Acupuncture

Chapter 92Acupuncture



image Equine Acupuncture for Lameness Diagnosis and Treatment


Allen M. Schoen


Interest in veterinary acupuncture for lameness diagnosis and treatment has increased greatly in the public and veterinary medical communities. With this increased awareness has come an increase in veterinary acupuncture research and thus a better understanding of the physiological basis of acupuncture and its clinical applications. Acupuncture may be used as an adjunct diagnostic and therapeutic tool to our traditional lameness examination and to the treatment of lameness, but it is not meant to be a substitute.


With the increased interest in equine acupuncture, there has also been additional controversy and use and misuse of this modality. It is important to understand the scientific basis, traditional Chinese medical theories, and clinical indications and limitations if acupuncture is to be used in a professional manner as part of an integrated approach to equine lameness. Currently, equine acupuncture is practiced by veterinarians trained in the Western medical perspective of scientific acupuncture and the traditional Chinese and Japanese medical theories. The approach may vary slightly based on the practitioner’s perspective.


The history of equine acupuncture dates back to 2000 to 3000 bce during the Shang and Chow dynasties in China. Around 650 bce Bai-le wrote Bai-le’s Canon of Veterinary Medicine, one of the first veterinary textbooks, which described acupuncture and moxibustion in equine medicine. The first atlas of equine acupuncture points and channels, Ma Jing Kong-xiue Tu, was written during the Sui period, from 581 to 618 ce.1 Equine back pain was first addressed in the ancient veterinary textbook Yuan-Heng Liao Ma Ji (Yuan-Heng’s Therapeutic Treatise of Horses).2 Periodically, anecdotal reports of using equine acupuncture would come to the Western world. The first substantial introduction occurred in the 1970s, when the International Veterinary Acupuncture Society was established and developed training programs in veterinary acupuncture in the United States. In 1996 the American Veterinary Medical Association stated, “Veterinary acupuncture and acutherapy are considered valid modalities, but the potential for abuse exists. These techniques should be regarded as surgical and/or medical procedures under state practice acts. It is recommended that extensive continuing education programs be undertaken before a veterinarian is considered competent to practice acupuncture.”3 Postgraduate education in veterinary acupuncture throughout the world—including Australia, Europe, Scandinavia, North and South America, and other areas—is offered by the International Veterinary Acupuncture Society, based in Fort Collins, Colorado.4 The Chi Institute of Traditional Chinese Medicine in Reddick, Florida5; Colorado State University College of Veterinary Medicine continuing education program in Fort Collins, Colorado6; Tufts University School of Veterinary Medicine in North Grafton, Massachusetts7; and the Veterinary Institute for Therapeutic Alternatives in Sherman, Connecticut8 also offer postgraduate programs. All of the programs are in the United States.



Scientific Basis


Acupuncture may be defined in a Western medical perspective as the stimulation of specific predetermined points on the body to achieve a therapeutic or homeostatic effect. Recent research has provided evidence for the anatomical classification of acupoints. Acupuncture points are areas on the skin of decreased electrical resistance or increased electrical conductivity. Acupuncture points correspond to four known neural structures. Type I acupoints, which make up 67% of all acupoints, are considered motor points. The motor point is the point in a muscle that, when electrical stimulation is applied, will produce a maximal contraction with minimal intensity of stimulation. Motor points are located near the point where the nerve enters the muscle. Type II acupoints are located on the superficial nerves in the sagittal plane on the midline dorsally and ventrally. Type III acupoints are located at high-density foci of superficial nerves and nerve plexuses. For instance, acupoint GB-34 is located at the point where the common fibular (peroneal) nerve divides into the deep and superficial branches. Type IV acupoints are located at the muscle-tendon junctions, where the Golgi tendon organ is located.9 Recently, histological studies have revealed that small microtubules, consisting of free nerve endings, arterioles, and venules, penetrate through the fascia at acupuncture points (Figure 92-1).10



Acupuncture has many varied physiological effects on all systems throughout the body. No one mechanism can explain all the physiological effects observed. Traditional Chinese medical theories have explained these effects for 4000 years, based on empirical observations and descriptions of naturally occurring phenomena. Western medical theories include the gate and multiple gate theories, autonomic theories, humeral mechanisms, and bioelectric theories.10 Detailed discussions of the neurophysiological basis of acupuncture are reviewed in a number of texts.9-12 Essentially, acupuncture stimulates various sensory receptors (pain, thermal, pressure, and touch), which stimulate sensory afferent nerves, which transmit the signal through the central nervous system to the hypothalamic-pituitary system (Figure 92-2). The acupoints correlate with cutaneous areas containing higher concentrations of free sensory nerve endings, mast cells, lymphatics, capillaries, and venules. Various neurotransmitters and neurohormones are then released and have subsequent effects throughout the body. Research in rabbits using electroacupuncture-induced neural activation, detected by the use of manganese-enhanced functional magnetic resonance imaging, demonstrated a corresponding cerebral link between peripheral acupoints and central neural pathways. Research such as this is aiding in further understanding the effects of local peripheral stimulation on specific areas in the brain.13 Electroacupuncture has also been found to stimulate endogenous opioids, vasoactive peptides, adrenocorticotrophic hormone, cortisol, and catecholamine in cerebrospinal fluid and peripheral plasma in ponies.14 Bossut and colleagues15 documented changes in plasma cortisol and β-endorphin in horses subjected to electroacupuncture for cutaneous analgesia. Changes in serum protein and blood gas concentrations also have been demonstrated in donkeys after acupuncture.16,17 Xie and colleagues18 documented that electroacupuncture could relieve experimental pain in the horse via the release of β-endorphin. They found that acupuncture stimulation using local acupuncture points with high frequency (80 to 120 Hz) is more effective than using distal points with low frequency (20 Hz). They found that acupoints close to the painful areas require high-frequency electroacupuncture stimulation, whereas the acupoints far from the painful areas may be stimulated with low-frequency electroacupuncture. Electroacupuncture generally is considered to have stronger effects than other types of acupuncture methods.18 The degree of stimulation appears to depend on the location of the specific acupoints.19,20



Through understanding the neurophysiology and neuroanatomy of acupuncture, one can appreciate that acupuncture may stimulate nerves, increase local microcirculation to joints and muscles, relieve muscle spasms, and cause a release of various neurotransmitters. Clinically, one may see the benefits of these effects in treating equine lameness caused by soft tissue injury, muscle spasms, nerve trauma, and other conditions.



Traditional Chinese Medical Theories


Acupuncture has been used in China to treat equine lameness for a few thousand years. Chinese acupuncture was based on the empirical use of acupoints for certain conditions. Historically, acupuncture meridians were not acknowledged in animals. Specific empirical points based on experience were identified and named for location or function. Equine acupuncture meridians, or pathways, have been transposed onto horses from human acupuncture maps only in the past 40 years.


Traditional Chinese medicine acupuncture diagnosis and treatment are based on the pattern differentiations that are developed from two main theories of traditional Chinese medicine: the Five Element theory and the Eight Principles, which require a great deal of study.21 The traditional Chinese medicine diagnosis is defined as a specific pattern based on imbalances in the five elements (also called five phases), imbalances and disorders in specific meridians or organs, or specific patterns of disharmony. The diagnosis is based on a physical examination of the horse, including evaluation of the tongue and pulse. Tongue inspection includes evaluation of the color of the tongue, the moistness, and the color and thickness of any tongue coating. Palpation of the jugular pulse would be described as weak, strong, wiry, and so on. Tongue and pulse examination and an overall examination would lead to a traditional Chinese medicine diagnosis and treatment of appropriate acupuncture points. Xie22 describes a traditional Chinese medicine five-step method for diagnosis and treatment. This includes the following:







In contrast, the Japanese technique, frequently termed meridian therapy, is based more on palpation of the acupuncture points and the reaction. The anatomical location of equine acupoints is based on the traditional Chinese acupuncture atlases or a transpositional atlas based on transcribing human acupuncture points onto the equine anatomy. The location of the points is similar in each method, though anatomical variation exists, as discussed by Fleming23 (Figure 92-3).




Techniques and Instrumentation


Numerous techniques exist to stimulate acupuncture points. The following modes of stimulation are commonly used in equine acupuncture: dry needle stimulation, electroacupuncture, aquapuncture, moxibustion, laser stimulation, gold implants, and acupressure. Each method has its indications and limitations. Dry needle stimulation and aquapuncture are used most routinely in the West.


Aquapuncture is the injection of various solutions into the acupuncture points. The hypodermic needle is stimulating the acupuncture point as a traditional acupuncture needle would. In addition, the solution is stimulating the pressure receptors for a period, and the solution is having its specific effect as well. Solutions injected include saline, vitamins such as B12, nonsteroidal analgesics, local anesthetic solutions such as lidocaine, and occasionally homeopathic and herbal solutions, depending on the veterinarian’s preference. Electroacupuncture, using a portable electroacupuncture unit, normally is used for nerve stimulation to treat severe chronic cervical, thoracolumbar, or lumbosacral problems or an affected joint, tendon, or ligament. These electroacupuncture units have electrodes attached to the acupuncture needles. Positive results with electroacupuncture have been documented for treatment of lameness in horses. Electroacupuncture decreased the lameness score in horses (P < .001).24 Although poorly documented, electroacupuncture without needles is sometimes applied as well. Moxibustion is a form of thermostimulation using a Chinese herb, Artemisia vulgaris. Low-level or cold laser therapy is also used to stimulate acupuncture points. Gold implants have been used to treat navicular disease and chronic back pain and provide long-term stimulation of acupoints. This approach is an adaptation of the Chinese technique of sutures embedded into acupoints. Acupressure often is taught to the client to administer between acupuncture treatments to potentiate the effect. Detailed descriptions of these techniques are provided by Altman.25


From a Western medical perspective, acupuncture point selection is based on locating points on the body where stimulation produces a beneficial change in the central nervous system by modulating ongoing physiological activity, releasing local muscular spasms, and increasing local microcirculation. From a traditional Chinese medicine perspective, acupoints are selected based on a pattern differentiation developed from the Five Element theory or Eight Principles. The choice of acupoints based on the Eight Principles depends more on tongue and pulse findings and a comprehensive history. The Japanese approach to point selection follows a diagnostic acupuncture point examination, palpating diagnostic acupoints, including association (Shu) points on the dorsal aspect of the thoracolumbar region, alarm (Mu) points on the ventral aspect of the abdomen, and other diagnostic points. Many clinicians choose their points based on a combination of Chinese, Japanese, and Western diagnostic techniques, including tongue and pulse examination and diagnosis, diagnostic acupuncture point examination, sometimes including Ting points (points around the coronary band), and a comprehensive Western medical examination and history.26,27 The number of acupuncture points treated may vary from one to more than 20, depending on the condition treated and the approach and experience of the practitioner. The depth of needle insertion varies from 1 mm to 12 cm, depending on the location of the point, such as the coronary band versus dorsal lumbar musculature. The number of treatments required depends on the condition treated and the chronicity of the problem, usually ranging from one to eight treatments. The length of treatment varies from 5 to 30 minutes.


Manual therapies, such as chiropractic or osteopathy, are often applied along with acupuncture. They appear to work synergistically, acupuncture relieving muscle spasms and increasing circulation, chiropractic helping to correct skeletal fixations (see Chapter 93), and osteopathy affecting the fascia and skeletal structures (see Chapter 95). The combination of these therapies often leads to a more rapid response and greater efficacy, with fewer treatments required.



Clinical Applications in Lameness Examination and Treatment



Acupuncture Diagnostic Examination


Acupuncture and manual therapies may be used diagnostically to aid in evaluating various lameness and performance problems. Acupuncture is an excellent diagnostic aid as an adjunct to a conventional lameness examination. Many of the diagnostic acupoints are located lateral to the dorsal midline, between the longissimus and iliocostalis muscles, along the acupuncture meridian known as the bladder meridian.26 In addition, some diagnostic points are actually trigger points, knots or tight bands in a muscle. For instance, a triceps trigger point is often sensitive to palpation when a distal forelimb lameness is present and correlates with the acupoint Small Intestine 9. A triceps trigger point may not indicate exactly where the lameness is or what the cause is, but it does indicate that something is reactive in that region (Figure 92-4).



Diagnostic acupoints also are located around the coronary band on the forelimb and hindlimb, known as Ting points (Figure 92-5).15

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Jun 4, 2016 | Posted by in EQUINE MEDICINE | Comments Off on Acupuncture

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