medical acupuncture review course...section 2 - musculoskeletal / neuroanatomic acupuncture this...

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

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

MUSCULOSKELETAL/

NEUROANATOMIC

ACUPUNCTURE

SECTION 2

Section 2 - Musculoskeletal / Neuroanatomic Acupuncture

This section is designed to review various musculoskeletal and

neuroanatomic acupuncture techniques.

After completing Section 2, participants will be able to:

1. Compare different levels (superficial to deep) of musculoskeletal

acupuncture treatments.

2. Identify the neuroanatomical targets of each level of treatment.

3. Design treatments for common musculoskeletal pain problems.

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.

7

Musculoskeletal/Neuroanatomic Acupuncture

• Surface

• Myofascial

• Neuromuscular

• Periosteal

8

Neuroanatomic Basis of Acupuncture Effect of Local Needles

Local mechanical effects

▪ Release of spasm

▪ Breakup of fibrosis

▪ Stimulation of blood flow

▪ Current of injury

▪ Diffuse noxious inhibitory control

9

Musculoskeletal/Neuroanatomic Acupuncture-Surface

• Kori (Seem)

• Cupping and Scraping

• Surface Release Technique-SRT (Helms)

10

Combined Neurodermatomal and Classical Techniques

Mark Seem, PhD, LAc

• Surface Energetics

o Superficial nontender "kori" bands, nodules

o Superficial "Ashi" points

o Body-Zone

• Body-zone appropriate meridian points

American Academy of Medical Acupuncture 11

Cupping


Cupping

• Suction

• Pulls to the surface


(Scraping) Gua Sha

14

Gua Sha

➢ Scraping to mobilize

circulation, release fibrosis➢ Cover up/ warm afterwards

15

Surface Release Techniques (SRT)

• Applied to loose connective tissue

• Helps underlying muscles

• Treats surface layer directly and provides avenues for

release of deeper pathology

• From the deeper Principal Meridians to the Surface,

there are Luo vessels or connections that link the

surface with the depth

• Helps avoid deeper penetration of pathology

16American Academy of Medical Acupuncture


• Connective tissue surrounds arteries, veins, lymphatics, nerves

• Connective tissue can regulate its own tension level

• Structure implies function(tension)

• Slow process

Surface Release Techniques (SRT)

18

Musculoskeletal/Neuroanatomic Acupuncture-Myofascial

• Trigger Points (Travell)

• Trigger Point Deactivation

• 4 Quadrant Technique

• Two Needle Technique-TNT (Elorriaga-Claraco)

• Daisy Chain

• Scar Deactivation

19

Acupuncture and the Myofascial System Symptoms

• Spontaneous pain

o Burning

o Atypical

• Abnormal responses to stimuli

• Vasomotor abnormalities

• Trophic changes

20

Trigger Points

• Travell and Simons

• Myofascial Pain and Dysfunction

• Trigger Point Deactivation

• Spray and Stretch

• 4 Quadrant Deactivation

21

Acupuncture and the Myofascial System Trigger Points

• Travell's Diagnostic Criteria

o Localized tenderness

o Palpable firm bands

o Referral patterns

o Reproducible pain on

palpation, jump sign

o Differentiate active and latent

points

• Early Inflammatory Phase

o Microscopy: fibers and

cells

o Biochemistry: mediators

22

Acupuncture and the Myofascial System Trigger Points

• Late dystrophic phase

o Neuropathy with negative evaluation

▪ Autonomic

▪ Sensory

▪ Motor

o Secondary myofascial strain Pain cycle

23

Acupuncture and the Myofascial System Trigger Point Referral Patterns

• Deceptive and non-dermatomal

• Predictable

• Diagram: typical head and neck trigger points

25 American Academy of Medical Acupuncture

27

Two Needle Technique (TNT)

• Two needles convergently aimed at a deep muscle knot

• Stimulation at 10 hz.

• Anode and cathode target same spot

• Post-tetanic relaxation

• Best technique to get rid of a stubborn muscle knot


Two Needle Technique

29

Daisy Chain

• Electrical stimulation at 15 Hz

• In series linking to multiple trigger points

• Black-Red-Black-Red-Black-Red, etc.

30

Scar Treatment

• Scars form as fibroblasts convert to myofibroblasts and

pull wound edges together

• In the process they may entrap fascia, nerves, venules,

capillaries, arteries, lymphatics

• Surround with needles

• Electrify the needles

• Infiltrate, hydro-dissect

• Soapbox….scars are forever


Wound Healing Fibrosis


Scar Deactivation

33

Musculoskeletal/Neuroanatomic Acupuncture-Neuromuscular

• One Needle Technique (Wong)

• Percutaneous Electrical Nerve Stimulation-PENS (Craig)

• KB1, KB2 (Bishop, Berry)

• Intramuscular Stimulation/Neuropathic Theory (Gunn)

34

One Needle Technique (ONT)

• Localized diagnosis

• Muscle, tendon, ligament, nerve

• Functional anatomy, neuroanatomy, pathology

• Neurofunctional Anatomic Exam (Elorriaga-Claraco)

35


• Good for neuromusculoskeletal problems

• Anatomic diagnosis by History & Physical, Functional

exam

• Consider neural elements and their hierarchy

• Apply one needle

• Did it work?

• No, go back to beginning

• Reconsider anatomic diagnosis, neural hierarchy

• Series of ONT

36


• Accurate diagnosis

• Point selection

• Hierarchy

• Needle placement

• Needle stimulation

• Immediate effects

• If no effect, reconsider


• Midline medial branch, dorsal ramus facet pain

• Inner Bladder line lateral branch, dorsal ramus segmental muscles

• Outer Bladder line aimed medially ventral roots

One Needle Techniques (ONT)


Myotendinous Shoulder Pain (ONT)

MOTOR POINT, MYOTENDINOUS, SUPRATENDINOUS, PERIPHERAL N, +/-AUTONOMIC SWITCHES


• 38 y.o. 6 weeks sciatica

• Normal neurologic, (+) SLR, tender sciatic notch

• X-ray-mild spondylosis @ L4-5, L5-S1

• Tx: GB.30Bl.40, BL.60 interspinal L4-5-S1

Low Back Pain (ONT)

40

Percutaneous Electrical Needle Stimulation (PENS)

William Craig, MD

• Stimulation to engage myotomes, dermatomes,

sclerotomes, autonomotomes

• Central modules

• Peripheral modules

• Variable frequencies

• Variable effects on neurotransmitters

• 2, 4, 15, 30, 90, 150, 300

41

Dermatomes, Myotomes, and Sclerotomes

• Needle insertion through multiple tissue layers

• Strategically selected points

• Simultaneous central & peripheral activation

• Augmentation via electrical stimulation at selected

frequencies

• Supported by significant research in recent years

43

Neurodermal Electrical Stimulation Sympathetic Activation

• T1 - head

• T1, T2 - neck

• T3, T4 - shoulder, arm

• T4, T5, T6 - thorax

• T7 - T11 - abdomen

• T10 - lumbar

• T10, T11 - gluteal

• T12, L1, L2 - leg


Lumbar PENS• The central module is

stimulated at 4 Hz.

• The periosteal module from the

PSIS to the hip is optional and

added if the patient's symptoms

and physical examination

indicate. This module is

stimulated at 30 Hz. Increase

the intensity of stimulation if

accommodation occurs.

• The PENS and periosteal

treatments run for 20 minutes.

• For improved results include

and appropriate N n+1

energy-moving input at 2 to 4

Hz for 10 to 12 minutes at

some point during your

patient's visit.


Cervical-Thoracic PENS

• Outer module optional,

depending on symptoms and

palpation findings.

• 4 Hz frequency may be

traded for 15 Hz if patient is

uncomfortable with thumping

in the cervical region.

• Include an appropriate

energy-moving input using

peripheral points and

possibly 2 Hz electrical

stimulation.

46

KB1 and KB2

• Treatments that pierce the interosseous membranes

• KB.1 Forearm

• KB.2 Foreleg

• Interosseous membranes richly innervated by

sympathetic nervous system (SNS)

• Pain problems of extremities can be maintained by deep

interosseous changes

• Structure Function


KB2


• Neuropathic Theory (GUNN)

• Compression of Adjacent Structures

• Pseudoradiculopathy

• Joint Distortion

• Tendinous/Ligamentous Distortion

• Bursa Compression

• Intramuscular Stimulation for Pain of Radicular Origin

• Intramuscular Stimulation to Release Spasm/Fibrosis

Acupuncture and the Myofascial System


• To treat pain and

tenderness over the

medial epicondylar

region.

• Needle the flexor muscles

on the front of forearm:

Pronator teres, flexor

carpi radialis, palmaris

longus, flexor digitorum

sublimis, and flexor carpi

ulnaris and their common

origin.


Neuropathic Theory (GUNN)

52

Musculoskeletal/Neuroanatomic Acupuncture-Periosteal

• Osteopuncture

• Periosteal Stimulation

53

Acupuncture and Bone: Osteopuncture

Ronald Lawrence, MD; Felix Mann, MD

• Periosteum rich in sympathetics

• Increase blood flow and modulate autonomic nervous

system pain

• C-fibers slow link to thalamic nuclei

• Activation by manual and electric stimulation

• Selected points may be acupuncture points

54

Acupuncture and Bone: OsteopunctureTechnique

• Insert 1-2 mm into periosteum

• 100-200 Hz (-) to bone needle, (+) to muscle needle(s)

• 15-45 min, q week x 4-6 treatments, increase current to

avoid accommodation

• Can use as local treatment during other acupuncture

circuitry

• Moxa where appropriate


Periosteal Stimulation

57

• Point Groupings

Barrier Points

Huato Jia Ji Points

• References

Acupuncture Energetics, Helms

Neuroanatomical Acupuncture, Wong, Vol 1 & 2

• Questions

1. Ways to deactivate trigger points?

2. How to set up a lumbar PENS treatment?

Musculoskeletal/Neuroanatomic

Acupuncture Summary

Conclusion of Section 2

medical acupuncture review course...section 2 - musculoskeletal / neuroanatomic acupuncture this...

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