
what is freeon Google scholar
References
Qmarketinginsignia guidelines wwwaacpukcom
Thank You for
listening
White A Cummings M and Filshie J (2008) An Introduction to Western Medical Acupuncture Philadelphia Churchill Livingstone Haker E Egekvist H and Bjerring P (2000) lsquoEffect of sensory stimulation (acupuncture) on sympathetic and parasympathetic activities in healthy subjectsrsquo Journal of the autonomic nervous system vol 79 no 1 February pp 52-59 Sandberg M Lundeberg T Lindberg LG and Gerdle B (2003) lsquoEffects of acupuncture on skin and muscle blood flow in healthy subjectsrsquo European Journal of Applied Physiology vol 90 no 1-2 September pp 114-9 Sandkuumlhler J Chen JG Cheng G and Randić M (1997) lsquoLow-frequency stimulation of afferent Adelta-fibers induces long-term depression at primary afferent synapses with substantia gelatinosa neurons in the ratrsquo Journal of neuroscience vol 17 no 16 August pp 6483-6491 Stein C Machelska H Binder W and Schaumlfer M (2001) lsquoPeripheral opioid analgesiarsquoCurrent Opinion in Pharmacology vol 1 no 1 February pp 62-65 Vas J and White A (2007) lsquoEvidence from RCTs on optimal acupuncture treatment for knee osteoarthritis--an exploratory reviewrsquo Acupuncture in medicine vol 25 no 1-2 June pp 29-35 White A Cummings M Barlas P Cardini F Filshie J Foster NE Lundeberg T Stener-Victorin E and Witt C (2008) lsquoDefining an adequate dose of acupuncture using a neurophysiological approach--a narrative review of the literaturersquo Acupuncture in Medicine vol 26 no 2 June pp 111-120 White A Foster NE Cummings M and Barlas P (2007) lsquoAcupuncture treatment for chronic knee pain a systematic reviewrsquo Rheumatology vol 46 no 3 March pp 384-390
23052014
1
Qmarketinginsignia guidelines
wwwaacpukcom
AACP
Conference 2014
Coventry
LBP- Practice makes perfect Lesley Pattenden MCSP lesleypattendenhotmailcom
Qmarketinginsignia guidelines
wwwaacpukcom
Lessons to be learned
What is ldquoAdvancedrdquo acupuncture after
Foundation Course completion
What do you want from your needle
Qmarketinginsignia guidelines
Aims of the session
1 Explore your current knowledge of acupuncture
and LBP
2 To examine the current evidence base and
review current guidelines concerning LBP
3 To review the clinical reasoning process and
relate it to LBP
4 To Review the various techniques associated
with acupuncture for LBP
How can you make your practice
more effective
UK population
- lifetime prevalence 70
- annual prevalence 40
Recurrences are common and prevalence of LBP has
not changed
90 of acute attacks that present for healthcare settle
sufficiently to prevent further intervention and return to
work within 6 weeks
7 of adults have persisting LBP which restricts
function
1 in 15 of the population will consult their GP for LBP
LBP accounts for between 25 and 45 of PT case
load
(NICE 2009 Yuan et al 2008 Kent and Keating 2005)
The scale of the problem
1 Consider offering a course of manual therapy including
spinal manipulation of up to 9 sessions over 12 weeks
2 Consider offering a course of Acupuncture up to
10 sessions over 12 weeks (pg 180)
3 Do not offer injections of therapeutic substances into
the back
4 Do not offer stand alone formal education programmes
5 Do not offer laserIFTherapeutic US or TENS
routinely
NICE (2009) Guidelines
Recommendations Research
Systematic Review
bull Furlan et al (2005) Acupuncture and Dry-Needling
for LBP Cochrane Database Syst Rev 2005 Jan 25(1)CD001351
RCTrsquos (4)
bull Brinkhaus et al (2006) Acupuncture in patients with
CLBP An RCT Arch Intern Med 2006 Feb 27166(4)450-7
bull Haake et al (2007) GERAC Trials for LBP Arch Intern Med
2007 Sep 24167(17)1892-8
bull Witt (2006) Pragmatic RCT for clinical and cost-
effectiveness for CLBP Am J Epidemiol 2006 Sep 1164(5)487-96
bull Thomas et al (2005) Longer term clinical and
economical benefits of AP and LBP Health Technol
Assess Aug9(32)iii-iv ix-x 1-109
23052014
2
NICE 2013 Review (Due 2016)
How may these affect us
Scope- what does this suggest
Low Back Pain and Sciatica Management
of non-specific LBP and Sciatica Pulse Article (2010) - non adherence to guideline
Of -127 PCTrsquos- frac12 provided funding and 15 offered AP in
GP practices
What Research is NICE likely to consider
Acupuncture Trialist Collaboration
Aim- To determine effect sizes of AP in 4 common
conditions with chronic pain states
Data- 29 trials data- 17922 patients
Outcome- Superior to sham and no control
ldquo reasonable referral option for effectrdquo
ldquostatistical significance between true AP and shamrdquo
ldquoindicate effect is more than placebo but other factors for effect are important contributorsrdquo
Vickers et al (2012)
STRICTA GUIDELINES Standards for reporting Interventions in
Clinical Trials of Acupuncture
2001 2002 revised 2010 H MacPherson D G Altman R Hammerschlag et al ldquoRevised standards for reporting interventions in clinical
trials of acupuncture (STRICTA) extending the consort statementrdquo Acupuncture in Medicine vol 28 no 2 pp 83ndash
93 2010
1 Acupuncture Rationale
2 Details of needling
I Number of needles
II Nameslocation
III Depth of insertion
IV Response sought
V Needle Stimulation
VI Time
VIINeedle diameterlengthtype
3 Treatment Regimen
4 Other components
5 Practitioner Background
6 Control
Session
Date
Points
Needle Size
(Angle)
De Qi
Further Stim
Treatment Duration
Adverse Effects
Outcome Measure
121013
Session1
BL252627 (bilaterally) BL54 BL57 GV43 GB30 GB31 ST36
40mm (perp)
40mm (perp) 40mm (perp) 25mm (perp) 70mm (obliq) 40mm (perp) 25mm (perp)
Achieved all
points except GB30
Further
stimulation all points x2
20 mins (all needles)
Slight anxiety with
first few needles ndash settled
VRS- 610
151013 Session 2
BL252627 (bilaterally) BL54 BL57 GV43 GB30 GB31 ST36
40mm (perp)
40mm (perp) 40mm (perp) 25mm (perp) 70mm (obliq) 40mm (perp) 25mm (perp)
De Qi on all points
Further stim X 2
20 mins (all needles)
None
VRS- 610
201013
Session 3
BL252627 (bilaterally) BL54 BL57 GV43 GB30 GB31 ST36
40mm (perp)
40mm (perp) 40mm (perp) 25mm (perp) 70mm (obliq) 40mm (perp) 25mm (perp)
De Qi on all points
Further stim
X 3
20 mins (all needles)
None
VRS- 410
Pt reports
less leg pain-more
into back
251013 Session 4
BL252627 (bilaterally) (HJJ pts adjacent to BL pts) LI4
40mm (perp)
25mm (obliq)
25mm (perp)
De Qi on all points
Further stim
X 3
25 mins (all needles)
Had to re position LI4 as it was too painful for
pt
VRS- 2-310
(Isolated to back
onlyoccasional buttock)
How do you choose your points
Recipesprotocols
Points you are familiar with
TCM associations
Western Scientific theory- and
what do we mean by this
Clinical Reasoning v Technical Operation
23052014
3
Questions to ask
yourself
What structures will the needle penetrate
What is the state of the tissues Do you want to needle
locally Or should you just use distal points
What stimulation are you wanting to perform
What indications does your patient give you regarding
needling
Why Why Why do we do anything
bull Peripheral effects
bull Segmentalspinal effects
bull Add a layer
bull Supraspinal effects
bull Sympathetic Outflow
bull Central Sympathetic effects
bull Immune effects
Bradnam (2007)
bull ldquomultisensory pain modulationrdquo
Campbell (2013)
Layering technique
Downs M Laporte C (2011) Conflicting Dermatome maps
Educational and Clinical Implications JOSPT Vol 41(6) 434
doi102519jospt20113506
)
Points (dermatomes myotomes sclerotomes)
Point Dermatom
e
Myotome Sclerotome Peripheral nerve
(motor)
ST 36 L45 L45 L45 Deep Peroneal
LR 3 L45 L5S1 or S2S3 L5S1 Medial Lateral
Plantar Nerve
GB 30 L2L3S2 L5S1S2 L4L5S1 Inferior Gluteal
NerveObturator
GB 39 L4L5S1 L4L5S1 L4L5S1 Superficial
Peroneal (PLPB)
Deep Peroneal
(PT)
BL 23 L2L3 L23 L23 Local Segmental
(dorsal rami)
BL 52 L23 L23 L23 Local Segmental
(dorsal rami)
Lumbar Spine Points- examples
Level Dermatome Myotome Sclerotome
L1 BL 2122 BL 2122
L2 BL 23 BL 25 GV 4 HJJ BL 23GV 4
L3 SP 9LR 3 SP 10 SP 9
L4 ST 36SP 6SP
9KI 3LR 3
BL 25ST 36 SP 10 GV 3 BL 25
L5 ST 36 LR 3 ST 36 BL 54 ST 36 LR 3
S1 SP 6BL 40 SP 6SP 9KI 3 LR 3
S2 SP 6 KI 3BL 40 SP 6SP 9KI 3 L 3 KI 3
Examples of Points related to spinal segments (White 2008)
Neural Anatomical Unit
Key issue Discussing the metaphysical
concepts of points and meridians in the
framework of modern scientific language
httpwwwhindawicomjournalsecam2012429412
NAU (Zhang 2012)
Classification Location
Muscle Spindle rich Around 60 of acupuncture
points are located in muscle
Cutaneous receptor rich Hands Face Feet (sensory
homonculus
Tendon Organ Rich Around joints
wristelbowknees
23052014
4
M receptors
Prostaglandins
Dynorphin
Allodynia
nociceptio
n
Spinoreticular
tract
Long Term
potentiation
serotonin
Inflammatory
mediators
PAIN PATHWAY
Peripheral Sensitisation
Inflammation
Interleukins
Tumor necrosis
factor
Serotonin (5-HT)
Hydrogen ions
High-threshold
nociception
Tissue damage Sympathetic Afferents
Low-threshold
nociception
Histamine
Potassium ions
Prostanoids
Purines
Norepinephine
Bradykinin
Neuropeptides
Leukotrienes
(Hudspith Munglani amp Siddall 2006) Kavoussi and Ross (2007) The neuroimmune basis of anti-inflammatory
acupuncture Integ Canc Therap 6251-257
CENTRAL SENSITISATION
bull Increased synaptic activity causing sub threshold
stimulus to produce response
bull Reflects functional states of circuits in the CNS
bull CNS distortamplify degree duration extent of
pain
bull Stimulus pain in segmentally related TPrsquos
(Woolf 2011)
ldquoOpening or Shutting the pharmaceutical box in the brainrdquo
bull Helen Langevin- connective tissue effects
bull Tom Myers- Anatomy Trains
bull Gil Hadley-Fuzz- ldquostrolling under the skinrdquo
bull MfTPrsquos
Structural
23052014
5
DEFINING DOSAGEDefining an adequate dose of
acupuncture using a neurophysiological approach--a
narrative review of the literature (2008) White A et al
Acupunct Med Jun26(2)111-20
Physical Procedure De QiTechnique
1+ needles Selection of Points
Consider patients perception
of pain
Sensory Affective
May be affected by the state
of the patient
Nervous immune-
suppressed etc
DIFFERENT CONDITIONS (in WM) MAY REQUIRE
DIFFERENT DOSES AS EFFECT MAY RELY ON
MANY MECHANISMS
(localsegmentalextrasegmentalcentralimmune
effects)
Think THRESHOLD v TOLERANCE
Evidence for 1 Number of needles- Ceccherelli et al (2010) ndash
Bradnam (200)- ldquoLayering theoryrdquo
2 Needle Retention time- Lewis and Abdi (2010) Yuan (2008)
3 Frequency of sessions- Sherman (2009)
4 Total number of sessions- Ezzo (2000) MacPherson (2004)
5 De Qi- Lundeberg et al (2012) White (2008)
6 LengthGauge of needles- Bradnam (2007) Zhang (2012)
7 Other Factors
Pariente et al (2005) + Wasan (2010) ndash Effect of expectation Witt (2011)- being female living in a multi person household
failure of other therapies before study former positive experience
Witt (2010) Therapeutic relationship (not training or length of qualification)
Harris (2009) Genetics ndasheffect of mu receptors and difference in opioid metabolism
Pearce (2006) Acupuncture time line model
Letrsquos review a pointBL 25
(40mm needle angled obliquely
towards spinous process)
bull Location 15 lateral to the lower border of L4
bull Skin
bull Thoracolumbar fascia
bull Muscles multifidus iliocostalis lumborum
bull longissimus thoracicis
bull fibresthoracolumbar fascia Lat Dorsi
bull Quadratus Lumborum
bull Bone
BL 25
BL 23 Cadaver
Qmarketinginsignia guidelines
LI 4 Cadaver
23052014
6
LR 3 Cadaver
Qmarketinginsignia guidelines
GB 30 Cadaver
Qmarketinginsignia guidelines
ST 36 Cadaver
Local ndash BL 20-35 BL 48-54 Ah Shi Extra points- HJJ Yao Yi Yuo Yan
Segmental- L5S1- GB 30 GB 31 GB 34 GB 41 GB 43 BL 60-67
Extra Segmental- KI channelSP channel LR channel AND all channels in arms head GV 20
Sympathetic- HT 7 PC 6 LU 9
LSP Points
Qmarketinginsignia guidelines
23052014
7
Acupuncture and the Emerging Evidence
base Contrived Controversy and
Rational Debate
3 areas of Research
1)Safety and the risk of serious adverse
events
2) Clinical Efficacy and Effectiveness
3)Physiologic Action
MacPherson Hammerschlag
(2012)
bull AACP website (must be on aacporguk)
bull (usernamepassword)
bull On-line databases
bull Access to AIM
bull Choose article-abstract- ldquofull textrdquo
bull Then look at references- it will denote
what is freeon Google scholar
References
Qmarketinginsignia guidelines wwwaacpukcom
Thank You for
listening
White A Cummings M and Filshie J (2008) An Introduction to Western Medical Acupuncture Philadelphia Churchill Livingstone Haker E Egekvist H and Bjerring P (2000) lsquoEffect of sensory stimulation (acupuncture) on sympathetic and parasympathetic activities in healthy subjectsrsquo Journal of the autonomic nervous system vol 79 no 1 February pp 52-59 Sandberg M Lundeberg T Lindberg LG and Gerdle B (2003) lsquoEffects of acupuncture on skin and muscle blood flow in healthy subjectsrsquo European Journal of Applied Physiology vol 90 no 1-2 September pp 114-9 Sandkuumlhler J Chen JG Cheng G and Randić M (1997) lsquoLow-frequency stimulation of afferent Adelta-fibers induces long-term depression at primary afferent synapses with substantia gelatinosa neurons in the ratrsquo Journal of neuroscience vol 17 no 16 August pp 6483-6491 Stein C Machelska H Binder W and Schaumlfer M (2001) lsquoPeripheral opioid analgesiarsquoCurrent Opinion in Pharmacology vol 1 no 1 February pp 62-65 Vas J and White A (2007) lsquoEvidence from RCTs on optimal acupuncture treatment for knee osteoarthritis--an exploratory reviewrsquo Acupuncture in medicine vol 25 no 1-2 June pp 29-35 White A Cummings M Barlas P Cardini F Filshie J Foster NE Lundeberg T Stener-Victorin E and Witt C (2008) lsquoDefining an adequate dose of acupuncture using a neurophysiological approach--a narrative review of the literaturersquo Acupuncture in Medicine vol 26 no 2 June pp 111-120 White A Foster NE Cummings M and Barlas P (2007) lsquoAcupuncture treatment for chronic knee pain a systematic reviewrsquo Rheumatology vol 46 no 3 March pp 384-390
23052014
2
NICE 2013 Review (Due 2016)
How may these affect us
Scope- what does this suggest
Low Back Pain and Sciatica Management
of non-specific LBP and Sciatica Pulse Article (2010) - non adherence to guideline
Of -127 PCTrsquos- frac12 provided funding and 15 offered AP in
GP practices
What Research is NICE likely to consider
Acupuncture Trialist Collaboration
Aim- To determine effect sizes of AP in 4 common
conditions with chronic pain states
Data- 29 trials data- 17922 patients
Outcome- Superior to sham and no control
ldquo reasonable referral option for effectrdquo
ldquostatistical significance between true AP and shamrdquo
ldquoindicate effect is more than placebo but other factors for effect are important contributorsrdquo
Vickers et al (2012)
STRICTA GUIDELINES Standards for reporting Interventions in
Clinical Trials of Acupuncture
2001 2002 revised 2010 H MacPherson D G Altman R Hammerschlag et al ldquoRevised standards for reporting interventions in clinical
trials of acupuncture (STRICTA) extending the consort statementrdquo Acupuncture in Medicine vol 28 no 2 pp 83ndash
93 2010
1 Acupuncture Rationale
2 Details of needling
I Number of needles
II Nameslocation
III Depth of insertion
IV Response sought
V Needle Stimulation
VI Time
VIINeedle diameterlengthtype
3 Treatment Regimen
4 Other components
5 Practitioner Background
6 Control
Session
Date
Points
Needle Size
(Angle)
De Qi
Further Stim
Treatment Duration
Adverse Effects
Outcome Measure
121013
Session1
BL252627 (bilaterally) BL54 BL57 GV43 GB30 GB31 ST36
40mm (perp)
40mm (perp) 40mm (perp) 25mm (perp) 70mm (obliq) 40mm (perp) 25mm (perp)
Achieved all
points except GB30
Further
stimulation all points x2
20 mins (all needles)
Slight anxiety with
first few needles ndash settled
VRS- 610
151013 Session 2
BL252627 (bilaterally) BL54 BL57 GV43 GB30 GB31 ST36
40mm (perp)
40mm (perp) 40mm (perp) 25mm (perp) 70mm (obliq) 40mm (perp) 25mm (perp)
De Qi on all points
Further stim X 2
20 mins (all needles)
None
VRS- 610
201013
Session 3
BL252627 (bilaterally) BL54 BL57 GV43 GB30 GB31 ST36
40mm (perp)
40mm (perp) 40mm (perp) 25mm (perp) 70mm (obliq) 40mm (perp) 25mm (perp)
De Qi on all points
Further stim
X 3
20 mins (all needles)
None
VRS- 410
Pt reports
less leg pain-more
into back
251013 Session 4
BL252627 (bilaterally) (HJJ pts adjacent to BL pts) LI4
40mm (perp)
25mm (obliq)
25mm (perp)
De Qi on all points
Further stim
X 3
25 mins (all needles)
Had to re position LI4 as it was too painful for
pt
VRS- 2-310
(Isolated to back
onlyoccasional buttock)
How do you choose your points
Recipesprotocols
Points you are familiar with
TCM associations
Western Scientific theory- and
what do we mean by this
Clinical Reasoning v Technical Operation
23052014
3
Questions to ask
yourself
What structures will the needle penetrate
What is the state of the tissues Do you want to needle
locally Or should you just use distal points
What stimulation are you wanting to perform
What indications does your patient give you regarding
needling
Why Why Why do we do anything
bull Peripheral effects
bull Segmentalspinal effects
bull Add a layer
bull Supraspinal effects
bull Sympathetic Outflow
bull Central Sympathetic effects
bull Immune effects
Bradnam (2007)
bull ldquomultisensory pain modulationrdquo
Campbell (2013)
Layering technique
Downs M Laporte C (2011) Conflicting Dermatome maps
Educational and Clinical Implications JOSPT Vol 41(6) 434
doi102519jospt20113506
)
Points (dermatomes myotomes sclerotomes)
Point Dermatom
e
Myotome Sclerotome Peripheral nerve
(motor)
ST 36 L45 L45 L45 Deep Peroneal
LR 3 L45 L5S1 or S2S3 L5S1 Medial Lateral
Plantar Nerve
GB 30 L2L3S2 L5S1S2 L4L5S1 Inferior Gluteal
NerveObturator
GB 39 L4L5S1 L4L5S1 L4L5S1 Superficial
Peroneal (PLPB)
Deep Peroneal
(PT)
BL 23 L2L3 L23 L23 Local Segmental
(dorsal rami)
BL 52 L23 L23 L23 Local Segmental
(dorsal rami)
Lumbar Spine Points- examples
Level Dermatome Myotome Sclerotome
L1 BL 2122 BL 2122
L2 BL 23 BL 25 GV 4 HJJ BL 23GV 4
L3 SP 9LR 3 SP 10 SP 9
L4 ST 36SP 6SP
9KI 3LR 3
BL 25ST 36 SP 10 GV 3 BL 25
L5 ST 36 LR 3 ST 36 BL 54 ST 36 LR 3
S1 SP 6BL 40 SP 6SP 9KI 3 LR 3
S2 SP 6 KI 3BL 40 SP 6SP 9KI 3 L 3 KI 3
Examples of Points related to spinal segments (White 2008)
Neural Anatomical Unit
Key issue Discussing the metaphysical
concepts of points and meridians in the
framework of modern scientific language
httpwwwhindawicomjournalsecam2012429412
NAU (Zhang 2012)
Classification Location
Muscle Spindle rich Around 60 of acupuncture
points are located in muscle
Cutaneous receptor rich Hands Face Feet (sensory
homonculus
Tendon Organ Rich Around joints
wristelbowknees
23052014
4
M receptors
Prostaglandins
Dynorphin
Allodynia
nociceptio
n
Spinoreticular
tract
Long Term
potentiation
serotonin
Inflammatory
mediators
PAIN PATHWAY
Peripheral Sensitisation
Inflammation
Interleukins
Tumor necrosis
factor
Serotonin (5-HT)
Hydrogen ions
High-threshold
nociception
Tissue damage Sympathetic Afferents
Low-threshold
nociception
Histamine
Potassium ions
Prostanoids
Purines
Norepinephine
Bradykinin
Neuropeptides
Leukotrienes
(Hudspith Munglani amp Siddall 2006) Kavoussi and Ross (2007) The neuroimmune basis of anti-inflammatory
acupuncture Integ Canc Therap 6251-257
CENTRAL SENSITISATION
bull Increased synaptic activity causing sub threshold
stimulus to produce response
bull Reflects functional states of circuits in the CNS
bull CNS distortamplify degree duration extent of
pain
bull Stimulus pain in segmentally related TPrsquos
(Woolf 2011)
ldquoOpening or Shutting the pharmaceutical box in the brainrdquo
bull Helen Langevin- connective tissue effects
bull Tom Myers- Anatomy Trains
bull Gil Hadley-Fuzz- ldquostrolling under the skinrdquo
bull MfTPrsquos
Structural
23052014
5
DEFINING DOSAGEDefining an adequate dose of
acupuncture using a neurophysiological approach--a
narrative review of the literature (2008) White A et al
Acupunct Med Jun26(2)111-20
Physical Procedure De QiTechnique
1+ needles Selection of Points
Consider patients perception
of pain
Sensory Affective
May be affected by the state
of the patient
Nervous immune-
suppressed etc
DIFFERENT CONDITIONS (in WM) MAY REQUIRE
DIFFERENT DOSES AS EFFECT MAY RELY ON
MANY MECHANISMS
(localsegmentalextrasegmentalcentralimmune
effects)
Think THRESHOLD v TOLERANCE
Evidence for 1 Number of needles- Ceccherelli et al (2010) ndash
Bradnam (200)- ldquoLayering theoryrdquo
2 Needle Retention time- Lewis and Abdi (2010) Yuan (2008)
3 Frequency of sessions- Sherman (2009)
4 Total number of sessions- Ezzo (2000) MacPherson (2004)
5 De Qi- Lundeberg et al (2012) White (2008)
6 LengthGauge of needles- Bradnam (2007) Zhang (2012)
7 Other Factors
Pariente et al (2005) + Wasan (2010) ndash Effect of expectation Witt (2011)- being female living in a multi person household
failure of other therapies before study former positive experience
Witt (2010) Therapeutic relationship (not training or length of qualification)
Harris (2009) Genetics ndasheffect of mu receptors and difference in opioid metabolism
Pearce (2006) Acupuncture time line model
Letrsquos review a pointBL 25
(40mm needle angled obliquely
towards spinous process)
bull Location 15 lateral to the lower border of L4
bull Skin
bull Thoracolumbar fascia
bull Muscles multifidus iliocostalis lumborum
bull longissimus thoracicis
bull fibresthoracolumbar fascia Lat Dorsi
bull Quadratus Lumborum
bull Bone
BL 25
BL 23 Cadaver
Qmarketinginsignia guidelines
LI 4 Cadaver
23052014
6
LR 3 Cadaver
Qmarketinginsignia guidelines
GB 30 Cadaver
Qmarketinginsignia guidelines
ST 36 Cadaver
Local ndash BL 20-35 BL 48-54 Ah Shi Extra points- HJJ Yao Yi Yuo Yan
Segmental- L5S1- GB 30 GB 31 GB 34 GB 41 GB 43 BL 60-67
Extra Segmental- KI channelSP channel LR channel AND all channels in arms head GV 20
Sympathetic- HT 7 PC 6 LU 9
LSP Points
Qmarketinginsignia guidelines
23052014
7
Acupuncture and the Emerging Evidence
base Contrived Controversy and
Rational Debate
3 areas of Research
1)Safety and the risk of serious adverse
events
2) Clinical Efficacy and Effectiveness
3)Physiologic Action
MacPherson Hammerschlag
(2012)
bull AACP website (must be on aacporguk)
bull (usernamepassword)
bull On-line databases
bull Access to AIM
bull Choose article-abstract- ldquofull textrdquo
bull Then look at references- it will denote
what is freeon Google scholar
References
Qmarketinginsignia guidelines wwwaacpukcom
Thank You for
listening
White A Cummings M and Filshie J (2008) An Introduction to Western Medical Acupuncture Philadelphia Churchill Livingstone Haker E Egekvist H and Bjerring P (2000) lsquoEffect of sensory stimulation (acupuncture) on sympathetic and parasympathetic activities in healthy subjectsrsquo Journal of the autonomic nervous system vol 79 no 1 February pp 52-59 Sandberg M Lundeberg T Lindberg LG and Gerdle B (2003) lsquoEffects of acupuncture on skin and muscle blood flow in healthy subjectsrsquo European Journal of Applied Physiology vol 90 no 1-2 September pp 114-9 Sandkuumlhler J Chen JG Cheng G and Randić M (1997) lsquoLow-frequency stimulation of afferent Adelta-fibers induces long-term depression at primary afferent synapses with substantia gelatinosa neurons in the ratrsquo Journal of neuroscience vol 17 no 16 August pp 6483-6491 Stein C Machelska H Binder W and Schaumlfer M (2001) lsquoPeripheral opioid analgesiarsquoCurrent Opinion in Pharmacology vol 1 no 1 February pp 62-65 Vas J and White A (2007) lsquoEvidence from RCTs on optimal acupuncture treatment for knee osteoarthritis--an exploratory reviewrsquo Acupuncture in medicine vol 25 no 1-2 June pp 29-35 White A Cummings M Barlas P Cardini F Filshie J Foster NE Lundeberg T Stener-Victorin E and Witt C (2008) lsquoDefining an adequate dose of acupuncture using a neurophysiological approach--a narrative review of the literaturersquo Acupuncture in Medicine vol 26 no 2 June pp 111-120 White A Foster NE Cummings M and Barlas P (2007) lsquoAcupuncture treatment for chronic knee pain a systematic reviewrsquo Rheumatology vol 46 no 3 March pp 384-390
23052014
3
Questions to ask
yourself
What structures will the needle penetrate
What is the state of the tissues Do you want to needle
locally Or should you just use distal points
What stimulation are you wanting to perform
What indications does your patient give you regarding
needling
Why Why Why do we do anything
bull Peripheral effects
bull Segmentalspinal effects
bull Add a layer
bull Supraspinal effects
bull Sympathetic Outflow
bull Central Sympathetic effects
bull Immune effects
Bradnam (2007)
bull ldquomultisensory pain modulationrdquo
Campbell (2013)
Layering technique
Downs M Laporte C (2011) Conflicting Dermatome maps
Educational and Clinical Implications JOSPT Vol 41(6) 434
doi102519jospt20113506
)
Points (dermatomes myotomes sclerotomes)
Point Dermatom
e
Myotome Sclerotome Peripheral nerve
(motor)
ST 36 L45 L45 L45 Deep Peroneal
LR 3 L45 L5S1 or S2S3 L5S1 Medial Lateral
Plantar Nerve
GB 30 L2L3S2 L5S1S2 L4L5S1 Inferior Gluteal
NerveObturator
GB 39 L4L5S1 L4L5S1 L4L5S1 Superficial
Peroneal (PLPB)
Deep Peroneal
(PT)
BL 23 L2L3 L23 L23 Local Segmental
(dorsal rami)
BL 52 L23 L23 L23 Local Segmental
(dorsal rami)
Lumbar Spine Points- examples
Level Dermatome Myotome Sclerotome
L1 BL 2122 BL 2122
L2 BL 23 BL 25 GV 4 HJJ BL 23GV 4
L3 SP 9LR 3 SP 10 SP 9
L4 ST 36SP 6SP
9KI 3LR 3
BL 25ST 36 SP 10 GV 3 BL 25
L5 ST 36 LR 3 ST 36 BL 54 ST 36 LR 3
S1 SP 6BL 40 SP 6SP 9KI 3 LR 3
S2 SP 6 KI 3BL 40 SP 6SP 9KI 3 L 3 KI 3
Examples of Points related to spinal segments (White 2008)
Neural Anatomical Unit
Key issue Discussing the metaphysical
concepts of points and meridians in the
framework of modern scientific language
httpwwwhindawicomjournalsecam2012429412
NAU (Zhang 2012)
Classification Location
Muscle Spindle rich Around 60 of acupuncture
points are located in muscle
Cutaneous receptor rich Hands Face Feet (sensory
homonculus
Tendon Organ Rich Around joints
wristelbowknees
23052014
4
M receptors
Prostaglandins
Dynorphin
Allodynia
nociceptio
n
Spinoreticular
tract
Long Term
potentiation
serotonin
Inflammatory
mediators
PAIN PATHWAY
Peripheral Sensitisation
Inflammation
Interleukins
Tumor necrosis
factor
Serotonin (5-HT)
Hydrogen ions
High-threshold
nociception
Tissue damage Sympathetic Afferents
Low-threshold
nociception
Histamine
Potassium ions
Prostanoids
Purines
Norepinephine
Bradykinin
Neuropeptides
Leukotrienes
(Hudspith Munglani amp Siddall 2006) Kavoussi and Ross (2007) The neuroimmune basis of anti-inflammatory
acupuncture Integ Canc Therap 6251-257
CENTRAL SENSITISATION
bull Increased synaptic activity causing sub threshold
stimulus to produce response
bull Reflects functional states of circuits in the CNS
bull CNS distortamplify degree duration extent of
pain
bull Stimulus pain in segmentally related TPrsquos
(Woolf 2011)
ldquoOpening or Shutting the pharmaceutical box in the brainrdquo
bull Helen Langevin- connective tissue effects
bull Tom Myers- Anatomy Trains
bull Gil Hadley-Fuzz- ldquostrolling under the skinrdquo
bull MfTPrsquos
Structural
23052014
5
DEFINING DOSAGEDefining an adequate dose of
acupuncture using a neurophysiological approach--a
narrative review of the literature (2008) White A et al
Acupunct Med Jun26(2)111-20
Physical Procedure De QiTechnique
1+ needles Selection of Points
Consider patients perception
of pain
Sensory Affective
May be affected by the state
of the patient
Nervous immune-
suppressed etc
DIFFERENT CONDITIONS (in WM) MAY REQUIRE
DIFFERENT DOSES AS EFFECT MAY RELY ON
MANY MECHANISMS
(localsegmentalextrasegmentalcentralimmune
effects)
Think THRESHOLD v TOLERANCE
Evidence for 1 Number of needles- Ceccherelli et al (2010) ndash
Bradnam (200)- ldquoLayering theoryrdquo
2 Needle Retention time- Lewis and Abdi (2010) Yuan (2008)
3 Frequency of sessions- Sherman (2009)
4 Total number of sessions- Ezzo (2000) MacPherson (2004)
5 De Qi- Lundeberg et al (2012) White (2008)
6 LengthGauge of needles- Bradnam (2007) Zhang (2012)
7 Other Factors
Pariente et al (2005) + Wasan (2010) ndash Effect of expectation Witt (2011)- being female living in a multi person household
failure of other therapies before study former positive experience
Witt (2010) Therapeutic relationship (not training or length of qualification)
Harris (2009) Genetics ndasheffect of mu receptors and difference in opioid metabolism
Pearce (2006) Acupuncture time line model
Letrsquos review a pointBL 25
(40mm needle angled obliquely
towards spinous process)
bull Location 15 lateral to the lower border of L4
bull Skin
bull Thoracolumbar fascia
bull Muscles multifidus iliocostalis lumborum
bull longissimus thoracicis
bull fibresthoracolumbar fascia Lat Dorsi
bull Quadratus Lumborum
bull Bone
BL 25
BL 23 Cadaver
Qmarketinginsignia guidelines
LI 4 Cadaver
23052014
6
LR 3 Cadaver
Qmarketinginsignia guidelines
GB 30 Cadaver
Qmarketinginsignia guidelines
ST 36 Cadaver
Local ndash BL 20-35 BL 48-54 Ah Shi Extra points- HJJ Yao Yi Yuo Yan
Segmental- L5S1- GB 30 GB 31 GB 34 GB 41 GB 43 BL 60-67
Extra Segmental- KI channelSP channel LR channel AND all channels in arms head GV 20
Sympathetic- HT 7 PC 6 LU 9
LSP Points
Qmarketinginsignia guidelines
23052014
7
Acupuncture and the Emerging Evidence
base Contrived Controversy and
Rational Debate
3 areas of Research
1)Safety and the risk of serious adverse
events
2) Clinical Efficacy and Effectiveness
3)Physiologic Action
MacPherson Hammerschlag
(2012)
bull AACP website (must be on aacporguk)
bull (usernamepassword)
bull On-line databases
bull Access to AIM
bull Choose article-abstract- ldquofull textrdquo
bull Then look at references- it will denote
what is freeon Google scholar
References
Qmarketinginsignia guidelines wwwaacpukcom
Thank You for
listening
White A Cummings M and Filshie J (2008) An Introduction to Western Medical Acupuncture Philadelphia Churchill Livingstone Haker E Egekvist H and Bjerring P (2000) lsquoEffect of sensory stimulation (acupuncture) on sympathetic and parasympathetic activities in healthy subjectsrsquo Journal of the autonomic nervous system vol 79 no 1 February pp 52-59 Sandberg M Lundeberg T Lindberg LG and Gerdle B (2003) lsquoEffects of acupuncture on skin and muscle blood flow in healthy subjectsrsquo European Journal of Applied Physiology vol 90 no 1-2 September pp 114-9 Sandkuumlhler J Chen JG Cheng G and Randić M (1997) lsquoLow-frequency stimulation of afferent Adelta-fibers induces long-term depression at primary afferent synapses with substantia gelatinosa neurons in the ratrsquo Journal of neuroscience vol 17 no 16 August pp 6483-6491 Stein C Machelska H Binder W and Schaumlfer M (2001) lsquoPeripheral opioid analgesiarsquoCurrent Opinion in Pharmacology vol 1 no 1 February pp 62-65 Vas J and White A (2007) lsquoEvidence from RCTs on optimal acupuncture treatment for knee osteoarthritis--an exploratory reviewrsquo Acupuncture in medicine vol 25 no 1-2 June pp 29-35 White A Cummings M Barlas P Cardini F Filshie J Foster NE Lundeberg T Stener-Victorin E and Witt C (2008) lsquoDefining an adequate dose of acupuncture using a neurophysiological approach--a narrative review of the literaturersquo Acupuncture in Medicine vol 26 no 2 June pp 111-120 White A Foster NE Cummings M and Barlas P (2007) lsquoAcupuncture treatment for chronic knee pain a systematic reviewrsquo Rheumatology vol 46 no 3 March pp 384-390
23052014
4
M receptors
Prostaglandins
Dynorphin
Allodynia
nociceptio
n
Spinoreticular
tract
Long Term
potentiation
serotonin
Inflammatory
mediators
PAIN PATHWAY
Peripheral Sensitisation
Inflammation
Interleukins
Tumor necrosis
factor
Serotonin (5-HT)
Hydrogen ions
High-threshold
nociception
Tissue damage Sympathetic Afferents
Low-threshold
nociception
Histamine
Potassium ions
Prostanoids
Purines
Norepinephine
Bradykinin
Neuropeptides
Leukotrienes
(Hudspith Munglani amp Siddall 2006) Kavoussi and Ross (2007) The neuroimmune basis of anti-inflammatory
acupuncture Integ Canc Therap 6251-257
CENTRAL SENSITISATION
bull Increased synaptic activity causing sub threshold
stimulus to produce response
bull Reflects functional states of circuits in the CNS
bull CNS distortamplify degree duration extent of
pain
bull Stimulus pain in segmentally related TPrsquos
(Woolf 2011)
ldquoOpening or Shutting the pharmaceutical box in the brainrdquo
bull Helen Langevin- connective tissue effects
bull Tom Myers- Anatomy Trains
bull Gil Hadley-Fuzz- ldquostrolling under the skinrdquo
bull MfTPrsquos
Structural
23052014
5
DEFINING DOSAGEDefining an adequate dose of
acupuncture using a neurophysiological approach--a
narrative review of the literature (2008) White A et al
Acupunct Med Jun26(2)111-20
Physical Procedure De QiTechnique
1+ needles Selection of Points
Consider patients perception
of pain
Sensory Affective
May be affected by the state
of the patient
Nervous immune-
suppressed etc
DIFFERENT CONDITIONS (in WM) MAY REQUIRE
DIFFERENT DOSES AS EFFECT MAY RELY ON
MANY MECHANISMS
(localsegmentalextrasegmentalcentralimmune
effects)
Think THRESHOLD v TOLERANCE
Evidence for 1 Number of needles- Ceccherelli et al (2010) ndash
Bradnam (200)- ldquoLayering theoryrdquo
2 Needle Retention time- Lewis and Abdi (2010) Yuan (2008)
3 Frequency of sessions- Sherman (2009)
4 Total number of sessions- Ezzo (2000) MacPherson (2004)
5 De Qi- Lundeberg et al (2012) White (2008)
6 LengthGauge of needles- Bradnam (2007) Zhang (2012)
7 Other Factors
Pariente et al (2005) + Wasan (2010) ndash Effect of expectation Witt (2011)- being female living in a multi person household
failure of other therapies before study former positive experience
Witt (2010) Therapeutic relationship (not training or length of qualification)
Harris (2009) Genetics ndasheffect of mu receptors and difference in opioid metabolism
Pearce (2006) Acupuncture time line model
Letrsquos review a pointBL 25
(40mm needle angled obliquely
towards spinous process)
bull Location 15 lateral to the lower border of L4
bull Skin
bull Thoracolumbar fascia
bull Muscles multifidus iliocostalis lumborum
bull longissimus thoracicis
bull fibresthoracolumbar fascia Lat Dorsi
bull Quadratus Lumborum
bull Bone
BL 25
BL 23 Cadaver
Qmarketinginsignia guidelines
LI 4 Cadaver
23052014
6
LR 3 Cadaver
Qmarketinginsignia guidelines
GB 30 Cadaver
Qmarketinginsignia guidelines
ST 36 Cadaver
Local ndash BL 20-35 BL 48-54 Ah Shi Extra points- HJJ Yao Yi Yuo Yan
Segmental- L5S1- GB 30 GB 31 GB 34 GB 41 GB 43 BL 60-67
Extra Segmental- KI channelSP channel LR channel AND all channels in arms head GV 20
Sympathetic- HT 7 PC 6 LU 9
LSP Points
Qmarketinginsignia guidelines
23052014
7
Acupuncture and the Emerging Evidence
base Contrived Controversy and
Rational Debate
3 areas of Research
1)Safety and the risk of serious adverse
events
2) Clinical Efficacy and Effectiveness
3)Physiologic Action
MacPherson Hammerschlag
(2012)
bull AACP website (must be on aacporguk)
bull (usernamepassword)
bull On-line databases
bull Access to AIM
bull Choose article-abstract- ldquofull textrdquo
bull Then look at references- it will denote
what is freeon Google scholar
References
Qmarketinginsignia guidelines wwwaacpukcom
Thank You for
listening
White A Cummings M and Filshie J (2008) An Introduction to Western Medical Acupuncture Philadelphia Churchill Livingstone Haker E Egekvist H and Bjerring P (2000) lsquoEffect of sensory stimulation (acupuncture) on sympathetic and parasympathetic activities in healthy subjectsrsquo Journal of the autonomic nervous system vol 79 no 1 February pp 52-59 Sandberg M Lundeberg T Lindberg LG and Gerdle B (2003) lsquoEffects of acupuncture on skin and muscle blood flow in healthy subjectsrsquo European Journal of Applied Physiology vol 90 no 1-2 September pp 114-9 Sandkuumlhler J Chen JG Cheng G and Randić M (1997) lsquoLow-frequency stimulation of afferent Adelta-fibers induces long-term depression at primary afferent synapses with substantia gelatinosa neurons in the ratrsquo Journal of neuroscience vol 17 no 16 August pp 6483-6491 Stein C Machelska H Binder W and Schaumlfer M (2001) lsquoPeripheral opioid analgesiarsquoCurrent Opinion in Pharmacology vol 1 no 1 February pp 62-65 Vas J and White A (2007) lsquoEvidence from RCTs on optimal acupuncture treatment for knee osteoarthritis--an exploratory reviewrsquo Acupuncture in medicine vol 25 no 1-2 June pp 29-35 White A Cummings M Barlas P Cardini F Filshie J Foster NE Lundeberg T Stener-Victorin E and Witt C (2008) lsquoDefining an adequate dose of acupuncture using a neurophysiological approach--a narrative review of the literaturersquo Acupuncture in Medicine vol 26 no 2 June pp 111-120 White A Foster NE Cummings M and Barlas P (2007) lsquoAcupuncture treatment for chronic knee pain a systematic reviewrsquo Rheumatology vol 46 no 3 March pp 384-390
23052014
5
DEFINING DOSAGEDefining an adequate dose of
acupuncture using a neurophysiological approach--a
narrative review of the literature (2008) White A et al
Acupunct Med Jun26(2)111-20
Physical Procedure De QiTechnique
1+ needles Selection of Points
Consider patients perception
of pain
Sensory Affective
May be affected by the state
of the patient
Nervous immune-
suppressed etc
DIFFERENT CONDITIONS (in WM) MAY REQUIRE
DIFFERENT DOSES AS EFFECT MAY RELY ON
MANY MECHANISMS
(localsegmentalextrasegmentalcentralimmune
effects)
Think THRESHOLD v TOLERANCE
Evidence for 1 Number of needles- Ceccherelli et al (2010) ndash
Bradnam (200)- ldquoLayering theoryrdquo
2 Needle Retention time- Lewis and Abdi (2010) Yuan (2008)
3 Frequency of sessions- Sherman (2009)
4 Total number of sessions- Ezzo (2000) MacPherson (2004)
5 De Qi- Lundeberg et al (2012) White (2008)
6 LengthGauge of needles- Bradnam (2007) Zhang (2012)
7 Other Factors
Pariente et al (2005) + Wasan (2010) ndash Effect of expectation Witt (2011)- being female living in a multi person household
failure of other therapies before study former positive experience
Witt (2010) Therapeutic relationship (not training or length of qualification)
Harris (2009) Genetics ndasheffect of mu receptors and difference in opioid metabolism
Pearce (2006) Acupuncture time line model
Letrsquos review a pointBL 25
(40mm needle angled obliquely
towards spinous process)
bull Location 15 lateral to the lower border of L4
bull Skin
bull Thoracolumbar fascia
bull Muscles multifidus iliocostalis lumborum
bull longissimus thoracicis
bull fibresthoracolumbar fascia Lat Dorsi
bull Quadratus Lumborum
bull Bone
BL 25
BL 23 Cadaver
Qmarketinginsignia guidelines
LI 4 Cadaver
23052014
6
LR 3 Cadaver
Qmarketinginsignia guidelines
GB 30 Cadaver
Qmarketinginsignia guidelines
ST 36 Cadaver
Local ndash BL 20-35 BL 48-54 Ah Shi Extra points- HJJ Yao Yi Yuo Yan
Segmental- L5S1- GB 30 GB 31 GB 34 GB 41 GB 43 BL 60-67
Extra Segmental- KI channelSP channel LR channel AND all channels in arms head GV 20
Sympathetic- HT 7 PC 6 LU 9
LSP Points
Qmarketinginsignia guidelines
23052014
7
Acupuncture and the Emerging Evidence
base Contrived Controversy and
Rational Debate
3 areas of Research
1)Safety and the risk of serious adverse
events
2) Clinical Efficacy and Effectiveness
3)Physiologic Action
MacPherson Hammerschlag
(2012)
bull AACP website (must be on aacporguk)
bull (usernamepassword)
bull On-line databases
bull Access to AIM
bull Choose article-abstract- ldquofull textrdquo
bull Then look at references- it will denote
what is freeon Google scholar
References
Qmarketinginsignia guidelines wwwaacpukcom
Thank You for
listening
White A Cummings M and Filshie J (2008) An Introduction to Western Medical Acupuncture Philadelphia Churchill Livingstone Haker E Egekvist H and Bjerring P (2000) lsquoEffect of sensory stimulation (acupuncture) on sympathetic and parasympathetic activities in healthy subjectsrsquo Journal of the autonomic nervous system vol 79 no 1 February pp 52-59 Sandberg M Lundeberg T Lindberg LG and Gerdle B (2003) lsquoEffects of acupuncture on skin and muscle blood flow in healthy subjectsrsquo European Journal of Applied Physiology vol 90 no 1-2 September pp 114-9 Sandkuumlhler J Chen JG Cheng G and Randić M (1997) lsquoLow-frequency stimulation of afferent Adelta-fibers induces long-term depression at primary afferent synapses with substantia gelatinosa neurons in the ratrsquo Journal of neuroscience vol 17 no 16 August pp 6483-6491 Stein C Machelska H Binder W and Schaumlfer M (2001) lsquoPeripheral opioid analgesiarsquoCurrent Opinion in Pharmacology vol 1 no 1 February pp 62-65 Vas J and White A (2007) lsquoEvidence from RCTs on optimal acupuncture treatment for knee osteoarthritis--an exploratory reviewrsquo Acupuncture in medicine vol 25 no 1-2 June pp 29-35 White A Cummings M Barlas P Cardini F Filshie J Foster NE Lundeberg T Stener-Victorin E and Witt C (2008) lsquoDefining an adequate dose of acupuncture using a neurophysiological approach--a narrative review of the literaturersquo Acupuncture in Medicine vol 26 no 2 June pp 111-120 White A Foster NE Cummings M and Barlas P (2007) lsquoAcupuncture treatment for chronic knee pain a systematic reviewrsquo Rheumatology vol 46 no 3 March pp 384-390
23052014
6
LR 3 Cadaver
Qmarketinginsignia guidelines
GB 30 Cadaver
Qmarketinginsignia guidelines
ST 36 Cadaver
Local ndash BL 20-35 BL 48-54 Ah Shi Extra points- HJJ Yao Yi Yuo Yan
Segmental- L5S1- GB 30 GB 31 GB 34 GB 41 GB 43 BL 60-67
Extra Segmental- KI channelSP channel LR channel AND all channels in arms head GV 20
Sympathetic- HT 7 PC 6 LU 9
LSP Points
Qmarketinginsignia guidelines
23052014
7
Acupuncture and the Emerging Evidence
base Contrived Controversy and
Rational Debate
3 areas of Research
1)Safety and the risk of serious adverse
events
2) Clinical Efficacy and Effectiveness
3)Physiologic Action
MacPherson Hammerschlag
(2012)
bull AACP website (must be on aacporguk)
bull (usernamepassword)
bull On-line databases
bull Access to AIM
bull Choose article-abstract- ldquofull textrdquo
bull Then look at references- it will denote
what is freeon Google scholar
References
Qmarketinginsignia guidelines wwwaacpukcom
Thank You for
listening
White A Cummings M and Filshie J (2008) An Introduction to Western Medical Acupuncture Philadelphia Churchill Livingstone Haker E Egekvist H and Bjerring P (2000) lsquoEffect of sensory stimulation (acupuncture) on sympathetic and parasympathetic activities in healthy subjectsrsquo Journal of the autonomic nervous system vol 79 no 1 February pp 52-59 Sandberg M Lundeberg T Lindberg LG and Gerdle B (2003) lsquoEffects of acupuncture on skin and muscle blood flow in healthy subjectsrsquo European Journal of Applied Physiology vol 90 no 1-2 September pp 114-9 Sandkuumlhler J Chen JG Cheng G and Randić M (1997) lsquoLow-frequency stimulation of afferent Adelta-fibers induces long-term depression at primary afferent synapses with substantia gelatinosa neurons in the ratrsquo Journal of neuroscience vol 17 no 16 August pp 6483-6491 Stein C Machelska H Binder W and Schaumlfer M (2001) lsquoPeripheral opioid analgesiarsquoCurrent Opinion in Pharmacology vol 1 no 1 February pp 62-65 Vas J and White A (2007) lsquoEvidence from RCTs on optimal acupuncture treatment for knee osteoarthritis--an exploratory reviewrsquo Acupuncture in medicine vol 25 no 1-2 June pp 29-35 White A Cummings M Barlas P Cardini F Filshie J Foster NE Lundeberg T Stener-Victorin E and Witt C (2008) lsquoDefining an adequate dose of acupuncture using a neurophysiological approach--a narrative review of the literaturersquo Acupuncture in Medicine vol 26 no 2 June pp 111-120 White A Foster NE Cummings M and Barlas P (2007) lsquoAcupuncture treatment for chronic knee pain a systematic reviewrsquo Rheumatology vol 46 no 3 March pp 384-390
23052014
7
Acupuncture and the Emerging Evidence
base Contrived Controversy and
Rational Debate
3 areas of Research
1)Safety and the risk of serious adverse
events
2) Clinical Efficacy and Effectiveness
3)Physiologic Action
MacPherson Hammerschlag
(2012)
bull AACP website (must be on aacporguk)
bull (usernamepassword)
bull On-line databases
bull Access to AIM
bull Choose article-abstract- ldquofull textrdquo
bull Then look at references- it will denote
what is freeon Google scholar
References
Qmarketinginsignia guidelines wwwaacpukcom
Thank You for
listening
White A Cummings M and Filshie J (2008) An Introduction to Western Medical Acupuncture Philadelphia Churchill Livingstone Haker E Egekvist H and Bjerring P (2000) lsquoEffect of sensory stimulation (acupuncture) on sympathetic and parasympathetic activities in healthy subjectsrsquo Journal of the autonomic nervous system vol 79 no 1 February pp 52-59 Sandberg M Lundeberg T Lindberg LG and Gerdle B (2003) lsquoEffects of acupuncture on skin and muscle blood flow in healthy subjectsrsquo European Journal of Applied Physiology vol 90 no 1-2 September pp 114-9 Sandkuumlhler J Chen JG Cheng G and Randić M (1997) lsquoLow-frequency stimulation of afferent Adelta-fibers induces long-term depression at primary afferent synapses with substantia gelatinosa neurons in the ratrsquo Journal of neuroscience vol 17 no 16 August pp 6483-6491 Stein C Machelska H Binder W and Schaumlfer M (2001) lsquoPeripheral opioid analgesiarsquoCurrent Opinion in Pharmacology vol 1 no 1 February pp 62-65 Vas J and White A (2007) lsquoEvidence from RCTs on optimal acupuncture treatment for knee osteoarthritis--an exploratory reviewrsquo Acupuncture in medicine vol 25 no 1-2 June pp 29-35 White A Cummings M Barlas P Cardini F Filshie J Foster NE Lundeberg T Stener-Victorin E and Witt C (2008) lsquoDefining an adequate dose of acupuncture using a neurophysiological approach--a narrative review of the literaturersquo Acupuncture in Medicine vol 26 no 2 June pp 111-120 White A Foster NE Cummings M and Barlas P (2007) lsquoAcupuncture treatment for chronic knee pain a systematic reviewrsquo Rheumatology vol 46 no 3 March pp 384-390