acupuncture cpd back & lower limb · extra lower limb points •ex-le 2 heding lower extremity...

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ACUPUNCTURE CPD Back & Lower Limb

Jonathan Hobbs MSc MCSP FHEA

AACP Chairman & Accredited Tutor

ACUPUNCTURE ASSOCIATION OF

CHARTERED PHYSIOTHERAPISTS

Aims

• Improve knowledge of BL, GB, ST, SP, LR, KI and GV meridians

• Review meridian point selection for msk conditions

• Review extra point location and usage for msk conditions

• Review additional techniques for the treatment of msk pain related to the back and lower limb

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Objectives

To be able to:

• Have a greater understanding of BL, GB, ST, SP, LR, KI and GV channels for the treatment of msk pain

• Treat back and lower limb msk pain and dysfunction with BL, GB, ST, SP, LR, KI and GV channels

• Treat back and lower limb msk pain and dysfunction with trigger points and off channel techniques

Overview

• Mechanisms and theories

• Layering technique

• Classic meridian points

• HTJJ

• Extra points

• Myofascial trigger points

• Paraspinal Needling

• Summary

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Acupuncture Trialists’ Collaboration

• Systematic review 29 (RCTs), n=17 922, acupuncture for chronic pain (back and neck pain, osteoarthritis, chronic headache, and shoulder pain).

Conclusion:

• Effective for the treatment of chronic pain - reasonable referral option

• Significant differences between true and sham acupuncture

• Indicates acupuncture is more than a placebo

• Relatively modest difference – additional effects to needling important to therapeutic effect

• Vickers et al, (2012)

Acupuncture Needle Painful Stimulus

Skin

Muscle

Spinal Cord

Mid Brain

Pituitary

Hypothalamus

Thalamus

Cortex

1

2

7

6

5

8 9 10 11

3

14 12

13

4

E

ALT

DLT

M

M

E

E E

E

STT

Legend

Nerve Cell

Excitatory Synapse

Inhibitory Synapse

Sensory Nerve

Blood Vessel

Direction of Impulse

Acupuncture needle

Sensory Receptor

Painful Stimulus

Hormone Release

ALT - Anterolateral

Tract

DLT – Dorsolateral

Tract

STT – Spinothalamic

Tract

M – Monoamines

E - Endorphins

Acupuncture Analgesia

(after Stux & Hammerschlag, 2001)

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Peripheral (local) effects

• Needle points close to injury

• Stimulate gently to maximise local effect.

• Superficial tissues –low-intensity to reduce sympathetic tone and aid circulation

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Segmental/spinal effects

• Local points anatomically near to damaged tissue

• Or points away from damaged tissue with same segmental innervation

• Same myotome, choose area with tender points

Supraspinal effects

• Extra-segmental points & “big points‟ of the extremities

• Strong stimulation to activate descending inhibitory systems from the hypothalamus, and DNIC

• Rx time 20-40minutes

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Central sympathetic effects

• Autonomic nervous system controlled by the hypothalamus; stimulated in same manner as analgesic supraspinal effects.

• Choose large points of extremities and stimulate strongly for 20 to 40minutes

Checklist – what do you want?

• Peripheral effects?

• Segmental/spinal effects?

• Supraspinal effects?

• Sympathetic outflow?

• Central sympathetic effects?

• Immune effects?

• Bradnam L . A proposed clinical reasoning model for Western acupuncture J of AACP Jan 2007:21-30

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Layering Technique

Location of points needled

• Points distal to elbows and knees:

• Have a larger peripheral nerve plexus – less stimulation, stronger central response?

• Have a greater sympathetic innervation – more efficient at modulating response?

• More superficial (hands and feet) – connective tissue and periosteum stimulated - greater sensory input into the CNS?

• Concept of „Big Points‟ Bradnam L. A pathway of progression for Western acupuncture: Using the power of the brain. J of AACP July 2003:27-33

Classic Meridians

Ordinary

• Bladder

• Gall Bladder

• Stomach

• Spleen

• Liver

• Kidney

Extraordinary

• Governor Vessel

Extra

• Huatuojiaji

• Extra Back

• Lower Extremity

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• Inner branch - Back Shu spinal segments

• Consider inner sacrum (BL31-35)and BL54

• Consider KI3+BL60 for chronic LBP

• BL 52

• BL 54

• BL 36

• BL 40

• BL 57

• BL 60

• BL62

Bladder Meridian - Back Shu

Back Shu/Influential Points Segment

• BL 11 Influential point for bone T1

• BL 13 Lung T3

• BL 14 Pericardium T4

• BL 15 Heart T5

• BL 16 Governor vessel T6

• BL 17 Influential blood T7

• BL 18 Liver T9

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• BL 19 Gallbladder T10 • BL 20 Spleen T11 • BL 21 Stomach T12 • BL 22 Triple Energizer L1 • BL 23 Kidney L2 • BL 24 Sea of Qi L3 • BL 25 Large Intestine L4 • BL 27 Small Intestine S1 • BL 28 Bladder S2

EX-B 2 Huatuojiaji 0.5 cun lateral to the lower border of the spinous processes T1-L5.

• T1-T3 HTJJ Points: disorders of the upper limbs.

• T4-T6 HTJJ Points: disorders of the HT.

• T7-T9 HTJJ Points: LV/GB issues.

• T10-T12 HTJJ Points: ST/SP issues.

• L1-L2 HTJJ Points: KD issues.

• L3-L5 HTJJ Points: UB, LI, SI, Uterine & Lower Limb issues.

• Consider C1-C7 options?

• Also EX-B 1 Dingchuan – “Stop Wheezing”

• 0.5 cun lateral to C7. Local point for neck, shoulder and upper back pain.

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• GV 3

• GV 4

• GB 29

• GB 30

• GB 31

• GB 33

• GB 34 as master point for connective tissues.

• GB 39

• GB 40

• GB 41

• GB 42

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• ST 30

• ST 32

• ST 34

• ST 35

• ST 36

• ST 41

• ST 42

• ST 44

• SP 3

• SP 4

• SP 5

• SP 6

• SP 9

• SP 10

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• LR 2

• LR 3

• LR 8

• KI 1

• KI 3

• KI 6

• KI 7

• KI 9

• KI 10

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Extra lower limb points

• EX-LE 2 Heding Lower extremity 2

• Location: Above the knee, in the depression of the midpoint of the superior patellar border. Needle perpendicularly 0.5 - 0.8 cun.

• Knee, leg and foot pain and weakness.

• EX-LE 4 Xiyan Lower extremity 4

• Location: Medial knee depression.

• Needle perpendicularly 0.7 – 1 cun.

• Knee pain and inflammation.

Extra lower limb points

• EX-LE 10 Bafeng Lower extremity 10

• Location: On the dorsum of the foot between the web and metatarsophalangeal joint (4 points on each foot). Needle obliquely and proximally 0.5 cun.

• Foot pain, swelling and numbness.

• LR 2, ST44, extra, GB 43

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Myofascial Trigger Points

• ‘‘a hyperirritable spot in skeletal muscle that is associated with a hypersensitive palpable nodule in a taut band’’ (Simons and Travell, 1999)

• 400 muscles all can develop MTrPs- referred pain and motor dysfunction (Simons et al, 1999).

• Active: Painful at rest, tender on palpation with referred pain pattern that replicates the patient’s pain

• Latent: do not cause obvious pain, may restrict movement or cause weakness or dysfunction

• Melzack (1977) reported a high degree (71%) of correspondence between MTrPs & acupuncture points.

• Referred pain distribution matching meridian?

• headaches - GB1-GB21

• All MTrPs may be Ah-Shi acupuncture points?

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Criteria for identifying active or latent MTrPs (Simons et al, 1999)

Essential criteria:

1. Taut band palpable (if muscle accessible)

2. Exquisite spot tenderness of a nodule in a taut band

3. Patient’s recognition of current pain complaint by pressure on the tender nodule (identifies an active MTrP)

4. Painful limit to full stretch ROM

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Integrated Trigger Point Hypothesis Simons et al, (1999)

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• Needle cause very small focal lesions (no risk of scar tissue formation)

• Needle diameter - 160-300μm (0.16mm-0.3mm)

• Muscle fibre diameter 10-100μm (Dommerholt et al., 2006).

• Muscle damaged - satellite cells are activated from other areas in the muscle to repair or replace damaged myofibres - muscle regeneration (Schultz et al, 1985).

• Process occurs 7-10 days (Schultz et al, 1985)

• Baldry (2005) recommends leaving the needle in situ for 30-60 seconds (may be up to 2-3 minutes?)

Radiculopathic Model for Muscular Pain • Gunn (1997) suggested a radiculopathic model for muscular pain

and states that;

“myofascial pain describes neuropathic pain that presents predominantly in the musculoskeletal system’

• Gunn (1997); Quintner and Cohen (1994) - proposes neurological cause as the primary stimulus and MTrPs as a secondary phenomenon

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Gunn (1997) states:

• Neuropathic nerves are most commonly found at the rami of segmental nerves -therefore represent a radiculopathy

• Myofascial pain relates to intervertebral disc degeneration with nerve root compression or angulation due and resultant paraspinal muscle spasm

• Neuropathy sensitises structures in the distribution of the nerve root

• Leads to distal muscle spasm and degenerative changes in tendons and ligaments related to muscle shortening

• Shortening of the paraspinal muscles - disc compression - narrowing intervertebral foramina - pressure on nerve root - peripheral neuropathy & supersensitive nociceptors = pain, dysfunction, taut bands with MTrPs.

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• Radiculopathic model may explain MTrP formation and tendinopathy and enthesopathy

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• Long lasting pain relief requires needle treatment to the shortened paraspinal muscles to reduce nerve root compression & local trigger points (Gunn, 1997).

• Cannon and Rosenblueth’s Law of Denervation Supersensitivity states that “when a tissue is deprived of its nerve supply, it will develop hypersensitivity to its own neurotransmitter(s).”

• Cohen & Quintner (2008) suggest that with regards to trigger point theory;

“in the face of evidence of refutation’ we should ‘stop flogging a dead horse’ and reject the concept of MTrP pain as a clinical entity”

IMS concepts (paravertebral) Gunn

• Diagnostic tool

• Deep contractures beyond palpation

• Penetration of contracture: firm resistance, needle grasp, cramping/grabbing

• Fibrotic tissue: grating sensation (cutting a pear)

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Practice

Needle grasp:

• Provokes fasciculation and release quickly

• Shortened muscle grasps the needle.

• Grasp resists withdrawal.

• Leave in situ 10 to 30 minutes leads to release of persistent contracture.

• Failure (correctly placed needle) to induce needle-grasp - spasm is not present - not the cause of pain - not respond to this treatment.

Lumbar/Sacral Myotomes

Ant. Primary Rami L2 L3 L4 L5 S1 S2

Femoral/Obturator group

Iliacus

Thigh adductors

Quadriceps femoris

Representation Major Minor Equivocal



Gluteal/Sciatic group

Glute med.

Glute max.

Med hamstrings

Lat hamstrings


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Peroneal group

Tibilais ant

Ex hal long

Ext dig brev

Peronei




Tibial group

Tibilais post

Fle dig long

Gastroc lat

Gastroc med

Soleus

Abd dig pedis

Abd hallucis


Additional techniques

• “Circle the Dragon”

• “Herringbone”

• “Threading”

• “5 Pointed Star”

• “Stonehenge”

• “Matrix”

• “Periosteal Pecking”

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Summary

• Layering

• Classic meridian points

• HTJJ- segments: local, visceral, referred, triggers

• Myofascial trigger points- local & spinal

• Consider Extra points & techniques

• Prescriptions/combinations

• Always: • Respect your client

• Respect the anatomy

• Respect the technique

References • Baldry P (2002) Management of myofascial trigger point pain. Acupuncture in

Medicine. 20(1), 2-10.

• Bradnam L (2003) A pathway of progression for Western acupuncture: Using the power of the brain. J of AACP July, 27-33

• Cohen M, Quintner J(2008) The horse is dead: let myofascial pain syndrome rest in peace. J. Pain Med. May Jun; 9(4): 464-5

• Dommerholt, J., Mayoral del Moral, P. T. and Grobli, C. (2006) Trigger Point Dry Needling. The Journal of Manual & Manipulative Therapy; 14(4): E70-E87.

• Gunn, C.,(1997) Radiculopathic pain: diagnosis and treatment of segmental irritation or sensitisation. Journal of Musculoskeletal Pain 5, 119–134.

• Keown, D (2013)What God forgot to tell surgeons: the science of acupuncture. Original Medical Publishing.

• Langevin, H. M., Churchill, D. L., Wu, J., Badger, G. J., Yandow, J. A., Fox, J. R. and Krag, M. H. (2002) Evidence of connective tissue involvement in acupuncture. Journal of the Federation of American Societies for Experimental Biology; 16: 872- 874.

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• Langevin, H (2008) Potential role of fascia in chronic musculoskeletal pain. In: Audette, J.F., Bailey, A. (Eds.), Integrative Pain Medicine: The Science and Practice of Complementary and Alternative Medicine in Pain Management. Human Press, Otowa, pp. 123–132.

• Ma, Y (2011) Biomedical acupuncture for Sports and Trauma Rehabilitation: Dry Needling Techniques. Churchill Livingstone. St Louis, Missouri.

• Melzack R, Stillwell DM, Fox EG (1977) Trigger points and acupuncture points for pain: correlations and implications. Pain 1977; 3: 3-23.

• Quintner, J., Cohen, M (1994) Referred pain of peripheral nerve origin: an alternative to the “myofascial pain” construct. The Clinical Journal of Pain 10, 243–251.

• Shang C (1989) Singular point, organizing center and acupuncture point. Am J Clin Med17:119–127.

• Shang C (1993) Bioelectrochemical oscillations in signal transduction and acupuncture: An emerging paradigm. Am J Clin Med ;21:91–101.

• Shang C (1995) Health indicators beyond the absence of disease. AMSA Task Force Quarterly, Fall, 22.

• Shang C (1999) Toward a unified theory of acupuncture and modern sciences. In: Handbook of Faculty Syllabus Materials for the 1999 Symposium. The American Academy of Medical Acupuncture, Los Angeles, 299–312.

• Shang, C (2001) The Journal of Alternative and Complementary Medicine. Volume 7, Number 1, pp. 83–91.

• Simons, D.G., Travell, J.G., Simons, L. (1999) Myofascial Pain and Dysfunction: The Trigger Point Manual. Williams & Wilkins, Baltimore.

• Vickers AJ, Cronin AM, Maschino AC, Lewith G, MacPherson H, Foster NE, Sherman KJ, Witt CM, Linde K, (2012) Acupuncture for Chronic Pain: Individual Patient Data Meta-analysis. Arch Intern Med Published Online September 10, 2012.

• Winfree AT (1984) A continuity principle for regeneration. In: Malacinski GM, ed. Pattern Formation. New York: Macmillan, 106–107.

acupuncture cpd back & lower limb · extra lower limb points •ex-le 2 heding lower extremity...

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