Pulling it together

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12 Pulling it together

• This chapter deals with the arrival of the patient: how are we to apply all these ideas and theories? We suggest ways of organizing our thoughts, according to the response we are hoping to encourage.

• For instance, if the presentation seems to have a Western medical feel to it then it will be best to consider it in that way, checking off the systems that are demonstrating damage and attempting to place the needles in sites that will elicit a change in physiology.

• Western medical acupuncture, as described in Chapter 2 by White [1], will support the choices, whether aiming for a local, spinal or supraspinal effect.

• The first part of Chapter 12 deals with the direct application of Western ideas.

• When the picture is complex with many different symptoms competing for the chief problem, or the picture changes from hour to hour, day to day, it may be that the philosophies of Chinese medicine have as much to offer, specializing as they do in interactivity, complicated interactions and results that may progress through further syndromes before resolving.

• The second part of Chapter 12 offers a loose structure to support the traditional Chinese medicine treatment model.

The Western therapist

The Western approach is summed up perfectly by the following quotation:

Acupuncture is a valuable method of complementary medicine with broad application in neurology. It is based on the experiences of traditional Chinese medicine as well as on experimentally proven biological (biochemical and neurophysiological) effects. Acupuncture-induced analgesia is mediated by inhibition of pain transmission at a spinal level and activation of central pain-modulating centers by release of opioids and other peptides that can be prevented by opioid antagonists (naloxone). Modern neuroimaging methods (functional MRI) confirmed the activation of subcortical and cortical centers, while transcranial Doppler sonography and SPECT showed an increase of cerebral blood flow and cerebral oxygen supply in normal subjects. Clinical experience and controlled studies confirmed the efficacy of acupuncture in various pain syndromes (tension headache, migraine, trigeminal neuralgia, posttraumatic pain, lumbar syndrome, ischialgia, etc.) and suggest favorable effects in the rehabilitation of peripheral facial nerve palsy and after stroke. Appropriate techniques, hygiene safeguards and knowledge of contraindications will minimize the risks of rare side effects of acupuncture which represents a valuable adjunction to the treatment repertoire in modern neurology. There is sufficient evidence of acupuncture to expand its use into conventional medicine and to encourage further studies of its pathophysiology and clinical value [2].

Although broadly encouraging, this raises a number of questions, the first being safety. Are we certain that acupuncture is safe? We do have results from a couple of very important safety trials, mentioned elsewhere in this book [3, 4], which support clinical practice and we also have additional anatomical work where skeletal anomalies have been examined and confirmed for prevalence. The two most important are the possibility of a sternal foramen at the level of CV 17 Shanzhong, and the thinning and occasional hole in the subspinal area of the scapula [5]. Once aware of the existence of these problems, and recognizing that the general bulk of muscle tissue can be greatly diminished in neurological disease, needling can be adjusted to avoid inflicting damage to the patient in any way.

Other safety issues are concerned with the physiological actions of acupuncture, such as increases in blood flow and velocity, sudden changes in blood pressure, unrealistic expectations produced by pain relief or euphoric responses to needling. Reviews of safety have concluded that, while acupuncture is not free of adverse events, they are rare, and it remains a relatively safe procedure [6].

It is also worth remembering that some of the recorded side-effects of acupuncture can be positive, the chief among them being described in a study of acupuncture as used by Swedish physiotherapists as ‘a pleasant feeling of fatigue’ [7].

Western supporting techniques

Ear acupuncture

This is a technique claimed by both Western and Eastern camps and probably belongs equally well in both. It is probably the best-known microsystem in acupuncture. It was first recognized as a reflex system by Paul Nogier in the 1950s. There are two distinct classifications of points, those according to Nogier, adapted by Bahr, and those according to traditional Chinese medicine (TCM).

The ancient Chinese recognized that some channels passed around or through the ear and described all the Yang meridians as having some connection but had not fully appreciated the reflexes involved. Nogier on the other hand spent many years studying the ear and slowly built up his concept of the ‘man in the ear’, in which he described a human fetus in an upside-down position with the head in the region of the earlobe and the limbs towards the top of the ear (Figure 12.1).

Figure 12.1 • ‘The man in the ear’ according to Nogier.

(From Hopwood V. Acupuncture in Physiotherapy. Oxford: Butterworth-Heinemann, 2004, p. 142.)

Nogier’s ideas were imported into China in the mid-1950s and barefoot doctors were trained in auricular therapy techniques, using the map of points as illustrated, and enabled to treat a large range of problems.

Nogier postulated that if there is a change in the body system due to pathology then a corresponding change can be shown in the ear, on the appropriate region. In the case of pain the areas where pain is felt in the body have been shown to have a high correlation with tenderness in the points on the ear that correspond with the sites. Oleson et al. provided the statistical evidence for these defined regions with a 74% accuracy rate in defining the musculoskeletal pains of 40 patients [8]. This applies to many kinds of pathology, not just pain [9]. The area occupied on the ear surface is proportional to that in the cortex, so the upper limb, particularly the hand and face, seems well represented.

The standardization of nomenclature for ear acupuncture points has been slow: the two main schools, that of Nogier and the TCM point locations, have now been joined by the work of Frank and Soliman [10, 11] who built on the original Nogier extended work which described three basic phases – mesodermal, ectodermal and endodermal. The theory underlying this division is that the ear is composed of three different kinds of tissue in the developing embryo and each of these types is involved in differing somatotropic responses relating to the ear. Further, the different phases are associated with acute, intermediate and chronic pain conditions. An acupuncture atlas [12] just gives all the points with little or no explanation, leading to much confusion among students.

Auricular therapy is defined as a physical reflex therapy which detects somatic level disturbances on the auricle. There are precise zones of representation of organs, though these are not thought of as fixed points as they tend to have fluctuating boundaries, depending as they do on the metabolism of the organ. The right ear is said to represent the left hemisphere of the brain whereas the left ear represents the right hemisphere. Thus treatment will be on the same side as the problem.

The ear is associated with the parasympathetic nervous system, effectively modulating the sympathetic responses. The innervation of the central part of the ear links directly into the vagal nerve (the 10th cranial nerve). This means that rather than the ‘fight or flight’ response it tends to reduce the heart rate, lower blood pressure and facilitate digestion and excretion, thus returning the body processes to their normal rate. In short, in times of danger, the sympathetic system prepares the body for violent activity; the parasympathetic system reverses these changes when the danger is over.

Nogier discovered that there was a change in the amplitude of the human pulse as monitored at the wrist when tactile stimulation of the ear occurred. This was evidence of a sympathetic reflex affecting peripheral blood vessel activity. He referred to this as the auricular cardiac reflex. The changes detected are in waveform or amplitude, not in pulse rate. It is an involuntary arterial reflex and also known as the vascular autonomic signal, and is found as a vascular cutaneous reflex in response to other stimuli. This response to any form of tactile stimulus may explain the soothing effect of rubbing the ears, in both small children and dogs!

Acupuncture technique in the ear is slightly different to any other body surface. Short, fine needles are preferable and these are inserted carefully without piercing the cartilage of the ear. The reason for this care is that the cartilage has a poor blood supply so if it becomes infected it is difficult to eliminate the infection. This has led to recommendation of alcohol swabs to clean the surface before needle insertion.

Originally auriculotherapy was recommended for the treatment of nicotine or alcohol addiction and subdermal needles like tiny tacks were left in situ from one treatment to the next and covered by a small piece of plaster. This is discouraged nowadays because the risk of infection is too great.

The Chinese ear charts differ quite radically from those produced by Nogier, leading to considerable confusion among acupuncturists (Figure 12.2). There are many points on the TCM ear, located by way of a grid system and requiring a fine location skill. Chinese texts recommend the use of the points according to TCM principles, i.e. the Kidney point to treat bones, but since this appears to be a true reflex system this use is not supported scientifically.

Figure 12.2 • Chinese map of ear points

(from Hopwood V. Acupuncture in Physiotherapy. Oxford: Butterworth-Heinemann, 2004, p. 14.)

More important is the nerve supply to each part of the structure. The ear has an abundant innervation, being supplied by the sensory fibres of the trigeminal, facial and vagus nerves. The endings of these nerves are closely interwoven and can influence many distant body areas. Bourdiol gives an explanation based on embryology, emphasizing the fact that these nerves travel only a short distance to the reticular formation of the brainstem [13].

There are several ways of classifying the points. Oleson and Kroening [14] suggested nomenclature that depends on whether the points are located on raised, depressed or hidden areas in the ear. Otherwise the Chinese or Nogier maps are commonly used.

The mechanism appears to be the same as in the rest of the body. Ear acupuncture has been shown to affect the endorphin concentration and to be reversible by naloxone [15]. The study by Simmons and Oleson investigated changes in dental pain threshold after electroacupuncture stimulation to the ear, showing that true electroacupuncture produced a significant rise in the pain threshold while the placebo, using inappropriate ear points, did not.

All areas of the ear surface are utilized, with some points being located on raised areas, some in the depressions and some in hidden areas under folds of tissue and still others on the posterior surface of the ear.

When the two maps, that of Nogier and the TCM map, are compared it can be seen that some regions are similar but there are many single points that do not seem to tally. In physiotherapy practice the most commonly used auricular point is Shenmen, common to both, a sedative point located in the navicular fossa. As might be deduced from the name, this has similar applications to Heart 7 Shenmen, being used to calm anxious patients, often before further acupuncture is undertaken. The musculoskeletal zones are also frequently used, perhaps because they are easily located.

These points are used in conjunction with body acupuncture in many protocols for musculoskeletal acupuncture. They offer an alternative when points are inaccessible, either because of medical problems or plaster, or simply because of the difficulty of positioning or undressing the patient.

Points derived from the Chinese system of ear acupuncture are regularly used in drug addiction withdrawal programmes. The National Acupuncture Detoxification Association protocol uses five points – Shenmen, Liver, Lung, Sympathetic and Kidney – and is supported by some research [16]. This combination of points can produce profound relaxation in distressed patients so it has an application beyond that of drug withdrawal. It may owe more to the fact that the pinna is richly innervated and offers a good site to stimulate the central nervous system in a general way, but it has been utilized successfully in palliative care patients with serious anxiety states.

Technique

The indications of pathology are similar to those elsewhere in the body. Among these are changes in the appearance of the skin, redness or small skin lesions, changes in tenderness or sensitivity of the skin and changes in the electrical resistance of the skin. The usual way of detecting these tender points is to use manual pressure via the blunt end of an acupuncture needle or a blunt spring-loaded instrument. Care must be taken to maintain an even pressure and the location of tender spots indicates both the area of the body in trouble and the point in the ear to insert the needle.

Electrical point finders are often recommended for use in the ear. Where the points are so close together distinguishing between one and the next might be a critical factor in treatment. While theoretically a good idea, these are difficult to use in practice because it is easy to produce a false impedance reading if the pressure on the skin is too great or if the patient is sweating. It is also possible to burn a low-resistance pathway through the dermis if the current is too high, also producing a false point.

Treatment is usually most effective with the least number of needles. The tiny needles are usually left in for 10–20 minutes, normal treatment time and, as explained previously, it is not recommended that they be left between treatments. Slight bleeding may occur after removal of the needles; an alcohol swab can be used to clear this.

If a longer effect is required patients can be asked to stimulate the point themselves. Sterilized mustard seeds or small ionic beads (Magraine) may be left securely stuck to the ear with small plaster patches. This makes it possible for the patient to apply acupressure in between treatments, whenever the presenting problem recurs.

If body acupuncture is to be combined with the use of ear points, the points on the ear must be located first as the delicate organ cutaneous reflex can be altered by body needling and the ear points will be harder to locate.

Research

The original work supporting this theory was performed by Oleson et al. [8]. In a blinded trial it was found that body pathology in patients could be detected with 74% accuracy by testing for tenderness in the ear and measuring changes in the electrical resistance of the skin. The result was highly statistically significant and anecdotal evidence from the same trial indicated that old pathology that the patients themselves had forgotten about was also detected.

A more recent study has taken this apparent correlation further. Given that the pathology of a particular organ appears to give rise to changes in the electrical impedance of the skin on the ear over the corresponding point, the researchers tested the validity of this reflex with patients undergoing surgery [17]. Forty-five patients, admitted for surgery for cholecystectomy, appendectomy, partial gastrectomy or dilatation and curettage after miscarriage, were tested. The initial value of skin resistance was estimated at the auricular organ projection area on five occasions: (1) before premedication; (2) after medication; (3) under general anaesthesia; (4) after skin incision; and (5) after surgery. Two healthy organ projection areas were measured on each patient each time as a control. The examiners performed all measurements without knowledge of the corresponding points.

Of more relevance to neurological disease, a recent systematic review has now indicated that auricular acupuncture appears to be effective for treating insomnia [18]. Ear acupuncture is a useful addition to the needling skills of a physiotherapist. It seems to have a reasonable evidence base and lends itself to use on nervous or debilitated patients. Since it can also be utilized in patients where access to the normal body points is not possible for some reason, for instance in cases of pain after major surgery, during childbirth or extensive application of plaster fixation, it can be versatile. It also provides a means of treating a patient where mobilization is difficult and normal transition from chair to bed presents problems with increased muscle tone.

Trigger point acupuncture

Trigger point acupuncture is a phrase loosely used in acupuncture circles. It needs to be made clear whether one is referring to the use of Ah Shi points in TCM terms (where there is a single painful spot needled in the usual manner) or whether one is using Western-type trigger point acupuncture, which is often referred to as ‘dry needling’. This term is often misunderstood but it is only used to distinguish it from other forms of medical use of needles where fluids may be administered or extracted.

Trigger points are points within the muscles, tendons, ligaments and joint capsule that demonstrate hypersensitivity and pain. These points may be latent, not actually referring pain, or active, referring pain in clearly recognizable patterns.

Myofascial pain, commonly treated by trigger point needling, appears to be modulated by local or segmental effects, perhaps not always requiring a fully intact nervous system. It is worth noting that the myofascial pain points described as trigger points often correlate with traditional acupuncture points [19]. The best textbook, detailing both patterns and treatment techniques, is that by Peter Baldry [20] describing a minimally invasive form of needling which can be very effective and often preferable to the deeper kind when treating neurogenic conditions.

Trigger points are recognized by physiotherapists and appear to form when there is disruption at the motor endplate causing increased adrenocorticotrophic hormone release with sarcomere contraction and compression of blood vessels and a resulting sort of ‘energy crisis’. The clinical characteristics of these points include local tenderness, a palpable taut band and a local twitch response in the contracted band on palpation with a concentration of acetylcholine. Pain is referred distally and there is restricted movement and muscle weakness. There is also often autonomic dysfunction with possible trophoedema.

There are two ways of dealing with this. Since they have not been scientifically compared and both seem to have a clinical effect they are described below.

Superficial needling [20]

The trigger point is first palpated. Either the patient may exhibit a disproportional response, the so-called ‘jump and shout’ response, and/or the operator may be able to palpate a taut band in the muscle. Using a short needle, the point is introduced subdermally and the needle allowed to fall against the skin. No manipulation is given and the Deqi sensation is not elicited. This needle is retained for only 30 seconds, removed and then the point is palpated again. If the sensation remains unchanged, the needle can be reinserted (provided it has not been in contact with anything else in the meantime) and left for a further 30 seconds before final removal. This often appears to deactivate the tender trigger point after the first application [21].

Deep trigger point needling [22]

This involves deep needling into the palpated taut band and a visible muscle twitch is often produced. Quite a long needle is used and, to facilitate easy insertion and prevent contact with the shaft of the needle, a tubular guide is used. Needle grasp conforms to muscular spasm and the accuracy of the insertion. The patient experiences a strong sensation rather like a muscle cramp which can be very painful but does guarantee the eventual success of the intervention. The needle is vigorously manipulated. This manipulation is aimed at disrupting the dysfunctional endplates in order to provoke a healing response. The needle is left for 10–20 minutes and then removed once relaxation has occurred. This may be obtained more quickly with manual stimulation, particularly with ‘pecking’ movements, although it may cause the spasm to intensify initially. Although placing the needle at the motor zone or musculotendinous junction is most effective for releasing spasm, in neuropathy extrajunctional acetylcholine receptors or ‘hot spots’ are formed throughout the entire length of the muscle. Thus a needle inserted almost anywhere into a shortened muscle can relieve spasm [23].

Both types of treatment depend on knowledge of the muscle innervations, nerve roots and the distribution of referred pain from trigger points. Neither really involves Deqi and they are not dependent on knowledge of the meridians and their actions.

Recently published work [24] has offered links between the distal acupuncture points and changes in the painful loci within the trigger point regions. These loci are probably located in the endplate zone and endplate ‘noise’ in trapezius muscles in patients with chronic pain has been shown to decrease after acupuncture is applied to Waiguan and Quchi. The story is not yet fully explored and use of the major distal points remains important whichever school of acupuncture is followed.

Electroacupuncture

Electroacupuncture involves the electrical stimulation of acupuncture points by passing a current through acupuncture needles. It was developed into its modern form in China in the 1950s, when it was used for surgical anaesthesia. Since then it has been used for acupuncture analgesia and many other clinical presentations. It allows the provision of a stronger, more continuous level of stimulation and can be less time-consuming for the practitioner. In some conditions it may produce more rapid and prolonged treatment effects. This form of acupuncture is widely used in research studies since the level of stimulation provided may be carefully standardized [25].

Application of electroacupuncture

The effects of electroacupuncture are influenced by the frequency of stimulation used and the intensity selected. The application of low frequencies of 2–8 Hz will stimulate small-diameter afferent fibres and provide analgesic effects by the release of β-endorphin, enkephalin and orphanin, whilst high frequency, of 80–100 Hz, stimulates large afferent fibres, causing the release of dynorphin [26]. Other neurotransmitters are released and probably include noradrenaline (norepinephrine), dopamine and serotonin [25]. Intensity of stimulation may be varied.

Strong stimulation is often used for pain relief, particularly in situations of chronic nociceptive pain which has failed to respond to milder stimulation. Strong stimulation will increase sympathetic tone, whereas milder stimulation may enhance parasympathetic activity. Electroacupuncture has been used for many situations other than pain, including spasticity, tissue repair and bladder dysfunction.

Electroacupuncture in neurological conditions

Electroacupuncture has been used widely for neurological conditions in China and has also been used in many of the research trials on acupuncture for stroke. Studies relevant to neurological conditions have been considered in Chapter 4. In practical terms electroacupuncture seems to be useful for sensory and motor problems. Evidence shows that lack of afferent information from areas of impaired sensation or movement results in reorganization of cortical maps. Interventions to increase somatosensory stimulation are being used increasingly to influence sensory and motor function, with promising results in some studies [27]. Electroacupuncture could provoke a strong stimulus in this regard, providing afferent information from skin and muscle contraction.

Contraindications and safety specific to neurological conditions

In addition to the usual contraindications and precautions there are particular considerations when using electroacupuncture in neurological conditions. Electroacupuncture may be used in well-controlled epilepsy with caution, although the option of choice would be manual acupuncture. Strong or sustained muscle contraction should be avoided in this condition as well as stimulation applied over the scalp [25].

Caution should also be exercised when considering electroacupuncture stimulation in those with spinal cord injury at T6 and above. Noxious stimulation below the level of the spinal lesion may precipitate autonomic dysreflexia in some individuals. Therefore mild stimulation or perhaps manual acupuncture would be preferred options. Monitoring the patient’s blood pressure before and after treatment would provide valuable information if the practitioner was concerned about this possibility. Reports by the patient of pounding headache, nausea, anxiety and blurred vision require immediate action since this condition may progress rapidly and lead to seizures, intracranial haemorrhage or death.

Intensity of stimulation needs to be considered carefully when treating patients with spinal spasticity, for example in multiple sclerosis or spinal cord injury. Stimulation may provoke disinhibited spinal reflexes, resulting in spasms in the legs, most commonly flexor spasms [28]. Needling should consider the possibility of limb movement during treatment and the practitioner may need to stay immediately by the patient to stabilize the limb and prevent movement if spasms occur.

Transcutaneous electrical nerve stimulation (TENS)

TENS is the application of an electrical current to the body through surface electrodes. There are similarities between electroacupuncture and TENS and the electrodes are frequently applied to acupuncture points. However their physiological effects are different, since TENS can only effectively stimulate nerve endings near the body surface. In general electroacupuncture has stronger and more long-lasting effects than TENS. Even so, TENS may have useful applications in neurological conditions for relief of pain, spasms and spasticity as well as improvement in motor and sensory function [29–31]. TENS is a useful option to provide sensory stimulation over a longer period of time and can be used by the patient as part of a home maintenance programme. Further research is required to clarify the most beneficial applications.

Scalp acupuncture

The insertion of needles into points on the Governor Vessel channel as it runs over the scalp is as old as acupuncture itself. However scalp acupuncture as a distinct system is a relatively new technique which emerged in China and Japan in the early 1970s. It is variously reported as being invented by Jiao Shunfa in 1971, Fang Yunpeng in 1970 and Toshikatsu Yamamoto in 1970. Jiao outlined a system based on the premise that needling points on the surface overlying an organ could produce beneficial effects on the underlying organs in the same way as needling mu points could benefit the associated organ. He extended this thinking to disorders of the brain and incorporated modern awareness of the functional divisions of the cerebral cortex to devise a system of stimulating the scalp to influence the brain [32].

Jiao’s system seems to have some logic to it – needling over the sensory homunculus to influence sensation and over the motor homunculus to influence movement. The system is reported to be particularly useful for neurological conditions such as stroke and Parkinson’s disease, with benefits noted for motor, sensory and speech problems, chronic muscle spasm, balance problems and tremor (see Figures 7.1 and 7.2 in Chapter 7).

Yamamoto’s system, called Yamamoto New Scalp Acupuncture, involves the needling of various points on the scalp according to zones which are reported to influence different parts of the body. It is based on a combination of Chinese medicine, Five Phases principles and Yamamoto’s microsystem theory. The important ‘brain’ points are located either side of the midline just inside the frontal hairline [33]. Yamamomoto’s system is reported to be useful for musculoskeletal and neurological conditions but has not been subjected to rigorous research protocols.

Practical application of Jiao’s system

The hair needs to be parted and skin sterilized with a solution of 2.5% iodine and 75% alcohol. The use of needles up to 7 cm in length is described, with insertion just under the skin of the scalp into the space between the epicranial aponeurosis and the periosteum. However Western practitioners usually use three or four short needles inserted obliquely along the line (see Figure 6.2 in Chapter 6). Needles may be stimulated manually. However, electroacupuncture is commonly applied, usually to each end of the line being stimulated. A frequency of 100–200 Hz is usually used, although some report using lower frequencies. Treatment lasts 20–40 minutes. Some people find scalp acupuncture to be a strong stimulation. However many experience a general warmth, tingling, pins and needles or buzzing sensation and find it relaxing. Sometimes general warmth is also felt in the body part being targeted [34].

The Eastern way

Chinese medicine provides a particularly attractive model for holistic health care. It sees health and well-being as a state of balance between a person and every aspect of that person’s context. This indicates primarily a respectful and caring relationship with the natural environment and a lifestyle appropriate to the exigencies of natural forces and climates. It can also be extrapolated to include relationships between the body’s constitution and the way we work and play, where we live, what we eat, how we modulate our relationships with others and so on. The interdependence of mind and body goes without saying in such a comprehensive view of health. Illness is not usually an arbitrary and unlucky event but an expression of a lack of balance, and as such it is up to the individual to take care of their lifestyle to keep their health [38].

General application of TCM ideas and techniques

Probably the most useful thoughts to begin with will be those concerning Pathogens. Which Pathogen do the symptoms most remind you of? Given that we are dealing with the neurology syndromes, which is the most predominant subpattern? Is it more to do with Wind or Feng, or does the situation make you think more of Wei or withering, with a clear decrease in muscle activity? Or finally, is it more that nothing seems to be working very well, there is a ‘stuckness’ of Qi or Blood and the Bi syndrome seems dominant?

The two types of stagnation may be manifest in the superficial layers of the body, and both will respond to acupuncture treatment. There is a TCM saying: ‘The Blood nourishes the Qi and the Qi leads the Blood’. Qi is more Yang than Blood, which tends to be Yin. If the predominant symptom is pain it is relatively easy to distinguish between them; the main points are given in Table 12.1.

Table 12.1 Qi or Blood stagnation?

Qi stagnation	Blood stagnation
Dull pain	Sharp, strong
Less severe	Severe pain
Mobile	Fixed
Palpable changes less likely	Clearly palpable by therapist, dry, scaly skin. Possible varicosities
Patient vague about location	Patient indicates painful point(s) clearly
Affected by stress or emotion	Unaffected
Improves with gentle massage	No immediate improvement with light massage but deep, invigorating massage may help in treatment
Responds to acupuncture	Responds to acupuncture
Distal acupuncture points are the most important	Fixed local points are more effective; these may include Ah Shi and Extra points
Overall regulation of body energy required	Does not affect internal functions