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  1. 1. INDICATIONS AND MECHANISMS OF ACUPUNCTURE IN PAIN Quirico Piero Ettore M.D. Acupuncture School C.S.T.N.F. - Torino F.I.S.A. - Italian Federation of Acupuncture Societies
  2. 2. <ul><li>infectious diseases </li></ul><ul><li>musculoskeletal diseases </li></ul><ul><li>internal diseases </li></ul><ul><li>metabolic diseases </li></ul><ul><li>hormonal imbalances </li></ul><ul><li>mental and nervous system diseases </li></ul>For over 3000 years Acupuncture has been used to treat many diseases, as
  3. 3. Acupuncture has been practiced for over fifty years in Western countries, achieving great success in treating different diseases. More than 10,500 scientific publications are available on Medline database, demonstrating Acupuncture effectiveness and safety.
  4. 4. %
  5. 5. Acute and chronic painful pathologies are one of the more interesting fields of application of Acupuncture, that often can cure, alone or with other therapies, many diseases difficultly treatable only by the conventional resources. Acupuncture in pain
  6. 6. <ul><li>anti-inflammatory </li></ul><ul><li>analgesic </li></ul><ul><li>decontracting-miorelaxing </li></ul><ul><li>vasoregulatory </li></ul><ul><li>sedative </li></ul><ul><li>neuroendocrine regulatory </li></ul>So many diseases treated suggest a wide variety of acupuncture effects, as follows:
  7. 7. Vasoregolatory-trophic effect Documented from the thermography and other fluxmetric methods, it restores the correct blood flow in the affected area. Painful diseases are often characterized by local ischaemia or light inflammation, frequently associated to edema. This situation favors the accumulation of waste and the evolution towards fibrosis, with functional failure.
  8. 8. Infrared thermography in Acupuncture
  9. 9. The tissue distress <ul><li>naturally </li></ul><ul><li>after pression </li></ul>These areas correspond to the traditional Ah Shi acupoints and to the Trigger points (TP) described from Travell and Simons as ischaemic zones with larger metabolic needs. Each TP embodies a “warm” hyperexcitated area, that can cause reflex phenomena locally and at some distance. In the affected area we can see limited zones very painful capable of causing pain locally and in a distant area.
  10. 10. <ul><li>reflex constriction of Vasa Nervorum </li></ul><ul><li>nociceptive autonomic feedback </li></ul><ul><li>release of vasoactive peptides (SP, CGRP) from afferent C fibres, that increases the stimulation of nociceptive pathways </li></ul>The ischaemic-irritative tissue condition of TP zones, through the afferent nerves, can maintain this distress. Reflex nervous pathways are involved and these mechanisms can play a role:
  11. 11. The “silent afferences” In 1994 G.D. Schott (Brain, 117:397-413) pointed out the role of autonomic nervous fibres in the origin of chronic visceral and musculoskeletal pain. These afferent fibres represent over 50% of the amielinic C fibres found in the different tissues (skin, joints, muscles, viscera).
  12. 12. “ Silent fibres” become sensitive and they are capable of evoking a reaction only after longtime injuries, as inflammatory and ischaemic processes. The activation of these afferences can lead to a central sensitisation, with an enlargement of receptive fields, causing a more intense and continuing activity. In this way chronic pain mantains itself.
  13. 13. Ischaemic-irritative condition of TP and oedematose-phlogistic state of affected areas can both activate C “silent” fibres and lead to a chronic condition of the painful disease. Through the convergence-facilitation and -projection mechanisms, pain can get the chronic condition also in the projection zones, which sometimes are very far from its origin.
  14. 14. Deactivation of Trigger Points Mechanic disorganization of TP area can resolve at the same time local and projected symptoms, breaking at the root the vicious circle mantaining the painful disease. The injection of anestetic drugs inside the TP does not give better results than dry needle method. Needle infixion must reach the center of TP and the stimulation must be strong; it is also very important to obtain the De Qi (needle sensation) and the propagated sensation of the needle along the channels.
  15. 15. Thermal stimulation: the moxibustion Failing visible phlogosis symptoms, the vasodilating effect is increased from local application of heat. So, it is possible to resolve ischaemic pathology forever. The recovery of a correct blood flow in the affected areas is the mean condition capable to ensure: <ul><li>the elimination of waste </li></ul><ul><li>the restoration of tissue nourishment </li></ul>
  16. 16. Moxibustion: different methods 1 6 5 4 3 2
  17. 17. The recovery of the tissue nourishment and of the blood flow, aid the intervention of cellular and humoral components of the immune system in the affected areas. Many trials demonstrate the effect of Acupuncture stimulation on different components of immune function. Anti-inflammatory effect
  18. 18. <ul><li>It is possible to get it through two ways : </li></ul><ul><li>Electroacupuncture (EA) applied for over 60 min. due to the release of endogenous opiates by CNS employed in surgical analgesia the effect may last some hours </li></ul><ul><li>Manual stimulation for a brief time (few seconds) segmental and suprasegmental r eflex mechanisms are involved, as gate-control system and descending anti-nociceptive system short lasting and low importance effect </li></ul>Antalgic-analgesic effect
  20. 20. Inibition of nociceptive afferences in the posterior medullar horn (gate control system)      G S E A  C A  Dorsal column Paleospinothalamic Neospinothalamic tract G = gabaergic interneuron, E = enkefalinergic interneuron, S = efferent deutoneuron tract
  21. 21. Acupuncture electroanalgesia and CNS G = gabaergic interneuron E = enkefalinergic interneuron S = efferent deutoneuron Nrm = rafe magnus nucleus PGC = parvigigantocellular nucleus PAG = periaqueductal grey PAG PGCN nor RMN ser      G S E A  C + + A  Thalamus Thalamus
  22. 22. Acupuncture electroanalgesia (EA) This method was conceived from Chinese Acupuncturists in 1958 and later it spread accross the world, favoured by its good degree of efficacy. Athough limited to some operations and thanks to its spectacularity, it was very appreciated by mass media. Now EA is not very practised, but it had the historical role of introducing Acupuncture scientific research in Western Medicine, pointing out its capacity to produce endorphins in CNS.
  23. 23. “ Maoist” Acupuncture
  24. 24. Manual Acupuncture and EA Over the millennia Acupunture has been always executed by hand, to cure the diseases and not only their painful symptoms. EA, due to an increased production of endorphines in CNS, only points out a single effect and it can’t explain by any means the large therapeutic value of Acupuncture.
  25. 25. Antalgic effect: therapeutic value Although Acupuncture antalgic effect has not a true therapeutic role, it can be useful for treating musculoskeletal diseases. Some analgesia degree, even if for a short time, aids joints mobilization after the treatment and favours the functional recovery of the affected areas.
  26. 26. Decontracting-miorelaxing effect Muscle contracture depends on segmentary distress and it represents an attempt to protect the diseased area. The quick decontracting effect of Acupuncture involves reflex nervous mechanisms and affects proprioceptive and nociceptive pathways. Muscle decontraction and relaxation permit the resolution of painful diseases and the recovery of a suitable tissue nutrition.
  27. 27. Sedative effect Patients suffering from painful and chronic diseases are often afflicted with anxiety and depression, caused by the sufference and the fear thath they will not be cured. The Acupuncture sedative-antidepressive effect is very important to improve the patient’s mental condition, including the quality of sleep.
  28. 28. Conclusions We can say that Acupuncture has a main role in painful diseases’ therapy, through its proven effects. In Western countries Acupuncture technique is not always the same and often its quality is not adequate. Acupuncture and Reflextherapy are in addition often confused, inside a big group of “alternative cares”. This fact favours a big disorder and the diseased people take all the consequences on themselves.
  29. 29. Elements for a gold standard Acupuncture.... <ul><li>a complete acupoint prescription (local, regional, distal and general points) </li></ul><ul><li>deep infixion in the local points (needle sensation radiated in the affected area) </li></ul><ul><li>accurate stimulation of the distal points (propagated sensation towards affected area) </li></ul><ul><li>accurate selection of the general points ( based on the individual clinical picture) </li></ul>
  30. 30. Acupuncture in painful diseases: main clinical indications <ul><li>Musculoskeletal diseases: arthrosis, disk disorders, shoulder and hip periarthritis , tendinitis, tennis elbow, carpal tunnel syndrome, joints distortions, muscles contractures and cramps </li></ul><ul><li>Neurological diseases : neuralgias, tensive and vascular headache </li></ul><ul><li>Gastrointestinal diseases: gastritis and peptic ulcer, hiatal hernia and esophageal spasm, hemorrhoids </li></ul>
  31. 31. <ul><li>Gynecological diseases: dismenorrhea, pain relief during delivery </li></ul><ul><li>Urological diseases : interstitial cystitis, renal colic </li></ul><ul><li>Hearth diseases : angina pectoris </li></ul><ul><li>Otorhinological diseases : sinusitis, otitis </li></ul>