Complex Solutions for Complex Problems

Th e Eas t - Wes t Ap p r oach t o Fu n ct ion a l Pa in

Andrew Shubov, MDAssistant Clinical ProfessorDirector, Inpatient Integrative MedicineUCLA Center for East-West Medicine

20th century diseasesTuberculosisPneumoniaHeart AttackPeptic Ulcer DiseaseCOPDCongestive Heart Failure

FibromyalgiaMigraine HeadacheHypertension/PalpitationsFunctional GI DisordersDysmenorrhea/EndometriosisOveractive Bladder/Chronic Pelvic Pain

21st century diseases

Vandenbroeck P., Goossens J., Clemens M. Foresight tackling obesities: Future choices -obesity systems atlas. 2007.

How to use homeostatic reserve clinically?

How to use homeostatic reserve clinically?

How to use homeostatic reserve clinically?

Adequate Rest

Adequate Nutrition

Specific Foods

Reduce Virility Support Host

What happens when you’re fru s t r a t ed…

STAGNATION

Stagnation leads to spasm

● Musculoskeletal● Neuro● Cardiovascular● Gastroenterological● Gynecologic● Genitourinary

➢ Fibromyalgia➢ Migraine Headache➢ Hypertens ion/ Palpita tions➢ Functional GI Disorders➢ Dysmenorrhea/ Endometrios is➢ Overactive Bladder/ Chronic Pelvic Pain

"Lifestyle m odifica t ion s"

Regular exercise

Mindfulness

Sleep

Equanimity

Psychotherapy

CBTWhat intervention can we administer directly?

Let's talk Acu p u n ct u r e

Gate Control Theory

The circuit diagram of the gate-control theory of pain perception as proposed by

Melzack and Wall (1965)

https://faculty.washington.edu/chudler/pain.html

Somatic pain

Acupuncture

Gate Control Theory

Molecular biology mechanisms of acupuncture

fMRI findings during acupuncture

• 779 fMRI acupuncture investigations as of 2012

• Changes found in somatosensory cortices, limbic system, basal ganglia, brain stem, and cerebellum”

• The meta-analysis of 35 studies demonstrated a greater response in the middle cingulate for the true acupuncture as opposed to sham acupuncture.

Huang, et al 2012

Somato - Au t on om ic Reflex

Stomach-36 and autonomic modulation

• Acupuncture of this point has been thoroughly studied in animal models of decreased gastrointestinal motility.

– Increases lower esophageal sphyncter pressure– Restores gastric accommodation after vagotomy– Increases activity of the sacral parasympathetic

pathway– Increases the frequency of intestinal and colonic

movement– Attenuates visceral hypersensitivity.

• 1. Zou D, Chen WH, Iwakiri K, Rigda R, Tippett M, Holloway RH. Inhibition of transient lower esophageal sphincter relaxations by electrical acupoint stimulation. Am J Physiol Gastrointest Liver Physiol. 2005;289:G197–G201

• 2. Ouyang H, Xing J, Chen J. Electroacupuncture restores impaired gastric accommodation in vagotomized dogs. Dig Dis Sci. 2004b;49:1418–1424.• 3. Choi M, Jung J, Seo M, Lee K, Nam T, Yang I, Yoon Y, Yoon J. Ultrasonographic observation of intestinal mobility of dogs after acupunctural

stimulation on acupoints ST-36 and BL-27. J Vet Sci. 2001;2:221–226• 4. Iwa M, Nakade Y, Pappas TN, Takahashi T. Electroacupuncture elicits dual effects: stimulation of delayed gastric emptying and inhibition of

accelerated colonic transit induced by restraint stress in rats. Dig Dis Sci. 2006b;51:1493–1500• 5. Iwa M, Matsushima M, Nakade Y, Pappas TN, Fujimiya M, Takahashi T. Electroacupuncture at ST-36 accelerates colonic motility and transit in

freely moving conscious rats. Am J Physiol Gastrointest Liver Physiol. 2006a;290:G285–G292• 6. Xu GY, Winston JH, Chen JD. Electroacupuncture attenuates visceral hyperalgesia and inhibits the enhanced excitability of colon specific sensory

neurons in a rat model of irritable bowel syndrome. Neurogastroenterol Motil. 2009

Thalamus and Hypothalamus

affected

Fig. 5. Regional CBF changes in a 20-min treatment. Brain regions associated with the CBF changes in the state of a 20-min treatment againstbaseline, including the (A) 2-Hz and (B) 100-Hz TEAS groups. Using paired t-test. The threshold of display was set to cluster level correctedP<0.05. Color bar indicates T-values. There was no region above the statistical threshold in the MTEAS group. Comparisons of the absolute rCBFchanges (20 min-baseline) among the three groups were showed in (C), by using a one-way ANOVA with Newman–Keuls multiple comparison test,⁄P<0.05; ⁄⁄P<0.01. (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.)

Can be Interpreted as a Parasympathetic Agonist

Beta-Blockade

ACE Inhibitors

Clonidine

Stellate Ganglionectomy

Renal Denervation

Conditions under investigation for Vaga l Ner ve St im u la t or s

● Sepsis● Prevention of CHF following MI● Pain● Migraines● Obesity● CVA and TBI● RA● DM

Johnson, R. L., & Wilson, C. G. (2018). A review of vagus nerve stimulation as a therapeutic intervention. Journal of inflammation research, 11, 203–213. doi:10.2147/JIR.S163248

What’s a Meridian?

FasciaFascia: A functional 3-dimensional collagen matrix that surrounds and connects every muscle and organ.

Highly innervated (mostly proprioceptive) and is deeply involved with the autonomic nervous system.

Collagen: shown to have semi-conductive, piezoelectric, and photoconductive properties in vitro.

Connective Tissue Planes

Acupuncture and Fascia

• Needle manipulation causes mechanical deformation of connective tissue

• In response to mechanical stimulation of fibroblasts:– Active changes in fibroblast cell shape– Fibroblasts expand within minutes to remodel their

cytoskeleton– Drop in tissue tension along the fascial plane

Other ways to increase fascial mobility

Superficial Back Line Urinary Bladder MeridianForward Fold

Other ways to increase fascial mobility

Lateral Line Gallbladder MeridianExtended Side Angle Pose

Which explanation is easier?

Gate Control Theory

Endogenous endorphin release

Inflammatory signaling cascade

Limbic system deactivation

Autonomic modulation

Fascial Manipulation

Relieves stagnation and restores normal flow of ‘Qi’

● Local● Sys temic

WESTERN EASTERN

How effective is acu p u n ct u re a t r e lievin g m an ifes t a t ion s of St agn a t ion ?

Cochrane review for Fibromyalgia

Low to moderate‐level evidence that compared with no treatment and standard therapy, acupuncture improves pain and stiffness in people with fibromyalgia.

Moderate‐level evidence that the effect of acupuncture does not differ from sham acupuncture in reducing pain or fatigue, or improving sleep or global well‐being.

Deare JC, Zheng Z, Xue CCL, Liu JP, Shang J, Scott SW, Littlejohn G. Acupuncture for treating fibromyalgia. Cochrane Database of Systematic Reviews 2013, Issue 5. Art. No.: CD007070. DOI: 10.1002/14651858.CD007070.pub2

➢ Fibromyalgia➢ Migraine Headache➢ Hypertens ion➢ Functional GI Disorders➢ Dysmenorrhea/ Endometrios is➢ Overactive Bladder/ Chronic

Pelvic Pain

Let's d iscu ss Placebo

Acupuncture for NauseaExample of adequately powered study to differentiate between sham and placebo acupuncture

A Cochrane review of 40 included trials involving 4858 participants, compared to sham:

Post-operative nausea (RR 0.71, 95% CI 0.61 to 0.83);

Vomiting (RR 0.70, 95% CI 0.59 to 0.83)

Need for rescue antiemetics (RR 0.69, 95% CI 0.57 to 0.83)

Cochrane Review:

"Available studies suggest that acupuncture is at least as effective as, or possibly more effective than, prophylactic drug treatment [of migraines], and has fewer adverse effects."

Linde K, Allais G, Brinkhaus B, Manheimer E, Vickers A, White AR. Acupuncture for migraine prophylaxis. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD001218. DOI: 10.1002/14651858.CD001218.pub2.

➢ Fibromyalgia➢ Migraine Headache➢ Hypertens ion➢ Functional GI Disorders➢ Dysmenorrhea/ Endometrios is➢ Overactive Bladder/ Chronic

Pelvic Pain

Acupuncture vs none

Acupuncture vs sham

Acupuncture vs medication

➢ Fibromyalgia➢ Migraine Headache➢ Hypertens ion➢ Functional GI Disorders➢ Dysmenorrhea/ Endometrios is➢ Overactive Bladder/ Chronic

Pelvic Pain

Improvement of total scores of dyspeptic symptoms (in diabetic gastroparesis) after acupuncture

Yang, M., Li, X., Liu, S., Li, Z., Xue, M., Gao, D., Li, X. and Yang, S., 2013. Meta-analysis of acupuncture for relieving non-organic dyspeptic symptoms suggestive of diabetic gastroparesis. BMC complementary and alternative medicine, 13(1), p.311.

➢ Fibromyalgia➢ Migraine Headache➢ Hypertension➢ Functional GI disorders

○ Gas tropares is○ Functional Dyspeps ia○ GERD○ IBS○ Chronic Cons tipation

➢ Dysmenorrhea/ Endometrios is➢ Overactive Bladder

In a Cochrane review included 7 RCTS containing 542 participants :

4 RCTs s howed no difference in effectivenes s between acupuncture and medications (cis apride, domperidone, and itopride).

➢ Fibromyalgia➢ Migraine Headache➢ Hypertens ion➢ Functional GI disorders

○ Gas tropares is○ Functional Dyspeps ia○ GERD○ IBS○ Chronic Cons tipation

➢ Dysmenorrhea/ Endometrios is➢ Overactive Bladder/ Chronic

Pelvic Pain

Real-world RCT:

Thirty patients with PPI refractory GERD:1- Acupuncture plus PPI2 - Double their PPI dose

Outcome measures:Daily GERD symptoms diary

Results:Acupuncture + PPI group: Improvement in all measured symptoms

Double-dose PPI group: improvements for the symptom of daytime heartburn only.

Five acupuncture points were used, including P-6 and St-36

➢ Fibromyalgia➢ Migraine Headache➢ Hypertension➢ Functional GI disorders

○ Gas tropares is○ Functional Dyspeps ia○ GERD○ IBS○ Chronic Cons tipation

➢ Dysmenorrhea/ Endometrios is➢ Overactive Bladder/ Chronic

Pelvic Pain Dickman, R., Schiff, E., Holland, A., Wright, C., Sarela, S.R., Han, B. and Fass, R., 2007. Clinical trial: acupuncture vs. doubling the proton pump inhibitor dose in refractory heartburn. Alimentary pharmacology & therapeutics, 26(10), pp.1333-1344.

Acupuncture compared with other interventions

➢ Fibromyalgia➢ Migraine Headache➢ Hypertens ion➢ Functional GI disorders

○ Gas tropares is○ Functional Dyspeps ia○ GERD○ IBS○ Chronic Cons tipation

➢ Dysmenorrhea/ Endometrios is➢ Overactive Bladder/ Chronic

Pelvic Pain

Acupuncture compared with Sham Acupuncture

➢ Fibromyalgia➢ Migraine Headache➢ Hypertens ion➢ Functional GI disorders

○ Gas tropares is○ Functional Dyspeps ia○ GERD○ IBS○ Chronic Cons tipation

➢ Dysmenorrhea/ Endometrios is➢ Overactive Bladder/ Chronic

Pelvic Pain

"Augmented Placebo" acupuncture in IBS

Kaptchuk, T. J., Kelley, J. M., Conboy, L. A., Davis, R. B., Kerr, C. E., Jacobson, E. E., … Lembo, A. J. (2008). Components of placebo effect: randomised controlled trial in patients with irritable bowel syndrome. BMJ (Clinical research ed.), 336(7651), 999–1003. doi:10.1136/bmj.39524.439618.25

➢ Fibromyalgia➢ Migraine Headache➢ Hypertens ion➢ Functional GI disorders

○ Gas tropares is○ Functional Dyspeps ia○ GERD○ IBS○ Chronic Cons tipation

➢ Dysmenorrhea/ Endometrios is➢ Overactive Bladder/ Chronic

Pelvic Pain

The East - Wes t Ap p r oach :

Acu p u n ct u r e t o facilit a t e self- ca r e

Consultation:

Reduce a long list of medical diseases to one or two major processes related to circumstances within their control

Treatment:

Show people that they are capable of feeling better

Success:

Empower and coach patients how to maintain this through “lifestyle modifications”

UCLA East-West Medicine

53

7 x Full Time MDs-Internal/Family Medicine-All completed EW fellowship training

25 x Administrative Staff, Managers, Front Desk, Medical Assistants

10 x Acupuncturists LAc

3 Current Fellows -2 year clinical fellowship-17 total graduates

TOTAL PATIENT POPULATION : 1993-2017

Clinic Visits for June 2016-July 2017

Total: 24,845

Projected Clinic Visits for 2018

Total: 31,000

UCLA started its Inpatient East -West consult service July 2018

20th Century 21s t Century