INTRODUCTION
Acupuncture (AP) literally means needle (acus) puncture. In the past it referred to needling specific points of the body to assist the healing (homoeostatic) power of the human or animal patient. The word AP has a much wider meaning today. It infers diagnostic and prognostic value as well as therapeutic effects.
Many methods can be used to activate the defensive systems of the body via the AP points. These include: simple needling, injection of the AP points (with orthodox or unorthodox medicaments, non-isotonic saline, B12 or local anaesthetic solutions), insertion of surgical staples or other implants at the points, electro-needling, transcutaneous electrical stimulation, ultrasound, low level laser therapy (LLLT), application of heat (microwave; infrared; moxa; thermostatically controlled heat probes) or cold (ice massage; ethyl-chloride or other vapocoolant sprays), massage etc. As long as it is adequate, the method of stimulation is less important than the correct choice of AP points.
This paper, discusses AP in small animal (SA) practice under 6 headings:
1. AP concepts and mechanisms
2. Methods of choosing AP points for therapy
3. Diagnostic prognostic and therapeutic aspects of AP with examples in emergencies, musculoskeletal problems, disc disease and reproductive disorders
4. AP analgesia for surgery
5. Practical methods of AP stimulation, especially in Trigger Point (TP) therapy
6. Further training
1. AP CONCEPTS AND MECHANISMS
Traditional Chinese Medicine (TCM) is based on oriental philosophies of Qi, Yin-Yang, Five Phases, Perverse Causes of Disease, the Concept of Change and other concepts which western-style professionals find difficult to understand. These concepts are discussed in detail elsewhere. Those interested may read the basic human texts, listed below.
Briefly, Qi is the vital energy which comes from heaven (air), earth (food) and ancestors (genetic vitality). The Channel-Organ System (COS) is a vast network of superficial Channels (Jing), superficial and deep Collaterals (Luo, pathways connecting one Channel with a specific Phase-Mate Channel) and deep pathways which connect the exterior with the interior, the superficial Channels with their named Organs. The COS comprises an extensive 3-dimensional system of the Channels (Jing), Collaterals (Luo), superficial and deep pathways of Qi and the organs and their TCM Functions. The COS is the anatomical and functional system which controls all body organs, parts and functions and interfaces the interior to the exterior and the exterior to the external world beyond. The Jing-Luo (Channels and Collaterals) used to be called the Meridians and Qi Pathways of TCM.
Yin-Yang is the principle of opposite, yet complementary forces (female/male; hypo-/hyper-; cool/warm; chronic/acute; parasympathetic/sympathetic; diastole/systole etc).
Five Phases (Fire, Earth, Metal, Water, Wood) represented the five basic types, once called the Five Elements. Everything in existence can be categorised by analogy to Yin-Yang and Five Phases. The Sheng Cycle (anabolic, creative) and the Ko Cycle (catabolic, restraining) keeps the Five Phases in perfect harmony and balance. Each body organ and function relates to a specific Phase and disease patterns reflect the Phases. For example, in Winter (Phase = Water), the diseases to expect would be diseases of bladder and kidneys (Water), bones (Water), nervous system (Water).
In TCM, the classical Exogenous Causes of Disease (the Perverse Causes, or External Evils in TCM) are Wind, Damp, Heat, Summer Heat, Dryness and Cold. If the Wei (Defensive) Qi in the skin is weak, the External Evils can penetrate the body via the AP points and Channels. If the Qi in the Jing-Luo is not strong enough to throw off the attack, the Evil Qi can reach the viscera via the Jing-Luo and lead to fatality. Trauma, diet and internal causes are recognised also as causes of disease, as are phycological factors. In modern China, much of this philosophy is replaced by "scientific concepts" of medicine and pathology. However, many aspects of TCM still retain their full value in today's world, especially the holistic concepts of TCM and the validity (objective reality) of the AP points and their diagnostic, prognostic and therapeutic functions.
Two basic types of points are used in AP: Classical AP points and Tender Points which may or may not correspond with documented AP points
Classical AP Points: More than 2500 years ago, TCM described the functions and anatomical positions of hundreds of points on the classical human Jing-Luo System. These points have diagnostic and therapeutic properties. They occur on the head, neck, trunk and limbs. Specific sets of points relate to and/or have functional connections with each other and with the COS, its TCM Functions and Qi-COS network.
The 12 Main Jing (Channels): In TCM, there are 12 Jing (Qi pathways) which run in the long axis of the body and are bilaterally symmetrical. Each Jing has a superficial path, along which lie its Channel points (close to the skin) and a deep path through the interior of the body, to connect with its organ and other related body parts and functions. Each Jing connects also with one "upstream" and one "downstream" in the daily energy (Qi) circuit. The 12 main Jing are LU (Lung); LI (Large Intestine or Colon); ST (Stomach); SP (Spleen); HT (Heart); SI (Small Intestine); BL (Bladder); KI (Kidney); PC (Pericardium; Circulation-Sex, Heart Constrictor); TH (Triple Heater: respiratory, digestive, reproductive functions); GB (Gallbladder); LV (Liver). Each of these Jing controls both superficial and deep functions.
The Qi in three Channels flows from thorax to fingers (LU, PC, HT); in three from fingers to face (LI, TH, SI); in three from face to foot (ST, BL, GB) and in three from foot to chest (SP, KI, LV).
Diurnal Qi circulation: Qi circulates in the Jing Luo to reach every cell in the body. The Qi tide flows through the Jing-Luo in a definite direction and time sequence: LU -> LI -> ST -> SP -> HT -> SI -> BL -> KI -> PC -> TH -> GB -> LV (and back to LU). The Qi peaks in LU between 0300-0500h and peaks in the other Jing in sequence at 2-hour intervals, to begin a new energy circuit in LU at 0300h next morning. Thus the Qi of each COS has its high- and low- tide.
In TCM, blockage or imbalance in the flow and distribution of Qi is the cause of ill-health. When there is disease, the Channel Qi is disturbed and certain points along the Channel become sensitive to palpation, heat and electric current. Stimuli applied to the sensitive points can normalise the energy flow, helping the adaptive responses to remove the disease (restore ease).
Example of a Channel path: The BL Jing begins at the inner canthus of the eye, goes across the skull, then paravertebral to the sacrum, then down the posterior midline of the buttock, thigh and calf to pass between the lateral malleolus of the tibia and the Achilles tendon and thence to the lateral aspect of the little toe.
Along the course of each Channel, a specific number of points is recognised. Each of these points is said to influence the parts and functions "controlled" by the Channel. For example, there are 67 BL points and BL67 (on the little toe) could influence the eye (BL01) and BL01 could influence the little toe. Each Jing also has a deep course and is "connected" to the organ bearing its name. Thus any BL point could influence BL function.
Each Channel point has local functions also. For example, BL40 (old BL54, in the popliteal crease) is used in knee (stifle) pain, arthritis etc; BL23 (between transverse processes of L2-L3) in nephritis; BL01 in acute opthalmitis etc.
Channel points also influence the organs lying close to them. For example, BL13,14,15 (beside vertebrae T3, T4, T5) influence the lungs, pericardium and heart; CV03,4,12,17 influence the bladder, small intestine, stomach and heart respectively because of their proximity to these organs.
The Eight Mo (or Mai): These are called the Eight Extra Vessels. As well as the 12 main (bilaterally symmetrical) Jing, there are 8 special Qi reservoirs. Two of these are in the midline: the Ren Mo (Conception Vessel, CV, in the ventral midline, from perinaeum to lower lip) and the Du Mo (Governing Vessel, GV, in the dorsal midline, from the anococcygeal area to the upper lip). The CV and GV are said to be reservoirs of energy and contain many important AP points for cranial, thoracic and abdominal problems. The six other Mo (Vessels, Qi reservoirs) are the Chong Mo; Dai Mo; Yangqiao Mo; Yinqiao Mo; Yangwei Mo and Yinwei Mo. The Eight Extra Vessels link with some of the main COSs, thereby allowing one COS to influence many other COSs and other body parts.
AP diagnosis: So far, we have discussed the relationship between points and organs mainly as a one-way system (the points influencing the organs). In fact, AP has diagnostic aspects as well as therapeutic aspects. The organs influence the points and the points influence the organs. When an organ or its function is upset, reflex changes occur on the surface of the body and can be detected by careful examination of the points. The best examples of the diagnostic reflex points are the Shu (Back Association, paravertebral) and the Mu (Front Alarm, abdominal/thoracic) points. In disease of the heart, BL15 (Shu) and CV14 (Mu) are frequently tender to palpation, as are HT Channel points. In appendicitis (large intestine, LI), ST25 (Mu, McBurney's point) and BL25 (Shu, paravertebral point between L4-L5) may be tender in addition to LI Channel points.
Thus, via the Jing-Luo of TCM (or via neuroendocrine reflex/hormonal mechanisms in western physiology) AP points have a two-way relationship with the COSs. Channel or Organ pathology alters point sensitivity (diagnostic) and stimulation of the sensitive point helps to normalise the affected organ. Point sensitivity also returns to baseline as the organ or its function is normalised.
The relationships between point sensitivity and diagnostic/therapeutic aspects led to the search (in recent years) for other sensitive points in specific pathologies. This uncovered another 300 or so points not mentioned in the ancient texts. They are described in recent texts as "Extra-Channel, New or Strange Points" and their human positions are described.
In modern physiology, segmental reflexes explain many of the therapeutic and diagnostic relationships between internal organs and their related AP points; the same spinal nerves service both the area of the point and the area of the pathology. However, not all the therapeutic/diagnostic relationships can be explained by segmental reflex. For example, in acute appendicitis, a new point (LanWei: literally gut tail or appendix) on the tibialis anterior muscle (right side) is usually very tender to palpation. This point is very powerful in relieving the pain and spasm of acute appendicitis. Its effect may be explained by short inter-segmental reflexes. Other effects, for example between Earpoints and abdominal organs can be explained by supraspinal reflexes.
As well as the documented AP points, Trigger Points (TPs) are another point category of diagnostic and therapeutic value in AP. TPs often occur in pain syndromes, especially in myofascial syndromes. They have no fixed location but may appear in the musculature, where they may be palpated as "nodules" or areas of localised spasm. Heavy pressure on (or needling of) the TP causes severe pain which radiates back to the area of complaint (i.e.) it "triggers" the complaint. Other points can act as triggers, for example scar tissue is frequently a trigger for muscle or organ pain elsewhere. TPs occasionally arise near the Golgi apparatus of tendons and at motor points (where the motor nerve enters the muscle). International experts, such as Melzack (Canada), Pontinen (Finland), MacDonald (UK) and Chung (Taiwan), have done intensive research on TPs in relation to human pain syndromes and a Belgian colleague has recently described TPs in myofascial problems in dogs (Janssens 1987).
In AP, location of tender points (including TPs) is extremely important in diagnosis and stimulation of these points can give pain relief in 50-70% of cases. The quickest and easiest way to convince sceptics of the benefits of AP therapy is to persuade them to experiment with TP therapy. It needs no knowledge of AP points or of the very detailed laws of AP. The clinical success of TP therapy is usually met with disbelief at first. Later the sceptic comes to accept it. It is then be easier to persuade him/her to undertake serious study of the complete AP system. The weakness of TP therapy is that many clinical cases (including some myofascial cases) do not develop triggers. Therefore many of these cases can not be treated successfully by needling unless the practitioner knows classical AP.
AP POINT STIMULATION
AP stimulation means the application of a sufficient stimulus to the AP points to activate a desired response. There is not time in this talk to discuss mechanisms in detail. Briefly, AP effects are mediated by the peripheral and CNS, autonomic, neuroendocrine and endocrine systems.
(a) (b) (c)
Point ---> sensory nerve ---> spinal cord ---> CNS ---> Neuroendocrine
^ | | |
| ENDOCRINE.<---| |--> AUTONOMIC |
(+) | CENTRE CENTRE |
| (-) | | |
DISORDER <---- RESPONSE <-------<----v-------<-----------v---<------v
Local anaesthetic block or experimental section of the neural input at (a), (b), or (c) abolishes the effect. Certain drugs active at central and peripheral sites can act as agonists or antagonists to AP effects. Therefore, correct choice of points and adequate stimulation of the points are critical to success.
For >2500 years, the points were stimulated by insertion of "needles" into them. Over the millennia the "needles" were refined from crude instruments made of bamboo, flint or porcelain, to lancets of metal and (finally) to extremely fine, solid, stainless steel needles. Today, human AP needles are made of the finest quality steel and are 28-34 gauge. Vet AP needles are usually 22-26 gauge (large animals) or 26-30 gauge (small animals).
Apart from needling, many other types of stimuli can activate the points. Modern methods of stimulation include point injection; implantation of absorbable or non-absorbable materials; TENS; faradism; magnetotherapy; ultrasound; low level laser therapy (LLLT); application of heat or cold; massage; blisters etc. Thus the term AP therapy, though originally meaning therapy by needle puncture, is now used to mean therapy using the AP points. The choice of correct reflex points is more important than the method of stimulation used. For more details, see "Techniques of stimulation of the AP points".
Up to now, we have discussed concepts of human AP. This was necessary because there are no texts on small-animal AP other than those based on the human system. Since 1974, small-animal vets around the world have been successful with transposition of the human principles to dogs and cats etc, (In, fact, even large-animal vets must learn the human system before they can hope to progress to the classical texts on large-animal AP).
We can summarise the talk so far by four points:
a. AP has diagnostic and therapeutic aspects.
b. Point sensitivity (to palpation and other stimuli) is a critical guide to the location of the diagnostic points.
c. When present, the diagnostic points are also therapeutic points.
d. Successful AP therapy depends on a knowledge of classical points and concepts when tender points are absent.
2. METHODS OF CHOOSING AP POINTS FOR THERAPY
In TCM, choice of AP points depends on the diagnosis in terms of: which Channel(s) are involved; whether the Qi is deficient or excessive in the Channel(s) and whether or not AP is appropriate. (TCM makes extensive use of herbal medicine, dietary advice, exercises (physical and mental) fasting, sweating, purgation etc as needed. AP was only a small part of TCM).
TCM has many Laws of Choosing Points. These include:
1. AhShi points (tender points, TPs; see later).
2. Local points (points near the problem area or near the affected organs).
3. Distant points, especially on Channels passing through the affected part or organ.
4. Points on the affected Channel.
5. A chain of points on an affected Channel, for example GB30,32,34,39 along the GB Channel, from the hip to the lower lateral leg in leg paralysis.
6. Points on related Channels (on the "Husband or Wife" Phase-Mate, or on Channels near the affected one.
7. Encircling the affected area.
8. "Fore and Aft" combination (points anterior and posterior to the problem organ or area).
9. Mu-Shu combination (combination of thoracoabdominal alarm points with paravertebral reflex points for the affected organ or function).
10. Yuan-Luo combination (combination of Yuan-Source point of the affected Channel with the Luo-Passage (Qi transfer) point of its Phase-Mate Channel).
11. Symptomatic Points: Certain symptoms were long known to respond to certain points, for example, GV26 (in the philtrum) in shock; PC06 (over median nerve) in nausea and vomiting etc.
12. Xi (Cleft, Accumulation) points (special points for acute diseases)
13. The use of the 5 Phase points (special points for energy transfer between Channels).
To these laws, modern medicine adds the following:
14. Needling along the affected nerve trunks relating to the affected parts or organs. Needling near the affected dorsal nerve roots. Needling the affected dermatomes.
15. Needling "Extra-Channel" points (new points discovered in recent decades), such as "Scalp", "Ear", "Face", "Nose", "Hand" or "Foot" zone points related to the affected function or area. Examples are: Scalp Zone "Lower Motor Area" in paralysis of the legs; "Hand" point "Loin and Leg" in sciatica; NX04 (TingChuan = Soothing Asthma) in asthma or bronchitis etc.
The most common prescription is a combination of AhShi points + local points + distant points on the affected Channel. This may seem to be a simple matter to resolve but a look at any standard charts shows the difficulties. (It is advisable to limit the number of needles to 6-12 in most sessions, therefore one must discriminate which local and distant points are most relevant). The textbooks (as individual texts) do not help much either. A careful study of the texts shows that there is major variation between them in their choice of points for specific conditions.
One solution to the problem is to construct a database from many textbooks and to use the computer to do a frequency ranking on the points for specific conditions. In this way, the most commonly recommended points for any specific condition can be output in seconds.
COOKBOOK AP: Cookbooks usually provide instant details of the ingredients needed to prepare the required dish. They are used mainly by cooks, who have bad memories, or have not tried to prepare the dish before. Either way, they are very useful and many an enjoyable meal was prepared in this way. Master Chefs, however, are in a class apart from cooks. They, through experience, good memory and intuition, seldom need to refer to cookbooks.
Cookbook AP is basically "prescription AP". It is suitable for statistical medicine (standardised approach to all "similar" cases). It is quite unsuitable for difficult, complicated or atypical cases, especially in humans. To treat such cases successfully by AP would require a deep study of the classical concepts. Having said that, Cookbook AP is ideal for routine and simple cases. It is the quickest, least painful way of introducing busy professionals to the AP techniques. Whether right or wrong, many busy professionals are not prepared to devote the effort and time to a deep study of AP. Without the cookbook approach, most of these would never be able to attempt AP therapy (except for the simplest type, TP therapy or AhShi therapy).
There are dozens of AP textbooks available. The main problem with the cookbook method is to decide which text to use. The best include: Anon 1974; O'Connor & Bensky 1983; Cheng et al 1987; Ellis et al 1989; Anon 1993. However, no one text lists all the conditions which can be helped by AP, and there are many differences within and between texts. Thus, the serious student is forced to either construct a personal database (as already discussed) or to purchase a commercial AP point database (such as Shenberger's card-index system). The latter, based on only a few textbooks, is good but is very incomplete. Tables 1 to 3 are examples of Cookbook AP, as compiled by computer analysis. For more details on point selection, see "Choice of AP points for particular conditions".
3. DIAGNOSTIC, PROGNOSTIC AND THERAPEUTIC ASPECTS OF AP
Diagnostic aspects of AP are based on the tenderness/sensitivity which occurs in certain points when their related organs are affected. Five types of AP points may have diagnostic value in humans: (a) Mu-Shu points; (b) Earpoints; (c) general tenderness along the Channel (d) Voll-Akabane-Ryodoraku points; (e) Trigger Points (TPs).
a. MU-FRONT ALARM AND SHU-BACK ASSOCIATION POINTS
There are 12 main COSs: LU-LI, ST-SP, HT-SI, BL-KI, PC-TH, GB-LV. Each COS has a specific point on the anterior abdomen-thorax called the Mu (Front Alarm) point and on the paravertebral area between T3 to S2, called the Shu (Back Association, or Reflex) point, corresponding with BL13-30. For example, the Mu-Shu points for stomach in humans are halfway between the navel and the xiphoid (CV12, Mu point) and 1.5 cun paravertebral to the lower edge of the spine of T12, or just caudal to the last rib (BL21, Shu point).
In disease, if there is tenderness to palpation at the Mu and Shu point of an organ, disease of that organ must be considered. However, the spinal innervation of the internal organs comes from several neighbouring spinal nerves and each spinal nerve can innervate more than one internal organ. Thus, because of this overlap of spinal innervation, the Mu-Shu points are not as specifically valuable as TCM would claim. They are, however, quite useful guides to the affected organs.
b. EAR POINTS
A French worker (Nogier) discovered that the human ear contained a somatotopic representation of the body and its organs. This has been developed by the European and Oriental schools of Auriculotherapy. Certain zones on the ear become tender to probe-pressure or to electrical current when the related organ or body part is diseased. These points have diagnostic value and therapeutic value. Blind studies at University College of Los Angeles (Oleson et al 1989), confirmed the diagnostic value of the human Ear zones. The therapeutic value of the human Earpoint system is well documented also. Workers in Europe, USA, Czechoslovakia and elsewhere have evidence to support the diagnostic and therapeutic value of Earpoints in animals also but more work is needed before strong claims can be made for the diagnostic and therapeutic value of ear points in the dog.
c. CHANNEL TENDERNESS
General tenderness along the course of a specific human Channel is diagnostic of a problem in that COS.
d. CHANGES IN POINT SENSITIVITY
Changes in sensitivity to heat or electrical current at special measurement points on the human hands and feet have diagnostic value in the Voll, Akabane and Ryodoraku systems of AP. It is claimed that diseases can be diagnosed in the very early stages (such as pre-clinical cancer) with these methods but, unfortunately, there is little written in orthodox scientific refereed journals on these claims. Little research seems to have been done with these methods in animals.
e. TRIGGER POINTS
Travell and Simons (1984) published the definitive textbooks on TPs. Part 1 deals with TPs in every muscle from the hips up. Part 2 (1985) deals with the pelvic limb. TPs arise in most cases of myofascial and musculoskeletal pain, whether of soft-tissue, arthritic or disc origin. These TPs maintain pain and dysfunction long after the original causes have disappeared.
Janssens (1984) described TP therapy for myofascial lameness in 21 dogs. Mean duration of lameness before therapy was 24 weeks. TP therapy was successful in 70% of cases in a mean time of 17 days (2.5 treatments). The relapse rate was 33% but relapse cases also responded well to therapy.
It is most important to identify TPs and eliminate them. TPs may occur in cases of disease of internal organs and they may trigger autonomic effects (vasospasm, cardiovascular effects, altered peristalsis etc), as well as effects on proprioception, muscle coordination, eye sight, hearing and taste (when muscles relating to the cranial nerves are involved).
Prognostic aspects of AP: the tenderness in the Mu-Shu, Earpoints, the course of a Channel or at the special measurement points returns to normal as the case improves. Disappearance of tenderness at these points and at TPs during the course of therapy is taken as a sign that the case is resolving satisfactorily.