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Proceedings of the Thirty-Fourth Annual International Congress

On

Veterinary Acupuncture
20th 23rd September, 2008 Keystone Resort, CO USA

Sponsored by THE INTERNATIONAL VETERINARY ACUPUNCTURE SOCIETY

Proceedings of the 34th Annual International Congress On Veterinary Acupuncture

Keystone Resort, CO USA September 20-23, 2008

Edited by The IVAS Congress Program Committee Published by IVAS Printed in the United States

Sponsored by The International Veterinary Acupuncture Society

Obtaining Copies

Copies of the Proceedings may be ordered from:

Curran & Associates 57 Morehouse Ln. Red Hook, NY 12571 Tel. No.: +845-758-0400 FAX No.: +845-758-2633 Email: curran@proceedings.com www.proceedings.com The content of papers printed in the Proceedings does not necessarily reflect the views of IVAS.

ISBN # 0-9616627-8
Copyright 2008

Proceedings of the Thirty-Fourth Annual International Congress on Veterinary Acupuncture. All rights reserved.

The International Veterinary Acupuncture Society (IVAS) has edited and copyrighted these Proceedings as a collective work. The papers presented at this congress are the property of IVAS and/or author. The recordings and written materials of papers presented may be used strictly for personal use only. They may not be published, reprinted, or used commercially without prior permission from IVAS or the author.

Table of Contents
Welcome Message from the President Sponsors and Exhibitors Board of Directors Speakers Program THE INS AND OUTS OF ACUPUNCTURE Robert G. Schaeffer, Jr., DVM, Ph.D. FUNDAMENTAL SUBSTANCES Shana Buchanan, DVM TCVM PATHOLOGY Cindy Wallis, DVM VAS / RAC : BASIC INFORMATION Andy Roesti, DMV GBI LAB: THEORY AND APPLICATION Terry Durkes, DVM BLOOD FLOW: THE KEY TO ACUPUNCTURE POINT SELECTION AND EFFICACY 41 Steven P. Marsden, DVM ND MSOM LAc Dipl.CH RH(AHG) THE HEMODYNAMIC LOGIC BEHIND PULSE AND TONGUE DIAGNOSIS Steven P. Marsden, DVM ND MSOM LAc Dipl.CH RH(AHG) CVA CHINESE MEDICAL TREATMENT OF RENAL FAILURE IN THE DOG AND CAT Steve Marsden, DVM ND MSOM LAc Dipl.CH RH(AHG) CVA TRANSLATION FROM TRADICIONAL CHINESE VETERINARY MEDICINE PHILOSOPHY INTO MODERN MEDICINE Susanne Rodekohr, MD, DVM Student ANCESTRAL SINEWS AND TENDINOMUSCULAR CHANNELS Linda Boggie, DVM, IVAS Certified Acupuncturist 77 61 53 27 23 17 5 i ii iii v vii 1

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HOMEOPATHY IN TERMS OF TRADITIONAL CHINESE VETERINARY MEDICINE (TCVM) Susanne Rodekohr, MD, DVM Student THE APPLICATION OF JING-JIA-JI AND HUA-TUO-JIA-JI IN SMALL ANIMALS Han-Wen Cheng, DVM, MS A SIMPLE FLOW CHART TO SELECT ACUPOINTS AND ITS CLINICAL CASES: A RETROSPECTIVE STUDY OF 102 CASES Hee-Young Kim, DVM, Ph.D. ACUPUNCTURE AND PULSED MAGNETIC FIELD THERAPY: A PROMISORY MARRIAGE Dr. Mara del Carmen Barba, DVM, CVA PREEMPTIVE ANALGESIA WITH ACUPUNCTURE SEEN IN THE C-FOS EXPRESSION IN RATS Maria Doris Bedoya Henao, DM, Msci, Ph.D. TREATMENT OF MYASTHENIA GRAVIS J.G.F. Joaquim, DVM, Msci IMPROVING PATIENT OUTCOME IN DIFFICULT CASES USING CRANIAL ELECTROTHERAPY STIMULATION (CES) Ava Frick, DVM THERAPEUTIC EFFECT OF BEE-VENOM AND DEXAMETHASONE Duck-hwan Kim, DVM, MS, Ph.D. TREATMENT BY INJECTION-ACUPUNCTURE WITH BEE-VENOM(APITOXIN) AND APITOXIN COMBINED BY CHINESE HERBAL MEDICINE IN PATIENTS WITH CANINE HIND LIMB PARALYSIS: Duck-hwan Kim, DVM, MS, Ph.D. ACUPUNCTURE TREATMENT FOR PARAPARESIA IN A MARMOSET IN CAPTIVITY J.G.F. Joaquim, DVM, Msci THE NEUROPHYSIOLOGIC BASIS OF ACUPUNCTURE MOVING BEYOND QI Narda G. Robinson, DO, DVM, MS, FAAMA THE NEUROVASCULAR ANATOMY OF ACUPUNCTURE, INCLUDING THE EIGHT EXTRAORDINARY VESSELS Narda G. Robinson, DO, DVM, MS, FAAMA

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BIOMEDICAL ACUPUNCTURE FOR NECK AND BACK PAIN, BASED ON A NEUROANATOMIC PERSPECTIVE Narda G. Robinson, DO, DVM, MS, FAAMA A SYSTEMATIC LOOK AT TONGUE DIAGNOSIS IN THE DOG WHAT DOES IT REALLY TELL US? Narda G. Robinson, DO, DVM, MS, FAAMA

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TREATMENT OF ACUTE AND CHRONIC HEART DISEASE IN HORSES AND DOGS BY PURE ACUPUNCTURE USING PULSE CONTROLLED LASER ACUPUNCTURE CONCEPT (PCLAC) 173 Uwe Petermann, DVM MANAGEMENT OF CARDIAC ARRHYTHMIAS WITH TRADITIONAL CHINESE MEDICINE Michelle C Schraeder, DVM, FAAVA EVIDENCE-BASED VETERINARY ACUPUNTURE Dr. Sagiv Ben-Yakir, BSc, DVM, MRCVS GOLD BEADS IMPLANTATION (GBI) THE SCIENTIFIC BASIS Dr. Sagiv Ben-Yakir BSc(Biology), DVM(in honor), MRCVS, CVA(IVAS) THE USE OF BRAIN IMAGING TECHNIQUES IN EXPLAINING ACUPUNCTURE: A REVIEW Anna K. Hielm-Bjrkman, DVM, Ph.D. TREATMENT OF FACIAL NERVE PARALYSIS IN DOGS USING ACUPUNCTURE: A WESTERN AND EASTERN VIEW OF THE PATTERN OF THE DISEASE C. C.T. Haddad, DVM INTERRELATIONSHIPS BETWEEN EQUINE ACUPUNCTURE, CHIROPRACTIC AND DENTISTRY Kevin J. May, DVM COMBINING MIRROR IMAGING AND CONSTITUTIONAL TREATMENT IN THE MANAGEMENT OF EQUINE PAIN Peggy Fleming, DVM, AP, Dipl.Ac. TRADITIONAL CHINESE MEDICINE HERBAL STRATEGIES FOR ANEMIA Sign Beebe, DVM, CVA TRADITIONAL CHINESE MEDICINE HERBAL STRATEGIES FOR SKIN PATTERNS 229 Sign Beebe, DVM, CVA 223 193 189

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TRADITIONAL CHINESE MEDICINE HERBAL STRATEGIES FOR CHRONIC URINARY TRACT INFECTION IN DOGS Sign E. Beebe, DVM, CVA THE ALTERNATIVE PATHWAY OF LAMENESS- DIAGNOSIS AND TREATMENT BY RAC CONTROLLED EAR ACUPUNCTURE Uwe Petermann, DVM EQUINE TRADITIONAL, TRANSPOSITIONAL AND NON-MERIDIAN POINTS Kevin J. May, DVM

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Welcome Message from the President


Howdy, I would like to extend a warm WELCOME to my fellow veterinary acupuncturists from around the world. I would also like to extend my appreciation to the IVAS office and Program Committee for providing us with a program I am sure you will enjoy. What an assortment of theories and approaches regarding the use of acupuncture! This is a meeting that certainly brings both the East and West together, and what better place than the Colorado Rocky Mountains. Keystone provides an environment you will never forget. If you take some time to experience the outdoors, I am sure you will become familiar with what the locals here call, Rocky Mountain High. This will be my last year as your President. It has fulfilled a long time dream for me, and I feel privileged to have served you in this capacity. We are all privileged to have Boudewijn Claeys as our next IVAS President. He is a person that I have come to admire, and I believe you will soon feel the same way. I would encourage you to take the time, during this meeting, to talk with at least one person you do not know. This organization is full of interesting people. Take a chance to meet someone new and learn from one another. This is our opportunity to grow. Lastly, I would encourage everyone to Donate One Treatment to the IVAS Endowment Fund. This act will help this organization to support and promote the use of veterinary acupuncture around the world. The amount is different for each of us, but the intent is the same and the reward shared by all. Respectfully yours, Kevin May IVAS President 2006- 2008

Special Thanks to our Sponsors and Exhibitors

KAN Herb Company 2008 Bronze Needle Sponsor


6001 Butler Lane, Scotts Valley, CA 95066-3557 Phone: (831) 438-9450 FAX: (831) 438-9457 Email: customer@kanherb.com Web: www.kanherb.com American Herbal Labs Spectrahue Wapiti Labs Eddies Wheels Qpuncture Inc. Reimers & Janssen GmbH Alpha Stim Aura Photo & Reading Animal Essentials Chi Institute Golden Flower Chinese Herbs CEFCO AAVA
8526 E. Garvey Ave, Rosemead, CA 91770 Phone: (626) 307-0928 FAX: (606) 307-9445 Email: herbal@newvita.com Web: www.newvita.com Box 85507,842 Eglinton Ave West, Toronto, ON M5N 2Z8 CANADA Phone: (416)-340-0882 FAX: (416)-581-1252 Email: info@spectrahue.com Web: www.spectrahue.com 13739 Lincoln St. NE, Ham Lake, MN 55304 Phone: (763) 746-0980 FAX: (763) 951-7792 Email: info@wapitilabsinc.com Web: www.wapitilabsinc.com 140 State St, Shelburne Falls, MA 01370 Phone: (413) 625-0033 FAX: (413) 625-8428 Email: leslie@eddieswheels.com Web: www.eddieswheels.com 5824 E. Camino Pinzon, Anaheim, CA 92807 Phone: (714) 685-0900 FAX: (714) 685-8909 Email: info@qpuncture.com Web: www.qpuncture.com Frohnaoker 8, D-79297 Winden GERMANY Phone: 49 7682 6558 FAX: 49 7682 6640 Email: innovativeprojects@yahoo.com Web: www.rj-laser.com 2425 Burns Ave, St. Louis, MO 63114 Phone: (314) 799-4052 FAX: (314) 423-5643 Email: rschilling@swbell.net Web: www.midwestmicrocurrent.com 385 Pearl St, Boulder, CO 80302 Phone: (303) 249-6958 FAX: (303) 449-5881 Email: labellestar@earthlink.net Web: www.bellestar.net 1369 Hwy 93 N #3, Victor, MT 59875 Phone: (888) 551-0416 FAX: (406) 961-8601 Email: info@animalessentials.com Web: www.animalessentials.com 9700 West Hwy 318, Reddick, FL 32686 Phone: (352) 591-5385 FAX: (352) 591-2854 Email: admin@tcvm.com Web: www.tcvm.com 2724 Vassar Place NE, Albuquerque, NM 87107 Phone: (800) 729-8509 FAX: (866) 298-7541 Email: info@gfherbs.com Web: www.gfherbs.com PO Box 429, Inola, OK 74036-0429 Phone: 918-543-8415 FAX: 918-543-2554 Email: cefcoinc@tds.net 100 Roscommon Dr Ste 320, Middletown, CT 06457-1591 Phone: (860) 632-9911 FAX: (860) 635-6400 Email: aava@cttel.net Web: www.aava.org

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Members of the Board of Directors:


Kevin J. May, DVM, * President, (El Cajon, CA, USA) Boudewijn Claeys, DVM, * President-Elect, (Quebec, CANADA) Rick Schafer, DVM, MS, * Treasurer, (Corpus Christi, TX, USA) Linda C. Boggie, DVM, * Past President, (Deventer, NETHERLANDS) Kristine Elbaek, DVM, * President House of Delegates (Hellerup, DENMARK) Vikki Weber, MBA, * Executive Director, (Fort Collins, CO, USA) Elaine Cebuliak, DVM, (Mansfield, AUSTRALIA) Anna K. Hielm-Bjorkman, DVM, PhD, (Helsinki, FINLAND) Robert Schwyzer, DVM, (Santa Fe, NM, USA) Peter Grob, DVM, (Ammerzwil, SWITZERLAND) Uwe Petermann, DVM, (Melle, GERMANY) * Designates Member of the Executive Committee

35th Annual Intl Congress: 2009


Marriott Riverwalk San Antonio, TX, USA August 26-29, 2009:

International Education Committee:


Ritva Krokfors, DVM, (SWEDEN) Linda Boggie, DVM, (NETHERLANDS) Kristine Elbaek, DVM, (DENMARK) Michelle Tilghman, DVM, (USA) Ulrike Wurth, BVSc, Dipl.Ac, (AUSTRALIA) Emiel Van den Bosch, DVM, (BELGIUM) Vikki Weber, MBA, USA) Elena Petrali, DVM, (CANADA) Richard Schafer, DVM, MS (USA) Boudewijn Claeys, DVM, (CANADA)

Exam Committee:
Robert Schaeffer, DVM, PhD, (Chair)

Program Committee:
Linda Boggie, DVM (Chair, NETHERLANDS) Elena Petrali, DVM (CANADA) Emiel Van den Bosch, DVM (BELGIUM) Richard Schafer, DVM, MS (USA) Kevin May, DVM (USA) Christina Matern (GERMANY) Kim Henneman, DVM (USA) Martina Steinmetz (GERMANY) Peter Grob (SWITZERLAND)

Continuing Education Committee:


Kristin Edwards, DVM, (Chair, USA) Kevin May, DVM (USA) Sally Strawn, DVM (USA) Lois Sargent, DVM (USA) Tracy Akner, DVM (USA) Shana Buchanan, DVM (USA) Lynn Kalsbeck (USA) Michelle Schraeder (USA) Rick Schafer (USA) Boudewijn Claeys (CANADA) Vikki Weber, MBA (USA)

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Speakers
Maria del Carmen Barba, DVM, CVA Naturalvet Echenique 4724 Nunoa, Santiago CHILE Ph: +562-277-9779 Fax: +562-277-9779 Email: naturalvet@vtr.net Sign E. Beebe, DVM, CVA Integrative Veterinary Center 5524A Elvas Ave Sacramento, CA 95819-3023 Ph: +916-454-1825 Fax: +916-454-5865 Email: sebeebe@aol.com Sagiv Ben-Yakir, BSc, DVM, MRCVS Hod-Hashron Veterinary Clinic 17 Gordon St Hod-Hasharon 45203 ISRAEL Ph: +972-9-741-2252 Fax: +972-9-741-2252 Email: benyakir@netvision.net.il Linda C. Boggie, DVM Dierenkliniek Deventer Smeenkhof 12 7429 AX Deventer NETHERLANDS PH: +31-570-653000 Fax: +31-570-658225 Email: lindaboggie@earthlink.net Han-Wen (Peter) Cheng, DVM, MS 113 Chung Jeng Road Yong He, Taipei 234-55 Terry E. Durkes, DVM Western Animal Hospital 909 N Western Ave Marion, IN 46952-2505 Ph: +765-664-0734 Fax: +765-651-9158 Email: durkes1@mcleodusa.net Peggy Fleming, DVM, AP, Dipl.Ac. Florida Equine Acupuncture Center 21412 Field of Dreams Lane Dade City, FL 33523-0605 Ava Frick, DVM 1825 Denmark Road Union, MO 63084 Carolina C.T. Haddad, DVM Bioethicus Institute, Botucatu, Brazil Rua Imperatiz Leopoldina 27 Apt 11 Ponta da Praia, Santos Sao Paulo, CEP: 11030.480 BRAZIL Ph: +13-3271-7368 Email: carolhaddadvet@hotmail.com Maria Doris Bedoya Henao, DM, Msci, Ph.D. Visto Permanente RNE V-126.956-A CPF: 081.727.218-62 End. Commercial. Rua Dr. Damiao Pinheiro Machado 620 Vila Sao Lucio-Botucatu-Sao Paulo, Cep 18603-560 BRAZIL Anna K. Hielm-Bjorkman, DVM, Ph.D. Visiting Professor Stanford University Kruunuvuorenk 3 Helsinki 00160 FINLAND Ph: +358-9-662661 Fax: +358-9-19149670 Email: anna.hielm-bjorkman@helsinki.fi Jean G. F. Joaquim, DVM, Msci University of Sao Paulo State-Botucatu, Brazil Bioethicus Institute-Botucatu, Brazil Luiz C Amorim Rodrigues St #487 Botucatu, SP 18609-685 BRAZIL Ph: +55-1438133718 Fax: +55-1438152529 Email: jeanvet@yahoo.com

Duck-Hwan Kim, DVM, MS, Ph.D. Chungnam National University Laboratory of Veterinary Internal Medicine Gung-Dong 220 Yuseong-Gu, Daejon City 305-764 KOREA Hee-Young Kim, DVM, Ph.D. University of Texas Medical Branch Dept of Neuroscience and Cell Biology Galveston, TX 77555-1069 Ph: +409-772-9854 Email: hykim@utmb.edu Steve Marsden, DVM, ND, MSOM, Lac, Dipl.CH, RH (AHG), CVA Edmonton Holistic Veterinary Clinic 8215-102 Street Edmonton, AB T6E 4A5 Canada Ph: +780-436-3040 Kevin J. May, DVM El Cajon Valley Veterinary Hospital 560 N Johnson Ave El Cajon, CA 92020-3118 Ph: +619-444-9491 Fax: +619-444-9306 Email: kjmaymsi@cox.net Uwe Petermann, DVM Schmale Strasse 20 Melle 49326 GERMANY Ph: +49-5428-93003 Fax: +49-5428-93004 Email: DrUwePetermannmelle@t-online.de Narda G. Robinson, DO, DVM, MS, DABMA, FAAMA Colorado State University College of Veterinary Medicine and Biomedical Sciences Veterinary Medical Center Vet Teaching Hospital 300 West Drake Road Fort Collins, CO 80523 Ph: +970-221-4535 Fax: +970-491-1275 Email: nrobinso@Lamar.colostate.edu

Susanne Rodekohr, MD, DVM Student Iberamerican University, Mexico City Meixan Institute of Veterinary Complementary Medicine Zamora 39A Col. Condesa 06140 Mexico City MEXICO Ph: +00-5252641591 Fax: +00-5252641591 Email: susannerodekohr@mac.com Andreas Roesti, DMV Chruemigstrasse 18 Wimmis 3752 SWITZERLAND Ph: +41-33-657-16-16 Fax: +41-33-657-26-52 Email: roesti_vet.wimmis@bluewin.ch Kim Samuelsen, DVM, Cert. Acup., Cert. Osteopath Ejdrupvej 43 - 9240 Nibe DENMARK Ph: +45-98623100 Fax: +45-98625339 Email: mr.kim@mail.tele.dk Robert G. Schaeffer, Jr., DVM, Ph.D. St Louis Hills Veterinary Clinic 7001 Hampton Ave Saint Louis, MO 63109-3924 Ph: +314-353-3444 Email: calldrbob@aol.com Michelle C. Schraeder, DVM, FAAVA 3413 Mt Baker Hwy Bellingham, WA 98226 Ph: +360-592-5113 Fax: +360-592-3112 Email: mtnvet@telcomplus.net

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Program

Saturday, September 20, 2008


Red Cloud Peak
09:00-12:00 12:00-13:00 13:00-16:00 Certification Examiner Training Lunch Introduction to Veterinary Acupuncture Dr. R. Schaeffer Dr. R. Schaeffer

Crestone 1
09:00-09:45 09:45-10:00 10:00-12:00 12:00-13:00 13:00-15:00 Reflex Auriculo Cardial Vascular Autonomic Signal Introduction (Canine/Equine) Break Canine Reflex Auriculo Cardial Vascular Autonomic Signal Lab Lunch Gold Bead Implant Theory and Application Wetlab Dr. A. Roesti

Dr. A. Roesti

Dr. T. Dukes

Crestone 2
10:00-12:00 12:00-13:00 Canine Point Lab Lunch Dr. J. Joaquim

Crestone 3
12:00-13:00 13:00-15:00 Lunch Traditional Chinese Veterinary Medicine Herbal Live Patient Diagnosis and Treatment Plans Lab Dr. S. Beebe

Off-site
10:00-12:00 10:00-12:00 12:00-13:00 13:00-15:00 13:00-15:00 Embryo Containing the Information of the Whole Organism Points & Treatment Lab Equine Point Lab Lunch Equine Reflex Auriculo Cardial Vascular Autonomic Signal Lab Equine Point Lab Dr. K. Samuelsen Dr. K. May Dr. A. Roesti Dr. K. May

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Sunday, September 21, 2008


Shavano Peak
08:15-10:00 10:00-10:30 10:30-11:30 11:30-12:30 Part 1 of Impact of Acupuncture on Hemodynamics Relation to Pulse Dx & Patient Assessment Break Part 2 of Impact of Acupuncture on Hemodynamics Relation to Pulse Dx & Patient Assessment Disease Specific Presentation Based on the Impact of Acupuncture on Hemodynamics Relation to Pulse Dx & Patient Assessment Lunch Translation from Traditional Chinese Veterinary Medicine Philosophy into Modern Medicine The Use of the Ancestral Sinews Break Homeopathy in Terms of Traditional Chinese Veterinary Medicine Annual General Meeting of the Membership Dr. S. Marsden

Dr. S. Marsden Dr. S. Marsden

12:30-13:30 13:30-14:30 14:30-15:30 15:30-16:00 16:00-17:00 17:30-19:00

Dr. S. Rodekohr Dr. L. Boggie Dr. S. Rodekohr

Red Cloud Peak


13:30-14:30 The Application of Jing-Jai-Ji (Cervical Paravertebral Points) and Hua-Tuo-Jia-Ji (Hua-Tuo Paravertebral Points) in Small Animals A Simple Flow Chart to Select Acupoints and Its Clinical Cases Break Acupuncture and Pulsed Magnetic Field Therapy: A Promissory Marriage Dr. H. Cheng

14:30-15:30 15:30-16:00 16:00-17:00

Dr. H. Kim

Dr. M. Barba

Crestone Peak
13:30-14:00 14:00-14:30 Research Paper: Preemptive Analgesia with Acupuncture Seen in the C-Fos Expression in Rats Research Paper: Treatment of Myasthenia Gravis in Dogs With Acupuncture: A Western and Eastern View of the Pattern of The Disease Improving Patient Outcome in Difficult Cases Using Cranial Electrotherapy Stimulation (CES) Break Research Papers: 1) Therapeutic Effect of Bee-Venom and Dexamethsone In Dogs with Facial Nerve Paralysis 2) Treatment by Injection-Acupuncture with Bee-Venom (Apitoxin) and Apitoxin Combined by Chinese Herbal Medicine in Patients with Canine Hind Limb Paralysis: Case Report Research Paper: Acupuncture Treatment for Paraparesia in a Marmoset (Callithrix Penicillata) in Captivity Dr. D. Henao Dr. J. Joaquim

14:30-15:30 15:30-16:00 16:00-16:30

Dr. A. Frick

Dr. D. Kim

16:30-17:00

Dr. J. Joaquim

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Monday, September 22, 2008


Shavono Peak
08:15-10:00 The Neurophysiology Basis of Acupuncture: Moving Beyond Qi The neurovascular Anatomy of Acupuncture, Including the Eight Extraordinary Vessels Break Biomedical Acupuncture for Neck and Back Pain, Based on a Neuroanatomic Perspective A Systematic Look at Tongue Diagnosis in the Dog: What Does It Really Tell Us? Lunch Dr. N. Robinson Dr. N. Robinson

10:00-10:30 10:30-11:30 11:30-12:30 12:30-13:30

Dr. N. Robinson Dr. N. Robinson

Shavano Peak
13:30-14:30 Treatment of Acute and Chronic Heart Disease in Horses and Dogs by Pure Acupuncture Using Controlled Laser Acupuncture Concept (PCLAC) Management of Cardiac Arrhythmias with Traditional Chinese Medicine Break Management of Cardiac Arrhythmias with Traditional Chinese Medicine Dr. U. Petermann

14:30-15:30 15:30-16:00 16:00-17:00

Dr. M. Schraeder

Dr. M. Schraeder

Red Cloud Peak


13:30-14:30 14:30-15:30 15:30-16:00 16:00-16:30 Bjorkman 16:30-17:00 Evidence-Based Acupuncture or the Full Answer Dr. Douglas H. Slatter Was Asking For Gold Implantation: The Scientific Mechanism Break Research Paper: The Use of Brain Imaging Techniques in Explaining Acupuncture A Review Research Paper: Treatment of Facial Nerve Paralysis in Dogs Using Acupuncture: A Western and Eastern View of the Pattern of the Disease Dr. S. Ben-Yakir Dr. S. Ben-Yakir Dr. A. Hielm-

Dr. C. Haddad

Crestone Peak
13:30-14:30 14:30-15:30 15:30-16:00 16:00-17:00 Relationships Between Acupuncture, Chiropractic and Dentistry Combining Mirror Imaging and Constitutional Treatment in the Management of Equine Pain Break Combining Mirror Imaging and Constitutional Treatment in the Management of Equine Pain Dr. K. May Dr. P. Fleming

Dr. P. Fleming

BANQUET
19:00-20:00 20:00-21:00 21:00-? Cocktails Banquet Dance

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Tuesday, September 23, 2008


Shavano Peak 09:00-10:00 Traditional Chinese Medicine Herbal Strategies for Anemia 10:00-10:30 Break 10:30-11:30 Traditional Chinese Medicine Herbal Strategies for Common Skin Patterns 11:30-12:30 Traditional Chinese Medicine Herbal Strategies for Chronic UTI in Dogs 12:30-13:00 FAREWELL Dr. S. Beebe Dr. S. Beebe Dr. S. Beebe

Red Cloud Peak 09:00-10:00 Alternate Pathway of Lameness: Diagnosis and Treatment by RAC Controlled Ear Acupuncture 10:00-10:30 Break 10:30-12:30 Equine Traditional, Transpositional and Non-Meridian Points

Dr. U. Petermann

Dr. K. May

Proceedings
of the

Thirty-Fourth Annual International Congress


On

Veterinary Acupuncture

34th International Congress on Veterinary Acupuncture _____________________________________________________________________________________

THE INS AND OUTS OF ACUPUNCTURE


Robert G. Schaeffer, Jr., DVM, Ph.D. Purpose: The purpose of this session is to present enough basic information about veterinary acupuncture that someone totally unfamiliar with acupuncture may be able to understand some of what is presented in the rest of the sessions. This may also serve as a useful review for those who may have forgotten some of their early training. In our basic acupuncture courses many hours are spent discussing the neurophysiology of acupuncture in great detail. That is well beyond the scope of this session. The object is to present a user-friendly look at the neurolophysiology involved. However, several of the major presentations at this Congress will involve some pretty detailed neurophysiologic/neuroanatomic discussions, so we will need to cover enough basic information to allow us to follow the discussions. For the sake of clarity, we will divide the reaction to acupuncture into four basic areas: 1. Local tissue reaction 2. Peripheral Nervous System and spinal reaction 3. Upper Central Nervous System reaction (mid-brain) 4. Hypothalamic-pituitary-adrenal axis (HPA) Local Tissue Reaction According to Kendall (1) the tissue reaction is divided into six phases: 1. Vasodilatory 2. Nociceptive Excitation 3. Chemotactic 4. Solubility 5. Tissue Repair 6. Inactivation Peripheral Nervous System and Spinal Cord Knowledge of the types of nerves involved is essential to understanding how acupuncture works. Nociceptors A-Beta (Group II) A-Delta (Group III) C-polymodal (Group IV) How does sticking a needle in the skin work to stop pain?

Tissue damage nociceptive information reaches the dorsal horn via C-polymodal fibers. The pin prick reaction from acupuncture stimulation activates A-beta and A-delta fibers. The Abeta fibers release GABA at the level of the substantia gelatinosa, which inhibits the onward

34th International Congress on Veterinary Acupuncture _____________________________________________________________________________________

transmission of C-fiber information. The A-delta fibers release Enkephlins at the level of the substantia gelatinosa, which block interneurons and the onward transmission of C-fiber information. Upper Central Nervous System In addition, at higher levels the A-delta fibers activate serotonergic descending inhibitory pathways, which feed back at the spinal level and block C-fiber information. At even higher levels of the brain, the A-delta pathways stimulate the release of endorphins and possibly block NMDA receptors thus modulating the recognition of pain. It has been proposed that the prolonged action of acupuncture may be due to the production of a serotonin, metenkephlin mediated circuit, which develops a neuronal loop in the brain leading to continuous stimulation of the descending inhibitory pathways. Hypothalamic-Pituitary-Adrenal Axis (2) Inputs Afferent Nerve stimuli Cognitive-emotional stimuli Chemical signal messengers (Endogenous or Exogenous) Integration of signals within the Hypothalamus HPA Outputs Humoral Pathway Neurohumoral Pathway Sympathetic Autonomic Pathway Parasympathetic Autonomic Pathway Central Descending Inhibition Pathway Acupuncture Points Histology: Most acupuncture points are found to be at locations where a neurovascular bundle penetrates from deep tissue through the fascia to approach the surface. Physiology: Acupuncture points are found to be areas of reduced electrical resistance and increased electrical conductance. Function: Many acupuncture points are found at the motor points of muscles. They are also often found at the margins of muscles. Many myofascial Trigger Points are found to be acupuncture points as well.

34th International Congress on Veterinary Acupuncture _____________________________________________________________________________________

BEYOND THE NEUROHUMORAL THEORIES OF ACUPUNCTURE Morphogenetic Singularity Theory (3) Historical/philosophical review Early authors (2000-200BCE) Fu Xi (King Wen, King Wu) Ba Gua, I Ching Shen Nong Shen Nong Ben Cao Jing Huang Di Huang Di Nei Jing Su Wen (Simple Questions) Ling Shu (Spiritual Pivot) Nan Jing Shang Han Lun Zhang Zhong Jing Systematic Classic of Acupuncture and Moxibustion Huang Fu Mi Systematic Correspondences Traditional Chinese Medicine vs. Chinese traditional medicine References 1. Kendall, D.E. Dao of Chinese Medicine. Oxford University Press, 2002. 2. Robinson, N.G. Biomedical Acupuncture For Neck and Back Pain, Based On A Neuroanatomic Perspective. International Veterinary Acupuncture Society Congress Proceedings, 2008. Keystone Colorado 3. Shang, Charles. Mechanism of Acupuncture - Beyond Neurohumoral Theory. Medical Acupuncture Online Journal, Volume 11, #2, 2000.

34th International Congress on Veterinary Acupuncture _____________________________________________________________________________________

34th International Congress on Veterinary Acupuncture _____________________________________________________________________________________

FUNDAMENTAL SUBSTANCES
Shana Buchanan, DVM Fundamental substances, or vital substances, are the foundation of functional activities of the body. There are five fundamental substances: Qi, Blood, Essence (or Jing), Body Fluids, and Mind (or Shen). We will explore each of the fundamental substances Qi Qi is the fundamental substance constituting the universe. Is consists of both the essential substances of the human body which maintains it vital activities and the functional activities of the Zang-Fu organs and tissues. In general, Qi is vitality and is not palpable. The main components of Qi include: Hereditary Qi, from Jing, Nutritive Qi, from the food we eat, and Cosmic Qi, from the air we breathe. There are several types of Qi. They include: Original Qi (Yuan Qi): this is related to Essence Food Qi (Gu Qi): from the food ingested Gathering Qi (Zong Qi): also known as Ancestoral Qi True Qi (Zhen Qi): which is derived from Nutritive Qi (Ying Qi) and Defensive Qi (Wei Qi) Nutritive Qi (Ying Qi): this nourishes the internal organs and the entire body Defensive Qi (Wei Qi): courser form of Qi that protects the body from attacks from External Pathogenic Factors (EPFs) Central Qi (Zhong Qi) Upright Qi (Zheng Qi) Blood Blood is a form of Qi and is inseparable from Qi since Qi infuses life into the blood. Without Qi, Blood would be an inert fluid. Bloods source is from Food Qi produced by the SPLEEN. It functions in nourishing the body (complements the nourishing action of Qi), moistens (which Qi does not have), and provides the material foundation for the Mind, or Shen. Body Fluids Body Fluids originate from food and drink. The body separates the fluid into more and more pure and impure fluids. The pure fluid is transported upwards and the impure downwards. There are two different types of body fluids: Jin and Ye. Jin is the clear, light, thin and watery fluids that circulate with the Defensive Qi on the exterior. Jin functions to moisten and in part to nourish skin and the muscles. Ye is turbid, heavy, and dense liquid. It circulates with the Nutritive Qi in the Interior and thus moves relatively slowly. Ye functions to moisten the joints, spine, brain and bone marrow. It also lubricates the orifices of the sense organs, eyes, ears, nose and mouth. They are exuded as sweat and manifests as tears, saliva, and mucus. Mind (Shen) The Shen is the spirit and the psyche of the body. It encompasses the emotional well being, thoughts and beliefs. Additionally, the Shen helps guide the survival instincts, allows expression

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of love, compassion and caring and keeps the heart-spirit calm. The state of the mind will affect the Qi and Essence, and emotional stress will affect the Qi. The Shen functions as consciousness, thinking, memory, insight, cognition, sleep, intelligence, wisdom, ideas, affections, feelings and senses. TCM Organs There are 12 organs which correlate with the 12 meridians, or channels. The meridians of the body are analogous to one-way highways on particular aspects of the body in which the Qi travels for that particular organ. The organs includes: Heart (HT), Liver (LIV), Lungs (LU), Spleen (SP), Kidney (KI), Pericardium (PC), Stomach (ST), Small Intestines (SI), Large Intestines(LI), Gallbladder (GB), Bladder (BL), and Triple Heater (TH). Each of the five Yin organs is related to a certain mental-spiritual aspect. Heart: Shenentire mental and spiritual aspects of the body Liver: Ethereal Soul (Hun)related to the Western concept of Soul Lungs: Corporeal Soul (Po)gives the capacity of sensation, feeling, hearing and sight Kidneys: Will-power (Zhi)mental drive that gives determination and single mindedness in pursuit of goals Spleen: Intellect (Yi)capacity for applied thinking, studying, concentrating and memorizing Each organ has a different function and will be explored below.

HEART The Heart governs the Blood and blood vessels and houses the mind, or Shen. It is manifested in the complexion, opens in t the tongue, controls sweat, and is related to joy.

LIVER The Liver stores the Blood ensuring the smooth movement of Qi throughout the body and houses the Ethereal Soul. Liver Blood is important to nourish the sinews (aka tendons and ligaments), thus allowing physical exercise. Additionally, Liver Blood is important in storing the blood for the uterus ensuring regular menstruation. Therefore, the Liver functions include storing the blood, ensuring the smooth flow of Qi, and controlling the sinews. The Liver houses the Ethereal Soul, manifests in the nails, controls the tears, opens into the eyes, and is affected by anger.

LUNGS The Lungs govern the Qi and the respiration and also influences the skin. Other functions include controlling the channels and blood vessels, controlling diffusing and descending of Qi and Body Fluids, regulating all physiological activities, regulating water passages, controlling the skin and space between the skin and muscles. The Lungs manifests in body hair, opens into the nose, controls nasal mucus, houses Corporeal Soul, and is affected by worry, grief and sadness.

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SPLEEN The Spleen assists the stomach digestion by transporting and transforming food essences, absorbing the nourishment from the food and separating the useable from the unusable part of food ingested. The Spleen is the central organ in the production of Qi from the food and drink ingested by extracting Food Qi, which is the basis for the formation of True Qi and Blood. The Spleen controls the ascending aspect of Qi by directing the Food Qi upward to the Lungs to combine with the air to form Gathering Qi and upward to the Heart to form Blood. Therefore, the Spleen indirectly controls the Blood. The Spleen manifests in the muscles and the four limbs, controls the saliva and raises the Qi, opens into the mouth, houses the Intellect, and is affected by pensiveness.

KIDNEY The Kidney stores the Essence in its Pre-Heaven form. The Pre-Heaven Essence is derived from parents and established at conception. It also determines the basic constitution of the individual. The Kidney is the foundation for all Yin and Yang energetics of the body. It is nicknamed the Root of Life. The functions of the Kidney include: storing Essence, governing birth, growth, reproduction and development. It, also, produces the marrow, fills up the brain and controls the bones. The Kidney manifests in the head hair, controls the receptions of Qi, governs water, opens into the ears, , controls spittle, controls the two lower orifices, controls the Gate of Life, houses the Will Power, and is affected by fear and terror.

PERICARDIUM The Pericardium envelopes the Heart, and is thus the master of the Heart. Since the Pericardium is so closely related to the Heart, it has similar functions as the Heart. Therefore, the Pericardium houses the Shen. There are certain clinical signs that arise from Pericardium dysfunction. Blood deficiency of the Pericardium will cause depression and slight anxiety. Blood-heat of the Pericardium will cause anxiety, insomnia, and agitation. Phlegm in the Pericardium will cause mental confusion and in severe cases, mental illness. Pericardium is affected by the emotional problems from relationships.

STOMACH The Stomach is the most important of all the Yang organs and is knows as the Root of PostHeaven Qi because this is the place where all of the Qi and Blood is produced after birth. The Stomach controls: the receiving of ingested food and drink and holds them down, the rotting and ripening of food, the transportation, and the descending of Qi.

SMALL INTESTINES The Small Intestines receives food and drink after digestion by the Spleen and Stomach and is further separated into clean and dirty portions. Small Intestines controls the receiving and transforming of the food and separates the fluids.

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LARGE INTESTINES The Large Intestines receives food and drink from the Small Intestines. In TCVM theory, Large Intestines functions are brief since most of the familiar Large Intestines functions are attributed to the SPLEEN and Liver in Chinese medicine. Therefore, the Large Intestines moves digested food from the Small Intestines and conducts it downward for excretion as stool.

GALLBLADDER The Gallbladder is the only Yang organ that does not deal with food, drink and their waste products. Additionally, it does not communicate with the exterior directly via the mouth, rectum, or urethra nor does it receive food or transport nourishment like all of the other Yang organs. The Gallbladder stores and excretes bile, controls decisiveness, and controls the sinews.

BLADDER The Bladder stores and excretes urine and participates in the transformation of fluids necessary for production of urine. Therefore, the function of the Bladder in Chinese medicine is similar to the function of the Kidney in Western medicine. The Bladder functions are to remove water by Qi transformation.

TRIPLE HEATER The Triple Heater has been an area of debate for several centuries on whether or not is has a form and whether or not is in as actual organ. It mobilizes the Original Qi thus allowing the Original Qi to perform its various functions relative to several organs and controls the transportation in water passages and excretion of fluids. There are four views of the Triple Heater. 1) Triple Heater is one of the 6 Yang Organs; 2) Triple Heater is a mobilizer of Original Qi; 3) Triple Heater has three divisions of the body; 4) Triple Heater as body cavities: UpperChest MiddleAbdomen LowerPelvic. The upper burner is like a mist. The middle burner is like a maceration chamber for digestion and transportation of food and drink and transportation of nourishment extracted from the food to all parts of the body. The lower burner is like a ditch in which is separates the clean and the dirty food. Channels or Meridians Twelve Meridians or Channels Webster defines a meridian as a great circle on the surface of the earth passing through the poles or any of the pathways along which the body's vital energy flows according to the theory behind acupuncture. Therefore, the meridians on the body are like highways of energy flow with specific stops, or points, of interest. Each of the 12 organs has its own acupuncture meridian and points distributed on a fixed portion of the body surface. This is true regardless if an organ is Yin or Yang. There exists an exterior-interior relationship with the meridian and the given organ. A pathological manifestation of the meridian results when the organs Qi fails to flow properly. The flow of Qi makes three cycles around the body to cycle through all of the meridians. The cycles begin and end on the chest. The flow goes: chest to fingers, fingers to face, face to toes,
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and toes to chest to begin again. There exists a relationship with the flow of Qi and the husband/wife relationship (Yin and Yang organs of a particular element). Either the flow will be from the Yin to the Yang organ of the same element or vice versa. There are 6 general regions on the body, 3 Yin and 3 Yang, in which the meridians travel. Therefore, each of the regions will have two different Yin and Yang organs that are similarly named but in different locations. These general regions are similar to saying that there is a lateral, medial, cranial, and caudal portion to right and left arm. They only indicate location of the meridian on that given body part. The general regions are: Tai Yin, Shao Yin, Jue Yin, Shao Yang, Tai Yang, and Yang Ming. The flow of Qi is correlated with the Circadian Clock which will be discussed later. The flow of Qi is outlined below as well as the beginning and ending location of the channel, the circadian clock high tides, and the region of the body where the channel is located.

Meridian Lungs Large Intestine Stomach Spleen Heart Small Intestine Bladder Kidney

Time 3am-5am 5am-7am 7am-9am 9am-11am 11am-1pm 1pm-3pm 3pm-5pm 5pm-7pm

Direction of the Qi Flow Chest to Fingers: Hand Tai Yin Fingers to Face: Hand Yang Ming Face to Toes: Foot Yang Ming Toes to Chest: Foot Tai Yin Chest to Fingers: Hand Shao Yin Fingers to Face: Hand Tai Yang Face to Toes: Foot Tai Yang Toes to Chest: Foot Shao Yin Chest to Fingers: Hand Jue Yin Fingers to Face: Hand Shao Yang Face to Toes: Foot Shao Yang Toes to Chest: Foot Jue Yin

Beginning Point 1st intercostal space 2nd phalanx of front foot Eye 1st phalanx of rear foot Chest 5th digits of front foot Eye Between 2nd and 3rd digit of rear foot Chest 4th phalanx of front foot Eye 1st phalanx of rear foot

Ending Point 1st phalanx of the front foot Nose 2nd digit of rear foot Chest 5th phalanx of the front foot Ear 5th digit of rear foot Chest 3rd phalanx of the front foot Eye 4th phalanx of rear foot Chest

Pericardium Triple Heater Gallbladder Liver

7pm-9pm 9pm-11pm 11pm-1am 1am-3am

Twelve Divergent Channels The Divergent Channels are branches from the 12 regular channels that run inside the body and connect the organs and Yin and Yang organs of the same element to the outside meridians. These channels are distributed on the chest, abdomen and head, strengthen the relationship between the Zang-Fu organs, (aka Yin and Yang organs), govern inside the body, and serve as an extension of the main meridians. The 12 Divergent Channels can be paired into 6 confluences

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according to their internal and external relationship. Webster defines a confluence as a coming or flowing together, meeting, or gathering at one point. Divergent Channels mainly run deeper in the body, supplementing the pathway that the main meridians do not reach. There are NO POINTS located on the Divergent Channels. However, these channels can be accessed through points on the primary channels as we do with six of the Extraordinary Vessels

1st Confluence: 2nd Confluence: 3rd Confluence: 4th Confluence: 5th Confluence: 6th Confluence:

Divergent Channel of the BL Foot Tai Yang Channel Divergent Channel of the KI Foot Shao Yin Channel Divergent Channel of the ST Foot Yang Ming Channel Divergent Channel of the SP Foot Tai Yin Channel Divergent Channel of the GB Foot Shao Yang Channel Divergent Channel of the LIV Foot Jue Yin Channel Divergent Channel of the SI Hand Tai Yang Channel Divergent Channel of the HT Hand Shao Yin Channel Divergent Channel of the LI Hand Yang Ming Channel Divergent Channel of the LU Hand Tai Yin Channel Divergent Channel of the TH Hand Shao Yang Channel Divergent Channel of the PC Hand Jue Yin Channel

Twelve Tendinomuscular Channels These channels are distributed within the muscles regions of the body where the Qi and Blood of the meridians nourish the muscles and tendons. The muscular regions are distributed under the skin and follow the cutaneous meridians (aka the 12 Main Channels) but do not have specific points. These Channels are more superficial to the 12 Main Channels and only follow the path of the Main Channels. The Tendinomuscular Channels are conduits in which Qi and Blood is distributed from the 12 Main Channels in order to: nourish the muscles, connect all of the bones and joints of the body, and maintain normal range of motion. These channels do not reach the Zang & Fu organs, thus are not related to these organs and the flow of Qi and Blood. However, there are three Yang muscle regions of the rear foot, three Yin muscle regions of the rear foot, three Yang muscle regions of the front foot, and 3 Yin muscles regions of the front foot which is the same as the 12 Meridians. The indications of the Tendinomuscular Channels are for muscular problems, especially Bi syndrome, contracture, stiffness, spasm, and muscle atrophy. The 12 Tendinomuscular Channels and their distribution follow.

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The Yang three muscle regions of the rear foot are distributed on the ventral, lateral, and dorsal aspects of the trunk. These all connect with the eyes Foot Tai Yang (Bladder) Foot Shao Yang (Gallbladder) Foot yang Ming (Stomach) The three Yin muscle regions of the rear foot connect with the genital region. Foot Tai Yin (Spleen) Foot Jue Yin (Liver) Foot Shao Yin (Kidney) The three Yang muscle regions of the hand connect with the forehead. Hand Tai Yang (Small Intestines) Hand Shao Yang (Triple Heater) Hand Yang Ming (Large Intestines) The three Yin muscles regions of the hand connect with the thoracic cavity. Hand Tai Yin (Lungs) Hand Jue Yin (Pericardium) Hand Shao Yin (Heart)

Eight Extraordinary Channels There are 8 Extraordinary Channels that do not connect to the Zang and Fu Organs and thus, are not exteriorly-interiorly related. All of the Channels, except for the Governing and Conception Vessels, share points with the other 12 Regular Meridians. The 8 Extraordinary Channels assume the role of controlling, joining, storing and regulating Qi and Blood of each of the regular channels. Governing Vessel (aka Du Mai): Runs along the dorsal midline from the rectum to the face Meets all the Yang Meridians Sea of the Yang Meridians Fct: Govern the Qi of all of the Yang Meridians Conception Vessel (aka Ren Mai): Runs along the ventral midline from the rectum to the face Sea of the Yin Meridians Fct: Receives and bears the Qi and the Yin Meridians Penetrating Channel (aka Chong Mai): Runs parallel to the KI Meridian up to the intra-orbital region Meeting of all the 12 Meridians Fct: Reservoir of the Qi and Blood of the 12 Main Channels Girdling Vessel (aka Dai Mai): Originates in the hypochondrium (below the ribs) and goes around the waist as a girdle. Fct: binding up all of the meridians Yang Heel Vessel (aka Yang-Qiao Mai): Starts in the lateral aspect of the heel and merges into the meridian of the Foot Tai Yang to ascend. The Yang- Qiao Mai shares much of its distal trajectory and, thus, points with the Bladder channel but also travels to points on the Gallbladder channel, Small Intestines, Large Intestines and Stomach channels Meets with the Yin Heel Vessel at the medial canthus Fct: Motion regulation of the rear limbs
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Yin Heel Vessel (aka Yin-Qiao Mai): Starts in the medial aspect of the heel and merges into the meridian of the Foot Shao Yin to ascend. Although it shares its distal trajectory and many points with the Kidney channel it also travels to the Stomach channel (according to some authors), and it lends support to the Kidney as the Yang-Qiao Mai lends support to the Bladder channel. Meets with the Yang Heel Vessel at the medial canthus Fct: Motion regulation of the rear limbs Yang Linking Vessel (aka Yang-Wei Mai): Connects all of the Yang meridians Fct: Dominates the exterior of the entire body, regulates the flow of Qi in the Yang meridians to help maintain coordination and equilibrium between the Yin and Yang Meridians Yin Linking Vessel (aka Yin-Wei Mai): Connects all of the Yin meridians Fct: Dominates the interior of the entire body, regulates the flow of Qi in the Yin meridians to help maintain coordination and equilibrium between the Yin and Yang Meridians Special Action Points Master Points These are the points that are used in treating conditions in certain areas. These points are not located over the area of interest but are located in a different region of the body. As a result, their external and internal channel pathways will have an effect over specific areas from a distance.

Master Point LI 4 LU 7 PC 6 BL 40 ST 36 SP 6

Region Face and Mouth Head and Neck Chest and Cranial Abdomen Back and Hips Abdomen and GI Caudal Abdomen and Urogenital

Association Points (Back Shu Points) and Alarm Points (Front Mu Points) These points are named for the organ/meridian they treat. The Back Shu Points are all located on the Bladder Meridian. These points are where the Qi of the Zang and Fu organs are infused and distributed. Typically, the MU points are located near the organ of affiliation and not necessarily on the Meridian/ Channel. They are excellent diagnostic and treatment points of the internal organs. Sensitivity upon palpation can indicated a disorder of the corresponding Zang-Fu organ.

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Organ

Lungs Pericardium
Heart Liver Gallbladder

Spleen
Stomach

Triple Heater
Kidney

Large Intestines
Small Intestines

Bladder

Back Shu Point (Association Point) BL 13 BL 14 BL 15 BL 18 BL 19 BL 20 BL 21 BL 22 BL 23 BL 25 BL 27 BL 28

Front Mu Point (Alarm Point) LU 1 CV 17 CV 14 LIV 14 GB 24 LIV 13 CV 12 CV 5 GB 25 ST 25 CV 4 CV 3

Luo Points (Connecting Points) Luo means network. Therefore, the Luo Channels are an extensive network within the body. The channels lie between the main channels and skin. It criss-crosses between the main channels and skin while being more superficial than main channels. Due to the crisscrossing action, these channels run in all directions like a net and fill the space between the skin and muscles.

There are 12 main channels (Heart, Pericardium, Small Intestines, Triple Heater, Spleen,
Stomach, etc.) situated between the Yang and Yin connecting channels. These channels allow

the Nutritive & Defensive Qi and Qi and Blood of the main channels to spread in all directions, permeating and irrigating the internal Organs. The Essence of the Internal Organs is transported to the main channels and through the whole body by these channels.

When a Luo Point is stimulated it allows direct transfer of energy, Qi, from one meridian to its coupled counterpart. Typically, Luo Points are used to treat disorders involving the two exteriorly-interiorly related meridians (ex. Gallbladder, Liver) and those in the area supplied by the two meridians (ex. Knees)

Coupled Meridian Luo Point Luo Point

LU / LI LU 7
LIV 6

ST/SP ST 40 SP 4

HT/SI HT 5 SI 7

BL/KI BL 58 KI 4

PC/TH PC 6 TH 5

GB/LIV GB 37 LIV 5

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Source Points (Yuan Points) These points are always located in the carpal or tarsal area. They are used in the treatment of an organ disease or dysfunction and are extremely powerful.

Yin Source Points: This is where the Qi of the Source Points stems from the original Qi. Original Qi is related to the Yin organs, especially Kidney. Yuan Qi is retained within the Yuan Points; thus the reason for their significance. These points are more Yin in nature than Yang and affects Yin organs more. They would be selected when the 5 Yin organs are diseased. Also, they are used to tonify the particular Yin organ. Yang Source Points: These are used mostly in excess patterns of the Yang organs. They expel the pathogenic factors from the organs. They can also be used to tonify the Yang organ but not the best point for tonification of Yang organs since these points are typically more Yin in nature. Therefore, the best points for Yang tonification are the Lower He-Sea Points

Meridian

Lungs Large Intestines


Stomach Spleen Heart Small Intestines

Bladder
Kidney

Pericardium Triple Heater


Gallbladder Liver

Source Point LU9 LI 4 ST 42 SP 3 HT 7 SI 4 BL 64 KI 3 PC 7 TH 4 GB 40 LIV 3

Transporting Points (Five Shu Points) These are all below the knees and elbows toward the distal end of the extremities (end of extremity) Jing-Well=Well Ying-Spring=Spring/Pool Shu-Stream=to transport Jing-River=to pass thru He-Sea=to unite, join

(elbow/ knee)

Qi of the meridian flows from the extremities to the elbow/knee and gradually flourishes (hence the names) before getting to the body. There are three Lower He-Sea Points in the rear coinciding with the Yang organs of the front. Lower He-Sea Points are mostly employed to treat disorders of the Fu (Yang) Organs

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LI: ST 37 SI: ST 39 TH: BL 39 The progression of size and depth of the channel is irrespective of the direction of the flow of the channel and is equally applied to Yin and Yang of the front and rear limbs. The section of the channels between the elbows/knees and extremities are more superficial than the rest and the energetic action of the point is more dynamic than other points on the meridian. The section between the elbows/knees and extremities represents the connection between the body and the environment. This is the section of the channel thats influenced most promptly and directly by the climate and EPF. These points are more directly related to the season and can be used according to their cycle. The points along this part of the channel are points of entry of EPF: Cold, Damp, Wind. A reason for the dynamism is that the Qi changes polarity from Yin to Yang at the extremities, thus causing Qi to be unstable and easily influenced. Another reason for the dynamism is that the 2nd point is in contrast with the polarity of the channel On Yang Channels the Ying-Spring is Water On Yin Channels the Ying-Spring is Fire Well Pt (Jing) = point at the tips of extremities Yin=Wood Point Yang=Metal Point Spring Pt (Ying) = always the 2nd pt of the 5 Yin=Fire Point Yang=H2O Point Stream Pt (Shu) = 3rd point of the 5, except GB where its the 4th Yin=Yuan Point, Earth Point Yang=Wood Point River Pt (Jing) = 4th point of the 5 but not always the 4th point on the channel Yin=Metal Point Yang=Fire Point Sea Pt (He) = 5th point of the 5 and is ALWAYS at the elbows/knees Yin=H20 Point Yang=Earth Point
Meridian Jing-Well (Wood) LU 11 PC 9 HT 9 SP 1 LIV 1 KI 1 Jing-Well (Metal) LI 1 TH 1 SI 1 ST 45 GB 44 BL 67 Ying-Spring (Fire) LU 10 PC 8 HT 8 SP 2 LIV 2 KI 2 Ying-Spring (Water) LI 2 TH 2 SI 2 ST 44 GB 43 BL 66 Shu-Stream (Earth) LU 9 PC 7 HT 7 SP 3 LIV 3 KI 3 Shu-Stream (Wood) LI 3 TH 3 SI 3 ST 43 GB 41 BL 65 Jing-River (Metal) LU 8 PC 5 HT 4 SP 5 LIV 4 KI 7 Jing-River (Fire) LI 5 TH 6 SI 5 ST 41 GB 38 BL 60 He-Sea (Water) LU 5 PC 3 HT 3 SP 9 LIV 8 KI 10 He-Sea (Earth) LI 11 TH 10 SI 8 ST 36 GB 34 BL 40

Lower He-Sea Points:

Lungs Pericardium
Heart Spleen Liver Kidney Meridian

Yin Transporting Points

Large Intestines Triple Heater


Small Intestines Stomach

Gallbladder Bladder Yang Transporting Points

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Circadian Clock The 12 Meridians join with one another in a specific order. The clock indicates when the Qi of that organ is at its highest level. In other words, the Qi dominates a certain channel at certain times of the day. Just like there is a high-tide, there is the corresponding 12 hour period low tide. There is an endless cycle of Qi and Blood flow in the channels during a channels high-tide.

Meridian

HighTide Time 3am-5am 5am-7am 7am-9am 9am-11am 11am-1pm 1pm-3pm 3pm-5pm 5pm-7pm 7pm-9pm 9pm11pm 11pm-1am 1am-3am

Low-Tide Time

Corresponding Meridian

LU LI ST SP HT SI BL KI PC TH GB LIV

3pm-5pm 5pm-7pm 7pm-9pm 9pm11pm 11pm1am 1am-3am 3am-5am 5am-7am 7am-9am 9am-11am 11am1pm 1pm-3pm

BL KI PC TH GB LIV LU LI ST SP HT SI

Corresponding High-Tide Time of Meridian 3pm-5pm 5pm-7pm 7pm-9pm 9pm-11pm 11pm-1am 1am-3am 3am-5am 5am-7am 7am-9am 9am-11am 11am-1pm 1pm-3pm

Corresponding Low-Tide of Meridian 3am-5am 5am-7am 7am-9am 9am-11am 11am-1pm 1pm-3pm 3pm-5pm 5pm-7pm 7pm-9pm 9pm-11pm 11pm-1am 1am-3am

References 1. Liangyue, D. et al. (1999). Chinese Acupuncture and Moxibustion Revised edition), Beijing: Foreign Languages Press. 2. Maciocia, G. (2005). The Foundations of Chinese Medicine: A Comprehensive Text for Acupuncturists and Herbalists (2nd ed.). China: Elsevier. 3. Schoen, A. (2001). Veterinary Acupuncture: Ancient Art to Modern Medicine (2nd ed.), Missouri: Mosby, Inc. 4. Xie, H & Preast V. (2007). Xies Veterinary Acupuncture. Iowa: Blackwell Publishing.

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TCVM PATHOLOGY
Cindy Wallis, DVM INTRODUCTION Health, in Traditional Chinese Medicine, is based on the bodys ability to maintain equilibrium in the face of a variety of challenges. This overall balance requires that the individual systems within the larger system are also in balance. The body is not considered a collection of parts or of cells, but a complete system unto itself with subsystems whose functions are interdependent, cogenerating and mutually regulating to maintain the balance and harmony of the whole. Disease occurs when the body is unable to maintain equilibrium, due to external factors, such as a virus or trauma, or internal factors such as grief or overwork. Everything is interrelated and interacts. Life consists of dynamic, constantly shifting relationships of functional systems always within the whole system. What is happening within the body affects emotions and emotions affect bodily functions. External factors have effects on the organs as well as the body as a whole and, internally, the organs themselves interact with each other. When the diagnostic methods of looking, listening, asking, smelling and feeling are used, patterns of disease are found. The overall constitution of the patient is taken into consideration as well as pathogenic factors and substances and the organs and meridians involved. These patterns are patterns of imbalance and when we know where and what is out of balance then we can treat to bring the body back into balance. If we have too much Heat, we can add Cold. If we have a Blood deficiency we can tonify Blood, if the Liver is overacting on the Spleen, we can sedate the Liver or Tonify the Spleen. PATHOLOGIC FACTORS There are both external and internal pathologic factors that can act on and in the body to disrupt balance and cause disease. External Pathologic Factors The external factors include: Wind, Cold, Heat, Damp, Dryness and Summer Heat. Signs of Wind include trembling, shaking, itching, seizures and convulsions. Intermittent signs that come and go apparently without reason can be a sign of Wind. When looking for Wind, look for signs that resemble the leaves of a tree being rustled by the Wind. Cold invasion causes everything to slow down. Poor circulation, chills and sluggishness or weariness are signs of Cold as well as heat-seeking behavior and a craving for warm foods and liquids.

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Heat, on the other hand, speeds up metabolism. The skin may be red and hot to the touch. Excess Heat can cause a rapid pulse, fever and inflammation. Increased thirst, cool-seeking behavior and an aversion to warm foods and liquids can indicate Heat. Dampness causes things to sink and accumulate. Think of a swamp when you think of Damp. There is an excess of fluids, often appearing as swelling or just a sense of heaviness. Lethargy, edema and phlegm can indicate dampness. Dryness is characterized by a lack of moisture. Dry, cracked skin and nails, brittle dry crispy hair, decreased urine output and constipation are all signs of dryness. Summer Heat occurs, as advertised, in the summer. It is due to overexposure to extreme heat conditions such as overexposure to the hot sun with no shade. It is also characterized by signs of extreme Heat: high fever, severe thirst and profuse sweating as well as weakness and shortness of breath. If severe enough, Summer Heat can lead to seizures, ataxia and coma. Heatstroke is an example of Summer Heat. Summer Heat can also refer to viral infections and flu that occur in the summer months. Internal Pathogenic Factors The internal pathogenic factors are emotional factors. The internal pathogenic factors include: Joy, Anger, Worry, Grief, Melancholy, Fear and Fright. The emotions are normally felt throughout day to day life and are often appropriate. It is when they take over that they become a problem. It can be a challenge to evaluate some animals emotional state, and in others, it can be quite obvious. Joy is a pathogen when the pleasure/fun seeking creates a situation in which energy reserves are depleted. There is a loss of attention, anxiety and insomnia. This patient does not want to be left alone and they are beyond excited when their person returns. They are often very vocal and hyperactive and this hyperactivity can accelerate the metabolism and deplete Qi. Anorexia, hypoglycemia and schizophrenia can all be signs of excess Joy. Anger is often seen as irrational behavior and even rage. You know this one when you see it. Excess Anger can lead to ulcers, headaches and rage syndromes. Worry can lead to over concern and obsessive behavior. Better safe than sorry can lead to apathy. Energy can become stagnant leading to poor digestion, heaviness, flabbiness and inertia. Grief and Melancholy are often seen as over-control in an effort to self protect from feelings of loss or sadness. This animal will likely be somewhat distant and aloof. The difference between Melancholy and Grief is that with Grief there are outward signs of sadness such as crying or whining, whereas within Melancholy the sadness remains hidden inside. Melancholy and Grief tend to have the most affect on the Lung. Signs of excess sorrow can include: depression, fatigue, hoarse voice, shortness of breath and asthma.

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Fear is seen as an animal that hides and/or runs away, or one that lashes out such as a fearbiter. Fearful animals often prefer to be left alone, cutting them off from life. Fear tends to disrupt Kidney Qi causing signs of arthritis, incontinence, deafness and hind limb weakness.

Fright is different from Fear because it is associated with the Heart instead of the Kidney. With Fright, the Heart Shen is out of control. Excess fright can lead to panic, palpitations, insomnia and mental illness. Other Pathologic Factors Trauma Parasites Poisons Iatrogenic factors (i.e. vaccine reactions, long-term steroid use) Congenital factors (hereditary or due to conditions prior to parturition) Dietary factors (poor quality or not enough food, too much food or an unbalanced diet) Activities (overwork, both physical and mental, excess sexual activity, excessive exercise or not enough exercise, excess visual activities) PATHOLOGIC SUBSTANCES The pathologic substances include: Qi Stagnation, Blood Stagnation, Food Stasis, and Phlegm. Qi stagnation occurs when the flow of Qi is blocked or there is a decrease in normal activity of Qi. Qi stagnation is characterized by distension, fullness and dull pain at the affected area. The pain associated with Qi stagnation is unfixed or scurrying. Causes include mental or emotion issues, external injury, Cold or Dampness, Blood stasis, or Qi deficiency. Blood stagnation is the impairment or cessation of the normal free flow of blood. It occurs with trauma, bleeding, Qi stagnation or deficiency or Cold. Blood stagnation manifests as pain (where there is stoppage there is pain), swelling and masses, purple tongue and choppy pulses. The pain associated with Blood stagnation is fixed and stabbing. Food stasis occurs when an animal is fed a poor quality diet or when an animal is overfed. Signs include: decreased appetite or aversion to food, nausea and vomiting, belching, acid reflux, painful bloating of the abdomen, bad breath, flatulence, diarrhea or constipation. In Chinese medicine, it is recommended to not eat until you are full, but leave enough room for Qi to move. Phlegm, in Chinese medicine, refers to a viscous fluid that can accumulate anywhere in the body causing a variety of diseases. It forms secondary to impaired movement and transformation of fluids by the Lung, Spleen and Kidney. Phlegm can also result from the boiling of fluids with excess Fire or Heat. Clinical signs of Phlegm depend on its location. In the Lung, it will cause a cough, in the Channels it will cause lumps or numbness, it the Spleen and Stomach it causes abdominal distension and sloppy diarrhea or vomiting. Insubstantial Phlegm can mist the mind obstructing the Shen and causing mental disorders. Anything really strange is often due to Phlegm.

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DIAGNOSTIC METHODS Observation: Observe the animals overall appearance, its attitude (Shen), gait, posture, coat, eyes, nails, and tongue. Auscultation: Listen to the voice, the sound of the breath. Olfaction: Smell the breath, the skin, the ears, and any excretions or secretions. Inquiry: Ask about the medical history, current complaints, appetite, sleep, activity level, attitude, urination and defecation, any coughing or sneezing, vomiting or diarrhea, weight gain or loss or any other changes. Palpation: Palpate the meridians and Shu and Mu points. Evaluate the range of motion of the joints. Feel for temperature changes or abnormally hot or cold areas. Feel for lumps and bumps. Evaluate for muscle atrophy and painful areas. Palpate the pulses.
Five Elements PERSONALITY BODY TYPE ORGANS SEASON EMOTION NOISE SENSE TISSUE FUNCTION EXTERIOR ORIFICE SECRETION TONGUE DESIRES VIRTUE VALUES TALENT PATH CLIMATE COLOR TASTE ODOR WOOD Leader/Strong Muscular/Athletic Liver / GB Spring Anger Shout Vision Tendons/Ligaments Purification Nails/Hooves Eyes Tears Sides Purpose Fervor Utility Initiative Action Windy Green Sour Rancid FIRE Fun-loving/Lively Energetic/ Graceful Heart/ SI / PC Summer Joy/Fright Laughter Speech Vascular System Circulation Complexion Tongue Sweat Tip Fulfillment Charisma Intuition Communication Compassion Hot Red Bitter Scorched EARTH Sweet/Caring Study Spleen/Stomach Late Summer Worry Singing/sighing Taste Muscles Digestion Lips Mouth Saliva Center Connectedness Loyalty Harmony Negotiation Service Damp Yellow Sweet Fragrant METAL Thoughtful/Serious Trim Lung/Large Intestine Fall Grief/Melancholy Weeping Smell Skin/Hair Coat Respiration Skin/Pores Nose Nasal Fluid Behind tip Order Righteousness Purity Discrimination Mastery Dry White Pungent Rotten WATER Easy-going / Timid Strong-Large boned Kidney/Bladder Winter Fear Groaning Hearing Bones Elimination Head/Hair Ears Urine Back Truth Honesty Durability Imagination Knowledge Cold Black Salty Putrid

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PATTERN DIFFERENTIATION FIVE ELEMENTS Sheng Cycle or Generating Cycle Wood nourishes Fire Fire nourishes Earth Earth nourishes Metal Metal nourishes Water Water nourishes Wood The parent nourishes the child, creating a circle. Ko Cycle or Control Cycle Wood controls Earth Earth controls Water Water controls Fire Fire controls Metal Metal controls Wood The grandparent controls the grandchild, creating a star. Eight Principles/Six Roots Excess/Deficiency Exterior/Interior Hot/Cold Yin/Yang The six roots of Excess/Deficiency, Exterior/Interior and Hot/Cold are the six roots that are under the super principles of Yin and Yang. All together, they form the Eight Principles. Zang Fu pathology is based on the organ(s) involved in the disease process. Substance pathology is based on the pathogenic substance involved in the disease process. Channel/Collateral pathology is based on the channel or meridian involved in the disease process. Case: Rhonda is a 9 year old spayed female Rottweiler. She has a history of chronic allergies, manifesting primarily as conjunctivitis and occasional seizures (about 2 a year since she was 6.) She recently tore her ACL jumping off of the deck to run after a Jack Russell that was walking by her yard. Her tongue is dark red with a purple center and is dry. Her coat is dry. Her pulses are wiry and weaker on the left. She has a good appetite and even with a torn ACL, she drags her owner into the clinic. She sleeps through the night, except after she has a seizure, then she paces and is restless. She also wakes up if she hears any noise outside and barks loudly. 1. Which of the 5 elements fits Rhonda best? 2. Is she Excess or Deficient? Is her problem Interior or Exterior? Hot or Cold? Yin or Yang? 3. What external pathologic factors are involved? 4. What internal pathologic factors are involved? 5. What other pathologic factors are involved? 6. What pathologic substances are involved?
7. What is your TCVM diagnosis?

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VAS / RAC : BASIC INFORMATION


Andy Roesti, DMV Chrmigstrasse 18, Ch 3752 Wimmis, Switzerland Holistic, Cybernetic, Integrative Medicine for Men and Animals (Manimal Therapist) In the year 1943 Prof. Ren Leriche published an utmost interesting phenomenon of a 39 year old man with an aneurysm (pathological junction of an artery and a vein) at the femoral artery in the adductor channel. Three days after the operation he saw that the femoral artery pulsation visibly increased at the moment of the dressing removal, at the moment of ointment application onto the scar or even when the patient was reading a thrilling passage of a detective novel. Also many other sympathetic stimuli could provoke this palpable pulsation. In the year 1968 Dr. med. Paul Nogier from Lyon, France detected a similar indispensable phenomenon which resembled this arterial pulsation. He called this phenomenon RAC (Rflex Auriculo Cardiac) or (Rflex Autonome Circulatoire). In the USA this signal is called ACR (Arterial Cardiac Reflex) [Kenion]. In Germany ART (Arterial Resonance Test) [Wiebicke] and nowadays the experts call it VAS (Vaso Autonomic Signal) [De Sousa]. The VAS is a highly specific Yes or No answer of any artery to any exogenous stimulus. Under no circumstances must this signal be confused with the considerably more esoteric, subjectively and qualitatively static, non reproducible TCM (Traditional Chinese Medicine) pulse diagnosis. The Classic of Difficulties established the practice and feeling the pulse at the radial artery, dividing it into three areas (cun, guan, chi) and feeling it at three different levels: superficial, middle and deep. This is the regular arterial pulse, which represents all energetic (Qi) aspects of the Zang Fu organs (Yin and Yang organs) and Blood. This pulse interpretation is very difficult. The VAS is a dynamic and reproducible reflex in answer to external induced stimulus of the neuro-vascular system. It is expressed through a modulation of the regular arterial pulse. Several research investigations were performed by Bricot, with the bidirectional Doppler-Sonograph, a Plethysmograph and an electro-mechanical CrystalTransducer, and by Prof. Moser from the Physiological Institute of the University of Graz, in collaboration with other institutes, exploring this extraordinary cardio-vascular signal. M. Moser could prove, during the MIR-aerospace project of the astronauts with their sensory jacket that the pulse varies after having an external irritation or stimulus to the organism, similar to the orientation and defence reaction of the psychophysiology. The verification was based on the plethysmografical blood pressure curve, the ballistogramm (change of body length), the seismogram (dorsal-ventral distance), the electrocardiogram, the carotid pulse and the breathing frequency. The VAS is a variability of the heart frequency together with the amplification of the pulse amplitude. The VAS is triggered through a simultaneous agonistic and antagonistic activation of

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the hearts parasympathetic (Acetylcholine), the peripheral sympathetic - and -receptors (Adrenalin and Noradrenalin), the vasomotor CNS centres, other mediators (Kallikrein and Bradykinin) and axon reflexes. The former parasympathetic system slows down the heart beat; the latter sympathetic system contracts the peripheral blood vessels and thus amplifies the pulse amplitude. Dr. Fiche from France could now prove the VAS by means of the Heliopan apparatus (Expert Seminar Davos, February 2008). The therapist detects by means of the VAS the variability of the arterial blood pressure within the time and not anymore within the length of measurement (classical plethysmographical curve of the blood pressure). We differ between nociceptive, proprioceptive and metabolic stimuli combined with the biological feedback mechanisms to regulate the vasomotor tonus. The therapist feels the VAS subjectively at the radial artery (close to the processus styloideus) as a longitudinal distal deviation of the standing pulse wave and a feeling of a reinforcement of the pulse abundance. The VAS is a physical spoken answer of our brain-computer to a peripheral stimulus. By means of the VAS, the organism answers qualitatively and quantitatively for the experienced therapist many questions: e.g. Do we have to stimulate or sedate this Acupuncture point? How much extended (quantitative aspect) is the Aura and from which quality (deviation from orthopathy)? Which Zang-fu organ is involved? Do we deal with an allergy? Does an intolerance exist? to which substance? Which Flower Essence do we need? Which homeopathic drug comes into resonance and in which potency? Do we deal with a heavy metal- or environmental pollution? Which oligoelement is indicated? Do we have a vaccination problem? Is this food for this animal compatible or not?, etc. The skin of the palpating fingers of the therapist act as a sense organ for the transmission of this informative signal. It happens through the mechano-receptors within the skin. The Meissner bodies react onto the speed of the arterial blood pressure variability, whilst the Paccini bodies react onto the acceleration of the arterial blood pressure variation. We can provoke the VAS signal through different irritations. The significance of the positive VAS signals were quantitatively classified in three categories: (p<0.01) 1. VAS noticeable 2. VAS well noticeable (average) 3. VAS very well noticeable Clapping hands 60 % Heine light 40 % 3 V Hammer 25 % Toxic vials 20 % LASER 15 % Placebo 7% The detection of the VAS signal can be noted with the one-, two- or three finger methods. One- finger method: With the thumb at the Acupuncture point LU07 (radial artery) With the index finger at the Acupuncture point ST09 (carotid artery) With the Index finger at the Acupuncture point SI19 (temporal artery)

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Two finger method: With the Middle- and the Index finger at the Acupuncture point LU07 (radial artery) Three finger method: TCM palpating method at the radial artery with the index-, middleand ring finger at the Acupuncture point LU07 References Available Upon Request

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GBI LAB: THEORY AND APPLICATION


Terry Durkes, DVM Western Avenue Animal Hospital Marion, IN, USA We began our studies in gold bead implant in 1975. Our reason for choosing gold over other metals was according to Chinese theory; you use gold needles to treat chronic conditions and silver to treat acute condition. If you look at both gold and silver on the chemistry charts, they have a plus 1 positive charge and gold is heavier then silver. According to Chinese theory in acute conditions you have excess positive charge and in chronic conditions you have excess negative charge. As you look at the body and its parts, you find that the outside of the body is more positive then the inside. The polarity of the body is in constant change. Accepting the Chinese theory as being correct, we then said that all acute conditions have an excess positive charge and would be considered acidotic. All chronic conditions would have excessive negative charge and would be considered alkalotic. Once we started applying this information to different disease conditions and fractures it did not take long before we realized that the excess positive and negative charge was not related to time but was related to deterioration of the tissue. Example: acute kidney or liver disease can be picked up by doing the Chinese pulse or Nogier pulse. By the time blood chemistry picks up liver and kidney disease, they are in the chronic stages. Systemically we may be seeing acute signs but locally they are chronic. About the same time in Japan a physician was treating muscle pain by injecting NaOH at 10 9th molar. The results were great. He was injecting an alkalotic product into a condition that was acidotic and this resulted in a neutral condition. We started injecting conditions with either acid or alkaline solutions to see how the body would respond. All arthritic conditions, seizures, liver and kidney disease would respond to HCL at 10-9th molar and disc disease and all other conditions would respond to NaOH at 10-9th molar. We next decided to use gold beads in conditions that responded to HCL injections and we found equal results but they did not require additional treatment. The conditions we initially treated with the gold bead implant were hip dysplasia and epileptic seizures. The first dog that had hip dysplasia, we placed the gold beads in GB 29, GB 30 plus BL 54. The dog was clinically sound on the right hind limb but had no improvement on the left hind limb. Radiographs showed the bead placement on the left hip was different than the right hip. We added more gold beads to the left hip and the dog was sound in both limbs. We were able to place gold beads in GB 29, 30, and BL 54 to treat hip dysplasia for about 10 years and we were getting very good results. In the mid 1980s we started seeing deterioration in the dysplastic dogs. The basic three points would no longer give good results. Dogs coming from Europe would still have good results with the 3 basic points but dogs bred in the US would need to have the gluteal muscles treated up to

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their origin. Originally we were able to use only 2 gold beads per acupuncture point; now we use 3 to 4 gold beads per point. The additional acupuncture required to treat hip dysplasia and other arthritic joints has caused us to change our opinion on the cause of arthritis. It appears that the number one problem is weakness in the muscles, tendons, and ligaments around the joint. The body tries to stabilize the joint by depositing calcium in and around the joint and we call this arthritis. So what are we doing when we do the gold bead implant for arthritic joints? Number one, we are tightening the tendons, ligaments, and muscles around the joint which prevents subluxation of the joint and this stops the pain. Second, is we are neutralizing the excessive negative charge of the joint with the positive charge of the gold. It is the negative charge of the joint that causes the calcium to deposit around the joint. The more positive charge of the gold, the more absorption of the calcium you will get. The basic points used in doing the gold bead implant for HIP DYSPLASIA are GB 29, 30, 31, 32, 33, and BL 54. These points can be found by palpation, electrical measurement, or pulse diagnosis. We feel pulse diagnosis is the most accurate method of selecting the acupuncture points that need to be treated. After treating the basic points, then we start looking dorsal and lateral to GB 29, 30, and BL 54 for trigger points. These trigger points can be found as far dorsal as the lumbosacral junction. Each basic acupuncture point and trigger point found will have 3 to 4 gold beads placed into them. Post implant for hip dysplasia, we expect a dog to be clinically normal within one week and the implant should last a life time. In animals up to 7 years of age we are 98% successful; 7 to 12 years of age we are 75% successful; and from 12 to 17 years of age we are 50% successful. We have seen up to 40% absorption of the arthritis post implant, but it takes 1 to 2 years for this to happen. SPONDYLOSIS of the back is also very common, especially in the larger breeds of dogs. About 25% of the dogs that have wobblers or hip dysplasia will also have spondylosis of the back. Both conditions should be treated with the gold bead implant to see good success. We use to just treat the areas of spondylosis, but we have found that with time the whole back will develop spondylosis. Most dogs are 3 to 4 years of age before you can see radiographic changes in the back but we have seen it in dogs as young as 7 months of age. We start placing three to four gold beads along the Bladder Meridian starting at BL 13 and going back to BL 27. We also treat the reactive GV points and look for trigger points between the BL and GV meridians. Most dogs with spondylosis will be back to normal within one week post implant and we have had all the arthritis removed within 2 years post implant. WOBBLERS Syndrome is another very important disease of the larger breeds of dogs. Most of the dogs that we treat for wobblers are from 3 to 9 years of age with the oldest being 11 1/2 years old and the youngest at 5 months of age. Twenty five to thirty years ago 95% of the wobbler cases were under 18 months of age. Today 95% are over 2 years of age. I have asked several surgeons and neurologist and they are seeing the same thing.

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Like arthritis, hereditary factors and nutrition are the major contributing factors causing wobbler disease. We do not want the large breeds of dogs to gain more then 7 pounds in 2 weeks during their growing stages. We like for their diet to contain no more then 18% protein and 0.5 % calcium. W/D would be a good diet; it contains 14% protein and 0.4% calcium. If the dog is going to be a large dog, then it will just take a longer period of time to obtain full height and you are less likely to get wobblers. We have tried several methods to treat wobblers but we have had the highest success rate by treating along the dermatomes in the dorsal half of the neck. The dermatomes are about 1 to 1 1/2 inches apart and as you go from the dorsal midline ventrally you will find acupuncture points about every inch. Four gold beads are placed in each acupuncture point on both sides of the neck. After doing the implant a neck brace is placed on the neck for about 3 weeks. In dogs with weakness only in the rear legs, we are having about 75% success rate and if the front legs are involved, our success rate drops to around 50%. We expect to achieve our clinical results in 3 to 6 weeks post implant, but the internal healing takes up to 2 years. ARITHRITIS OF THE STIFLE responds to the gold bead implant but most cases are secondary to torn anterior cruciate ligament. You must correct the anterior cruciate ligament first before doing the gold bead implant. If the patient has a chronic torn ACL with capsular swelling, with or without ankylosis, we will just do the gold bead implant. Many times if you correct the torn ACL, you may not have to do the gold bead implant. For stifle problems, the gold bead implant must be done on the lateral and medial side of the stifle joint. On the lateral side of the stifle the major points that we treat are ST 35, 36, GB 33, 34, and BL 40. You will also find many trigger points dorsal and ventral to these points and they will usually be on the meridian. On the medial side of the stifle the major points are SP 9, 10, LIV 7, 8. Again look for trigger points dorsal and ventral to these points that are on the meridian. You will also find trigger points over the medial meniscus even though is not torn. These points will also need to be implanted with gold beads. Most of the gold beads around the stifle will be implanted just under the skin. OSTEOCHONDRITIS AND OSTEOCHONDRITIS DESSICANS of the shoulder responds well to the gold bead implant. If joint mice are present we usually do not have to remove them. They will dissolve on their own following the gold bead implant. The main shoulder points that we treat today are TH 14, 15, LI 15, 16, SI 9, 10, 12, and14. Some times we have to treat LU 1 and LU 2. ARTHRITIS OF THE ELBOW can be caused by many things but the most common cause is failure to treat the ununited anconeal process of the elbow. Sixty to seventy percent of the cases that we see have severe ankylosis of the joint. All we are able to do for these animals is to relieve the pain. They will still walk with a stilted gait. Should the anconeal process be removed before doing the gold bead implant? I dont have a good answer for you. We have done the gold bead implant on elbows that have never had surgery. Even though we have had good results in these cases, I feel like in the very young dog it would be best to remove the anconeal process before doing the gold bead implant.

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When implanting the elbow both the medial and lateral sides need to be treated. On the lateral side of the elbow the main points are LU 5, LI 11, SI 9, TH 5 and TH 10. It is not unusual to find several trigger points. On the medial side of the elbow the main points are HC 3, HT 3, SI 8, and a series of trigger points dorsal and ventral to SI 8. Many of the gold beads are placed just under the skin when treating the elbow. EPILEPTIC SEIZURES are very complicated to treat, but many dogs and cats respond well to the gold bead implant. A seizure is a sudden, involuntary alteration in motor activity, consciousness, sensation, or autonomic function. They may be partial or generalized. In partial seizures you will see head turning, staring into outer space, muscle twitching, biting into the air and barking. Generalized seizures can be grand mal or petit mal. Grand mal is the most common type of seizure and partial seizures are the hardest to treat. In grand mal seizures you can have one seizure in 24-plus hours; a cluster seizure is 2 or more seizures in 24 hour; or you can have continuous seizures (status epilepticus). There are several types of medication for treating seizures, but Phenobarbital and Potassium Bromide are the most common ones used. From an acupuncture point of view, we classify seizures into cluster and non-cluster. The non-cluster seizures are the easiest to treat. Each time the dog has a non-cluster type of seizure there are the same meridians involved, usually 2 to 3. The GB, ST and BLADDER meridians are most common involved. From an acupuncture point of view, seizures are due to excess Liver Wind. I feel like we should say seizures are due to excess Wind.

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BLOOD FLOW: THE KEY TO ACUPUNCTURE POINT SELECTION AND EFFICACY


Steven P. Marsden, DVM ND MSOM LAc Dipl.CH RH(AHG) Edmonton Holistic Veterinary Clinic Edmonton, Alberta, Canada Lessons from a Caveman Throughout the world, schools teaching acupuncture advocate a treatment approach first detailed in the seminal texts of acupuncture, namely the Huang Di Nei Jing Su Wen (The Yellow Emperors Inner Canon: Simple Questions) , the Ling Shu (The Spiritual Pivot), and the Nan Jing (Classic of Difficulties). This approach requires the practitioner to first diagnose the patient in Chinese medical terms and then prescribe appropriate acupuncture points for the treatment of the patients condition. With its pedigree rooted in the classical literature, such an approach seems incontestable, but recently a dead man named tzi is changing all that. tzi is the name given posthumously to a body found a few years ago by alpine hikers on the border of Italy and Australia. The forty year old man had been murdered, his sub-clavian artery pierced by an arrow. He died where he fell, in a small gully that was quickly covered in a snow storm, to eventually become part of a glacier. When the glacier retreated 5300 years later, his body would emerge back out of the ice to become the worlds oldest, best preserved mummy. Following his discovery, tzi was extensively studied over many months by an international multi-disciplinary team of scientists at the Museum of Natural History in New York. What they found has revolutionized theories about Stone Age man and his technology. Information about his clothing, weaponry, and food sources proved invaluable enough, but the most startling discovery arose from careful study of tattoos on tzis back and legs. The tattoos were modest in appearance, a group of fifteen well-preserved lines and dots permanently etched into tzis skin. Their modesty and concealment beneath clothed areas convinced researchers the tattoos could not be of ornamental importance but, for a time, no other theory seemed a satisfactory explanation for their presence. Eventually, however, it struck the researchers that some of the tattoos seemed to overlie well-known acupuncture points. Through extensive digital mapping procedures, it was determined that not just some of the tattoos, but the majority of them, precisely correlated with acupuncture points, and that a third of them overlay points commonly prescribed for the treatment of low back pain. A CT scan of the body showed extensive arthrosis of the lumbar spine, confirming suspicions that the tattoos constituted a Stone Age point prescription for back pain. The guidebook that now accompanies the traveling exhibit of this remarkable archaeological discovery, while carefully worded, nonetheless clearly acknowledges tzi as historys first acupuncture patient.

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There are only two possible explanations for how tzi could have ended up practicing acupuncture in Stone Age Eurasia. One is that therapeutically intended acupuncture originated in Eurasia and was later transmitted to China through far-reaching and previously unsuspected intercultural contacts of prehistoric man. A second explanation is simply that acupuncture was somehow independently discovered by at least two primitive cultures (China and Europe), but with the practice eventually only enduring in China. Since it is improbable that prehistoric Eurasians made an elaborate Chinese medical diagnosis for their patients before treating them with acupuncture, the right point to use for a patient must somehow have been tangible and obvious, independent of any elaborate theoretical foundations. In the past decade or two, researchers in various fields all appear to be circling around the answer of how effective points could have been so quickly and easily identified, and how their actions could have been so prompt and complete, as to allow their discovery by stone-age culture. The answer appears to be found in something Chinese medicine has advocated the importance of all along the flow of blood. The Importance in Chinese Medicine of Blood Flow Beginning with even its most seminal texts, Chinese medicine has believed in the importance of blood flow in both diagnosing and treating patients. Normalization of blood flow was considered paramount in the resolution of any illness. In chapter 20 of the Nei Jing, Determining Life and Death, Qi Bo thus states that regardless of the type of illness, one must first regulate and balance the flow of Qi and Blood. Abnormalities of blood flow that accompanied and produced disease also produced the two most important attributes used by these ancient practitioners in diagnosing patients complexion and pulse. Chapter 3 of the Ling Shu, An Explanation of the Minute Needles, states that taking the patients pulse is to know his disease. Likewise, in Chapter 13 of the Nei Jing, Treatment of the Mind and Body, Qi Bo states that the key to accurate diagnosis of conditions lies in the observation of the patients color and complexion and palpation of the pulses. These two techniques are the essential tools of diagnosis. If one does not understand and cannot utilize them, when one attempts to treat a condition, malpractice and further injury to the patient will occur. It is ironic that many, and perhaps even the majority, of acupuncturists do not utilize pulse diagnosis in their evaluation of patients, based on their beliefs that pulse diagnosis is too subjective. The reality is that treatments which effect an improvement in the pulse reliably eliminate doubts as to their efficacy. Indeed, the classical acupuncturists of antiquity went so far as to check the pulse during and immediately after treatment, basing all their expectations of clinical outcome on any improvements they were able to achieve. Thus we see Qi Bo, in Chapter 9 of the Ling Shu, use an immediate change in pulse as the basis of his prognosis in the treatment of excess conditions, stating that if the pulse is as large as before, but the treatment has caused it not to be as firm, it is a sign of recovery. If however, it is as firm as before the treatment, the disease will not depart even though ones words are encouraging. Acupuncture and Blood Flow When acupuncture first caught the North American public eye, it was its ability to induce analgesia that attracted interest. For the past few decades, acupunctures pain relieving mechanisms have been researched and validated, resulting in the advent of a number of pain

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relieving technologies, such as the TENS unit. Beginning in the mid-nineties, though, as questions surrounding acupuncture analgesia were answered, focus shifted to how acupuncture doesnt just relieve pain, but treats disease. While the number of studies showing an ability of acupuncture to treat various diseases is still too low to satisfy the requirement of most meta-analyses to label it as effective, it is growing steadily. As an example, traditional acupuncture compared favourably with sham acupuncture in the treatment of Crohns disease, an autoimmune syndrome. While both patient groups perceived improvement, only traditional acupuncture was additionally able to lower levels of alpha 1 glycoprotein, a by-product of inflammation (1). In another study of the use of acupuncture in pelvic inflammatory disease, acupuncture was likewise found to be effective in reducing the level of inflammation in patients, as determined by significant declines in ESR and serum IgM (2). Other studies have shown clear benefits of acupuncture in the reduction of inflammation associated with asthma and rhinitis (3). Numerous other studies exist echoing the general anti-inflammatory effects of acupuncture. How are these clinical results being achieved? Given the historical interest of Chinese medicine in the flow of blood, and the dramatic changes in tissue perfusion associated with inflammation, exploring the ability of acupuncture to manipulate circulation seems a good place to start. Just as numerous as the number of studies showing acupuncture can treat various diseases are the number of studies showing it can manipulate circulation in various organs. Doppler imagery demonstrated the ability of acupuncture to limit ischemia and then enhance reperfusion of the gastric mucosa following ligation of the right gastric artery in rats, relative to controls (4). Fibromyalgia in humans is marked by a reduction in regional perfusion above focal areas of chronic pain, as demonstrable by thermographic imaging. Following administration of acupuncture, skin temperature and blood flow to affected areas increased as pain levels declined (5). Many similar studies have been conducted demonstrating the ability of acupuncture to manipulate blood flow in almost every organ, from the heart and lungs to the stomach and muscles; from the kidneys and testicles to the brain and ligaments. This effect is also seen in patients under general anesthesia, as evidenced by a study where patients receiving acupuncture during cholecystectomy experienced reduced fluctuation and greater stability of systemic hemodynamics intra-operatively relative to controls (6). Mechanisms of Blood Flow Manipulation Given the rapidity with which changes in pulse and circulation can be detected during an acupuncture treatment, it would almost seem that it must be reflexively mediated. The ideal condition to validate this theory is thus a vascular reflex disorder, namely reflex sympathetic dystrophy. This is a chronic syndrome in humans where pain occurs simultaneously to the loss of normal circulation in one or more limbs. In stage II of the disorder, circulation is reduced, but can be dramatically improved following the administration of acupuncture (7), suggesting the change in circulation is mediated at least in part by reflex pathways. Practitioners observing the rapid pulse changes that Qi Bo describes cannot help but wonder when a thin pulse becomes instantly much broader, where the extra blood is coming from. The splanchnic capacitance vessels account for much of the bodys circulatory reservoir. If blood was

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being instantly recruited from here in the acupuncture patient, we would expect that reflexive vasosconstriction of these vessels in response to acupuncture could be demonstrated. A Japanese study did, indeed, demonstrate this phenomenon, through electroacupuncture stimulation of points on the hind limb and back of animals. The reflex was achieved through a manipulation of central arterial pressure (8). While reflex changes in blood flow are undoubtedly important, humoral mechanisms also play a crucial role. Stimulation of acupuncture points is believed to cause the release of three compounds, all playing a major role in the control of inflammation and blood flow (3): betaendorphins, calcitonin gene related peptide (CGRP), and substance P. The three substances together produced a blended effect on the regulation of blood flow and inflammation. The interactions and mechanisms are very complex, but can be distilled down to: CGRP released from nerve endings increases local and systemic blood flow. Menopausal women have direct experience with this effect. During menopause, low gonadal hormone levels result in an up-regulation of CGRP receptors, resulting in numerous menopausal complaints such as vascular headaches (migraines) and hot flashes. Substance P released from nerve endings likewise increases blood flow through the point and associated tissues, in part by activating an inflammatory cascade utilizing mast cells that culminates in the synthesis of nitric oxide, a key determinant of the amount of blood flowing through a tissue. The pro-inflammatory effects of Substance P are somewhat self-regulating, with increases in nitric oxide inhibiting further mast cell degranulation, and with Substance P itself feeding back negatively on the release of CGRP by the neuron Beta-endorphin is also released from nerve endings, but usually has an inhibiting effect on blood flow by activating T Helper cells to produce interleukin-10, a compound which interferes with vasodilation. Beta-endorphin also inhibits pain sensation In low levels, CGRP inhibits blood flow, in part by activating the release of interleukin-10 Given that all this is happening simultaneously, it might seem the vascular effect produced is rather balanced. As shown in the study on people receiving acupuncture during cholecystectomy, this can, indeed, be the case (6). But acupuncture can also be used to shift the balance between Substance P and beta-endorphin in favour of the latter, to have an antiinflammatory effect. The review by Freek and others (3) posits that repetitive higher intensity (i.e. sedative) acupuncture will exhaust nerve ending supplies of Substance P and CGRP, while increasing beta-endorphin to a critical threshold level, at which the pain and vascular engorgement associated with acute inflammation, is eliminated. As Substance P and CGRP supplies become exhausted, the net effect is mediated by high endorphins and trace levels of CGRP, which results in the suppression of inflammation Conversely, infrequent short-term stimulation (i.e. tonification) should have the opposite effect of increasing blood flow to a tissue, which becomes more important in the management of chronic inflammation, by helping to flush out the inflammatory mediators and free radicals that are propagating tissue damage and activating chemically-sensitive nociceptors to produce sensations of chronic pain. CGRP, as a mediator of angiogenesis (9), is also instrumental in

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fostering the re-orientation and organization of vascular beds following the mess made by acute inflammation, and likely has a critical role in ensuring the import of fresh supplies (e.g. fibroblasts) with which to repair tissues. Depending on the phase of inflammation the patient is in, then, frequency of return visits and the intensity of needle stimulation can be manipulated to achieve completely opposite hemodynamic effects. Undoubtedly, then, the humoral mechanism of blood flow regulation is as important as the reflex-mediated mechanism. Indeed, they may both occur together. A 2006 study showed that the impact on nitric oxide synthesis of electro-acupuncture at ST 36 in hamsters was highest along the Stomach channel meridian (i.e. those sites reflexively linked to the point) and not shown anywhere else. Sham acupuncture was incapable of producing these blood flow effects (10). Studies have shown that this regulatory role of afferent nerve activity on blood flow is crucial in the healing of tissues such as cruciate ligaments, and may explain the clinical experience of acupuncture resolving ligament tears that are not yet complete, if given sufficient time (11). Ordinarily, the vascular response to injury of the ACL is considered inadequate over time to allow healing to occur (12), but acupuncture can conceivably heighten the vascular response, tilting the odds in favour of repair. Integrating Therapies Based on Their Blood Flow Effects Acupunctures effects on blood flow give us a firm scientific foundation on how other treatment modalities will integrate with it to either hasten or halter tissue healing. For example, non-steroidal anti-inflammatory (NSAID) drugs are well-known inhibitors of nitric oxide activity, resulting in both an impairment of blood flow through the tissue and a suppression of the inflammatory response. It is this ability to produce ischemia that gives the drug class its reputation for causing renal ischemia and gastrointestinal ulceration. NSAIDs would thus seem to be of most benefit in the management of acute inflammation, where they could be used synergistically with repetitive and/or long duration electro-acupuncture treatments to reduce tissue congestion, inflammation, and pain. Continued use of NSAIDs in chronic inflammation, however, would counteract the general goal of acupuncture therapy, which would now be to increase tissue perfusion in order to flush out inflammatory mediators; provide materials for repair; and promote re-ordering of the vasculature. In this context, NSAIDs would, in fact, be contraindicated. Many other drugs, herbs, vitamins, and nutraceuticals have been researched for their impact on tissue blood flow, through their modulating effect on nitric oxide synthase (NOS). A summary of some of these studies are presented in tables 1 and 2. Most plant compounds have some impact on nitric oxide synthase, one way or the other. For example, the beneficial effects of flavonoids, catechins, tannins and other polyphenolic compounds present in vegetables, fruits, soy, tea and even red wine are believed to exert much of their effect through inducing nitric oxide formation. Angelicin, pimpinellin, sphondin, byakangelicol, oxypeucedanin, oxypeucedanin hydrate, xanthotoxin, and cnidilin are all NOS inhibitors and would serve to reduce tissue perfusion. Likewise, the saponins from ginseng (ginsenosides) have been shown to relax blood vessels, thus lowering blood pressure and increasing circulation in the corpus cavernosum (accounting for its ability to aid erectile dysfunction).

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Some plants and undoubtedly many formulas contain molecules with competing effects on nitric oxide synthesis. In those cases, the overall effect of a plant on tissue blood flow would be determined by the net effect of the whole plant on nitric oxide levels. Thus, even though some compounds in Gingko (Gingko biloba) inhibit nitric oxide synthase, the plant as a whole increases nitric oxide production, and increases perfusion in its target tissues. Adequate levels of data are not yet available to guide the Chinese medical practitioner in meshing their acupuncture treatments with multi-herb formula prescriptions. Data are probably adequate, however, for the integration of nutraceuticals, vitamins and minerals with acupuncture, an undertaking which, in the absence of a tradition of use of these products in Chinese medicine, has previously been speculative at best. For example, vitamin B6 is commonly advocated in the treatment of depression, in part because of its role in neurotransmitter synthesis. Where depression is due to Liver Qi stagnation and is improved by frequent sedative acupuncture treatments of LIV 3, there may be a synergistic interaction between the point prescription and the vitamin. But where the depression is due to Qi deficiency, and is responsive to tonifying acupuncture treatments and herbs like Panax Ginseng (an NOS promoter), vitamin B6 would potentially be contraindicated, due to a conflicting influence on NOS and cerebral blood flow. Indeed, as it turns out, B6 has been shown to be most helpful in depression occurring premenstrually, when the patient is more likely to be requiring sedative treatment of LIV 3 than any purely tonifying treatment. Understanding acupuncture in terms of blood flow gives Chinese medical practitioners a simple yet effective way to combine multiple modalities with the maximum chances of synergistic interaction, thus fighting imbalances on a number of fronts with a variety of tools, resulting in accelerated patient recovery. The Role of Blood Flow in Point Selection and Efficacy We now have a plausible answer for half the riddle of how acupuncture could have been discovered and used in Western Europe 3000 years before its appearance in China. We surmised that for acupuncture to have been developed as a therapeutic technique there would have to have been a fairly prompt and easily observable cause-and-effect relationship between stimulation of a particular point and some beneficial result. Weve discussed how the classics alluded to one impact of acupuncture being a prompt shift in circulation, and have reviewed some of the scientific literature supporting the ancient Chinese notion that acupuncture achieves much of its benefits through correction of pathological circulatory dynamics. We now turn our attention to the next question how did stone-age Europeans know where the points were? Most Chinese acupuncture training programs espouse the same four-step patient approach utilized in western medicine. The sequence of events in tackling a problem is the same, namely the (1) taking a history and (2) performance of a physical examination to (3) pronounce a diagnosis. Based on this diagnosis, (4) a prescription is formulated and administered. If points are painful (reactive), they may be included as local points, but this stands in contrast to Japanese acupuncture styles, where points found to vary in temperature and texture are ascribed great significance, and are often the basis around which the rest of the prescription is constructed.

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The tactile differences between points and their surrounding tissues have a basis in histology. Acupuncture points are relatively rich in muco-polysaccharides, collagen fibers, and nerve endings, relative to surrounding tissues. In addition, the points considered most effective clinically exhibited a well-developed capillary network (14). Clearly the capillary network is probably valuable in regional and systemic dispersal of Substance P, CGRP, and betaendorphins released during needling. Indeed, blood flow through the capillary network of acupuncture points increases immediately upon needling. But the capillary network may also serve as a guide to which points should be needled in the first place. In other words, blood flow to the point may already be increased even before the needle is inserted, helping to create the subtle differences in temperature and tone that Japanese acupuncturists key in on as important. Evidence for the points serving as a guide to their own detection through altered hemodynamics comes from Doppler and thermographic imaging. One study showed that the velocity of blood flowing through acupuncture points (LI 4) was significantly slower than the surrounding tissues, making them easier to detect (15) and implying vascular dilation and engorgement even before needling is performed. Another laser Doppler study was able to show the relative vascular engorgement of GB 21 relative to surrounding tissues (16). Thermography is another method of detecting locally increased cutaneous blood flow, revealing it as an increase in infra-red radiation. Thermography has advanced enough in sensitivity and resolution over the past several years to now allow it to be used in point detection and selection. In one study of sixty cases of facial hemi-paralysis, those points showing a one half Celsius degree difference between one side of the face and the other were needled on the affected side, with re-evaluation at each treatment. Comparison of treatment outcomes with 120 controls, whose point prescription was derived through the four-step method outlined above, showed a significantly higher cure rate (over 68%) from treatment of those points selected by thermographic imaging, compared to those points used in the control group (46%) (17). Even more dramatic were the differences in speed of recovery. The average treatment duration for the thermography group was 6 weeks (25 sessions), compared with 24 weeks (79 sessions) for the control group (18). Thermography is not yet practical for day-to-day practice, but fortunately the human hand excels at detecting differences in infra-red radiation from one region to another. Jean-Pierre Barral reviews the utilization of touch as a detector of infra-red radiation in his unique work, Manual of Thermal Diagnosis (Eastland Press, Seattle, 1996). He discusses the typical ability of most people to detect increases in infra-red radiation as a three dimensional cloud of warmth, due in part to the central processing of thermoreceptor data with the same centers and neurons as mechanoreceptor data, resulting in the detection of differences in infra-red radiation as a three-dimensional graduated cloud above the surface of the skin. In addition, the skin will often feel warm to the touch, and the surrounding tissues swollen and turgid (if the point is located in a muscle mass). It thus becomes fairly easy to see how stone-age humans could have identified the ideal acupuncture points to render a prompt improvement, helping to ensure acupuncture would survive to modern times as an important therapeutic tool.

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Conclusions Acupuncture first received serious research attention in the sixties and seventies, with emphasis focusing on its ability to relieve pain. Unfortunately, the larger importance of acupuncture in the resolution of disease may have been missed, simply because acupuncture became widely known in the western world at a time when neurophysiology was in its heyday. Since the mid-1990s, the importance of blood flow in the treatment and resolution of disease has gained prominence in medical research, resulting in a number of studies which suggest acupunctures real benefit is hemodynamic, and that its ability to relieve pain is almost of secondary importance. This paper has reviewed some of that research, showing at the same time how the conclusions beginning to be drawn in the most current research are the same as espoused in the classical Chinese medical literature published millennia ago.

References 1. Joos S, Brinkhaus B, Maluche C, Maupai N, Kohnen R, Kraehmer N, Hahn EG, Schuppan D. Acpuncture and moxibustion in the treatment of active Crohns disease: a randomized controlled study. Digestion. 2004;69(3):131-9. 2. Wozniak PR, Stachowiak GP, Pieta-Dolinska AK, Oszukowski PJ. Anti-phlogistic and immunocompetent effects of acupuncture treatment in women suffering from chronic pelvic inflammatory diseases. Am J Chin Med. 2003;31(2):315-20. 3. Freek JZ, Frank I, Huygen JPM, and Klein J. Anti-inflammatory actions of acupuncture. Mediators of Inflammation 12(2),59-69 (April 2003). 4. Zhang D, Li SY, Ma HM, Wang SY. Study on effect of electroacupuncture on gastric ischemia-reperfusion by laser Doppler blood perfusion imaging. Zhongguo Zhen Jiu 2007 Nov;27(11):833-8. 5. Sprott H, Jeschonneck M, Grohmann G, Hein G. Microcirculatory changes over the tender points in fibromyalgia patients after acupuncture therapy (measured with laserDoppler flowmetry). Wien Klin Wochenschr. 2000 Jul 7;112(13):580-6. 6. Ding YH and Gu CY. Effect of acupuncture-general anesthesia on hemodynamics in perioperative period of patients undergoing cholecystectomy. Zhong Guo Zhong Xi Yi Jie He Za Zhi. 2008 Mar;28(3):206-08. 7. Bar A, Li Y, Eichlisberger R, Angst F, Aeschlimann A. Acupuncture improves peripheral perfusion in patients with reflex sympathetic dystrophy. J Clin Rheumatol. 2002 Feb;8(1):6-12. 8. Takagi K, Yamaguchi S, Ito M, Ohshima N. Effects of electroacupuncture stimulation applied to the limb and back on mesenteric microvascular hemodynamics. Jpn J Physiol 2005 Jun;55(3):191-203.

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9. Toda M, Suzuki T, Hosono K, Kurihara Y, Hayashi I, Kitasato H, Hoka S, Majima M. Roles of calcitonin gene-related peptide in facilitation of wound healing and angiogenesis. Biomed Pharmacother. 2008 Mar 6. 10. Bray RC, Leonard CA, Salo PT. Vascular physiology and long-term healing of partial ligament tears. J Orthop Res. 2002 Sep;20(5):984-9. 11. Ivie TJ, Bray RC, Salo PT. Denervation impairs healing of the rabbit medial collateral ligament. J Orthop. Res. 2002 Sep;20(5):990-5. 12. Kim DD, Pica AM, Duran RG, and Duran WN. Acupuncture reduces experimental renovascular hypertension through mechanisms involving nitric oxide synthases. Microcirculation. 2006 Oct-Nov;13(7):577-85. 13. Achike FI, Kwan CY. Nitric oxide, human diseases and the herbal products that affect the nitric oxide signalling pathway. Clin Exp Pharmacol Physiol. 2003 Sep;30(9):605-15. 14. Ifrim-Chen F, Ifrim M. Acupoints and meridians: a histochemical study. Ital J Anat Embryol. 2005 Jan-Mar;110(1):51-7. 15. Hsiu H, Huang SM, Chao PT, Hsu WC, Hsu CL, Jan MY, Wang WK, and Wang YY. Study on the microcirculatory blood velocity of acupoints monitored by laser Doppler signal. Conf Proc IEEE Eng Med Biol Soc. 2007;2007:959-62. 16. Burklein M, Banzer W. Noninvasive blood flow measurement over acupuncture points: a pilot study. J Altern Complement Med. 2007 Jan-Feb;13(1):33-7. 17. Zhang D, Wei Z, Wen B, Gao H, Peng Y, Wang F. Clinical observations on acupuncture treatment of peripheral facial paralysis aided by infra-red thermography a preliminary report. J Tradit Chin Med 1991 Jun;11(2):139-45. 18. Zhang D. A method of selecting acupoints for acupuncture treatment of peripheral facial paralysis. Am J Chin Med 2007;35(6):967-75.

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Compounds/extracts Andrographolides

Herb species (Chinese name) Andrographis paniculata (Chuan Xin Lian)

Traditional use/biological actions Used as an antihypertensive by Malaysians and as an antimicrobial by Chinese

Tissues/cells

Lowers blood pressure in the rat Whole animal (rat) Causes +E vasorelaxation Induces NO release and cGMP formation Rat aorta Human EC

Aqueous extract

Artemisia verlotorum Lamottee

Used as an antihypertensive in Turkey Shows a transient hypotensive effect in the rat +E relaxation; elevated NO and cGMP due to muscarinic receptor agonism Whole animal (rat) Rat aorta

Aqueous extract

Crataegus monogyna or Hawthorn

Used for circulatory disturbances +E relaxation, sensitive to lNAME or methylene blue As an antihypertensive Induces +E relaxation sensitive to K+ channel blockers Used to improve cerebral blood flow Induces NO formation in EC, which is partially inhibited by K+ channel blockers Used to improve uterine blood flow and treat menstrual irregularity Induces +E, l-NAME-sensitive relaxation, which is mimicked by gallotannins Used to increase coronary blood flow Enhances NO release via increased expression of eNOS Human EC line (ECV304) Rat aorta Rat aorta Cultured EC Rat mesenteric artery

Aqueous extract

Eucommia ulmiodis Oliv (Du Zhong)

A standardized extract

Ginkgo biloba L (Yin Xing Ye)

Aqueous extract

Paeonia lactiflora Pallas (Bai Shao)

Danshinoate-B

Salvia miltiorriza (Dan Sheng)

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Compounds/extracts

Herb species Traditional use/biological actions Tissues/cells (Chinese name) Coptis chinesis Used as an anti-arrhythmic agent Rat mesenteric artery

Berberine

(Huang Lian) Induces l-NAME-sensitive +E relaxation and inhibits caffeine contraction Partly responsible for +E relaxation and abolishes caffeine contraction Inhibits SMC growth Gypenosides Gynostemma Used for circulatory improvement pentaphyllum (Jiao Chiu Lan) Induces l-NAME-sensitive vasorelaxation Increases NO release Methanol extract and haematoxylin Casesalpinia sappan (Su Mu) Used to enhance blood flow and as an anti-inflammatory agent +E relaxation inhibited by l-NAME and enhanced by l-arginine with NO and cGMP formation Rutaecarpine Evodia rutaecarpa Used as an antihypertensive and an anti-inflammatory agent

Rat mesenteric artery Rat aortic SMC

Pig coronary artery Bovine aortic EC

Rat aorta

(Wu Shu Yu) +E relaxation sensitive to l-NAME and methylene blue Inhibits L-type Ca channels in SMC, but opens non-voltage-dependent cation channels in EC

Rat mesenteric artery Patch SMC and EC

+E, endothelium-dependent; SMC, smooth muscle cells; EC, endothelial cells; l-NAME, NG-nitro-l-arginine methyl ester; NO, nitric oxide; eNOS, endothelial nitric oxide synthase.

Table 1. Plants and compounds that promote nitric oxide synthesis (13

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Drugs/extracts Tetrandrine and related alkaloids Higenamine Tetramethyl pyrazine Andrographolides Aqueous extract Baicalein, Wogonin Yomogin EGb 761 Quercetin Catechin Tannins Dehydrocostus lactone Methanol extract, honokiol and magnolol Aqueous extract Aqueous extract, sanquiin and proanthrocyanidin

Species (Chinese name) Tetrandra Stephenia (Fen Fang Ji) Aconittum coreanum (Wu Tou) Ligusictum wallichii (Chuang Xiong) Andrographis paniculata (Chran Xin Lian) Salviae miltiorryzae (Dan Shen) Scutellaria baicalensis (Huang Qin) Artemisia princeps Rampan (Ai Ye) Ginkgo biloba L (Yin Xing Ye) From many plant species; commercially available Camellia sinensis (Cha Ye) Melastoma dodecandrum Lour Saussurea lappa (Mu Xiang) Magnolia fargesii (Xin Yi) and M. obovata (Yu Lan) Dichroa febrifuga Lour (Chang Shan) Sanguisorbaeofficialis L (Di Yu)

Table 2. Plants and compounds that reduce nitric oxide synthesis (13)

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THE HEMODYNAMIC LOGIC BEHIND PULSE AND TONGUE DIAGNOSIS Steven P. Marsden, DVM ND MSOM LAc Dipl.CH RH(AHG) CVA Introduction While commonly associated with Chinese medicine, the historical record indicates that most traditional medical systems utilized pulse diagnosis in patient assessment. This is perhaps not surprising, given that early medical theory presumed the parts reflected the whole, and that pulse diagnosis could therefore provide insight into an overall disease dynamic pervading an entire organism. What is remarkable, however, is that there was substantial agreement as to what kind of general perturbation was needed to manifest each pulse, clearly implying the practice is based on an inherent logic and some physiologic truths that surpass cultural boundaries. Another implication of the near-universal reliance on the pulse as an assessment tool is that many of them essentially believed diseases were caused and treated through perturbations in the circulation. Certainly the health of an organ depends on the oxygenation and nutrition it receives from the bloodstream. Reduction of blood flow would also have its benefits in some tissues if it improved waste and free radical removal. The question, though, is whether simple changes in blood flow are enough to substantially improve chronic disease in the 21st century. Recent research indeed indicates that the clinical effectiveness of hydrotherapy, acupuncture, chiropractic, osteopathy, and even botanical medicine all owe much to their influence on tissue perfusion. Objectivity in Pulse Diagnosis A major obstacle to practitioners beginning to use pulse diagnosis is its apparent subtleness and subjectivity; most diagnostic methods utilized in conventional medicine are quite ephemeral, however. Variations by as much as a few micromoles per litre of a hormone are considered clinically significant, while interpretation of radiograph and ultrasound images is an art in itself. Conventional medical practitioners nonetheless rely on these methods because they have grown accustomed to them. Pulse diagnosis can similarly be learned easily through repetition and is also quite objective; interpretations are essentially the same as those made from an arterial pressure graph.

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Figure 1 A typical arterial pressure graph While the data are obtained through different means, both pulse palpation and arterial pressure graphs measure the same thing - pulse pressure. Pulse pressure is the difference between systolic and diastolic pressure. In Figure 1, it is depicted as the highest and lowest elevations of the arterial pressure graph. In pulse palpation, it is represented by the ease with which the pulse can be detected, since increased pulse pressure results in an increased distention of the vessel walls. The total duration of the wave in Figure 1 is correlated exactly with the degree that the pulse lifts the finger. A prolonged rise and fall on the graph would similarly be detected as a more prolonged lifting of the finger with each beat. The three main determinants of pulse pressure are stroke volume, blood velocity and arterial wall compliance. Reduced ejection of blood with each beat leads to a lower systolic pressure, a reduction in pulse pressure, and a weaker pulse. Velocity of the blood stream is decreased by any increase in peripheral resistance, which essentially acts as a bottleneck. As peripheral resistance increases, systolic pressure stays elevated for longer, the arterial pressure graph is longer in duration, and the finger experiences a greater lift. Reduced arterial wall compliance increases resistance to flow, raising the systolic pressure and making the pulse feel more forceful, at the same time as the blood vessel wall seems to possess more wiriness or tone. Given these correlations, we can easily interpret how a particular graph would feel upon digital pulse palpation, and draw the same conclusions from the pulse as from the graph. Note in Figure 2 how the curve of the right hand graph is much lower, and the downward slope more gradual. The implication is that there is a reduced quantity of blood being ejected from the ventricles, resulting in a compensatory increase in peripheral resistance. Upon digital palpation, the pulse of this patient would be expected to feel relatively weak, but with a degree of finger lift. The vessel wall might also be expected to have some obvious tone. The Chinese medical diagnosis rendered on the basis of this pulse is Blood deficiency; the conventional medical diagnosis of the patient is anemia.

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Figure 2 Comparison of pressure graphs from normal and anemic patients

Figure 3 Arterial pressure in critical anemia

Figure 3 shows the arterial pressure graph of a patient that is critically anemic following acute hemorrhage. Sympathetic tone dramatically increases in such patients, leading to forceful contractions and sharp reductions in vessel wall compliance as peripheral resistance increases. The net effect is a very high systolic pressure. Even the increased resistance is not sufficient to maintain a normal diastolic pressure, however, and it drops off steeply following each beat to well below the normal of 80. Digitally, we would expect the force of the pulse for the patient in Figure 3 to feel surprisingly forceful. The rapid fall off would produce a slapping sensation rather than a finger lift. Chinese medicine refers to this pulse as a surging or even an onion stalk pulse, and interprets it as a grave imbalance between the Yin and Yang of the body, where body fluids have been suddenly and critically decreased, leaving Yang in relative abundance. Again, the correlation between interpretations is quite clear. Acupuncture typically results in a marked improvement in the pulse of such patients, by drawing blood from the venous to the arterial circulation. Sympathetic tone reflexively reduces, resulting in less violent contractions and improved vessel wall compliance. Diastolic pressure remains sub-normal, though, since a volume depletion state still exists. The net result is a conversion, using acupuncture, of the graph from Figure 3 into the graph on the right in Figure 2, or the conversion of a Surging pulse into a Blood deficient pulse. Other attributes of the pulse that can be likewise assessed using an arterial pressure graph are the rate and the consistency of one beat to the next. As with the other traits, there is complete accord

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between their conventional and Chinese medical interpretations. A more rapid rate would be associated with increased heat or metabolism. A failure for the beats to appear uniform would be interpreted as possible impending circulatory failure. Pulse Traits and Their Correlations There are only a few pulse traits measurable with digital palpation that cannot be assessed with an arterial pressure graph: width, tone, and depth. The width of the pulse is simply the vessel diameter, and is partly correlated with the blood volume. Tone is the relative compressibility of the pulse using digital pressure. Increased tone implies increased resistance to the flow of blood. The depth of the pulse is indicated by the amount of digital pressure required before the maximum beat intensity is appreciated. A pulse detected only with significant pressure implies reduced peripheral circulation, often due to waning vitality. In Chinese medicine, the depth is said to reflect the degree to which Yang energy is mobilized. Table 1 lists for each trait its Chinese medical interpretation and the sensation elicited at the finger tip. A normal pulse is relatively nondescript with respect to the seven traits, and is described as moderate. Otherwise, each of the immoderate pulse traits identified is individually interpreted to disclose the pathological circulatory dynamic pervading the organism. Trait Force Rate Width Tone Rhythm Sensation Obviousness Rate Width Compressibility Consistency of beats Interpretation Strength (Qi or Yang) Temperature (Hot or Cold) Fluid Level (Yin or Blood) Ease of Circulation (Stasis) Ease of Circulation (Stasis)

Amplitude Depth

Lifting of finger Location of strongest sensation

Ease of Circulation (Stasis) Location and mobilization of Qi

Table 1: Pulse traits, their correlations, and interpretations For example, a deep pulse that lifts the finger and resists compression reflects impaired peripheral circulation, associated with increased peripheral resistance. In Chinese medicine, this pulse is called a Sinking pulse, and was described as being like a hard stone sunk at bottom of a pond. While poetic, such a description does not immediately tell us the interpretation. The parsing of this and the 27 other possible pulses according to the seven traits and their interpretation suggests Yang energy is trapped in the body interior, resulting in stagnation of Qi

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and even Blood, since Yang is the motive force of Blood. Once the pulse is dissected, and the meaning of each of its traits identified, a clear understanding of the hemodynamic nature of the patients problems is obtained. Some Common Pulse Scenarios and Their Hemodynamic Implications Armed with the preceding, were ready to interpret some pulses associated with too much peripheral circulation. Superficially located forceful pulses with increased vessel wall tone imply a pathogenic Wind invasion, almost invariably of the Tai Yang and Wei Qi. Some texts describe this as a Floating Tight pulse. Commonly this manifests as back and neck pain, such as in lameness or disk disease. Another type of broad superficial forceful pulse has no vessel wall tone, sometimes known as a Surging pulse. In this instance, successful treatment restores vessel wall tone and greatly narrows diameter, creating a sort of astringing effect. Traditional texts described the Surging pulse as being associated with severe Yang excess and precipitous loss of Yin, such as during a high fever. In modern veterinary medicine, this pulse is most often associated with severe acute hemorrhage (internal or external). The superficial and obvious pulse indicates a strong Yang state. The breadth of the pulse is misleading, belying the precipitous Yin deficiency that actually exists. The thin pulse only becomes evident after needling, while the initially dilated state of the vessel and lack of tone reflects distension by exuberant Yang and unbridled peripheral and centrifugal circulation. From a conventional medical perspective, catecholamine levels are very high in this patient, creating a violent increase in contractility, yet a precipitously low diastolic blood pressure due to volume depletion. Acupuncture recruits blood from the splanchnic circulation to the body periphery, helping reduce the risk of further hemorrhage and stabilizing blood pressure. Two pulses are commonly associated with relatively too much circulation in the interior. One, a more excess type of pathology, produces a deep, wiry pulse that is extremely commonly encountered in clinical practice and has several differential diagnoses as causes, all of which are consistent with the above discussion: Deep penetration of an external pathogen that drives the Zheng Qi internally, trapping it there Inability of Qi to circulate from the interior to the exterior, due to either obstruction of the Gall Bladder channel, where Qi that mobilizes the exterior is not able to be delivered, or Liver Qi Stagnation, resulting in a failure of Jing-Luo Qi to adequately exit the Lungs, course through the peripheral channels, then return into the interior via the Liver channel. Cold accumulation, or even Yang deficiency, where Qi cannot be mobilized due to a lack of Yangs centrifugal force Stagnation of Qi in the lower abdomen, such as in Spleen Qi Sinking or a Chong Mai imbalance The second pulse associated with too much circulation in the interior is the thin weak pulse. Normally this patient would be expected to need a purely tonifying strategy. In some instances, though, moving acupuncture treatments (such as sedation of SP 6 or LIV 3) produce the required strengthening of the pulse. This is indicative of Liver Blood deficiency and Liver Qi

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stagnation, where restoration of the normal movement of Qi and Blood in the upper and middle burner allows them to function properly, resulting in the generation of Blood and Qi, and their delivery to the exterior. Tongue Traits and Their Correlations While the pulse reflects the current circulatory dynamic operative in the patient, the tongue reflects the net impact of all the patients previous circulatory dynamics on tissue perfusion and engorgement. Such circulatory perturbations are repetitive, occurring on a regular basis because of the consistent strengths and weaknesses inherent in the genetic make up of each patient. Thus while the interpretation of a patients tongue may be at odds with the interpretation of their pulse, usually there is some degree of accord. As with interpretation of the pulse, tongue trait interpretations are quite logical, transcending differences between medical systems. For example, the degree and nature of moisture coating the tongue reflects the bodys relative hydration, with a dry tongue indicating dehydration and a wet tongue indicating moisture possibly to the point of edema. In Chinese medicine, these two conditions are described as Yin deficiency and Dampness accumulation, respectively. Table 2 lists the Chinese medical interpretation of various types of moisture on the tongue surface. Moisture Trait Conventional Interpretation Denuded coating None Dry Dehydration Wet Maximal hydration Frothy None Tenacious saliva None Table 2 Interpretation of tongue moisture Chinese Medical Interpretation Yin deficiency Yin deficiency Damp accumulation Phlegm accumulation Phlegm accumulation

Tongue size is also a reflection of hydration, with a swollen tongue reflecting a general tendency to water retention, also known as Damp accumulation. Small sized tongues are commonly associated with tissue wasting conditions in conventional medicine, or Yin deficiency in Chinese medicine. The appearance of ulcers or distended blood vessels would signal the development of severe inflammation (Heat) and venous congestive tendencies (Blood stasis), respectively. Like the pulse, tongue color is reflective of the hemodynamic pervading the patient. A pale tongue would indicate an insufficient blood supply in conventional medicine. Chinese medicine similarly interprets pallor as Blood deficiency, which may in turn be secondary to Qi or Yang deficiency. Increasing purpling of the tongue implies increased impairment of circulation in both systems. The presence of redness implies inflammation or heat in conventional medicine and an excess of heat or Yang in Chinese medicine. Chinese medicine further believes that vascular congestion can generate this heat, releasing its motive Yang energy through friction.

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Colour Pale Red Pale Lavender Purple

Conventional Interpretation Anemia Inflammation or heat Mild congestion

Interpretation Qi, Blood, or Yang deficiency Heat Mild Stasis Blood Stasis Stasis producing Heat

Vascular congestion or cyanosis Dark Red or Purple Red Inflammation with congestion Table 3: Interpretation of Tongue Colour

At first glance, Chinese medicines interpretation of tongue geography seems impossible to understand from a conventional medical perspective (Figure 4), but it too is based on hemodynamics. For example, just as blood flow is altered through the arms and legs, blood flow to the tongue is controlled through constriction and dilation of the blood vessels in its root, located at the middle of the tongue. When the tongue is fully perfused such as when the body is hot and the heart is racing, redness extends to the very tip. In conditions of mild volume contraction, blood is squeezed from the extremities to the body core, producing a relative congestion in the splanchnic vasculature, and a corresponding purpling in the center of the tongue (Figure 5). At such times, pallor may be seen along the edges of the tongue, reflecting the impaired peripheral circulation. In Chinese medicine, the organs assigned the task of ensuring smooth laminar peripheral circulation are the Liver and Gall Bladder.

Figure 4: Tongue Geography in Chinese Medicine

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Figure 5: Tongue perfusion in anemia. Note in this cross section the relative congestion at the center of the tongue and the pallor at the edges Conclusion While pulse and tongue diagnosis seem at first glance to be arcane and esoteric, they are based on a simple hemodynamic principles familiar to conventional medical practitioners. While the extent to which Chinese medicine interprets these findings is further than in conventional medicine, there is no question that reintroduction of these techniques to conventional medicine would contribute to a broader understanding of the patient by the clinician.

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CHINESE MEDICAL TREATMENT OF RENAL FAILURE IN THE DOG AND CAT


Steve Marsden, DVM ND MSOM LAc Dipl.CH RH(AHG) CVA Edmonton Holistic Veterinary Clinic Edmonton, Alberta, Canada

In Chinese medicine, as in conventional medicine, the cornerstone of treatment is a diagnosis. Understanding diagnoses requires, in turn, an understanding of how Chinese medicine views the urinary tract to function under normal circumstances. Physiology Chinese medical concepts of urine formation and excretion are not entirely alien to conventional medical models of understanding. For example, the Bladder, like the Kidney, is considered to be primarily a fluid storage organ. The storage is temporary, until useful clear fluids are retained while turbid waste material is discharged. This notion of concentration of urine in the Bladder is not at odds with the conventional medical model, when it is clarified that the Bladder receives the power to concentrate urine from the Kidneys themselves. In the end, then, adequate urine concentration in Chinese medicine depends on good Kidney function. The urine is considered to be effectively steamed by Kidney Yang, with the resulting rising vapor being condensed and retained by the body as pure water, and the remaining turbid distillate being discharged as urine from the Bladder. The Kidneys also govern the lower orifices, ensuring continence. Other aspects of Chinese medical physiology do not even loosely jibe with conventional medicine, but were never meant to be anatomically correct anyway, and only serve to describe in abstract terms functional relationships that seemed apparent. In its role of urine concentration, the Bladder receives assistance from the Small Intestine, Triple Heater, Lung, and Kidneys. The Small Intestine provides residual moisture to the Bladder after first extracting useful, clear, or pure fluid from ingesta leaving the Stomach (as in Western medicine, it is a major fluid absorption organ). The remaining turbid water not absorbed by the Small Intestine does not remain in the intestinal lumen, but is passed instead to the Bladder via the Triple Burner. The Triple Burner is best considered a super highway, through which Yang, Qi, Essence, and fluids move up and down to various locales in the body. The Qi that descends the Triple Burner originates in the Lungs, and it is this Qi that picks up and guides turbid water to the Bladder for further processing. One form of turbid water is Damp, which is produced through faulty digestion by the Spleen and Stomach. Normally, everything the Spleen and Stomach produce in the way of Fundamental Substances from processing of food and water enters the body for use and storage by other

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organs. If Damp is successfully detected as an abnormal and useless by product of digestion, it will be passed as turbid water to the Bladder for elimination, often as a profuse clear discharge. Sometimes, Damp is not detected as pathological and enters the system to go where normal fluid goes. Some of it ends up in the wall of the Bladder, leading to distention and obstructing the flow of circulation. Yang energy that drives circulation is released following this friction as a useless form of Heat. Together, the swelling and heat produce the common clinical signs in cystitis of tenesmus and burning urination. Other signs may be present indicating that Damp accumulation is the cause of the cystitis, including increased exudation and discharge, the appearance of various growths and warts, an increase in body weight, and a tendency to seborrhea oleosa. Renal Disease Excess Pathologies While many forms of renal disease exist in conventional medicine, there are considerably fewer types in Chinese medicine, and each can be assigned to one of two broad categories Excess or Deficient. Excess cases all stem from the entry or accumulation of a substance in the body that is not wanted. Sometimes they are Damp or Phlegm accumulations, and sometimes they are wind invasions. Generally, Excess cases are overtly inflammatory in nature and benefit from herbs that suppress nitric oxide synthesis. Acupuncture protocols to complement the actions of these formulas should be repeated relatively frequently and should employ sedating types of needle stimulation. Wind Cold Invasion Wind Cold invasions constitute the earliest phase of pathophysiology in many excess cases of renal disease. The Wind Cold pathogen invades the superficial layers of the body, namely the face and neck, manifesting as a local edema accumulation that arises following obstruction of the movement of Lung Qi and its carriage of fluid down to the Kidneys. In small animals, this edema quickly moves to dependent areas, presenting often as a mysterious neck and forelimb edema accompanied by fever. If the practitioner is lucky enough to witness this stage of pathology, chronic renal disease can possibly be averted, using the Chinese herbal formula Fang Ji Huang Qi Tang (Stephania and Astragalus Combination). Acupuncture points with an action sympathetic to the formula include LI 4, LI 11, GB 20, LU 7, and BL 11 to 13. Stasis in Triple Heater Obstructions in the Triple Heater constitute another form of pathological excess, since they are formed by a plug of congealed Damp, known as Phlegm, resulting in severe Qi stagnation. Phlegm obstruction of the Triple Heater presents a particular problem for renal function, since the Triple Heater is the gate keeper of the Kidneys, governing all deposits and withdrawals from their Yin reservoir. Gall Bladder 25 is the specific point that influences the movement of Yin and Qi in and out of the Kidneys. Phlegm obstruction of the Triple Burner appears to be the most common type of pathological excess affecting the kidneys of small animals. High protein diets should be avoided for these patients. Not only does Triple Heater obstruction prevent Essence or Yin deposition in the Kidney reserves, it also prevents the descent of Heart Yang energy to where it can interact with stored Kidney Yin to produce Kidney Qi. Meanwhile Kidney Yin cannot ascend to cool the Heart and

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interact with Heart Yang to form Heart Qi. Neither do Yin and Yang meet and pass each other in the middle burner to produce Qi in general. As Qi declines, the risk of sudden collapse and death rises. Despite the potentially dire outcome, patients with Triple Heater Phlegm obstructions usually present as exuberant and apparently healthy, but with moderately high ALP levels, and also usually cholesterol elevations. Cases in cats may be more common in geriatric patients and appear substantially deficient, resulting in potential confusion of the diagnosis with simple Kidney deficiency. Only the cholesterol elevations and the active Gall Bladder points (see below) indicate the cat is not a typical Kidney Qi deficient cat. Indeed, sometimes both diagnoses are present, and Kidney Qi tonics may need to be used after relief of obstruction of the Triple Heater. Triple Heater obstruction produces several other symptoms that may aid in diagnosis. The tongue is often purplish or lavender, and the pulse deep and wiry. Stiffness, lameness, weakness, and paralysis may occur due to obstructions in not only the TH but the GB channel. In addition to the resultant poor flow of Qi to the legs via these channels, the patient suffers from an overall lack of descent of Heart Yang to the lower burner, resulting in progressive weakness. Collapse may eventually ensue, due to the failure to generate Qi. Other signs related to Triple Heater obstruction include rebellious Qi arising from the obstruction, manifesting as a chronic cough, nausea, or vomiting. The entrapment of Yang in the upper burner results in restlessness, excitability, irritability, blurring of vision, heat intolerance and eye irritation. The rising Yang may also produce seizures and loss of balance, while the failure of Lung Qi to descend results in the entrapment of water in the Triple Burner and resultant oliguria. Muscular trembling can occur, secondary to the uneven flow through GB channel to the limbs, and also due to weakness from a failure to generate Qi. Lastly, there may be vaginal or preputial discharge, secondary to Qi stagnation in the Dai Mai, a part of the TH and GB channel network. The most telltale sign that Triple Heater obstruction exists is the increased warmth or swelling of major Gall Bladder and Triple Heater points, including GB 25, BL 19, BL 22, and GB 34. All these points promote the smooth flow of Qi in the middle burner and the kidney area. Herbal Treatment consists of Xiao Chai Hu Tang (Minor Bupleurum) Combination: Chai Hu Ban Xia Gan Cao Sheng Jiang Da Zao Ren Shen Huang Qin Bupleurum root Pinellia rhizome Licorice root Ginger rhizome Jujube Ginseng root Scutellaria root

Cool and pungent Bupleurum expels pathogens from the Shao Yang by expanding forcefully upwards and outwards. It also is a nitric oxide inhibitor, and thus has potent antiinflammatory

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effects. Bitter cold Scutellaria descends Yang from the upper burner to where it can reintegrate with the lower burner to generate Qi that will give the animal more strength and stamina. Ginseng, Jujube, and Licourice address any Qi deficiency that has occurred following the failure of Yang and Yin to merge, and Pinellia transforms any Phlegm obstructions of the Triple Heater. Ginger harmonizes the middle burner, helping to direct rebellious Qi down, and stop nausea and vomiting. An important modification of Xiao Chai Hu Tang that allows it to excel in the treatment of this type of renal failure is the addition of Qin Jiao (Large-leafed Gentian Root). Laboratory research confers this plant with potent anti-inflammatory action, although its ability to treat renal disease appears as yet unappreciated. The research supporting the use of Bupleurum in renal inflammation is impressive, on at least a bench research level of evidence. Following reduction of cholesterol levels and symptom improvement on Minor Bupleurum, many animals may require a Kidney deficiency tonic such as Ba Wei Di Huang (Rehmannia Eight Combination) to experience final stabilization or complete reversal of azotemia. Damp Heat Accumulation Some of the excess cases of renal pathology will be due to Damp Heat accumulation. These animals can appear similar to Triple Heater obstruction cases, since they are also often exuberant and can have high ALP levels. Indeed, one of the sites of Damp accumulation is in the Triple Burner. Cholesterol levels are usually normal, however. The tongue may be more red, or as much red as purple, but heat intolerance may still be evident. As with other Triple Heater obstruction cases (see above), patients may eventually need to be treated with Kidney Qi or yang tonics. While a few formulas have shown promise in the treatment of Damp Heat cases, the most consistently effective formula uncovered to date is San Ren Tang (Three Seeds Decoction): Xing Ren Yi Yi Ren Hua Shi Ban Xia Bai Dou Kou Dan Zhu Ye Hou Po Tong Cao Apricot seed Coix seed Talc Pinellia rhizome Round Cardamon Lopatherum Magnolia bark Rice Paper pith

The formula is designed to unblock the descent of Lung Qi; transform and dry Damp in the middle burner (body) and Stomach; and drain Damp down to and out of the lower burner (body). The three seeds that fulfill this function in the formula are Apricot seed, Coix seed, and Cardamon. Apricot seed descends Lung Qi and Large Intestine Qi, helping to relieve cough and constipation. Coix drains Damp from the lower burner, resolves diarrhea and provides Spleen support. It also has a pronounced anti-inflammatory effect by serving as a nitric oxide (iNO) synthesis inhibitor. This form of nitric oxide has powerful proinflammatory effects. At the same

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time, however, Coix has a tradition of use in Chinese herbal medicine of promoting renal filtration, such that it is preserved even while inflammation is suppressed, an important benefit in Damp and Damp Heat animals. Round Cardamon transforms damp and dries the Spleen and Stomach. The other herbs also facilitate the downward movement of Qi and fluids. Magnolia and Pinellia address distention of abdomen due to Damp and Phlegm accumulation and reorder the normal descent of Stomach and abdominal Qi. Rice Paper, Lopatherum and Talc promote urination and clear Heat. Lopatherum cools the Heart in particular, helping to relieve agitation. There are some specific symptoms that can immediately suggest the appropriateness of this formula in a renal failure patient: Nasal congestion, wheezing, or snoring Constipation Recurrent cystitis Reverse sneezing (dogs) Abundant nose and especially eye discharge that is not caused by KCS Weight gains Chronic vomiting not necessarily ascribed to renal azotemia Crystalluria As with Minor Bupleurum Combination (above), Three Seeds Decoction can be used with Rehmannia 8 (see below) to provide a balanced long-term effect on reducing renal inflammation while ensuring adequate blood flow. Acupuncture points that can aid in the treatment of Damp Heat renal disease include SP 9, BL 25, LI 11, SP 15, BL 22, BL 39, LV 13 and perhaps BL 20. Renal Disease Deficiency Pathologies Deficient renal pathology is very common in small animals and correlates with certain conventional medical diagnoses, including ischemic necrosis, low grade renal inflammation, and low grade pyelonephritis. In these animals, contrary to the treatment of Excess pathologies (see above), the goal is to increase blood flow to the kidneys. This is true even in inflammatory conditions, where increased blood flow would help increase collateral circulation through the cortex, flush out inflammatory mediators and free radicals, and provide materials for repair. Increased circulation might also improve renal tubular function, to the extent that it recruits a population of nephrons that is hypoxic and hypo-functioning, but not yet irreversibly damaged. The most common Deficiency conditions causing renal failure and inflammation are Kidney Yin and Qi deficiency. In either case, one of the key plants used to manage these patients is Rehmannia glutinosa, which has been shown in multiple studies to preserve renal blood flow even following partial renal artery ligation, presumably by interfering with the development of renal hypertension by down regulating the sensitivity of the juxtaglomerular apparatus. At the

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same time, its content of catalpol suppresses the production of iNO, an important inflammatory mediator. Lastly, Rehmannia has been shown to stimulate two separate stem cell lines in the bone marrow to produce erythrocytes, helping to replace the effects of erythropoietin that have been lost due to renal ischemia. While most animals in this category will receive a Rehmannia-based formula, a small percentage of cases will still be early enough along in their progression to benefit from Spleen tonification and the support of its production of Kidney Essence. Spleen Deficiency In Spleen deficiency associated renal failure, the Spleen is failing to produce adequate postnatal Essence for storage in the Kidney. Kidney Essence deficiency correlates closely with chronic renal failure in felines. Essence is inadequate to supply Kidney Yin and Yang, and their resultant lack of interaction to produce Kidney Qi. Instead of Essence, the Spleen is producing more Damp instead. In the early Spleen deficiency stage of renal pathology, the patients are often relatively asymptomatic. Loss of appetite, occasional vomiting of slimy mucous, slight reductions in body weight, and chilliness might be the only symptoms seen. Renal azotemia is mild and the patient is usually diagnosed with renal insufficiency, as opposed to failure. The goals in this stage is to tonify the Spleen and Stomach using acupuncture points like BL 20, BL 21, ST 36, and SP 6. The best formula for the treatment of sub-clinical renal insufficiency due to Spleen deficiency is Wei Ling Tang: Bai Zhu Cang Zhu Chen Pi Fu Ling Hou Po Ze Xie Tong Cao Gan Cao Sheng Jiang Da Zao Rou Gui White Atractylodes rhizome Atractylodes rhizome Citrus peel Poria Magnolia bark Alisma tuber Rice Paper pith Licorice root Ginger rhizome Jujube Cinnamon bark

The formula is composed of two smaller formulas, Ping Wei San and Wu Ling San. Ping Wei San (Harmonize the Stomach Formula) contains Atractylodes, Magnolia, Citrus, Ginger, Licorice and Jujube. Atractylodes and Magnolia both dry Damp. Magnolia additionally disperses stasis from the abdomen while Atractylodes warms the Spleen and Stomach. Citrus assists in moving Qi of the abdomen while also cutting the Damp. Ginger and Jujube tonify the Stomach and Spleen, respectively, without being cloying. Licorice tonifies the Spleen and Stomach Qi while also harmonizing the formula as a whole.

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Wu Ling San (Five Herbs with Poria) contains several herbs that drain Damp and promote urination, namely Alisma, Poria, and Polyporus. White Atractylodes tonifies the Spleen to reduce the production of Damp. Cinnamon activates the Damp draining action of the diuretics, warms the Yang of the middle and lower burner, normalizing the production and discharge of urine by the Bladder. Kidney Deficiency By the time most renal failure cats are receiving Chinese veterinary herbal care, the Deficient type cases have progressed to Kidney deficiency, whether of Yin, Qi or Yang. All types are aided by the use of formulas containing significant amounts of Rehmannia (Sheng Di Huang; Shu Di Huang). Rehmannia enhances renal blood flow but probably also reduces renal hypertension, resulting in improved renal filtration and possible restoration of function of hypoxic tubules. It also allows improved delivery of the immune system to kidneys that are prone to infection, and can help complete resolution on inflammatory lesions by flushing out chronically inflamed areas. Its immune stimulating effects don't seem to aggravate immune-mediated pathology in the kidney. Diets with normal protein intake also promote better renal filtration and can be used synergistically with Rehmannia to preserve renal blood flow without producing renal hypertension. Rehmannia containing formulas and high protein diets must be avoided, however, until all stasis symptoms (i.e. Excess pathologies, see above) have been resolved. Kidney Yin Deficiency Kidney Yin deficiency is the single most common cause of recurrent asymptomatic cystitis or pyelonephritis. In Kidney Yin deficiency, there is inadequate Kidney Yin to rise and cool Heart Fire. Heart Fire may flare, and fail to descend to warm the Kidney Yang, resulting in increasing heat in the upper body and increasing cold in the lower body. Separation of Yin and Yang may eventually result, leading to death. Symptoms of Heart Fire typically include a red and perhaps dry tongue, increased thirst, crying at night, nocturnal restlessness, a rapid and sometimes forceful pulse, and a preference for cool surfaces. Resultant Kidney Yang deficiency results in polyuria, chronic weight loss, dry hair coat, lower limb weakness and low back stiffness. Kidney Yin deficiency aggravates the Heart Fire symptoms and also produces dry stools and constipation. The goals of therapy in Kidney Yin deficiency are to tonify Kidney Yin and cool Heart Fire. Useful points include BL 23, 24, or 26; KI 3 or KI 6; and BL 15. Several herbal approaches, all containing Rehmannia, exist, including Liu Wei Di Huang Wan (Rehmannia Six Combination), Zhi Bai Di Huang Wan (Anemarrhena, Phellodendron, and Rehmannia Combination) and Yi Guan Jian (Glehnia and Rehmannia Combination). Use Zhi Bai Di Huang Wan for cases with a pronounced Heat or Fire element. Consider Yi Guan Jian for cases with concomitant liver inflammation. Liu Wei Di Huang Wan is the basic formula to treat the condition:

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Sheng Di Huang Fu Ling Shan Zhu Yu Mu Dan Pi Shan Yao Ze Xie

Rehmannia root Poria Cornus fruit Moutan bark Chinese Yam rhizome Alisma tuber

Three of these six herbs are tonics. Rehmannia nourishes Kidney Yin and cools Blood. Cornus nourishes Liver Blood and Yin, and helps astringe Kidney Essence leakage. Chinese Yam astringes Essence as well, helping to avoid dryness in the Kidneys, Lung, and middle burner. Balancing the potential cloying effects of these three tonics are three moving and draining herbs. Alisma promotes urination in the lower burner where Rehmannia acts, giving it a cooling action. Poria provides gentle Spleen support and leeches Damp from the middle burner where Chinese Yam acts. Moutan Bark clears Heat and drains Fire from the Liver, moderating the Empty Heat accumulating in the system as well as the warming and astringing effects of Cornus. To this base formula of six herbs, Phellodendron and Anemarrhena are added to create Zhi Bai Di Huang Wan. The latter two clear Heat and protect the Yin, respectively, adding significantly to the overall cooling effect of Rehmannia Six. Yi Guan Jian contains the following herbs:

Sheng Di Huang Gou Qi Zi Dang Gui Shen Mai Men Dong Bei Sha Shen Chuan Lian Zi

Rehmannia root Wolfberry fruit Chinese Angelica root Ophiopogon root Glehnia root Sichuan Chinaberry

The structure of Glehnia and Rehmannia Combination is relatively simple. Lycium and Angelica nourish Liver Blood while Rehmannia clears any Empty Heat and ensures adequate Kidney Yin. Glehnia moistens the Stomach Yin, and Ophiopogon the Lung Yin, where they have become injured by the Yin deficient Empty Heat state. Chinaberry is the sole bitter element amongst all the sweet tasting tonics. It serves to regulate stagnant Liver Qi, and also ensures the formula is not too cloying to the middle burner. This formula is a consideration for management of cats with concomitant liver pathology and also stomatitis secondary to Stomach Fire. Kidney Qi or Yang deficiency In pure Kidney Qi or Yang deficiency cases, the Heat element of Kidney Yin deficiency cases is missing. In affected animals, the Kidneys fail to supply adequate Yang to the Bladder, resulting in its failure to separate the clear from the turbid, resulting in polyuria. Inadequate Yang is available to steam Yin up to the Heart and control Heart Fire; Heart grows hotter and Kidneys 68

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colder, but the Fire element in these cases is more feeble. Instead of the tongue appearing red, it is slightly purple and swollen, reflecting the progressive build up of Yin as Yang dissipates, resulting in the gradual slowing of circulation. Instead of acting hot, the patients are chilly, seeking out heating registers, sunshine, or beds to lie on. Other typical symptoms include lower limb weakness, polyuria, polydipsia, a greasy coat, weight loss, chronic vomiting of slimy mucous, nocturnal restlessness, low back pain, and a deep, feeble or weak pulse. Goals of therapy are to tonify the Kidney Qi and Yang, using points like BL 23, KI 3, and GV 4. The main herbal approach to Kidney Qi or Yang deficiency is (Ba Wei Di Huang Wan) Rehmannia Eight Combination. Indeed, it is the default formula for the management of all renal azotemia until a further differentiation can be made. Ba Wei Di Huang Wan, known also a s Jin Gui Shen Qi Wan (Precious Golden Tonify the Qi Pill) contains the following herbs:

Shu Di Huang Shan Yao Shan Zhu Yu Fu Ling Ze Xie Mu Dan Pi Rou Gui Fu Zi

Prepared Rehmannia root Chinese Yam rhizome Cornus fruit Poria Alisma tuber Moutan bark Cinnamon bark Prepared Aconite root

The first three herbs are Yin tonics. Prepared Rehmannia has an overall warming effect, and nourishes Kidney Yin and Blood. Cornus nourishes Liver Blood and Yin, and helps astringe Kidney Essence leakage. Chinese Yam astringes Essence as well, helping to avoid dryness in the Kidneys, Lung, and middle burner. Balancing the potential cloying effects of these three Yin tonics are three moving and draining herbs. Alisma promotes urination in the lower burner where Rehmannia acts. Poria provides gentle Spleen support and leeches any Damp from the middle burner where Chinese Yam acts. Moutan Bark clears Heat and drains Fire from the Liver, moderating any Empty Heat accumulating in the system as well as the warming and astringing effects of Cornus. The final two herbs warm the Kidney Yang, allowing the restoration of urine concentrating ability as well as the cooling of any mild Heart Fire.. Originally, Cinnamon twig was used in Rehmannia Eight; the Tang dynasty changed the recipe to include Cinnamon bark, which has a greater affinity for the lower burner.

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TRANSLATION FROM TRADICIONAL CHINESE VETERINARY MEDICINE PHILOSOPHY INTO MODERN MEDICINE
Susanne Rodekohr, MD, DVM Student Instituto Mexicano de Medicina Veterinaria Complementaria A.C. Mexico City, Mexico Introduction: There is still a discrepancy between the philosophy of Traditional Chinese Medicine (TCM) and modern concepts in medicine. History is the only way in which we can understand the reasons why the TCM concepts are so different from our understanding of todays medicine. If we focus in the essential concepts of TCM and its functions, we can find multiple congruencies among the two types of medicine. It is really amazing to think that when TCM was developing, more than two thousand years ago, some processes were already described, which are processes that were later explained by modern Medicine in the last century. The difference between the two is the language with which Traditional Chinese Medicine works, which is very different from western science. Translating the events of ancient times can help us to narrow the gap between these concepts. Mainly, the energetic concepts of TCM are the ones that can be explained and translated into current concepts. In the rest of this document, the relation of basic energies used in TCM and Traditional Chinese Veterinary Medicine (TCVM) will be presented. 1. Essential Jing Prenatal Jing energy is formed from the essential Jing energy of the parents. Prenatal Jing energy is the first energy of the embryo. The mother holds the Yin quality and the father holds the Yang quality. The new being is formed by the union of the sky energy (Yang) and the earth energy (Yin). The quality of this prenatal essential Jing energy depends on the quality of the essential Jing energies of the parents and cannot be replaced. Prenatal essential Jing is the energy responsible for the adequate growth and development of the fetus. The moment in which the prenatal Jing energy is formed, is equivalent to the union of the male spermatozoid and the female ovum. In that moment, new genetic material is formed by the genome of both male and female. The genetic information, equivalent to prenatal essential Jing energy is fixed for the whole life of the animal and cannot be replaced. Similarly, prenatal essential Jing energy has a potential already determined in the moment in which it is formed. From the TCVM point of view, inherited diseases like hip dysplasia, heart level malformations, or portosystemic shunts are originated by a deficiency in the essential Jing energy. Defects are predetermined from the formation of the organ or structure. Other diseases are genetically determined, but they do not necessarily appear. We are talking about the predisposition to acquire certain diseases and we know that some animals present them and some animals do not. Diabetes mellitus in dogs, for example, has multiple factors of origin. Among others, there are genetic factors (between breeds and dog families) and

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overweight. Some animals present the disease, others remain sub-clinical and some others do not develop it. How can the predisposition to acquire certain diseases be interpreted through TCVM? After birth, the prenatal essential Jing energy is transformed into postnatal essential Jing energy under the influence of alimentary Ying energy. Alimentary Ying is the energy which extracts the Spleen of consumed foods. Deficient nutrition can be a trigger factor to diseases developing in animals with a genetic predisposition. Here we find, for instance, overfeeding in dogs and the presence of diabetes mellitus. The diet factor is compared with an alteration in the formation of alimentary Ying energy, which is related to a Spleen deficiency. 2. Alimentary Ying Alimentary Ying energy is produced by the Spleen. The transformation process of the foods consumed produces alimentary Ying energy. This energy is important to the formation of other energies, such as postnatal Jing essential energy, Yuan Qi, Wei Qi, pectoral Zong or Blood and it demonstrates that it is a central energy for the good working order of the organism. It is also one of the three basic energies of the organism (alimentary Ying, air Qi and essential Jing). The digestive process is equivalent to the formation of alimentary Ying. Alimentary Ying is comparable to energy transporters and energetic substances. It refers to carbohydrates and proteins, which are the precursors to produce alimentary Ying. Other, more defined forms of energy are ATP (Adenosine triphosphate), ADP (Adenosine diphosphate) or AMP (Adenosine monophosphate). ATP is a molecule with two phosphoric anhydride atoms among its three phosphate atoms. When the molecule is hydrolyzed to adenosine monophosphate (AMP), 10.9 kcal mol-1 (45.6 kJ mol-1) of free energy is released, which can be used to favor other biochemical reactions. The energy released and the energetic molecule itself can be compared with alimentary Ying energy. Gluconeogenesis is the biochemical means that allows producing glucose from non carbohydrate precursors. Some important precursors are lactate, amino acids and glycerol, which are transformed into pyruvate, which is the basic molecule to start glucose production. Glucose storage is carried out by means of glycogen production, which is stored mainly in the liver and in the skeletal muscle; it is a molecule that can be easily degraded to provide glucose as an energy source(6). In TCVM the Liver has the function of controlling energy dynamics and providing it to the whole body, depending on its needs. Nowadays, we know that the liver can quickly mobilize energy to the place required by the organism. In the TCVM philosophy the Spleen, as an energy source, controls the muscles and promotes their adequate operation. If we consider that glycogen is stored in the skeletal muscle to be rapidly degraded in situations of heavy muscular activity, we can find a relationship between the ancient concept of TCVM and our current knowledge. The Krebs cycle is another biochemical means that provides energy. This cycle provides high energy electrons using substrates such as amino acids, fat acids and carbon hydrates. The 72

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basic molecule that enters into the Krebs cycle is acetyl coenzyme A (acetyl CoA). In the transformation process, energetic molecules such as nicotinamide adenine dinucleotide (NADH) and Flavine adenine dinucleotide (FADH2) can provide the necessary energy to produce ATP. The lipids consumed in food are substrates to produce energy (such as fatty acids) which are combustible molecules. They are stored as triglycerides and are degraded by means of oxidation generating acetyl CoA, which can enter into the Krebs cycle to dispose of the energetic molecules NADH and FADH2, which in turn produce energy to generate ATP. (6) Proteins and their basic components, amino acids, are less important when compared with alimentary Ying energy as an immediate energy, since the proteins work to use energy only in extreme situations. A severe Spleen deficiency (especially Spleen Yang) leads to lack of Blood, which needs alimentary Ying for its formation. The importance of proteins is rather structural, as well as Blood in TCVM. Considering that nutrition is important to develop erythrocytes (referring for example to vitamins and minerals) and that immune cells like lymphocytes use a lot of protein components to perform their functions like producing antibodies, Ying qi plays an important role in the intact immune system and hematopoietic system. Summarizing: The energy provided by carbon hydrates, lipids and proteins with important molecules of ATP, NADH, FADH2, and acetyl CoA can be considered as a part of alimentary Ying energy in TCVM. This energy plays a very important role in this type of medicine, since it is the source of other types of energy. Just like it happens with current medicine, TCVM considers that an insufficient or poor quality diet can damage the most important digestive organ: the Spleen, and alter the production of alimentary Ying energy and all processes related to it, thus bringing about malnutrition and the predisposition to become ill, among other consequences. 3. Pure air Qi (Qing qu) Breathing provides oxygen to the organism in the inhalation phase and rids the body of carbon dioxide in the exhalation phase. The most important component in air for life is oxygen and in TCVM oxygen corresponds to the pure energy of air, which forms one of the three basic energies which are necessary to create life. It is worth mentioning that the Lung promotes inhaling pure air and the Kidney holds the received energy. The Heart needs energy to make the blood flow. This energy is provided by the Lung. Lung and Heart depend on each other, just like blood depends on energy. Comparing the biochemical processes that happen under the influence of oxygen in the organism, we can point out the following relationships: The oxidative phosphorylation (respiratory chain) occurs in the internal mitochondrial membrane, where NADH or FADH2 are transferred to molecular oxygen, reducing it to water. The energy released in this process is used to produce ATP. (6) Here, we have a combination of correspondent energies, alimentary Ying (NADH, FADH2, ATP) and pure air energy (oxygen), which enters the Lung. The union of pure air energy and alimentary Ying energy is in accordance with the TCVM philosophy of the pectoral Zong energy. This energy is concentrated in the thorax (which is the anatomical location of the 73

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lungs) and it is the energy that provides strength for functions such as voice, barking, meowing, etc. It also controls the breathing process and supports the heart function and blood flow. The oxygen penetrates the alveolar membrane and enters the lung capillaries, where it is added to erythrocyte hemoglobin. Transporting oxygen into the lung capillaries and the exit of carbon dioxide towards the alveoli is carried out by means of different concentration gradients of these gasses in its various compartments. The force that promotes spreading is the concentration gradient, since the organism always tries to balance concentrations. Just like in TCVM, the organism wishes to establish an energy balance similar to homeostasis. The pectoral Zong deficiency is reflected in a weak voice or weak barking or meowing. If the Lung energy is deficient and is not properly distributed, signs of cough or dyspnea appear. The lack of oxygen or alimentary Ying leads to a lack of pectoral Zong energy, (which helps blood flow) and can bring about blood stagnation, due to the fact that pectoral Zong is the force that promotes blood flow (among other factors). 4. Wei qi Wei qi, also known as defensive energy, corresponds to the immune system of the individual. One of its functions is defending the organism from pathogenic factors. TCVM considers both external and internal pathogenic factors. External factors are environmental aspects such as cold, heat, moisture, dryness or the wind, as well as the entry of bacteria or viruses into the organism. Internal factors are defined as an energetic lack of balance of the Zang-fu organs that very frequently can cause chronic problems. An inadequate diet, stressful situations and a lack of balance between rest and work are some of the etiological factors that predispose an individual to suffer from chronic diseases. Wei qi defends the organism against external pathogen factors and can be related to innate immunity, which includes physical barriers (skin, mucose), chemical barriers (antimicrobial chemical products) and blood proteins such as the complementary system and cells such as phagocytes (macrophages, neutrophiles). Additionally, Wei qi circulates more in the surface of the organism (cou li region) to defend the organism from external pathogen factors. Wei qi is formed when the Yuan qi (the energy formed in the Kidney, which is produced by the union of essential Jing and alimentary Ying) is joined with the alimentary Ying energy. It is important to mention the importance of the alimentary Ying energy, for example, regarding the fact that malnourished patients are more prone to become ill. The Spleen, which is a source of alimentary Ying and a very important element in the defense of the organism in TCVM, has its place in current medicine as an organ of the immune system and it participates in the specific immunity processes. Additionally, patients with an essential Jing energy deficiency have a weak health and are sickly. Specific immunity (lymphocytes and antibodies) is not directly related to just one TCVM function. The capability of the organism to react specifically and directly to pathogenic agents (antigens) and have memory cells is rather a general function to resist diseases and includes the totality of the well-being of the animal. Innate and specific immunity as a whole can be compared to Zheng qi energy, which refers to the ability of the organism to defend itself against harmful agents in general. Another approach could be the interpretation of all factors, which lead to the well-being of the animal (diet, exercise, rest, life form) is reflected by means of a Zheng qi sufficiency and the specific factors to defend itself against pathogen agents (innate and specific immunity) are reflected by means of Wei qi energy.

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Conclusion: The comparison between basic energies included in TCVM and modern medicine prove useful to narrow the gap between both concepts and disproving TCVM as an ancient and unintelligible therapy. It is not possible to compare all TCVM as such, but it is possible to attain a significant approach.

References 1. Day MJ. Clinical Immunology of the Dog and Cat. 1ed. London: Iowa State University Press, 1999. 2. Maciocia G. Die Grundlagen der Chinesischen Medizin. 2nd ed. Ktzing: Verlag fr ganzheitliche Medizin, 1997. 3. Rodekohr . El concepto energtico en la acupuntura veterinaria y la Medicina Tradicional China: Comparacin con conceptos actuales de la medicina. Revista de la AMMVEPE 2007:Vol.18 (2): 52-56 4. Stryer L, Berg JM. Tymoczko JL. Bioqumica. Barcelona: Editorial Revert S.A., 2002. 5. Xie H, Preast V. Traditional Chinese Veterinary Medicine. 1ed. Reddick: Jing Tang, 2002.

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ANCESTRAL SINEWS AND TENDINOMUSCULAR CHANNELS


Linda Boggie, DVM, IVAS Certified Acupuncturist The Netherlands The Ancestral Sinews, or Zong jin, refers to five pairs of muscles whose primary function is to maintain the integrity of the relationship and communication of the three body cavities the head, the chest and the pelvic cavities. Through this network of muscles the structural relationship between the cavities is maintained as well as the circulation of Qi and Blood. They also provide padded areas to absorb shocks both physical and emotional. As such, these muscle groups can also store latent pathology and, as this occurs, they themselves can be affected. The result can be painful muscles and sinew tissues, nodules or trigger points in specific muscle bellies, stiffness, soreness and lameness. These may include some patients that have severe lameness but no radiographic abnormalities are detected. When discussing this concept there needs to be an understanding of the Chinese Medical concept of Latency. As veterinarians we have become familiar with the latent viral infections those that stay hidden without clinical signs until there is a stressor that diminishes the function of the immune system thus allowing the latent virus to cause clinical disease. The reasons animals have become infected with these latent pathogens in the first place is debatable but an insufficiency of the immune system can be suspected. This can be seen in Chinese medical theory as well, but instead of viruses or prions we have the External Pathogenic Factors of Wind, Cold, Damp, Heat, Fire and Dryness. If Wei Qi is insufficient to expel these pathogenic factors they will become trapped in regions that hold these PF away from the Zang-Fu Organs (ZF). Primarily we see this reflected as the arthritic Bi Syndromes as the major articulations of the body are a confluence of Wei Qi, brought to them by the Sinew or Tendinomuscular channels, and Jing provided by the marrow of the bone. Thus the Jing comes to the support of the Wei Qi to prevent the EPF from traveling deeper into the body and affecting the ZF. If the Ancestral Sinews (AS) become a holding place for latent PF the clinical symptoms will involve pain and tightness within the muscular and sinew tissue. This may be reflected in the patient that improves but never quite resolves an issue, be it lameness, skin problems, digestive complaints, etc. In order to fully resolve an issue the ancestral sinews may need to be released. The five Ancestral Sinews are: 1) SCM sternocleidomastoideus m. head to chest clavicle to drain the shock 2) Diaphragm chest to spine anchors KID grasping LU Qi 3) Iliopsoas spine to pelvis 4) Rectus abdominus chest to pelvis 5) Paravertebral mm +/- gluteals spinal support The Ancestral Sinews are closely related to the Extraordinary Vessels, they are controlled by the Chong and the diaphragm specifically is heavily influenced by the Chong. Examining some of the pathology of the Chong Mai Running Piglet Qi and poor communication between the upper and lower jiaos we can see how the diaphragm is important to proper support and circulation. In some cases of chronic digestive complaints, complete resolution 77

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may not occur until the diaphragm is released. The Ren Channel influences the rectus abdominus and has control over the sphincters, thus the AS can also be involved with pathology of the sphincters and can be used to influence response to treatment. The Du Mai will influence the integrity of the paravertebral muscles, and vice versa; thus, stagnation in the paravertebral muscles and gluteals can have an affect on the expression and function of the Du. The AS can account for some of the pathology seen in the Dai Mai when it is involved with low back pain. This is a low back pain of emptiness and the legs will be weak. This has to do with the Dai Mai support of the Zong jin. In using the AS in treatment all muscle pairs are opened with GB 41 and GB 27. Then the respective points for each set of muscles are stimulated. SCM Diaphragm Iliopsoas Rectus abd. points Paravertebrals GB 41, GB 27 BL 10, BL23, BL 40, BL 17 GB 41, GB 27 GB 41, GB 27 GB 41, GB 27 GB 41, GB 27 GB 12, TH 17, ST 12 BL 17, Du 4 ST 25 (Celestial Axis), Ren 2 palpate along KID and ST channels for tight

The name of GB 27 is Five Axes or Five Pivots; this directly infers the importance of this point on the five AS. One way to rid latency is to relax the sinews holding on to the latency. The set of muscles treated is determined upon the disease pattern and on palpation of the muscle groups. For example, in a cat with chronic sinusitis that is not resolving with adequate treatment, palpation of the SCM muscles may reveal nodules and tight muscular bands. Releasing the SCM with the specific point mentioned and direct needling of remaining trigger points may be necessary for complete resolution. In some cases more than one set of AS is involved and must be released. Dogs with chronic arthritis often will have tightness in the iliopsoas muscles and in the diaphragm. Once these muscles are released the underlying Bi Syndrome pathology can be addressed more effectively. This is not a well-known system in human or veterinary acupuncture and as a presenter of this information I can only speak from my own experience when using this system. There have been some patients that I have only used the above strategy during a treatment session, including no other points in the treatment, and have re-evaluated those patients 1-2 weeks later. These patients have often been very painful patients, young, with no clear deficiencies or Zang-fu Organ imbalances. In other cases I have used the AS strategy, waited for 15-20 minutes and then needled additional points based on pulse and palpation findings. Generally these patients have had chronic diseases, such as chronic sinusitis, or have chronic Bi syndrome that has not responded to straightforward TCM treatment strategies. In either case scenario, it has been an effective tool in helping patients. References Jeffrey Yuen, various lectures, 1997-2006.

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HOMEOPATHY IN TERMS OF TRADITIONAL CHINESE VETERINARY MEDICINE (TCVM)


Susanne Rodekohr, MD, DVM Student Instituto Mexicano de Medicina Veterinaria Complementaria A.C. Mexico City, Mexico Introduction The founder of Homeopathy is the German Physician Friedrich Christian Samuel Hahnemann (1755 1843). He developed the use of potentially toxic substances in very small doses with therapeutic properties, due to the disappointment he had in traditional medicine at that time and to a document he translated from William Cullen. This work (Abhandlung ber die Materia medica, Leipzig, 1790) describes the properties of the quinine tree bark, and its relationship with malaria. Hahnemann did not agree and thought that it should have other properties and conducted a self-experiment. He took small quantities of the substance and he developed symptoms similar to the ones presented in malaria, which disappeared after a few hours. He came to the conclusion that, small quantities of a substance with characteristic symptoms in a healthy person can be used in sick patients that present with similar symptoms to cure such patients and he continued to experiment with several and multiple substances. The core of his work can be translated into the following affirmation: Similia similibus currentur: like cures like (law of Similars). The doses that have to be used in the sick person to produce a beneficial effect are very small. In Homeopathy there is talk about dynamizations, when referring to the dilution degree of the substance during its preparation process. The homeopathic materia medica describes the signs and symptoms that can be produced by a substance in small quantities in a healthy subject. The selection of the Homeopathic medicament is made by means of a clinical history, which reveals the clear signs of the patient. Clear signs are very detailed signs. Instead of saying: the patient has cough, this sign is described as: cough, which was produced after exposure to cold air weather. It is an acute illness, the cough is dry, dog-like and it gets worse with cold weather and at midnight; it is reduced in warm environments. The most similar medicament to the ailment of the patient is chosen. Looking at the signs, which are described in this medical subject, it is possible to find multiple relationships in the philosophy of Traditional Chinese Medicine (TCM). This fact becomes even more interesting when we discover that Hahnemann did not have any knowledge about TCM. When possessing knowledge about both therapies, it is possible to establish relationships with the prescription process of Homeopathy. Each Homeopathic medication has a core of characteristics for its use and typical signs that, when matched with the ailment of the patient, increase the probability of prescription success.

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In the rest of this document, the core of some Homeopathic substances is compared with the philosophical principles of TCM in a table. Comparison of some Homeopathic substances with the principles of Traditional Veterinary Chinese Medicine 1) Aconitum napellus Aconitum napellus has a blue flower, which is very poisonous when ingested in considerable amounts. In Veterinary Homeopathy it is used mainly for acute illnesses, ailments in the respiratory and cardiac tracts, and behavior and pain problems.
Characteristic sign Diseases produced by exposure to cold wind Acute disorders Extreme anxieties, restlessness, fear episodes. Disorders after a fright Comparison with TCVM Wind invasion and external cold syndrome.

External syndromes, Yang type syndromes. Shen disorder due to a Kidney alteration, which altered the Heart by the Ko cycle or a direct heart disorder. The fright affects the Kidney or the Heart (Ko cycle) and it produces alteration in these organs or it can affect other organs by means of the Sheng and Ko cycles. Probable tachycardia is a sign of an excess at Heart level. Yang type excess syndrome. The Yang excess is so strong that the Yin is not capable of containing Yang at night and the Shen wanders in the night and is not contained in the Heart Blood. a) External syndrome due to cold invasion b) Headache appears, when the cold contains the energy and does not allow it to flow, especially at the Yang channels level in the head. a) The external cold syndrome is transformed in an external heat syndrome. (Typical: the change is manifested by cold waves and then the fever occurs). The struggle between the Wei defensive energy and the External Pathogen Factor at cou li zone level causes heat, which produces fever and hot skin. High fever at night can be explained with a previous Yin deficiency and the Yang signs are augmented at night, since Yin is incapable of containing Yang or if the Yang excess is extremely dominant. b) External heat syndrome. The heat directly invades the organism like in the case of a sunstroke a) Cold and wind, which are both external, invade the most superficial organ: the lung and they cause the rebellious energy of the lung, which produces the cough. The excess of these energies can produce dyspnea at Lung level. b) If an asthma type breathing appears in animals with behavior problems, the respiratory problem is produced by an excess at Lung level, that cannot lower the energy by its own deficiency or because the Kidney is deficient and cannot capture the energy emitted by the Lung. The breathing will appear in animals typically when they are fearful, scared or frightened, which are the emotions related to the Kidney. In this case, the illness is chronic, which is aggravated under certain circumstances. The Shen alteration caused by the Kidney, who is unable to control the Heart (Ko cycle), and produces an excess at Heart level or the Heart directly affects the Spleen and Stomach system through the Sheng cycle and causes the rebellious energy of the Stomach, which provokes vomiting. Typical pulse of an excess syndrome. Homeopathy does not separate a superficial pulse from a deep pulse. For the prescription, it is necessary to feel a superficial pulse, full and hard, since these are acute illnesses.

Insomnia

It worsens with cold Headache

High fever, dry with hot skin, worse at night. Cold waves.

Dry, bark-like cough caused by cold air. Dyspena. Asthma.

Vomit with fear

Full hard pulse

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2. Belladonna atropa The Homeopathic medication Belladonna atropa is prepared from the whole plant atropa belladonna. Among other substances, it contains atropine, which explains the signs presented in case of intoxication. In Veterinary Homeopathy it is used mainly for acute illnesses, fever, convulsions, severe swelling, alterations in the respiratory tract and pain.
Characteristic sign Acute illnesses, rough and violent. Comparison with TCVM External syndromes. Yang type syndromes.

Hypersensitivity of the External heat affects Shen and produces hypersensitivity and can alter senses to light, shiny sense organs such as eyes and ears. Photophobia is the manifestation objects and noises. of the Yang excess. High fevers without thirst, worse at noon. External heat produces the fever. This Yang excess sign becomes more noticeable in the most Yang time of the day. The sign of lack of thirst is typical for Belladonna, however it cannot be explained at TCVM level. a) External heat produces internal wind and causes the convulsions. b) Heat due to a deficiency related to the Liver Yang. Although these types of convulsions are not produced in parallel with the fever, Belladonna atropa is a useful medication for this type of convulsions. Pathognomonic is the presence of mydriasis during the convulsions. It is also useful to know if the convulsions were triggered by a scare. Hypersensitivity of the senses. All organs can be easily affected due to a great Yang excess. Heat excess causes Yang type signs. Mydriasis is the expression of an acute situation. External heat can affect the pharynx. In mastitis, the pathogen factor is of bacterial type, which is interpreted as an invasion of an external pathogenic heat factor. Belladonna atropa type swelling is an acute one. There is no purulent secretion yet. The heat and Yang syndrome produce pulsations or tachycardia.

Convulsions due to high fever.

Easy scare, Restlessness Mydriasis

Severe swelling, pharyngitis, mastitis

Pulsations Tachycardia

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3) Calcarea carbonica The Homeopathic medication Calcarea carbonica is prepared from the internal layer of the oyster shell. It is used for behavior, growth and development problems. It is more frequently used in puppies and in patients who repeatedly contract diseases related with the digestive or respiratory tracts. Carbonic Calcarea increases the defenses.

Characteristic sign Deep fear. Slowness, easy weariness, Laziness. It gets worse with effort and/or after eating. Growth problems: Fontanels are closed late. Late dentition.

Comparison with TCVM Severe Kidney alteration. Kidney Yang deficiency. Qi deficiency, jointly with a Kidney and Spleen Yang deficiency. The effort consumes energy and the signs become more severe. After eating, the Spleen needs energy for its transformation process and there is not enough energy to sustain all other functions. The patient feels even wearier. Essential Kidney Jing deficiency. The energy responsible for development cannot perform its duties. The Spleen Yang deficiency causes the lack of alimentary Ying, which is needed to form Essential Postnatal Jing. The double deficiency of Spleen Yang and Kidney Yang causes extreme cold, which is experienced by these patients. Although they always seek warm places, they are always susceptible to feel cold. The Spleen Yang deficiency causes Damp. Damp, over time, becomes P4hlegm and causes a predisposition to develop adenopathies, polyps and calculus. Using Calcarea carbonica for calculus problems must be carefully considered, due to the fact that small fragments of the calculus can produce colic crisis and the need of urgent surgery. It is best to use this medication as a post-surgery prevention. The lack of essential Jing and alimentary Ying due to the deficiency at Kidney and Spleen level prevent the formation of sufficient Wei Qi energy and the patients become easily ill. Calcarea carbonica is used to increase Wei Qi, not for the acute illness. The appetite is controlled by the Spleen and the Stomach. If there is obesity, the patient has already developed Damp due to the Spleen Yang deficiency. Exaggerated appetite is a heat sign, typically at Stomach level. In Calcarea carbonica, however, there are no other signs of heat or fire at Stomach level.

Prone to cold, seeks warm places.

Adenopathies, Polyps Bladder Stones. Kidney lithiasis

Repeated alterations of the respiratory tract: Otitis, Pharyngitis, Bronchitis Exaggerated appetite with slimming or obesity.

Constipation with hard Constipation is presented because the patient does not have enough energy for intestinal peristalsis, but there is still enough energy to feces, large and absorb liquids. The feces stay longer in the intestine and there is afterwards soft feces. more time to absorb liquids. Depending on the severity of the process, partially hard or soft feces appear.

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4) Chamomilla matricans Chamomilla matricans is prepared from chamomile. It is useful mainly in gastrointestinal and behavior problems and it is more frequently used in puppies.

Characteristic sign Prone to anger and irritability. It is calmed in the arms. Difficult dentition with pain.

Comparison with TCVM The relative excess of liver Yang produces an angry and furious behavior.

The patient requiring Chamomilla matricans is hypersensitive to pain, which can be experienced in dentition. The pain related to energetic stagnation and relative excess at Liver level, make dentition even harder because of the emotional state of the patient. The relative Liver Yang excess affects the Spleen and Stomach system by means of the Ko cycle and causes the rebellious energy of the Stomach with bilious vomit. The Spleen alteration due to the relative excess of heat causes the bad smell diarrhea. This smell is caused by the relative heat.

Bilious vomit after an anger attack. Bad smelling diarrhea.

Conclusion: The interpretation of the characteristic signs that we can find in Homeopathy is very interesting and useful for prescriptions. However, prescriptions are always individual, just like it happens when the Acupuncture points are selected for our patients. This comparison does not intend to be a complete one, although the most important signs of the medications were presented. There are also signs that are not directly related to the Philosophy of Traditional Chinese Medicine. Possessing knowledge of both types of therapy can be useful for veterinary physicians.

References 1. Maciocia G. Die Grundlagen der Chinesischen Medizin. 2nd ed. Ktzing: Verlag fr ganzheitliche Medizin, 1997. 2. Steingassner HM, Homopathische Materia Medica fuer Veterinrmediziner. Wien: Verlag Wilhelm Maudrich, 2001. 3. Tischner R. Das Werden des Similesatzes. In: Tischner R, 1ed. Geschichte der Homopathie. Wien: Springer Verlag, 1998:159 175. 4. Vijnovsky B. Tratado de Materia Medica Homeoptica. Buenos Aires:Buenos Aires, Argentina, 1997. 5. Xie H, Preast V. Traditional Chinese Veterinary Medicine. Reddick: Jing Tang, 2002.

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THE APPLICATION OF JING-JIA-JI AND HUA-TUO-JIA-JI IN SMALL ANIMALS


Han-Wen Cheng, DVM, MS Sino Union Animal Hospital Yong He town, Taipei County, Taiwan E-mail: hanwun@ms.21.hinet.net And Tzong-Fu Kuo, DVM, MS, Ph.D Department and Institute of Veterinary Medicine National Taiwan University Taipei city, Taiwan, E-mail: tzongfu@ntu.edu.tw Abstract Jia-Ji-Xue (Paravertebral Points) has widely been used in human patients with substantial benefits but not paid much attention by the veterinarians although the acupuncture is now commonly used in small animals all over the world. Jing-Jia-Ji (Cervical Paravertebral Points) are two rows of acupuncture points located on the lateral aspect of the cervical region, 0.5 cun above and below the transverse processes of each cervical vertebrae (6). Hua-TuoJia-Ji (Hua-Tuos Paravertebral Points) are the acupuncture points on the dorsal lateral region of the back, 0.5 cun right and left lateral to the dorsal spinous process of each of the vertebrae from T-01 to L-07 (6). In this study, we use Jing-Jia-Ji and Hua-Tuo-Jia-Ji to treat cervical Bi syndrome with Blood stagnation, Kidney Yang deficiency Bi syndrome, trauma with Liver Qi and Blood stagnation, Cervical Bi syndrome with Qi stagnation and Kidney Yin deficiency, constipation. All cases are healed. Clinically, Jia-Ji-Xue may be an effective treatment for many diseases, and is a good choice for small animal practice in combination with local points, herbal medicine, and other drugs. Key words: Jing-Jia-Ji, Hua-Tuo-Jia-Ji, Acupuncture, herbal drugs, dog, cat Introduction Jia-Ji or Paravertebral Point, Tuo-Ji, and Hua-Tuo-Jia-Ji or Hua-Tuos Paravertebral Point are named after well-known Chinese physician Hua Tuo in three kingdoms Wei, Shu, and Wu which existed in China simultaneously from A.D. 222 to 265. Jia-Ji-Xue has long been used by ancient Chinese Practitioners, which had been documented by Huang Di Nei Jing Su Wen (The Yellow Emperors Classic of Internal Medicine-Simple questions, 300-100 B.C.E.), Hua Tuo Bie Zhuan (Hua-Tuos Separate Collection and Anthology, 398-445) and Zhou Hou Bei Ji Fang (Pocketbook for emergency Therapies, 281-340). After their application of generation to generation in practice, these points are improved and developed into 56 points from its original 34 points. Jia-Ji-Xue (Paravertebral Point) is not paid much attention by the veterinarians although the acupuncture is now widely used in small animals all over the world. These points for acupuncture can be used as a method to address various disorders of dogs and cats, including cervical, thoracic or lumbar pain or intervertebral disk disease, cervical spondylomyelopathy (wobblers syndrome), upper or lower limb weakness, paresis, or

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paralysis, vomiting, abdominal fullness and pain, and urine incontinence, etc., especially the lesion located on the vertebral column or near to it. Jia-Ji-Xue may be clinically an effective treatment for many diseases, and is a good choice for small animal practice in combination with local points or herbal medicine. This is a study result concerning five clinical cases of four dogs and a cat treated with acupuncture in JingJia-Ji-Xue and Hua-Tuo-Jia-Ji-Xue which combined with oral administration of Chinese herbal drugs. 1. The concepts of Jia-Ji-Xue (Paravertebral Point) A. Location Jing-Jia-Ji (Cervical Paravertebral Points) are two rows of acupuncture points located on the lateral aspect of the cervical region, 0.5 cun above and below the transverse processes of each cervical vertebrae (6). Hua-Tuo-Jia-Ji (Hua-Tuos Paravertebral Points) are the acupuncture points on the dorsal lateral region of the back, 0.5 cun right and left lateral to the dorsal spinous process of each of the vertebrae from T-01 to L-07 (6). B. Nomenclature There is no unified name for these points, but we can use each vertebra (cervical, thoracic, lumber, and sacral) by giving Arabian number of order (x-y) to describe the point what we apply. Thus, if we use the point of cervical vertebra, we will name it as Paravertebra Cx or Jing-Jia-Ji Cx, and if we use the continual point in the cervical vertebrae, it will be Paravertebrae Cx-y or Jing-Jia-Ji Cx-y. For example, if I needle the first point in the cervical vertebra, I will describe it as Paravertebra C1 or Jing-Jia-Ji C1, and if the points from the first to the third cervical vertebrae are needled, it will be Paravertabrae C1-3 or Jing-Jia-Ji C1-3. The other vertebra may be deduced by analogy, e.g. Paravertebra T1 or Hua-Tuo-Jia-Ji T1 and Paravertebrae T1-3 or Hua-Tuo-Jia-Ji T1-3 (7, 8). C. Indication Jia-Ji-Xue may harmonize Zang-Fu, regulate Yin and Yang, support right and dispel evil, activate channels and collaterals, and relieve pain (2). It may have a wide range of effect in the treatment of different system diseases, such as musculoskeletal, gastrointestinal, urogenital, and respiratory disorders, etc. a. Cervical Paravertebral Point It is useful for the treatment of the neck and upper limb disorders, e.g. neck and shoulder pain, and upper limb pain, paresis, and paralysis, etc (7). b. Thoracic Paravertebral Point The points from the first to the third thoracic vertebrae (Paravertebrae T1-3 or Hua-Tuo-Jia-Ji T1-3) treat disorders of upper limb and chest, e.g. panting, cough, and chest pain, etc. The points from the fourth to the sixth thoracic vertebrae (Paravertebrae T4-6 or Hua-Tuo-Jia-Ji T46) treat disorders of chest. The points from the seventh to the eighth thoracic vertebrae (Paravertebrae T7-8 or Hua-Tuo-Jia-Ji T7-8) treat disorders of chest and upper abdomen, e.g., thoracic oppression, belching, and acid upflow, etc. The points from the ninth to the twelfth thoracic vertebrae (Paravertebrae T9-12 or Hua-Tuo-Jia-Ji T9-12) treat disorders of mesogastric and hypogastric regions, e.g., pain of the hepatic region, pain in the right hypochondrial region, stomachache, and vomiting, etc (7).

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c. Lumbar Paravertebral Point The points from the first to second lumbar vertebrae (Paravertebrae L1-2 or Hua-Tuo-Jia-Ji L12) treat disorders of abdomen, e.g., abdominal fullness and pain, intestinal adhesion, enteritis, etc. The points from second to seventh lumbar vertebrae (Paravertebrae L2-7 or Hua-Tuo-JiaJi L2-7) treat disorders of abdomen and lower limb, e.g. lower limb pain and lameness, limb weakness, paresis and paralysis, and back pain, etc (7). d. Sacral Paravertebral Point These points can be used to treat disorders of urogenital tract, e.g., impotence, urine incontinence, anal prolapse, and lower limb paresis and paralysis, etc (7). 2. The point Selection and combination for the Jia-Ji-Xue (Paravertebral Point) Hua-Tuo-Jia-Ji is a group of acupoints. It is very important for correctly choosing the points to increase the effect of these points. Since Hua-Tuo-Jia-Ji is closely associated with Governing Vessel Channel (GV) and BLADDER Channel (BL), and also shares the special connection with spinal cord and sympathetic trunk, it has a particular method to select the point and combine the point with others (7). A. Point selection a. To select the point according to character of neuroanatomy The innervations of spinal nerves and its segments are commonly used by practitioners to treat diseases (8). Jing-Jia-Ji C1-4 can be selected to treat disorders of head; Jing-Jia-Ji C1-7 can be selected to treat disorders of neck; Jing-Jia-Ji C4-7 can be selected to treat disorders of upper limb; Hua-Tuo-Jia-Ji T1-4 can be selected to treat disorders of Lung and upper limb; Hua-Tuo-Jia-Ji T5-7 can be selected to treat disorders of Heart; Hua-Tuo-Jia-Ji T8-10 can be selected to treat disorders of Liver and Gallbladder; Hua-Tuo-Jia-Ji T11-13 can be selected to treat disorders of Spleen and Stomach; Hua-Tuo-Jia-Ji L1-2 can be selected to treat disorders of Kidney; Hua-Tuo-Jia-Ji L3-7 can be selected to treat disorders of Urinary Bladder, Large Intestine, Small Intestine, Uterus and lower limb. Hua-Tuo-Jia-Ji S1-3 can be selected to treat disorders of Urinary Bladder, Perineum, and lower limb (1, 7, 8). b. To select the point according to the theory of Zang-Fu Channel as well as the effect of Back-Shu Association Point Hua-Tuo-Jia-Ji and Back-Shu Points share the same level and similar effect along the side of vertebral column, i.e. Hua-Tuo-Jia-Ji T3, T5, T10, T12 and L2 corresponding to BL-13 (FeiShu), BL-15 (Xin-Shu), BL-18 (Gan-Shu), BL-20 (Pi-Shu), and BL-23 (Shen-Shu). Thus, while we try to address Zang-Fu and its corresponding disorders, we may choose the point by the theory of Zang-Fu Channel and the point at the same level of Back-Shu Association Points. For example, if the Liver is in disharmony or the lesion occurs on the channel of Pelvic limb Jue-Yin, we can needle Hua-Tuo-Jia-Ji T10 which shares the same level with BL18 (Back-Shu Association Point for the Liver) to nourish the Liver; However, we can also select the same-name channel points Pericardium Channel (Thoracic Limb Jue-Yin) and the exterior-interior-related channel points Gallbladder Channel (Pelvic Limb Shao-Yang) combined with Hua-Tuo-Jia-Ji T4 (corresponding to BL-14 Jue-Yin-Shu) and T11 (corresponding to BL-19 Dan-Shu) to harmonize the Liver. As a general rule, the ipsilateral Paravertebral Point may be selected while the lesion is involved unilaterally and both sides of the Paravertebral Points are selected when the lesions affect bilaterally (7, 8).

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c. To select the point according to trigger point and local sensitive point Since Jia-Ji-Xue may reflect the condition of Zang-Fu syndrome in the trigger point or local sensitive point, the Paravertebral Point near to or on it can be needled to treat disorders of corresponding Zang- Fu and the local lesion (7, 8). d. To select the local point When the neck, thorax, and back are compromised, Hua-Tuo-Jia-Ji-Xue can be applied by the local point at the help of image examination. If the cervical and lumbar vertebrae are affected by osteophytes, the Cervical and Lumbar Paravertebral Point can be used. If the lesions are involved multifocally or continuously, the continual Paravertebral Point or the point every other site can be applied. If the lesion occurs singly, the single point can be applied with adding the point prior and posterior to the lesion (8). B. Point Combination Jia-Ji-Xue can combine with Back Shu (Association) Points, Front Mu (Alarm) Points, Yuan (Source) Points, and Lower He Sea (Uniting) Points to strengthen the effect in corresponding Zang-Fu. a. Combination of Jia-ji-Xue and Mu (Alarm) Points Jia-Ji-Xue combining with Mu (Alarm) Points are developed from the application of combination of Shu (Association) and Mu (Alarm) Points in the Front and Back as well as Yin and Yang by which Zang-Fus Qi and Blood regulated and disorders of Zang-Fu treated (7, 8). The Simple Question in chapter 5 saying: guide Yin to Yang, and guide Yang to Yin (3) is true for the treatment principal of balancing Yin and Yang and balancing Front and Back in the point combination of acupuncture when a disease is treated. For example, Hua-Tuo-Jia-Ji T3 and LU-1(Zhong-Fu) can be needled if cough is noted; Hua-Tuo-Jia-Ji T13 and CV-12 (Zhong-Wan) may be selected if the stomach is disordered (7, 8). b. Combination of Jia-Ji-Xue and Shu (Association) Points Hua-Tuo-Jia-Ji-Xue and Back Shu Points are located at the same level each other. The Qi and Blood communicate in between. This can lead to strengthen the circulation of Qi and Blood in the meridians and channels, Zang-Fu interconnection, Exterior-Interior communication, and balance of upper and lower parts of the body when Hua-Tuo-Jia-Ji and Back Shu Points are used together. For example, Hua-Tuo-Jia-Ji T3 and BL-13 (Fei-Shu) are needled when the lung is disordered. Hua-Tuo-Jia-Ji T12, T13 and BL-20 (Pi-Shu), BL-21 (Wei-Shu) are selected if the Spleen and Stomach are disordered (7, 8). c. Combination of Jia-Ji-Xue and Yuan (Source) Points Yuan (Source) Points is where the Source Qi of Zang-Fu is stored and passed through. They are proximal to the wrist and ankle and can be used to treat conditions of the distributed channels whether it is acute or chronic or deficient pattern. Hua-Tuo-Jia-Ji is located on the nearby area of Zang-Fu and regulates directly their Qi and Blood. Yuan (Source) Points are distal points from a given point in the Hua-Tuo-Jia-Ji. If we take a long distal point combined with Hua-Tuo-Jia-Ji, the energy will find their channel to which it belongs. For example, Hua-Tuo-Jia-Ji T5 and HT-7 (Shen-Men) are selected when insomnia is noted. Hua-Tuo-Jia-Ji L2 and KID-3 (Tai-Xi) are selected when Kidney is deficient (7, 8). d. Combination of Jia-Ji-Xue and Lower He Sea (Uniting) Points

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Lower He Sea (Uniting) Points are six points located on the three Yang meridians of foot and associated with the functions of the six Fu organs (8). The Simple Question in chapter 38 says: the Shu Points are needled if Zang organs are disordered; the Lower He Sea points are needled if Fu organs are affected (3). The Spiritual Axis in chapter 4 says: the Qi of Spring (Ying) Point and Stream (Shu) Point in the channels are floating and superficial, which can be used to address disorders of external channels; the Qi of He Sea (Uniting) Point in the channels are deep, which can be used to treat disorders of internal organs (4). Because of their dynamism, these points are to be used in the treatment of six Fu organs disorders, especially in excess pattern. For example, Hua-Tuo-Jia-Ji T13 and ST-36 (Hou-San-Li) can be needled if vomiting is noted (8). 3. The Proposed Mechanism of Jia-Ji-Xue A. Activate channels and meridians Since Hua-Tuo-Jia-Ji is closely associated with Governing Vessel Channel, Bladder Channel, and other related channels such as Conception Vessel Channels (Ren Mai), and Penetrating vessel point (Chong Mai), it stands to reason that the stimulation will reflect to these channels when the Hua-Tuo-Jia-Ji is needled. Therefore, Hua-Tuo-Jia-Ji can free the channels and quicken the network vessels, soothe the sinews and ease the joints, promote Blood and resolve the stasis, move Qi and relieve pain (2, 5, 7, 8). B. Regulate Qi and Blood of Zang-Fu The Pelvic Limb Tai-Yang Bladder Channel is in command of five Zang and six Fu and in connection with other channels and meridians. The Qi of Zang-Fu converges at Bladder Channels. In addition, the Governing Vessel Channel intersects the Bladder Channel at GV13 (Toa-Dao), GV-14 (Da-Zhui), GV-17 (Nao-Hu), and GV-20 (Bai-Hui) with which the Qi between communicate. The Governing Vessel Channel, or Sea of the Yang Vessel, ascends inside the spine, and reaches the point GV-16 (Feng-Fu) and from here it enters the brain. This gives rise to a close relationship of brain and spine. While Hua-Tuo-Jia-Ji is needled, it involves two channels and makes the Qi and Blood in the whole body flow smoothly. Again, Hua-Tuo-Jia-Ji and Back Shu Points are located on the same level and in the nearby area, therefore Hua-Tuo-Jia-Ji can be considered as a pathway of Qi from Zang-Fu and also as a mirror of internal organs in the exterior part of the body as Back Shu Points. Hua-Tuo-Jia-Ji not only reflect the function of the Zang-Fu and its corresponding Five Offices (Wunose, eyes, lips, tongue, and ears) and Nine Offices (Jiu-Qiao 2 eyes, 2 ears, 2 Guan nostrils, mouth, and either 2 yin or tongue and throat), but also diagnose and address disorders of Zang-Fu and Five Offices and Nine Offices. If the disorders can be treated by Back Shu Points, it also can be treated by Hua-Tuo-Jia-Ji (2, 5, 7, 8). C. Through the stimulation of nerves to regulate the function of Zang-Fu Both sides of vertebra are innervated by the spinal segmental nerves, and sympathetic trunk, which communicate by their branch and innervate peripheral tissue and Zang-Fu, i.e. lung, trachea, heart, aorta, and esophagus from sympathetic innervations of T2-6 segments; stomach, small intestine, and colon from sympathetic innervations of T5-6 segments; liver, gall bladder, pancreas, and kidney from sympathetic innervations of T6-10 segments and L1 segment; descending colon and rectum from sympathetic innervations of L1-2 segments. While Hua-Tou-Jia-Ji is needled, the needling stimulation shall transfer to Zang-Fu by regulating neurotransmitters (i.e. bradykinin, serotonin, and -endorphin), therefore promoting t

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4. Acupuncture There are several needling methods for the Hua-Tuo-Jia-Ji, including dry needle, electroacupuncture, moxibustion, aquapuncture, acupoint closing, catgut embedding, hot needle, fire cupping, tui-na (massage). Some are often used, some not. A. Dry needle: Perpendicular insertion (at 90-degree angle to the body surface) is used for Cervical Paravertebral Point C2-7 and T10-L7; slanted or angled insertion (at 70- to 80degree angle to the body surface) is used for Hua-Tuos Paravertebral Point T1-10; horizontal insertion (at 15-to-25-degree angle to the body surface) is used for back and lumbar area (8). B. Electroacupuncture: Can be used unilaterally or bilaterally. Based on De-Qi (needling sensation) response, the electrical current can pass through the acupuncture needle that has already been inserted into acupoint. The safety current and frequency may be chosen depending on the acceptance of the animal and the size of patient (8). C. Aquapuncture: The drugs using for acupoint injection can be glucose, saline, vitamin B1, B6, B12, and C, Chinese herbal extracts, or others, etc (8). D. Acupoint closing: Dexamethasone sodium phosphate and 2% of Lidocaine HCL combination can be used to close the acupoint to treat Cervical Paravertebral and Lumbar Paravertebral, i.e. neck and shoulder pain and lower back pain (8). Case examples Case 1 Xiao Bai, a 52/1year-old, 2.3-kg, intact, male Pomeranian was presented with neck pain, root signature of left thoracic limb, arched back, reluctant to recumbence, disliked walking, and sitting still most of time. Xiao Bai was sent to an animal shelter by a bystander because he was hit by a car. The current owner obtained him from the animal shelter two months previous to presentation. He is very active and often jumping up and down from the sofa. Two weeks ago, the patient refused to allow the owner to touch him and was unable to jump up to the sofa any more. He was diagnosed with atlantoaxial subluxation by radiographs. His tongue was purple and the pulse was wiry. The TCVM diagnosis was cervical Bi syndrome with Blood stagnation. He was treated with herbal medicine Ge Gan Tang (Pueraria Root Decoction, 0.5 gm tid) plus Shen Tong Zhu Yu Tong (Drive Out Stasis from a painful Body, 0.5 gm tid) and acupuncture. Acupuncture treatment (2 bouts of needling) included dry needle at Jing-Jia-Ji C1-7, Hua-Tuo-Jia-Ji T1 and Bo-Jian (Scapula Tip), Bo-Lan (Scapula Post), Fei-Men (Lung Gate), LI-15 (Jian-Jing), Jian-Wai-Yu (Shoulder Lateral Clavicle) and Liu-Feng (Six Raphes) of thoracic limb. Xiao Bai was given acupuncture once every two week for two treatments and herbal medicine for 3 weeks. The owner claimed Xiao Bai was walking longer than before and decreased 50 % of pain after the first treatment, 80 % improvement after the second treatment, and almost normal after the third week of herbal medicine treatment. Case 2 Bei Bei, a four-year -old, 6.2-kg, male, intact Shih Tzu was referred to the acupuncture service because of rear limb weakness and severe back pain with stiffness and whining. His tongue was pale purple and the pulse was difficult to feel. The condition was worse in the cold weather. Radiographs from another veterinarian showed disc calcification at T12-L2 and

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L6. The TCVM diagnosis was Kidney Yang deficiency Bi Syndrome. After the first acupuncture treatment and herbal medicine therapy, Bei Bei could stand and jump on his rear limbs and lift a pelvic limb to urinate. His spirit also became good and he began barking at owner. The acupuncture treatment included electroacupuncture (10 Hz, continual wave, for 20 min) with apitherapy (1mg vial bee venom plus 10 ml distilled water, 0.1ml per point) at Hua-Tuo-Jia-Ji T12-L7, ST-36 (Hou-San-Li), GB-34 (Yang-Ling-Quan), BL-40 (Wei-Zhong), KI-3 (Tai-Xi), and pelvic Liu-Feng. The herbal medicine therapy was Du Huo Ji Sheng Tang (Angelica and Loranthus Decoction, 1gm tid) plus Shen Tong Zhu Yu Tang (Drive Out Stasis from a painful Body, 0.6 gm tid). After four treatments of acupuncture and Chinese herbal medicine, Bei Bei is looking very happy and can run and walk anywhere although mild rear limb weakness and occasional hunched back is noted. Case 3 Ji Di, a 9-year-old, 3.2-kg, intact male Chihuahua came to the clinic with pelvic limb weakness and pain in the costal and lumbar area. He was diagnosed as suffering a brain stroke another veterinarian in emergency the previous night when he collapsed suddenly and was found by the owners maidservant. His blood examination was normal, except for CPK 3000 IU/L, GOT 459 IU/L, and GPT 248 IU/L were noted. The tongue was purple and the pulse was wiry, rapid and thin. Local sensitive points and Trigger points were present at L2/3, L4/5, and L6/7. There were also painful areas in the costal area and patellar luxation in the left pelvic limb. After the physical examination and laboratory test, the owner was told that Ji Di could have been beaten by someone or something. Thus, the maidservant said that she had beat Ji Di on the back with a broom due to his chasing every sweep while she was cleaning the room. The TCVM diagnosis was trauma with Liver Qi and Blood Stagnation. Chai Hu Shu Gan Tang (Bupleurum disperse the Liver Powder) was given at 0.5 gm three times daily for two weeks. Hua-Tuo-Jia-Ji L2-7, GV-3 (Yao-Yang-Guan), GV-4 (Ming-Men), GV-14 (Da-Zhui), Bai-Hui, LIV-3 (Tai-Chong), LIV-13 (Zhang-Men), GB-30 (Huan-Tiao), GB-34 (Yang-Ling-Quan), GB-39 (Xuan-Zhong), BL-36 (Xie-Qi), BL-38 (Yang-Wa), and ST 36 (Hou-San-Li) are needled every week. After three treatments, Ji Di could walk and run normally. The blood examination was normal (CPK 103 IU/L, GOT 15 IU/L, and GPT 58 IU/L) 21 days later. Case 4 Dou Dou, an 8-year-old, 7-kg, female Chin presented with 10-day history of neck and thoracolumbar pain and fore limb paresis was referred for acupuncture treatment her veterinarian. The referring veterinarian had performed a blood examination (normal) and diagnosed spinal stroke based on clinical signs. The dog was treated with NSAIDs, but there was no improvement. At the initial visit the owner claimed Dou Dou had a sudden weakness of thoracic limb after going outside for exercise. Dou Dou had a preference for cold surface. Her tongue was purple red and the pulse was thin and fast. The radiograph showed spinal ankylosis at T13/L1, L5/L6, L6/L7, L7/S1, and narrowed disc space between T10/T11, T11/T12, T12/T13, T13/L1 and L1/L2. The TCVM diagnosis was cervical Bi syndrome with Qi stagnation and Kidney Yin deficiency. She was treated with acupuncture at LI-4 (He-Gu), LI-10 (QianSan-Li), LI-15 (Jian-Jing), GV-20 (Bai-Hui), Lumbar Bai-Hui, Wei-Jian, ST-36 (Hou-SanLi), KID-1 (Yong-Quan), KID-3 (Tai-Xi), and Jia-Ji-Xue at Cervical Paravertebral and Lumbar Paravertebral every 3 days for a total of six treatments. She also received 0.7 gm of Xiao Huo Luo Dan (Minor Invigorate the Collateral Circulation Pill) and 1 gm of Shen Tong Zhu Yu Tang (Drive Out Stasis from a painful Body) twice daily for 12 days. She walked normally 3 weeks later.

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Case 5 Yu Ki, a 4-year-old, 5.4-kg, female mixed domestic cat was presented with severe feces accumulation in the colon. She had a history of subtotal colectomy with colocolic anastomosis because of megacolon with recurrent constipation in the past 2 years. She came to the clinic for recurrent megacolon, but this time the owner didnt want further surgery for her cat. So TCVM treatment combined with western conventional medicine was recommended for Yu Ki. Her pulse was thin and weak, and her tongue was pale with dry mouth. The rectal examination showed hardened feces, hot bowel wall and dry rectum. According to TCVM, dry colon with Qi deficiency was diagnosed. After manual removal of feces by forceps, Cisapride, Metamucil, and Run Chang Tang (Moisten the Intestine Decoction) was given for two months without any improvement. So the acupuncture treatment with apitherapy (see Case 2 for the dose used) was recommended at ST-36 (HouSan-Li), ST-37 (Shang-Ju-Xu), LI-4 (He-Gu), and Hua-Tuo-Jia-Ji T12-L3 and L5. The herbal medicine Si Jun Zi Tang (Four Gentlemen Decoction) 10 gm with added Da Huang (Rhei) 2.25gm was given at 0.875gm combined with Cisapride at 0.3 mg twice daily for 7days. No recurrence is noted so far (for one month at the moment of writing this case). References 1. Deadman, Peter and Mazin Al-Khfaji with Kevin Baker (2006): A Manual of Acupuncture. Journal of Chinese Medicine Publications (Distributed in North American press). P574-575. USA. 2. He, Jian You and Yu Ming, Wang (2008): Use of Hua-Tuo-Jia-Ji to Treat Hundred Diseases. Chinese Medical Science Press. P 1-49. China. 3. Long, Bo Jian and Shi Zhao, Long (2004): The Yellow Emperors Classic of Internal MedicineSimple Questions (Huang Di Nei Jing Su Wen). A Variorum Edition. P76-105 and P496-502. China. 4. Long, Bo Jian and Shi Zhao, Long (2004): The Yellow Emperors Classic of Internal MedicineSpiritual Axis (Huang Di Nei Jing Ling Shu). A Variorum Edition. P1351-1383. China. 5. Wang, Hui Min and Lan Lan, Wang (2005): Paravertebral Needling. Bei Jing Science and technology Press. P1-59. China. 6. Xie, Hui Sheng and Vanessa Preast (2007): Xies Veterinary Acupuncture. Blackwell Publishing. P222-226. USA. 7. Yu, Ming Zhe and Yu Ying, Fan (2003): Clinical Application of Jia-Ji-Xue. Dong Da Books Company. P1-44. Taiwan. 8. Zhang, Yong Chen and Hong Lin, Jia (2007): Study and Clinical Application of Hua-TuoJia-Ji. Shang Hai Chinese Medicine University Press. P1-44. China

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A SIMPLE FLOW CHART TO SELECT ACUPOINTS AND ITS CLINICAL CASES: A RETROSPECTIVE STUDY OF 102 CASES
Hee-Young Kim, DVM, Ph.D. Corresponding Author Department of Neuroscience and Cell Biology, University of Texas Medical Branch Galveston, TX 77555-1069, USA. Tel: 1-409-772-9854, Fax: 1-409-772-4687 Email: hykim@utmb.edu Jong-Ho Jeong, DVM* Boo-Young Animal Hospital Gigeumdong, Namyangjusi, Gyeonggi-do 472-080, Korea Un-Gyo Seo, OMD, PhD* Department of Internal Medicine Bundang Hospital attached to College of Oriental Medicine, Dongguk University Sunae-3dong, Bundang-gu, Sungnam, Gyeonggi-do 463-825, Korea Joo-Young Song, DVM Sarang Animal Hospital Guro-3dong, Guro-gu, Seoul 152-053, Korea Hyo-Gwon Jo, DVM Jakjeon 24 hour Animal Hospital Jakjeon1-dong, Gyeyang-gu, Incheon-si, Gyeonggi-do, 407-060, Korea Ji-Min Kim, DVM Jun Animal Hospital Galsan-dong, Dongan-gu, Anyang-si, Gyeonggi-do 431-088, Korea Hyejung Lee, OMD, PhD Department of Oriental Medical Science, Graduate School of East-West Medical Science, Kyung Hee University Seocheon-dong, Giheung-gu, Yongin-si, Gyeonggi-do 449-701, Korea Insop Shim, PhD Department of Integrative Medicine, College of Medicine The Catholic University of Korea Seoul 137-701, Korea * These two authors contributed equally to this work

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Introduction Practitioners have to select the appropriate acupoints to treat patients. To apply acupuncture effectively, they must know the properties of the meridians, the specific function of each acupoint and methods to combine their acupoints. However, it is quite difficult to memorize all the information about acupoints, and to design treatment according to the patients condition, especially for new acupuncturists. Therefore, we have developed one simple chart based on Oriental medical theory, and have applied it to clinical cases. The results of the acupuncture treatment of 102 dogs are described in this article.

Materials and methods Flow chart (table 1) The proposed chart was designed to select acupoints in a total of 5 steps. In step 1, according to the location of disease in the body (e.g. internal, dorsal, lateral or respiratory), two or three acupuncture points of Extraordinary Vessel Master Coupled Points and Six Command Points were selected. In step 2, one acupoint was chosen according to the body components (Eight influential points: Zang, Fu, muscle, bone, Qi, blood, circulation and bone marrow) affected by diseases. In step 3, the sensitive points on the back or the abdomen (Shu or Mu points) were selected and diagnosed as the affected organs for the next step 4. In step 4, two or three points on the meridian (diagnosed in Step 3) were selected according to the patients condition such as acute, chronic, emergency, Heat or Cold. In the 5th step, local points or empirical points for each case were chosen.

Cases One hundred two dogs that received acupuncture treatment based on simple flow chart during the period from September 1, 2005 to August 31, 2007 were reviewed. The following data were obtained from 5 veterinarians with less than 1 year in acupuncture training. Except epilepsy cases, dogs treated with the combination therapy of Oriental and Western medicine were not included in this study. The sex and age of 102 cases were summarized according to main symptoms at presentation (table 1). One hundred two cases were divided into groups as follows; intervertebral disk disease (IVDD), vomiting, diarrhea, cough, abdominal pain and epilepsy. Furthermore, dogs with IVDD were sub-grouped into four categories [1], according to neurological status before acupuncture. Group I included dogs with back pain only; Group II included those dogs that were paretic; Group III was formed by those animals that were paraplegic, without loss of deep pain perception, and Group IV was formed by dogs with loss of deep pain perception for less than 24 hours. Except IVDD dogs, other cases were classified by the duration of onset to clinical presentation as acute (<2 days), subacute (2~7 days) or chronic (>7 days).

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Acupuncture treatment After selecting acupoints according to flow chart, acupuncture needles (stainless steel, 0.240.30 mm in diameter, 15-40 mm in length) were inserted, as described in text [2] and left for 15-20 minutes with/without manipulation. Acupuncture was applied 2-3 times a week. Clinical follow-up was determined either by a phone call to the owners at the time of this study, or by return of the dog to the veterinary hospital. Treatment was discontinued if the owner stated the symptoms had ceased and if main symptoms were apparently resolved on laboratory or physical examination. Results 102 medical records using this simple flow chart were obtained from 5 clinical veterinarians with less than one year of experience; three veterinarians had less than 6 months experience; two had less than one. Table 2 shows the signalment of the cases including age, sex and duration of onset. The average age of the dogs was 4.1 years (range, 3 months to 15 years). Forty-five percent (46/102) were males, and 55% (56/102) were females. Purebred dogs accounted for 52% (53/102) and were represented by 8 pure breeds (15 poodles, 14 Maltese, 7 Shih tzus, 1 Chihuahua, 1 Siberian husky, 9 Yorkshire terrier, 2 English cocker, and 4 Miniature schnauzers). The remaining 48% (49/102) were mixed-breed dogs. Diseases IVDD Grade Grade I Grade II Grade III Grade IV acute subacute chronic acute subacute chronic acute subacute chronic acute subacute chronic acute subacute chronic acute subacute chronic Duration of onset case (n) 1 1 6 4 6 2 3 1 1 sex male 1 1 2 2 2 3 1 1 age (year) female 3.00 2.00 2.87 5.25 2.77 3.50 3.00 1.50 0.60

vomiting

diarrhea

cough

abdominal pain

epilepsy

urinary incontinence Total

<2 days 2~7 days > 7 days <2 days 2~7 days > 7 days <2 days 2~7 days > 7 days <2 days 2~7 days > 7 days <2 days 2~7 days > 7 days <2 days 2~7 days > 7 days

4 2 4 2

66 5

30 2

36 3

4.55 2.54

1 4

1 1

0.60 5.95

1 102

46

1 56

4.00

Table 2. Cases signalment

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Table 3 shows the acupoints selected according to flow chart in Table 1 and the results of their treatment. The average number of treatment was 5.89 (range, 1 to 24). In some cases, vomiting (acute or subacute), subacute cough and abdominal pain, response was seen to one treatment without western medicine intervention. Interestingly, some cases of acute vomiting and acute abdominal pain began to eat food within 30 min after acupuncture treatment and recovered to normal in one day. However, cases showing chronic vomiting (over 7 days) needed a longer time to recover than acute or subacute cases. Twelve cases of IVDD received acupuncture and 9 of 12 cases (75%) recovered to almost normal although 2 cases still showed mild abnormal gaits. Three cases of severe IVDD (n=4) failed to acupuncture treatment. Two of the failed cases (n=3) cases recovered to Grade I after acupuncture treatment, but they relapsed within 20 days after ceasing acupuncture treatment, were not responsive to acupuncture treatment anymore and euthanatized. Four cases of chronic epilepsy presented with recurrent seizures 1- 2 times per month while being medicated with antiepileptic drugs. These 4 cases received the combination therapy of acupuncture and antiepileptic drugs and did not show any epilepsy during the follow-up period of 4 months.
Table 3. The acupoints selected according to flow chart and treatment outcome Diseases Grade Grade I Grade II Grade III Grade IV acute subacute chronic acute subacute chronic acute subacute chronic acute subacute chronic case (n) 1 1 6 4 6 2 3 1 1 5 same as treatment of vomiting Step 1: LU7, KI6, LI4 Step 2: CV17 or LV13 Step 3: sensitive points on back shu and frontal mu Step 4: source point and He point of LU meridian (LU9, LU5) Step 5: CV22 Step 1: (1) when dorsal area was affected-SI3, BL62 (2) when lateral brain area was affected, TH5-GB41 Step 2: GB39 Step 3: sensitive point on back shu Step 4: (1) when dorsal brain area was afftected, source and He point of BL or SI meridian (SI4, SI8 or BL64, BL40), (2) when lateral brain area was affected, source and He point of TH or GB meridian (TH4, TH10 or GB40, GB34) Step 5: GV20, GV16, GB20, Yintang point (midpoint between the eyebrows) Step 1: LU7, KI6, SP6 Step 2: Step 3: sensitive point on back shu Step 4: source and He point of KI meridian (KI3, KI10) commonly used acupoints Step 1:SI3, BL62, BL40 Step 2: GB34 Step 3: sensitive points on back shu Step 4: Source point and He point of BL meridian (BL64, BL40) Step 1: PC6, SP4, ST36 Step 2: LV 13, CV12 Step 3: sensitive points on back shu and frontal mu Step 4: source point and He point of ST or SP meridian (ST42, ST36, SP3, SP9) same as treatment of vomiting+GV1 treatment numbers 1.0 8.0 12.5 15.0 1.0 1.0 6.7 2.0 1.0 1.0 recovery times (day) 5.00 49.00 38.67 49.00 0.84 1.00 18.67 9.00 2.00 0.62 failure (n) succssful rate (%) 100 100 100 25 100 100 100 100 100 100

IVDD

vomiting

diarrhea

abdominal pain

66

1.0

4.58

100

cough

acute subacute epilepsy chronic

3.0

8.00

100

5.3

25.00

100

acute urinary incontinence subacute chronic 1 7.29

24.0 5.89

89.00 21.45 3.00

100 94.64

Conclusion This simple chart has been applied successfully in various clinical cases such as neurological, respiratory and gastrointestinal disorders in Korean veterinary clinics since 2004. This simple chart may allow beginners or clinicians to design acupuncture points easily, quickly and effectively.

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Acknowledgement The corresponding author appreciates and acknowledges the financial support for basic course on Veterinary Acupuncture (2007-2008, San Antonio, USA) provided by the International Veterinary Acupuncture Society (I.V.A.S.) via the Grady Young Memorial Scholarship program. References 1. Coates J. Intervertebral disk disease. Vet Clin North Am Small Anim Pract. 2001; 2000: 77-110. 2. Kim H, Shim I, Hahm D, Seo K, Nam T, Lee H, Canine Acupuncture, Seoul; Korvet Co.; 2004.

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ACUPUNCTURE AND PULSED MAGNETIC FIELD THERAPY: A PROMISORY MARRIAGE


Dr. Mara del Carmen Barba, DVM, CVA Magnetic fields are noninvasive and nontoxic, which makes them ideal for the gentle and gradual body rebalancing and healing. Magnetic fields work individually on the natural healing systems of the body but also work through the acupuncture systems. The mechanism most commonly offered for various therapeutic effects of magnets is improved blood circulation. Other suggestions include alteration of nerve impulses, increased oxygen content and increased alkalinity of bodily fluids, magnetic forces on moving ions, and decreased deposits on the walls of blood vessels. The broadest explanation was presented by Dr. Kyochi Nakagawa of Japan, who claims that many of our modern ills result from "Magnetic Field Deficiency Syndrome." The earth's magnetic field is known to have decreased about 6 percent since 1830, and indirect evidence suggests that it may have decreased as much as 30 percent over the last millennium. He argues that magnetic therapy simply provides some of the magnetic field that the earth has lost. If viewed simply as inert material, the human body, like its primary constituent, water, is diamagnetic, i.e., weakly repelled by magnetic fields. In response to an applied magnetic field, the electrons in water molecules make slight adjustments in their motions, producing a net magnetic field in the opposing direction about 100,000 times smaller than the applied field. With the removal of the applied field, the electrons return to their original orbits, and the water molecules once again become nonmagnetic. Some dubious literature suggests that magnetic fields attract blood, citing all the iron it contains. However, iron in the blood is very different from metallic iron, which is strongly magnetic because the individual atomic magnets are strongly coupled together by the phenomenon we call ferromagnetism. The remarkable properties of ferromagnetic materials are a result of the cooperative behavior of many, many magnetic atoms acting in unison. The iron in blood consists instead of isolated iron atoms within large hemoglobin molecules, located inside the red blood cells. Although each of the iron atoms is magnetic, it is not near other iron atoms, and remains magnetically independent. The net effect of the weak paramagnetism of the isolated' iron atoms in hemoglobin is only a slight decrease in the overall diamagnetism of blood. Thus, blood, like water, is weakly repelled by magnetic fields, not attracted. More likely mechanisms are those based on magnetic forces on moving charged particles, possibly including ions or charged molecules in flowing blood, moving across cell membranes, moving across synapses between nerve cells, etc., or those based on more subtle effects on biochemical reactions (Frankel and Liburdy 1996). Although no physical mechanisms for magnetic therapy have been established, the possibilities are numerous and complex. Only further clinical tests, carefully controlled to account for placebo effects, can

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confirm or dispute the results of the Baylor study and prove or disprove the claims of magnetic therapy.
Thermography, a method of measuring the heat in tissues caused by increased circulation, shows that magnetic fields in specific pulses cause an increase in circulation. The improvement in circulation flow is also demonstrated thermographically following the application of static magnets. The consequence of an increased circulatory flow and a more efficient oxygen uptake is improved tissue activity. In the case of tissue damage, improved tissue activity leads to the enhancement of repair processes.

Pulsed magnetic fields are very different from static magnetic fields, because, via Maxwell's equations, time-varying magnetic fields induce electric fields. Electric fields have pronounced biological effects, particularly on nerve and muscle cells, as we have known since the days of Gaivani and his twitching frogs' legs. Many years ago the FDA approved the use of pulsed magnetic fields in "bone growth stimulators" for the treatment of fractures that were slow to heal, and research on "magnetic stimulation" - pulsed magnetic fields applied to the brain or other components of the nervous system - has grown rapidly in recent years.
The normal electrical change across the cell membrane is considered to have specific control on cell behavior, influencing the ionic exchange across the membrane. It is proposed that changes in the local ionic microenvironment caused by electro-stimulation, such as that produced by a pulsating magnetic field, may influence the cell and redirect the energy behavioral pattern. As each cell type enjoys its own unique environment, devices with a wide band of electromagnetic fluxes may influence a wider group of interacting molecules. In theory, magnetic fields used for therapeutic purposes, provided their fields are appropriately calculated to interact with those living tissues, should be able to contribute to restoring tissue stabilization by activating atoms, ions and molecules, in order to restore the required membrane polarization of disturbed cells. The reduction of pain by transcutaneous nerve stimulation was demonstrated by Melzack and Wall (1965). PMF frequencies subject large nerve fibers to varying wave forms; if these nerve fibers lie within the treated area, pain perception may be significantly reduced. As reduction of pain occurs there is an increase in circulatory flow to enhance natural healing. The effects of PMF should be beneficial.

The Baylor study, seemingly a careful double-blind study, was conducted by Dr. Carlos Vallbona on fifty post-polio patients at Baylor's Institute for Rehabilitation Research in Houston. Bioflex, Inc., of Corpus Christi provided both the magnets (multipolar, circular pattern) and a set of visually identical sham magnets to serve as controls. To keep the study "double-blind" neither the patients nor the staff were informed as to which devices were active magnets, and which were shams. Before and after the forty-five-minute period of magnet therapy, the patients were asked to grade their pain on a scale from 0 to 10. The twenty nine patients with active magnets reported, on average, a significant reduction of pain (from 9.6 to 4.4), while the twenty-one patients with shams reported a much smaller average reduction (from 9.5 to 8.4). This is a substantial difference, and if the double-blind study was successfully conducted, cannot be explained by a placebo effect.
Magnetic field can influence wound healing, reduce post-traumatic edema, improve the function of an arthritic joint, reduce the pain associated with spinal problems, tendon injuries, fractures and other bone-associated conditions. From clinical experiments, we know that Pulsating Magnetic Fields can reduce pain sensations almost immediately. This is due in part to the increase in the oxygen partial pressure in the terminal tissue and the increase in the local perfusion and velocity of the capillary blood flow alleviating the accumulation of metabolites due to small vascularization and blood flow (transmitted by the sympathetic nervous system).

Another primary action of magnetic fields is to reduce muscle contraction. This means that the muscles of the back and shoulders can be relaxed at the end of every day. This prevents stress gradually asserting its damage in the body. Whenever there is muscular tension the blood supply to the tissues involved is diminished. This is a primary cause of fibromyalgia and chronic fatigue, an everyday ailment seen in patients with spinal and joint disorders; mainly in patients who have several joints and/or spinal tracts involved and can occur in both middle-age adults and geriatric patients. Pulsed electromagnetic fields, using a whole body

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treatment mattress, can simulate the oxygen improving benefits of exercise. Therefore, magnetic fields can be a major anti-aging preventive care system. In addition, research is showing that magnetic fields have strong actions on bone, particularly in the treatment and prevention of osteoporosis. Many studies have also shown a benefit in treating arthritis, which almost everyone will have with age, although young patients developing these disorders are seen more commonly. To effectively treat most conditions and to enhance the success rate, follow these priorities: 1. Pain and Inflammation 2. Stimulation 3. Increase Circulation Progress from 1-3 on each condition to take the cells through the healing process. Because magnetic fields act on many specific physical processes, they can be used in almost any kind of illness, either as a prevention or treatment. The primary actions of magnetic fields include: muscle relaxation, increased circulation, pain reduction, reduced nerve irritability, enhanced tissue and bone healing, reduction in swelling, bruising and inflammation, decreased clotting, improvement in scars, enhancement of acupuncture and rebalancing of the sympathetic/parasympathetic system. The nervous system is particularly sensitive to magnetic fields. Like acupuncture, magnetic fields appear to act in a more obvious fashion when obvious imbalances exist, such as pain, scars, injuries, etc. Magnetic fields do not interfere with most medical therapies and in fact appear to enhance them. ACTION Increased blood supply all areas - body & legs New blood vessels (revascularization) form where needed Increased circulation of the blood throughout body & legs 200% increase in oxygen in blood - muscles, tissues skin BENEFIT Reduces Swelling Eliminates pain No effect on heart rate or blood pressure Injured and inflamed tissues regenerate faster...faster healing

1 2 3 4

Increased oxygen use by all cells in areas treated with pulsating Magnetic Field. Polarizes in addition to standard polarization, the cell wall/membrane of all cells treated with PMF therapy.

Ionic migration = movement of potassium, chloride, calcium, protein through every cell wall. Improved energy condition of all cells treated with PMF therapy. Resistance and body defenses against infection and inflammation are optimized.

Main effects of PMFT over tissues are: increase blood flow to treated area, increase oxygencarrying ability in blood, increase enzyme activity, increase cell division, regulation of altered acid-base balance in tissues, etc. All this effects allow that antiinflamatory blood agents reach and work better on affected tissues, also, local nervous function is restored as PMFT stimulates depolarization and cell function.

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Since Pulsed Magnetic Field Therapy (PMFT) has shown to be a very effective method to reduce inflammation and pain, and to stimulate healing processes in local areas under active or chronic inflammatory processes (which lead to energetic blockage in such areas) to use PMFT before acupuncture session restores neurological pathways and tissue blood supply and healing process, thus enhancing acupuncture effects. Thus, acupuncture would work better over this tissue environment where circulation is restored and, of course, the energy (Qi) can start flowing again. I have found that applying PMF for 20 to 60 before acupuncture on local areas before acupuncture session enhances acupuncture effects. Most of time 50 Hz and 100 Hz frequencies are used in alternating fashion over affected areas such as spinal cord, hips, lumbosacral joint, knees, elbow, etc. Also, for example, patients who suffer degenerative joint disease, degenerative myelopathy, and other conditions, would be benefit with PMF per se effects and acupuncture. Case example: Flaca is a 14 year old Greyhound crossbred, neutered female. She has chronic liver disorder, degenerative stifle disease with ruptured cruciate ligament, chronic back pain and epilepsy. Flaca has been on acupuncture PMFT, nutraceuticals, western herbs, homeopathy and Flower Essences for past two years. PMF pads are placed medially on knee and over the thoracolumbar area, thus creating a pulsed magnetic field which covers not just knee and back, but abdomen, including the liver. Acupuncture points needled are: BL40, BL60, ST 36, ST 35, GB 33, GB 34, LIV 8, LIV 3, BL 18, BL 19, and BL11. Nowadays, Flaca looks younger than she really is, bearing weight properly over her right hind limb; even her liver function has been improving during this year. References 1. Barker, A. T. et al. 1984. Pulsed magnetic field therapy for tibial non-union. Lancet 994996. Berry, M. V. and A. K. Geim. 1997. Of flying frogs and levitrons. Eur. J. Phys. 18: 307-313. 2. Bromiley, Mary W., Equine Injury, Therapy and Rehabilitation, 3rd edition, Blackwell publishing, 2007. 3. Buranelli, V. 1975. The Wizard from Vienna. Coward, McCann & Geoghegan. 4. Frankel, Richard B. and Robert P. Liburdy. 1996. Biological effects of static magnetic fields (in Handbook of Biological Effects of Electromagnetic Fields, second edition, Charles Polk and Elliot Postow, eds. CRC Press). 5. Hong, C. Z. et al. 1982. Magnetic necklace: Its therapeutic effectiveness on neck and shoulder pain. Archives of Physical Medicine and Rehabilitation 63:162-164. 6. Livingston, James D. 1996. Driving Force: The Natural Magic of Magnets. Harvard University Press. 7. Mackay, Charles. [1841] 1932. Extraordinary Popular Delusions and the Madness of Crowds. Reprint, L. C. Page. 8. Macklis, Roger M. 1993. Magnetic healing, quackery, and the debate about the health effects of electromagnetic fields. Annals of Internal Medicine 118(5): 376-383.

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9. Malmivuo, Jaakko and Robert Plonsey. 1995. Bioelectromagnetism: Principles and applications of bioelectric and biomagnetic fields. Oxford University Press. 10. Payne, Buryl. 1988. The Body Magnetic (self-published). 11. Vallbona, Carlos, Carlton F. Hazlewood, and Gabor Jutida. 1997. Response of pain to static magnetic fields in postpolio patients: A double-blind pilot study. Archives of Physical and Rehabilitation Medicine 78(11): 1200-1203.

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PREEMPTIVE ANALGESIA WITH ACUPUNCTURE SEEN IN THE cFOS EXPRESSION IN RATS (1)
Maria Doris Bedoya Henao, DM, Msci, Ph.D. Mdica - MS, Bolsista do CNPq.. Email: dorbedhv@uol.com.br and Lino Lemonica Professor Titular em Anestesiologia da FMB/UNESP Campus de Botucatu/SP ABSTRACT The behavior and the pain awareness experience are characterized by alert and anxiety and disappear as soon as the cure process starts. Based on this idea, the present study aimed to quantify the c-fos expression in spinal marrow segments, at sacrum-lumbar level in rats, after a surgery stimulus (algesia), using sodium thiopental anesthesia and acupunctural practices pre and post-operative. Thirty-six similar animals were used, after an experimental trial with 6 rats. The animals were stimulated with intraperitoneal injections of saline solution (NaCl) 0.2% (2ml), and were divided into two groups, pre and post-operative. Each of them was subjected to the treatments: Control (CL), Manual Acupuncture (MA) and Electro Acupuncture (EA). The animals were randomly distributed into pre and post-operative groups with 18 animals each and then, redistributed in 6 animals for each treatment group. The c-fos expressions were quantified using immune-histochemistry for all situations. The collected data were analyzed by using the T-test, at 5% probability, in order to check differences between groups, treatments and inside each group. After the surgery, the c-fos expression was similar in all treatments when compared to the pre-surgery phase. The animals, under presurgery condition, showed c-fos expression higher than that in the post-surgery control treatments, contradicting the principles observed in acupuncture applications and preemptive analgesia. The MA and EA treatments showed similar values for c-fos expression in both phases, and they were not effective as an analgesic practice. Finally, it is conclude that acupuncture practice used as preemptive analgesia in rats must be studied again, using different application points, and different measurement technique of c-fos expression and/or use the brain laminas to measure the c-fos expression, as it has been done in most of the recent papers. Key Words: Pain; Electro Acupuncture; Marrow Spinal; Protein c-fos; Rats. ________________________________________________________________________ (1) - Parte da tese de Doutorado apresentada FMB/UNESP, Campus de Botucatu, SP. 1. INTRODUCTION Pain is an uncomfortable sensorial and emotional experience associated with a lesion in the royal tissue that can be potential or psychogenic. It is a very important sensation due to its role in the protection of the organism against nocive agents. For this, the painful stimuli represent one of the

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principle and most relevant sensorial signs, and the rapid patterns of removal due to these stimuli are innate responses in the organization of the spinal cord (Menezes, 2002). The sensation of pain and the responses to these stimuli are motivating of the acquired behavior. In the daily activity, man and animals avoid the risk of being harmed or of remaining in continuous conditions of painful stimulation. The conscience behavior and experience of pain, which are characterized by anxiety and alertness, disappear at the moment that healing is processed. The chronic states of pain are more deleterious to the individual and promote deep psychic depression. They may be considered as a pathologic state, because there is no evident biological utility. For the control of this pain, a multimodal approach may be utilized that may include pharmacological and non-pharmacological techniques. One can intervene in the painful sensation at distinct moments, in a manner that it could be theoretically possible to propose a treatment technique in a prior period in relation to the beginning event, which would configure a preventive treatment for pain, the analgesia noticed now-a-days as "pre-emptive". Pain and EA: Bastos (1993) refers that one of the mechanisms of analgesia mediated by EA is the acceleration in the liberation of opioid peptides in the CNS. The EA promotes two effects: by electrostimulation, deflagrates the liberation of enkephalins and beta endorphins of the brain and in the spinal cord, that interact in the M and S opioid receptors and in the CNS; it was observed that the electro stimulation of high intensity and low frequency can induce long term analgesia, with cumulative effects and reversible by the administration of naloxone (morphine antagonist). Acupuncture and c-fos expression: immunohystochemistry for the c-fos has been used for the mapping of structures involved in the effects of acupuncture. Lee & Beitz (1992) showed that the EA in the ST 36 point reduces the c-fos expression in the dorsal cornus of rats. Takayama et al. (1994) compared various anesthetics showing that pentobarbital and fentanyl interfered less in c-fos expression. Acupuncture in analgesia: Oliveira, (1996) mentions that the analgesia by acupuncture is very efficient in the treatment of chronic pain what is comparable to the efficiency of powerful drugs as morphine. Ways to reduce the c-fos induced by stress: The repetition of the same stimulus is capable of reducing the c-fos expression that is normally induced with a unique presentation of this same stimulus (Papa et al., 1993). This reduction has been suggested as an adaptive process, which would allow the genesis of bigger and qualitatively distinct responses to only new stimuli. The objective of the present study is to quantify the c-fos expression in the spinal cord of rats, after a stimulus of algesia (operative), utilizing anesthesia with sodium thiopental, to evaluate the pre and post-operative effect of acupuncture. 2. Methodology We utilized 36 rats of the Wistar breed, adult males weighing between 210-235g and maintained in number of five animals per locus. The animals were distributed randomly in pre and post-operative groups, with 18 animals each, that were redistributed with six animals in each treatment group: CL, MA and EA.

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All animals were submitted to anesthesia with sodium thiopental until absence of the motor sensibility. After 20 minutes, an incision was made in the plantar region of the left paw and placed in a heated box for sixty minutes, to sacrifice and perfusion. The pre-operative groups were submitted to manual acupuncture (MA), Electroacupuncture (EA) and Control (C) in the points: Stomach 36 (ST 36), Kidney 1 (KI1) and Bladder 67 (BL 67), bilaterally. After 20 minutes the needles were taken out and the surgery proceeded. After 60 minutes, the animals were sacrificed and perfusion was conducted. In the post-operative groups the same proceedings were conducted. The painful stimulus was applied, conducting a longitudinal incision in the plantar region of the left paw with a scalpel blade. The rats were sacrificed after sixty minutes. The spinal cord was removed and the immunoreactivity for c-fos was detected using the conventional technique of avidine-biotine-immunoperoxidase. The averages, median and standard deviation were calculated in each group. To verify the effect of surgery (pre and post) and of the treatments (control, manual acupuncture and EA), a Variance Analysis was conducted, calculating the F statistics and p for the comparison among the 3 treatments in pre and post-operative conditions; t and p for the comparison between pre and post-operative. The results were considered statically significant when p < 0.05. 3. RESULTS The results of the present study revealed that there was no significant difference between the pre and post-operative groups. This result indicates that the animals submitted to the painful pre and post-operative stimuli were taken into a stress situation with a consequent manifestation of the c-fos in the cells of spinal cord dorsal cornus, independent from the experimental group for which they pertained. We studied the possible causes of modification of the c-fos expressions, it was observed for the pre-operative group that the animals showed similar medium values of the c-fos expressions in the spinal cord comparing the animals from the control subgroup and the subgroups treated with manual acupuncture and with EA. In the animals of the post-operative group, the counting of neurons of c-fos expression was similar to the pre-operative group, with no significant difference. With exception of the control group, the other animals treated with MA showed similar oscillations. However, in the post-operative group differences between treatments were not observed. In the EA treatment, in the pre and post-operative groups, the average values were high values, but it was observed values from the minimum of 0.16 to 38.25, in the post-operative group, but no statistical difference was observed for these results. By the variance analysis, the results were similar among the groups, with no statistical difference observed between the subgroups. The same result was found for the pre and post-operative groups. It was observed significant differences in the control group, only when each subgroup was compared, when the results reveal a higher number of neurons of c-fos expression in the pre-operative control group. The other subgroups of AM and EA did not present significant statistical differences.

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4. DISCUSSION The evaluation of the pain experimental model used in the present research, did not allow us to evaluate the preemptive analgesia, because in some models the type of the nociceptive stimulus used may not induce the spinal hyper excitability and consequent central sensitization. The absence of significant difference between the pre and post-operative treatments in the c-fos expression, when considering the three groups as a whole, indicates that the animals submitted to the pre and post-operative stimuli were taken into a similar stress situation. Such results indicate that, independently from the treatments, the animals did not present a complete sedation that would lead them to the non-manifestation of the c-fos expression. Although not significant, the highest values of c-fos in the animals submitted to preemptive EA, suggests that this technique is more stressful than the other treatments. Other consideration is that the Ting points selected in this study (Bladder 67 and Kidney 1), are localized in the edges of the foot fingers and because they are more innervated they are also more sensitive to painful stimuli. It was observed that the MA used either in the preemptive form for pre and post-operative conditions or as analgesic and sedative, was not effective to reduce the c-fos expression, so it is not a recommend practice for this purpose. The use of the ST 36 has been confirmed an analgesic and sedative effect, and can also improve the intestinal peristalsis, although the treatment using this point was not sufficient to reduce the c-fos expression, showing that, possibly, the animals were under stress. In this study, the lower value shows that the EA reduced the stress and so revealed to be effective as analgesia. On the other side, the animals that showed the higher values reveal exactly the contrary. This suggests that the use of EA with frequency of 100 Hz, used as a preemptive treatment and post-operative to ease and minimize pain and stress, did not seem to be effective for the proposed goal. The pre and post-operative acupuncture period, which resulted in the absence of analgesic effect, probably without liberation of endogenous opioids and consequently leading to an increase of the liberation of the c-fos expression, mainly due to the fact that the initial stimuli of analgesia by manual acupuncture, or with electro stimulation, can be painful. Concerning analgesia by acupuncture, it must be demanded always the correct expression, the analgesia, once anesthesia would lead to the loss of sensation, while analgesia acquired through acupuncture could only increase the limit of pain of the organism (FAN, 1995). 5. CONCLUSION The practice of acupuncture as preemptive analgesia in rats needs to be re-studied, using different application points, and different measurement technique of c-fos expression and/or use the brain laminas to measure the c-fos expression, as it has been done in most of the recent papers. References 1. Chaves, L.D. Controle da dor ps-operatria: comparao entre mtodos analgsicos. Rev. Am Enf., v. 1, n. 2., 2003. 2. Fan, X. Z. Best of tradicional Chinese medicine. Beijing: New World Press, 1995. 158 p.

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3. Katz, J.; Vaccarino A.L.; Coderre, T.J.; Melzack, R. Injury prior to neurectomy alters the pattern ofautotomy in mts. Anesthesiology., v.75, p.876-883, 1991. 4. Lee, J. H; Beitz, A.J. Electroacupuncture modifies the expression of c-fos in the spinalcord induced by noxious stimulation. Brain Res., v. 577, p. 80-91, 1992. 5. Oliveira, R.C.P. Efeitos da acupuntura no controle da dor. 1996. 38p. Monografia. 6. Papa, M.; Pellicano, M. P.; Welzl, H.; Sadile, A. G. Distributed changes in c-fos and c-Jun immunoreactivity in the rat brain associated with arousal and habituation to novelty. Brain Res. Bull., v. 32, p. 509-515, 1993. 7. Takayama, K.; SuzukI, T.; Miura, M. The comparison of effects of various anesthesics on expression of Fos protein in the rat brain. Neurosci. Lett., 176: 59-62, 1994.

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TREATMENT OF MYASTHENIA GRAVIS


J.G.F. Joaquim, DVM, Msci Institute Bioethicus Botucatu SP Brazil. Assistants of University of So Paulo Acupuncture and Chronic Pain Service University of State of Sao Paulo Botucatu SP Brazil E-mail: jeanvet@yahoo.com Haddad, C. C.T. Institute Bioethicus Botucatu SP Brazil Assistants of University of So Paulo Acupuncture and Chronic Pain Service Luna, S.P.L. University of State of Sao Paulo Botucatu SP Brazil Torelli, S. CALE Veterinary Animal Clinic ABSTRACT The intent of this paper is to review Myasthenia gravis in dogs and report some cases treated at the Acupuncture Unit at the University of Sao Paulo State, Botucatu, Brazil. Most animals were presented at the University for a second opinion for a recent onset of collapsing and regurgitation or dysphagia. Most of them were healthy until presented for this problem. On physical examination most animals were bright and alert with normal temperature, pulse, respiration, and capillary refill times. Neurological evaluation, including cranial and spinal nerves, was considered abnormal in all animals. 1. Introduction Myasthenia gravis is a chronic disease due to disturbance of the conductive function in the neuromuscular junction 1. The disease may attack first the muscle in the eyes, face and throat, then the muscles in the four limbs 1. It interrupts the way nerves communicate with muscles. Normal transmission of impulses from nerves to muscles occurs via the neurotransmitter acetylcholine (Ach). Myasthenia gravis is characterized by a dysfunction of neuromuscular transmission, due to a reduction in the number of functional receptors of acetylcholine in the postsynaptic membrane of the neuromuscular junction. This results in fatigue and muscular weakness that becomes worse with exercise and improves with rest 2. In dogs and cats there are two forms of myasthenia gravis: acquired and congenital 2. Acquired myasthenia is considered to be an auto-immune disease 2 and is characterized by the presence of antibodies against acetylcholine receptors in the neuromuscular junction 2. It has been suggested that thymus may play a role 2.

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Most of the patients are 5-7 years old, without sex preference. They show clinical signs such as muscle weakness which becomes worse with exercise, fatigue, salivation, regurgitation and megaesophagus 2. In congenital myasthenia the patient is born without normal neuromuscular junctions and has the same clinical signs as the acquired form but it is first noticed in pups by 6-9 weeks of age. 1.1 Western Diagnosis The diagnosis is made based on the clinical signs, chest radiographs (megaesophagus and thymoma) and can be presumptively diagnosed by a rapid response to injection of edrophonium hydrochloride (Tensilon 5mg I.V.), an anticholinesterase drug for ruling out myasthenia gravis. Electrodiagnosis can be done with electroneuromyography. Also, the immunoprecipitation radioimmunoassay for detection of circulating antibodies against the nicotinic acetylcholine receptor (AChR), is the gold standard for the diagnosis of acquired MG in humans, dogs, and cats. The assay is specific, sensitive, and demonstrates the presence of antibodies specifically against AChRs. The canine antibodies reference level in the serum is less than <0.6 nmol/l) 1, 2. Previous corticosteroid therapy at immunosuppressive dosages for longer than 7-10 days will lower antibody levels so a pre-corticosteroid serum sample is recommended. 1.2 Eastern Diagnosis According to TCM theory, the disease myasthenia gravis can be divided into 3 types: Yin Deficiency of the Liver and Kidney, Qi Deficiency of the Spleen and Stomach and Deficiency of both Qi and Blood 1. Myasthenia gravis can also be classified as a Wei Syndrome 3, which is caused by Deficiency in Qi and/or Blood, Deficiency of all organs and is identified principally by atrophy 4. Wei Syndrome is characterized by weakness of the limbs, atrophy, flaccid muscles and tendons, and eventual paralysis 3. This condition generally progresses without pain 3. Wei Syndrome can result from dysfunction in both sensory and motor systems 3. With acupuncture we are able to restore function much quicker in those conditions which are due to sensory and or proprioceptive impairment 3. 2. Material and Method The veterinary team of the Acupuncture, Homeopathy and Chronic Pain unit of the State of Sao Paulo University Unesp Botucatu has treated five animals with signs compatible with myasthenia gravis. The animals had different clinical progression, but three of them were treated with acupuncture. The treatment with acupuncture, Western medicines, Western and Eastern diagnosis will be discussed on paper. The aim of this study was to analyze 5 cases of Myasthenia gravis in dogs, from different breeds and ages, treated at the Acupuncture Ambulatory Unit and Small Animal Surgery Unit at the Faculty of Veterinary Medicine and Animal Science, University of So Paulo State, Botucatu, Brazil, comparing the results obtained after acupuncture with the literature.

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2.1 Background All five animals had a history of flaccid tetraparesis and some were misdiagnosed as spinal problem or as infectious disease such as Ehrlichiosis. A clinical sign of cough was present for some days in one animal. Most of the animals were presented with flaccid tetraparesis, generalized weakness and dysphasia. Two of them could bear weight on all 4 limbs but collapsed when they attempted to walk The animals had been treated by a private veterinarian. Since no improvement was seen, they were referred to the University. At the Acupuncture and Surgery unit, the animals were submitted to a conventional exam and to a neurological evaluation, resulting in a diagnosis of Myasthenia gravis or flaccid tetraparesis. On physical examination, all the dogs were presented with normal vital signs but with generalized weakness, flaccid tetraparesis, dysphagia, and fatigue in the morning and after exercise. The vaccines were up-to-date, the mucosal color was normal, and temperature, respiratory rate and pulse were normal. 2.2 Neurological Exam The objective of the neurologic evaluation is to determine the presence or absence of a neurologic disease and, when present, to determine its location and the probable extent of damage to the nervous system. The neurological evaluation was done weekly and every time a visual improvement was observed or when the owner asked about something new they had observed in the dog. A basic examination was performed in all acupuncture sessions, consisting of a local exam related to the disease symptoms. The more detailed examination, performed, consisted of the general and specific tests described below: 1. General: History of the animal and physical exam. 2. Ability to gait. 3. Head evaluation: position, coordination, sensitivity, mental status. 4. Cranial Nerves: observation, motor observation, muscle tone, muscle strength, coordination and gait. 5. Reflexes: sensory, position sense (postural reaction), dermatomal testing (cutaneous trunci reflex), pain (deeper and superficial), flexor and extensor reflex (patellar, tibialis, etc) and others if required. All animals, which were treated, had tetraparesis, loss of position sense (postural reaction), and, contrary to the literature, hypotonic reflexes. The pain reflex, as expected for this disease, was preserved in all animals studied15. Table of the most common neurological signs findings: Foreleg Reflex Reflex Left Right Triceps 1 1 Biceps 1 1 Extensor Carpi Radialis 1 1 0 = absence of reflex; 1+ = diminished reflex; 2+ = normal reflex; 3+ = hyperactive reflex; and, 4+ = hyperactive reflex with clonus.

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Rear Leg Reflex Reflex Left Right Patellar 1 1 Cranial Tibialis 1 1 Sciatic Notch 1 1 0 = areflexia; 1+ = diminshed reflex; 2+ = normal reflex; 3+ = hyperactive reflex; and, 4+ = hyperactive reflex with clonus Cranial Nerve Examination CNI CNII CNIII CNIV CNV CNVI CNVII CNVIII CNIX CNX CNXI CNXII A= absent; P=present Proprioception Proprioception Right Foreleg Unconscious P/A Conscious P/A A= absent; P=present Miscellaneous Reflexes Anal Bulboanal A= absent; P=present Pain Hyperpathia Superficial pain Deep pain A= absent; P=present

P P P P P P P P P P P P

Left Foreleg P/ A P/ A

Right Leg P/ A P/ A

Rear Left Rear Leg P/ A P/ A

P P

A P P

2.3 Diagnose The diagnosis of Myasthenia disease is based on the medical history, physical examination, neurologic examination, and electromyography (EMG) or nerve-conduction studies16. Every effort must be made by the clinician to determine the location of the lesion and the presence or absence of concomitant physical or neurologic disease processes. A neurologic examination form is useful to gather the necessary information.

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The western diagnosis of Myasthenia Gravis can also be made based on the clinical and neurological signs plus presumptively diagnosed by administration of pyridostigmine. For the animals analyses in this study, both techniques were used: - ENMG: normal, except for the reduction in muscular response elicited after repetitive neural stimulation of 5/ second.

Example of a diagnostic result of one of the dogs treated: Figure 1: Neural potential waves decreasing with continuous stimulation, more than the 10% normal decrease.

Reference: Dra. TORELLI, S. Figure 2: Neural potential waves decreasing with waves overlapping each other.

Reference: Dra. TORELLI, S. - Administration of Pyridostigmine (Mestinon), at a dose of 30-60mg, every 8h-12h2 or 0,5 a 3mg/kg every 8-12h17 instead of using Tensilon. 2.3.1 History The history includes all pertinent medical and a neurologic history. The neurologic history should include the following information: Duration of the problem rapidity of onset (acute versus chronic), status of the problem (progressive, static, improved), history of trauma, history of spinal problems, previous therapy and response alterations in bladder or bowel function, vaccination history, alterations in personality and other additional information may be necessary in certain cases. 2.3.2 Differential diagnoses Differential diagnoses must be done for botulism, distemper, polyradiculoneuritis, polyneuropathy due to chemical substances, and others such as paraneoplastic polyneuropathy. Confirmation of the diagnosis can be made by electromyography (EMG) or nerve-conduction studies.

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2.4 Treatment6, 7, 8 2.4.1 Medications All animals, before being referred for acupuncture were medicated with prednisolone acetate (Meticorten PDS) 0.5 mg/kg BW, PO, q24h for 10 days in average. Other medications used were Enrofloxaxin 150mg q24h PO for 7 days (Duotril, Duprat); Doxycycline 400mg q12h for 20 days (Doxitrat, Agener Unio); Pyridostigmine (Mestinon) was the medication of choice for therapeutic diagnosis and for maintenance of the animals during the first three weeks.

2.5 Eastern Diagnose The TCM diagnosis suggested Spleen and Stomach Qi Deficiency based on the clinical signs, pulse and tongue diagnosis. According to this finding, the selection of the acupuncture points was based on the Eight Principles and the Zang Fu1, 3, 9, 10, 11, 14. Points and technique used 14,3: Technique: leave the needles in place for 20 minutes while lifting and pumping the needles up and down to reach the De Qi. - LI10 (Shou San Li): Strengthens the forelimb. Location: Two cun distal to LI11, between the m. extensor carpi radialis and common digital extensor. - GV20 (Bai Hui): Sea of marrow point. Warms Yang and restores collapsed Yang; regulates and Tonifies Qi. Location: On the dorsal midline of the skull, on the anterior edge of the base of the ears, in the notch between the sagittal crest and the frontal crest. - ST36 (Zu San Li): Sea and Earth point of the Stomach channel and Sea of nourishment point. Regulates, strengthens and Tonifies Spleen Qi and Yang and regulates Stomach Qi and Yin. Location: 3 cun distal to ST35, distal to the tibia tuberosity and lateral to the cranial border of the tibia, in a depression approximately in the middle of the cranial tibialis muscle. - BL17 (Ge Shu): Influential point of the Blood. Regulates and Tonifies the Spleen Qi, regulates and Tonifies the Blood, facilitates Blood flow. Location: 1.5 cun lateral to the caudal border of the spinous process of the 7th thoracic vertebra, in the depression caudal to the medial border of the scapula. - BL20 (Pi Shu): Associated point of the Spleen. Regulates, strengthens and Tonifies Spleen Qi and Yang; regulates Stomach Qi and Yin; Tonifies nutritive Qi and Blood. Location: 1.5 cun lateral to the caudal border of the spinous process of the 11th thoracic vertebra. - BL21 (Wei Shu): Associated point of Stomach. Associated point of the Spleen. Regulates, strengthens and Tonifies Spleen Qi and Yang; regulates Stomach Qi and Yin; Tonifies nutritive Qi. Location: 1.5 cun lateral to the caudal border of the spinous process of the 13th thoracic vertebra. - BL23 (Shen Shu): Associated point of the Kidney. Tonifies Kidneys Qi and Yang and Essence; neurological point. Location: 1.5 cun lateral to the caudal border of the spinous process of the 2nd lumbar vertebra.

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3. RESULTS The results were considered as: - Cured: if medication was no longer needed; - Improved: if a small dose of medication was still needed; - Not improved: if there was no symptom remission when a normal dose of pyridostigmine was used, 0.5-3mg/ kg every 8-12h or 30-60mg every 8-12h, depending on the literature queried. With those parameters above, we could make a table:
Animal Adla - Doberman Neurological signs Ataxia, tetraparesia,lostof positionsense (posturalreaction), and,contrarytothe literature,hypotonic reflex Improvement She improved to walk after 1 month of weekly treatment and after two week of starting medication with pyridostigmine. She also had colic due to the collateral effect of the medication Weekly with acupuncture Improved with prednisone in 2 days of administration but could not walk. Improve to walk 1 day after using the pyridostigmine No improvement with prednisone for months. With Pyridostigmine 60mg, first 3 days and them 90mg and 120mg. Medication Still on 30mg SID of pyridostigmine for about 6 months. Others No signs of disease except for a chronic licking syndrome on left member due to cervical disease (cervical fusion at C2-C3).

Poodle Mixed breed

Ataxia

No necessity of medication. Pyridostigmine 60mg q48h.

Still using Chinese herbs

Honey Poodle

Worse with exercise

Nizan German Dog

Worse with exercise

Died during anesthesia for electroneuromyograp hy Died after no response to Pyridostigmine and use of high doses of the drug.

Suspect of neoplastic lesion on the lungs.

Table 1: Results of the treatment: 4. DISCUSSION The evolution of the disease from the Western perspective depends on the cause. Mainly, the cause according to the literature is the paraneoplastic syndrome of canine thymoma16. Although not cited by the literature, the main sign of myasthenia observed by the authors was the diffuse hyporeflexia involving the spinal nerves. Lambert-Eaton myasthenic syndrome (LEMS) It is an autoimmune disorder of the neuromuscular junction characterized by muscle weakness and autonomic dysfunction and, on electromyography, by low compound muscle action potential after nerve stimulation with decrement at low frequency stimulation. Almost 60% of patients with LEMS are paraneoplastic and Small Cell Lung Cancer is the main associated cancer, detected mostly within two years after the diagnosis of LEMS18.

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None have described it in animals. For the first time, we think we have been in contact with this kind of Syndrome in animals with the poodle called Honey. She exhibited signs of lung cancer and also signs of myasthenia gravis on the ENM exam, leading to a result of paraneoplastic syndrome on the ENM. During anesthesia she died of cardio respiratory insufficiency. It was a collapse of both yin and yang due to an extreme Wei Syndrome with Xue Deficiency. Eastern treatment: TCM 4, 9, 10, 11, 12, 13 Since the pathology is a Qi Deficiency of the Spleen and Stomach, the treatment must focus on Tonifying Qi and Yang of the Spleen and Stomach. The needles were placed at a depth of 5mm for 20 minutes. The treatment points were: LI10 for weakness in the fore and hind limbs; GV20 Tonifies the Yang energy; ST36 strengthens and Tonifies the Spleen Qi and Yang; BL17 regulates and Tonifies Qi Spleen and nourishes Blood; BL20 is the Association point for Spleen; BL21 is the Association point for Stomach; BL23 is the Association point for Kidney 14. The Chinese herbs that can be used are: - Bu Zhong Yi Qi Tang for Spleen Qi and Blood Deficiency; - Gui Pi Tang for Qi Spleen Deficiency. Both can be used at 30 drops TID. Western Medication If acupuncture can not be done at least once a weekly, pyridostigmine must be used at least at q48h. The medical literature recommends a dose of 0.5-3mg/ kg every 8-12h. Although the use of glucocorticoids has been suggested17 (prednisone 0.25-1ml/kg, oral, every 12h, none of the animals took it during acupuncture treatment. Follow-up The literature suggests that after 3-12 months spontaneous remission can occur, so it is important to note that none of the acupuncture treatment was longer than 3 months. The literature also states a death rate of 50%, which was also observed by the authors. As observed by the results, the dogs had better results when they were treated by TCM together with the Western Medicine. The advantage of a TCM treatment in Myasthenia is that animal can recover all the movements taking a half of the dosage that the literature recommends. At a 6 months follow up, the neurological symptoms had not returned in any of the treated animals. References 1. Kong, Y.; Ren, X.; Lu, S.: The acupuncture treatment for paralysis. New York, Science Press Beijing, 1996, 87-94 p. 2. Pellegrino, F. & Suraniti A. & Garibaldi L.: Sndromes Neurolgicas em Ces e Gatos. So Paulo, Interbook Comp., 2003, 180-182 p.

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3. Veterinary Acupuncture Society. IVAS Veterinary Acupuncture Course Notes. Ft. Collins, CO: 2006, pp 3.1.1-3.1.8; 10.8.1-10.8.11 4. Schoen, A.: Veterinary Acupuncture. 2nd ed., St. Louis, Mosby, 1994, 544-545p. 5. Zhen, L. S.: Pulse Diagnosis. Sydney, 1985, 12 p. 6. Andrade, S. F.: Manual de Teraputica Veterinria. 2 ed. So Paulo, Roca, 2002. 77 p. 7. Lorenz, M.D. & Kornegay, J. N.: Neurologia Veterinria. 4 ed. So Paulo, Manole, 2006, 8 p. 8. Birchard & Sherding. Manual Saunders Clnica de Pequenos Animais. 2 ed. So Paulo. Roca. 2003. 1421 p. 9. Maciocia, G.: Os Fundamentos da Medicina Chinesa. So Paulo, Roca, 1996, 279 p. 10. Maciocia, G.: A Prtica da Medicina Chinesa. So Paulo, Roca, 1996, 675, 687 p. 11. Xie, H. & Preast V.: Tradicional Chinese Veterinary Medicine. Fundamental Principles. Vol 1, 1996. 210 p. 12. Ehling, D.: The Chinese Herbalists Handbook. 3rd ed. Twin Lakes, Lotus Press, 2002. 98, 111p. 13. Xie, H. & Preast V.: Chinese Veterinary Herbal Handbook. 170 most commoly used herbal formulas. Florida, Chi Institute of Chinese Medicine,2004, 86, 93p. 14. Lade, A.: Acupuncture Points Images and Functions. Seatle, Eastland Press, 1996, 29 p 15. De Lahunta, A. Clinical Neurology in Small Animals - Localization, Diagnosis and Treatment, K. G. Braund (Ed.). Publisher: International Veterinary Information Service (www.ivis.org), Ithaca, New York, USA. Neurological Examination (19-Oct-2001 ). 16. Lainesse, M.F.; Taylor, S.M.; Myers, S.L.; Haines, D.; Fowler, J.D. Focal myasthenia gravis as a paraneoplastic syndrome of canine thymoma: improvement following thymectomy. J Am Anim Hosp. Assoc., v.32(2), p.111-7. 1996 17. Chrisman, C.; Mariani, C.; Platt, S.; Clemmons, R. Neurologia para o Clnico de Pequenos Animais. So Paulo, Editora Roca Ltda, 2005, 336p. 19. Honnorat, J.; Antoine, J.C. Paraneoplastic neurological syndromes. Orphanet Journal of Rare Diseases 2007, 2:22. This article is available from: http://www.OJRD.com/content/2/1/22

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IMPROVING PATIENT OUTCOME IN DIFFICULT CASES USING CRANIAL ELECTROTHERAPY STIMULATION (CES)
Ava Frick, DVM Animal Fitness Center, Union, MO Veterinary Medical Director, Electromedical Products International, Inc., Mineral Wells, TX

Cranial Electrotherapy Stimulation (CES) is a prescription medical device that when applied can benefit many patients experiencing emotional upsets and an unbalanced Autonomic Nervous System, imparting positive physiological and behavioral changes.(1,2) The noninvasive application of low levels of microcurrent (less than 1 to 3 microampere in animals) is easily applied via ear clips. CES was named in 1978 by the FDAs Neurology Panel after new laws required the assessment of the safety and effectiveness of prescription only devices then on the market.(3,4) It is now FDA authorized for anxiety, depression and insomnia. Also it is used (with or without medication) for fibromyalgia, ADD/ADHD, PTSD, CRPS (RSD), phantom limb pain, and other pain syndromes. Electromedicine in the form of CES imparts an electrical signal with a frequency that perfectly matches the receptors in the body to resonate and activate intra-cellular responses, even from long distances (like tuning in a radio). It can produce within the body an electrical activity pattern known as an alpha state, as measured by EEGs.(5) QEEG changes were reported in 30 subjects treated with 20 minutes of Alpha-Stim CES. There was an increase in alpha activity with a simultaneous decrease in delta activity. (Courtesy of Richard Kennerly, University of North Texas, Ph.D. dissertation.) The resultant central and peripheral effects of feelings of calmness, relaxation, increased mental focus, decreased stress-effects, reduced agitation, stabilized moods and the ability to control both sensations and perceptions of particular types of pain, makes cranial electrotherapy stimulation a welcome modality in treating patients with behavior disorders.(6) CES can change the electrical and chemical activity of certain nerve cells in the brainstem thereby amplifying activity in some neurological systems, and diminishing the activity of others, such as in the hypothalamus. This form of CES engages distinct populations of on and off modulatory cells of the serotonergic (5-HT) raphe nuclei of the brainstem reticular formation. 5-HT inhibits brainstem cholinergic and noradrenergic systems that project supratentorially. This suppresses thalamo-cortical activity, arousal, and agitation, alters sensory processing and induces an EEG alpha rhythm. As well, 5-HT can act directly to modulate pain sensation in the dorsal horn of the spinal cord, and alter pain perception, and cognition and emotionality within the limbic forebrain.(7)

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CES research by neurosurgeon C. Norman Shealy, MD found Beta-endorphins to be 98% higher in plasma and a 219% increase in cerebrospinal fluid (CSF). Serotonin was 15 40% greater in the plasma and elevated by 50 200% in the CSF. As of 2002, 29 experimental animal studies have been documented. A study performed on primates where receptor electrodes were placed across varying sites in the brain, showed that CES current across the head sent electrical impulses through every area of the brain focusing heavily in the limbic system.(6) That means that CES stimulates the brains pain neuromatrix directly and it also stimulates the limbic, or emotion center of the brain, either one or both of which could be important in altering or raising the threshold of the pain message.(8) An experimental rat study with CES documented as much as a 3-fold increase in B-endorphin after just one CES treatment. (Krupisky, 1991) Stinus, 1990, Tail Flick Latency studies in rats revealed a significant increase in the analgesic effect of opiates when combined with CES. Further testing suggested that CES potentiation of opiate-induced analgesia is centrally mediated. A double-blind study done by Clark, Mills, and Marchant in England in 2000 evaluated the potential efficacy of Alpha-Stim CES in horses for stress reduction. Thirty three behavioral traits including body locomotion, head motion, ear position, oral behavior, and lower lip response were monitored. All of the changes were highly intercorrelated and strongly indicated a reduction in the horses state of arousal following CES treatment that was not noted in the sham treatments.(9) Pozos, et.al.1971 at University of Tennessee Medical Center studied the cholinergic/adrenergic system in several experiments with dogs. Reserpine, a dopamine reuptake blocker, was injected followed by application of electrical current to engender increased dopamine release into the synapse. It would consequently be broken down by monoamine oxidase (MAO) giving the dogs Parkinson-like symptoms. Then, while the reserpine was still blocking the dopamine reuptake, atropine was injected to act as a blocker to the postsynaptic uptake of acetylcholine, thereby preventing or reducing acetylcholines effect on the postsynaptic membrane. The Parkinson-like symptoms disappeared and the dogs returned to normal behavior. In phase two the researchers removed the atropine and added physostigmine to the still reserpinized dogs. The physostigmine was intended to block the MAO breakdown of intrasynaptic acetylcholine, making more of it available. The dogs responded with their most profound Parkinson-like symptoms. Lastly, they removed all drugs from the dogs bloodstream and found that dogs allowed to go about their normal activities recovered in three to seven days, while a similar group given CES stimulation recovered in two to eight hours!(10) Human studies have further shown EMG responses with a reduction in spasticity in patients with hemiplegia and paraplegia that was maintained for one week post treatment. Other patients showed an increase in relaxation and reduction of involuntary movements. Also some of those with Parkinsons and dystonia musculorum symptoms were seen to change during treatment and eventually completely eliminated.

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Research methodology of 86 pivotal (out of 126) studies of CES included 35 Double-Blind Placebo-Controlled, 9 Single-Blind, 5 Controlled Study, 6 Crossover 22 Open Clinical Trials, 2 Retrospective Studies, 3 Case Studies and 3 Follow-up. Two Meta-Analyses studies reconfirmed the significance of CES research for treating anxiety. Both found CES significantly effective for anxiety (P<.05). CES is three times more efficacious than the average SSRI. Specific conditions have shown positive response following the use of CES. Improvement in RSD (Reflex Sympathetic Dystrophy), Alpher and Kirsch, 1998 and on an assessment of 363 fibromyalgia patients over a 3 week to 2 year period 42% reported 50-74% improvement in symptoms. Normal thalamic function can be altered by a variety of psychological and physical traumas resulting in deranged firing orders from the thalamus. Deranged firing orders from the thalamus to other areas of the brain can result in depression, anxiety, insomnia, ADD, eating disorder, addictions, and OCD. The conclusion is that most health problems arise from overarousal, underarousal, or instability in the CNS.(11) The proposed net effect of multiple streams of diverse information reaching into and being sent back to the cerebellum is that the cerebellum integrates multiple internal representations with external stimuli and selfgenerated responses. The cerebellar contribution to these different subsystems permits the ultimate production of harmonious sensorimotor, cognitive, and affective autonomic behaviors.(12) CES is effective in improving thalamic and cerebellar function through a variety of known and potentially other yet unknown mechanisms. Since only 2% of neuronal communication occurs at the synapse there are many medications that cannot come close to helping the body the way cranial electrotherapy stimulation can. CES has the capacity to improve patient outcome for chronic degenerative, neurological pain and stress-related cases and elevate the therapeutic response when combined with acupuncture. References 1. Shealy CN, Cady RK, Culver-Vehoff D, Cox R, Liss S. Cerebral spinal fluid and plasma neurochemical: response to cranial electrical stimulation. Journal of Neurological and Orthopaedic Medicine and Surgery 1998:18(2):94-07. 2. Childs, A. Cranial electrotherapy stimulation reduces aggression in violent retarded population: a preliminary report. The Journal of Neuropsychiatry and Clinical Neurosciences, 17(4): 548-551, 2005. 3. Kirsch DL, Smith R. Cranial electrotherapy stimulation for anxiety, depression, insomnia, cognitive dysfunction, and pain. Bioelectromagnetic Medicine Paul Rosch, ed.; 2004, 727740. 4. Gilula MF, Barach PR. Cranial electrotherapy stimulation: a safe neuromedical treatment for anxiety, depression or insomnia. Southern Medical Journal. 97(12): 1269-1270, 2004.

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5. Hefferman MS. Comparative Effects of Microcurrent Stimulation on EEG Spectrum and Correlation Dimension. Integrative Physiological and Behavioral Science 1996 31 (3);202209. 6. Kirsch DL. The Science Behind Cranial Electrotherapy Stimulation 2nd ed., Medical Scope Publishing Co., Canada 2002. 7. Giordano J. Putative Mechanisms of Cranial Electrotherapy Stimulation (CES): Effects and Implications and How Alpha-Stim Cranial Electrotherapy Simulation (CES) Works, www.alpha-stim.com 8. Kirsch, DL: Cranial Electrotherapy Stimulation in the Treatment of Fibromyalgia. Practical pain Management, Sept 2006. 9. Clark N, Mills D, Marchant J. Evaluation of the potential efficacy of the Alpha-Stim SCS in the horse. DeMontfort University Equestrian Centre and Field Station, Caythorpe, Lincolnshire, United Kingdom. January 2000. (Available online at: http://www.alphastim.com/Information/Technology/Research/Research_PDF/horse_study.pdf) 10. Pozos RS, Strack LF, White RK, et.al. Electrosleep versus electroconvulsive therapy, Neuroelectric Research. 23:221-225, 1971. 11. Robbins, J. A symphony in the brain, Grove Press 2000; 200-202. 12. Schmahmann. The Cerebellum and Cognition, Int Rev Neurobiology, Vol. 41. RERE

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THERAPEUTIC EFFECT OF BEE-VENOM AND DEXAMETHASONE IN DOGS WITH FACIAL NERVE PARALYSIS
Duck-hwan Kim, DVM, MS, Ph.D. Corresponding author College of Veterinary Medicine, Chungnam National University Daejeon, Korea. Email: dhkim@cnu.ac.kr Hyung-kyou Jun College of Veterinary Medicine, Chungnam National University Daejeon 305-764, Korea Hyun-uk Oh, College of Veterinary Medicine, Chungnam National University Daejeon 305-764, Korea Ji-won Han College of Veterinary Medicine, Chungnam National University Daejeon 305-764, Korea Hyun-hwa Lee College of Veterinary Medicine, Chungnam National University Daejeon 305-764, Korea Seong-mok Jeong College of Veterinary Medicine, Chungnam National University Daejeon 305-764, Korea Seok-hwa Choi College of Veterinary Medicine, Chungbuk National University Cheongju 361-763, Korea Cristopher Mun-ho Kim Anapunsesang Clinic Seoul, Korea

Abstract: Although canine facial nerve paralysis (FNP) occurs similarly in humans, there is no properly recognized therapy using Western medicine for idiopathic causes. To elucidate therapeutic measures by acupuncture (AP) on canine FNP, we examined the therapeutic effect of injection-AP on the artificially induced canine FNP. Twelve dogs on artificially induced canine FNP were divided into a control group (4 dogs), an experimental dexamethasone-treated group (dexamethasone group, 4 dogs) and an experimental bee venom-treated group (apitoxin group, 4 dogs). Saline (1 ml) was intramuscularly injected into the head muscle after the induction of FNP in the control group. On the other hand, injectionAP with dexamethasone was performed on such acupoints as LI04, LI20, ST02, ST07, TH17, SI18, GB03 and GB34, twice per week after induction of FNP in the dexamethasone group. 125

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In addition, injection-AP with 100 of apitoxin was performed on the same acupoints as the dexamethasone group twice per week after the induction of FNP in the apitoxin group, respectively. The changes of the clinical symptoms of FNP with each treatment during the experimental period were recorded by using clinical scores, respectively. The changes of serum creatine kinase (CK) activities along with each treatment were determined using an autoanalyzer. The significant differences of clinical scores were detected on day 14 (p<0.05) in the apitoxin and dexamethasone groups, compared with those in the control group, respectively. However, significant difference was not detected between the apitoxin and dexamethasone groups. Significant differences of serum CK activities were detected on day 7 (p<0.05) and day 14 (p<0.05) in the dexamethasone and apitoxin groups, compared with those in the control group, respectively. However, significant difference was not detected between the dexamethasone and apitoxin groups. In coclusion, injection-APs with apitoxin and dexamethasone were all effective for treatment of canine FNP and the therapeutic effect by injection-AP with apitoxin was similar to that of injection-AP with dexamethasone. Key words: Injection-acupuncture, apitoxin, canine, facial nerve paralysis

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TREATMENT BY INJECTION-ACUPUNCTURE WITH BEE-VENOM(APITOXIN) AND APITOXIN COMBINED BY CHINESE HERBAL MEDICINE IN PATIENTS WITH CANINE HIND LIMB PARALYSIS: CASE REPORT Duck-hwan Kim, DVM, MS, Ph.D. Corresponding author College of Veterinary Medicine, Chungnam National University, Daejeon, Korea. e-mail: dhkim@cnu.ac.kr Hyung-kyou Jun College of Veterinary Medicine, Chungnam National University, Daejeon, Korea Se-kun Park College of Veterinary Medicine, Chungnam National University, Daejeon, Korea Christopher Mun-ho Kim Anapunsesang Clinic, Seoul, Korea Chin-yuan Hsu Yeon Chang Veterinary Clinic, Miaoli City, Miaoli Province, Taiwan Chin-ling Hsu Yeon Chang Veterinary Clinic, Miaoli City, Miaoli Province, Taiwan Jim-cai Liao Shan Qun Animal Hospital, Shang Cheng City, Taipei Province, Taiwan Hao-jen Chueh Zoo Animal Hospital, Taipei City, Taiwan Han-wen Cheng Sino Union Animal Hospital, Young He, Taipei, Taiwan
Abstract: The therapy by injection-acupuncture(AP) with bee-venom(apitoxin) and injection-AP with apitoxin combined by administration of Chinese herbal medicine was applied in 2 cases with canine intervertebral disc disease(IVDD). Case 1 was diagnosed as thoraco-lumbar IVDD (T11-T12, T12-T13, L3L4 and L4-L5) and case 2 was diagnosed as IVDD at T 10- T11 and T 12- T 13, respectively. Injection-AP with apitoxin(Apitoxin, total 200 of apitoxin, 0.1 ml/acupoint) plus physical exercise(walking with gocart, TID/day) and aquatherapy(swimming treatment, BID/week) were given to each patient. The used acupoints were GV20(Bai Hui), GB30(Huan Tiao), ST36(Zu San Li), GB34(Yang Ling Quan), ST40(Feng Long), ST41(Jie Xi) and BL40(Wei Zhong), the lesions, and trigger points. In addition, Chinese herbal medicine(Koda Pharmaceutical Co., Taiwan) including Zheng Gu Zi Jin Dan( : 1 g), Shiuh Duann( : 0.2 g), Du Zhong( : 0.2 g), Mo Yao( : 0.2 g), Ru Xiang( : 0.2 g) and Pyrite( : 0.2 g) were orally medicated BID for 9 days in case 2. Walking was possible after session 11 for 4 weeks in case 1 and after session 6 for 2 weeks in case 2, respectively.

Key words : Canine, IVDD, injection-AP, apitoxin, Chinese herbal medicine

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ACUPUNCTURE TREATMENT FOR PARAPARESIA IN A MARMOSET IN CAPTIVITY Paula SADER, Juliana Lehn LINARDI, J.G.F. Joaquim, DVM, Msci. 1. Vet. Med., MSc. Professora Associada do Instituto Bioethicus, 14-97541844, psadervet@yahoo.com.br 2. PZMQB Parque Zoolgico Municipal Quinzinho de Barros. 3. FMVZ Unesp Botucatu Dept. of Surgery and Anesthesiology.

ABSTRACT This article report a case of acute paraparesia in a black female of marmoset (Callithrix penicillata), in the Zoo of Sorocaba, in So Paulo, Brazil. The animal was found in the ground, with paraparesia, lost of position sense (postural reaction), reduced reaction at the dermatomal testing (cutaneous trunci reflex) and superficial pain reflex. The animal was reporter to the veterinary medicine unit, where physical and complementary exam was done. On clinical evaluation, the animal showed lost the motor and sensitive functions of the hind limbs due to a spinal cord lesion at the thoracolumbar level between T11 - T12 and T12 - T13. Then it was submitted to the acupuncture using the technique of B12 vitamin injection in local and distal points to the medullar injury. As a result improvement was observed after three interventions. The animal was considered health after ten applications and after the recovering of the motor and sensitive functions. With the results, one can conclude that acupuncture can be used in the treatment of neurological patterns with satisfactory results inside of the wild animal veterinary medicine. The lack of studies in acupuncture on wild beasts in the country, ally to the good results of this technique, justifies the incentive and the propagation of alternative treatments in the medicine veterinary medicine. Acknowledgments: Veterinary unit and technicians of Municipal Park Quinzinho de Barros, Sorocaba, S.P. Brazil.

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THE NEUROPHYSIOLOGIC BASIS OF ACUPUNCTURE MOVING BEYOND QI


Narda G. Robinson, DO, DVM, MS, FAAMA Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences Colorado State University, Fort Collins, CO, USA Hundreds of years before the invention of the energy-meridian theory, the Dutch physician Willem ten Rhijne wrote about the ways in which the Chinese physicians thought acupuncture worked.1 Ten Rhijne noted that the lines traced on Chinese diagrams of the human body corresponded to vessels. Points appearing along these lines represented critical junctures (i.e., acupuncture points) where deeper blood vessels and nerves rose to the surface.2 These nerves relayed afferent and efferent information.3 The acupuncture channels (jingluo), which many now refer to as meridians, unsurprisingly first pertained to actual blood vessels, as acupuncture originated as a bloodletting technique. Thus, acupuncture points historically represented avenues and crossroads of neurovascular input. Well in advance of Heads 19th century observation that organ dysfunction causes referred pain,4 the ancient Chinese physicians had recognized reflex connections between acupuncture points and internal organs. This awareness informed their diagnostic palpation and helped determine their point selection.5 While the growth in evidence substantiating a neurophysiological basis of acupuncture is mounting exponentially, no evidence supports what many hope or claim, i.e., that acupuncture works by pushing energy through invisible circuitry.6 The inventor of the energy-meridian concept, George Souli de Morant, was the first to translate the word Qi into energy. According to Souli de Morant, Having observed the existence of something that passes through a meridian when a point is stimulated, the ancients gave this fluidity, this flux, the name qi, which we translate, for lack of a better word, energy. However, relying on the term energy to explain acupuncture fails to describe how acupuncture works. Even the translator of lAcuponcture Chinoise, Paul Zmiewski, pointed out in his introduction that, While ideas found in modern English texts are often expressed in English words derived from lAcuponcture Chinoise, these words do not always mean what was meant in the classic works upon which lAcuponcture Chinoise is based.7 Regarding Souli de Morants energy, Zmiewski wrote, At the beginning of the twentieth century concepts like human energy were referenced in dictionaries and were considered valid matters for scientific inquiryMany nineteenth century ideas of nature were still broadly regarded as truths. Today, however, the scientific era that had just begun when Souli de Morant chose to use the term energy, has left that word with new and different associations in both popular and scientific writing. As such, even Souli de Morants original idea behind the Qi translation has taken on a life and further evolution of its own, independent of its meaning in ancient China.

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As the acupuncturist and author Khoubesserian noted as far back as 1965: If we wish to be taken seriously, and not to be confused with bone-setters or faith-healers, we must abandon the whole more or less Chinese mass of philosophy, cosmogony and mythology in which we have been entangled these forty years past. Let us clear the decks, and look at our problems without preconceived ideas. The study of the anatomy and physiology of the skin, and of the central and sympathetic nervous systems, the investigation of the physico-chemical and enzymic reactions in the body, all these should provide us with the means of solving the problem of what acupuncture really is and does.8 In this context of his contemporaries, Souli de Morants selection of energy for Qi is forgivable. What is less forgivable is insisting that it remain energy today. Forcing acupuncture to languish within the energy-meridian paradigm may be appealing in its simplicity, but it is divorced from reality. The biomedical, scientifically understood mechanisms that guide and control the development, maintenance, and repair of living tissues embody a bewildering and stunning complexity that outrivals the fanciful, energy-based and metaphysical notions surrounding acupuncture today. The Neural Basis of Acupuncture Reports began filtering into Western journals during the 1970s and 1980 showing that acupuncture works via the nervous system. 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24. In 1972, the Peking Acupuncture Anesthesia Coordinating Group reported, [A]bout half of the known acupuncture points are located right over various nerves and the rest are within half a centimeter of one or another nerve. From this, the conclusion was drawn that acupuncture acts in fact on the nervous system, and it is through a nerve that the stimulus produced by needling or applying a mild electric current is transmitted to a certain part of organ of the body where it effects a cure or brings about a state of analgesia.25 The most accurate term to describe how acupuncture works, given our current state of understanding, is through neuromodulation. Neuromodulation, or the intentional modification of nerve function in the direction of healing, links together all of the individual physiologic processes and helps explain the effects of acupuncture with one common thread. The route to reproducible and effective neuromodulation (or acupuncture treatment) is selection and stimulation of the appropriate nerves (or acupuncture points) that produce the intended healing effect. 26 27 28 29 30 31 32 Thus, the cornerstone of effective acupuncture practice rests on finding the right point locations, knowing the anatomical structures nearby, and what happens when acupuncture stimulates these structures. In highly simplified terms, acupuncture begins as an afferent signal initiated near the needling site that travels centripetally, into the central nervous system (CNS). Propagated sensations along acupuncture channels arise as nerve signals converge and relay between various sites within the central nervous system. 33 Connections made at the spinal level course in several directions. Impulses arriving at the cord may 1) send efferent signals back out to the periphery (leading to antidromic activation of free nerve endings at the site of needling), 2) loop into related visceral neural networks and alter internal organ function in a spinal segmental manner, 3) foster endogenous opioid release in the dorsal horn of the spinal cord to reduce spinal

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facilitation, or wind-up, and block pain, or 4) proceed to higher centers in the brain, altering neural and hormonal functions. If acupuncture worked by moving energy and not by nerves, its effects would continue regardless of neural health or integrity. However, partial neurologic injuries cause the needling effects to diminish or disappear, depending on the locus of the lesion.34 Acupuncture has no effect in the face of complete denervation. In fact, the neural basis of acupuncture is so clear that some authors have replaced the conventional alphanumeric naming system of acupuncture points and channels with names referencing the relevant nerves not remote and possibly irrelevant organs.35 As early as 1974, Dr. Patrick Wall, the co-developer of the gate control theory, felt that a new classification system based on acupuncture points and nerves was overdue.36 Despite the evidence showing that acupuncture effects involve nerves, those who instead insist that acupuncture fixes patients by moving invisible energy [Qi] that has become stuck can still obtain beneficial results, because the bodys response to needling is likely to be independent of either the practitioners belief system or scientific rationale. As Kendall indicates in his book, the Dao of Chinese Medicine, The primary goal is to present the true way (dao) of Chinese medicine, and its important anatomical and physiological findings, along with its consistency with respect to the cause and treatment of disease. For those students and practitioners who were trained in the energy-meridian school, [a physiological view, as presented in the Dao of Chinese Medicine, is] consistent with what they have learned with respect to diagnosis and clinical applications.37 Although it may be true that acupuncture practitioners obtain good results whether they design their treatments based on current neurophysiologic information and evidence or two-thousand year-old metaphors, there is little reason to cling to outdated medical concepts when better and more accurate ones have become available. Again, quoting Kendall: Why does anyone care whether Chinese anatomy and physiology are explained as energy flowing through meridians, or by the circulation of blood, nutrients, other vital substances, and vital air (qi) through the vascular system? The answer to that lies in the moral obligation of every practitioner to provide each patient with the latest medical understanding available. The need to continually search for the truth is the most fundamental principle of science and medicine. If the functioning of the human body cannot be understood under normal physiological conditions, then there is little hope of knowing how to treat it when disease conditions exist. Research so far show that the true concepts of Chinese medicine operate under known physiological principles, involving the complex organization of the neural, vascular, endocrine, visceral, and somatic systems, sustained by the circulation of nutrients, vital substances, and oxygen from vital air.38 An Example of Science versus Metaphor: the Case of LI 4 The following comparison illustrates the richness of knowledge added to the classical Chinese point actions by scientific investigation. The illustration focuses on Large Intestine 4 (LI 4),

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the most commonly used acupuncture point at two hospitals in Beijing (>65% of treatments used LI 4).39 Actions of LI 4 stimulation, according to Chinese medicine40 Regulates the defensive qi and adjusts sweating Expels wind and releases the exterior Regulates the face, eyes, nose, mouth and ears Activates the channel and alleviates pain Induces labour; Caution: contraindicated in pregnancy. Restores the yang (i.e., for the treatment of collapse of yang characterised by loss of consciousness, aversion to cold, cold counterflow of the limbs, purple lips etc.) Effects of LI 4 stimulation, according to scientific studiesa Diaphoretic or circulatory effects Both high and low frequency electroacupuncture (EA) stimulation of LI4 (with SI 3) produced short-term cooling.41 Manual and EA stimulation of LI4 can also produce long-lasting warming (indicating a sympatholytic effect) after the transient, segmental increase in sympathetic activity that induced a localized, short-term cooling.42 Acupuncture at LI 4 caused an increase in palm temperature, probably due to cutaneous vessel dilation.43 Pain control benefits EA diminishes dental pain perception; high intensity EA is most effective.44 Naloxone failed to reverse elevated pain thresholds induced by EA, indicating that non-opioid transmitters are involved in dental analgesia.45 Nitrous oxide blocks the effects of electrical stimulation at LI4.46 Needle manipulation at LI4 significantly increases pain pressure thresholds.47 Unilateral EA at LI4 (and LI11) transiently inhibited the motoneuron pool in the extensor digitorum communis muscle of the contralateral arm, suggesting that EA operates by central effects, instead of or in addition to peripheral influences.48 Transcutaneous electrical nerve stimulation (TENS) at LI4 reduced the sensation of pain but not vibration.49 Obstetrical influences Acupuncture at LI4 suppressed uterine contractions induced by oxytocin in pregnant rats.50 Acupuncture at LI4 inhibited the expression of the cyclooxygenase-2 (COX-2) enzyme and reduced uterine motility significantly.51 Acupuncture at LI4 (and SP6) helped ripen the cervix at term and shortened the time interval between estimated date of confinement (EDC) and delivery.52 Ice massage on LI4 reduced labor pain during contractions.53 Acupressure at LI4 and BL67 reduced labor pain during the active phase of the first stage of labor, but did not significantly affect uterine contractions.54 Effects on brain function Manual and EA stimulation of LI4 produce differential brain activation. Manual needle manipulation caused prominent functional magnetic resonance imaging (fMRI) signal decreases in the posterior cingulate and superior temporal gyrus as well as the putamen/insula. EA caused

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signal increases in the precentral gyrus, the postcentral gyrus/inferior parietal lobule, and the putamen/insula.55 Somatosensory evoked potentials obtained after EA at LI4 (which activates radial nerve fibers) differ markedly from those obtained after EA at the median nerve.56 Needle manipulation at LI4 modulates activity in limbic and subcortical gray structures of the brain, as shown by fMRI.57 _____
a Only studies evaluating LI 4 alone or in combination with one other point were included.

Brain magnetic fields measured by SQUID (superconductive Quantum Interference Device) after acupuncture at LI4 revelaed changes in the biomagnetic fields relating to the projection areas of the face and jaw.58 LI4 stimulation causes a significant increase in the latency and decrease in the amplitude of peaks reflecting primary cortical afferent activities.59 Needle manipulation of LI4 activated the hypothalamus, supporting the notion that this classical analgesic point works at least in part to reduce pain through hypothalamic activation.60 61 Manual acupuncture to LI4 activated both somatosensory cortical areas and the periaqueductal gray.62 High-frequency EA at LI4 induced specific electroencephalographic (EEG) modulation of Theta activity in the midline frontal region. This may reflect reduced activity in the anterior cingulate cortex, resulting in anti-nociception.63 Needle manipulation at LI 4 activates structures in the descending antinociceptive pathway (i.e., the hypothalamus and nucleus accumbens) and deactivates multiple areas in the limbic system associated with pain (rostral part of the anterior cingulate cortex, amygdala formation, and hippocampal complex), indicating ways in which endogenous pain modulation circuits in the brain may function.64 Autonomic influences: EA at LI4 selectively activates the sympathetic, but not parasympathetic, nervous system. In so doing, the rhythmic micturition contraction cycle lengthened and urine excretion increased, as did renal sympathetic nerve activity and blood pressure. These results indicated that EA at LI4 may benefit patients with hyperactive bladder problems.65 EA at LI4 and LI11 increased both pain thresholds and muscle sympathetic nerve activity.66 Spinal cord activation EA at LI4 and LI11 caused a positive spread of activation across the spinal cord segments C5 to T1, with peak activity taking place at C7. Activation occurred at both the dorsal and ventral parts of the cord, indicating that LI4 and LI11 can indeed modulate specific spinal cord regions. This study suggests that individuals with sensorimotor deficits arising from these spinal segments may benefit from acupuncture at these points.67 It is difficult to deny the value of treating patients with the additional insights gained through research. Determining which nerves relate to which acupuncture points, learning about the functions of these nerves for both local and systemic influences, comparing the classically described point applications with current evidence, and pursuing research to confirm, refute, or modify these applications revitalizes the practice and study of acupuncture.

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References 1. Kendall DE. Dao of Chinese Medicine. Understanding an Ancient Healing Art. Hong Kong: Oxford University Press, 2002. P. 2. 2. Kendall DE. Dao of Chinese Medicine. Understanding an Ancient Healing Art. Hong Kong: Oxford University Press, 2002. P. 2. 3. Kendall DE. Dao of Chinese Medicine. Understanding an Ancient Healing Art. Hong Kong: Oxford University Press, 2002. P. 2. 4. Head WM. On disturbances of sensation with special reference to the pain of visceral disease. Brain. 1893;16:1-133. 5. Kendall DE. Dao of Chinese Medicine. Understanding an Ancient Healing Art. Hong Kong: Oxford University Press, 2002. Pp. 2-3. 6. Engelhardt U. Translating and interpreting the Fu-ChI I Ching-I Lun: Experiences gained from editing a Tang Dynasty Taoist medical treatise. In: Unschuld PU (ed.). Approaches to Traditional Chinese Medical Literature. Proceedings of an International Symposium on Translation Methodologies and Terminologies. Dordrecht/Boston/London: Kluwer Academic Publishers, 1989. pp. 129-138. 7. Souli de Morant G. Chinese Acupuncture. [Grinnell L, Jeanmougin C, and Leveque M, translators; Zmiewski P, editor]. Brookline: Paradigm Publications, 1994. P. ix. 8. Khoubesserian H. Libres Propos. RAC. 1965;3-4, 7. In Gwei-Djen L and Needham J. Celestial Lancets. A History and Rationale of Acupuncture and Moxa. New York: RoutledgeCurzon, 2002. P. 185. 9. Dung HC. Acupuncture points of the cranial nerves. Am J Chin Med. 1984;12(1-4):80-92. 10. Dung HC. Acupuncture points of the cervical plexus. Am J Chin Med. 1984;12(1-4):94105. 11. Dung HC. Acupuncture points of the brachial plexus. Am J Chin Med. 1985;13(1-4):49-64. 12. Dung HC. Acupuncture points of the lumbar plexus. Am J Chin Med. 1985;13(1-4):133143. 13. Dung HC. Acupuncture points of the sacral plexus. Am J Chin Med. 1985;13(1-4):145-156. 14. Dung HC. Acupuncture points of the typical spinal nerves. Am J Chin Med. 1985;13(14):39-47. 15. Bossy J. Morphological data concerning the acupuncture points and channel network. Acupuncture & Electrother Res, Int J. 1984;9:79-106.

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16. Mann F. Acupuncture The Ancient Chinese Art of Healing and How It Works Scientifically. New York: Random House, Inc., 1962. 17. Matsumoto T and Lyu B. Anatomical comparison between acupuncture and nerve block. The American Surgeon. 1975;41:11-16. 18. Dung HC. Anatomical features contributing to the formation of acupuncture points. American Journal of Acupuncture. 1984; 12:139-143. 19. Gunn CC, Ditchburn FG, King MH, and Renwick GJ. Acupuncture loci: a proposal for their classification according to their relationship to known neural structures. American Journal of Chinese Medicine. 1976;4:183-195. 20. Filshie J and White A. Medical Acupuncture, A Western Scientific Approach. London: Churchill Livingstone, 1998. 21. Wong JY. A Manual of Neuro-Anatomical Acupuncture. Volume I: Musculoskeletal Disorders. Toronto: The Toronto Pain and Stress Clinic, Inc., 1999. 22. Wong JY. A Manual of Neuro-Anatomical Acupuncture. Volume II: Neurological Disorders. Toronto: The Toronto Pain and Stress Clinic, Inc., 2001. 23. Fu H. What is the material base of acupuncture? The nerves! Medical Hypotheses. 2000;54:358-359. 24. Cho ZH, Wong EK, and Fallon J. Neuro-Acupuncture. Scientific Evidence of Acupuncture Revealed!. Los Angeles: Q-Puncture, Inc., 2001. 25. Peking Acupuncture Anesthesia Coordinating Group. Acupuncture Anesthesia. Peking: Foreign Languages Press, 1972. Cited in: King Liu Y, Varela M, and Oswald R. The correspondence between some motor points and acupuncture loci. American Journal of Chinese Medicine. 1975;3(4):347-358. 26. Dung HC. Anatomical features contributing to the formation of acupuncture points. American Journal of Acupuncture. 1984; 12:139-143. 27. Matsumoto T and Lyu B. Anatomical comparison between acupuncture and nerve block. The American Surgeon. 1975;41:11-16. 28. Shaozong C. Modern acupuncture theory and its clinical application (Chapter 5 The Morphological Relationship between Points and Nerves). International Journal of Clinical Acupuncture. 2001;12:149-157. 29. Shaozong C. Modern acupuncture theory and its clinical application. (Chapter 5 The Morphologic Relationship between Points and Nerves). International Journal of Clinical Acupuncture. 2001;121(2):149-158.

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30. Li A-H, Zhang J-M, and Xie Y-K. Human acupuncture points mapped in rats are associated with excitable muscle/skin-nerve complexes with enriched nerve endings. Brain Research. 2004;1012:154-159. 31. Lu G-W. Characteristics of afferent fiber innervation on acupuncture points zusanli. Am J Physiol. 245 (Regulatory Integrative Comp Physiol. 14): R606-R612, 1983. 32. Zaslawski CJ, Cobbin D, Lidums E, and Petocz P. The impact of site specificity and needle manipulation on changes to pain pressure threshold following manual acupuncture: a controlled study. Complementary Therapies in Medicine. 2003;11:11-21. 33. Bossy J. Morphological data concerning the acupuncture points and channel network. Acupuncture & Electrother Res, Int J. 1984;9:79-106. 34. Li S, Jiang C, and Chen G. The relationship between needling sensation and acupuncture ffects, with special reference to their ascending pathway in the spinal cord. Acupuncture & Electro-Therapeutics Res., Int J. 1983;8:105-110. 35. Dung HC, Clogston CP, and Dunn JW. Acupuncture. An Anatomical Approach. Boca Raton: CRC Press LLC, 2004. 36. Gunn CC, Ditchburn FG, King MH, and Renwick GJ. Acupuncture loci: a proposal for their classification according to their relationship to known neural structures. Am J Chin Med. 1976;4(2):183-195. 37. Kendall DE. Dao of Chinese Medicine. Understanding an Ancient Healing Art. Hong Kong: Oxford University Press, 2002. P. 15. 38. Kendall DE. Dao of Chinese Medicine. Understanding an Ancient Healing Art. Hong Kong: Oxford University Press, 2002. P. 11. 39. Napadow V, Liu J, and Kaptchuk TJ. A systematic study of acupuncture practice: acupoint usage in an outpatient setting in Beijing, China. Complementary Therapies in Medicine. 2004;12:209-216. 40. Deadman P, Al-Khafaji M, and Baker K. A Manual of Acupuncture. East Sussex [ENGLAND]: Journal of Chinese Medicine Publications, 1998. Pp. 103-106. 41. Landry MD and Scudds RA. The cooling effects of electroacupuncture on the skin temperature of the hand. J Hand Ther. 1996;9:359-366. 42. Ernst M and Lee MHM. Sympathetic vasomotor changes induced by manual and electrical acupuncture of the Hoku point visualized by thermography. Pain. 1985;21:25-33. 43. Kuo T-C, Lin C-W, and Ho F-M. The soreness and numbness effect of acupuncture on skin blood flow. Am J Chin Med. 2004;32(1):117-129.

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44. Schimek F, Chapman CR, Gerlach R, and Colpitts YH. Varying electrical acupuncture stimulation intensity: effects on dental pain-evoked potentials. Anesth Analg. 1982;61(6):499503. 45. Chapman CR, Benedetti C, Colpitts YH, and Gerlach R. Naloxone fails to reverse pain thresholds elevated by acupuncture: acupuncture analgesia reconsidered. Pain. 1983;16(1):1331. 46. Chapman CR, Schimek F, Gehrig JD, Gerlach R, and Colpitts YH. Effects of nitrous oxide, transcutaneous electrical stimulation, and their combination on brain potentials elicited by painful stimulation. Anesthesiology. 1983;58(3):250-256. 47. Zaslawski CJ, Cobbin D, Lidums E, and Petocz P. The impact of site specificity and needle manipulation on changes to pain pressure threshold following manual acupuncture: a controlled study. Complementary Therapies in Medicine. 2003;11:11-21. 48. Milne RJ, Dawson NJ, Butler MJ, and Lippold OCJ. Intramuscular acupuncture-like electrical stimulation inhibits stretch reflexes in contralateral finger extensor muscles. Experimental Neurology. 1985;90:96-107. 49. Wang N and Hui-Chan C. Effects of acupoints TENS on heat pain threshold in normal subjects. Chin Med J (Engl). 2003;116(12):1864-1868. 50. Pak SC, Na CS, Kim JS, Chae WS, Kamiya S, Wakatsuki D, Morinaka Y, and Wilson L Jr. The effects of acupuncture on uterine contraction induced by oxytocin. Am J Chin Med. 2000;28(1):35-40. 51. Kim J, Shin KH, and Na CS. Effect of acupuncture treatment on uterine motility and cyclooxygenase-2 expression in pregnant rats. Gynecol Obstet Invest. 2000;50(4):225-230. 52. Rabl M, Ahner R, Bitschnau M, Zeisler H, and Husslein P. Acupuncture for cervical ripening and induction of labor at term a randomized controlled trial. Wien Klin Wochenschr. 2001;113(23-24):942-946. 53. Waters BL and Raisler J. Ice massage for the reduction of labor pain. J Midwifery Womens Health. 2003;48(5):317-321. 54. Chung UL, Hung LC, Kuo SC, and Huang CL. Effects of LI4 and BL67 acupressure on labor pain and uterine contractionsin the first stage of labor. J Nurs Res. 2003;11(4):251-260. 55. Kong J, Ma L, Gollub RL, Wei J, Yang X, Li D, Weng X, Jia F, Wang C, Li F, Li R, and Zhuang D. A pilot study of functional magnetic resonance imaging of the brain during manual and electroacupuncture stimulation of acupuncture point (LI-4 Hegu) in normal subjects reveals differential brain activation between methods. Journal of Alternative and Complementary Medicine. 2002;8(4):411-419.

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56. Wei H, Kong J, Zhuang D, Shang H, and Yang X. Early-latency somatosensory evoked potentials elicited by electrical acupuncture after needling acupoint LI-4. Clin Electroencephalogr. 2000;31(3):160-164. 57. Hui KK, Liu J, Makris N, Gollub RL, Chen AJ, Moore CI, Kennedy DN, Rosen BR, and Kwong KK. Acupuncture modulates the limbic system and subcortical gray structures of the human brain: evidence from fMRI studies in normal subjects. Hum Brain Mapp. 2000;9(1):1325. 58. Yang ZL, Ouyang Z, Cheng YG, and Chen YX. A neuromagnetic study of acupuncturing LI-4 (Hegu). Acupunct Electrother Res. 1995;20(1);15-20. 59. Abad-Alegria F, Adelantado S, and Martinex T. The role of the cerebral cortex in acupuncture modulation of the somesthetic afferent. Am J Chin Med. 1995;23(1):11-14. 60. Hsieh J-C, Tu C-H, Chen F-P, Chen M-C, Yeh T-C, Cheng H-C, Wu Y-T, Liu R-S, and Ho L-T. Activation of the hypothalamus characterizes the acupuncture stimulation at the analgesic pointing human: a positron emission tomography study. Neuroscience Letters. 2001;307:105108. 61. Chiu J-H, Chung M-S, Cheng H-C, Yeh T-C, Hsieh J-C, Chang C-Y, Kuo W-Y, Cheng H, and Ho L-T. Different central manifestations in response to electroacupuncture at analgesic and nonanalgesic acupoints in rats: a manganese-enhanced functional magnetic resonance imaging study. Canadian Journal of Veterinary Research. 2003;67:94-101. 62. Liu WC, Feldman SC, Cook DB, Hung DL, Xu T, Kalnin AJ, and Komisaruk BR. fMRI study of acupuncture-induced periaqueductal gray activity in humans. Neuroreport. 2004;15(12):1937-1940. 63. Chen CAN, Liu F-J, Wang L, and Arendt-Nielsen L. Mode and site of acupuncture modulation in the human brain: 3D 0124-ch) EEG power spectrum mapping and source imaging. Neuroimage. 2005; in press. 64. Wu MT, Hsieh JC, Xiong J, Yang CF, Pan HB, Chen YC, Tsai G, Rosen BR, and Kwong KK. Radiology. 1999;212(1):133-141. 65. Lin T-B, Fu T-C, Chen C-F, Lin Y-J, and Chien C-T. Low and high frequency electroacupuncture at Hoku electits a distinct mechanism to activate sympathetic nervous system in anesthetized rats. Neuroscience Letters. 1998;247:155-158. 66. Knardahl S, Elam M, Olausson B, and Wallin BG. Sympathetic nerve activity after acupuncture in humans. Pain. 1998;75(1):19-25.

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67. Li G, Ng MC, Wong KK, Luk KD, and Yang ES. Spinal effects of acupuncture stimulation assessed by proton density-weighted functional magnetic resonance imaging at 0.2T. Magnetic Resonance Imaging. 2005;23:995-999.

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THE NEUROVASCULAR ANATOMY OF ACUPUNCTURE, INCLUDING THE EIGHT EXTRAORDINARY VESSELS


Narda G. Robinson, DO, DVM, MS, FAAMA Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences Colorado State University, Fort Collins, CO, USA Nerves as the final common pathway in acupuncture Ancient point prescriptions indicate that the early acupuncturists recognized somatovisceral and somato-somatic reflexes. Although the metaphor-based Chinese medical description of these point actions speak of vague and arcane physiologic processes, the neuroanatomic basis for these actions promotes a deeper understanding of both the point actions and connections from the peripheral to the central nervous system. This approach for three commonly employed veterinary acupuncture points is demonstrated in Table 1. As early as the 1970s, articles began appearing in the veterinary medical literature indicating recognition of the links between acupuncture and the autonomic nervous system.15 In the ensuing decade, recognition of the interrelationship between acupuncture and the nervous system strengthened further.16 In 2004, Kothbauer clearly outlined the relationship between acupuncture points and nerves in his review of steps toward anatomical verification of point locations in cattle.8 Inserting a needle into skin, muscle, vessel, fascia, etc., one engages and activates various afferent nerve fibers. Somatic sensory stimulation activates impulse relays in the central nervous system (CNS), which then alter processing and output. Acupuncture works by modulating activity in the central, peripheral, and autonomic nervous systems. 17-19 As such, acupuncture point innervation and the subsequent central neuronal processing help to explain the traditional applications of acupuncture points. Neurologic connections adjoin acupuncture points on the body wall and sympathetic pathways in the thoracolumbar spine. These lend insight into how one might influence internal organ function by stimulating paraspinal points such as the Back Shu points.20 However, because of incomplete delineation of autonomic nervous pathways in most non-human species, accurate mapping of the Back Shu points onto the non-human spine will require further research.20 For this reason, several authors have advocated treating several spinal segments at one time, as further reassurance that the correct levels corresponding to internal organ innervation will receive input.21, 22

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Acupuncture point stimulation also affects supraspinal processing. A key pathway involves the nucleus tractus solitarius (NTS). The NTS, a major visceral sensory nucleus in the brainstem, receives input from both somatic and visceral sources, including the heart, lungs, digestive tract, baroreceptors, and chemoreceptors. General and special visceral afferent fibers arising from cranial nerves III, VII, and X also converge onto the NTS. The NTS integrates the myriad incoming signals and responds with efferent volleys sent to numerous end-organs, including the gut. The NTS alters gastric function by modulating output from the dorsal motor nucleus of the vagus (DMNV) which, together with the NTS, comprises the dorsal vagal complex (DVC).23 The plasticity of responses generated by intimate neuronal communications between the NTS and the DMNV allow the body to closely regulate digestive and other processes through their control over widespread autonomic activities. One group of researchers, looking to uncover the basis of channel-organ relationships, compared activity in the NTS in rats after stimulating three different acupuncture points on the face.23 The somatic afferent projection that enters the NTS from the face arises mainly from the trigeminal nerve. The three points studied were: ST 2 (in the infraorbital foramen), SI 18 (at the intersection of lines drawn from the lateral canthus and the inferior border of the zygomatic bone), and a sham point (0.5 cm lateral to ST 2). The results showed that neuronal response rates in the NTS were nearly double for ST 2, compared to the non-acupuncture point and SI 18. Thus, all three points, linked to the trigeminal nerve, affected the NTS, but ST 2 did so most strongly. Perhaps anatomical features of the nerves related to each of these points account for some of the differences in their responses to stimulation. That is, the trunk of the infraorbital nerve emerges from the infraorbital foramen below ST-2. SI-18 receives fibers from both the infraorbital and mandibular nerves (from the 2nd and 3rd divisions of the trigeminal nerve, respectively), but is not located over a nerve trunk. The non-acupuncture point, or sham point, receives fibers from the infraorbital nerve but is not over the trunk. That is, the nerves supplying SI-18 and the sham point were smaller in diameter than the nerve underlying ST-2. As noted above, bigger nerves near points deliver bigger effects when the points are needled. Another study compared ST-2 stimulation with GB-14 and ST-6 in rats.24 Because all of these points appear on the face, they all receive nerve supply from the trigeminal nerve. GB-14, above the pupil on the forehead, relates to the supraorbital nerve. ST-2 again corresponds to the infraorbital nerve as it emerges through the infraorbital foramen. ST-6, in the center of the belly of the masseter muscle, receives innervation from the auriculotemporal and masseteric nerves. Of these three, ST-2 once again demonstrated the strongest activation of the NTS, followed by ST-6 and then GB-14.

These two studies highlight the relevance and central importance of correctly transposing points from humans to non-humans, according to related neural characteristics. Not long ago, ST 2 appeared in a position that looked like its location in humans, which is right under the eye, but this is not consistent with the location of the infraorbital foramen in dogs and horses.25 This erroneous placement persisted for almost twenty years, only to be changed in the last few years.

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If nerves didnt matter, why not leave it in the same topographical region as in the human? Why do a comparative neuroanatomic placement for some points and not others?

Point Specificity in Acupuncture Point specificity is important. Point specificity implies nerve specificity. As noted by Tjen-ALooi, 26 stimulation of certain nerves engender specific cardiovascular changes, whereas stimulation of other nerves does not cause the same effects. Activation of deep, as opposed to superficial, somatic neural structures caused differential cardiovascular responses by providing more input to the rostral ventrolateral medulla (rVLM). Some nerves, but not others, participate in particular autonomic responses. Blood pressure modulation results from cardiovascular reflexes in the rostral ventrolateral medulla, the ventrolateral periaqueductal gray, and the arcuate nucleus of the hypothalamus. Electroacupuncture drives these reflexes when applied to some points and their respective nerves, but not others. The nerves and points that send input to the arcuate nucleus include the median nerve (PC-5 and PC-6); deep radial nerve (LI-4 LI-11); ulnar nerve (HT-6 and HT-7); trigeminal and facial nerves (ST-2 and GB 2); deep peroneal nerve (ST-36 and ST 37); and the tibial nerve (SP-6 SP-9). In contrast, points overlying the superficial radial nerve (LI-6 LI-7) and the superficial peroneal nerve (GB-37 GB- 39) send little to no input to the arcuate nucleus.27 Neuroanatomic Relationships Decades ago, researchers quantified the number of points related to either cranial or spinal nerves, and found almost a complete association (323/324 points studied) between the two.28 This is despite the fact that some refute the idea that acupuncture points relate to nerves or blood vessels, looking instead for an invisible linking phenomenon common to both plants and animals.29 In the mid-1980s, anatomist and acupuncturist Houchi Dung, PhD, wrote extensively on the nerve-acupuncture point relationships throughout the body.30-35 Dung identified ten features of peripheral sensory nerves associated with the formation of acupuncture points.36 These included: 1. Nerve size: Larger nerves tend to form more important acupuncture points than smaller ones. 2. Nerve depth: Acupuncture points tend to occur where deep nerves rise to more superficial levels. 3. Emergence of nerves through deep fascia: When nerves penetrate fascial layers, they can be affected by tension in the fascia; this is likely one of the reasons that acupuncture points are associated with these zones. 4. Nerve passage through bone foramina: Sites where foramina of the skull transmit cranial nerves qualify as acupuncture points. 5. Neuromuscular attachments, or motor points: Many acupuncture points arise at the site where a muscular nerve branch attaches to and enters a muscle.37 The nerve branch may be carrying motor, sensory, and sympathetic nerve fibers. 6. Concomitant arteries and veins accompanying nerve trunks: These vessels travel with the nerves, often in neurovascular bundles. Since acupuncture began as a

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7. bloodletting therapy, the tight relationship of vessels, nerves, and acupuncture points brings no surprise. 8. Fiber types in nerves: Tender acupuncture points more often contain three fiber types (sensory, postganglionic sympathetic, and larger efferent (motor)) than those with only the first two. 9. Nerve bifurcations: These sites include places where nerve trunks divide into smaller nerves, predominantly in the distal extremities. From a comparative anatomical acupuncture perspective, finding equivalent locations in distal, non-human limbs can pose insurmountable challenges because of missing digits, which may require omitting certain human points from the equine acupuncture atlas. 10. High-sensitivity connective structures: Some connective tissue components possess abundant afferent innervation. As such, they readily convey information regarding stretching and pressure. Examples of these structures include tendons, retinacula, thick sheets of fascia, joint capsules, and collateral ligaments. Acupuncture points often occur near these entities. 11. Cranial sutures: The Governing Vessel illustrates the close relationship between acupuncture points and cranial sutures. The Governing Vessel relates to venous structures in the head and body. On much of the human head, it overlies the sagittal venous sinus.38 By accurately defining nerves and nerve characteristics typical of human acupuncture points, researchers in veterinary acupuncture anatomy are well-armed to move forward with a systematic re-examination of the entire veterinary acupuncture transpositional point system, in order to improve needling accuracy and treatment outcomes. Visions for the Future As authors of a recent systematic review on veterinary acupuncture effectiveness stated, Some encouraging data do exist that warrant further investigation in independent rigorous trials.39 However, most agree that the quality of comparative acupuncture research needs improvement.40 Researchers have isolated three main issues that are inhibiting the advancement of acupuncture research; one of these is the gap in results reported between animal and human studies.41 The quality and reproducibility of the research will both improve once a systematic delineation of all veterinary acupuncture points takes place. Since acupuncture works through neuromodulation, and because structure and function are so intimately related, precise neuromodulation depends on anatomically accurate point location. Research on the anatomy and histology of veterinary acupuncture points is underway around the globe.42 Work at the Colorado State University College of Veterinary Medicine and Biomedical Sciences has begun to first completely identify all of the key structures inherent at each human point, and then determine whether a comparable location exists in other species.

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Table 1: Points and their applications


Acupuncture point GV-26 TCM Function43 Neuroanatomic Explanation Most acupuncture points on the face receive fibers from the trigeminal nerve. The trigeminal nerve connects with other nerves, carrying their fibers to their respective destinations. These nerves include the facial nerve, the vagus nerve, sympathetic nerve fibers from cranial thoracic cell bodies, and parasympathetic fibers. Somato-autonomic relationships of cranial nerves and the autonomic nervous system help link somatic stimulation of points on the face with strong physiologic alterations. Some of these reflexes include: trigemino-cardiac reflexes44, 45; nasotrigeminal reflexes46; and trigemino-cervical-spinal reflexes47,48.

Revives consciousness, calms the spirit, clears the brain.

Nasotrigeminal afferents acting on medullary respiratory neurons might help reinstate inspiration after a period of apnea. 49 Input from trigeminal afferents may provide somatic input to the pneumotaxic center in the pons, which participates in respiratory reflexes.50 ST-36 Regulates the stomach and spleen, reduces digestive stagnation, redirects rebellious qi downward, and drains pathogenic influences from the stomach. Regulates and tonifies the heart, clears heart fire, calms the spirit, clears the brain. Electroacupuncture at ST-36 accelerates motility and transit speed of the colon by sending afferent volleys to the NTS and activating sacral parasympathetic output through the pelvic nerve.51 In contrast, gastric stimulation arising as a consequence of electroacupuncture at ST-36 emanates from the dorsal motor nucleus of the vagus and projects to the stomach via gastric branches.51 Electrical stimulation of the median nerve, which lies beneath the surface of PC-5 and PC-6, causes a long-lasting modulation of blood pressure elevations caused by visceral afferent activation. In part, this occurs through inhibition of cardiovascular neurons converging with somatic afferent neurons in the rostral ventrolateral medulla (rVLM). 52 This pathway involves opioids and the arcuate nucleus in the hypothalamus, which produces opioids. Excitatory projections from the arcuate nucleus onto the ventrolateral periaqueductal gray (vlPAG) also comprise part of the essential mechanism through which electroacupuncture at PC 5 and PC 6 inhibit reflexive increases in blood pressure following either gallbladder visceral afferent excitation or its surrogate, activation of the splanchnic nerve. Stimulation of the vlPAG results in lowering of blood pressure, while stimulation of the dorsal PAG elevates it. Stimulation of the median nerve at PC 6 stabilized blood pressure in a canine animal model of hemorrhagic hypotension.53

PC- 6

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References 1. Schippers R. Some aspects of horse acupuncture in China in the Middle Ages. Argos: bulletin van het Veterinair Historische Genootschap. 1994;10:326.

2. Hua X. On animal acupoints. Journal of Traditional Chinese Medicine. 1987;7(4):301-304.

3. Cockrill WR. Veterinary medicine in China: a blend of art and science. Modern Veterinary Practice. 1975;56(5):352-330.

4. Ramey DW. Do acupuncture points and meridians actually exist? Compendium on Continuing Education for the Practicing Veterinarian. 2000; 22(12):1132-1136.

5. Krueger CP. Acupuncture point topography in the horse. Am J Acupuncture. 1976;4(3):276-280.

6. Still J. Relationship between electrically active skin points and acupuncture meridian points in the dog. Am J Acupuncture. 1988;16(1):55-71.

7. Ly J-P. Medical Acupuncture. New South Wales Veterinary Proceedings. 1975;11:38-41.

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8. Kothbauer O. Anatomical verification of acupuncture in cattle: a review. Vet Med Austria. 2004;91:4-13.

9. Culp LB, Skarda ST, and Muir WW. Comparisons of the effects of acupuncture, electroacupuncture, and transcutaneous cranial electrical stimulation on the minimum alveolar concentration of isoflurane in dogs. Am J Vet Res. 2005;66:1364-1370.

10.Kothbauer O. A general introduction to cattle acupuncture. Cattle practice. 2002;10(2):81-89.

11.Helms JM. Acupuncture Energetics: A Clinical Approach for Physicians. Berkeley: Medical Acupuncture Publishers, 1995. Pp. 211-212.

12.Noguchi E, Ohsawa H, Kobayashi S, Shimura M, et al. The effects of electro-acupuncture stimulation on the muscle blood flow of the hindlimb in anesthetized rats. Journal of the Autonomic Nervous System. 1999;75:78-86.

13.Zhou W, Fu L-W, Tjen-A-Looi SC, Li P, et al. Afferent mechanisms underlying stimulation modality-related modulation of acupuncture-related cardiovascular responses. J Appl Physiol. 2005;98:872-880.

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14.Kong J, Ma L, Gollub RL, Wei J, et al. A pilot study of functional magnetic resonance imaging of the brain during manual and electroacupuncture stimulation of acupuncture point (LI-4 Hegu) in normal subjects reveals differential brain activation between methods. Journal of Alternative and Complementary Medicine. 2002;8(4):411-419.

15.Clifford DH and Lee MO. Trends in acupuncture research 2. Acupuncture and the autonomic nervous system. Veterinary Medicine Small Animal Clinician. January, 1979: 35-40.

16.Still J. Role of the nervous system in the appearance of the ear acupuncture points in the dog. Acta Vet Brno. 1986;55:55-64.

17.Wu M-T, Hsieh J-C, Xiong J, Yang C-F et al. Central nervous pathway for acupuncture stimulation: Localization of processing with functional MR imaging of the brain preliminary experience. Radiology. 1999;212:133141.

18.Chiu J-H, Chung M-S, Cheng H-C, Yeh T-C et al. Different central manifestations in response to electroacupuncture at analgesic and nonanalgesic acupoints in rats: a manganese-enhanced functional magnetic imaging study. Canadian Journal of Veterinary Research. 2003;67:94-101.

19.Kimura A and Sato A. Somatic regulation of autonomic functions in anesthetized animals Neural mechanisms of physical therapy including acupuncture. Jpn J Vet Res. 1997;45(3):137-145.

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20.Lindley S and Cummings TM. Essentials of Western Veterinary Acupuncture. Oxford: Blackwell Publishing, Ltd., 2006. Pp. 111-127.

21.Panzer R. A comparison of the traditional Chinese vs. transpositional zangfu organ association acupoint locations in the horse. Am J Chin Med. 1993;21(2):119-131.

22.Travagli RA, Hermann GE, Browning KN, and Rogers RC. Brainstem circuits regulating gastric function. Annu. Rev. Physiol. 2006;68:279305.

23.He J, Yan J, Chang X, Liu J, et al. Neurons in the NTS of rat response to gastric distention stimulation and acupuncture at body surface points. Am J Chin Med. 2006;34(3):427-433.

24.Liu J-H, Li J, Yan J, Chang X-R, et al. Expression of c-fos in the nucleus of the solitary tract following electroacupuncture at facial acupoints and gastric distension in rats. Neurosciences Letters. 2004;366:215-219.

25.The Ottaviano Dog Chart. In Klide AM and Kung SH: Veterinary Acupuncture. University of Pennsylvania Press, 1977. P. 205.

26.Tjen-A-Looi SC, Li P, and Longhurst JC. Medullary substrate and differential cardiovascular responses during stimulation of specific acupoints. Am J Physiol Regul Integr Comp Physiol. 2004;287:R852R862.

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27.Li P, Tjen-A-Looi SC, and Longhurst JC. Excitatory projections from arcuate nucleus to ventrolateral periaqueductal gray in electroacupuncture inhibition of cardiovascular reflexes. Am J Physiol Heart Circ Physiol. 2006;290:H2535-H2542. 28.Chous PH, Qian PD, Huang DK, Gu HY, et al. A study of the relationships between the points of the channels and peripheral nerves. National Symposia of Acupuncture-Moxibustion & Acupuncture Anesthesia. Beijing, 1979, p. 302. Cited in: Cao X. Scientific bases of acupuncture analgesia. Acupuncture & Electro-therapeutics Res., Int J. 2002;27:1-14. 29.Yung K-T. A birdcage model for the Chinese meridian system: Part V. Applications to animals and plants. Am J Chin Med. 2005;33(6):903-912.

30.Dung HC. Acupuncture points of the brachial plexus. Am J Chin Med. 1985;13(1-4):49-64.

31.Dung HC. Acupuncture points of the typical spinal nerves. Am J Chin Med. 1985;13(1-4):39-47. 32.Dung HC. Acupuncture points of the sacral plexus. Am J Chin Med. 1985;13(1-4):145-156. 33.Dung HC. Acupuncture points of the lumbar plexus. Am J Chin Med. 1985;13(1-4):133-143.

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34.Dung HC. Acupuncture points of the cranial nerves. Am J Chin Med. 1984;12(1-4):80-92.

35.Dung HC. Acupuncture points of the cervical plexus. Am J Chin Med. 1984;12(1-4):94-105.

36.Dung HC. Anatomical Acupuncture. San Antonio: Antarctic Press, 1997. Cited in: Dung HC, Clogston CP, and Dunn JW. Acupuncture An Anatomical Approach. Boca Raton: CRC Press, 2004, pp. 8-9.

37.Dung HC, Clogston CP, and Dunn JW. Acupuncture An Anatomical Approach. Boca Raton: CRC Press, 2004, pp. 8-9.

38.Tubbs RS, Salter G, Elton S, Grabb PA, et al. Sagittal suture as an external landmark for the superior sagittal sinus. J Neurosurg. 2001;94:985-987.

39.Habacher G, Pittler MH, and Ernst E. Effectiveness of acupuncture in veterinary medicine: systematic review. J Vet Intern Med. 2006;20:480488.

40.Ramey DW, Lee ML, and Messer IV NT. A review of the Western language equine acupuncture literature. Jorunal of Equine Veterinary Science. 2001;21(2):56-60.

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41.Ahn AC and Kaptchuk TJ. Advancing acupuncture research. Altern Ther Health Med. 20043;11(3):40-45.

42.Zilberschtein J, Cano G, Valverde S, Laredo F et al. Acupoint Renzhong (Jenchung GV-26) in the horse. Anatomical and histological study. An Vet (Murcia).I 2004;20:87-94.

43.Lade A. Acupuncture Points Images and Functions. Seattle: Eastland Press, Inc., 1989.

44.Lang S, Lanigan DT, and Van der Wal M. Trigeminocardiac reflexes: maxillary and mandibular variants of the oculocardiac reflex. Can J Anaesth. 1991;38(6):757-760.

45.Schaller B. Trigeminocardiac reflex. A clinical phenomenon or a new physiological entity? J Neurol. 2004; 251:658-665.

46.Dutschmann M and Paton JF. Influence of nasotrigeminal afferents on medullary respiratory neurons and upper airway patency in the rat. Pflugers Arch. 2002;444(1-2):227-235. 47.Serrao M, Perrotta A, Bartolo M, Fiermonte G, et al. Enhanced trigeminocervical-spinal reflex recovery cycle in pain-free migraineurs. Headache. 2005;45(8):1061-1068.

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48.Kato S, Papuashvili N, and Okada YC. Identification and functional characterization of the trigeminal ventral cervical reflex pathway in the swine. Clinical Neurophysiology. 2003;114:263-271.

49.Dutschmann M and Paton JFR. Influence of nasotrigeminal afferents on medullary respiratory neurones and upper airway patency in the rat. Eur J Physiol. 2002;444:227-235.

50.Song G, Yu Y, and Poon C-S. Cytoarchitecture of pneumotaxic integration of respiratory and nonrespiratory information in the rat. Journal of Neuroscience. 2006;26(1):300-310.

51.Iwa M, Matsushima M, Nakade Y, Pappas TN, et al. Electroacupuncture at ST-36 accelerates colonic motility and transit in freely moving conscious rats. Am J Physiol Gastrointest Liver PHysiol. 2006;290:G285-G292.

52.Li P, Tjen-A-Looi SC, and Longhurst JC. Excitatory projections from arcuate nucleus to ventrolateral periaqueductal gray in electroacupuncture inhibition of cardiovascular reflexes. Am J Physiol Heart Circ Physiol. 2006;290:H2535-H2542.

53.Syuu Y, Matsubara H, Hosogi S, and Suga H. Pressor effect of electroacupuncture on hemorrhagic hypotension. Am J Physiol Integr Comp Physiol. 203;285:R1446-R1452.

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BIOMEDICAL ACUPUNCTURE FOR NECK AND BACK PAIN, BASED ON A NEUROANATOMIC PERSPECTIVE
Narda G. Robinson, DO, DVM, MS, FAAMA Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences Colorado State University, Fort Collins, CO, USA Between 65% and 80% of humans experience back or neck pain at some point in their lives; the elderly complain of back pain more often than any other musculoskeletal ailment.1 Whether or not small animals experience spinal pain with similar frequency is unknown. Perhaps the majority of animals afflicted with back or neck pain recovers spontaneously within six weeks, as do humans.2 However, for those who do not recover, the pain frequently remains untreated, under treated, or treated inappropriately.3 4 5 Clients may misinterpret alterations in their animals behavior as slowing down, getting old and grouchy, or being just plain stubborn. Determining the proper course of action for spinal pain requires in-depth knowledge of veterinary anatomy and pathology.6 Some clients are tempted to pursue treatment from nonveterinarian chiropractors or physical therapists in lieu of proper diagnostics. Doing so may cause irreparable harm to the animal due to delayed diagnosis and improper treatment, especially when back pain arises from neoplastic or infectious causes.7 Nevertheless, clients may prefer a nonpharmacologic approach for their animals condition, given the potential adverse effects of conventional approaches. Nonsteroidal anti-inflammatory drugs (NSAIDs) increase the risk of gastrointestinal bleeding and renal damage, especially in older animals. Narcotic analgesics cause constipation; straining to eliminate worsens the pain. Sustained inactivity from cage rest leads to deconditioning and may worsen spinal instability, if it exists. A commonly overlooked source of musculoskeletal pain is the musculature itself and its enveloping fascia. In fact, myofascial pain syndrome can sometimes mimic radicular pain or internal organ disease.8 The key to identifying this type of pain involves palpating for taut bands and trigger points encased within the myofascial fabric. Once identified, myofascial pain can readily respond to physical medicine approaches such as acupuncture, even after medication has failed.9 10 Evidence in support of acupuncture for back and neck pain Controlled trials and systematic reviews in human research provide increasingly stronger evidence that acupuncture effectively treats chronic spinal pain.11 12 13 14 15 16 17 18 19 Several uncontrolled studies have reported that acupuncture improves spinal pain of various causes in dogs and horses.20 21 22 23 24 25 26 According to Adrian R. White, MD, the author of several systematic reviews on acupuncture, Acupuncture treatment should be considered for anyone who has nonspecific mechanical back pain that has persisted for 6 weeks or more despite

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standard treatment.27 28 In humans, ten sessions of needle body acupuncture produced stable, long-term effects lasting at least six months according to a recently published prospective cohort study.29 A 2005 paper systematically reviewing acupuncture for chronic low back pain echoed the findings of earlier work, concluding that adding acupuncture plus conventional treatment produced better analgesia and functional improvement than conventional treatments alone.30 31 However, not all acupuncture treatments are equal. Deeper acupuncture stimulation in humans with lumbar myofascial pain provides greater pain reduction than does superficial needling, although it causes more post-treatment soreness.32 33 34 Neuroanatomically focused acupuncture addresses spine-related pain by treating the nerves mediating pain from spinal structures.35 36 Stimulation of paravertebral somatic afferent fibers at acupuncture points along the spine suppresses activity in spinal nociceptive neurons.37 How acupuncture helps back and neck pain In general, acupuncture alleviates pain and restores physiologic homeostasis. The process of needling activates self-healing on several levels. To begin with, the mechanical stimulation of a needle entering body tissue becomes transduced into biological responses. That is, the needle and surrounding collagen fibers lead to a biomechanical coupling, caused in part by surface tension in the tissue and by electrical affinity between the metallic needle and charges within the connective tissue itself. The nature of the engagement of the needle within the tissue then generates frictional forces, which increase as the practitioner rotates the needle in one direction and then the other. The friction pulls temporarily deform the extracellular matrix; this tugging leads to a range of biochemical and conformational cellular changes that alter the extracellular environment in the vicinity of the needle, leading to tissue healing. Specifically, these changes include 1) Intracellular reorganization of the cytoskeleton associated with cells comprising the connective tissue; 2) Cell contraction and migration; 3) Growth factor release through autocrine mechanisms; 4) Activation of intracellular signaling; 5) Activation of nuclear binding proteins that promote specific gene transcription; and 6) Additional changes involving synthesis and release of an array of chemicals into the local tissues. These chemicals include growth factors, vasoactive substances, degradative enzymes, structural matrix elements, and cytokines. The assemblage of these biochemical elements lead to local healing but also can influence connecting connective tissue to expand the response downstream and also encourage longer lasting changes. Needle manipulation also produces signal transduction that can help desensitize sensory receptors and move the patients pain threshold back to a normal level. From a neuromodulatory perspective, needle introduction creates micro-trauma that invokes a series of responses. Specifically, the sequence proceeds as follows: trauma inflammation repair anti-inflammation, tissue regeneration, pain modulation, and continued healing. When performing acupuncture, the medical acupuncture practitioner first selects the appropriate location based on neuroanatomic principles, and then inserts the needle to the required depth, depending on which tissue the practitioner wants to effect (i.e., muscle, tendon, periosteum, or more superficial elements such as skin or fascia). Needle stimulation follows. Sometimes, one looks to attain de qi, which is a reflex generated by stimulating afferent fibers (usually Type II, III, or IV muscular afferents) and eliciting a muscle contraction. This event is accompanied by sensations of heaviness, soreness, or local cramping a consequence of stimulating the afferent fibers mentioned above. After the acupuncturist has satisfactorily activated the necessary

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afferents, needle retention typically follows, with or without additional stimulation. One then withdraws the needle, after a sufficient amount of time has elapsed to produce the desired signal inputs into the patients nervous system. This time period may only last a few minutes or up to forty-five or more. The average treatment time in a human is twenty to thirty minutes; a small animal treatment time may range only from ten to fifteen minutes. Neuromodulation The activation of afferent fibers inspires a sequence of reflexes within the nervous system, starting with local changes and issuing forward to the spinal cord and brain. Peripheral mechanisms involve changes in the local milieu surrounding the needle, most notably resulting from fluxing cytokines. Central mechanisms of acupuncture involve the central nervous system, including autonomic centers overseeing visceral function. Changes in resting autonomic tone, especially a winding down of sympathetic hyperactivity to a more normal state allow for reductions in physical and emotional stress. Certain acupuncture points, also known as homeostatic points, are employed in a nonsegmental manner, whereas points for pain or other localized problems address the pain specifically in a spinal segmental fashion. Points selected for pain relief help to change firing patterns within the CNS. For example, stimulation of tender acupuncture points associated with painful regions affects the same levels of the spinal cord responsible for the generation and perpetuation of nociceptive information to the brain. Acupuncture provided in this spinal segmental manner blocks the transmission of pain in part by acting on the spinal cord via gate control mechanisms. That is, stimulation of an acupuncture point sends impulses to the spinal cord and activates neurons residing in the dorsal horn of the cord. Neurons in the dorsal horn release enkephalin and dynorphin to block nociceptive information from ascending to the brain where it would be recognized as pain. Some impulses from the local point also reach the midbrain, thereby activating the descending mechanisms that also inhibit nociceptive transmission from ascending the spinal cord. Other signals reach the pituitary which releases endorphin into the general circulation. In contrast, the aforementioned homeostatic points provide neuromodulatory effects on convergent autonomic and other centers and occur at body sites distal to the segmentally related points. When acupuncture information enters the central nervous system, neurotransmitter changes modulate nociceptive information and the recognition of pain. Implicated neurotransmitters include: endogenous opioids (enkephalin, beta-endorphin, dynorphin), cholecystokinin, serotonin, adrenocorticotropic hormone (ACTH), vasoactive intestinal peptide, neurotensin, calcitonin gene-related peptide (cGRP), gamma aminobutyric acid (GABA) and more. fMRI Functional brain imaging allows detailed study of the supraspinal effects of acupuncture. Techniques such as functional magnetic resonance imaging (fMRI) shows areas involved in processing during pain and the changes that occur in pain pathways with the addition of acupuncture. Two key areas include the anterior cingulate cortex and the thalamus. The anterior cingulate cortex (ACC) can be further broken down into three important brain regions that participate in pain signal processing exist in the cingulate cortex. These are, namely: the dorsal

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anterior cingulate cortex (dACC), which focuses attention on the pain signal; the caudal anterior cingulate cortex (cACC) relates to the emotional component of pain; finally, the rostral anterior cingulate cortex (rACC) modulates pain. In addition, the thalamus serves as a relay station for incoming pain signals and also focuses attention. Effects on Muscle Tissue Muscular changes occur as a result of acupuncture, lessening pain and tension. Muscle pain may arise from 1) one instance of trauma (mechanical, chemical, or physical), 2) chronic trauma, as in repetitive strain injury, 3) referral from viscera, and 4) referral from related joints or joint structures. Several neuropeptides lead to muscle pain, including substance P, calcitonin generelated peptide (cGRP), and somatostatin from afferent fibers. These neuropeptides influence myriad aspects of tissue function, such as local metabolism, microcirculation, and the excitability of nerve endings in the vicinity. They can also cause neurogenic inflammation in response to noxious stimuli, whether physical (such as thermal exposure), chemical, or mechanical. Substance P and cGRP cause vasodilation and enhanced permeability of the microvasculature. Substance P may also cause mast cell degranulation and the liberation of histamine. As the neuropeptides diffuse into the surrounding tissue, the area of inflammation expands, accompanied by a shift of proteins and fluids from the intravascular to the extravascular space. Concurrently, levels of vasoneuroactive substances such as bradykinin (from the protein, kalidin, in plasma) and serotonin (from platelets) rise. The injured tissue releases arachidonic acid from the ruptured membranes that produces leukotrienes and prostaglandins. Bradykinin, serotonin, leukotrienes, and prostaglandins sensitize nerve endings. Sensitized nociceptors are more likely to fire due to the reduction in their firing threshold. Both nociceptive and mechanical information becomes interpreted by the brain as painful (allodynia). Muscle can become tender to palpation, and muscle swelling corresponds to inflammation. Tension generated from the entire reaction can cause limitations in range of motion; facilitated spinal cord segments elevate output from motor neurons in both synergistic and antagonistic muscles. Muscles that cross joints endure sustained contraction and increase stress on the joint and the joint capsule or other connective tissue structures associated with the joint, such as ligaments or discs. Trigger points Trigger points are unique structures associated with pain and local tension that most often occur in myofascial tissue, but also can arise in ligaments, tendons, superficial and deep fascia, and periosteum. When one applies pressure to these hyperirritable nodules or bands of tension, the patient feels an exaggerated amount of pain; this discomfort may radiate. As such, the pressure triggered referred pain. Trigger points tend to be chronic and grow more numerous the longer they remain untreated. Muscle shortening in one muscle or muscle group leads to biomechanical dysfunction and lessened mobility and range of motion that affects nearby muscles and may lead to stress and pain in those as well. Trigger points also affect the nervous system and invoke windup in the spinal cord segments supplying them. Sensitized afferent nerves evoke activation of motor output by promoting the release of excess acetylcholine (ACh) into the neuromuscular junction. The increase in ACh leads to longer depolarization of the post-synaptic membrane. Longer depolarization of the sarcoplasmic

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reticulum causes the calcium concentration in the cytoplasm to be sustained at a higher level. The actin and myosin filaments respond to the high levels of calcium in the cytoplasm by staying coupled longer, which causes the muscle fiber to contract for an increased duration. Ongoing muscle contraction leads to compression of microvasculature, reducing available nutrients and oxygen supply. The depletion in metabolic energy availability compromises the capacity of the molecular pumps to return calcium into the sarcoplasmic reticulum. Because calcium remains in the cytosol, the muscle stays contracted. This engenders a vicious cycle of ischemia/hypoxia/low metabolic energy supply --> muscle tension --> ischemia, etc. Acupuncture interrupts the vicious cycle by stretching the muscle fibers, causing muscle relaxation by reducing alpha motoneuron output at the level of the spinal cord, and vasodilating through previously described mechanisms. Hypothalamic-pituitary-adrenal (HPA) Inputs HPA stimulation arises from four main sources of signal inputs: 1) Afferents from somatic and/or vagal nerves (i.e., neurogenic stimulation such as that which arises from acupuncture or acupuncture-like inputs); 2) Cognitive-emotional stimuli, arriving at the HPA-axis via the prefrontal area and limbic system (i.e., psychogenic stimulation); 3) Blood-borne chemosensory inputs arriving via the circumventricular area (e.g., drug or other biochemically based inputs),and 4) Integration of these signals within the hypothalamus itself. Hypothalamic inputs converge at the paraventricular nucleus, or PVN. Efferents from the PVN and perhaps also from the arcuate nucleus, that acupuncture initiated, can leave through five pathways. HPA Outputs At least five efferent pathways from the PVN are responsible for the myriad health benefits of acupuncture: Humoral pathway Corticotropin releasing hormone from the PVN of the hypothalamus activates pro-opiomelanocortin (POMC) in the anterior pituitary. POMC is the precursor of ACTH and -endorphin, both of which get released into the bloodstream. Neural and humoral pathway: This hypothalamic-autonomic-sympathetic nervous system pathway causes norepinephrine (NE) release from the adrenal medulla. NE enters the bloodstream and activates -adrenergic receptors on target organs, including macrophages. adrenergic receptor activation leads to the production of IL-10, an anti-inflammatory cytokine. Although NE is typically associated with sympathetic nerve activation, its benefits involve helpful actions such as the aforementioned effect on IL-10. In this way, NE works in concert with ACh to suppress inflammation via their effects on cytokines. Sympathetic autonomic neural pathway: These connections involves noradrenergic sympathetic outflow connected to the intermediolateral (IML) gray column of the spinal cord. Parasympathetic autonomic neural pathway: HPA links via (cholinergic) vagal nerve outflow act on macrophages and affect the nicotinic cholinergic receptor nAChR-?7, which suppresses pro-inflammatory cytokines TNF- ? and IL-1. Central descending pain inhibition pathway: This travels from the PVN arcuate nucleus of the hypothalamus PAG ventral raphe/raphe magnus nucleus dorsal horn of the spinal cord. Acupuncture analgesia by means of a spinal segmental approach The first step in treating pain with acupuncture is to select paravertebral points that related to the origin of spinal nerve roots supplying nerve function to the painful area. Next, one identifies

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points related to segmental innervation of skin (dermatome), muscles (myotome), bones (sclerotome), viscera (viscerotome), when possible. Finally, the addition of homeostatic points related to autonomic function helps deactivate pain processing centers in the brain as observed on fMRI exams. Table 1 lists various structures pertaining to the spine which can generate back or neck pain in small animals. Inflammation, compression, developmental anomalies, or degeneration of these tissues can lead to spinal pain. The table includes mention of particular acupuncture point groupings that may most directly influence pain transmission in the affected nerves.
Table 1: Potential Sources of Neck and Back Pain in Dogs and Cats. Adapted from Webb38 and Wong39 Structural Source of Back Pain Related Neural Elements Acupuncture Points Influencing Nerves Related to the Pain Source Intervertebral disc The periphery of intervertebral discs Huatojiaji points, Facet joint in dogs contains nociceptors and points40 mechanoreceptors; the sinuvertebral nerve supplies sensory innervation. Facet joint capsule The joint capsule is richly innervated Huatojiaji points, Facet joint by proprioceptors and nociceptors. points41 Dorsal root ganglion (DRG) Mechanically sensitive nociceptors Points along the inner Bladder (i.e., mechano-nociceptors) in the channel nervi nervorum of the epineuria surrounding the DRG may contribute to pain if compression or tension affects the DRG. Spinal ligaments: These ligaments contain free nerve Points along the Governor Vessel 1) Dorsal longitudinal ligament endings that have been implicated as channel 2) Supraspinal ligaments potential contributors to back pain. 3) Interspinous ligaments Vertebral periosteum The periosteum contains an Huatojiaji points or points along the extensive plexus of nerve fibers that Governor Vessel channel exhibits the lowest pain threshold of any of the deep tissues. Meninges The dura is sensitive to mechanical Points along the Bladder channel and noxious stimulation; meningeal irritation may contribute to back and neck pain in dogs and cats. Local, direct needling into the taut Muscles attaching or referring to the Myofascial pain is characterized by band or trigger point back or neck palpable, taut bands occurring lengthwise along muscles that contain exquisitely tender regions. Myofascial pain is often mistaken for radicular pain and may be accompanied by visceral pain syndromes including bowel irritability and cystitis. 42 43 Points along the Governor Vessel, Thoracolumbar fascia Cutaneous branches from dorsal Bladder, or Gallbladder channels, rami of lumbar spinal nerves depending on the area affected by innervate the thoracolumbar fascia. Nerves supplying the thoracolumbar pain, as determined by palpation fascia in humans with chronic mechanical back pain may undergo degeneration secondary to ischemia or inflammation.44

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References: 1. Meng CF, Wang D, Ngeow J, Lao L, Peterson M, and Paget S. Acupuncture for chronic low back pain in older patients: a randomized, controlled trial. Rheumatology. 2003;42:1508-1517. 2. Wang RR and Tronnier V. Effect of acupuncture on pain management in patients before and after lumbar disc protrusion surgery a randomized control study. American Journal of Chinese Medicine. 2000;28(1):25-33. 3. Webb AA. Potential sources of neck and back pain in clinical conditions of dogs and cats: a review. The Veterinary Journal. 2003;165(3):193-213. 4. Facco E and Ceccherelli F. Myofascial pain mimicking radicular syndromes. Acta Neurochir. 2005;92:147-150. 5. Webb AA. Potential sources of neck and back pain in clinical conditions of dogs and cats: a review. The Veterinary Journal. 2003;165(3):193-213. 6. Webb AA. Potential sources of neck and back pain in clinical conditions of dogs and cats: a review. The Veterinary Journal. 2003;165(3):193-213. 7. Ross MD and Bayer E. Cancer as a cause of low back pain in a patient seen in a direct access physical therapy setting. Journal of Orthopaedic and Sports Physical Therapy. 2005;35:651658. 8. Facco E and Ceccherelli F. Myofascial pain mimicking radicular syndromes. Acta Neurochir. 2005;92:147-150. 9. Gerwin RD. A review of myofascial pain and fibromyalgia factors that promote their persistence. Acupuncture in Medicine. 2005;23(3):121-134. 10. Lundeberg T, Hurtig T, Lundeberg S, and Thomas M. Long-term results of acupuncture in chronic head and neck pain. The Pain Clinic. 1988;2(1):15-31. 11. Ernst E and White AR. Acupuncture for back pain. Arch Int Med. 1998;158:2235-2241. 12. Irnich D, Behrens J, Gleditsch JM, Str W, Schreiber MA, Schps P, Vickers AJ, and Beyer A. Immediate effects of dry needling and acupuncture at distant points in chronic neck pain: results of a randomized, double-blind, sham-controlled crossover trial. Pain. 2002;99:83-89. 13. Ghoname EA, Craig WF, White PF, Ahmed HE, Hamza MA, Henderson BN, Gajraj NM, Huber PJ, and Gatchel RJ. Percutaneous electrical nerve stimulation for low back pain. A randomized crossover study. JAMA. 1999;281(9):818-823.

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14. Carlsson CPO and Sjlund BH. Acupuncture for chronic low back pain: a randomized placebo-controlled study with long-term follow-up. The Clinical Journal of Pain. 2001;17:296305. 15. White P, Lewith G, Prescott P, and Conway J. Acupuncture versus placebo for the treatment of chronic mechanical neck pain. Ann Intern Med. 2004;141:911-919. 16. Irnich D, Behrens N, Molzen H, Knig A, Gleditsch J, Krauss M, Natalis M, Senn E, Beyer A, and Schps P. Randomised trial of acupuncture compared with conventional massage and sham laser acupuncture for treatment of chronic neck pain. BMJ. 2001;322:1574-1578. 17. Blossfeldt P. Acupuncture for chronic neck pain a cohort study in an NHS pain clinic. Acupuncture in Medicine. 2004;22(3):146-151. 18. Molsberger AF, Mau J, Pawalec DB, and Winkler J. Does acupuncture improve the orthopedic management of chronic low back pain a randomized, blinded, controlled trial with 3 months follow up. Pain. 2002;99:579-587. 19. Leibing E, Leonhardt U, Kster G, Goerlitz A, Rosenfeldt J-A, Hilgers R, and Ramadori G. Acupuncture treatment of chronic low-back pain a randomized, blinded, placebo-controlled trial with 9-month follow-up. Pain. 202;96:189-196. 20. Han HJ, Jeong SW, Kim JY, Jeong MB, and Kim JS. The effect of conservative therapy on thoracolumbar intervertebral disc disease on 15 dogs. Journal of Veterinary Clinics. 2003;20(10:52-58. 21. Graw U. Acupuncture as the standard therapy for discopathy with ataxia of the hind legs. Ganzheitliche Tiermedizin. 2003;17(1):9-13. 22. Kim MS, Kim SY, Seo KM, and Nam TC. Acupuncture treatment for acute torticollis (wry neck) in a dog. Journal of Veterinary Clinics. 2004;21(4):395-397. 23. Jeong SM and Park SW. Application of traditional acupuncture on canine intervertebral disc disease. Journal of Veterinary Clinics. 2004;21(1):49-51. 24. Janssens LAA. Trigger points in 48 dogs with myofascial pain syndromes. Veterinary Surgery. 1991;20(4):274-278. 25. Kim M-S, Xie H, Seo K-M, and Nam T-C. The effect of electro-acupuncture treatment for chronic back pain in horses. Journal of Veterinary Clinics. 2005;22(2):144-147. 26. Klide AM and Martin BB. Methods of stimulating acupuncture points for treatment of chronic back pain in horses. JAVMA. 1989;195(10):1375-1379. 27. White AR. Interview. Modern Medicine. 1999;67:46.

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28. Manheimer E, White A, Berman B, Forys K, and Ernst E. Meta-analysis: acupuncture for low back pain. Ann Intern Med. 2005;142:651-663. 29. Kukuk P, Lungenhausen M, Molsberger A, and Endres HG. Long-term improvement in pain coping for cLBP and gonarthrosis patients following body needle acupuncture: a prospective cohort study. European Journal of Medical Research. 2005;10:263-272. 30. Furlan AD, Van Tulder M, Cherkin D, Tsukayama H, Lao L, Koes B, and Berman B. Acupuncture and dry-needling for low back pain: an updated systematic review within the framework of the Cochrane Collaboration. Spine. 2005;30:944-963. 31. Longworth W and McCarthy PW. A review of research on acupuncture for the treatment of lumbar disk protrusions and associated neurological symptomatology. Journal of Alternative and Complementary Medicine. 1997;3(1):55-76. 32. Ceccherelli F, Rigoni MT, Gagliardi G, and Ruzzante L. Comparison of superficial and deep acupuncture in the treatment of lumbar myofascial pain: a double-blind randomized controlled study. Clin J Pain. 2002;18(3):149-153. 33. Itoh K, Katsumi Y, and Kitakoji H. Trigger point acupuncture treatment of chronic low back pain in elderly patients a blinded RCT. Acupuncture in Medicine. 2004;22(4):170-177. 34. Baldry P. Superficial versus deep dry needling. Acupuncture in Medicine. 2002;20(2-3):7881. 35. Wong JY. A Manual of Neuro-Anatomical Acupuncture. Volume I: Musculo-Skeletal Disorders. Toronto: The Toronto Pain and Stress Clinic Inc., 1999. 36. Gunn CC, Milbrandt WE,Little AS, Mason KE. Dry needling of muscle motor points for chronic low-back pain: a randomized trial with long-term follow-up. Spine. 1980; 5(3):279291. 37. Gillette RG, Kramis RC, and Roberts WJ. Suppression of activity in spinal nocireceptive low back neurons by paravertebral somatic stimuli in the cat. Neuroscience Letters. 1998;241:45-48. 38. Webb AA. Potential sources of neck and back pain in clinical conditions of dogs and cats: a review. The Veterinary Journal. 2003;165(3):193-213. 39. Wong JY. A Manual of Neuro-Anatomical Acupuncture. Volume I: Musculo-Skeletal Disorders. Toronto: The Toronto Pain and Stress Clinic Inc., 1999. 40. Wong JY. A Manual of Neuro-Anatomical Acupuncture. Volume I: Musculo-Skeletal Disorders. Toronto: The Toronto Pain and Stress Clinic Inc., 1999.

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41. Wong JY. A Manual of Neuro-Anatomical Acupuncture. Volume I: Musculo-Skeletal Disorders. Toronto: The Toronto Pain and Stress Clinic Inc., 1999. 42. Facco E and Ceccherelli F. Myofascial pain mimicking radicular syndromes. Acta Neurochir Suppl. 2005;92;147-150. 43. Gerwin RD. A review of myofascial pain and fibromyalgia factors that promote their persistence. Acupuncture in Medicine. 2005;23(3):121-134. 44. Bednar DA, Orr FW, and Simon GT. Observations on the pathomorphology of the thoracolumbar fascia in chronic mechanical back pain. Spine. 1995;20(10):1161-1164.

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A SYSTEMATIC LOOK AT TONGUE DIAGNOSIS IN THE DOG WHAT DOES IT REALLY TELL US?
Narda G. Robinson, DO, DVM, MS, FAAMA Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences Colorado State University, Fort Collins, CO, USA Tongue diagnosis is a mainstay of Chinese medical assessment, and researchers have linked tongue appearances to certain disease states.1 As one researcher put it, The tongue is a mirror reflecting the activity of the interior of the human body. The morbid conditions of viscera and bowels emerge as the alternations of the tongue so that visual inspection enables one to grasp the state of the inside of the body.2 Tongue diagnosis in humans has been practiced as part of Chinese medicine for many centuries, but rigorous scrutiny evaluating its diagnostic value is a new phenomenon.3 4 5 6 7 8 9 10 11 12 Although a growing number of veterinarians have incorporated Chinese medical diagnostic and treatment techniques into their practices, they do so without evidential support showing that empirically driven methods adapted from human medicine provide reliable information in dogs. While veterinary practitioners have utilized TCM diagnostic techniques for centuries in China, their practices focused predominantly on large animals, not dogs and cats. Veterinarians practicing TCM-style acupuncture and prescribing Chinese herbs for small animals are therefore extrapolating TCM diagnostic approaches from humans to dogs, without any historical or evidential basis for doing so.13 14 Dogs in China have never achieved the same status as family members that dogs in the United States have, and in some parts of China, dogs are served as food. Nonetheless, courses in Chinese veterinary herbal prescribing and TCM-style acupuncture have sprung up across North America,15 and companies selling Chinese herbs are finding a growing number of customers hungry for their products. 16 While work remains to be done to establish the safety and effectiveness of each of these plant products in dogs, the very basis of prescribing these herbs and acupuncture approaches based on TCM pattern differentiation) should be analyzed insofar as its ability to distinguish between healthy and unhealthy animals. The results of such a study would impact veterinarians across the globe. This systematic evaluation is the first to evaluate the diagnostic reliability of TCM approaches applied to dogs, in whom no systematic investigations of this nature yet exist.17 Even data related to actual lingual lesions in dogs is sparse.18

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Materials and Methods One hundred dogs were recruited for this study, following Animal Care and Use Committee approval. Dogs were photographed while spontaneously panting. The specific characteristics required to establish TCM tongue evaluation were recorded by the examiner. These characteristics included size, shape, and color of the tongue, as well as moisture, coating, cracks, and movement. 19 Results In our analysis so far, two relationships have surfaced. First, dogs with a TCM diagnosis of Bony Bi syndrome were significantly more likely to exhibit tongues with poor Spirit, robustness and vitality, and diffuse cracking than dogs without Bony Bi. [Submitted to the American Journal of Traditional Chinese Veterinary Medicine. In press.] Second, an association with tongue abnormalities, such as changes at the tip of the tongue, and dogs having a history of cardiovascular issues was also found. [Manuscript in preparation.] Discussion Tongue abnormalities may offer tip-offs about a patients health status and genetic makeup not readily observable elsewhere. Conditions such as black hairy tongue, scalloped tongue, scrotal tongue, geographic tongue, and median rhomboid glossitis have been associated with various health issues such as congenital and genetic abnormalities, infectious diseases, certain drugs, and foods.20 Tongue diagnosis includes monitoring the relationship and distribution of lesions according to a somatotopic map of the tongue (see Figure 1) that links areas of the dorsal lingual surface to specific internal organs. In this way, lingual abnormalities observed through visual inspection thereby may lead the practitioner to seek further clues or draw conclusions regarding problems in that organ.

Somatotopic map of the tongue. Certain regions of the tongue supposedly relate to internal organs, as noted here.

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While both Chinese and Western medical practitioners have noted correlations between tongue pathology and internal disease states for centuries and decades, respectively,21 22 23 24 rigorous scrutiny evaluating its diagnostic value is new, and has thus far taken place only for humans.25 26 27 28 29 30 31 32 33 34 The mechanisms by which tongue abnormalities relate to internal organ disorders or disease processes remain unclear, but may stem from either genetic abnormalities, insults occurring during embryogenesis, or acquired changes.35 36 37 38 39 40 41 42

References 1. Cohen I, Tagliaferri M, and Tripathy D. Traditional Chinese Medicine in the treatment of breast cancer. Seminars in Oncology. 2002;29(6):563-574. 2. Takeichi M and Sato T. Studies on the psychosomatic functioning of ill-health according to Eastern and Western Medicine 1. Visual observation of the sublingual vein for early detection of vital energy stagnation and blood stasis. American Journal of Chinese Medicine. 1999;27(1):43-51. 3. Diaoyuan K, Miller IJ, and Little FB. Tongues of TCM constitutional types in otolaryngology outpatients. Journal of Traditional Chinese Medicine. 1987; 7(4):251-262. 4. Guo S, Liang X, Hong G, et al. Tongue color and whole blood viscosity in patients of diabetes mellitus after treatment by TCM prescription for replenishing qi, nourishing yin, and activating blood circulation. Journal of Traditional Chinese Medicine 1989;9(4):294-296. 5 Dong G. [Relation of pale tongue, purple tongue, and TXA2-PG12 regulation system.] Zhong Xi Yi Jie He Za Zhi. 1990;10(4):219-220, 197. 6. Li N, Zhang YF, and Wang SY. [Tongue picture of blood stasis symptom-complex.] Zhong Xi Yi Jie He Za Zhi. 1991;11(1):28-30, 5. 7. Zhou AG, Din YX, and Jiang SJ. [Pre-, post-operation and before death of blood stasis syndrome in patients with gastric malignant tumor.] Zhong Xi Yi Jie He Za Zhi. 1990;10(9):540-541, 517. 8. Zou JP, Wang WD, and Li GX. [Study on relationship between quantitative data of tongue picture and state of illness in 224 patients with severe acute respiratory syndrome.] Zhong Xi Yi Jie He Za Zhi. 2003;23(10):740-743. 9. Liu Q, Yue XQ, Ren RZ, et al. [Characteristics of sublingual venae in primary liver cancer patients in different clinical stages.] Zhong Xi Yi Jie He Za Zhi. 2004;2(3):175-177. 10. Liu Q, Yue XQ, Deng WZ, et al. [Quantitative study on tongue color in primary liver cancer patients by analysis system for comprehensive information of tongue diagnosis.] Zhong Xi Yi Jie He Za Zhi. 2003;1(3):180-183.

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11. Pang B and Zhang D. The bi-elliptical deformable contour and its application to automated tongue segmentation in Chinese Medicine. IEEE Transactions on Medical Imaging. 2005;24(8):946-956. 12. Pang B, and Zhang D. Computerized tongue diagnosis based on Bayesian networks. IEEE Transactions on Biomedical Engineering. 2004;51(10):1803-1810. 13. Jiang W-Y. Therapeutic wisdom in traditional Chinese medicine: a perspective from modern science. TRENDS in Pharmacological Sciences. 2005;26(11):558-563. 14. Ramey DW, Imrie RH, and Buell PD. Veterinary acupuncture and Traditional Chinese Medicine: facts and fallacies. Compendium. 2001;February: 188-193. 15. Wynn SG. CAVM in veterinary education. Clinical Techniques in Small Animal Practice. 2002;17(1):vi-viii. 16. Marsden S, Messonnier S, and Yuill C. Traditional Chinese Medicine. Obtained at http://www.lifelearn.com/c3/Veterinary%20TCM.pdf on 02-17-07. 17. Schnyer RN, Conboy LA, Jacobson E, et al. Development of a Chinese Medicine assessment measure: an interdisciplinary approach using the Delphi method. Journal of Alternative and Complementary Medicine. 2005;11(6):1005-1013. 18. Dennis MM, Ehrhart N, Duncan CG, et al. Frequency of and risk factors associated with lingual lesions in dogs: 1,196 cases (1995-2004). JAVMA. 2006;228(10):1533-1537. 19. Xie H. How to select Chinese herbal medicine for cancer patients. American Journal of Traditional Chinese Veterinary Medicine. 2006;1(1):49-52. 20. Joseph BK and Savage NW. Tongue pathology. Clinics in Dermatology. 2000;18:613-618. 21. Joseph BK and Savage NW. Tongue pathology. Clinics in Dermatology. 2000;18:613-618. 22. Menni S and Boccardi D. Melanotic macules of the tongue in a newborn. J Am Acad Dermatol. 2001;44:1048-1049. 23. Rogers III RS and Bruce AJ. The tongue in clinical diagnosis. JEADV. 2004;18:254-259. 24. Abe S, Ishihara K, Adachi M, et al. Tongue-coating as a risk indicator for aspiration pneumonia in edentate elderly. Arch Geriontol Geriatr. 2007 {Epub ahead of print]. 25. Diaoyuan K, Miller IJ, and Little FB. Tongues of TCM constitutional types in otolaryngology outpatients. Journal of Traditional Chinese Medicine. 1987; 7(4):251-262.

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26. Guo S, Liang X, Hong G, et al. Tongue color and whole blood viscosity in patients of diabetes mellitus after treatment by TCM prescription for replenishing qi, nourishing yin, and activating blood circulation. Journal of Traditional Chinese Medicine 1989;9(4):294-296. 27. Dong G. [Relation of pale tongue, purple tongue, and TXA2-PG12 regulation system.] Zhong Xi Yi Jie He Za Zhi. 1990;10(4):219-220, 197. 28. Li N, Zhang YF, and Wang SY. [Tongue picture of blood stasis symptom-complex.] Zhong Xi Yi Jie He Za Zhi. 1991;11(1):28-30, 5. 29. Zhou AG, Din YX, and Jiang SJ. [Pre-, post-operation and before death of blood stasis syndrome in patients with gastric malignant tumor.] Zhong Xi Yi Jie He Za Zhi. 1990;10(9):540-541, 517. 30. Zou JP, Wang WD, and Li GX. [Study on relationship between quantitative data of tongue picture and state of illness in 224 patients with severe acute respiratory syndrome.] Zhong Xi Yi Jie He Za Zhi. 2003;23(10):740-743. 31. Liu Q, Yue XQ, Ren RZ, et al. [Characteristics of sublingual venae in primary liver cancer patients in different clinical stages.] Zhong Xi Yi Jie He Za Zhi. 2004;2(3):175-177. 32. Liu Q, Yue XQ, Deng WZ, et al. [Quantitative study on tongue color in primary liver cancer patients by analysis system for comprehensive information of tongue diagnosis.] Zhong Xi Yi Jie He Za Zhi. 2003;1(3):180-183. 33. Pang B and Zhang D. The bi-elliptical deformable contour and its application to automated tongue segmentation in Chinese Medicine. IEEE Transactions on Medical Imaging. 2005;24(8):946-956. 34. Pang B, and Zhang D. Computerized tongue diagnosis based on Bayesian networks. IEEE Transactions on Biomedical Engineering. 2004;51(10):1803-1810. 35. Majewski F, Ozturk B, and Gillessen-Kaesbach G. Jeune syndrome with tongue lobulation and preaxial polydactyly, and Jeune syndrome with situs inversus and asplenia: Compound heterozygosity Jeune-NMohr and Jeune-Ivemark? American Journal of Medical Genetics. 1996;63:74-79. 36. Temizsoylu MD and Avki S. Complete ventral ankyloglossia in three related dogs. JAVMA. 2003;223:1443-1445. 37. Yamane A. Embryonic and postnatal development of masticatory and tongue muscles. Cell Tissue Res. 2005;322:183-189. 38. Nevin NC, Craig BG, Mullholland C, et al. Cleft lip and palate, hypertelorism, brachycephaly, flat facial profile, and congenital heart disease in three brothers. American Journal of Medical Genetics. 1997;73:412-415.

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39. Hsieh Y-C and Hou J-W. Oral-facial-digital syndrome with Y-shaped fourth metacarpals and endocardial cushion defect. American Journal of Medical Genetics. 1999;86:278-281. 40. Villagomez DAF and Alonso RA. A distinct Mendelian autosomal recessive syndrome involving the association of anotia, palate agenesis, bifid tongue, and polydactyly in the dog. Can Vet J. 1998;39:642-643. 41. Evans HE. Hyoid muscle anomalies in the dog (Canis familiaris). Anat. Rec. 1959; 133:145-162. 42. Guven MA, Ceylaner S, Prefumo F, et al. Prenatal sonographic findings in a case of VaradiPapp syndrome. Prenatal Diagnosis. 2004;24:989-991.

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TREATMENT OF ACUTE AND CHRONIC HEART DISEASE IN HORSES AND DOGS BY PURE ACUPUNCTURE USING PULSE CONTROLLED LASER ACUPUNCTURE CONCEPT (PCLAC)
Uwe Petermann, DVM Summary In this lecture my personal ideas and my personal experience with Pulse Controlled Laser Acupuncture Concept (PCLAC) in animal heart disease treatment will be explained. PCLAC is a holistic treatment concept based on traditional acupuncture including as many factors as possible that lead to chronic disease, such as environment factors, eating habits, and most important, disturbing foci in scars and teeth. It also uses RAC pulse control to find the imbalanced active acupuncture points and modern ear acupuncture. First aid treatment points in collapsed patients for saving life are demonstrated. These points are working in one or two seconds so that one has the idea to switch on the life light again, avoiding the complete breakdown of blood circulation (I call them switch on points). Further on, the points for stabilisation of circulatory regulation are shown. Treatment of patients with chronic heart disease, the points used and treatment concepts are explained and will be demonstrated in many case studies. All points will be explained by traditional Chinese energy rules (middaymidnight, mother-child, etc.) and, if possible, parallel to this by western acknowledgement. Introduction In heart disease we can do a lot more with acupuncture than one may believe. For me it seems that most heart disease is caused less by damaged structures of the heart muscle, the bicuspid or tricuspid valves or the aortic valves, than by vegetative deregulations. In most chronic heart disease there is only a small problem in the heart muscle itself, but the result is a very poor performance, that is not explainable by the Heart muscle problem alone. So the main effect must come from disturbances in passing on the vegetative stimulus. Generally the response to the acupuncture treatment is so prompt, that nothing else other than vegetative regulation could show such quick results. If the main problem is vegetative deregulation, acupuncture, (the treatment which strives to attain vegetative regulation), can have wonderful results in many cases. For treating these diseases Pulse Controlled Laser Acupuncture Concept (PCLAC) was used. That means we search and treat only active acupuncture points that we find by RAC control.

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This may be the Shu-Mu points BL 15 and CV 14 and the Midday Midnight rule connected Luo points PC 6 (Stellate ganglion) and ST 40 (- blocker) or HT 5 and GB 37 or points following other traditional treatment concepts, that show clear RAC reactions. In nearly all cases of chronic disease we must add disturbing focus treatment. Acupuncture in shock treatment Shock is often caused by a sudden deregulation of the vegetative system (SYMPATHETIC AND PARASYMPATHETIC). This may be due to blood being centralized to the internal organs with lack of peripheral circulation and more commonly in allergic reaction or shock caused by a stressful situation. Acupuncture works directly with the vegetative nerve system and has a depressing/ inhibiting effect on it, thus, will be of help in correcting vegetative function dysregulation. Normally every combination of points that creates balance between Yin and Yang, in other words parasympathetic and sympathetic balance, would help in such cases. But there are two points that make a very sudden global Yin/Yang balance, because they make a short circuit between the Yang of the GV and the Yin of the CV. These two points are GV 26 and the tip of the tail point, the traditional point Wei jian. Only one of them is enough to give the impulse to the vegetative system to set regulation in motion again. And because setting a needle in it will not take longer than a few seconds, I would do this first, before I start closing a serious bleeding wound. Next I choose the point HT 9 or PC 9. My choice between these two points is determined by the RAC control. That point which gives the strongest reaction on the pulse gets the needle. These two points always show such a spontaneous reaction that you have the idea to switch on the life light again, so that I and perhaps other acupuncturists as well, call them switch on points. Chronic heart disease As already explained even chronic heart disease is primarily caused by vegetative deregulations; even in Myocarditis, heart dilatation, heart valve problems, nearly all kinds of insufficient hearts in dogs and horses. Especially in older dogs, I have treated many patients that already had a long-term treatment because of the above mentioned diagnosis with different conventional heart medications. During the first week of acupuncture treatment I only reduce the medication. In nearly all cases I could stop the conventional treatment, heart drugs, diuretics, etc., completely after the 2nd or 3rd session and the dogs felt much better with the pure acupuncture treatment than before with the conventional medication. All the symptoms they still had while on conventional medications, such as walking around at night, poor performance, disappeared. The owners report that they start playing again; they are running during their walks like the times before their illness. For acupuncture therapy two pairs of points to find by Midday-Midnight rule are of very special interest. My favorite rule for balance is this Midday-Midnight rule, because here we always combine two Luo points of one Yang and one Yin meridian;

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one on the hand, one on the foot; and these meridians have 12 hours difference between their maximum energy. So we balance the Yin and Yang; hand and foot and midday and midnight, meaning the maximum energy difference between the connected meridians. In the case of heart diseases we have two pairs of points. The first pair is PC 6, very interesting for western physicians, it is the ear point of the Ganglion Stellatum, (Petermann U. 2001), and its partner ST 40 (very interesting for western physicians as well, it is the ear point of beta-blocker). And here we can see how close in reality is western to eastern medicine and vice versa. The second point combination by Midday-Midnight rule is HT 5 and GB 37. These points I normally use more to prevent emergency cases in horses with bad heart conditions, e.g., in chronic heart disease following myocarditis. When we look at the Mother-Son rule we find an indication for these two points as well. Gall bladder is the Wood Yang partner of the Liver and because Wood is the mother of Fire (Heart is the Yin part of Fire) with these points we can do many helpful things: first we create a Yin-Yang balance from the hind part of the body to the front part and second we make a very special Yin-Yang balance because we give Yang energy of the mother (Wood) to the Yin part of the child (Fire). Another point that will be discussed is the point HT 3, sometimes called the small Tonifying point of the Heart. It is the He Sea-point of its meridian and it is the motoric Heart point of the ear (point of the Heart muscle, HT 4 is the vegetative Heart point). At last the very simple Shu-Mu technique will be described, because very often acute blocked (fixed) vertebras in the heart region can cause heart emergency situations because of acute vegetative heart regulation disturbance. This is seen especially in horses. These horses are characterized by extreme pain, extreme sweating and a circulatory situation close to shock that occurs suddenly while riding. In these horses after first treating the switch on-points I look for vertebral blockades. Normally there is one blockade in the neck and the second blockade in the thoracic region in the segment of BL 14 or BL 15, the Shu points of PC and HT meridians. In the Shu-Mu technique these points are combined with the Alarmpoints; in this case CV 17 (Mu point of the upper burner and Pericardium) with PC (BL 14) and CV 14 with the HT (BL 15). The perturbative field principle in chronic heart disease Many cases of chronic diseases are caused by disturbing foci or perturbative fields, sometimes also known as toxic scars. This is also true for chronic heart disease. Here we find scars in the Heart meridian, the Pericardium meridian and the Stomach meridian that are responsible for chronic heart disease and the 3rd premolar tooth in the upper jaw. This tooth is known in PCLAC disturbing the acupuncture point HT 4 which is the vegetative Heart point of ear acupuncture. In the case that we have a disturbing focus that is responsible for the heart disease, we of course must treat the scar or the tooth. In addition to the above mentioned points we have to search the perturbative field by the principles of PCLAC and to treat it with laser as described in the case studies, and also TH 5 is treated; the most important point for demarcation of the disturbing focus inside the scar or tooth.

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Now I will report some cases to show this reaction. Case Study No. 1: 17 year old Andalusia mare in shock situation A 17 year old Andalusia mare had fallen backwards in a small hole in the ground, 2m deep with an area of 1 square metre. So, for us, only the forelimbs where reachable. The horse was hidden there like a cork in a bottle for nearly 3 hours before we could pull it out of the hole with a rope and the front loader of a tractor. When we had finished this operation the horse laid in a lateral position on the ground like she was dead, without any reaction; the pulse was barely felt and had a very high pulse rate. So this horse seemed to be really in shock and all our work seemed to have failed. So I treated first the switch-on points. No more than two seconds after inserting the needles the horse opened her eyes, raised her neck, set herself into sternal position and seemed to ask: whats the matter? A few seconds later it stood up and seemed to be in a relative normal condition. But the pulse rate was still a little bit high (60/min) and the quality of the pulse was still a little bit slippery. Because the Heart meridian was already treated with HT 9 I looked to regulate the PC meridian with PC 6 and ST 40 as described above. After this the horse was quite all right and needed no further treatment. Case Study No. 2: 8 year old Lousitano mare with long standing poor performance resistant to therapy A veterinary acupuncture colleague came to me with his horse because of long standing therapy-resistant very poor performance. The horse couldnt trot more than 20 m and was not able to gallop because it was too weak. The horse had been examined and treated in several Veterinary Clinics. They found several different western diagnoses and several different treatments had been applied to this horse. Also a former acupuncture treatment done by her owner had been not successful. She had a very strong holosystolic heart noise with point of intensity over the aortic cardiac valve. There were many extra-systolic heart beats which did not disappear after a short period of work. So this horse had vegetative heart function disease. With the help of the controlled ear acupuncture I found that there must be a disturbing focus in the left front hoof region.

Scar in HT 9 as a cause of vegetative deregulation of the heart

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Now looking at the left front hoof I found a scar that the owner had not told me about before, exactly on the point HT 9. The following points where treated: HT 9 (as a disturbing focus scar) with laser frequency A from Nogier, PC 6 and partner ST 40 with frequency C from Nogier. Because in cases of disturbing focus nearly always Yin energy of the Kidney is weak, I treated the Source point with reference to the inherited energy. KI 3 has a double connection to the inheritance energy. It is the point for inheritance in inheritance, because Kidney is source of inheritance and the source point of every meridian is the inheritance point of its meridian. That means KI 3 is one of the most important points for giving inheritance energy to the body. And this energy is helpful to heal the disturbing focus. The next point was TH 5. It is the point of the Thymus on the ear. This point is known as a good anti-infection point and is used in treating problems of disturbing foci even without his partner in the Midday-Midnight rule, SP 4. This point is very effective in setting demarcation of tissue in motion again, which had not finished during wound healing and so lead to becoming a disturbing focus. Lastly, I treated Shu- Mu points BL 15 and CV 14 to balance the Yin and Yang of the heart. After this treatment immediately there were no more abnormal heart sounds and no more extra systolic heart beats. Four treatments, one per week in the same way, were carried out by my colleague who was the owner of the horse. She has been in a very good condition again for 3 years. Case Study No. 3: 12 years old jumping horse (Westfalian) with acute blockage of the vertebra Th9/10 I was called for an emergency case to a nearby stable, where a horse had developed a circulatory collapse while riding. This 12 years old Westfalian mare was a successful jumping horse some years ago until it was kept out of tournament sport because of serious back problems. Unfortunately, this horse didnt come to acupuncture with this problem. When I came, the horse stood there like a sawhorse sweating so strongly that the water ran from the body. The pulse was hard to feel and the horse seemed ready to collapse. The switch-on points didnt work, which made me really wonder because I seldom had seen this before. Than I realized that the sweating was particularly strong in a region of the neck and behind the scapula in the BL 14 and BL 15 region. When I wanted to touch these areas the horse became extremely anxious. So I looked with laser frequency C from Nogier, the frequency for vertebra blockades for RAC-reactions. I found a blockade between C4/C5 on the right side and between Th9/Th10 on the left side that both were treated with Fr. C. Because of the irritation of the stellate ganglion through the neck blockade I treated PC 6 (without his partner). After lasering these three points an obvious relaxation in the horse was seen. For this day the treatment was completed by making pain reduction and muscle relaxation by treating the following points with the laser: SI 3 and its opening point (cardinal- point) partner BL 62 for opening the Du Mai and Yang Qiao Mai; BL 10-1 (C1/C2) for relaxation of the spinal column, and LI 4 as the masterpoint of pain. Immediately after this treatment the horse started to walk normally, there was no sign of pain in the former untouchable points even with strong pressure, and the horse was dry within 20 minutes of walking. In this case the chronic back pain was caused by the vertebral blockades. While riding on this day

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probably the blockade of the neck had worsened and had irritated the stellate ganglion (PC 6). This was followed by a worsening of the thoracic blockade which was followed by a vegetative irritation of the heart function, which led to the dramatic acute situation. In this case the complete Yin and Yang was not in disharmony, thus the switch-on points could not be effective. The main pathological problem was the local disturbance by the irritated stellate ganglion and the irritated vegetative heart function by the radicular nerve irritation in the heart segment, just as it is described by Bergsmann and Eder (1977) in the segment regulatory complex. After 4 further treatments the horse had no more back pain and worked so well that the owner decided to start again with training for jumping competition after more than 3 years of intermission. Case study No 4 A four year old Jack Russell terrier with insufficient heart A four year old, male Jack Russell terrier suffered from a deformity on his right paw in the form of a growth between his fourth and fifth toes. After surgery on the paw, the dog seemed to regain his normal gait. However, within a short period, a partial, right rear leg paralysis developed which seemed to originate in the back region. Shortly after this, his general condition deteriorated. The examination showed a cardiac insufficiency that colleagues treated with cardiac glycosides, like Metildigoxin (Lanitop ). According to the owner, within a period of one year, the condition of the patient appeared to be stabilized. After that, his heart condition deteriorated, the paralysis of the right hind limb worsened and more and more a lameness of the front limbs also appeared. The picture the dog showed was not a real lameness of the front limbs, but they seemed to have weak nerve power. It was at this point that the patient was presented to me for an acupuncture treatment. The acupuncture diagnosis showed a blockage in the 5th and 6th thoracic vertebrae that was also quite painful during palpation. Interestingly enough, this is the area associated with the acupuncture point BL 15, which is the corresponding Shu-point of the Heart meridian. An acupuncture treatment, without including the disturbing focus, was not successful. This treatment was laser acupuncture of the following points (each 30sec with 90Watt impulse Laser, impulse peak power): BL15 (Fr.C), CV14 (Fr.B), HT 5/GB 37 (Midday-Midnight-Rule), Opening points SI3/Bl 62(Fr.5) to open Du Mai and because it is the masterpoint of spasm (also spasm in the musculature of the pack). Because this therapy was not successful, a disturbing focus diagnosis using the method of controlled acupuncture was begun. This showed the location of the disturbing focus in a scar on the left front paw, near acupuncture point HT 9, the tonification point of the Heart meridian. In acupuncture, this point is the most important emergency point. Immediately after laser treatment of the disturbing focus, (LLLT, 90Watt (impulse peak power) Impulse Laser Fr.A,) and TH5, at Fr.5, each for 30sec, the patients condition improved. The dog no longer had his back raised, showed no sign of pain during palpation and was generally quite mobile. Within the next four weeks further treatment with laser acupuncture

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(BL 15 (Fr.C), CV 14 (Fr.B) HT 5/GB 27 (Midday-Midnight-Rule), Opening (Cardinal) points SI 3/ BL 62(Fr.5) and disturbing focus ((LLLT, 90Watt (impulse peak power) Impulse Laser Fr.A, TH5, FR.5, each 30sec) sessions were administered once a week. During this period, the administration of the original heart medication was slowly reduced and finally stopped. The dog has been very active and has shown no symptoms of pain or problems in his cardiac system for several years .

Operation scar of the malformed toe in HT 9

Conclusions As these patients from about 100 similar cases show, even in severe acute and chronic heart disease acupuncture has a wonderful effect on different kinds of heart diseases. It also shows that most of these problems must result from vegetative dysregulation as this is the only way that explains the good therapy results in acupuncture treatment. The way in which acupuncture works is mainly by balancing the vegetative system. Acupuncture can not let grow a new heart! References 1. Bahr, F. (1997) Scriptum Systematik und Praktikum der wissenschaftlichen Akupunktur fr weit Fortgeschrittene und Experten. Eigenverlag, Mnchen 2. Bergsmann, O. (1980) : Pathogenetische Aktivitt der Strfelder. Der informierte Arzt 20, 41-48 3. Kellner, G. (1965): Nachweismethoden der Herderkrankungen und ihre Grundlagen. Therapiewoche15, 1267-1274 4. Kellner, G. (1979) : Der Herd in experimentell-histologischer Sicht. st

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5. 6. Kluger, L. (1991) : Odontogene Strfeldmglichkeiten. In: sterr. Med. Ges. f. Neuraltherapie - Regulationsforschung (Hrsg.): Herd-Strfeldgeschehen. Facultas, Wien, 40 - 46 7. Petermann, U. (1997) Auffinden von Strfeldern mit Hilfe der kontrollierten Akupunktur. Ganzheitliche Tiermedizin 1999; 13; 10-13 8. Petermann, U. (2001) Acupuncture in Emmergency Treatment, Procc. of 27th IVAS 2001 world congress, Ottawa, Canada 45-56 9. Petermann, U. (2002) Earacupuncture Map of the horse, Procc. of 28th IVAS 2001 world congress, Liuhe Hawaii, USA, 1-3 10. Petermann, U. (2002) A Holistic View of Chronic Disease with Special Consideration of Adaptation Syndrome and Disturbing Focus in Controlled Acupuncture, Procc. of 28th IVAS 2001 world congress, Liuhe Hawaii, USA, 123140 11. Petermann, U. (2007) PCLAC (Pulse Controlled Laser Acupuncture Concept), private publishing www.akupunkturtierarzt.de 12. Strittmatter, B. (1998) Das Strfeld in Diagnostik und Therapie Hippokrates Verlag, Stuttgart

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MANAGEMENT OF CARDIAC ARRHYTHMIAS WITH TRADITIONAL CHINESE MEDICINE


Michelle C Schraeder, DVM, FAAVA Mountain Veterinary Hospital Bellingham, WA, USA Cardiac Arrhythmias are often not well described in various acupuncture and Traditional Chinese Medicine references. Sometimes they are only referred to instead as palpitations, rarely they are indexed as heart arrhythmias, and other times they are missing altogether. Palpitations includes not only arrhythmias, but also other conditions where the patient feels a functional altered heart rate due to fear, stress, or exertion that can have nothing to do with an ongoing organic arrhythmic disease process as being considered here, but more a Shen disturbance. This discussion is to combine several references on this topic and also consider the physiology behind cardiac arrhythmias and how one can use it to explain how acupuncture can alter cardiac rhythm and rate. An excellent reference is Clinical Handbook of Internal Medicine: The Treatment of Disease with Traditional Chinese Medicine: Volume 1 by Will MacLean & Jane Lyttleton which contains a large chapter on Palpitations (pp 796-824). They note that although these two broad types of palpitations are quite different, there is often considerable overlap due to the intimate relationship between the Heart and Shen (p796). 1. Another interesting and helpful discussion of cardiac arrhythmias is in Zhou Zhong Ying and Jin Hui Des Clinical Manual of Chinese Herbal Medicine: It is necessary to make an initial analysis of the condition into Deficiency and Excess first. Deficiency may involve insufficiency of Qi, Blood, Yin and Yang and the principle of treatment is then to tonify Qi, produce Blood, nourish Yin, and warm Yang respectively. Excess refers to Phlegm-Fire and Stagnation of Blood and the principle of treatment is then to clear Fire, resolve Phlegm, activate Blood circulation, and remove Blood stasis. In either condition, [treatment should] soothe the Heart and calm the Mind. Complicated conditions involving both Deficiency and Excess are commonly seen clinically. Generally, a functional arrhythmia presents with more Excess signs than Deficiency, and an organic one presents with more Deficiency signs than Excess (pp 123-4).1 In The Treatment of Cardiovascular Diseases with Chinese Medicine by Simon Becker, Bob Flaws & Robert Casanas, the first chapter is entitled Cardiac Arrhythmias and explores the topic of cardiac arrhythmias in depth. They note that most patients with heart palpitations suffer from a combination of vacuity [deficiency] and repletion [excess]. This is particularly so in the elderly, where vacuity is commonly mixed with phlegm obstruction and blood stasis (p72). 2

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This book also places palpitations due to anxiety and such in a separate chapter called Cardiac Neurosis.11 TCM PATHOPHYSIOLOGY OF CARDIAC PALPITATIONS/ARRYTHYMIAS 3 o Qi is commander of Blood: it moves and contains Blood. o Blood is mother of Qi: if Blood deficient or stagnant then Qi becomes deficient. o Heart palpitation/arrhythmia comes from HT Qi dysfunction which can come from: 1. Qi and/or Yang deficiency so cant move Blood and Yin to nourish HT so HT Qi can function properly. Due to: a. If SP deficient under conversion of food to HT Qi & Blood so both deficient b. KI = root of all Yin & Yang of body so if KI Yin or Yang deficient HT Yin/Blood or Yang/Qi deficiency c. HT Qi + LU Qi = chest or Zhong Qi so if LU Qi deficient HT Qi deficient (and visa versa) 2. Any Heat (excess or false) Blood moves too rapidly or frenetically. a. Qi stagnation heat b. Heat rises to chest + phlegm Phlegm Heat c. Heat consumes yin Yin deficiency hyperactivity of Yang 3. HT Blood stagnation due to: a. Yang deficiency Deficiency Cold b. Qi Deficiency c. Phlegm obstruction d. Qi stagnation CARDIAC ARRYTHYMIA TCM DIFFERIENTIALS 1 Patterns More Associated with Organic Disorder: HT Qi Deficiency o Pathophysiology: HT Qi gives energy to heart contractions, thus its deficiency causes irregular and less powerful contractions. SP Qi Deficiency can be the root of it. o Signs: T= pale, thin white coat P=thready and weak, +/- irregular Signs worse with exercise and better with rest SOB, lethargy, insomnia o Treatment Principle: Tonify HT Qi. o Associated Disorders: Anemia, sinus tachycardia, premature ectopic beats, sick sinus syndrome, and anxiety. o Often precedes HT Yang Deficiency. Often responds well to acupuncture (Maclean & Lyttleton, p 803). HT Yang Deficiency o Pathophysiology: Worsening of HT QI Deficiency and more likely to happen with constitutional or pre-existing SP/KI Yang Deficiency (Maclean & Lyttleton, p 803), palpitations worse and HT weaker, addition of Cold signs and fluid accumulation o Signs: T=pale bluish or pale purple and swollen, white or greasy coat P=thready and weak, slow or knotted and intermittent

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Signs worse with exercise and better with rest SOB, possibly dyspnea Lethargy Cold extremities, cold aversion Pitting edema, stuffy chest o Treatment Principle: Warm and tonify HT Yang, and tonify Qi. o Associated Disorders: Congestive heart failure, atrial fibrillation, and coronary artery disease. o Mild cases may respond well to correct TCM treatment and fluid metabolism improves quickly. Severe cases difficult to treat (especially when HT and KI Yang Deficiency). Predisposing pathology for more severe and potentially fatal cardiac events. (Maclean & Lyttleton, p805) SP and KI Yang Deficiency o Pathophysiology: Root of weak Fluid metabolism and distribution, leading to Phlegm Fluid accumulation in lower and middle Jiao first and then the upper Jiao. HT Yang may be intact (Maclean & Lyttleton, p818). See more middle and lower Jiao signs compared with HT Yang Deficiency. o Signs: T=pale and swollen with greasy white coat P=slippery and wiry, or slow, deep and possibly knotted or intermittent (if HT Yang involved) SOB worse with exercise, chest fullness, dizzy Wheezing and cough with thin white sputum Nausea, poor appetite, loose stools Cold extremities and back, back pain Pitting edema o Treatment Principle: Warm and transform Phlegm, tonify SP and resolve Damp. o Associated Disorders: Congestive heart failure, chronic nephritis, chronic bronchitis, and coronary artery disease. o SP and KI Yang Deficiency respond well to treatment. Herbals may be best way to treat, though acupuncture and moxabustion enhance results (Maclean & Lyttleton, p820) Blood Stagnation o Pathophysiology: Chronic palpitations, usually follows other chronic chest or Heart pathology like Yang Deficiency, Phlegm or Qi Stagnation. Stagnant Blood obstructs HT channel disrupting smooth Qi and Blood flow and thus leading to irregular beats and pain. o Signs: T=dark or red purple, thin white coat P=deep and choppy or wiry, or intermittent Chest pain worse at night Stuffy chest Irritability, restless, depression Possibly signs of stagnant Liver Qi Purplish lips and nails o Treatment Principle: Move Blood and Qi, break Blood stasis, and open channels. o Associated Disorders: Coronary artery disease and mitral stenosis.

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o Symptoms respond reasonably well to correct and prolonged treatment (Maclean & Lyttleton, p 823). Add appropriate tonic formula when using Blood stagnation formulas long-term in frail or geriatric patients to avoid excessive dispersal of Qi and Blood. o Caution: never use Blood moving formulas if also giving blood thinning drugs. HT Blood (and SP Qi) Deficiency o Pathophysiology: Functional and organic in that Qi Deficiency leads to weak HT function and HT Blood Deficiency fails to nourish the Shen. Overwork, worry and bad diet can cause this. o Signs: T=pale, thin white coat P=thready, weak Insomnia, hard to fall asleep, dream-disturbed sleep Anxiety, panic attacks Poor concentration Postural dizziness Fatigue and weak Palpitations mostly worse at night o Treatment Principles: Tonify HT and SP, tonify Qi and Blood, and calm Shen. o Associated Disorders: Anemia, sinus tachycardia, premature ectopic beats, sick sinus syndrome and arrhythmia. o Use acupuncture to tonify SP Qi and herbals to tonify Blood (Maclean & Lyttleton, p812) Patterns More Associated with Shen Disturbance/Functional: HT & GB Qi Def HT Yin Deficiency o Associated Disorders: Mitral stenosis, hyperthyroidism, FUO, and anxiety neurosis. Phlegm Heat ACUPUNCTURE TREATMENTS 5,6,7 More Associated with Organic Disorder: HT Qi Deficiency: BL 15, CV 17, CV 14, CV 6, HT 5, HT 7, PC 6, ST 36 HT Yang Deficiency: MOXA, BL 15, BL 14, CV 14, CV 4, CV 6, HT 5, HT 7, PC 6, ST 36 SP & KI Yang Deficiency: MOXA, BL 13, BL 15, BL 20, BL 22, BL 23, CV 9, GV 4, PC 4, ST 40 Blood Stagnation: BL 14, BL 15, CV 14, CV 17, CV 6, HT 5, HT 7, LI 4, PC 4, PC 5, PC 6, SP 10, SP 6 HT Blood & SP Qi Deficiency: BL 15, BL 17, BL 20, HT 5, HT 7, SP 6, ST 36 More Associated with Shen Disturbance/Functional: HT & GB Qi Deficiency HT Yin Deficiency: BL 15, HT 7, KI 3, PC 6, SP 6 Phlegm Heat

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Acupuncture Points by Western Clinical Disease 4,5: Tachycardia: BL 1, BL 15, BL 2, PC 5, PC 6, ST 1, ST 9 Bradycardia: BL 17, CV 17, GV 14, GV 25, HT 5, HT 7, LU 7, PC 6, SP 6, ST 36 Ventricular Arrhythmias (PVCs): PC 6 Supraventricular Tachycardia1: CV 17, HT 7, PC 6 CHINESE HERBAL TREATMENTS 5, 6, 7 More Associated with Organic Disorder: HT Qi Deficiency o Gui Pi Wan (Restore the Spleen Decoction) o Sheng Mai Wan (The Great Pulse) o Wu Wei Zi Tang (Schizandra Decoction) o Yang Xin Tang (Nourish the Heart Decoction) o Zhi Gan Cao Tang (Honey-fried Licorice Decoction) HT Yang Deficiency o Fu Zi Zhong Wan (Li Chung Yuen Medical Pills) good for warming HT Yang has aconite o Gui Zhi Gan Cao Long Gu Mu Li Tang (Cinnamon, Licorice, Dragon Bone and Oyster Shell Decoction o Jin Gui Shen Qi Wan (Golden Book Pills/ Rehmannia 8) KI Yang more o Xiao Huo Luo Dan Wan - small dose of this hot formula for severe cases (Maclean & Lyttleton, p805) o Zhen Wu Tang (True Warrior Decoction) with pulmonary edema SP & KI Yang Deficiency o Fu Zi Zhong Wan (Li Chung Yuen Medical Pills) o Jin Gui Shen Qi Wan (Golden Book Pills/ Rehmannia 8) o Li Zhong Wan o Ling Gui Zhu Gan Tang (Atractylodes and Hoelen Combination) o Zhen Wu Tang (True Warrior Decoction) with severe fluid accumulation Blood Stagnation o Dan Shen Yin Wan (Salvia Teapills) o Fu Ke Wu Jin Wan (Woo Garm Yuen Medical Pills) o Gua Lou Xie Bai Bai Jiu Tang (Trichosanthis Fruit, Chinese Chive and Wine) o Jian Kang Wan (Sunho Multi Ginseng Tablets) o Jin Gu Die Shang Wan (Chin Koo Tieh Shang Wan) o Sheng Tian Qi Pian (Raw Tian Qi Ginseng Tablets) o Xue Fu Zhu Yu Wan (Achyranthes and Persica Combination/Stasis in the Mansion of Blood) HT Blood & SP Qi Deficiency o Bai Zi Yang Xin Wan (Biota Seed Reinforce the Heart Pill) o Bu Nao Wan (Cerebral Tonic Pills) o Dang Gui Ji Jing (Tang Kuei Essence of Chicken) o Gui Pi Tang (Ginseng and Licorice Combination/Restore the Spleen Decoction) with digestive weakness and Shen signs o Zhi Gan Cao Tang (Honey-Fried Licorice Decoction) with Qi and Yin deficiency and knotty, intermittent or irregular pulse (Maclean & Taylor, p260)

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More Associated with Shen Disturbance/Functional: HT & GB Qi Def HT Yin Deficiency o Bai Zi Yang Xin Wan (Biotiae Seed Pill to Nourish the Heart) o Ding Xin Wan (Stabilize Heart Pill) o Huang Lian E Jiao Tang after febrile disease o Tian Wang Bu Xin Dan (Heavenly Emperor Supplement the Heart) o Yi Guan Jian + Suan Zao Ren Tang more LIV and KI Yin Deficient o Zhu Sha An Shen Wan (Cinnabar Pill to Calm the Spirit) with anxiety and insomnia Phlegm Heat Herbals by Western Clinical Disease: Tachyarrhythmia: Individual herbs: Wan Nian Qing Gen Radix Rohdeae Japonicae Xian He Cao Herba Agrimoniae Formulas: Premature ventricular contraction: Individual herbs: Ku Shen Radix Sophorae Shan Dou Gen Radix Sophorae Subprostratae seu Tonkinensis Formulas: Zhi Gan Cao Tang Bradyarrhythymia (ex. Sick sinus syndrome): Formulas: Ling Bao Hu Xin Dan Miraculous Treasure Pill Xin Bao Heart Treasure Pill Zhi Gan Cao Tang Palpitations in general: Formulas: Bu Xin Dan Tonify the Heart Pill Zhu Sha An Shen Wan Cinnabar Pill to Calm the Spirit Bai Zi Yang Xin Wan Biotiae Seed Pill to Nourish the Heart Ci Zhu Wan Magnetite and Cinnabar Pill PHYSIOLOGY OF ACUPUNCTURE EFFECTS ON RHYTHYM & RATE Physiology review of cardiac rhythm regulation1: o Sinoatrial (SA) node: Located near where superior vena cava comes into right atrium. Autorhythmic at ~100 BPM without parasympathetic nervous system (PSNS) stimulation. Heart beat starts here. SA node rate is considerably faster than atrioventricular (AV) node or Purkinge Fibers. Has sympathetic (SNS) and parasympathetic nervous system innervations. Usually PSNS slows heart to regular sinus rhythm. o Action potential spreads from SA node through both atriums to AV node and then to Bundle of His where it goes on to left and right bundle branches to Purkinge Fibers and then to cardiac muscle of ventricles.

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o Each portion of conduction system can become autorhythmic (become starter of beat) if prior ones fail. As this happens heart rate (HR) becomes slower and less rhythmic. o PSNS is primary nervous system of heart: rest & repose via the vagus nerve into area of SA node primarily but also somewhat to AV node. o SNS innervates on SA node (primarily), AV node, and ventricular myocardium. o Medulla Oblongata in brain has Cardiovascular Control Center (CVCC) which takes information on how fast the HR should be and then lifts PSNS to increase HR. Example: exercise increase CO2 sensed by chemoreceptors sensory nerves (vagus and hypoglossal nerves) to CVCC. o Autonomic nervous system controls visceral function. Acupunctures physiological effect on cardiac rhythm and rate 9, 10: Innervations and autonomic effects: o PC 6 = Medial and lateral cutaneous antebrachial nerve, approximately where median nerve is blocked (Schoen, p130). Shown experimentally in rabbits that PC 6 stimulation will increase HR in bradycardic patients and decrease HR in tachycardic patients (Zhang et al cited in Schoen, p213). o CV 17 = Fourth intercostals nerve (Schoen, p147). o HT 7 = Caudal cutaneous antebrachial nerve. Ulnar nerve deep to point (Schoen, p130). o Any Shu Point = Sympathetic ganglia chain runs closely parallel to spine o T3-6 fibers run into chest: BL 13(LU), BL 14(PC), BL 15(HT) o T7-11 fibers run into abdomen: o GV 26 called the sympathetic (DC Lee et al cited in Schoen, p38) and resuscitation point Schoen p37-39, 213-215 References 1. Ying, Zhou Zhong & Jin Hui De. Clinical Manual of Chinese Herbal Medicine and Acupuncture. New York: Churchill Livingstone, 1997: 123-4. 2. MacLean W & Lyttleton J. Clinical Handbook of Internal Medicine: The Treatment of Disease with Traditional Chinese Medicine: Volume 1. Australia: University of Western Sydney, 1998: 796 3. Chapter One: Cardiac Arrhythmias. In Becker, S, Flaws, B, & Casanas, R. The Treatment of Cardiovascular Diseases with Chinese Medicine. Boulder, CO: Blue Poppy Press, 2005: p72. 4. Chapter Two: Cardiac Neurosis. In Becker, S, Flaws, B, & Casanas, R. The Treatment of Cardiovascular Diseases with Chinese Medicine. Boulder, CO: Blue Poppy Press, 2005: 101-115. 5. Chapter One: Cardiac Arrhythmias. In Becker, S, Flaws, B, & Casanas, R. The Treatment of Cardiovascular Diseases with Chinese Medicine. Boulder, CO: Blue Poppy Press, 2005: p71-72. 6. MacLean W & Lyttleton J. Clinical Handbook of Internal Medicine: The Treatment of Disease with Traditional Chinese Medicine: Volume 1. Australia: University of Western Sydney, 1998: 796-824.

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7. Ying, Zhou Zhong & Jin Hui De. Clinical Manual of Chinese Herbal Medicine and Acupuncture. New York: Churchill Livingstone, 1997: 123-126. 8. Becker, S, Flaws, B, & Casanas, R. The Treatment of Cardiovascular Diseases with Chinese Medicine. Boulder, CO: Blue Poppy Press, 2005: Chapter One: Cardiac Arrhythmias, 65-100. 9. Schoen, A. Veterinary Acupuncture, 2nd Ed. St. Louis, MO: Mosby, 2001: 37-39, 127148, 213-215 10. Smith, WK. Acupuncture for cardiovascular disorders. Problems in Veterinary Medicine, 1992; 4 (1): 125-131. 11. Sternfeld, M, Caspi, A, Eliraz, A, Finkelstein, Y & Hod, I. Acupuncture & supraventricular tachycardia. American Journal of Acupuncture, 1989; 17 (2): 119-124. 12. Tyme L. Student Manual on the Differentiation and Treatment of the Zang Fu Syndromes. San Diego, CA: Living Earth Enterprises, 1997: 149-187. 13. Silverthorn, DU. Human Physiology: An Integrated Approach, 2nd ed. Upper Saddle River, NJ: Prentice Hall, 2001: 422-437

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EVIDENCE-BASED VETERINARY ACUPUNTURE


Dr. Sagiv Ben-Yakir, BSc, DVM, MRCVS ORSHINA The Israeli Institute for Modern Holistic Veterinary Medicine & Sciences Hod-Hasharon, ISRAEL Veterinary acupuncture is not what it used to be. Nowadays veterinarians provide cuttingedge care for the animal members of the family in much the same way that physicians care for the human members of the family. Veterinary medical technologies continue to advance at exponential rates. Many improvements are made in the current methodologies, and are also replaced by new diagnostic modalities, therapeutic measures, and prognostic tools. Can we keep up with the rapid changes? It is not a question of ability to understand the new data, it is more lacking the capacity to memorize everything there is to know to succeed. We have to survive as professional veterinarians the new era of rapid changes by being able to find the necessary information quickly and efficiently. EBVA is a process of making the clinical decision in a way that allows us to find, evaluate, and integrate up-to-date best evidence with individual clinical expertise, patients needs and clients whishes. EBVA will provide us tools for identifying the information needs, accessing the best available evidence, evaluating the usefulness and value of that data, make an integration of our own data with the animal needs, and be able to evaluate the outcome of the clinical decision. As so, EBVA will also continue to offer us the best of the technology that grows in an exponential way. A few corner stones in the field of evidence-based medicine: in 1972, Dr. Cochran published a book that marked the beginning of the era, Effectiveness and efficiency: Random Reflections on Health Services(1). Later and during the early 1980s in McMasters Medical School in Canada the process of integrating new information and emerging technology into practice was termed evidence-based medicine (EBM). Ten years passed, and the act of searching rigorously for scientific evidences instead of observation and experience as a base for medical decision-making process gained more popularity (2). Toward the end of 1990s the term Evidence-Based Veterinary Medicine begun to appear in The Veterinary Record (3), and the first textbook on the issue was published in 2003; Handbook of Evidence-Based Veterinary Medicine(4). By now we can define EBM as a process of lifelong, self-directed problem-based learning done by integration of the best research evidence with our clinical expertise and our patients unique values and circumstances. That is to say we combine in our clinical decision making process three (almost equal) fields: clinical expertise, best available evidence and patient needs and client preferences.

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In this process we have five steps: 1) Convert information needs into answerable questions. 2) Efficiently track down the best evidence to answer the question. 3) Critically appraise the evidence for its validity and usefulness. 4) Integrate appraisal results with clinical expertise and patient values. 5) Evaluate outcomes. Step one: answerable questions: a stepwise process for clearly identifying information needs and form the basis for designing an effective clinical question is represented by the acronym PICO P: Patient population what group do you need information from (e.g. species, breed, gender)? I: Intervention what is the treatment or procedure you need or want to take (e.g. surgeries, medical procedure, diagnostic tests, therapeutics)? C: Comparison what do you want to compare the selected intervention with to assess efficacy (e.g. no treatment, past or current standard treatments, medical versus surgical procedures)? O: Outcomes what is the effect of the intervention (e.g. return to normal function, reduction in severity of clinical signs, increasing expected life span)? Step two: finding the evidence using PICO we establish our keywords list and look into Medline/PubMed/IVIS or other multiple databases sources. Step three: appraising the evidence evidence resources can be applied to a hierarchic pyramid of evidence to rank the evidence from strongest to weakest: Systematic reviews Meta-analyses Blinded Randomized Controlled Trials (RCTs) Cohort Studies Case Control Studies Cross-Sectional Studies Case Series Single Case Reports Ideas, Editorials, Opinions Consensus Reports Comparative Research In-vitro Research Beyond the strength of evidence the results need to be compared to determine if they help to answer the questions in step 1. To assist us another acronym is available RAAMbo R: Is the study population is representative of our patient? A: Allocation of the animal to the treatment has been done by randomization, observational studies, stratification? A: Are all the animals that began the study accounted for at the end of the study? If not do the authors identify what happened to these animals? M: Were outcome measurements in the study evaluated objectively, or were evaluators blinded to treatment or exposure? This is especially important in observational studies, which often are the highest level of available evidence in veterinary medicine.

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Step four: Integrating the evidence at this stage we make our primordial list of actions: can the client can afford the act? Is the action to be taken okay with the clients ethics, culture, religion? Does the veterinarian have the skills to perform? Does the clinic have the technology? At this moment we integrate the best available science, our clinical expertise, patient needs and client preferences to decide the best-evidence plan of action. Also our abilities in EBVA will allow us to debunk many internet treatment myths and educate the clients at the same time. Step Five: Evaluating the outcomes did we see the expected results? If not- how did they differ? Record all steps and make them part of our clinical expertise. A need to evaluate our own EBVA performance is important: did the clinical question yield the appropriate results? Were too many or too few resources allocated? Was the critical appraisal process cumbersome? Were the articles internally and externally valid? How did we integrate the clients preferences, patients needs and our own clinical expertise with the evidence? Were the outcomes of our clinical decision what we expected? EBVA is not easy to begin with, but we should adopt it for one case per day to begin with, adopt the five steps, and over time integrate it with normal clinical practice. In time the steps will be easy to go perform, and as our knowledge increases we can devote more time to explore new areas and improve ourselves, and be able to provide the best available care to our clients and the patients. References: 1) Cochran AL Effectiveness and efficacy: random reflections on health services. London:RSM Press; 1999. 2) Evidence-Based Medicne Working Group Evidence-Based Medicine. J. Am Med Ass 1992; 268:2420-5. 3) Malynicz G Evidence-based medicine Vet Rec 1998; 1439(22):619. 4) Cockcroft PD, Holmes MA.Handbook of evidence-based veterinary medicine. Oxford (UK): Blackwell Publishing; 2003.

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GOLD BEADS IMPLANTATION (GBI) THE SCIENTIFIC BASIS


Dr. Sagiv Ben-Yakir BSc(Biology), DVM(in honor), MRCVS, CVA(IVAS), CVHomotox (Baden-Baden, Germany) ORSHINA The Israeli Institute for Modern Holistic Veterinary Medicine & Sciences Hod-Hasharon, ISRAEL Noble metals such as gold have been used since ancient times as cures for a wide range of diseases (1). The use of gold implants was originated from acupuncture where gold needles had been used in the Far East (1). In the early 1970s some US veterinarians (Dr. Grady Young, followed by Dr. Terry Durkes) started to treat dogs suffering from hip dysplasia with gold implants (2). The implantation was usually done at acupuncture points GB-29, GB-30, and BL54, which lie close to the affected hip joint. Other arthritic conditions (e.g. elbow arthrosis, spinal spondylosis etc) had been treated similarly by implanting gold beads in other local acupuncture points chosen accordingly (3). The mechanism of action put forth by proponents of gold beads implantation is that the gold beads emit a minute positive electrical charge that neutralizes a negative electrical charge of the point, producing analgesia and preventing further arthritic changes at the joint (2,4). It seems that there is another possibility for explaining the basic scientific mechanism behind the gold bead implantation. Upon insertion of metallic gold beads in vivo and in situ it was found that gold ions are released from the implanted gold and diffuse out into the local surrounding tissue and mimic, on a local scale, the treatment with gold-containing drugs used for arthritic conditions (5). Local macrophages and other inflammatory cells attach themselves to the metallic gold surfaces almost immediately after implantation (6). This attachment is mediated by an activation of the complement system as C3 adsorbs to the implant surface. The C3 forms complexes with complement factor B or factor H resulting in the formation of C3b or iC3B respectively. C3b or iC3B are both ligands for macrophages surface receptors. Additionally, fibronectin and vitronectin also absorb to the locally implanted surface of the gold bead and act as a ligand for the macrophages through RGD-integrin receptor domains. These and other ligand-interactions are the primarily interactions between gold surface and macrophages and other inflammatory cells. The inflammatory cells produce an ultra-thin layer, a dissolution membrane, within which the necessary chemistry for liberation of gold ions is found. This is 10-100 nm thick biolayer membrane essential for the dissolution of metal implants and particles (which cannot be phagocytosed). The inflammatory cells (e.g. macrophages, other neutrophils) release cyanide into the dissolution membrane and into their immediate surroundings (7,8,9). The following chemical process takes place: 4Au + 8CN- + 2H20 + O2 = 4[Au(CN)2]- + 4OH-

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The complex ion aurocyanide, Au(CN)2- , a relatively stable ion, inhibits the lysosomal enzymes of inflammatory cells in the synovial tissue and decreases the number of inflammatory cells in situ. Also, the aurocyanide ions inhibit antigen processing and suppresses NF-kappa Bbinding activity and I-kappa B-kinase activation, and in turn reduces the production of proinflammatory cytokines. Aurocyanide is the active substance that inhibits the cellular functions of inflammatory cells (10,11,12). Also, these ions move from their dissolution membrane location into intercellular space where they are taken up both by the macrophages and by other inflammatory cells further away. We can find also that the longer the gold implant stays in the inflamed tissue, the further away gold ions will be taken by inflammatory cells. It was also found that when the cells surrounding the gold implant become heavily loaded they will leave their position on the dissolution membrane and be replaced by new inflammatory cells (5,6).
References: 1) Gold Symposium 1, June 20, 2007 at Institute of Anatomy, Aarhus University, Denmark. 2) Gold Bead Implants by Durkes T. E. in Veterinary Acupuncture, Ancient Art to Modern Medicine ed. by Schoen A. M. 2nd edition, Mosby, USA, 2001, Chapter 25, pp 303-305. 3) Gold Bead Implantation by Durkes T. E. in International Veterinary Acupuncture Society Certification Course notes, San Diego, USA, 1989-1990. 4) Revolutionary new pain theory and acupuncture treatment procedure based on new theory of acupuncture mechanism by Takase K, in Am J. Acupuncture 11:305-323, 1983. 5) In vivo liberation of gold ions from gold implants. Autometallographic tracing of gold in cells adjacent to metallic gold by Danscher G. in Histochem Cell Biol 117:447-452, 2002. 6) In vitro liberation of charged gold atoms: autometallographic tracing of gold ions released by macrophages grown on metallic gold surfaces by Larsen A. Stoltenberg M and Danscher G in Histochem Cell Biol 128:1-6, 2007. 7) The activation of gold complexes by cyanide produced by polymorphonuclear leukocytes, the formation of aurocynide by myeloperoxidase by Graham G.G in Biochem Pharmacol 39:1697-1702, 1990. 8) Serum lysozyme: a potential marker of monocyte/macrophage activity in rheumatoid arthritis by Torsteindottir I et al in Rheumatology 38:1249-1254, 1999. 9) Molecular mechanism of action of gold treatment in rheumatoid arthritis: an update by Burmester GR in Z. Rheumatol 60:167-173, 2001. 10) Mechanism of action of disease modifying anti-rheumatic agent, gold sodium thiomalate by Mangalam A. K. in Int Immunopharmacol 1:1165-1172, 2001. 11) Inhibition of IL-6 and IL-8 induction from cultured rheumatoid synovial fibroblasts by treatment with aurothioglucose by Yoshida S et al in Int Immuno 11:151-158, 1999. 12) Inhibition of the DNA-binding activity of NF-kappa by gold compounds in vitro by Yang J.P. in FEBS Lett 361:89-96, 1995.

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THE USE OF BRAIN IMAGING TECHNIQUES IN EXPLAINING ACUPUNCTURE: A REVIEW


Anna K. Hielm-Bjrkman, DVM, Ph.D. Faculty of Veterinary Medicine, Department of Equine and Small Animal Medicine, P.O. Box 57, FIN-00014, University of Helsinki, Finland. Email: anna.hielm-bjorkman@helsinki.fi

Since the late 1990s brain imaging techniques such as positron emission tomography (PET) and functional magnetic resonance imaging (f-MRI) have revolutionized the objective acupuncture (AP) research. In this review we will go through the major findings of this research and their implications. The papers reviewed have been collected using the major databases MEDLINE, PubMed as well as personal connections. In April 2008, 112 articles were found on the subject AP and MRI. The early studies are all on healthy subjects and most are on humans, only a few on rats. Some later studies have looked into patients with an ongoing disease. What is MRI? MRI uses the bodys natural magnetic properties to produce detailed images from any part of the body. The hydrogen nucleus with its one single proton (H+) is used. It normally spins with its magnetic axes randomly aligned. Under strong magnetic influence (in MRI scanner) the protons axes line up uniformly. When additional energy in the form of a radio wave is added, the hydrogen nuclei will resonate. This radio wave frequency is dependent on the hydrogen and the magnetic field. The radio wave is then turned off and the magnetic vector returns to its resting state and at this time emits a signal (also a radio wave). This signal creates the Magnetic Resonance Images. Receiver coils around the body help to detect the emitted signals. The signals are plotted on a grayscale and images build up. Different tissues relax at different rates and thus can be identified as different grays on the picture. Most disease will show more water content in the tissue. This can make it difficult to differentiate between a tumor and infection, for example. There is no hazard, as radio waves are all around us at all times. What is f-MRI? It does not require any radio-active tracer substances (like PET or SPECT) and uses the brains natural hemodynamic responses to brain activity as a tracer. Most common is BOLD = blood oxygenation level dependent. This depends on the ratio of oxygenated to deoxygenated hemoglobin. Where there is activity increased flow of oxygenated blood that surpasses consumption. The local changes cause increase in MR signal that the ultrafast scanning can measure and superimpose on the patients brain picture. Group averages can be superimposed into the same standard brain picture.

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AP use: Measuring the BOLD signal while the patient gets AP or different kind of sham treatments. Statistical tests are used to see if changes in signals are reliable and significant. An increase means BOLD activity and is often shown by a yellow/orange/red colour in the pictures, whereas a decrease means decrease in BOLD activity and is often shown by green/blue colours. F-MRI studies can be performed for dry needling, EA, laser, TENS, real AP, sham, minimal, in healthy, in diseased patients, with various depth, stimulation type, etc. The brain a quick review Usually 4 different pictures: 1. Lateral view of the left hemisphere of the brain: o 1 hemisphere has 4 lobes: Frontal (executive center; working memory, planning, cognitive evaluation) temporal (evaluative processes and memory), parietal (spatial processing) and occipital (supports vision). The Brodmann (BA) areas show the functional differentiation of the brain cortex, based on different neurons and is followed by a number. o SI (BA1,2,3): The primary somatosensory cortex in parietal lobe, sensing touch from body (=initial localization and qualitative characterization of stimuli) o SII (BA5): The secondary somatosensory cortex, in parietal lobe, sensing touch from head and face 2. Saggital section / Cross-sectional o ACC: Anterior cingulated cortex (part of limbic system, pain-matrix, rich in opioid receptors, attention, memory, affective processing) o Brainstem: Periaqueductal gray (PAG-rich in opioid receptors) and Raphe nuclei (pain-matrix, may participate in opioidergic and non-opioidergic anti-nociception) o CER: Cerebellum (helps control postural reflexes, may participate in higher order cognitive functions and affect). o Thalamus: Located centrally, relays sensory info from the periphery to the brain cortex 3. Coronal section / Cross-sectional o Amygdala: (in medial temporal lobe, part of limbic system; learning, memory, mood, pain-matrix) o Insula: pain-matrix o Hippocampus (in medial temporal lobe, part of limbic system; learning, memory) o Hypothalamus (Located centrally, part of limbic system; modulates neuroendochrine and autonomic regulation, maintains homeostasis) Interaction of all 3 affect motivational state of nervous system. 4. Dorsal view o 2 hemispheres: each with 4 lobes ACUPUNCTURE AND PAIN: 1. Acupuncture in healthy subjects: The pain response in the brain: The first acupuncture f-MRI study was published in 1998.

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Wu et al. (1999) published a very nice study in Radiology with 4 groups, using 9 healthy subjects. He gave them 1) Real AP at either left ST36 or 2) LI 4, 3) Minimal AP (only 0.5 cm in and at a non-meridian point 3 cm from left ST36, or 4) Superficial pricking on the skin of left ST36. Results (R): He noted a higher de-qi, bradycardia in the ST36 and LI4 groups, decrease in the rostral part of anterior cingulate cortex, in amygdala, in the hippocampal complex. Also noted was an increase in the hypothalamus and nucleus accumbens. These changes were not seen in sham AP groups. Implications AP deactivate limbic structures subserving pain association and activate anti-nociceptive pathways difference between AP and sham groups. Hui KKS et al. (2000) looked at13 healthy subjects that they gave 1) Real AP at LI4 or 2) sham AP (Tactile stimulation: tapping the same place with a monofilament at 2Hz). Needle AP R: (i) in 11/13 that experienced deqi there was decreased activity in Nucleus accumbens, hippocampus, parahippocampus, hypothalamus, ventral tegmental area, anterior cingulated gyrus (BA 24), caudate, putamen, temporal pole, insula. (ii) an increase in SI and SII and iii) in 2/13 that felt pain instead of deqi: increase of activity in anterior cingulated gyrus, caudate, putamen, anterior thalamus, posterior insula. Tactile stimulation however, gave a different response; there was increase in SI and SII but no decreases in deep structures. Wu et al. (2002) used 15 healthy subjects that were given 1) Real EA in GB34, left leg, 2) Sham EA, non meridian point on left leg (same stimulation as real EA): tapping the place with a monofilament at 2Hz , 3) Mock EA, non meridian point on left leg (no current/stimulation), 4) Minimal EA, non meridian point on left leg (superficial 0,3-0,5 mm, and light stimulation) or 5) Rest no stimulation. They noted R: (i) EA both in GB34 and in sham location both activated hypothalamus and SI + motor cortex and deactivated anterior cingulated cortex. Real EA reacted more than sham. This supports the idea that sham AP analgesia works in about 3350% of patients while real AP work in 55-85% of patients (Richardson and Vincent 1986). (ii) Minimal EA elicited significantly higher activation of medial occipital cortex than mock EA. (iii) The auditory cortex and the visual cortex frequently respond to all except mock stimulus. Implication: Sham EA and minimal EA cannot be used as placebos. Also Xiao YY et al.(2006) gave AP to 26 healthy subjects 1) 16 Real AP: ST36 right leg, all felt de-qi and 2) 10 Sham AP, non-meridian point right leg about 3 cm from ST36 right leg (same stimulation as real) 4/10 felt de-qi. R: AP both in ST36 and in sham location both activated preand post central gyrus, PAVN, insula, occipital cortex, parietal lobe, cingulated gyrus, pons, hypothalamus, thalamus, supramarginal gyrus and cerebellum. Only activation in the temporal gyrus was seen statistically more on the real AP stimulation. Implication: Sham EA cannot be used as placebo. Zhang WT et al. (2003) used high and low frequency TENS at LI 4 and saw more limbic deactivation in responders due to high frequency AP, compared to low. Liu WC et al. (2004) used 7 healthy subjects and 1) 30 min AP at LI 4 and 2) sham point on leg. They could see increased episodic PAG activity after 20-25 min of stimulation. SI and SII were active >90% of the time whereas sham stimulation reduced PAG and cortical activity.

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Qin W et al. (2006) looked at 14 healthy subjects 1) Resting state with no needle and no stimulus 15 min. 2) Real AP: ST36, aiming at deqi but no pain R: (i) with no needle and no stimulation there was a default endogenous analgesia network present in the brain, at a low level. Significant resting state connectivity in superior/middle frontal gyrus superior occipital sulcus, PCC, ACC, nucleus accumbens, hypothalamus, caudate, putamen, posterior thalamus, hippocampus, frontal lobe, parietal lobe. (ii) The connectivity network post AP is more extensive and significant: Significant connectivity with the regions of superior/middle frontal gyrus, parietal lobe, frontal lobe, PCC, ACC, nucleus accumbens, hypothalamus, caudate, putamen, posterior thalamus, hippocampus, dorsal thalamus, cerebellar vermis and mesencephalon periaquaductal grey matter (PAG). (iii) The difference mainly at anterior frontal cortex, brain stem, cerebellum (ACC, PCC, nucleus accumbens, hypothalamus, PAG). Indicates: May be that a default endogenous analgesia network is present in the brain at all times, at a low level. The pain response in the spinal cord: Some studies have now also looked at activation of the spinal cord after AP: Li G et al. (2005) used 11/(26) healthy subjects (15 moved too much), and they were all given real EA: LI4 and LI11 simultaneously, in the left arm. 73% showed positive activation (4%) in gray matter of the spinal cord at T1 to C7 with peak activity at C7. Bilaterally in spinal cord sensorimotor areas, both ventral and dorsal. Implications: These points are used for sensorimotor deficits and may benefit these patients by activating the spinal cord at areas that correspond to upper limb sensorimotor deficits. 2. Acupuncture in subjects with a pain disease As AP has been suggested to have a homeostatic role, it may have better effect on patients with a pathological disorder. Newer research has looked at subjects with disease. Acupuncture in subjects with Carpal tunnel syndrome (CTS) Napadow V et al. (2007a) looked at (13) 10 Carpal tunnel syndrome (CTS) patients, (12) 9 healthy controls (HC), doing a f-MRI scan before treatment (baseline) and 5 weeks after treatment of either 1) Real EA: 5 weeks AP (schedule: 3 wk: 3 x/wk + 2 wk: 2 x/wk), EA 2 Hz, 10 min TH5 to PC7 + manual needling in 3 other points (chosen from HT3, PC3, SI4, LI5, LI10, LU5), with deqi or, 2) No treatment (only healthy controls (HC)). R: (i) Subjective questionnaire, dyseathesia levels, paresthesia levels, median nerve sensory latency to digit 2 and 3, mean sensory latency, % change in grip strength all significantly improved in the AP group. (ii) The activation maps for the median nerve innervated digit 3 showed decreased activation in SI and SII. The SI representations of digits 2 and 3 were close at baseline but more separated after AP. In the HC they were separated at all times. Implications: The researchers suggest Hebbian plasticity plays a role in longer-term changes in the cortex activity, where it may be reinforced via synaptic strengthening from NMDA receptormediated long-term potentiation. Napadow V et al. (2007b) used the same groups again to look at f-MRI before treatment (baseline) and after treatment (after 5 weeks). He gave them 1) real AP at LI4 or 2) sham AP: Tapping a monofilament at LI4. Compared to HC the AP group showed a significant (i) deactivation of the contralateral amygdala. Implication: AP may function to ameliorate the

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affective component of chronic pain by deactivating a sensitized, hyperactive amygdala. This may initiate a progressive normalization of activity via neuroplasticity, leading to long-term physiologically and clinically relevant response. With accumulative treatments that are spaced regularly, a learned cognitive coping strategy may become more entrained and lead to a longerterm strategy for pain suppression. They could also see (ii) a decrease in anterior and posterior cingulated cortices (ACC, PCC), prefrontal cortices (PFC), anterior insula, septal area, SI, supplementary motor area, thalamus (Nucleus accumbens, hippocampus, parahippocampus, hypothalamus, ventral tegmental area, anterior caudate, putamen, temporal pole and (iii) activation of the lateral hypothalamic area (LHA). The greater the maladaptive plasticity in contralateral SI (Measured as representation blurring in digits 2 and 3) the greater the hypothalamic increase. Implication: Patients with central manifestations of their peripheral lesions might respond to AP with hypothalamic activity. The more sharp pain due to treatment, the less LHA increase thus it is not likely that AP analgesia is a stress or pain response. Also, chronic pain patients respond to AP differently than HC. There is a relationship between amygdala and hypothalamus: The more deactivation of amygdala, the less activation of hypothalamus and vice versa. In HC AP may alter brain function through neuroplasticity mechanisms by a combination of afferent somatosensory stimulus and affective evaluation and thereby modulating centrally maintained chronic pain states. ACUPUNCTURE AND STROKE: Acupuncture in subjects with stroke Jeun SS et al. (2005) used 10 healthy subjects that were given 1) Real AP at GB34, deqi but no pain or 2) Sham: tapping the place with a monofilament. R: Needle AP caused an increase in bilateral sensimotor areas (BA 3,4,6,7) thus could possibly be used for stroke patients Li G et al. (2006) looked at 12 clinically stable stroke patients + 12 matched healthy subjects that he gave 1) Real AP: EA from LI4 to LI11 or 2) Tactile stimulation (brushing the fingers with a sponge). He got nearly same results with both real AP and sponge stimulation: activation of contralateral PMC, SI, SII and ipsilateral cerebellum. With both stimulations better activity in the patients compared to the healthy. Statistically the larger stimulation area/more activation occurred with the sponge than with AP (p<0.001). This implies that sensory-implicated AP points have a correlation with the somatosensory cortex through somatosensory pathways. ACUPUNCTURE, PLACEBO and PET / f-MRI Wager et al. (2004) compared 2 groups: 1) one given an inert analgesia cream + pos. expectancy manipulation (where the testers implied that this would be a very good treatment) and 2) a control cream (in reality the same cream, but where testers implied that this was a cream with no effect). R: They found that placebo analgesia was related to decreased brain activity in painsensitive brain regions, including the thalamus, insula, and anterior cingulate cortex, and was associated with increased activity during anticipation of pain in the prefrontal cortex, providing evidence that placebos alter the experience of pain (not an AP study). Pariente et al. (2005) looked (PET) at 14 subjects with OA in metacarpal phalanx that got 1) Real AP at LI 4 + pos expectancy manipulation, 2) Placebo AP (Streitberger needle) at LI4, + pos expectancy manipulation and 3) Overt placebo: blunt AP needle that did not penetrate (No

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AP) + neg expectancy modulation. The ones that had been pos. expectancy modulated an unmistakable sensation of analgesia whereas the neg. expectancy modulated no analgesia. The Non-specific effects of AP: (Seen both in real AP and in the expectancy manipulated placebo) Relative activation of DLPFC (BA6), rostral ACC, and in the midbrain. There was only one area that ONLY reacted in AP, indicating a specific effect of AP: Activation of ipsilateral visceroceptive autonomic pathway: SII/posterior and anterior insular cortex. Kong J et al. (2006) looked at 16 healthy subjects that either got 1) placebo AP (Streitberger needle) at LI 4 or SI 3 + pos expectancy manipulation or that were a 2) Control: with no AP + neg. expectancy modulation. With the placebo acupuncture + pos expectancy the pain decreased significantly (p<0.0001) and showed a detectable placebo analgesic effect in the brain (post treatment pretreatment), i.e., significant changes in right AI, bilat rACC, DLPFC, left parietal cortex, supramarginal gyrus, whereas the control had an unmistakable sensation of no analgesia. None of them got any treatment. Implication: There is evidence that real acupuncture and sham acupuncture can produce complex brain changes in areas connected with pain transmission and pain perception, but there is uncertainty about how specific these effects are. Quite similar effects also occur in response to both placebo treatment and to hypnosis. Placebo analgesia may be configured through multiple brain pathways and mechanisms. The Streitberger needle can be used as an AP placebo (???) ACUPUNCTURE AND POINT RELATED RESEARCH: Cho et al (1998, 1999, 2001) found that stimulation of GB37 and BL67 correlated with activation over the visual cortex and that GB43 correlated with activation over the auditory cortex. Siedentopf et al (2002) found that Laser AP caused activation of cuneus at BA18 and medial occipital gyrus at BA19 of the ipsilateral visual cortex. In sham group no activation. Wu et al. (2002) found that nearly all stimulations (real EA of GB34 and non-meridian sham and minimal EA, but not mock EA) correlated with activation over both the visual and the auditory cortex the activation of these are not acupoint specific phenomenon. Also other research (Craig et al. 1996, Baciu et al. 1999) suggests that activation of the medial occipital cortex (vision) and superior temporal gyrus (hearing) might be elicited by any somatic-visceral sensory stimulation. Kong J et al. (2007) also found that (n=6) 1) real EA: BL60 and GB37 and 2) sham AP, (same stimulation at non AP point) gave similar results in both groups: Decreases in occipital cortex (bilateral cuneus, calcarine fissure, lingual gyrus, lat. Occipital gyrus). All these now indicate that change in activity is not point dependent, happens at real and sham points in the same way. The Cho et al. (1998) paper has therefore now been withdrawn. If this field interests you, please read an excellent review: Dhond RP et al. Neuroimaging acupuncture effects in the human brain. The Journal of Alternative and Complementary Medicine 2007; 13; 603-616. References Available Upon Request

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TREATMENT OF FACIAL NERVE PARALYSIS IN DOGS USING ACUPUNCTURE: A WESTERN AND EASTERN VIEW OF THE PATTERN OF THE DISEASE
C. C.T. Haddad, DVM Institute Bioethicus Botucatu SP Brazil Assistants of University of So Paulo Acupuncture and Chronic Pain Service Email: carolhaddadvet@hotmail.com Joaquim, J.G.F. University of State of Sao Paulo Botucatu SP Brazil Luna, S.P.L. University of State of Sao Paulo Botucatu SP Brazil ABSTRACT Paralysis of the Facial Nerve is one of the most common diseases of the cranial nerves15. Central facial nerve paralysis can be caused by intracerebral diseases, while peripheral facial nerve paralysis can be caused by facial neuritis, viral infection or compression due to trauma. The aim of this study was to analyze 5 cases of facial nerve paralysis in dogs, treated with acupuncture and evaluate the results obtained after the treatment. Symptoms that were common for them were: absence of palpebral reflex and difficulty in closing the eyes. One of them was presented with bilateral facial paralysis, which will be discussed in the text as an autoimmune disease due to Lyme disease. The TCM diagnosis was Qi Stagnation Blockage of the channels secondary to trauma, since all of them were peripheral. After an average of 10 weeks of weekly acupuncture treatment with dry needles, they were able to close the eyes again. 1. INTODUCTION 1.1 Paralysis of the Facial Nerve Paralysis of the Facial Nerve is also known as Facial Paralysis. It is one of the most common diseases of the cranial nerves15. Central facial paralysis can be caused by cerebrovascular accident, cerebrovascular malformation and intracranial tumor15. This disorder belongs to supranuclear paralysis of the facial nerves. Peripheral facial nerve paralysis can be caused by the facial neuritis inside the temporal bone (the facial canal), or by viral infection and compression of the facial nerves leading to disturbance of the blood circulation and axon myelin degeneration15. This disorder belongs to intranuclear paralysis of the facial nerves15. In TCM, it is called Waipi (deviation of the eye and mouth) 15. Central facial paralysis is caused by a Wind Stroke, while peripheral facial nerve paralysis is caused without a Wind Stroke2. The meridians most often involved in facial paralysis are the Stomach meridian and the Large Intestine meridian (Yang Ming)7.

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1.2 Lyme Disease Lyme borreliosis is the most commonly reported tick-transmitted disease in humans and is an important disease in dogs. Lyme disease is caused by Borrelia burgdorferi infections in dogs (canine Lyme disease). Clinical syndromes known to commonly be associated with canine Lyme disease include polyarthritis and glomerulopathy. Proteinuric dogs might need longer treatment as well as medications and diets for protein-losing. The difficulty in making a diagnosis is a result of the fact that dogs do not develop a characteristic symptom to mark the beginning of their disease, and many dogs become seropositive but never develop clinical manifestations. Also, Borrelia burgdorferi has been isolated from the blood of healthy dogs, which suggests that detecting a spirochetemia may not have diagnostic significance. After other common illnesses are ruled out, serology and response to antibiotic therapy help suggest a diagnosis. Serological test results can be used to document exposure to B. burgdorferi but not prove illness. Seropositive dogs with clinical abnormalities thought to arise from Lyme disease generally are treated with doxycycline (10 mg/kg q24h for 1 month) 18, 21 . In animals bilateral facial paralysis are rare, and establishing its etiology can be challenging.

2. MATERIALS AND METHODS 2.1 Animals Five dogs treated at the Acupuncture Ambulatory Unit at the Faculty of Veterinary Medicine and Animal Science, University of Sao Paulo State UNESP, Botucatu, SP BR. All animals were evaluated by the University Small Animal Medical team and other professionals before been referred for acupuncture. The animals were a 5 year-old German Shepard (Animal one), with no past history associated with trauma or other current disease until the clinical presentation; a 2 year-old male Dachshund with a history of being attacked by Doberman dog; a Coker spaniel with no history of trauma, or other current co-morbidity; another Dachshund with clinical history of ear abscess and another German Shepard with no co-morbidity nor current disease, only an acute facial paralysis. 2.2 Complementary exam A western diagnose was made based on clinical signs, blood samples analyses and electroneuromyography. Some routine laboratory blood tests were ordered and all of the laboratory investigations were within normal limits at the beginning of the acupuncture sessions. 2.3 Treatment 2.3.1 Medications Before being referred for acupuncture treatment, some medications such as doxyccycline (Vibramicina 5mg/kg twice a day, for 15 days) and prednisolone acetate (MeticortenPDS, 2mg/kg) were given orally once a day for the German Shepard with positive PCR for Erlichiosis. The Dachshund (which was attacked by another dog) was prescribed enrofloxaxin 50mg q24h PO for 7 days, meloxicam 1mg q24h Po for 7 days and local ice q8h on the lesion before being referred for acupuncture. One day after the trauma the dog could not close his left eye and had facial drop on the left side. It was also prescribed prednisone 5mg q12h for 3 days, than q24h for 3 days, than q48h for 3 days and an ophthalmic ointment, Epitezan, (containing Retinol acetate 10.000 UI +aminoacids 25mg + metionine 5 mg + cloramphenicol 5 mg) topically 0,5cm every 8h for 5 days. After 7 days without any change in clinical signs, he was presented for an acupuncture consultation. The Cocker Spaniel was

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prescribed prednisolone acetate, Meticorten (PDS), (2mg/kg) given orally once a day for 10 days. Finally, for the Dachshund with ear abscess was prescribed Cefalexin (10mg/ks SID, for 10 days). Nothing, except acupuncture, was proposed for the German Shepard with acute facial paralysis. 2.3.2 Acupuncture The acupuncture treatment was done with manual stimulation only, with weekly sessions, for an average of 10 treatments. For the treatment, only dry 0.25mm x 15mm Seirin needles were used. They were placed at a depth of 5mm and treated for 20 minutes. The treatment points were: LV 3 for Liver Blood Stagnation and GB 34 to drain Liver Pathogens along with BL18, the Association Point for the Liver; LI 4 to open and brighten the eyes; LU 7 as the master point for head and neck; ST 1, 2 and 4, GB 1, BL 1 and GB 14 were used as local points on the face. For the Dachshund with the chronic ear infection and the keratoconjunctivitis sicca (KCS) LV 8 and KD 10 were also used. When necessary, moxa was used on distal points for all of the animals and as local for one animal with the Chinese Medicine pattern of WindCold invasion. Points 4,5 and technique used: Technique: leave the needles in place for 20 minutes and tonify the distal points for 10 minutes. For the German Shepard dog, electroacupuncture stimulation was used with low frequency, which stimulates the types III and IV nociceptive fibers and the small motor fibers which can cause paresthesia and muscular contraction. The wave mode was dense-disperse with alternating current27. - LIV3 (Tai Chong): On the medial aspect of the second toe, proximal to the metatarsophalangeal joint, midway between the dorsal and medial aspect of the bone; - GB34 (Yang Lian Quan): In the depression cranial and distal to the head of the fibula. - LI4: Between the 1st and 2nd metacarpal bones, approximately in the middle of the 2nd metacarpal bone on the radial side; - LU7 (Lie Que): Proximal to the styloid process of the radius, 1.5 cun above the transverse crease of the carpus. - ST1 (Cheng Qi): On the conjunctival side of the point depicted on the lower eyelid, in the center, between the ventral border of the orbit and globe of the eye; - ST2 (Si Bai): On the infraorbital foramen, rostroventral to ST1. The infraorbital n. is deep to this point; - ST4 (Di Cang -Earth granary): At the lateral corner of the mouth. - GB1 (Tong Zi Liao): Lateral to the lateral canthus, in the depression on the lateral side of the orbit; - BL1 (Jing Ming): 0.1 cun dorsal to the medial canthus; - GB14 (Yang Bai): 1 cun above the midpoint of the eyebrow; - KD10 (Yin Gu-Yin Valley): At the internal extremity of the popliteal crease, between the tendons of the muscles semitendinosus and semimembranosus. - LIV 8 (Qu quan -Curved spring): On the medial side of the stifle joint, caudal to the medial epicondyle of the femur. The point is proximal to the medial end of the transverse popliteal crease, (when stifle is flexed) on the cranial border of the semimembranosus and semitendinosus. - BL18 (Gan Shu): 1.5 cun lateral to the caudal border of the spinous process of the 10th Thoracic vertebra;

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2.4 Evaluation 2.4.1 Clinical and neurological examination. On physical examination, all the animals were afebrile, with normal pulse and respiratory rate. The neurological examination revealed: - Ear drooping; lip commissural paralysis; - Sialosis, and collection of food on the paralyzed side of the mouth; - Menace (Threat) reflex: positive with blink in one eye for the animals except for the German Shepard which was absent in both eyes. - In two of them the superior eyelid could move a little bit, but the inferior eyelid could not move. The eye tearing was excessive or absent (German Shepard). The animals showed no pain during clinical exam 8,9,11. 2.4.2 Complementary exam The Coker was submitted to an ENMG and due to the results, including denervation potentials and absent evoked muscle potentials, peripheral Facial Paralysis was diagnosed as idiopathic facial paralysis since the aetiopathogenesis is presently unknown. The German Shepards diagnosis: since a trauma or idiopathic bilateral facial paralysis is not common (occurs in less than 1% of human patients with facial paralysis) 20, the German Shepard was submitted to PCR for evaluation of Erlichiosis, due to the relationship between this disease and Lyme disease. The PCR was positive for Erlichiosis. The Dachshund with keratoconjunctivitis sicca (KCS) was diagnosed as a facial nerve injury based on the history of a lesion close to the ear caused by the ear infection which consequently led to the KCS at the same time. The KCS was evaluated with Mean Schirmer tear test (STT) and the initial result for the affected eye was 4 mm/min. The Dachshund with a history of been attacked by Doberman dog had a Peripheral Facial Paralysis and the patients often have a history of blockage of the facial nerve transmission, inflammation close to the ear, 2/3 hypogeusesthesia of the tongue, hyperacusis, etc.15. The western diagnosis of Facial Nerve Injury and consequent paralysis was made based on clinical and neurological signs. The German Shepard dog with acute unilateral facial nerve paralysis was classified as idiopathic facial paralysis based on clinical and neurological findings. 3. RESULTS After treatment the animals were considered cured if they had neurological improvement, which consisted of return of the Menace Reflex, eye blink, production of tear (Shirmer test evaluation)9,11 absence of ear drooping and lip commissural paralysis. The sialosis and difficulty eating should also be reversed. For the 5 animals, all signs of neurologic disease were reversed. 4. DISCUSSION The Western diagnosis of Facial Nerve Injury and consequent paralysis was made based on clinical and neurological signs. Conventional treatment was done as the literature recommends and no signs of improvement were observed.

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All dogs had a Peripheral Facial Paralysis according to clinical evaluation and exams; the diagnose was clear for the Dachshund since he had a history compatible with blockage of the facial nerve transmission, inflammation close to the ear, etc.15. According to the literature, the facial nerve branch is very close to the ears, so any kind of ear disease can result in a facial nerve lesion. The TCM diagnosis suggested Qi Stagnation Blockage of the channels due to trauma. The Coker was diagnosed as having idiopathic facial paralysis and the Chinese treatment selected was also unblock the local channels that nourish the face, especially Yang Ming Channel, which consist of Stomach and Large Intestine. The German Shepard and the Coker Spaniel with acute facial nerve paralysis, also had Qi Stagnation with blockage of the channels but not due to trauma. Theoretically, since it is due to cold-wind invasion, moxa should be used on distal and local points. For all other animals, the moxa should be used just on the distal points. From the Chinese perspective, the moxa stimulates the bodys Yangenergy and the pathogenic Yin energy is supplanted by Yang thermal factor, raising the total Yang-level, eliminating the blockage of Qi and Blood, usually caused by Exterior WindCold-Damp, making it flow along the channels27. There are many human papers describing the relationship between Lyme disease and Erlichiosis. Molecular analyses indicate that the human granulocytic ehrlichiosis (HGE) agent is either similar to or identical to the agent that causes equine granulocytotropic ehrlichiosis (Ehrlichia equi), suggesting that these diseases may be caused by the same organism 23,24,25. Recently, coexistence of antibodies to tick-borne pathogens, such as Babesia microti, HGE agent, and Borrelia burgdorferi, have been reported, indicating that humans and animals may be infected simultaneously by these pathogens through tick bites22. Since the PCR was positive for Erlichiosis and since we have many human descriptions for Lyme disease causing Facial Paralysis, this is the first description of a supposed case of Erlichiosis disease causing bilateral facial paralysis due to autoimmune response in a dog, in a way that it affects both roots of the facial nerve, causing a probably neuritis26. From a Chinese perspective, the disease was caused by a Qi Stagnation Blockage of the channels caused by a Wind-Heat agent. In this case, moxa was not used and electrical stimulation was used on the local points. The points selected were the same for all dogs. According to those findings, the selection of the acupuncture points was based on the Eight Principles and the Zang Fu1,2,3,5,6,7. After an average of 7 treatments weekly the dogs were almost recovered and the improvement could be observed week-to-week, except for the German Shepard, which improved more slowly. 5. CONCLUSION We concluded that facial nerve paralysis can have very different etiology and in the Chinese perspective it can also have different pattern of diagnose and consequentially treatment. For the cases studied in this paper, acupuncture was a very effective form of treatment of facial nerve paralysis. References 1. Maciocia G. Padres do Fgado. Os Fundamentos da Medicina Chinesa. So Paulo: Roca, 1996: 279. 2. Maciocia G. Golpe de vento. A Prtica da Medicina Chinesa. So Paulo: Roca, 1996: 675687.

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3. Yamamura Y. Pontos de acupuntura dos canais de energia principal. A Arte de Inserir. 2nd ed. So Paulo: Roca, 2004: 55. 4. Inada T. Moxabusto. Tcnicas Simples que Complementam a Acupuntura e a Moxabusto. So Paulo: Roca, 2003: 191. 5. Lade A. Point images and functions. Acupuncture Points Images and Functions. Seatle: Eastland Press, 1996: 29-243. 6. Lorenz MD, Kornegay JN.Histrico e exame neurolgico. Neurologia Veterinria. 4th ed. So Paulo: Manole, 2006: 8-38. 7. Schoen A. Acupuncture for musculoskeletal and neurologic conditions in horses. In: Fleming P, ed. Veterinary Acupuncture. 2nd. St. Louis: Mosby, 1994: 454-455. 8. Zhen LS. Types of pulses. Pulse Diagnosis. Sydney: Paradigm, 1985: 12-19. 9. Pellegrino F, Suraniti A, Garibaldi L. Exame neurolgico. In: Garibaldi L, Ed. Sndromes Neurolgicas em Ces e Gatos. So Paulo: Interbook Comp, 2003, 40-63. 10. Andrade SF. Analgsicos. In: Andrade SF, Ed. Manual de Teraputica Veterinria. 2nd. So Paulo: Roca, 2002, 77-86.

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INTERRELATIONSHIPS BETWEEN EQUINE ACUPUNCTURE, CHIROPRACTIC AND DENTISTRY


Kevin J. May, DVM El Cajon Valley Veterinary Hospital El Cajon, CA, USA

The relationship between acupuncture, chiropractic and dentistry is one that needs to be recognized and addressed. A problem in one area can directly or indirectly affect the others, and treatment in one area can also directly or indirectly affect the others. The following discussion is going to reveal some of these relationships as far as diagnosis and treatment.

The primary involvement of acupuncture, in this discussion, is going to be the diagnosis of a problem in the head and/or poll area. This diagnostic process involves detecting sensitivity to digital palpation of three acupuncture points (Figure 1). Stomach 7 (ST 7) is a point located in the depression of the masseter muscle, just ventral to the zygomatic arch, cranioventral to the temporomandibular joint and caudoventral to the lateral canthus of the eye. Triple Heater 17 (TH 17) is located in the depression between the mandible and the mastoid process, caudoventral to the ear canal. Bao-Sai is located in the depression in the masseter muscle, midway on a line from the lateral canthus of the eye to the ventral aspect of the mandible, at the level of and just caudal to the interocclusal space of the lower 3rd molars (311/411).

Sensitivity to digital palpation of these points is helpful in the diagnosis of a dental and/or chiropractic problem, and helps in determining the response to treatment by its loss or persistence. Sensitivity on digital palpation of ST 7 could be indicative of a syndrome called, Temporomandibular Joint Myofascial Pain Syndrome or T.M.J.-M.P.S. Sensitivity at this point could be related either to a problem with the T.M.J. itself, masseter myofascial pain or both. Palpation of the T.M.J. with the mandible, in the resting position or in motion, to detect sensitivity and/or crepitation can help to determine if the T.M.J. is involved.

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Figure. 1

Figure. 2 One contributing factor in the development of T.M.J.-M.P.S. is the conformation of the poll area, more specifically the amount (or lack of) space between the wing of the atlas and the mandible. The width of this space, also known as the Wing of the Atlas Mandible Distance, or W.A.M.D. (Figure 2) is evaluated with the horse in a normal, upright position. The desired width or distance is a minimum of 2 fingers on an average sized horse using an average sized human hand. This is more of a problem for horses that are asked for ventral flexion in the poll area. As the flexion increases, the mandible comes closer to the wing of the atlas and the W.A.M.D. decreases. If there is not sufficient room for this to happen, excessive pressure will be applied to the soft tissues that lie between these two structures, as well as on the two

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structures themselves and the T.M.J. This can result in a chiropractic problem in the poll area (Dorsal Atlas - Figure 3), and put excessive stress on the T.M.J.

Figure. 3 These stresses can not only cause sensitivity to digital palpation of ST 7, but can also affect TH 17. If ST 7 is the only or the most sensitive point of all three of these points, then T.M.J.-M.P.S. syndrome is considered to be the primary problem and its predisposing factors need to be investigated. If sensitivity at both ST 7 and TH 17 are noted, then the problem is considered to involve the poll area as well. If TH 17 is more sensitive than ST 7, then this problem is considered to be more of a primary poll problem (conformation, chiropractic) with secondary T.M.J.-M.P.S. If Bao-Sai is the only point that is sensitive or the most sensitive, then it is usually considered to be associated with a more local problem, either in the soft tissues or cheek teeth in the area. Horses that have a narrow W.A.M.D., less than 2 fingers, will almost always have T.M.J. M.P.S., thus having a tendency to make poor prospects for any riding discipline that requires flexion of the head at the poll. When faced with this conformation problem, the owner should be encouraged to feed the horse on the ground. This will promote the mandible to move rostrally, create more space between the mandible and atlas and encourage the atlas to move ventrally, thus helping undo the stress and damage that the flexion has done. Stretches that encourage complete extension of the poll area will also encourage ventral movement of the atlas. Another contributing factor of T.M.J.-M.P.S. is dental problems. One of the most common problems is an abnormal pattern(s) of mastication, which may result from dental malocclusion and/or pain. Not only can dental malocclusions result in problems during mastication, but in the resting phase they can also cause abnormal stress on the T.M.J. and surrounding soft tissues. One example of this would be an Over Bite or Over Jet conformation (Figure 5.) where the upper incisors capture the lower incisors thus restricting the rostral movement of the mandible as the head is lowered and may actually cause the mandible to rest in a more caudal

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position. This restriction in rostral movement of the mandible can also result from large rostral hooks on the upper second premolars (PM2 or 106/206) (Figure 7.) and/or similar caudal ramps/hooks on the last lower molars (M3 or 311/411). This could result in decreasing, or narrowing, of the W.A.M.D. If these dental problems are properly addressed, there is a potential to increase or widen that same W.A.M.D., thus decreasing the possible development of sensitive acupuncture points and chiropractic problems in the head and poll area. An Under Bite or Under Jet conformation (Figure 6.) can also be a contributing factor to T.M.J.- M.P.S. Another example of a malocclusion that can be problematic is the slanted incisor bite (Figure 4), which can result in the mandible resting off center or more to one side. This unevenness can put stress on both the T.M.J. and the masseter muscles. Thus, sensitivity at ST 7 could lead an investigator to further examine the horses medical history and dental status. Many of these cases respond very well to proper dentistry, even if other factors are present. In fact, if it is perceived that more than one modality of therapy is needed to correct the horses problem, it is usually best to start with dentistry. A word of caution should be added here. Dentistry involving prolonged or over use of the speculum, abnormal head position (over extension or rotation) and/or bad balancing of the dental arcades can also cause T.M.J.-M.P.S. Thus, it is important to palpate these points before any dental procedure, to establish a baseline. This information can then be helpful in determining if the dentistry was successful in eliminating any sensitive points present prior to the procedure, or caused them to appear after the procedure.

Figure 4

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Figure 5

Figure 6

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Figure 7. One breed that commonly seems to have a narrow W.A.M.D. and dental conformation that restricts rostral movement of the mandible is the Arabian horse. If you recognize this, you can not only advise the owner of the dental problem(s), but that because of the poll conformation problem, the affected horse will always want to flex or bend behind the poll. This is a relief to some owners/trainers who were considering the use of severe training measures to get the affected horse to flex or bend at the poll, which would only lead to more pain in that area, followed by behavior and attitude problems. In this case, part of the treatment is the acceptance by the owner/trainer of the limitations of their horse and the avoidance of these severe training measures. As mentioned before, if the horse has a narrowed W.A.M.D., there may also be a chiropractic problem. This can involve the mandible, skull, atlas and even the axis. Chiropractic evaluation of these structures should be considered, especially if the dentistry and stretches do not alleviate previously found sensitive acupuncture points. As a result of previous stresses, these structures will not have or may not be able to complete their full range of motion. Chiropractic can help re-establish that range of motion. Finally, acupuncture is useful to help alleviate the spasms and pain associated with this problem. From a traditional Chinese medicine (TCM) approach, these areas of sensitivity are considered areas of excess/blockage. There are several ways in which to treat this. The first could be to treat the local points themselves to disperse the blockage at ST 7 and TH 17. This can be done with solid acupuncture needles, laser, topical magnets or any combination of these three methods, using a sedation technique. A second approach is to treat the distal points on those same meridians to drain the pain. One of the most commonly treated points is Stomach 45 (ST 45) (Figure 8.) which is located on the dorsal midline of the rear foot, in a depression just proximal to the coronary band. The next point is Triple Heater 1 (TH 1) (Figure 9.) which is located on the dorsal midline of the front foot, in a depression just proximal to the coronary band. Both of these points are usually treated with a solid acupuncture needle which is left in place for a minimum of 20 minutes, or with hemoacupuncture. The last approach utilizes Master

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points that can treat the affected area(s). The Master point for the head and neck region is Lung 7 (LU 7) (Figure 10.) which is located in a depression on the medial surface of the radius, 1.5 cun proximal to the most medial prominence of the styloid process, 0.5 cun distal to the level of Pericardium 6 (PC 6). The Master point for the face and mouth is Large Intestine 4 (LI 4) (Figure 11), which is located on the medial side of the forelimb, in the depression just palmar to the 2nd metacarpal (medial splint) bone and distal to its base. This would be at the level between the proximal and middle thirds of the 3rd metacarpal (cannon) bone. These two points are usually treated with a solid acupuncture needle, which is left in place for a minimum of 20 minutes. Usually, two or more of the above techniques for alleviating the meridian blockage are used, depending on the veterinary acupuncturist and the cooperation of the equine patient. From a Western approach, we know that acupuncture helps to alleviate the spasms and pain from the release of such things as endorphins, dynorphins and increased cortisol levels. The key is what acupuncture points do you treat for what condition. TCM theory will aid you in your point selection and ultimately a more successful treatment.

Figure 8

Figure 9

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Figure 10

Figure 11

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This example is but one of many on how acupuncture, chiropractic and dentistry can be involved in the diagnosis and treatment of a problem. These same combinations of effects can be seen in other areas such as the back and all four legs. If there is anything that affects the way a horse holds his head during exercise/work, then that can affect the rest of the body. Remember, in humans that perform gymnastic and diving maneuvers, there is one rule that they refer to: The body follows the head. This is the same in the horse, thus the relationship between these three modalities, which starts in the head area, is continued throughout the rest of the horses body. It is important to remember that they all should be considered when treating your equine patient

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COMBINING MIRROR IMAGING AND CONSTITUTIONAL TREATMENT IN THE MANAGEMENT OF EQUINE PAIN Peggy Fleming, DVM, AP, Dipl.Ac.

1. CONSTITUTIONAL ACUPUNCTURE THERAPY A.Terrain Set of an individuals innate predispositions that define his physical as well as psychological reactivity to any type of aggression, considered globally and assuming a close psychosomatic relationship genetics+changes throughout life Constitution Set of an individuals congenital, somatic and psychological features fixed and unchanging genetic heritage B.Terrain Medicines Consider the individual as a whole relationship between animal and environment Relationship between body and mind C.Types of Terrain Medicines Classical Homeopathy: S. Hahneman Classical Acupuncture: JR. Worsely Diathetic Medicine: Menetrier Diathetic Acupuncture: Y. Requena

D.Classical Acupuncture Symptoms are a distress signal from the body/mind/spirit and can branch in any of the five elements The root is found by determining the CF Discerned through the color/sound/ odor/ emotion Unchangeable as is constitution

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E.Diathetic Medicine Discovered terrains which united many different symptoms Uses trace elements which act psychologically as well as physically Morbid state between health and illness five diatheses which encompass many chronic ill defined disorders F.The Five Diatheses Allergic: Mg (wood) Hyposthenic: Mg, Cu (metal) Dystonic: Mg, Cobalt (fire) Anergic: Cu, Ag, Silver (water) Maladaptation: Zinc-Cu and Zinc-Nickel-Cobalt (water) G.Diathetic Acupuncture Combined the five constitutions according to constitution and the six temperaments according to the six levels The five phases and six energies are inseparable and their physiology is closely related The earthly cycle is characterized by five=stable=five constitutions The heavenly cycle is characterized by 6=movement=temperment H.The six temperaments Shao Yang (yang wood-fire types) Jue Yin (yin wood-fire types) Tai Yang (yang fire-water types) Shao Yin (yin fire-water types) Yang Ming (yang earth-metal types) Tai Yin (yin earth-metal types)

I.Meridian therapy The process controlled by the deficient meridian is the root cause of disease Requires the presence of a stressor and a weak structure in order to manifest Weak structure: joints of horses, udder of cows Stressor is dependent on the meridian that is weak o Fear and cold easily affect the kidney o External stressor=six evil qi o Internal stressor=emotions

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2. MIRROR IMAGING SYSTEMS A. B. C. D. Mirror Imaging and ECIWO Systems Auricular acupuncture Coronary band system Metacarpal System Balance method ECIWO Systems Embryo Containing Whole Organism Relates the whole and its parts Each cell has a totipotential=mirrors the organism Auricular Acupuncture System Straight forward anatomical imaging According to Nogiers pulse Use of filters Simple to adapt to constitutional therapies Coronary Band System of the Equine Representative of the musculoskeletal structures Straight forward anatomical imaging Simple to adapt to constitutional therapies

E.

Metacarpal System discovered by Dr. Yingqing Zhang represents the neurula stage of the embryo distal aspect=head proximal aspect=legs and lower portion of the back only one or two points are treated at one time actually found in all the long bones

F.Hierarchy of importance of various ECIWO systems Efficacy directly dependent on the sensory input to the area. Man= 2nd metacarpal is highly functional Horse= coronary band and 3rd metacarpal

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3. BALANCE METHOD OF DR. RICHARD TAN A. Balance Method Combines Anatomical imaging with ahshi points Needle symmetrically according to diagonal anatomy Bie Jing channel system (shaoyang hand-shaoyin foot, shaoyin hand-shaoyang Foot, etc) TH-KI, GB-HT Interior exterior(SI-HT) Chinese clock neighbor (LU-LIV) Chinese clock opposites (SI-LIV)

B. Anatomical Image System Tai Yang: SI-BL Shao Yang: TH-GB Yang Ming: LI-St Tai Yin: LU-SP Jue Yin: PC-LIV Shao Yin: HT-KI

B.

Bie Jing Channel System Hand Shao Yang (TH)-Foot Shaoyin (KI) Hand Tai Yang (SI)-Foot Tai Yin (SP) Hand Jue Yin (PC)-Foot Yang Ming (ST) Hand Shao Yin (HT)-Foot Shao Yang (GB) Hand Tai Yin (LU)-Foot Tai Yang (BL) Hand Yang Ming (LI)-Foot Jue Yin (LIV)

C.Interior-Exterior PC-TH SI-HT LU-LI BL-KI ST-SP LIV-GB

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D.Chinese Clock Neighbor Yang with yang and yin with yin SI-BL KI-PC TH-GB LIV-LU LI-ST SP-HT

E.Midday-Midnight LU-BL LI-KI ST-PC SP-TH HT-GB SI-LIV 4. METACARPAL SYSTEM OF THE EQUINE Use of the third metacarpal only Apply point along the constitutional path of the appropriate meridian May apply Nogiers pulse to facilitate location

5. USING ECIWO SYSTEMS WITH CONSTITUTIONAL ACUPUNCTURE A. Importance of determining the primary meridian Treats the root cause present before symptom development Treats the fundamental process that is constitutionally defective Vested in Five element theory Pays respect to the relationships among the elements B. C. Primary methods to determine the constitutional deficiency CF: color, sound odor emotion Pulse diagnosis: primary deficiency Subtle signature pattern Meridian palpation strategic use of ECIWO systems to balance the constitution Used for pain control to facilitate symptom expression Used to enhance the effect of the constitutional treatment Aimed to prevent disharmonious flow of qi along the 5 element cycle

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D. Ear, coronary band, and third metacarpal Can use a simple physical hologram of the body without addressing a meridian system Allows practitioner to treat pain without going against the CF, pulse, etc E. Balance method Depends first on finding the exact location of the pain After step one is determined, 6 mirroring options are available as treatment options Select the mirroring option that corresponds to the constitutional picture As a rule of thumb: excess is in the ko cycle relative to the deficiency Extremely important when treating cancer patients

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Sign Beebe, DVM, CVA Integrative Veterinary Center Sacramento CA 95819 INTRODUCTION Anemia in conventional medicine is defined as a lack of red blood cells, and is often described as synonymous with Blood Deficiency in Traditional Chinese Medicine. Blood deficiency however, is a much broader concept that includes the Western definition of anemia and much more. Thus there is no single pattern of Blood deficiency which corresponds to the anemia of conventional medicine. Blood Deficiency as defined by TCM may involve: a lack of production of vital substances needed to produce adequate blood, deficiency or dysfunction of the Zang-Fu organs, Blood stagnation where the presence of old stagnant Blood interferes with the generation of new blood, and blood loss without adequate replacement. The Blood of Chinese medicine is composed of Blood and Ying Qi (Nutritive Qi) which circulate throughout the body together, and are often referred to as ying-blood. Ying Qi functions to provide nourishment for the entire body and to serve as a component for the generation of Blood. Chinese medical treatments are chosen based on pattern discrimination. Whereas conventional medicine is disease-specific, Chinese medicine is based on identification and treatment of the individual animals overall pattern of illness. The treatment of anemia and Blood Deficiency conditions in Chinese medicine focuses on the use of herbal medicine as the primary therapeutic modality, with acupuncture considered secondary. In acute and severe cases of anemia, Chinese herbs can be safely and effectively combined with conventional medications and transfusions as needed for an integrative approach. An integrative approach to anemia is valuable in cases when conventional medications are contraindicated due to weak organ systems, when there are polypharmacy concerns, when adverse side effects have developed or when conventional veterinary treatment is ineffective. ETIOLOGY/PATHOLOGY Blood Deficiency and anemia can develop from blood loss (fleas, internal parasites, and trauma), exogenous pathogenic factors (infectious disease, toxicity, drugs, and vaccinations), deficiency or dysfunction of the Zang Fu organs which can include neoplasia, bone marrow, immune mediated disease and chronic diseases. The Spleen, Kidney and Liver are the Zang Fu organs most involved with the development of Blood Deficiency and are the focus of treatment for Blood Deficiency and anemia using herbal medications. Of these organs the Spleen and Kidney play a central role. The Spleen is responsible for the production of Qi and Blood (Post-Natal Essence) after birth and has the function of holding Blood within the vascular system. A lack of the Spleens holding function results in extravasation of blood and bleeding. The Kidney stores the Pre-Natal Essence which is responsible for production of bone marrow to produce Blood and catalyzes the production of Blood in the Heart. Kidney Essence is also responsible for the

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production of Normal Qi from Zong Qi which supports the Spleen function of generating Blood. If Kidney Essence is plentiful it can be transformed into Liver Blood and vice versa. If Kidney Essence is weak it can lead to Liver Blood Deficiency. The successful treatment of Blood Deficiency in Chinese medicine is directed at replenishing not only the red cell components of Blood but also in tonifying Qi because of the intimate relationship which exists between them. Qi and Blood are inseparable and what affects one will ultimately affect the other. This relationship is often expressed in the saying Blood is the mother of Qi and Qi is the commander of Blood. Blood is the mother of Qi means that Blood flows through out the body providing moisture and nourishment for the production and functional activities of Qi. Blood carries the Qi and without Blood to hold onto, Qi would scatter and float with no particular destination. Blood is called the home or dwelling place of Qi for this reason. When there is acute blood loss, both Qi and Blood are lost and clinical signs of Qi deficiency will appear. Qi is called the commander of Blood because Qi generates Blood, moves the Blood and holds Blood within the vascular system. If Qi is deficient, all steps in the production of Blood will be negatively impacted due to the lack of the moving and transforming action of Qi required to make Blood. This is why Qi supplementing herbs are typically always included in Blood deficiency formulas. In addition, many Qi boosting medicinal herbs function to regulate the immune system which is important in the management of immune-mediated anemias. It is often necessary to treat Blood stagnation that develops secondary to the Qi and Blood deficiency in chronic and severe cases of anemia such as that seen in immune-mediated disease to successfully resolve the problem. DIAGNOSIS It is important to note that no single laboratory test indicates a pattern of Blood Deficiency in Chinese medicine. For example three animals may each be diagnosed with idiopathic immunemediated hemolytic anemia with a positive Coombs test, while each animal has a different Chinese medical pattern as the underlying cause for its anemia. Because Chinese medical therapy is based on the individual animals pattern of disease, the herbal prescription chosen to treat each animal would be different for all three. Typically there is more than one TCM pattern present in most cases of severe anemia. It should be noted that in addition to tonifying Qi and Blood, the practitioner may be required to nourish Yin, warm Yang, clear Damp or Toxic Heat, stop bleeding and resolve Blood stagnation etc. It is beyond the scope of this lecture to discuss all of these many patterns and instead we will focus on the identification and use of herbal formulas for basic Qi-Blood deficiency patterns. The clinical signs of anemia and Blood deficiency are similar and include poor appetite, abdominal bloating, vomiting, hematuria, lethargy, exercise intolerance, weakness, pallor of the tongue and mucous membranes, increased capillary refill time, jaundice, enlarged liver and or spleen, bloody stool, epistaxis, petechiae, ecchymoses, tachypnea, tachycardia, systolic cardiac murmur, cool limbs and ear tips. In cases of basic QiBlood deficiency pattern the tongue and tongue will be pale, thin and dry. The pulse will be deep, rapid, weak and thin. When there are multiple patterns of disease present the tongue and pulse parameters will reflect these overlapping qualities and can be a diagnostic challenge to the practitioner. For the treatment of Blood Deficiency to be effective, an accurate TCM pattern(s) must be identified in order to choose the correct therapy. The diagnosis of anemia and Blood Deficiency conditions is determined from TCM pattern differentiation in combination with conventional diagnostics.

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TREATMENT Chinese medical treatment of anemia includes Chinese herbal therapy, acupuncture, dietary therapy and nutritional supplements. Herbal medications can be safely combined with conventional medicine and or blood transfusion for an integrative medicine approach as needed in acute and severe cases. Chinese herbal medical treatments are directed at correcting the underlying organ deficiency/dysfunction, stopping bleeding, and resolving or preventing blood stagnation in addition to restoring normal circulating blood volume. In infectious causes of anemia it may be necessary to clear Toxic Heat. Conventional diagnostics are routinely performed to monitor the progress of anemia and Blood deficiency in conjunction with serial tongue and pulse parameters. In small animals, anemia is seen most frequently in: acute and chronic blood loss (trauma, exo-endoparasitism) chronic renal disease immune-mediated hemolytic anemia and thrombocytopenia (idiopathic, infectious causes) secondary to chemotherapy and neoplasia non-regenerative anemia seen in chronic disease toxicity (plants, chemicals, drug-induced) Common Chinese herbal medications used to treat these types of anemia in small animal practice include: Si Wu Tang, Ba Zhen Tang, Shi Quan Da Bu Tang: Ren Shen Yang Ying Tang, Marrow Plus and Gui Pi Tang. For a brief explanation of these formulas, their TCM actions and their use to treat biomedical diseases see Table 1-Chinese Herbal Formula to Treat Anemia and Blood Deficiency. The inclusion of acupuncture to the therapeutic regimen will produce a more rapid clinical response than either modality used alone. Acupuncture treatment time and technique will vary depending on the severity of anemia and Blood deficiency. Commonly used acupuncture points to treat anemia and Blood deficiency are as follows: SP6, SP9 are used to tonify Spleen, nourish Yin, and transform damp; BL 20, 21 and ST36 are used tonify Qi and regulate Spleen and Stomach; CV4 the gate of original Qi and CV6 Sea of Qi are used to tonify Qi, SP10, the sea of Blood is used to nourish Yin and Blood; GB29 is the influential point for Bone Marrow; BL17 is the influential point for Blood; KI3 and BL23 nourish Kidney Yin. Chinese herbs in combination with acupuncture are highly effective for increasing and maintaining normal blood values as evidenced on repeat laboratory evaluations. Nutritional therapy, regular exercise and weight management are essential for the successful long-term management of anemia and Blood deficiency especially in chronic, geriatric and immune disease cases. A species-appropriate diet is essential to the successful treatment and maintenance of normal hematological values and to prevent relapse due to the central role of the Spleen (Pancreas) in the production of Qi and Blood and nourishment of Kidney Essence. Chinese Food therapy principles are used to formulate diets which strengthen the Spleen to improve its holding function and increase absorption and assimilation of nutrients to make Blood and nourish Kidney Essence. Chinese food therapy is prescribed according to Chinese medicine pattern differentiation in the same way that herbs are prescribed. Food therapy works synergistically with the other TCM modalities to address the current illness or disharmony and help the body return to a state of homeostasis. The use of digestive enzymes, probiotics, vitamin-

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mineral and essential fatty acid supplements help to further supplement the Spleen, potentiate the formation of high quality Food Essence and balance the diet. All food should be cooked to decrease the digestive work required by the Spleen (Pancreas) which in many cases is already weakened. Typical foods recommended for Blood deficient and anemic patients include: beef, beef marrow, duck, rabbit, liver, heart, sardines and eggs. For more details on Chinese Food Therapy to treat anemia see Table 2- TCM Food Therapy Chart. SUMMARY Chinese medicine can be safely combined with conventional medicine for an integrative medicine approach. Chinese herbs, acupuncture and food therapy are very effective in the treatment and resolution of anemia to help keep the dosage and dosing frequency of conventional medications to a minimum. Regular monitoring of laboratory values can be used to document the efficacy of Chinese medical treatments and to help determine changes or adjustments in Chinese herbal therapy and or the need for conventional medications. Information on herbal medications can be found at: Golden Flower Herbs www.gfcherbs.com, 800-729-8509 Evergreen Herbs: www.evherb.com, 866-473-3697 East Tao: www.easttao.com, 800-471-0624 May Way Corp: www.mayway.com, 800-262-9929 Bioessence: www.bioessence.com, 800-875-0798 Jing Tang Herbal: www.tcvmherbal.com, 800-891-1986 Health Concerns: www.healthconcerns.com 800- 233-9355

References 1. Becker, S., A Handbook of Chinese Hematology, Blue Poppy Press, Boulder CO, 2000: 269. 2. Bensky, D., and R. Barolet, Formulas and Strategies, Eastland Press, Seattle, WA, 1990: 235-260. 3. Chen, J., Chen, T., Chinese Medical Herbology and Pharmacology, Art of Medicine Press, City of Industry, CA. 2004: 559-673, 829-877, 918-938. 4. Proceedings, Seventh Advanced Traditional Chinese Veterinary Medicine Conference, Food Therapy, Chi Institute of Chinese Medicine, 2005. 5. De-Xin, Y, Aging & Blood Stasis, Blue Poppy Press, Boulder CO, 1995: 1-91. 6. Liu, Y., The Essential Book of Traditional Chinese Medicine, Vol. 1 Theory, Columbia Univ. Press, NY, 1988: 67-93. 7. Liu, Y., The Essential Book of Traditional Chinese Medicine, Vol. 2 Clinical Practice, Columbia Univ. Press, NY, 1988: 34-36.

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8. Maciocia, G. The Foundations of Chinese Medicine 2nd ed., Churchill Livingstone Press, 2005: 35-93. 9. Wang, B., Yellow Emperors Canon Internal Medicine, China Science and Technology Press, 1997: 595-596. 10. Xie, H., Preast, V. Traditional Chinese Veterinary Medicine Volume I, Beijing China 2002: 69-132. Table 1 Chinese Herbal formula to Treat Anemia and Blood Deficiency HERBAL FORMULA Si Wu Tang ACTIONS Tonifys Liver Blood INDICATIONS Chronic mild anemia, not for acute; Liver Blood deficiency Acute and chronic anemia: postsurgical, post-partum, anemia-CRF, infectious, toxic, drug induced Chronic anemia; non-regen anemia, cancer, drugs, chemotherapy, cold signs Chronic anemia: cancer, cardiac disease and anemia, radiation, chemotherapy non-healing wounds

Ba Zhen Tang

Tonifys Qi, Blood

Shi Quan Da Bu Tang

Tonifys Qi, Blood, Yang

Ren Shen Yang Yin Tang

Tonifys Qi, Blood Nourishes Heart Calms the Shen

Marrow Plus

Tonifys Qi, Blood Acute and chronic anemia; acute Invigorates Blood blood loss, post transfusion, Strengthens Spleen, Kidney chemotherapy radiation, anemiaCRF, infectious, toxic, drug induced Tonifys Qi, Blood Strengthens Spleen Nourish Heart Immune-mediated, bleeding disorders IHA, ITP, cardiac disease with anemia, toxic, infectious

Gui Pi Tang

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TCM PATTERN Food Stagnation: pungent and dispersing Yin Deficiency, Excess Heat: Cool or Cold Food

TCM FOOD RECOMMENDATIONS Foods to regulate Qi and relieve stagnation: chicken, crab, carrot, fresh ginger, cardamom, cinnamon, parsley, kelp Foods to tonify Yin and Blood and clear Heat: turkey, rabbit, beef liver, duck, cod, sardines, clam, scallop, eggs, barley, brown rice, buckwheat, millet, amaranth, barely sprouts, tofu, mung bean, carrot, spinach, chard, kale, broccoli, bok choy, celery, tomato, eggplant, kelp, sea vegetables, alfalfa, cucumber, Chinese cabbage, watermelon, pear, banana, pear, strawberry, kiwi, mango, mushroom, orange, honey Foods to tonify Qi: chicken, beef, mackerel, sweet potato, oats, lentils, millet yam, pumpkin, squash, dates, figs, peanut, molasses

Qi Deficiency: Warm Food Qi stagnation: pungent and sweet foods

Foods to circulate Qi: chicken, crab, basil, cardamom, cumin, coriander, garlic, fennel, lemon, tangerine peel, watercress, carrot, mustard greens, brussel sprouts, Jerusalem artichoke, asparagus Damp-Heat Foods to drain Damp and cool Heat: mushroom, aduki bean, rye, barley, bamboo shoots, broccoli, cabbage, lettuce, bitter melon, blueberries, cranberries, watermelon, Cool and Cold foods Avoid dairy products, grains, bananas, peanuts, pasta, fatty meats Cold Damp Foods to drain Damp and warm Cold: mushroom, aduki bean coriander, cardamom, garlic, ginger, Warm and Hot Foods Avoid dairy products, grains, bananas, peanuts, pasta, fatty meats Yang Deficiency, Qi Foods to warm the Cold: lamb, venison, buffalo, chicken, shrimp, Deficiency, Excess Cold: chicken liver, pheasant, trout, oats, white rice, parsnips, blackberry, Warm and Hot Food cherry, apricot, peach, papaya, plum, squash, pumpkin, asparagus, dry ginger, walnut, olive oil, turmeric, pepper, garlic, ginger, cinnamon, rosemary, sage, thyme Blood Deficiency Foods to tonify Blood: Beef, lamb and chicken liver, beef, chicken, bone marrow, sardine, eggs, lychee, longan, spinach and other dark leafy greens, carrots, molasses, grape, kidney beans, parsley, apricots, dates Neutral Foods: Food used as a general body tonic: Beef, beef liver, salmon, sardines, Blood, Qi and Yin tuna, catfish, tripe, quail, chicken eggs, mackerel, white rice, red, Deficiency black beans, kidney bean, green beans, green peas, yam, cabbage, apple, cauliflower, pineapple Table 2 Traditional Chinese Veterinary Medicine Food Therapy Chart

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Sign Beebe, DVM, CVA Integrative Veterinary Center Sacramento, CA INTRODUCTION Dermatological problems are some of the most difficult conditions to treat in veterinary medicine. Constant pruritis or itching is the most common reason a client seeks a Chinese medicine approach for a pet with skin disease. The most common cause of chronic itching in the dog is canine atopic dermatitis, also called allergic dermatitis or atopy, and is the most frequently diagnosed skin disorder. The etiology of atopy is unknown; it has been linked to flea, food and environmental allergens, singly or in combination. Current research suggests that the following clinical presentations are indicative of atopy: pruritis that responds to glucocorticoid therapy, clinical signs that begin at a young age (less than 1 year), pododermatitis, dermatitis of the face and perioral region, and erythema of the ear pinnae. A diagnosis of canine atopic dermatitis requires that three of these clinical findings be present and exclusion of all other causes of pruritis. Because the etiology for this disease is unknown, conventional veterinary treatment focuses on the control of symptoms, of which constant pruritis is the most distressing to pet owners. Conventional veterinary therapy typically consists of multiple courses of antibiotic, antifungal, steroidal and immunomodulatory drugs to control symptoms. Clients whose dogs are diagnosed with this frustrating and challenging disease often choose a Traditional Chinese Medicine (TCM) approach to alleviate their pets pain and suffering, and to prevent the long term effects of chronic drug therapy when conventional medicine fails to resolve or manage the problem adequately. TCM treatment of skin disease includes Chinese herbal medicine, acupuncture and food therapy. TCM can be used as a sole therapy to resolve the underlying causes of pruritis or in combination with conventional medicine for an integrative approach especially in acute, relapsing and severe cases. TCM ETIOLOGY AND PATHOLOGY Canine pruritis is considered to be a multi-factorial disease in TCM, and may involve one or more external and or internal disease factors occurring simultaneously: poor Kidney Jing (genetics), hypersensitivity to environmental allergens, food allergy, parasitic and infectious agents, over vaccination, inappropriate diet, lack of regular exercise, obesity, stress, aging, pharmaceutical drugs and Zang Fu organ deficiency or dysfunction. Pruritis or itching in Chinese medicine is called Wind. Wind can develop from exogenous (external invasion) or endogenous (internally generated) causes. Wind is characterized by acute onset and rapid changes in clinical signs and symptoms. Wind likes to move from place to place, cause abnormal movement and a large amount of destruction in a short period of time due to its violent blustery nature. Wind tends to injure Blood and Yin and one of the cardinal signs of Wind is itching. Wind can originate outside the body and is one of the six normal climatic factors. Once it invades the body it becomes a pathogenic factor called External Wind. The development of skin disease typically

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involves the presence of more than one pathogenic factor that readily combines with Wind such as Damp, Heat or Dryness. Wind is called the master pathogen because it acts as a vehicle for many other pathogenic factors to gain access to the body. It should be noted that the term External Wind can include exogenous factors that are not directly related to climate such as; external parasites, inhalant and contact allergens, drug and vaccine reactions. External Wind can easily invade the body when the Lung and Defensive Qi are deficient and cant protect the surface from invasion, when there is preexisting internal damp and heat accumulation and when Yin and Blood deficiency exist. The pruritus seen in early cases of External Wind is typically acute, seasonal and excess in nature. Wind can also be generated internally from a deficiency of Yin and Blood, deficiency and stagnation of Qi and Blood and the generation and accumulation of pathogenic factors such as Damp, Phlegm, Blood Heat and Toxic Heat. All of these factors can develop from an imbalance or dysfunction of one or more of the Zang Fu organs for example chronic Liver Qi-stagnation, Liver Fire, Liver Yin-Blood Deficiency, Liver-Gall Bladder DampHeat, Spleen-Stomach Damp Heat, and Kidney Yin-Essence Deficiency. The itching seen in these cases is usually chronic and non-seasonal in nature and characterized by signs of both excess and deficiency. Deficiency is the root cause of the problem and in turn leads to the development of excess signs as the branch. Animals with deficiency or dysfunction of the internal organs and internally generated Wind are highly susceptible to seasonal attack by External Wind. In these types of cases itching can be acute and severe as a result of both internal and external Wind. DIAGNOSIS The clinical signs of canine pruritis include itching, chewing, biting, rubbing, licking, and salivary staining of the axillae, inguinal region, flank, perineum, distal extremities and paws. Urticaria, erythema, alopecia, excoriation, papules, pustules, crusts, ulcers, scale, greasy hair coat, dandruff cracking of pads, toenails, hyper-pigmentation, lichenification and strong foul smelling body odor are often present. The typical distribution of lesions seen in canine pruritis include the face, ears, ventral abdomen, inguinal area and flanks, axillae, perineum, distal extremities and inter-digital areas of all four paws or may be generalized. The type and distribution of the dermatologic lesions serves to define the pattern of illness and to identify not only the underlying pathogenic factors, but also the organ deficiency or dysfunction. There are multiple TCM patterns of disharmony which correspond to pruritis or canine atopy and each will require a different therapeutic approach for successful treatment. There are five common TCM skin patterns which correspond to pruritis and canine atopy, these are: External Wind, Wind Heat, Damp Heat, Yin Deficiency, Blood Deficiency and Blood stagnation. These six patterns can be further complicated by the presence of Blood Heat. Blood Heat is a complex TCM skin pattern, can be a component of the milder skin patterns, is often a primary cause of severe immune-mediated disease, and is beyond the scope of this lecture. More than one pattern can be present at a time and the overlapping of patterns makes skin conditions a challenge to treat as both excess and deficiency can be present in the same animal, especially in chronic and severe cases. The five most common skin patterns and their associated biomedical conditions may be viewed in Table 1- TCM Patterns of Canine Pruritis and Associated Biomedical Conditions. TREATMENT The treatment of pruritis is based on the TCVM pattern of disease; without an accurate TCVM diagnosis treatment will be marginally effective. Once therapy has begun, it must be continued

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for an appropriate length of time I order to resolve the problem. Chinese medical treatment of pruritis includes Chinese herbal therapy, acupuncture, dietary therapy, nutritional supplements and topical therapy. Conventional medications can be combined with Chinese medicine for a synergistic effect and or to control acute symptoms. Acupuncture as a sole therapy is typically not effective to resolve canine pruritis and is most commonly used to help control itching and help balance underlying organ dysfunction. Of the treatments recommended, Chinese herbal medicine, food therapy and regular exercise are essential for the long term resolution of chronic itching and canine atopy. The treatment of chronic dermatitis cases usually involves the use of multiple herbal formulas. Many of the formulas used to treat skin patterns contain cold and bitter herbs which can injure the middle jiao. It is often necessary to use Spleen-Stomach tonics to protect the middle jiao and to treat Spleen deficiency which is commonly seen in long term dermatology patients who have been chronically medicated. It can take 2-6 weeks to see the beneficial effects of Chinese medicine and up to 8 months to consolidate the effects of initial treatment to resolve the dermatitis seen in chronic and severe cases. The herbal formula used to treat the five most common TCM skin patterns can be viewed in Table 2- Chinese Herbal Medicine for Treatment of Canine Pruritis. Information and purchase of Chinese herbal formula can be obtained from: East Tao easttao@aol.com 1-800-471-0624 Jing Tang www.tcvmherbal.com 1-800-891-1986 Golden Flower Herbs www.gfcherbs.com 1-800-729-8509 Evergreen Herbs www.elotus.org 1-866-473-3697 Integrative Veterinary Center www.sacvetrehab.com 1-916-454-1825 Health Concerns www.healthconcerns.com 1-800-233-9355 SUMMMARY Chinese herbal medicine and food therapy can be used as a primary system of medicine in the treatment of chronic pruritis and canine atopic dermatitis. There are six common patterns of canine pruritis in TCM, and each pattern is treated differently depending on the underlying cause. There can be more than one pattern operating at the same time that are responsible for the clinical signs seen, which makes pruritus difficult to treat and manage. Chinese medicine can be used to treat the root or underlying causes of canine pruritis and as an adjunct with conventional medications to resolve or improve the condition in order to avoid life long administration of pharmaceutical drugs for control of symptoms alone. The prognosis for canine pruritis is good provided that a correct TCM diagnosis has been made, an appropriate treatment plan chosen and the client complies with treatment for the recommended period of time. References 1. De-Hui S, Xiu-Fen W, Wang N. Manual of Dermatology in Chinese Medicine. Seattle, WA. Eastland Press, 1995: 382. 2. Jian-Hi, L. A Handbook of Traditional Chinese Dermatology. Boulder, CO. Blue Poppy Press, 1993: 176.

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3. Wu Y, Fischer W. Practical Therapeutics of Traditional Chinese Medicine. Brookline, MA, Paradigm Publications, 1997: 716. 4. Xie H, Preast V. Traditional Chinese Veterinary Medicine Volume I-Fundamental Principles. Reddick, Fla. Jing Tang, 2002: 639.

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Table 1 TCM Patterns of Canine Pruritis and Associated Biomedical Conditions TCM PATTERN External Wind CLINICAL SIGNS Tongue: red to purple Pulse: rapid, superficial Location: face, head, upper body. No signs of dermatitis may be present except for itching and rubbing the face, skin hypersensitivity and restlessness with erythema, initially is seasonal and acute Tongue: red to purple Pulse: rapid, superficial, forceful, can be wiry Location: face, head, dorsum, can be generalized itching, hives, wheals, angioedema, erythema, papules, excoriation, alopecia, initially may be seasonal and acute Tongue: red to purple, greasy coat Pulse: rapid, forceful, slippery or wiry Location: ventral abdomen, distal extremities, paws, flanks, perineum, ears, lips, generalized erythema, erosions, excoriation, papules, pustules crusts, scabs, alopecia, greasy, hair coat, itching. May be acute or chronic BIOMEDICAL DISEASE Type I-Hypersensitivity, atopy, flea allergy, drug allergy, vaccine reaction, contact dermatitis

Wind-Heat

Type I-Hypersensitivity, recurrent or persistent urticaria, atopy

Damp-Heat

Yin Deficiency

Blood Deficiency

food allergy, chronic GIT disease, bacterial pyoderma and otitis, chelitis, seborrhea, pododermatitis, onychitis, perianal dermatitis, malassezia dermatitis and otitis, lick granuloma, anal sacculitis, bacterial folliculitis Tongue: red, dry, no coating, may be cracked chronic illness, Pulse: rapid, weak, thready, may be deep chronically medicated Location: generalized, chronic itching that is dogs, seborrhea, worse at night, dislikes heat, seeks cool, endocrinopathies: panting, hyperactive, restless at night, dry, Cushings, flaky skin and haircoat, alopecia. Seen in hypothyroidism, diabetes geriatric animals, but also in chronically medicated young dogs Tongue: pale, dry Hypothyroidism, any Pulse: rapid, deep, weak and thin chronic disease, Location: generalized, chronic itching, dry, chronically medicated flaky skin and hair coat, dry cracked paws dogs especially those on and toenails, seen in chronically medicated antibiotic therapy young dogs, and old dogs

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Table 2 Chinese Herbal Medicine for Treatment of Canine Pruritis TCM PATTERN External Wind Wind-Heat HERBAL MEDICATIONS External Wind (JT) Silarex (EG) Xiao Feng San (classic) Wind Toxin (JT) Gentiana Compound-ET Gentiana Drain Fire (GFCH) Si Miao San (GFCH, EG) Jade Shining (ET) Glorious Sea (TT) Dang Gui Yin Zi (classic) Dermatrol PS (EG) Bu Yang Huan Wu Tang (classic) Tang Kuei & Salvia (GFCH) Marrow Plus (HC) Yu Ping Feng San Jade Screen (ET) CHINESE THERAPEUTIC ACTIONS Clear External Wind, cool Blood Disperse Wind-Heat, clear Heat, detoxify, drain Damp Clear Damp-Heat, detoxify Toxic Heat Nourish Yin and Blood, resolve Blood stagnation, clear Toxic Heat Nourish, move and cool Blood, drain damp, detoxify Nourish and move Blood

Damp-Heat Yin Deficiency Blood Deficiency

Blood Stagnation

Prevention of External Wind Attack

Tonify Qi (Wei, Lung and Spleen), harmonize the Ying and the Wei and consolidate the body surface

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TRADITIONAL CHINESE MEDICINE HERBAL STRATEGIES FOR CHRONIC URINARY TRACT INFECTION IN DOGS
Sign E. Beebe, DVM, CVA Integrative Veterinary Center Sacramento, CA

INTRODUCTION Chronic urinary tract infection (UTI) is one of the most challenging and frustrating conditions seen in small animal practice. Biomedically, chronic UTI is defined as recurrent or persistent bacterial infection of the urinary bladder in the absence of neoplasia, urolithiasis and or structural and functional abnormalities of the bladder. It can also include sterile inflammation of the urinary tract with clinical signs of urinary tract infection and absence of a documented bacterial infection. The common clinical signs of urinary tract infection include: dysuria, stranguria, pollakiuria, hematuria, pyuria, crystalluria, foul smelling urine, urine dribbling and pain. Urinary tract infection is called lin zheng (dysuria syndrome) in Chinese medicine and many patterns exist; the form described here is commonly referred to as Urinary Bladder Damp Heat. The primary pathogenic factor seen in chronic UTI is Damp Heat which affects the lower jiao and can be generated from multiple causes which include inappropriate diet, obesity, and underlying Zang-Fu organ deficiency or dysfunction which facilitate exogenous pathogen (bacterial) invasion of the bladder. There are often multiple overlapping patterns responsible for the chronic nature of the disease which will vary depending on the individual animal. Chinese medicine is often effective to treat and resolve chronic UTI because it is able to accurately identify the underlying patterns of disease responsible for the development and recurrence of chronic UTI. A Chinese medicine treatment plan for chronic UTI includes herbal medicine, acupuncture and food therapy. Conventional diagnostics are typically used to monitor the condition in addition to serial tongue and pulse evaluation. It is common to use pharmaceutical drugs in combination with Chinese medicine to treat acute exacerbation of the disease as needed for an integrative approach. ETIOLOGY AND PATHOPHYSIOLOGY Conventional medicine attributes acute and chronic urinary tract infection to invasion of the urinary bladder by bacteria. In acute uncomplicated UTI a single course of antibiotics is usually sufficient to resolve the infection. However, because it is unable to recognize other contributing disease factors responsible for the development of chronic UTI, conventional treatment is typically restricted to chronic antibiotic therapy. Low dose chronic antibiotic therapy is often prescribed for the life of the animal, with an increased potential for the development of antimicrobial resistance and multiple bacterial infection over time.

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In Chinese medicine chronic UTI is considered multifactorial in nature and develops from exogenous and endogenous causes. The basic pathophysiology seen in UTI revolves around the presence of Damp Heat. Damp Heat can result from invasion of exogenous Damp Heat pathogens (bacteria) or generated internally from Zang Fu organ deficiency or dysfunction. Damp Heat obstructs the normal Qi activity of the urinary bladder resulting in stranguria, pollakiuria, pyuria, and pain. Damp Heat can transform into Fire and damage the blood vessels of the bladder causing hematuria and long term Damp Heat can congeal into crystals and stones. If the condition is not appropriately treated during the acute phase, it then becomes chronic. It should be noted that it is not necessary to have a documented bacterial infection to make a diagnosis of Urinary Bladder Damp Heat; there are animals which exhibit classic signs of cystitis and have sterile urine on laboratory evaluation. Chronic UTI typically develops from an underlying dysfunction of the internal organs in conjunction with bacterial infection, thus there is typically a mixture of both excess and deficiency seen at presentation. The recognition and appropriate treatment of these underlying patterns in addition to the treatment of bacterial infection is essential to prevent continued development or persistence of Damp-Heat and recurrence of the disease: Kidney Deficiency (Jing, Qi, Yin) can lead to Damp Heat in the lower jiao; a weakness or disease of the wife (Kidney) can easily lead to a deficiency of the husband (Bladder). Poor Kidney Jing (genetics) can lead to overall weakness of the Kidneys and increased susceptibility to infection and poor immune function. Deficiency Fire secondary to Kidney Yin Deficiency can easily attract Damp. Kidney Qi deficiency results in urinary dribbling and incontinence and increased susceptibility to ascending bacteria. The Kidneys are the basis for the yin and yang of the body. Any chronic disease will eventually affect the Kidneys and lead to Kidney deficiency and increased potential for development of chronic Damp Heat in the lower jiao. Chronic Liver Qi stagnation can generate Liver Fire and is often seen in animals that are constitutionally predisposed, chronically medicated and stressed from isolation, lack of exercise, boarding, grooming etc. When the Liver becomes stagnant and hot it can invade and over-control the Spleen impairing its normal functions with production of Damp. Heat or Fire is attracted to and combines with Damp and is then transmitted through the Liver channels in the lower jiao. Spleen Qi deficiency results in the accumulation of chronic Damp due to consumption of species inappropriate diets made of energetically hot meats (lamb, venison), large amounts of Damp-engendering processed carbohydrates (grains), dyes and preservatives, chronic antibiotic use, and as a result of normal aging. Damp readily combines with Heat in the middle jiao which then sinks to the lower jiao. Once Damp forms it is very difficult to dislodge from the body. Heart Fire descending to the Small Intestine can be easily misdiagnosed as a chronic UTI. Heart Fire can develop in animals which are constitutionally predisposed and live in stressful conditions. Pre-existing Liver Fire can also invade the Heart causing the development of Heart Fire. The Heart is in the upper jiao; it is the nature of Heart Fire to travel upwards to scorch the mouth and tongue and affect the shen. Heart Fire also has a strong tendency to move downwards through the connecting channels to its

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Zang Fu partner, the Small Intestine, with whom it shares an interior-exterior relationship. The Small Intestine functions in the production and excretion of urine in the body along with the Urinary Bladder and the San Jiao. Heart Fire descends to the Small Intestine channel and accumulates to cause Excess Heat, which then empties into the Urinary Bladder, damaging the vessels and causing hematuria. This pattern can correspond to the biomedical diagnosis of feline lower urinary tract inflammation and idiopathic renal hematuria. The primary pathogenic factor in this pattern is Heat, not Damp. Many animals will show hematuria and signs of UTI without a documented bacterial infection of the bladder. The principles of treatment for this condition are to induce diuresis which will allow Heat to exit the body with the urine, instead of focusing treatment on elimination of Damp Heat pathogens. A thorough history and examination is necessary to accurately identify this pattern. That said, it is possible for Heart Fire descending to the Small Intestine to eventually weaken the bladder and secondarily allow the development of Damp Heat. Blood Stagnation will eventually be seen to some degree in all chronic urinary tract infections. A lack of nourishment and adequate perfusion of the bladder leads to thickening of the bladder walls and impaired Qi activity. In severe cases there can be tissue destruction with toxin accumulation. Blood Stagnation is commonly seen in animals with prolonged chronic UTI, (especially with multiple bacteria) postoperatively after bladder surgery to remove calculi, with concurrent chronic disease, and in geriatric or obese animals. The movement or invigoration of Blood is often necessary to effectively dispel Damp from the body.

DIAGNOSIS AND OVERVIEW OF TREATMENT PRINCIPLES For the treatment of chronic UTI to be effective, an accurate Chinese medicine diagnosis must be made; it is common to have overlapping patterns of disharmony responsible for the development of the disease and attending clinical signs. These overlapping patterns are typically a combination of excess or deficiency; in general it is best to treat excess patterns first and then deficiency. Without accurate Chinese medicine pattern or syndrome differentiation results will be marginal to poor. UTI acute or chronic is typically diagnosed using conventional diagnostics in conjunction with TCM pattern differentiation. There are multiple patterns of disharmony seen in chronic UTI. The most common pattern seen in long-standing infections of the urinary bladder in the dog and cat is dual deficiency of the Kidney and Spleen. These patterns commonly develop in animals that are: purebred and Kidney Jing deficient, fed a species-inappropriate diet or overfed, not regularly exercised (weakens the Spleen), kept isolated for long periods of time (stress-induced), confined indoors or in conditions which necessitate holding their urine for prolonged periods of time. The process of normal urination flushes out ascending bacteria and debris within the urinary tract. Any situation which prevents regular micturition and the healthy flow of urine can weaken the kidney and bladder and facilitate the development of UTI. The Kidney (the source of prenatal jing) and Spleen (the source of postnatal jing) mutually support and protect each other; when one is weak the other will soon follow. Most diseases of the Kidney will affect the Spleen because of this relationship and vice versa. Deficient Kidney and Spleen function results in the continued accumulation of Damp and failure to produce adequate amounts of Qi and Yin-Blood to nourish the body and support the immune system. Ultimately these factors can promote bacterial colonization of the bladder. In chronic infections of the urinary tract, Damp Heat eventually consumes Qi, Yin and Blood. Therapy should be directed toward

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replacing these substances and nourishing the organs responsible for their production. The use of Chinese herbal medicine is indispensable for this purpose. In all chronic cases it is necessary to tonify the Spleen to prevent Damp accumulation and to "feed the Kidney" and conserve pre-natal jing. During acute exacerbations of the disease, it is often necessary to use conventional drugs to control and or eliminate bacterial infection of the bladder. Chinese herbal medication may be safely combined with conventional medicine as needed with modification. In the time intervals between active bacterial infections, the management of chronic UTI should focus on the pattern (or patterns) of disharmonies that are primary at the time of reevaluation, the practitioner should treat what you see. The effective treatment of chronic UTI includes the control and resolution of the sources of Damp Heat. Once Damp Heat has been cleared and the body is strengthened, further bacterial invasion will be prevented and the opportunity to resolve the condition emerges. Specifically, this requires the tonification of Kidney and Spleen, resolution of Liver Qi Stagnation, clearing of Liver Fire, Heart Fire, exogenous pathogens, and resolution of Blood stagnation. A Chinese medicine treatment plan may include the use of herbal medications, acupuncture, food therapy, and conventional medications as needed. Antibiotics are energetically cold and bitter and effectively clear Heat, not Damp. Chronic antibiotics easily injure the Spleen, cause Liver Qi stagnation, and negatively impact the normal bacterial flora of the gastrointestinal and urinary tracts. Acute UTI often becomes chronic because residual Damp is not cleared and/or continues to be produced. The use of cold, bitter herbal medications should be undertaken carefully in weak patients. This is especially true if the animal is already on long term antibiotic therapy and eating a prescription diet. Chinese food therapy and nutritional supplement plans are an integral part of treatment. They are specifically designed to treat the individual animal and pattern of disease present just as herbal medicine and acupuncture are. In general, a diet is formulated which will nourish Qi, Yin-blood, drain Damp and promote normal healthy urination. The longer the UTI has been present, the more difficult it will be to manage and or resolve. Therapy is often prolonged and client education is essential in this regard. Unless appropriate treatment is given for the prescribed period of time, clinical signs will recur. In general, it can take four to six weeks to see the beneficial effects of Chinese medicine and up to one year to resolve chronic urinary tract infection. Chinese herbal medicine and appropriate diet are essential for the prevention, management, and/or resolution of chronic UTI. Acupuncture as a sole therapy is typically unable to resolve chronic UTI. Acupuncture is commonly used for gastrointestinal upset, pain relief, strengthening the immune system and to help restore normal organ function. The use of herbal medications and acupuncture in combination is superior to using either therapy alone in the management and treatment of chronic UTI. CHINESE HERBAL MEDICINE TREATMENT FOR CHRONIC UTI Ba Zheng San (Eight-Herb Powder for Rectification) is the classic herbal formula used to treat damp-heat in the lower jiao. The tongue is red and can have a thick white to yellow coating, with a forceful and rapid pulse indicating damp-heat in the body. This formula is effective to treat acute exacerbations of chronic urinary tract infections. It has antibiotic like activity and is

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cold and bitter in nature and is not recommended for long term use without modification or administration of tonic herbs or formula to protect the middle jiao. Ba Zheng San contains herbs which induce urination, relieve dysuria and clear damp-heat. This formula is often modified to increase heat and damp clearing effects, treat hematuria and crystals and relieve pain. There are many different modified patent medications of this formula available from Chinese herbal manufacturers. Ba Zheng San can be combined with conventional antimicrobials with precautions. Herbal ABX (EG) is a patent formula with herbs which have a primary function to clear Fire and Toxic Heat. Herbal ABX has marked antibiotic properties and is specifically formulated for the treatment of infections. It contains no tonifying herbs and is not for long term use. From a Traditional Chinese medicine viewpoint bacterial infection is characterized by fire, damp-heat and or toxic heat attacking the body. Therefore, the treatment of infection requires use of herbs that destroy the offending pathogen. It is also necessary to resolve the clinical signs of infection, such as swelling, inflammation, and fever. Herbal ABX can be used to increase the antimicrobial effects of Heat clearing herbal formula and antibiotics. Xiao Ji Yin Zi (Cirsium Decoction) is a classic formula which treats xue lin (bloody dysuria) caused by heat in the lower jiao. In this syndrome, heat burns and damages the vessels of the urinary bladder causing frequent voiding of bloody urine and pain. The treatment plan for this syndrome is to cool the blood, stop bleeding, promote urination, and relieve pain. It can be combined with Ba Zheng San to control UTI with significant hematuria and bacterial infection. Chuan Xin Lian (MW, GFCH) is a patent formula which contains Chuan Xin Lian (andrographis), Pu Gong Yin (dandelion) and Ban Len Gen (Isatis). It clears Heat, detoxifies and boosts the antimicrobial effects of conventional medications. It is often added to Ba Zheng San. Viola Clear Fire (GFCH) is a patent formula which contains many heat and toxin clearing herbs such as Oldenlandia (Bai Hua She She Cao), Viola (Zi Hua Di Ding), Isatis leaf and root (ban Len Gen, Da Qing Ye), Houttuyniae (Yu Xing Cao), andrographis (Chuan Xin Lian), Lonicera (Jin Yin Hua), Forsythia (Lian Qiao) and Coptis (Huang Lian). It is very effective to boost the antimicrobial effects of Ba Zhen San or conventional antimicrobials. Its primary function is to clear Heat not Damp. Si Miao San (Four Marvels Powder) is a classic formula which eliminates Damp-Heat in the lower jiao. It can be combined with conventional antimicrobial therapy to clear Damp and prevent recurrence of UTI. It can be used long term in low doses for up to four months. Once the signs of damp have resolved it is recommended to switch to a balanced Spleen tonic. Its treats more Damp than Heat and must be combined with herbal formula or conventional medications in animals with active bacterial infection. It is often combined with Ba Zheng San to boost its Damp clearing ability in dogs with significant Spleen Damp. Ling Syndrome (Formula to Cleanse the Urinary Bladder and Kidney) is a patent formula based on the herbal formulas Ba Zheng San, Wu Ling San, Si Miao San and Liang Xue Si Wu Tan. This formula functions to clear Damp-Heat and blood stasis entanglement in the lower jiao

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and relieve painful and difficult urination. It can be used long term for up to 6 months depending on dosage. It can be used in cases of chronic UTI with kidney or bladder stones as it contains herbals which dissolve crystals.

SUMMARY Although not a panacea, Chinese medicine should be considered for the treatment of chronic urinary tract infection. The cornerstone of treatment for chronic UTI in Chinese medicine is herbal medicine. In addition to herbal therapy, acupuncture and nutritional therapy are used to promote the successful management of chronic UTI. Chinese herbal medication may be safely combined with conventional medicine to control acute exacerbations of chronic UTI as needed. Chinese medicine is able to recognize and treat the root causes of chronic urinary tract infection to resolve the condition and avoid lifelong administration of antimicrobial therapy in many cases. Treatment is often prolonged due to the chronic nature of the disease, and once therapy has begun, it must be continued for an appropriate length of time to achieve success. The long term prognosis for management and resolution of chronic UTI is good using Chinese medicine in an integrative approach. References 11. Beebe, S., Salewski, M., Monda, L., Scott J., Clinical Handbook of Chinese Veterinary Herbal Medicine, Herbal Medicine Press, Placitas NM. 2006: 1-37, 136-137. 12. Bensky, D., and R. Barolet, Formulas and Strategies, Eastland Press, Seattle, WA, 1990. 13. Chen, J., Chen, T., Chinese Herbal Formulas and Applications, Art of Medicine Press, City of Industry, CA. 2004: 95-97, 173-197, 341. 14. Chen, J., Chen, T., Chinese Medical Herbology and Pharmacology, Art of Medicine Press, City of Industry, CA. 2004: 171-242, 379-428, 559-673. 15. Clinical Manual of Oriental Medicine 2nd edition, Lotus Institute of Integrative Medicine, City of Industry CA. 2006: 464-470. 16. Maciocia, G. The Foundations of Chinese Medicine 2nd ed., Churchill Livingstone Press, 2005: 95-121, 249-263, 287-292. 17. Maclean, W., and J. Littleton, Clinical Handbook of Internal Medicine: The Treatment of Disease with Traditional Chinese Medicine, Vol. 1 Lung, Kidney, Liver Heart, U. Western Sydney, 1998: 352-478. 18. Nelson, R., and C. G. Couto, Small Animal Internal Medicine, 3rd ed., Mosby Press, Press, St. Louis, MO, 2003: 568-650. 19. Wei, Li., and Frierman, D., Diseases of the Kidney and Bladder, Blue Poppy Press, Boulder CO, 2006: 322. 20. Xie, H., Preast, V. Traditional Chinese Veterinary Medicine Volume I, Beijing China 2002:105-132.

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THE ALTERNATIVE PATHWAY OF LAMENESSDIAGNOSIS AND TREATMENT BY RAC CONTROLLED EAR ACUPUNCTURE
Uwe Petermann, DVM Summary Ear acupuncture seems to be very different to the well known body acupuncture. When ear acupuncture was developed it first had only a scientific, western approach to disease. Body acupuncture had only traditional Chinese approach. In the meantime we have more than 30 years of experience with ear acupuncture in humans and 20 years of experience in animals. Nowadays both sides come together and are building a bridge between TCM and western medicine. In this lecture it is shown, how to work easily with ear acupuncture, to do a clear western lameness diagnosis and how to treat orthopedic diseases. All the newest maps of orthopedic points; all joints (hip point, elbow point), points of all locations of the spinal column and the spinal cord, points off all tendons and muscles etc., are shown and their use in diagnostics and treatment. Introduction Today we can use a very easy way of acupuncture thanks largely to the huge contribution made by Dr Nogier; who was the pioneer of ear acupuncture and RAC controlled acupuncture. This opened the door to a modern, scientific acupuncture. Without discarding traditional Acupuncture, the attempt was made to locate the exact ear acupuncture points for every joint and vertebra, and later on for all organs. Further investigation by Prof Bahr, Dr. Strittmatter and the DAA (German Academy for Acupuncture) also located points for every nerve, ganglion, brain locations, as well as many different functional points associated with well known drugs, and at lastly every body acupuncture point on the ear. So we have in ear acupuncture points like ACTH point, Endorphin point, Histaminic point, Prostaglandin point, or organ points, e.g. liver point, kidney point, adrenal gland point, thalamic point, and so on. Amazingly, methods, modern ear acupuncture and ancient traditional acupuncture, lead us to the same therapy points. The further we delve into both methods, the ear acupuncture that is closer to school medicine and body acupuncture that is developed by far eastern medicine, the more interesting it becomes. We see the many similarities and parallels which are so manifold and should be not be surprising since both methods describe the same conditions though by a different means.

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Still today for me and for people with western education the more simple method for a diagnosis and therapy is the school medicine approach using ear acupuncture. What is the way ear acupuncture works? Body acupuncture works in the scientific sense in a neurophysiologic way, via hormonal pathways, through mechanisms by bioactive substances, and at last the biocybernetic way. These same mechanisms we find again in ear acupuncture. But some things are different. An example how ear acupuncture works is demonstrated in a male black Labrador patient. It had an acute inflammation in the elbow with big swelling of the joint and intensive pain. When I searched the connected ear point for treatment, I saw also a clear pronounced swelling in the elbow point at the ear.

picture 1: acute inflammation, big swelling in the elbow joint, picture 2: pronounced swelling in the ear point of the elbow

The neurophysiologic explanation is as follows: when there is a trauma in the elbow (step 1) we have peripheral irritation and pain transmitted by sensory afferent nerves to the spinal cord and back by somatomotoric efferent nerves to the affected joint leading to local inflammation (swelling, pain, heat in the joint, step 2). But the sensory afferent irritation reaching the spinal cord not only answers the irritation by efferent reaction back to the local trauma (step 3), but also by an efferent central leading reaction, passing the thalamus and reaching the sensorial area in the brain cortex and the animal realizes pain (step 4) as we can see on the fMRI (arrow). From the cortex the irritation leads directly to the ear reflex zone and to local microinflammation (step 5). We find swelling, pain, increasing local temperature and reduced electric resistance of the point. The body has created, immediately after the acute trauma, an active ear acupuncture point.

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The neurophysiological way of Ear Acupuncture, from Petermann 2007 PCLAC, Pulse Controlled Laser Acupuncture Concept in Horses and Dogs

This direct connection is shown in the investigation by Alimi, Geissman and Gardeur. They showed us by fMRI that in case of trauma of the thumb the same area in the cortex is active (picture 1) as when we irritate the thumb point of the ear (picture 2).

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picture 1 picture 2

Controlled Ear Acupuncture as a diagnostic tool Orthopaedic diagnostics on animals is more difficult than on humans, for the veterinarian has no information about place, severity level of the pain and above all, he has no information as to which special movement causes the pain-reaction in which place of the body. The veterinarian merely can see on which foot the animal has the lameness. Further, he can try to provoke a pain or reaction, e.g., by stretching,

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bending or palpating the leg. In this way, he can draw conclusions on the point of the lameness. Finally, the point of the lameness can be limited by radiographic diagnostics. But interpretation of radiographs often is very difficult and can lead to a wrong diagnosis. Through this, the place for the local therapy can be incorrectly chosen. Controlled Acupuncture could offer valuable diagnostic assistance, if an ear chart with accurate orthopaedic point localizations is available. So the earacupuncture-chart in veterinary medicine has not only therapeutic but also an important diagnostic meaning. Different authors created ear charts of some animal species over the past years. The points of ear were in most cases found using electrical point detecting devices with well-known orthopaedic pain localizations or by pain provocation tests. But there where only few points for orthopedic treatment and most of the points seemed to me not to be at the right position.

The procedure of lameness diagnostics by RAC-controlled ear acupuncture First of course a thorough clinical examination is done. After that, one has to look for active earpoints; that show us which joint and vertebra is affected. This can be done in a couple of ways; using an electric point finder, or using a laser with various frequency settings according to Nogier combined with the RAC pulse diagnosis.

In body acupuncture we can find every body point by reduced electric skin resistance with help of an electric point-finder. Here we have no difference between active points, meaning acupuncture points that are not in balance, and non-active points, points that are not out of balance and so not must be treated. On the ear only active points have reduced electric skin resistance and so can be found by electric point finders.

Orthopedic ear map of the dog

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Orthopedic ear map of the horse

The second way to find active points is very much easier. We can find the active points by RAC-control. Pulse feeling (RAC-Control) is nearly indispensable as an instrument for locating the pathologic points of the ear (and for me those on the body as well). The RAC (Reflex Auriculo Cardial or VAS Vasoton Autonom Signal) is based on a vegetative micro-stress reaction. With the help of RAC it is as if you can have a detailed look into the body; often much more specific as with picture giving procedures like radiographic or ultra sound pictures. Using the laser, if you have lameness in the right forelimb you irradiate the area of the ear that represents the forelimb with the laser frequency C and at a certain point you will get a clear RAC-rebound. You mark the point, compare it with the chart and realize that you have the point of the shoulder joint. So you not only have found out which joint is affected, you also have at the same time the main point for acupuncture treatment of the lameness. Next you look for the area of the vertebrae, also with laser frequency C, and you find the connected blockade in the spinal column and in the same moment the masterpoint of its treatment.

Different options to get RAC rebounds For getting RAC rebounds on active points at the ear (and on the body as well) we have a lot of options. The best results we get with lasers, especially when we have the right frequencies that are in resonance to the point, e.g., frequency C for orthopedic points. We also obtain very good results with electric fields. Here we use the so called 3 volt hammer. With its (+) pole we find the gold points, that means points in deficiency, and with the () pole we find the silver points, points that are in

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excess. The body also reacts with RAC on Gold or Silver needles and an Ultracain ampule (anaesthetic). Every active acupuncture point on the ear and on the body will react to these RAC detectors. The advantage of RAC is localisation of active acupuncture points quickly and effortlessly. RAC finds and distinguishes the most important points. RAC opens the way for diagnosis of lameness via the ear.
What tools do we need for ear acupuncture in horses and dogs? For stimulation of active ear points we can use thin painless needles for body acupuncture, semi-permanent needles, injection of local anaesthetics and injections of homeopathic drugs. A very special kind of long term treatment is setting Goldbeads into ear acupuncture points. This is very simple and has the same effect as Gold bead acupuncture in body points. My personal favorite tool for ear acupuncture is the laser. With the laser we only need 20 sec of time for each point for stimulation.

Horses ear and Lottas ear showing needles through the cartilage

A needle is inserted in the hock point of a horse and in the elbow point of a dog. The needle is pricked through the ear cartilage. With special pain reduced needles this is possible without any reaction of the patient.
Indications for ear-acupuncture in combination with local laser therapy and traditional acupuncture One area of ear acupuncture is for any orthopaedic case. Ear acupuncture is very good and easy to use in back problems. Laser treatment is used most frequently for spinal problems. All forms of lameness, acute and even chronic in horses and dogs are also indicated. Very often, costly and unreliable operations can thereby be avoided. The active vertebra points and the joint point one finds by lameness diagnosis via the ear are the first points in treatment. In addition to these active points

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most commonly used acupuncture points you can add on the ear to aid in the treatment are, if you find them as active points by RAC: Thalamus point (LI 4), Prostaglandin point (GB 41), Point against anger (LIV 3), Anabolic-point (SP 2), Plexus Coeliacus (SI 3), and the Pituitary Gland point, BL 62). After the ear acupuncture treatment with laser, semi-permanent needles or normal needles, we can add LLLT (Low Level Laser Therapy) on the affected joint and vertebras. There is also the possibility to combine ear acupuncture with traditional acupuncture. I have developed ear maps with all the pathways of the meridians displayed on the dogs and horses ear, thus, one can stimulate every body acupuncture point on the ear as well. In addition, one can use all traditional ideas and treatment concepts like Shu-Mu, Midday-Midnight, Mother- son, Tendino-Muscular Meridian concept, etc. One also can combine ear acupuncture with normal body acupuncture treating the body points instead of the correlated ear points with the same effect.
References 1. Alimi D, Geissmann A, Gardeur D. (2002) Auricular Acupuncture Stimulation Measured on Functional Magnetic Resonance Imaging, Medical Acupuncture- A Journal for Pysican by Physicans Volume 13/Number 2

2. Ambronn, G., Petermann, U., Werner, L. Ohrakupunktur in der Veterinrmedizin Sonntag Verlag, Stuttgart 2001 3. Artmeier P. und Knig H.E. (1978) Zur Ohrakupunktur bei Hund. Kleintierpraxis 23 /1978/299ff 4. Bahr, F. (1997) Scriptum Systematik und Praktikum der wissenschaftlichen Akupunktur fr weit Fortgeschrittene und Experten. Eigenverlag, Mnchen 5. Krger P. und Krger H. (1980) Grundlagen der Aurikulotherapie bei Hund und Pferd. Der Akupunkturarzt/ Aurikulotherapeut 1/1980/13ff 6. Litscher, G. et al.: Die schmerzfreie Laser-"Nadel"-Akupunktur moduliert die Gehirnaktivitt. Schmerz und Akupunktur 2004; 1:4-1 7. Nogier, P. F.M. (1981) Lehrbuch der Auriculotherapie Maisonneuve, Sainte Ruffine 8. Petermann U. (1989) Die Ohrlokalisationen der Gelenke beim Pferd. Akupunkturarzt/Aurikulotherapeut 7-8/1989/167 9. Petermann, U. (2002) Earacupuncture Map of the horse, Procc. of 28th IVAS 2001 world congress, Liuhe Hawaii, USA, 1-3 10. Petermann, U. (2007) PCLAC (Pulse Controlled Laser Acupuncture Concept), private publishing, www.akupunkturtierarzt.de

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11. Still J. (1987) Auriculodiagnostic points in the dog: relationship to disorders of the nervous and locomotor system. Am J Acupunct 15: 261-268 12. Strittmatter, B. (2005) Taschenatlas Ohrakupunktur nach Nogier/Bahr 3. berarb. Aufl., Hippokrates Verlag, Stuttgart 13. Zohmann, A. (1990) Physiologische und pathophysiologische Grundlagen von Ohr-, Krperakupuntur und Neuraltherapie. Prakt. Tierarzt >collegium veterinarium< 71, 83 - 84

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EQUINE TRADITIONAL, TRANSPOSITIONAL AND NONMERIDIAN POINTS


Kevin J. May, DVM El Cajon Valley Veterinary Hospital El Cajon, California, USA The following is an effort to review anatomical locations of equine acupuncture points and their usage. Along the way, we will cover some discrepancies found in point descriptions, where points are located on an authors illustration/chart, and point names or combined names, where an author is trying to name a point both with a transpositional and a traditional Chinese veterinary acupuncture name. These discrepancies can be seen both between different authors and within the same body of work by one author. Many charts showing points vary in their accuracy of location, when compared to their written description. Be sure and read the definitions for each point and compare that description to the point shown on the illustration/chart do not take either for granted. We will also cover more recently transposed point names for equine points that, up to now, either did not have a name assigned to them, the name they had was a slang term, or the assignment of the new transpositional point name helped clarified that points position and usage, as well as the reassignment of other meridian points in the area. Many figures were compliments of the International Veterinary Acupuncture Society, I.V.A.S., and taken from the IVAS Equine Acupuncture Point CD. Some pictures from the CD were altered to accommodate the discussion of additional points not originally on them. When a transpositional point is mentioned, the IVAS name and location is used unless otherwise designated. This is by no means a complete list, but is a start, so let us begin.
GV 26 GV 27 (human) TCVM #21 (Fen-shui, Dividing Water) TCVM #26 (Wai Chun Yin, Outer Upper Lip) Location: (Figure. 1) GV 26: midway between ventral nares on dorsal midline. GV 27: On the midline, at the border of the skin and upper lip (human). It is on the ventral border of the Orbicularis oris m., not the dorsal border. TCVM #21 (Fen-Shui, Dividing Water): at center of vortex pilorum; TCVM #26 (Wai Chun Yin, Outer Upper Lip): On midline of the upper lip, at the level of the ventral margin of the nostrils.

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*Note: TCVM #26 at GV 26, TCVM #21 below GV 26, and above GV 27 GV 27 below them all.

Actions/Indications: GV 26: shock, unconsciousness, apnea, facial paralysis, local, acute inflammation in the caudal back area. GV 27: Mental problems; local lip, nose and gum problems.(human) TCVM #21 (Fen-Shui, Dividing Water): shock, facial paralysis, colic TCVM #26 (Wai Chun Yin, Outer Upper Lip): *Older TCVM Text: Pharyngolaryngitis, swelling of the lip, indigestion, and Stomach Cold (Spleen Damp, Stomach Cold) *Recent TCVM Text: Same as above, plus shock, laryngeal hemiplegia.

*Note:
The actions of TCVM #21 and GV 26, 27 are similar TCVM #26 is different. (Except in latest TCVM books, which add shock). *Conclusions: If one were to pick one of these TCVM points to represent GV 26 (human) based on action and Indications, one would probably pick TCVM #21. If it were to be picked on current IVAS GV 26 location and latest TCVM books, it would be TCVM #26

Figure 1. GV 25 (human) TCVM #27 (Chou-Jin, Pulling Tendon) Appetite Point (slang term)

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Location: (Figure. 1) GV 25 (human): At the center of the tip of the nose. In the nasal cartilage, at the tip of the nose. Appetite Point: On the dorsal midline, at the level of the dorsal margin of the nostrils. author via personal communications TCVM #27 (Chou-Jin, Pulling Tendon): On the midline of the upper lip, 1 cun dorsal to TCVM #26 (Wai Chun Yin). It is located above the center of the tendon of levator labii maxillaris. *Notes: GV 25 (human) would seem to correlate well to being on the dorsal midline at the level of the dorsal nares, similar to tip of nose. This also correlates to being just dorsal to the bifurcation of the levator maxillaris tendon. GV 25 and the Appetite point seem to share the same anatomical location (if the author is correct in the latters anatomical location). TCVM #27 (Chou-Jin, Pulling Tendon) does not seem to be the same as point GV 25. While GV 25 seems to be located above the bifurcation of the levator labii maxillaris tendon, TCVM #27 is located just above the center of the tendon, in the middle of the lip. Actions/Indications: GV 25 (human): Raises Yang to the head, restores the Qi, Clears the senses and clears Heat. Appetite Point: Loss of appetite. TCVM #27, (Chou-Jin, Pulling Tendon): Cervical Rheumatism/Stiffness

*Note:
Only GV 25 and the Appetite point have actions/indications which could correlate vs. TCVM #27 = Cervical Rheumatism/Stiffness.

LI 20 and TCVM #23 (Jiang-ya) Location: (Figure. 2) LI 20: caudal to the nostril, at the dorsal tip of the cornu of the alar cartilage. TCVM #23 (Jiang-ya): At the cornu of the alar cartilage on the lateral corner of the nostril. *Needling Techniques LI 20: needled just above the dorsal tip of the cornu of the alar cartilage. TCVM #23 (Jiang-ya): Older TCVM Text: an incision was made; the tip of the cartilage pulled out and a piece cut off. Recent TCVM Text: needled through the dorsal tip of the cornu of the alar cartilage. The needle can be bent to keep in place and stimulate as needed. It has been suggested to use a 1.5 to 2 inch, 21 gauge, hypodermic needle.

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Actions/Indications: LI 20: Nasal problems, facial paralysis and trigeminal neuralgia. TCVM #23, Jiang-ya: Colic *Note: Recent information says that if pain is not relieved within 15 minutes, then it is most likely a surgical vs. medical colic, otherwise, leave in for 30 minutes or until colic is under control. *Note: The fact that these two points are in close proximity, yet have different functions might be explained by the fact that LI 20 is considered to be the Meeting point of the Stomach and Large Intestine meridians.

Figure 2. M-HN-18 (Miscellaneous points Head and Neck 18, Jiachengjiang, Grasping Contain Fluid) Location: (Figure. 2) In the depression at the mental foramen of the mandible.(human) Action/Indications: Trigeminal neuralgia, facial paralysis or spasm. *Note: This is a human transpositional point. ST 2 TCVM #13 (San Jiang, Three Streams, Old IVAS ST 2) Location: (Figure. 3) ST 2: In the depression at the infraorbital foramen. TCVM #13 (San Jiang, Three Streams, Old IVAS ST 2): Traditional: On the angular vein, about 3 cm ventral to the medial canthus. IVAS Primary Location: In the depression, rostroventral to the medial canthus of the eye, just caudal to the bifurcation of the angularis oculi (angular) vein. IVAS Alternate Location: same except at the bifurcation of the angularis oculi (angular) vein. (same as TCVM #13)

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Actions/Indications: ST 2: Eye problems, facial paralysis, trigeminal neuralgia. TCVM #13 (San Jiang, Three Streams, Old IVAS ST 2): GI and eye problems.

Figure 3. GV 24 TCVM # 1 (DA-FENG-MEN, Great Wind Gate) Location: (Figure. 4) GV 24: In the depression on the dorsal midline at the rostral base of the forelock. This is where the left and right ridges of the external sagittal crest of the parietal bone join on the midline. TCVM #1 (DA-FENG-MEN, Great Wind Gate): GV 24 plus bilateral auxiliary points located in the depressions 1 cun rostrolateral to the main point on the left and right ridges of the sagittal crest of the parietal bone. Actions/Indications: GV 24: Anxiety, convulsions, other brain problems; rhinitis. Calms the mind; Dispels Wind, Damp. TCVM #1 (DA-FENG-MEN, Great Wind Gate): Encephalitis, encephalomyelitis, tetanus (Spleen deficiency, Damp, Wind conditions of the Heart).

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Figure 4 LI 10 TCVM #107 (Qian San Li, Thoracic 3 miles) Location: (Figure. 5) LI 10: In the muscular groove between the extensor carpi radialis and the common digital extensor mm. of the forelimb, 2 cun distal to the transverse crease, which is most evident when the elbow is flexed. TCVM #107 (Qian San Li, Thoracic 3 miles): At the junction of the proximal and middle one third of the lateral surface of the radius. In the muscular groove between the extensor carpi radialis and the extensor digitorum communis mm.

*Notes:

On examination of the horses forelimb, is would appear that given these descriptions above, that LI 10 would be higher than TCVM #107 and thus would not be in the same point location. This could vary depending on how the examiner judges the length of the radius. On most charts TCVM #10 7 is shown below the muscular bulge of the extensor carpi radialis while LI 10 is above that. Recent TCVM charts show TCVM #107 one cun distal to #209. Both are listed as two cun ventral to #106. That description would more fit LI 10 and not #107.

Actions/Indications: LI 10: All LI channel problems, especially pain, atrophy and radial nerve paralysis of the forelimb; GI problems, in combination with ST 36 and CV12 for gastric ulcers. TCVM #107 (Qian San Li, Thoracic 3 miles): Paralysis of the forearm or the radial nerve, stiffness of the thoracic limb, indigestion. (Recent TCVM text talks about using this point as a substitute for ST 36.)

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*Note: While these two points have similar local and GI functions, they are not the same point. You have two points on the forearm, in the same muscular groove that can do similar functions. Just palpate down the groove above and below the bulge of the extensor carpi radialis and you will find the two depressions. This is not uncommon in the human body, where meridian and adjacent non-meridian points have similar functions.

Figure 5.

PC 6 LU 7 TCVM # 171 (Ye-Yan, Chestnut) Earlier TCVM Text TCVM #171 (Ye-Yan, Night-Eye) Recent TCVM Text TCVM #210 (Ye-Yan, Chestnut) Recent TCVM Text Location: (Figure. 6) PC 6: In the depression just cranial to the cranial border of the chestnut, midway between the proximal and distal ends of the chestnut. LU 7: In the depression on the medial surface of the radius, 1.5 cun proximal to the most medial prominence of the styloid process, 0.5 cun distal to the level of PC 6. TCVM #171 (Ye-Yan, Chestnut): - Earlier TCVM Numbering System TCVM #210 (Ye-Yan, Chestnut): - Recent TCVM Numbering System Chestnut of the thoracic limb. Point is directly under the chestnut. TCVM #171 (Ye-Yan, Night-Eye): - recent nomenclature Two cun ventral to the chestnut. *Notes: Despite the written description, some of the recent charts show this point only one cun ventral. Two cun ventral would be at the level of the medial styloid process.

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From the above point descriptions, you can determine that PC 6 is two cun proximal to the most medial prominence of the styloid process. Thus, use your fingers and determine how many finger widths it is from the most medial prominence of the styloid process to the middle of the chestnut, and you will then know how many equal to two cun, and from there how many finger widths make up one cun.

Actions/Indications: PC 6: Master point for the chest and cranial abdomen; calm the Mind, pacify the Shen. LU 7: Master point for the head and neck; Respiratory and forelimb problems, anorexia associated with upper respiratory tract inflammation, retention of urine and constipation, edema, and sweating problems. TCVM #171 (Ye-Yan, Chestnut): Swelling or pain in the region. Traditionally treated with either moxibustion or cauterization. TCVM #210 (Ye-Yan, Chestnut): Pain in the forelimb and thorax. *Note: This point along with SI 9 (Qiang-feng, TCVM #94) and TH 5 are useful in forelimb analgesia.

Figure 6.

LI 4 LUOLINGWU (N-UE-3, Stiff (neck) One Half, Old IVAS LI 4) (Human) TCVM #110 (Xi-mai, Carpal vein)

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Location: (Figure. 7) LI 4: In the depression, just palmar to the 2nd metacarpal (medial splint) bone and distal to its base, approximately at the level between the proximal and middle third of the 3rd metacarpal (cannon) bone. LUOLINGWU [N-UE-3, Stiff (Neck) One Half, Old IVAS LI 4]: In the depression, distal to the base of the 2nd metacarpal (medial splint) bone, between the 2nd metacarpal and 3rd metacarpal (cannon) bones, at the level between the proximal and middle thirds of the 3rd metacarpal bone. TCVM #110 (Xi-mai, Carpal vein): At the junction of the proximal and middle thirds of the metacarpus on the medial palmar vein. *Notes:

Some books/charts describe and show LI 4 in the space between Metacarpal III (Cannon Bone) and II (Medial Splint Bone), and some on the 2nd metacarpal (Splint) bone itself. All are at the same level, just in a different anatomical orientation from dorsal to palmar (front to back). Transpositionally this can not be correct as LI 4 is located between MC II and I. This movement of the point onto MC II or between MC II and II is usually in response to the loss of MC I. The question you have here is that there is also a loss of MC V, so what then? There is no need to start crowding these points axially due to loss of metacarpal bones. The English translation of the TCVM #110, Carpal Vein, along with some of the traditional charts showing TCVM #110 in the proximal metacarpal to the mid-carpal area, adds to some confusion to this points location. The description is at the same level and just caudal to LI 4 and is a hemopuncture point. LI 4 is needled in an oblique direction palmaromedial to dorsolateral. This places both the point and the inserted needle used to treat this point dorsal (in front of) to the medial palmar vein and its associated point, TCVM #110 (Xi-Mai, Carpal Vein).

Actions/Indications: LI 4: Master point for the face and mouth (including the eyes), problems along the meridian, especially the upper forelimb and neck; LI and LU problems; Used with LIV 3 to activate the Four Gates, with GV 24 for anxiety; immunostimulation, fever; with KI 7 to regulate sweating; as an aid in labor during foaling and with SP 6 to induce abortion. LUOLINGWU (N-UE-3, Stiff (Neck) One Half, Old IVAS LI 4): Stiff neck, stomach spasms, and hypertension. TCVM #110 (Xi-mai, Carpal vein): swelling, pain, arthritis, tenosynovitis, tendonitis and myositis in the carpal region.

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*Note: The actions of all 3 points listed above have similar actions locally. LI 4 and Luolingwu are similar in their affects on the neck (thus leading to confusion on which is which when treatment of either could take care of sensitive LI points on the neck such as LI 16, 17 and 18. Of course, LI 4 goes on to affect the other points on the meridian such as LI 19 and 20, thus earning its roll as a Master point for the face and mouth.

Figure 7. SI 3 TCVM #113 (Qian-chan-wan, Thoracic Fetlock) Location: (Figure. 8) SI 3: In the depression just distal to the end of the 4th metacarpal (lateral splint) bone and proximal to the fetlock, on the palmarolateral border of the 3rd metacarpal (cannon) bone. TCVM #113 (Qian-chan-wan, Thoracic Fetlock): On both sides of the palmaromedial and palmarolateral aspects of the front fetlock. On the medial and lateral palmar veins, slightly proximal to the fetlock. Each limb has two points. *Notes: Some books/charts refer to these two points as being the same point. SI 3 in the human is located just palmar to MC V and just proximal to the 5th metacarpophalangeal joint. In the horse, the MC V is gone and MC IV is shortened. If we use the same logic that we did with the location of LI 4, not shifting points due to loss of osseous anatomical structures, it would be reasonable to assume that TCVM #113 is the same as transpositional SI 3. Thus, IVAS has listed this point as an alternative point location for SI 3.

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TCVM #113 is two points and the palmaromedial point has also been listed as being the same as LI 3. The problem with that is that while LI 3 is located at the same level as SI 3, it is just palmar to MC IV, not MC V, thus could not be that far back. It would make more sense for LI 3 to located in the medial mirror position of SI 3 just distal to the end of the 2nd metacarpal (medial splint) bone.

Actions/Indications: SI 3: Epilepsy, head, neck and upper back pain; with BL 62 for entire neck and back pain; TCVM #113 (Qian-chan-wan, Thoracic Fetlock): Older TCVM Text: Fetlock pain, swelling and arthritis; flexor tendonitis and tenosynovitis. Recent TCVM Text: A combination of TCVM 113 and SI 3, along with laminitis and sore throat.

Figure 8. TH 1 TCVM #116 (Qian-ti-tou, Toe of Hoof) Location: (Figure. 9) TH 1: On the dorsal midline of the front foot, in the depression just proximal to the coronary band. TCVM #116 (Qian-ti-tou, Toe of Hoof): 2/3s to 1 cun lateral to the dorsal midline, just proximal to the coronary band. *Note: some text/charts label these as the same point they are not.

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Actions/Indications: TH 1: Local problems; distal point for problems along the meridian; shock convulsions, colic, fever. TCVM #116 (Qian-ti-tou, Toe of Hoof): Older TCVM Text: Local and fetlock problems, colic. Recent TCVM Text: Leaves out fetlock problems.

Figure 9. LU 11 HT 9 TCVM # 115 (Qian Ti Men, Heels of the hoof) Location: (Figure. 10) LU 11: On the palmaromedial aspect of the front foot, in the depression just proximal to the coronary band, approximately two thirds of the distance from the dorsal midline of the coronary band to the palmar border of the medial bulb of the heel. HT 9: On the palmarolateral aspect of the front foot, in the depression just proximal to the coronary band, approximately two thirds of the distance from the dorsal midline of the coronary band to the palmar border of the lateral bulb of the heel. TCVM #115 (Qian Ti Men, Heels of the hoof): On the front foot, in the depression just proximal to the coronary band of the heel bulb, on the inside of the collateral cartilage (relative to the midsaggital plane of the foot). This point has two locations per foot, one on each bulb. *Note: some text/charts list LU 11 and HT 9 as TCVM #115, and they are not. Actions/Indications: LU 11: Alarm point for the Lung; Local foot problems; Distal point; Epistaxis, fever, HT 9: Restore consciousness; cardiac and chest pain; calm the Mind; Local foot problems. Distal point, Fever.

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TCVM #115 (Qian Ti Men, Heels of the hoof): Local foot problems, Pastern problems.

Figure 10.

BL 26 TCVM #69 (Shen-shu) Location: (Figure. 11) BL 26: 3 cun lateral to dorsal midline and Bai-hui. TCVM #69 (Shen-shu): 2 cun lateral to dorsal midline and Bai-hui

*Note: This makes BL 26 one cun more lateral than TCVM #69. Not the same.
Actions/Indications: BL 26: local point, used for caudal back and sacroiliac problems, GI and Urogenital problems, and rectal prolapse. TCVM #69 (Shen-shu): Older TCVM Text: TCVM Kidney Shu (Association) point, used for pain in lumbar and hip, lumbar paralysis. Recent TCVM Text: same, plus arthritis, Yang or Qi deficiency, overexertion.

*Note: Recent TCVM text says it can be substituted for Bai-hui, if it can not be used.

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Figure 11. BL 25 TCVM # 70 (Shen-peng) Location: (Figure. 11) BL 25: 3 cun lateral to dorsal midline. TCVM #70 (Shen-peng, Kidney Shelf): 2 cun lateral to dorsal midline and 2 cun cranial to TCVM # 69.

*Palpation tip = put index finger on Bai-hui and thumb on #69, now keep the same distance between them (which is 2 cun) and rotate the index finger cranially 90 degrees to find #70. *Note: This makes BL 25 more cranial and one cun more lateral than #70.
Actions/Indications: BL 25: Large Intestine Association (Shu) point, same as BL 26, except urogenital problems. TCVM #70 (Shen-peng, Kidney Shelf): same as TCVM #69. *Note: Recent TCVM text says that it can be substituted for Shen-Shu. BL 27 TCVM #71 (Shen-jiao, Kidney Corner) Location: (Figure. 11) BL 27: 3 cun lateral to dorsal midline. TCVM #71 (Shen-jiao, Kidney Corner): 2 cun lateral to dorsal midline and caudal to TCVM #69.

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*Palpation tip = put index finger on Bai-hui and thumb on #69, now keep the same distance between them (which is 2 cun) and rotate the index finger caudally 90 degrees to find #70. *Note: This makes BL 27 more caudal and one cun more lateral than TCVM #70. Actions/Indications: BL 27: Small Intestine Association (Shu) point, same as BL 26 TCVM #71 (Shen-jiao, Kidney Corner): same as TCVM #69. *Note: Recent TCVM text says that it can be substituted for Shen-shu. XUEFU (Bloods Residence, M-BW-19, Human point) and Old IVAS Ovary point Location: (Figure. 12) In the depression lateral to the dorsal midline, between the spinous process of the 2nd and 3rd lumbar vertebrae. The point is found on a vertical line from the L2-3 area to the caudal aspect of the last rib, 1 cun lateral to BL 52. Actions/Indications: Human: Amenorrhea, swelling of the ovaries, spermatorrhea, enlargement of the spleen or liver. IVAS: Detection and treatment of any ovary problem, as well as any related muscle soreness in the caudal back and upper flank, hormonal or behavioral problems.

Figure 12. GB 26 TCVM #121 (Yan-Chi, Wing of Ilium) Location: (Figure. 12) GB 26: Is located just caudal to the distal end of the 17th rib (LIV 13), in the external and internal oblique muscles and the transversus abdominis muscle, at the level of the navel (umbilicus CV 8).

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TCVM #121 (Yan-Chi, Wing of Ilium): Traditionally is listed as on the wing of the ilium, midway between TCVM #70 and the tuber coxae. It is also listed as being on a perpendicular line extending from the tuber coxae to the dorsal midline. It is located at 1/3 of this line from the tuber coxae.

*Note: It is obvious from these descriptions that GB 26 is more in the upper flank area between the end of the last rib and the tuber coxae, while TCVM #121 is in the dorsal gluteal area.
Actions/Indications: (similar) GB 26: Beginning point of the Girdle (Dai) Channel which it also regulates; alleviates Damp Heat; Used for reproductive problems, lumbar pain, colic, and convulsions. TCVM #121 (Yan-Chi, Wing of Ilium): Rheumatism, arthritis, and pain of the hindquarters, and infertility (recent TCVM text says male or female). Gallbladder Dorsal Tuber Coxae (IVAS GB-DTC) and (old GB 27 or GB 26) Location: (Figures. 12, 13) GB-DTC: In the depression just medial to the most dorsal aspect of the tuber coxae on a line drawn at a 90 degree angle from the dorsal midline to the most dorsal aspect of the tuber coxae. The Gallbladder does have a relationship with the iliac spine in humans and the tuber coxae in the horse. Since this point is located much too medial to be GB 27, IVAS used the point naming method of meridian and anatomical relationship. Gallbladder meridian point and most dorsal aspect of the tuber coxae. Old GB 27 (and sometimes GB 26): 0.5 cun caudal to the dorsocranial iliac spine above the wing of the ilium.

*Note: The dorsal aspect of the tuber coxae is confusing to many who try and palpate it. Many follow the circle or C shape that faces cranially. As you come to the top of the C of the tuber coxae, it turns caudodorsally. This final turn is missed by many thus needling cranioventrally to this point and getting similar results. In the description above for Old GB 27 (26) you see mention of going 0.5 cun caudally. This is probably reflective of stopping too soon on palpation of the tuber coxae and thus ending up in the same point location as GB-DTC.
Actions/Indications: Local problems; Maybe associated with a chiropractic problem of the pelvis or hindimb. Some authors give special consideration to the hock area, other also for fertility problems.

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Figure 13.

GB 27 and Old SP 13 (some authors 14) Location: (Figures. 12, 13, 15a) Same: In the depression just cranial to the mid-portion of the cranial border of the tuber coxae.

*Note: On the ventral abdomen, it is 5 cun from the umbilicus (CV 8) to the cranial border of the pubic symphysis (CV2). Spleen 13 and 14 are 4 cun lateral to the midline and are medial to the gallbladder meridian, so they could never come up to this level. SP 13 is only 0.7 cun cranial to the cranial border of the symphysis, and SP 14 is 3.7 cun, so they would be a long way from the mid-cranial border of the tuber coxae. See further explanation below under Spleen Meridian of the abdomen/flank area.
Actions/Indications: Same: Local, caudal back and upper hindlimb problems (hip, stifle); some say fertility problems.

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Figure 15a.

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Figure 15b. SPLEEN Meridian (in the abdominal/flank area) Location: (Figures. 12, 13, 15a, 15b) Facts: In brief, the Spleen points on the abdomen are pretty much a straight line parallel with the CV, and do not deviate up into the flank area as seen in most charts.

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1) In humans, the spleen meridian starts on the abdomen with SP 12, being located at the cranial border of the pubic symphysis, 3.5 cun lateral to CV2. SP 13 is 0.7 cun cranial to SP 12 and 4 cun lateral to the CV. It continues in a straight line to SP 14 and 15. SP 15, located in the lower flank, is at the same level as the umbilicus (CV 8) and GB 26 (just cranial to the tuber coxae). 2) Many charts depict the spleen meridian, right after SP 12 and 13, going medially to enter into the abdomen, where it crosses CV 3 and 4, then coming back laterally to SP 14 and 15. Many authors show this last lateral zag extending up into the upper flank of the horse. It does not. The lateral zag is only a line coming from the CV back to SP 14 which is only 4 cun lateral to the CV and 1.3 cun caudal to the umbilicus. 3) Care must be taken in reading one dimensional charts and trying to interpret where the points are. In the case of the spleen points: 12, 13, and 14, it appears that they might reside on the pelvis, if the chart shows the underlying pelvic bones. In this case, these points reside on the anterior (human) or ventral (horse) aspect of the abdomen. Some people will say that these points migrated towards the pelvis when the body position moved from a upright 2 legged individual to a 4 legged individual. This is not the case; they stayed on the abdomen and rotated with it. They are not to be perceived as points in space that stayed in the same place while the body moved independently.

GB 28 ST 30 and the STOMACH Meridian TCVM #122 (Dan-tian) TCVM #123 (Ju-liao) Location: (Figures. 12, 13, 15a) GB 28: In the depression just ventral to the ventral border of the tuber coxae. ST 30: ST 30 is located just 2 cun lateral to CV2, on the cranial border of the symphysis which is along way from the ventral border of the tuber coxae. TCVM #122 (Dan-tian): Older TCVM Text: In the depression 1.5 cun ventral to the tuber coxae. Recent TCVM Text: Same except = cranioventral TCVM #123 (Ju-liao): Older TCVM Text: In the depression caudoventral to the tuber coxae Recent TCVM Text: Same except mentions distance = 1.5 cun.

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*Notes:

It is obvious that ST 30 could never be near the tuber coxae since it is located on the cranial border of the pubic symphysis. It is obvious that TCVM #122 and #123 are not at the same as GB 28. They are located 1.5 cun ventral and caudoventral to the tuber coxae, respectively. In some recent TCVM charts, it shows TCVM #122 at the level and cranial to the ventral aspect of the tuber coxae and TCVM # 123 at the same level, both too high.

Actions/Indications: GB 28: Local problems; Sensitivity could indicate a problem in the hindlimb with some authors giving special consideration to the stifle area. ST 30: Local problems; Colic, hernia TCVM #122 (Dan-tian): Older TCVM Text: Infertility; Pain, stiffness and arthritis of the hip and loin. Recent TCVM Text: Stifle and hip problems; arthritis, contusion, sprain TCVM #123 (Juliao): Older TCVM Text: Swelling/pain in the loin and hip, pelvic limb paralysis, myositis of thigh muscles. Recent TCVM Text: Stifle and hip problems; arthritis, contusion, sprain BL 39 BL 40 TCVM #136 (Yang-ling, Yang grave) Location: (Figure. 14) BL 39: In the depression just medial to the caudal border of the caudal division of the biceps femoris m., at the ventral end of the muscular groove between the biceps femoris and semitendinosus mm. Found just lateral to BL 40 when stifle flexed. BL 40: In the depression at the midpoint of the transverse crease of the popliteal fossa, between the caudal division of the biceps femoris and semitendinosus mm. More easily found with the stifle flexed. TCVM #136 (Yang-Ling, Yang grave): In the depression at the ventral end of the muscular groove between the middle and caudal divisions of the biceps femoris m. (found easier with stifle slightly flexed).

Older and Recent TCVM Text: In the depression (10-14 cm or 4 cun) caudal to the stifle joint (dorsocaudal or caudoproximal to the lateral condyle of the tibia). Located between the cranial and middle parts of the biceps femoris. Underneath is the musculus gastrocnemius.

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*Notes:

Many people do not remember that the horse has 3 muscle bellies to the biceps femoris (cranial, middle and caudal), or not aware of their anatomy, thus tend to follow the groove between the middle and caudal bellies versus the one between the caudal belly of the biceps femoris and the semitendinosus to find BL 40. TCVM #136 is listed in most TCVM text as: 1) Located between the cranial and middle parts of the biceps femoris. 2) Having the musculus gastrocnemius located underneath. 3) This point is dorsocaudal/caudoproximal to the lateral condyle of the tibia. *These can not all be true. The last two statements can, but again the first statement has the point located too far forward and is probably another example of not being aware of the anatomy of the 3 muscle bellies of the biceps femoris. Remember that the semitendinosus is the long tall muscle in the caudal thigh find it and follow its cranial edge down the leg and you will not be mislead when trying to palpate and find BL 36, 37, 38 39 and 40.

Actions/Indications: BL 39: Local and hindlimb problems; urinary problems; Sensitivity could indicate a hock problem. BL 40: Master point for caudal back and hip region; Local, GI, Urogenital and skin problems; fever and heat exhaustion. TCVM #136 (Yang-Ling, Yang grave): Stiffness and pain in the hindlimb, especially stifle area. Sensitivity at this point, along with BL 39 and GB-DTC might indicate a problem with the hock area. Older TCVM Text: Rheumatism of pelvic limb, arthritis, pain or swelling of the stifle Recent TCVM Text: Similar, plus immune-mediated disease, urinary hemorrhage, Wei Syndrome

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Figure 14.

LIV 4 TCVM #143 (Qu-chi, Pond on the curve) Location: (Figure. 16) LIV 4: Over the depression of the dorsal branch of the medial saphenous vein, dorsomedial to the medial branch of the tibialis cranialis m. (cunean tendon), at the level of the distal intertarsal joint.

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TCVM #143 (Qu-chi, Pond on the curve): Older TCVM Text: same vein, located at the dorsomedial talus *Note: This places it more dorsal than LIV 4. Recent TCVM Text: same vein, located at the craniomedial aspect of the hock.

*Note: Most charts that show LIV 4 at the TCVM #143 point location will try and put LIV 3 in the current LIV 4 position instead of its location caudal to the medial splint bone at the same level as LI 4 in the forelimb.
Actions/Indications: LIV 4: local for hock problems and distal for stifle problems; Urogenital problems. TCVM #143 (Qu-Chi, Pond on the Curve): local hock and fetlock problems.

Figure 16. SP 1 BL 67 GB 44 *some authors have this point also listed as being one of the TCVM #152 points. TCVM #152 (Hou Ti Men, Heel of the Pelvic Hoof)

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34th International Congress on Veterinary Acupuncture

TCVM #151 (Hou Ti Tou, Pelvic Hoof Toe) Location: (Figures. 17, 18, 19) SP 1: On the plantaromedial aspect of the rear foot, in the depression just proximal to the coronary band, approximately two thirds the distance from the dorsal midline of the coronary band to the plantar border of the medial bulb of the heel. BL 67: On the plantarolateral aspect of the rear foot, in the depression just proximal to the coronary band, approximately two thirds of the distance from the dorsal midline of the coronary band to the plantar border of the lateral bulb of the heel. GB 44: On the dorsolateral aspect of the rear foot, in the depression just proximal to the coronary band, approximately one third the distance from the dorsal midline of the coronary band to the plantar border of the lateral bulb of the heel. TCVM #152 (Hou Ti Men, Heel of the pelvic hoof): On the rear foot, in the depression just proximal to the coronary band of the heel bulb, on the inside of the collateral cartilage (relative to the midsaggital plane of the foot). This point has two locations per foot, one on each heel bulb. TCVM #151 (Hou Ti Men, Pelvic Hoof Toe): On the rear foot, just lateral to the common digital extensor tendon, in the depression just proximal to the coronary band. Older TCVM Text: Counter point of the thoracic limbs #116 (which is 2-3 cm lateral to the dorsal median line, 1 cm dorsal to the periople or the junction between the coronary border of the hoof and skin. Recent TCVM Text: On the cranial midline of the hind hoof, proximal to coronary band. *Note: The recent TCVM text that claims this newer location for TCVM #151, also makes this point ST 45, whicht contradicts the older TCVM texts that say that TCVM #151 is a counter point to TCVM #116. Actions/Indications: SP 1: Local point for foot and pastern problems; Distal point; Bleeding anywhere in the body, especially the uterus; fever. BL 67: Local point for foot and pastern problems; Distal point; Difficult labor, malpositioned fetus, retained placenta, eye problems, generalized pruritis, fever. Contraindicated in pregnancy. GB 44: Local foot and pastern problems; Distal point, especially for hock and hip areas; eye problems; anxiety; fever. TCVM #152 (Hou Ti Men, Heel of the Pelvic Hoof): Local foot and pastern problems.

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34th International Congress on Veterinary Acupuncture

TCVM #151 (Hou Ti Tou, Pelvic Hoof Toe): Local and rear fetlock problems, Colic, laminitis. Older TCVM Text: similar to IVAS above Recent TCVM Text: same plus, sore throat, epistaxis, dental pain, fever, seizures, navicular disease.

Figure 17.

Figure 18.

Figure 19.

Figure 20.

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