Medical Acupuncture Review Course
Review Course Faculty
Bradley T. Lawrence, MD, FAAMA
Phoenix, AZ
Mitchell Elkiss, DO, FAAMA
Farmington Hills, MI
Tate Kauffman, MD
Newville, PA
Joseph Walker III, MD, DABMA
Farmington, CT
American Academy of Medical Acupuncture
Financial Disclosure
In order to comply with the ACCME’s Updated Standards for Commercial Support, The American
Academy of Medical Acupuncture has implemented a disclosure process to ensure that anyone in a
position to control the content of an educational activity has disclosed all relevant financial
relationships with any commercial interest. Per these updated standards. The faculty presenters
were required to disclose all financial relationships. The ACCME defines a “commercial interest” as
any proprietary entity producing health care goods or services consumed by or used on patients. It
does not consider providers of clinical service directly to patients to be commercial interests. The
ACCME considers “relevant” financial relationships as financial transactions (in any amount) that
may create a conflict of interest and occur within the 12 months preceding the time that the individual
is being asked to assume a role controlling content of the educational activity.
Disclosure Information:
Presenters have nothing to disclose.
COURSE SECTIONSScientific Basis and History of Medical Acupuncture1
Musculoskeletal / Neuroanatomic Acupuncture2
Circulation of Energy3
TCM Classical Evaluation and Therapy4
Microsystems in Acupuncture5
Energetics6
The 5 Phases in the Regulation of Qi7
Point Groupings8
Scientific Basis and
History of Medical
Acupuncture
SECTION 1
Section 1 - Scientific Basis of Acupuncture
This section is designed to review the scientific basis of acupuncture.
After completing Section 1, participants will be able to:
1. Describe typical anatomical features of acupuncture points.
2. Summarize the neurophysiology of pain, including relevant
structures and neurotransmitters.
3. Explain the neurophysiologic effects of acupuncture with high- and
low-frequency stimulation.
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Scientific Basis of Medical Acupuncture Chronology
• Anatomy of Acupuncture Points
• Stimulation of Nerves in Muscle
• Neurochemical Basis of Acupuncture
• Neurologic Basis of De Qi
• Gate Theory of Pain
• Neurophysiology of Acupuncture with
Stimulation
• Acupuncture and Fascia
• Neuroimaging and Acupuncture
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• Artery
• Vein
• Nerve
• Lymphatic
Anatomy of Typical Acupuncture Point
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Acupuncture Points
• High conductance, low resistance
• High density of gap junctions
• Associated with nerve, artery, vein, lymphatic clusters
• Palpable depressions on muscle, bone, tendon, ligaments
• Tender points on and off of channels
• Overlap with motor, trigger, Chapman’s points
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Bioelectrical Properties of
Acupuncture Points
• Low resistance
• High conduction
• High density of gap junctions
• Charles Shang, MD Emory University
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Acupuncture Points
• Topological
• Palpable
• Resist needle withdrawal compared to
surround
• Along fascial planes
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Anatomy of Acupuncture Points
Relation to:
• Nerves
• Vessels
• Bone
• Connective Tissue
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Anatomy of Acupuncture Points
Relation to nerves:
• Large peripheral nerves
• Motor points
• Areas of emergence from deep to
superficial
• Bony foramina
• Peripheral nerve bifurcation points
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Anatomy of Acupuncture Points
Relation to vessels:
• Vessels near neuromuscular attachments
• Vasa nervorum, especially muscular
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Nerves and Arteries
16
Nerves and Arteries
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Scientific Basis of Acupuncture
Stimulation of nerves in muscle
• Touch A-B
• Skin injury - A-d, I, II, III, IV, C
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Neurologic Basis of De Qi Muscle Afferents
Acupuncture Analgesia blocked by intra-muscular procaine, but
not subcutaneous
Type II* - numbness
Type III - distension, heaviness, aching
Type IV - soreness
*Fibers required for acupuncture analgesia
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Neurotransmitters Affected by Acupuncture
• Beta Endorphin
• Enkephalin
• Dynorphin
• Serotonin
• Norepinephrine
• Adenosine
• Anandamide
• Glycine
• Somatostatin
• Acetylcholine
• Dopamine
• GABA
• Substance P
• Glutamate
• Vasoactive intestinal polypeptide
(VIP)
• Histamine
• Nitric oxide
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Yin and Yang of the Neurochemical
Basis of Acupuncture
Inhibition and Excitation
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SG - substantia gelatinosa
T - central transmission cell
L - large diameter
S - small diameter
Melzack and Wall, 1963
Gate Theory of Pain I
Schematic of the gate-control theory of pain
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Nervous System Effects of Electro-Acupuncture (EA)
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Skin
1
2
7
6
Muscle
Spinal Cord5
Painful
Stimulus
Acu
Needle
3 4
9
11
10
8
Mid
Brain
Thalamus Cortex
14
1312
Pituitary
Hypothal
Blood
Vessel
Acupuncture
Needle
LegendPainful
Stimulus
Direction of
impulses
Nerve Cell
Excitatory Synapse
Inhibitory Synapse
Sensory
Nerve
Sensory
Receptor
STT = Spinothalamic Tract
Blood
Vessel
Overall Pain Pathway Schematic
Graphic courtesy of Joey Walker, MD, DABMA
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Skin
1
2
7
6
Muscle
Spinal Cord5
Painful
Stimulus
3 4
9
11
10
8
Mid
Brain
Thalamus Cortex
14
1312
Pituitary
Hypothal
Blood
Vessel Blood
Vessel
Acupuncture
Needle
Legend
Painful Stimulus
Direction of
impulses
Nerve Cell
Excitatory Synapse
Inhibitory Synapse
Sensory
Nerve
Sensory
Receptor
STT = Spinothalamic Tract DLT = Dorsolateral Tract
ALT = Anterolateral Tract M = Monoamines
E = Endorphins
ST
T
ALT
M
M
DLT
E
E
E
E
Acu
Needle
Low Frequency Electroacupuncture Stimulation Pain Pathway Schematic
<10 Hz
Graphic courtesy of Joey Walker, MD, DABMA
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Neuroanatomic Basis of Acupuncture
Hypothalamus/Pituitary
Low frequency stimulation
-Betalipotropin Beta-endorphin & ACTH
• To circulation distant analgesia
• To CSF periaqueductal gray
• Long Axons Midbrain raphe descending
system
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Skin
1
2
7
6
Muscle
Spinal Cord5
Painful
Stimulus
Acu
Needle
3 4
9
11
10
8
Mid
Brain
Thalamus Cortex
14
1312
Pituitary
Hypothal
Blood
VesselBlood
Vessel
Acupuncture
Needle
Legend
Painful Stimulus
Direction of
impulses
Nerve Cell
Excitatory Synapse
Inhibitory Synapse
Sensory
Nerve
Sensory
Receptor
STT = Spinothalamic Tract DLT = Dorsolateral Tract
ALT = Anterolateral Tract M = Monoamines
E = Endorphins
STT
ALT
MDLT
E
E
High Frequency Electroacupuncture Stimulation Pain Pathway Schematic
>80 Hz
Graphic courtesy of Joey Walker, MD, DABMA
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Neuroanatomic Basis of Acupuncture
Spinal Cord
Low frequency stimulation enkephalin, dynorphin
enkephalin decrease calcium inflow decrease, substance P
release
High frequency stimulation GABA
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Neuroanatomic Basis of Acupuncture
Midbrain
Low frequency stimulation enkephalin
• Secondary action on cord via raphe descending system
(dorsolateral tract)
High frequency stimulation bypasses enkephalin system
• synergistic cord inhibition by monoamines seratonin,
norepinephrine effect
• enhanced by tryptophan
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Electro-Acupuncture (EA) Low Frequency, High Frequency
• Slow onset of analgesia
• Generalized effect
• Continues after
stimulation
• Cumulative effect
• Endorphin dependent
• Rapid onset of analgesia
• Segmental effect
• Active during stimulation
• No cumulative effect
• Monoamine dependent
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• James Ochsman, MD
• DC currents conducted along
perineural transmission network
• Role of glial cells, 90% of cells in
central nervous system (CNS)
• Astrocytes, Microglia
• Oligodendrocytes
Perineural Transmission Network
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• Organized by connective tissue
• Fascial planes, between muscles, bone and muscle, etc.
• Mechanical effect on nerves, vessels,
• Chemical effect on connective tissue afferents
Acupuncture Meridians and Fascia
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Acupuncture Meridians
• Channel propagation
• Radiations from the deep
• Isotope studies (Tch99)
• Fascial planes
• Bioelectric morphogenesis: Erich
Bleckschmidt - metabolic, mechanical, and
field effects in embryologic development
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Biodynamic Embryology
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Isotope Scan of Acupuncture vs. Non-Acupuncture Point
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Loose Connective Tissue
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• Helene Langevin, MD
• Twirling the needle deforms connective tissue
• This results in a myofascial deformation signal
• Needle withdrawal resistance
Fascia, Microtubules, and Cytoskeletal Transmission
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• Mechano-transduction
• Purinergic signaling
• Peripheral sensory modulation via
Adenosine
Acupuncture and the Connective Tissue Matrix
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• Connective tissue matrix includes the extracellular matrix (ECM), fibroblasts, immune cells
• Whole body organ
• Needle rotation with increased grasp, correlates with collagen wrapping
• Collagenase blocks the effects of manual acupuncture (MA)
Acupuncture and the Connective Tissue Matrix
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• Acupuncture affects fibroblasts several cm. away
• Reorganize their cytoskeleton, change shape
• Become larger and flatter
• Similar with sustained stretch(30 min.)
Mechanotransduction
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• Change of fibroblast shape
associated with release of ATP
Purinergic Signaling
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Peripheral Sensory Modulation
• ATP Adenosine Peripheral Sensory Modulation
• Adenosine endogenous neuromodulator in the peripheral and
central nervous system
• Inhibits pain signals by hyperpolarizing neuronal membranes
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Acupuncture Pain Neuroimaging
• Vitaly Napadow, PhD, LAc
• FM vs. healthy, resting connectivity of DMN with S2 and insula
is increased with FM
• Amount of pain, more pain, more connected to the insula. If
SLR causes pain, insula connectivity increases
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• NEJM March 2013, DMN
plus Insula
• Pain Biomarker
Pain Signature (f-MRI) Biomarker
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Acupuncture Pain Neuroimaging
• Richard Harris, PhD
• Connectivity in Fibromyalgia (FM), Insula highly connected to
DMN, not in controls, correlates with clinical report, also seen
in neuropathic pain, LBP, TMD
• Can acupuncture affect this?
• FM with acupuncture, decrease Insula connectivity to DMN,
correlates with decreased pain.
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Acupuncture Pain Neuroimaging
• After acupuncture in FM, decreased pain, decreased
connectivity to the Insula
• Insula, stimulus salience, integrates subcortical homeostatic
information into action, cognition, and affect. Substrate for
clinical pain? Surrogate? Predictive?
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Pain/Acupuncture/f-MRI
Zang Hee Cho
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• Point Groupings
Shock Points, Nausea Points
Ba Feng, Ba Xie
GV20, GV24.5
• References
Acupuncture Energetics, Helms
• Questionso Differences between manual and electrical stimulation?
o Differences between low freq and high freq EA?
Scientific Basis and History of Medical
Acupuncture Summary
Conclusion of Section 1