+ All Categories
Home > Documents > Lesley Pattenden - AACP Back Pain... · Lesley Pattenden Biography Lesley qualified as a...

Lesley Pattenden - AACP Back Pain... · Lesley Pattenden Biography Lesley qualified as a...

Date post: 25-May-2020
Category:
Upload: others
View: 8 times
Download: 0 times
Share this document with a friend
12
Lesley Pattenden Biography Lesley qualified as a physiotherapist from Bristol School of Physiotherapy in the early 1980’s. 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.
Transcript
Page 1: Lesley Pattenden - AACP Back Pain... · Lesley Pattenden Biography Lesley qualified as a physiotherapist from Bristol School of Physiotherapy in the early 1980’s. Since then she

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

  • Biography
  • Title page
  • Abstract
  • Learning Outcomes
  • AACP CPD Record Form
  • NOTES
  • NOTES
Page 2: Lesley Pattenden - AACP Back Pain... · Lesley Pattenden Biography Lesley qualified as a physiotherapist from Bristol School of Physiotherapy in the early 1980’s. Since then she

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

  • Biography
  • Title page
  • Abstract
  • Learning Outcomes
  • AACP CPD Record Form
  • NOTES
  • NOTES
Page 3: Lesley Pattenden - AACP Back Pain... · Lesley Pattenden Biography Lesley qualified as a physiotherapist from Bristol School of Physiotherapy in the early 1980’s. Since then she

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

  • Biography
  • Title page
  • Abstract
  • Learning Outcomes
  • AACP CPD Record Form
  • NOTES
  • NOTES
Page 4: Lesley Pattenden - AACP Back Pain... · Lesley Pattenden Biography Lesley qualified as a physiotherapist from Bristol School of Physiotherapy in the early 1980’s. Since then she

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

  • Biography
  • Title page
  • Abstract
  • Learning Outcomes
  • AACP CPD Record Form
  • NOTES
  • NOTES
Page 5: Lesley Pattenden - AACP Back Pain... · Lesley Pattenden Biography Lesley qualified as a physiotherapist from Bristol School of Physiotherapy in the early 1980’s. Since then she

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

  • Biography
  • Title page
  • Abstract
  • Learning Outcomes
  • AACP CPD Record Form
  • NOTES
  • NOTES
Page 6: Lesley Pattenden - AACP Back Pain... · Lesley Pattenden Biography Lesley qualified as a physiotherapist from Bristol School of Physiotherapy in the early 1980’s. Since then she

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

  • Biography
  • Title page
  • Abstract
  • Learning Outcomes
  • AACP CPD Record Form
  • NOTES
  • NOTES
Page 7: Lesley Pattenden - AACP Back Pain... · Lesley Pattenden Biography Lesley qualified as a physiotherapist from Bristol School of Physiotherapy in the early 1980’s. Since then she

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

  • Biography
  • Title page
  • Abstract
  • Learning Outcomes
  • AACP CPD Record Form
  • NOTES
  • NOTES
Page 8: Lesley Pattenden - AACP Back Pain... · Lesley Pattenden Biography Lesley qualified as a physiotherapist from Bristol School of Physiotherapy in the early 1980’s. Since then she

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

  • Biography
  • Title page
  • Abstract
  • Learning Outcomes
  • AACP CPD Record Form
  • NOTES
  • NOTES
Page 9: Lesley Pattenden - AACP Back Pain... · Lesley Pattenden Biography Lesley qualified as a physiotherapist from Bristol School of Physiotherapy in the early 1980’s. Since then she

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

  • Biography
  • Title page
  • Abstract
  • Learning Outcomes
  • AACP CPD Record Form
  • NOTES
  • NOTES
Page 10: Lesley Pattenden - AACP Back Pain... · Lesley Pattenden Biography Lesley qualified as a physiotherapist from Bristol School of Physiotherapy in the early 1980’s. Since then she

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

  • Biography
  • Title page
  • Abstract
  • Learning Outcomes
  • AACP CPD Record Form
  • NOTES
  • NOTES
Page 11: Lesley Pattenden - AACP Back Pain... · Lesley Pattenden Biography Lesley qualified as a physiotherapist from Bristol School of Physiotherapy in the early 1980’s. Since then she

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

  • Biography
  • Title page
  • Abstract
  • Learning Outcomes
  • AACP CPD Record Form
  • NOTES
  • NOTES
Page 12: Lesley Pattenden - AACP Back Pain... · Lesley Pattenden Biography Lesley qualified as a physiotherapist from Bristol School of Physiotherapy in the early 1980’s. Since then she

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

  • Biography
  • Title page
  • Abstract
  • Learning Outcomes
  • AACP CPD Record Form
  • NOTES
  • NOTES

Recommended