2016 altermed robinson revised 071916
TRANSCRIPT
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MedicalAcupuncture
NardaGRobinson,DO,DVM,MS,FAAMAColoradoStateUniversity,DepartmentofClinicalSciences
LearningObjectives
1. DistinguishbetweenthewesternbiologicalrationaleformedicalacupunctureandChineseacupuncture
LearningObjectives
2. CompareandcontrastdiagnosticsandtreatmentapproachesfromamedicalacupunctureversusaTCMperspective
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LearningObjectives
3. Identifymedicalconditionstreatedwithacupunctureandresourcesforreferralandfurtherlearning
LearningObjectives
1. DistinguishbetweenthewesternbiologicalrationaleformedicalacupunctureandChineseacupuncture
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“WesternMedicalAcupuncture”ADefinition
• “Westernmedicalacupunctureisatherapeuticmodalityinvolvingtheinsertionoffineneedles;itisanadaptationofChineseacupunctureusingcurrentknowledgeofanatomy,physiologyandpathology,andtheprinciplesofevidencebasedmedicine.”
“WesternMedicalAcupuncture”ADefinition
• “…WhileWesternmedicalacupuncturehasevolvedfromChineseacupuncture,itspractitionersnolongeradheretoconceptssuchasYin/Yang andcirculationof qi,andregardacupunctureaspartofconventionalmedicineratherthanacomplete‘alternativemedicalsystem’.”
“WesternMedicalAcupuncture”ADefinition
• “…Itactsmainlybystimulatingthenervoussystem,anditsknownmodesofactionincludelocalantidromicaxonreflexes,segmentalandextrasegmentalneuromodulation,andothercentralnervoussystemeffects.Westernmedicalacupunctureisprincipallyusedbyconventionalhealthcarepractitioners,mostcommonlyinprimarycare.”
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“WesternMedicalAcupuncture”ADefinition
• “…Itismainlyusedtotreatmusculoskeletalpain,includingmyofascialtriggerpointpain.Itisalsoeffectiveforpostoperativepainandnausea.PractitionersofWesternmedicalacupuncturetendtopaylessattentionthanclassicalacupuncturiststochoosingonepointoveranother,thoughtheygenerallychooseclassicalpointsasthebestplacestostimulatethenervoussystem.”
“WesternMedicalAcupuncture”ADefinition
• “…Thedesignandinterpretationofclinicalstudiesisconstrainedbylackofknowledgeoftheappropriatedosageofacupuncture,andthelikelihoodthatanyformofneedlingusedasausualcontrolprocedurein“placebocontrolled”studiesmaybeactive.Westernmedicalacupuncturejustifiesanunbiasedevaluationofitsroleinamodernhealthservice.”
Source
• WhiteAandEditorialBoardofAcupunctureinMedicine.WesternMedicalAcupuncture– ADefinition.AcupunctMed 2009;27:33-35 doi:10.1136/aim.2008.000372
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NotAllMedicalAcupuncturistsPracticeScientifically
• ManyMDsandDOsinNorthAmericaincludeTCMandothermetaphoricalapproaches
• PhysiciansintheUnitedKingdomandCanadamayhaveamorescientificapproach– Neuroanatomicacupuncture
• Osteopathicphysicianstendtoincludeproportionallymoremyofascialpalpationandtriggerpointdeactivationintheirtreatments
AmericanAcademyofMedicalAcupuncture
• Primarilyaphysicianacupunctureassociation– medicalacupuncture.org
• AmericanBoardofMedicalAcupunctureconfersboardcertificationoneligibleMDandDOmemberswhohavecompletedallrequirements:DABMA.org
• Notallcoursesinmedicalacupunctureteachstrictlyscientific medicalacupuncture
OtherFormsof“MedicalAcupuncture”
• FrenchEnergetics• TraditionalChineseMedicine• Auricularacupuncture• FivePhases(orFiveElements)• KoreanHandAcupuncture• Scalpacupuncture
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DebatebetweenScienceandMetaphoricalApproaches
• Ongoingwithinthemedicalacupuncturecommunityaswellasnonphysicianacupuncturegroups
• Somesaythatapproachingacupuncturescientificallyandbasedonanatomyandphysiologycouldrobitofitsbeauty,elegance,traditionalroots
• Thisisnottrue
WhatAreAcupuncture
Points?
ScientificMedicalAcupuncture
• Acupuncturepointsaresitesthroughwhichwecanengenderneuromodulationandmyofascialnormalization
• Neuromodulationimpactsneuralsignalinglocally,regionally,andsystem-wide,leadingtophysical,psychological,andautonomicnervoussystemchanges
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LearningObjectives
2. CompareandcontrastdiagnosticsandtreatmentapproachesfromamedicalacupunctureversusaTCMperspective
TraditionalChineseMedicine
• “[S]kepticismremainsaboutthenatureandvalidityoftheconceptsthatunderlieTCMclinicaldiagnosisandtherapeuticdecision-making..”– O’BrienKAetal.UnderstandingthereliabilityofdiagnosticvariablesinaChineseMedicineexamination.JAltComplementMed. 2009;15(7):727-734.
TraditionalChineseMedicine
• “Thisskepticismextendstothediagnosisofdiseasesordisordersonthebasisoftonguediagnosis,pulsediagnosis,andotherclinicalsignsandsymptoms,theidentificationofsyndromesreflectingunderlyingpatternsofdisharmonyofaclinicalentityordiseaseandtheuseofChineseherbalmedicinalformulaetorestorethesupposedlydisruptedbalance.”
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TraditionalChineseMedicine
• “TherearerelativelyfewdataavailableconcerningthereproducibilityofmajorTCMdiagnosticvariables,suchaspulsediagnosisandtonguediagnosis,andadistinctlackofinformationaboutthereliabilityofotherclinicaldatagatheredinaTCMexamination.”
TraditionalChineseMedicine
• “OnlyasmallnumberofstudieshaveinvestigatedthereproducibilityofTCMsyndromediagnosis.”
TraditionalChineseMedicine
• “Iftheindividualdiagnosticobservationsarethemselvesunreliable,therecanbelessconfidencethattheTCMsyndromediagnosedthroughsynthesisofdiagnosticobservationswillbereliable.”
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ScientificMedicalAcupuncture
• Basetreatmentsontheresultsofamodernmedicalexaminationandmyofascialpalpation
• Thegoalsincludenormalizationofnervousfunction(neuromodulation)andalleviationofmyofascialdysfunction
WhyAnatomyinAcupuncture?
• Anatomyisfactual,rational,andidentifiable.• AncientChineseacupuncturistsactuallyknewagreatdealaboutanatomy.
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WhyAnatomyinAcupuncture?
• Thereisno“gap”intheeffectsofacupuncturethatneedtobefilledby“consciousness”,“Qi”,or“energies”.It’sallrealandcanbeexplained.
WhyAnatomyinAcupuncture?
• Knowingacupunctureanatomymakesacupuncturesafer
• Anatomyisthebasisofmedicineandshouldbethebasisofacupunctureasatypeofmedicalpracticethoughothersmayviewthebasisas“Qi”and“heat,wind,damp,fire,water,etc.”
• InteractiveMedicalAcupunctureAnatomy– RobinsonNG– CRCPress–March2016
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OURJOURNEYBEGINS
THORACICLIMB
LungChannel
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Cephalicvein
EarlyAcupuncture
• Beganasablood-lettingtechnique,whichiswhymanyofthechannelsfollowbloodvessels– EplerDCJr.BloodlettinginearlyChinesemedicineanditsrelationtotheoriginofacupuncture.BullHistMed. 1980;54(3):337-367.
EarlyAcupuncture
• Wedonotadvocatebloodletting– thisisonlyprovidedforhistoricalcontextandcertainlydoesnotmeetCMErequirementsforcareofpatients
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THEOUTCOMEOFNEEDLINGDEPENDSONTHESTRUCTURESTARGETED
LU5:“CubitMarsh”
WhatWillYouStimulate?
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WhatWillYouStimulate?
WhatWillYouStimulate?
ANATOMYDECIDESTHERESULTS
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CHANNELSFOLLOWNERVESANDVESSELS
CHANNELSARETHENERVESANDVESSELS
ChannelNomenclature
• Confusing• Mostrefertoorgans• Manyormostofthepointsoneachchannelhavelittletonothingtodowiththeorganafterwhichthechannelisnamed
• Somechannelnamesarepurelymetaphorical– E.g.,“TripleHeater”and“GovernorVessel”
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Channels=NervesandVessels
STRUCTUREDICTATESFUNCTION
THEOUTCOMEYOUGETDEPENDSONTHENERVESYOUACTIVATE
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Pericardium6:“Neiguan”“InnerPass”
“InnerPass”
• Referstothepassagethroughtheinterosseousmembraneoftheanteriorinterosseousvesselsthatsupplythedorsalaswellasthevolarsurfacesofthedistalantebrachium.
Whatarethelocal,regional,and
systemiceffectsofneedlingPC6?
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ConnectiveTissueatPC6
• Interosseousmembrane– Longitudinalstabilityoftheantebrachium,orforearm
• Clinicalrelevance– High-forcecompressivetraumacaninjuretheforearmandelbow,tearingthemembrane,andcausingnotonlyinstabilitybutalsoconsiderablepainanddisabilitybylimitingmotionandchangingthebiomechanicsofthewrist
NeuralElementsatPC6
• Mediannerve– Sensory–Motor– Autonomic
• Medialandlateralantebrachialcutaneousnerves
• Anteriorinterosseousnerve
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NeuralElementsatPC6
• Clinicalrelevance:– Local:Identifyandtreatsourcesofnerveentrapmentandcompressionthatmaymimiccarpaltunnelsyndrome
– Regional:Complexregionalpainsyndrome(akareflexsympatheticdystrophy
– Systemic:Longloopreflexestothebrainstemandtherostralventrolateralmedulla
LargeIntestine(LI)Channel
RadialNerve WristandDigitExtensors
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Radialnerve
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WhatMakesLI4a“BigPoint”?
LI4:“Hegu”
• Needlingaffectspotentiallyeverynerveofthethoraciclimb– Radial– Ulnar–Median(withdeepneedling)– Sympatheticfibers
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DorsalView PalmarView
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PELVICLIMB
Bladder(BL)
SciaticNerve
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Leftpelviclimb,canine
ConsidertheSpinalSegmentalSourcesofPeripheralNerves
KI1“GUSHINGSPRING”
TCM:
Stabilizesandcalmsthespirit
Descendsexcesscomingfromthehead
MedicalAcupuncture:
Richwithautonomicfibers“nervivasorum”
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HEADANDNECK
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TrigeminalNerve
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Knowinganatomymakesforasaferacupuncturepractice.
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ORGANEFFECTSTHROUGHSEGMENTALSTIMULATION
Evidence
• ChenCYetal• Thepossibleneuronalmechanismofacupuncture:morphologicalevidenceoftheneuronalconnectionbetweengroina-shipointanduterus.EvidBasedComplementAlternatMed. 2013;2013:429186.
Evidence
• ChangFYetal.• Effectoftranscutaneousnervestimulationonesophagealfunctioninnormalsubjects–evidenceforasomatovisceralreflex.AmJChinMed. 1996;24(2):185-192.
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Evidence
• SatoAetal.• Neuralmechanismsofthereflexinhibitionandexcitationofgastricmotilityelicitedbyacupuncture-likestimulationinanesthetizedrats.NeurosciRes.1993;18(1):53-62.
Director of the Experimental Institute of
Acupuncture and Moxibustion Therapy
“Autonomic Nervous System”, an illustration from Zhu’s New Acupuncture and Moxibustion, indicating her emphasis on Western
medical concepts.
SomatovisceralConnections
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TreatingEquineNon-SurgicalColic
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¡ Somatic afferent nerve stimulation leads to normalization of central, peripheral, and autonomic nervous system function.
¡ Noblett K.§ Neuromodulation and female pelvic disorders§ Clin Opin Urol. 2016;26(4):321-327.
¡ Yamanishi T et al.§ Neuromodulation for the treatment of lower
urinary tract symptoms. § Low Urin Tract Symptoms. 2015;7(3):121-132
¡ Mechanisms for overactive bladder involve:§ Reflex inhibition of detrusor contraction by the
activation of afferent fibers▪ Activation of the hypogastric nerve▪ Direct inhibition of the pelvic nerve within the sacral
cord▪ Supraspinal inhibition of the detrusor reflex
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¡ Mechanisms for stress incontinence involve:§ Contraction of the pelvic floor muscles through an
effect on the muscle fibers§ Stimulation of the pudendal nerves
¡ Somatic afferent nerve stimulation leads to normalization of central, peripheral, and autonomic nervous system function.
!
BACKANDPELVIS
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Whatarethelocal,regional,andvisceraleffectsofthepelvicBLpoints?
ThoracolumbarFascia
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TheDaoofChineseMedicine
• AccordingtoDonaldE.(“Deke”)Kendall’stranslationofthe“curiousmeridians”,theChinesewereindicatingthatthesewere“singularvessels”,suchastheaorta,venaecavae,andtheuniquevenousdrainageoftheback
Azygousandhemi-azygousveinsdraintheback
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Continuouswiththe
drainageofthebrain
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EvidenceforGV20andCirculationtotheBrain
LearningObjectives
3. Identifymedicalconditionstreatedwithacupunctureandresourcesforreferralandfurtherlearning
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WhatCanAcupunctureTreatinAdditiontoPain?
• Digestivedisorders:gastritisandhyperacidity,spasticcolon,constipation,diarrhea
• Respiratorydisorders:sinusitis,sorethroat,bronchitis,asthma,recurrentchestinfections
• Neurologicalandmusculardisorders:headaches,facialtics,neckpain,ribneuritis,frozenshoulder,tenniselbow,variousformsoftendinitis,lowbackpain,sciatica,osteoarthritis
• Urinary,menstrual,andreproductiveproblem[Fromhttp://www.medicalacupuncture.org/For-Patients/Articles-By-Physicians-About-Acupuncture/Doctor-Whats-This-Acupuncture-All-About]
SystematicReviews,Meta-Analyses• AcuteIschemicStroke:Acupunctureimprovestheneurologicscoreand
clinicaloutcomeoverconventionalapproach– WangYetal.Scalpacupunctureforacuteischemicstroke:ameta-
analysisofrandomizedcontrolledtrials.EvidBasedComplementAlternatMed.2012;2012:480950.doi:10.1155/2012/480950.
• Co-morbidsymptomsamongmilitaryfighters:Acupunctureeffectivelytreatsheadaches,anxiety,sleepdisturbances,depressionand chronicpain ascomponentsofthetraumaspectrumresponse– LeeCetal.Theeffectivenessofacupunctureresearchacross
componentsofthetraumaspectrumresponse(tsr):asystematicreviewofreviews.SystematicReviews.2012;1:46.doi:10.1186/2046-4053-1-46.
SystematicReviews,Meta-Analyses
• BurningMouthSyndrome:Acupuncturereducessensationofburningintheoralcavity– YanZetal.Asystematicreviewofacupunctureoracupointinjectionformanagementofburningmouthsyndrome.QuintessenceInt.2012;43(8):695-701.
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SystematicReviews,Meta-Analyses• AddictiveBehavior:Acupunctureimprovessmokingcessationrateandreducesthenumberofcigarettessmokedeachday– ChengHMetal.Systematicreviewandmeta-analysisoftheeffectsofacupointstimulationonsmokingcessation.AmJChinMed.2012;40(3):429-442.
• PostoperativeNauseaandVomiting:Bothinvasiveandnon-invasiveacupuncturepointstimulationpreventpost-operativenauseaandvomitingwithminimalsideeffects– HolmerPetterssonPetal.Acupuncturepriortosurgerytominimizepostoperativenauseaandvomiting:asystematicreview.JClinNurs.2012;21(13-14):1799-1805.
SystematicReviews,Meta-Analyses
• Acupuncturetreatsbothtensionandneurovascularheadache– LindeK etal.Acupuncturefortension-typeheadache.CochraneDatabaseSystRev2009:CD007587.
– ZhaoL,GuoY,WangW,etal.Systematicreviewonrandomizedcontrolledclinicaltrialsofacupuncturetherapyforneurovascularheadache.ChinJIntegrMed.2011;17(8):580-586.
SystematicReviews,Meta-Analyses
• ShoulderPainafterStroke:Acupuncturetreatspainintheshoulderafterstrokewhencombinedwithexercise– LeeJAetal.Acupunctureforshoulderpainafterstroke:asystematicreview.JAlternComplementMed.2012;18(9):818-823.
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SystematicReviews,Meta-Analyses
• BackPain:Acupuncturemaymoreeffectivelyalleviatethesymptomsofacutelowbackpainthannon-steroidalinflammatorydrugs– LeeJHetal.Acupunctureforacutelowbackpain:asystematicreview.ClinJPain.2013;29(2):172-185.
– HutchinsonAJetal.Theeffectivenessofacupunctureintreatingchronicnon-specificlowbackpain:asystematicreviewoftheliterature.JOrthopSurgRes.2012;7:36.
SystematicReviews,Meta-Analyses
• PelvicOrganDysfunction:PTNSimprovessymptoms,lessenspainandbolstersqualityoflifebymeansofpercutaneoustibialnervestimulation– BiemansJMAEetal.Efficacyandeffectivenessofpercutaneoustibialnervestimulationinthetreatmentofpelvicorgandisorders:asystematicreview. Neuromodulation.2013;16:25-34.
SystematicReviews,Meta-Analyses• PregnancyRatesinWomenFollowingIn-VitroFertilization:Acupunctureincreasesclinicalpregnancyrateandlivebirthrate– Zhengetal.Effectsofacupunctureonpregnancyratesinwomenundergoinginvitrofertilization:asystematicreviewandmeta-analysis.FertilSteril.2012;97(3):599-611.
• LaborPain:Bothacupressureandacupuncturelessenedtheintensityofpain;acupuncturereducedanalgesicdrugintake– SmithCAetal.Acupunctureoracupressureforpainmanagementinlabour.CochraneDatabaseSystRev.2011;(7):CD009232.
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SystematicReviews,Meta-Analyses• PrimaryDysmenorrhea:Acupuncturereducespainintheshorttermwithnon-invasivepointstimulation– ChungYCetal.Acupointstimulationinterventionforpeoplewithprimarydysmenorrhea:systematicreviewandmeta-analysisofrandomizedtrials.ComplementTher Med.2012;20(5):353-363.
• ChronicPain:Acupunctureoutperformsshamandno-acupunctureforthetreatmentofchronicpain– VickersAJetal.Acupunctureforchronicpain:individualpatientdatameta-analysis.ArchInternMed.2012;172(19):1444-1453.
SystematicReviews,Meta-Analyses• OsteoarthritisoftheKneeandOtherPeripheralJoints:Acupunctureoutperformsstandardcaretreatment,shamacupunctureandwaitingforfurthertreatmentincasesofkneepainfromosteoarthritis– ManheimerE,ChengK,LindeK,LaoL,Yoo J,WielandS,etal.Acupunctureforperipheraljointosteoarthritis.CochraneDatabaseSystRev2010:CD001977.
– CaoL,ZhangXL,GaoYS,etal.Needleacupunctureforosteoarthritisoftheknee.Asystematicreviewandupdatedmeta-analysis.SaudiMedJ.2012;33(5):526-532.
SystematicReviews,Meta-Analyses
• CancerCare– Acupuncturecontrolsnauseaandvomiting• KayGarciaM,McQuadeJ,HaddadR,etal.Systematicreviewofacupunctureincancercare:asynthesisoftheevidence.JClinOncol.2013Mar1;31(7):952-60.
– Acupuncturerelieveshiccups• ChoiT-Y,LeeMS,andErnstE.Acupunctureforcancerpatientssufferingfromhiccups:asystematicreviewandmeta-analysis.ComplementaryTherapiesinMedicine. 2012;20:447-455.
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SystematicReviews,Meta-Analyses
• Obesity:Acupunctureproducedsimilarefficacyasanti-obesity medicationbutwithfeweradverseeffects– SuiYetal.AsystematicreviewonuseofChinesemedicineandacupuncturefortreatmentofobesity.ObesRev.2012;13(5):409-430.
ResourcesforFurtherLearning
• AmericanAcademyofMedicalAcupuncture– Annualsymposia– Coursesinmedicalacupuncture– medicalacupuncture.org
• AmericanBoardofMedicalAcupuncture– Listofapprovedtrainingprograms– dabma.org/programs.asp
ReferralList
• AmericanAcademyofMedicalAcupuncture– medicalacupuncture.org– “FindanAcupuncturist”– Denotesboardcertifiedphysicianacupuncturists(DABMA)aswellasFellowsoftheAmericanAcademyofMedicalAcupuncture(FAAMA)
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Summary
FinalThoughts
• Thewayacupunctureworksisrightbeforeoureyesandinourhands
• Itinvolvesneuromodulationandconnectivetissuetreatment
• Takinganeuroanatomicandconnectivetissue,medicalacupunctureapproachdoesnotdiminishthewondermentofacupuncture
• Infact,itheightensit.
FinalThoughts…
• Medicalacupunctureexemplifieshowscientificresearchandcriticalinquiryallowustoanalyzetraditionalapproachesandtosortfactfrommyth.
• Medicalacupuncturebuildsupon,updates,andupgradesancientapproachessuchasChineseMedicine.
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FinalThoughts…
• Asmedicalacupuncturists,werecognizetheimportantstridesthatChineseandotherAsianacupuncturistsbroughttothedisciplineandtheastuteobservationstheymadeaboutstructure– functionrelationships
• Theseenduringconnectionsprovidefertileterritoryforfurtherexplorations
FinalThoughts…
• Approachingintegrativemedicinescientificallyfacilitatesitsintegrationintobothprimaryandspecialtycare.
AdditionalReading• RobinsonN.4mythsaboutacupuncture.VeterinaryPracticeNews. 10/27/14.http://www.veterinarypracticenews.com/4-Myths-About-Acupuncture/
• RobinsonNG.OneMedicine,OneAcupuncture.Animals. 2012;2(3):395-414.Accessedathttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC4494296/
• RobinsonNG.InteractiveMedicalAcupunctureAnatomy.TetonNewMediaandCRCPress.PublishedMarch2,2016.1251pages.