Integrative Medicine: Applications of Acupuncture

ver the past several decades, performance demands on equine athletes in racing, eventing, and endurance have greatly increased. Therefore, most equine acupuncturists have responded by focusing their practice of traditional Chinese medicine on management of chronic musculoskeletal pain and injuries. Acupuncture is one of the oldest and most common forms of therapeutic intervention in the world. Although debate exists regarding the origin of acupuncture, widespread views often date the roots of this procedure back at least 2500 years. Acupuncture made its “debut” in the United States in 1971 following a New York Times report documenting how doctors in China used needles to ease pain in patients following abdominal surgery. Acupuncture has subsequently grown in popularity in the United States in both human and veterinary medicine. In a 1998 Harvard University study it was estimated that Americans made more than 5 million visits per year to acupuncture practitioners. A 2002 National Health survey, the most comprehensive complementary and alternative medicine (CAM) study to date, estimated that 8.2 million U.S. adults had used acupuncture. A survey of members of the American Association of Equine Practitioners (AAEP) indicated that acupuncture referrals rose from 37% in 1998 to 56.4% in 2002, suggesting that owners and trainers are increasingly seeking CAM for treatment of chronic musculoskeletal pain and injury in their horses. This concept is also supported by the growing number of studies investigating CAM in both human and veterinary medicine. The National Institutes of Health (NIH) has increasingly funded research projects on acupuncture through the National Center for Complementary and Alternative Medicine (NCCAM). In response to both the increased interest and growth in CAM, many U.S. medical schools and several veterinary schools have created CAM curricula and academic departments of alternative medicine. Nonetheless, the question remains: does acupuncture work? A recent NIH consensus statement on acupuncture concluded that there have been many studies on acupuncture’s potential usefulness, yet results have been mixed, primarily because of complexities and inherent challenges with study design and size, along with difficulties in choosing placebos or “sham” acupuncture. However, promising results have emerged. A 2000 study published in the Journal of the American Medical Association revealed the efficacy of acupuncture in alleviating postoperative 902


nausea and nausea and vomiting associated with chemotherapy in adults. Another recent study funded by NCCAM, the longest and largest randomized, controlled phase III clinical trial of acupuncture ever conducted, was published in the December 2004 issue of the Annals of Internal Medicine. This study demonstrated that acupuncture reduces the pain and functional impairment of osteoarthritis of the knee in humans. Although there are an increasing number of studies investigating CAM in veterinary medicine, results are often equivocal or contradictory and not sufficiently compelling to recommend or reject acupuncture as a treatment option in domestic animals. A small number of randomized controlled equine clinical trials have been performed. Electroacupuncture was demonstrated to decrease thoracolumbar pain scores. Chronic thoracolumbar pain was successfully alleviated in three sessions of electroacupuncture treatment, with analgesic effect lasting at least 2 weeks. In comparison, phenylbutazone did not effectively alleviate signs of thoracolumbar pain in horses in that study. Equine and canine studies have also demonstrated some benefit of electroacupuncture in producing rectal analgesia. In contrast, other studies have found no significant benefit of acupuncture for treatment of recurrent airway obstruction, duodenal distension, laminitis, and navicular disease, or diagnosis of equine herpesvirus infection. Similar conflicting results are reported in the veterinary literature pertaining to dogs, with decreased emesis, sedation, increased gastric motility, and decreased colonic motility reported as effects of electroacupuncture. No significant benefit was reported in dogs with chronic elbow joint osteoarthritis secondary to elbow joint dysplasia. One of the primary advantages of acupuncture is that the incidence of adverse effects is substantially lower than that of many drugs or other accepted medical procedures used for similar conditions. For example, painful musculoskeletal conditions, including osteoarthritis, are often treated with nonsteroidal anti-inflammatory drugs (NSAIDs) or corticosteroids. Pharmacologic management of these conditions is often ineffective and may result in unwanted or deleterious side effects. Despite the absence of compelling evidence-based–supported proof of efficacy of acupuncture in pain management, accumulated literature suggests acupuncture as a potentially useful option. Acupuncture may be beneficial in the treatment of many of these conditions and should be part of a comprehensive

whereas Yang represents the hollow. diet. Yin represents the solid. resulting in systemic effects such as secretion of neurotransmitters and neurohormones. all of which are used with the goal of relieving obstruction of qi and restoring balance and health to the body. High-frequency electroacupuncture at greater than 70 Hz enhances monoamine-dependent responses. listening. Treatments such as massage. EASTERN THEORY OF ACUPUNCTURE Although it may seem foreign to western observers. and physical examination. including acupuncture. hot. In the traditional Chinese complex of medicine. moxibustion. are used to improve the flow of qi and restore balance to the body. cumulative effect that continues after stimulation ceases. Documented in ancient texts.Integrative Medicine: Applications of Acupuncture medical management program. sympathetic. or homeostasis. Overall the integrative approach to medicine—incorporating the technology and solid orthodoxy of western medicine along with [AQ3] basic principles of TCM and eastern medicine—is an ideal method of diagnosis and treatment of many equine disorders. and all objects in the universe include the two opposite aspects of yin and yang. it is important to maintain and observe the perspective of seeing the relationship of the symptom or symptoms to the entire body. Acupuncture is one of the key components in the complex theoretical framework of traditional Chinese medicine. Acupuncture may be particularly useful in the management of chronic pain and inflammation associated with windup phenomenon. Acupuncture describes the stimulation of acupoints along the meridians and employs penetration of the skin by thin. resulting in central sensitization and decreased neuronal sensitivity to opioid receptor agonists. This imbalance leads to blockage in the flow of qi (vital energy-force) along a series of pathways or channels known as meridians. with a segmental. A number of pharmaceutical NMDA receptor antagonists. Traditional Chinese medicine describes 12 main paired meridians. 903 effective in treatment of chronic pain conditions in dogs and cats. Regardless of the clinician’s approach. Compelling evidence supports the claim that a cascade of endorphins and monoamines is released during acupuncture and at least in part explains the analgesic and anti-nociceptive effects of acupuncture. transcutaneous nerve stimulation. and alterations in immune functions. and infrared light stimulation (laser). Because opioids also have NMDA antagonist activity. cold. These meridians serve as a means of communication relating to the flow of energy (qi) throughout the body. Traditional Chinese medical practices. have proven DIAGNOSTIC ACUPUNCTURE EXAMINATION The diagnostic challenge. slow. 8 secondary meridians. or active principle. rapid-onset. NEUROPHYSIOLOGIC BASIS OF ACUPUNCTURE In the gate control theory. Stimulation by acupuncture needles may also activate the hypothalamus and the pituitary gland. slow-onset. Activation of other types of nerve fibers can modify or block the sensation of pain by overriding pain messages carried by the A-δ and C-fibers. herbs. or passive principle. massage. including amantadine. Low-frequency electroacupuncture at 2 to 10 Hz enhances endorphin-dependent responses. a state produced by repetitive electrical input from C-fibers and activation of N-methylD-aspartate (NMDA) receptors in the spinal cord. other methods commonly used by equine acupuncturists include electrostimulation of traditional Chinese needles. or acupuncture can ameliorate a pain message by influencing interactions between nerve fiber transmissions. Activation of these receptors causes the spinal cord neuron to become more responsive to inputs. In addition to traditional Chinese needles. heat. myelinated. At least two types of afferent nerve fibers are thought to carry most pain messages to the spinal cord: small. allowing signal transduction. the experience of pain (nociception) depends on a complex interplay of pain messages originating in nerves (nociceptors) associated with the damaged tissue and conductance via peripheral nerves to the spinal cord and on up to the brain. and unmyelinated. excited. and exercise. and one cannot exist without the other. or close. Acupoints provide access to the meridian for influencing the flow of energy and are used both diagnostically and therapeutically by the acupuncturist. regardless of whether the traditional Chinese medicine or Western approach is used. (1 m per second) C-fibers. Yin and yang balance and control each other. with a generalized. aquapuncture. blocking signal transduction. solid metallic needles. Chinese medicine actually represents a coherent and independent system of medical practice developed over several millennia. the endorphin release during acupuncture should alleviate the effects of chronic pain and hyperpathia associated with spinal cord windup. Before impulses reach the brain. gold bead implants. Equine veterinary practitioners of acupuncture generally palpate acupoints on specific meridians (channels) to help isolate or localize . it is the result of critical thinking combined with extensive clinical observations and testing. Application of electrical stimulation (electroacupuncture) at acupuncture points may also enhance neural responses. This hypothesis is further strengthened by the fact that the opioid antagonist naloxone reverses the analgesic effects of acupuncture. slow. depending on a number of factors. noncumulative effect that stops after stimulation ceases. these messages encounter “nerve gates” in the spinal cord that open. cold. and more than 2000 acupuncture points on the body that connect with them. the body is viewed as a delicate balance of two opposing yet inseparable forces (yin and yang). fast (15 m per second) A-δ nerve fibers. is generally broken down into several distinct phases: asking. changes in regulation of blood flow. and that disease (pathology) results from an imbalance or disharmonious balance of the opposing forces yin and yang. parasympathetic. One of the major assumptions of traditional Chinese medicine is that health is achieved by maintaining the body in a balanced state.

The significance of specific acupoint “reactivity” is accomplished by the anatomic knowledge of the meridian pathway along with case history and general physical examination. In equine medicine. which indicates that the area should be imaged with radiographs or ultrasound. a calibrated device that delivers a controlled pressure stimulus. and BL 39) may indicate a hock problem. especially in practices with a large performance horse Figure 198-1 Acupuncture points used for diagnostic lameness evaluation treatment in the horse. A positive response is evidenced by a twitch or muscle spasm (slight or dramatic) to the light pressure of palpation. an equine practitioner can effectively use many of these acupoints diagnostically. It is also important to keep in mind that horses have varying levels of sensitivity.904 CHAPTER 198 points and can arise concurrently with a specific lameness or musculoskeletal issue. and for subsequent treatments. may be used for accurate evaluation of pressure responses before and after treatment. Meridians demonstrating abnormally reactive (painful) acupoints are considered unbalanced. For example. noninfectious inflammation. These reactive points are also referred to as trigger CLINICAL APPLICATIONS OF ACUPUNCTURE Acupuncture is most commonly used for pain management. A brief synopsis of the most common applications of equine acupuncture is included below. The palpation technique involves light pressure from point to point along the meridian until a reaction is noted. BL 35. Identification and knowledge of these points can be extremely useful from both a diagnostic standpoint. Musculoskeletal Disorders A significant component of equine practice generally involves lameness and musculoskeletal disorders. or functionally reversible disorders. Some practitioners palpate meridians with the fingers. Even with limited practice and a minimal working knowledge of acupuncture and meridians. identification of one or several specific reactive (hyperirritable) acupoints along the bladder (BL) meridian (BL 19. The skill and experience of the practitioner come into play along with consistent application of pressure of approximately 3 lbs. as the flow of qi has been disrupted. the bladder meridian is most commonly used for both diagnostic and therapeutic intervention. A pressure algometer. dysfunctions. The bladder meridian begins at a point on the medial canthus of the eye and courses over the head and neck just lateral to the dorsal midline (±12 cm) and ends on the caudolateral aspect of the pelvic limb just proximal to the coronary band. whereas others choose a device such as a needle cap. Arabians and Thoroughbreds may respond differently from the response of Appaloosas or Quarter Horses. This is interpreted as a meridian imbalance or obstruction in the flow of qi. . painful conditions or pathology. An example of commonly used diagnostic acupuncture points for lameness evaluation is illustrated in Figure 198-1 and Table 198-1.

level with the ventral border of the mandible. Acupuncture is frequently employed for equine musculoskeletal injuries. At the 5th intercostal space in the ascending pectoral muscle caudal to the tip of the olecranon Cranial border of the scapula at the intersection of the cranial margin of the supraspinatus muscle and the dorsal border of the omotransversarius muscle Between the 2nd and 3rd cervical vertebrae between the splenius muscle and the dorsal border of the brachiocephalicus and omotransversarius muscle group 3 cun* lateral to the dorsal midline in the 8th intercostal space between the longissimus thoracis and iliocostalis muscles at the caudal edge of the scapula 4th intercostal space. including trauma. However. and laminitis. stretching. acute and chronic osteoarthritis. back pain and poor performance. from the client’s standpoint. 2 cun* ventral to the level of the shoulder joint Between the transverse processes of C5 and C6 on the dorsal border of the omotransversarius muscle Along the cranial edge of the scapular halfway between BL-11 and the point of the shoulder Caudal border of the deltoid muscle between the long and lateral heads of the triceps brachii muscle Midway on a line connecting the greater trochanter of the femur and the lumbosacral space At a depression halfway between the tuber coxae and the greater trochanter of the femur 3 cun* lateral to the dorsal midline between the spinous processes of the 4th and 5th sacral vertebrae Between the biceps femoris and semitendinosus muscles 5 cun* distal to the tuber ischii In the muscular groove between the sternocephalicus and the cleidomastoideus branch of the brachiocephalicus muscle. The primary goal of these modalities. cranioventral to the junction of the 5th and 6th cervical vertebrae 3 cun* lateral to the dorsal midline in the 15th intercostal space between the longissimus thoracis and iliocostalis muscles At the ventral end of the muscular groove between the middle and caudal division of the biceps femoris muscle In the proximal end of the muscular groove between the biceps femoris and semitendinosus muscles Caudal to the wings of the atlas. is pain relief. massage. 2 cun* lateral to the midline between the cleidomastoideus branch of the brachiocephalicus and the splenius muscle In a depression caudal to the occipital condyle. and dietary modifications to effectively address musculoskeletal problems in horses. navicular syndrome. cranial to the wing of the atlas Diagnostic Correlation Foot pain Acupuncture Points Commonly Used for Lameness Diagnosis Acupuncture Point Large intestine 18 Pericardium 1 Large intestine 16 PC-1 LI-16 Foot pain Fetlock pain Small intestine 16 SI-16 Suspensory pain Bladder 13 BL-13 Carpal pain Spleen 20 Large intestine 17 Gallbladder 21 Small intestine 9 Bladder 54 Gallbladder 29 Bladder 30 Bladder 37 Stomach 10 SP-20 LI-17 GB-21 SI-9 BL-54 GB-29 BL-30 BL-37 ST-10 Carpal pain Carpal pain Shoulder pain Shoulder pain Coxofemoral pain Coxofemoral pain Stifle pain Stifle pain Stifle pain Bladder 19 BL-19 Hock pain Bladder 39 Bladder 35 Bladder 10 BL-39 BL-35 BL-10 Hock pain Hock pain Contralateral hind limb pain Contralateral hind limb pain Gallbladder 20 GB-20 *1 cun = width of the 18th rib or ± 4 cm. from a traditional . dorsal to the jugular vein. Acupuncture is frequently combined with chiropractic. cervical pain.Integrative Medicine: Applications of Acupuncture 905 Table 198-1 Abbreviation LI-18 Location Ventral border of the omotransversarius muscle. acute soft tissue and tendon or ligament injury. population.

BL-25. Any behavioral alterations. type 3 is located where there is a high density of superficial nerves. more frequent. along with range of motion (limb and cervical) and flexion tests. for acute-onset disorders. myofascial trigger points represent discrete. equine protozoal myelitis. Predisposing and perpetuating factors in chronic overuse or stress injury on muscles must. and BL-27. in the local region. and palpation. however. type 1 is located where the nerve enters the muscle. or injuries or ailments experienced during the show or race season. Repeat. hyperirritable spots located in a taut band of skeletal muscle that palpate as tight bands or knots. Acupuncture points have been grouped into four types. Stimulation at GV 26 activates the sympathetic nervous system. In addition. Examination of saddle fit and tack are also important. Frequency of Treatment Treatment frequency is highly variable and depends on the disease. represent “governing” systems and trigger points. ground surface. posture. Acupuncture has been demonstrated to be equally as successful as injection with 0. focal. The application and success of treatment are variable. Positive responses can be observed after one treatment but are usually more evident after three or four treatments. disease response or remission may be maintained with treatments at 2. type 2 is located on the superficial nerves.5% lidocaine solution in reducing myofascial pain in humans. be eliminated for long-term relief. Electrical stimulation at 2 Hz delivered to sympathetic fibers of the nose can cause vigorous sympathetic activation. An 18-gauge hypodermic needle is inserted deeply into a point on the upper lip midway between the ventral border of the nares until it reaches the underlying cartilage and is vigorously manipulated with a pecking motion. elevates catecholamine concentrations. although results are variable among individual animals. points are selected along meridians that overlie and innervate affected regions or are representative of the organ systems that govern the affected area. Sedation and behavioral modification can be induced by use of certain acupuncture points. with more controlled studies and documentation of protocols required. Alternatively. which are dependent on the practitioner. daily treatment is undertaken for 3 to 5 days. followed by treatment at 3. treatment frequency may be reduced to weekly or biweekly intervals. and practitioner or owner scheduling and preference. Commonly used points for colic analgesia include stomach 36 (ST-36). with the interstitial cells of Cajal acting as the pacemakers for inherent rhythmic activity.and 4-day intervals. and increases cardiac output and stroke volume. duration. and head shaking. The practice of acupuncture is based on a number of different neurophysiologic and traditional Chinese medicine approaches. CONCLUSIONS Acupuncture can be a useful adjunct in the diagnosis and treatment of equine disorders. . Acupuncture protocols developed for elite equine athletes begin with treatments before intensive exercise schedules. After stabilization or improvement of the disease. Chinese medicine and conventional veterinary standpoint. and approximates the frequency of “pecking” GV 26 during resuscitation maneuvers. bladder dysfunction. Stimulation of extracranial trigeminal nerve fibers can increase cortical cerebral blood flow. San Jiang bladder (BL) 21. a combination of central and autonomic effects will affect function. Neurologic Disorders The neurophysiologic explanations of the effects of acupuncture suggest it should be a very useful treatment modality for dysfunctions of this system. regardless of how subtle. exhibited as strong vasoconstriction of nasal mucosal blood vessels. and function in compensation to lameness. They are formed as a result of stress on muscle fibers after acute trauma or repetitive 3-month intervals or as required. observation. In some instances. work type. Point selection is guided by neuroanatomic location and traditional Chinese medicine classification. should be addressed. The basis of diagnostic acupuncture examination and acupuncture treatment is the correlation of certain points with alterations in muscle use.906 CHAPTER 198 Although external neural input is not required for contraction. Treatment protocols for lameness therefore include points that are reactive (see Figure 178-1). Acupuncture points can be selected along neural pathways to directly simulate nerve and muscle function with concurrent electrical stimulation. Electrical stimulation of points with the use of low frequency for chronic pain relief and high frequency for acute pain relief can provide additional benefit. treatments are based on performance. A thorough diagnostic evaluation always starts with a complete history. Additional use of regional anesthesia and diagnostic imaging to localize and define problems will assist conventional and integrative management plans. and type 4 at the muscle-tendon junction. We refer Gastrointestinal Disorders Innervation of the equine gastrointestinal tract involves a complex enteric nervous system and endogenous neurotransmitters. Trigger points may produce pain locally and in a referred pattern to result in decreased range of motion and weakness. with applications particularly for analgesia and neurologic dysfunction. Acupuncture can be used to alter sympathetic and parasympathetic input in the treatment of ileus and provide analgesia during colic episodes. Emergency Medicine Acupuncture stimulation at governing vessel 26 (GV 26) is routinely performed in animals with cardiac or respiratory arrest. Equine neurologic diseases that may respond to acupuncture treatment include equine herpesvirus neuropathy. In general. The diagnostic exercise includes careful observation of the horse at rest and while walking and jogging. identification and treatment of the underlying cause are the goal.

907 Schoen AM. ed 2. Xie H. Habacher G. White A: Medical acupuncture: A western scientific approach. the Chi Institute. St Louis. [AQ2] Suggested Reading [AQ1] Filshie J. J Vet Intern Med 20:480-488. Pittler MH. Edinburgh. 2001. 1997. editor: Veterinary acupuncture: ancient art to modern medicine. Mosby. 2006. Ernst E: Effectiveness of acupuncture in veterinary medicine: Systematic review.Integrative Medicine: Applications of Acupuncture interested readers to the American Academy of Veterinary Medical Acupuncture (Colorado State University). Churchill Livingstone. Ott EA: Evaluation of electroacupuncture treatment of horses with signs of chronic thoracolumbar pain. Colahan P. and the International Veterinary Acupuncture Society for further instruction in acupuncture point selection and the treatment of horses. 2005. . J Am Vet Med Assoc 227:281-286.

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