Hello, everyone. My name is Linda Boogie, and I'm a veterinary acupuncturist currently living in the Netherlands. And, the purpose of today's, presentation is to give you an idea about how the, acupuncture works according to scientific mechanisms and that hopefully, I'm gonna show you some cases that you can see where acupuncture can be a valuable tool in an integrative veterinary practise.

So why acupuncture? It's a question that I get often. Basically, for me, it was in.

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I will meet myself again. OK. Well hello, everyone.

My name is Linda Bogie, and I am a veterinary acupuncturist currently practising in the Netherlands. And the purpose of this presentation is to give you an idea about how acupuncture can be integrated into a Western medical practise and to give you some understanding of the scientific mechanisms of acupuncture. Now, why acupuncture?

This is a question that I have received a lot during my career. I've been a veterinarian now for about 35 years, and I've been doing it for 25 of those years. I also incorporate a lot of Chinese herbal medicine into my practise, but I got started with acupuncture when I had a practise in California, and I got started into acupuncture because of patients like Rocky.

Rocky came to me in, December or January, actually March of 2001. He had a ruptured lumbar disc for Christmas Eve, had emergency surgery by some superb veterinarians to remove the disc material. He had deep pain prior to and immediately post-op, but three months post-surgery, Rocky still could not use his hind limbs, and he was faecal urinary.

Also had a little kitty like this. In California, we would have the cats that would climb up into the engines where it was warm and you'd start up the car engine and they'd get trapped by one of the fan belts, and he had presented to an emergency clinic in our neighbourhood with a a fan for shock and trauma, was kept in the emergency clinic over the weekend on intravenous fluids, initially with an oxygen cage. Treated with intravenous dexamethasone and continued with the oral oral steroids and antibiotics for 3 days.

But on Monday when he was released, he still could not walk, and that's when he was able to, or that's when he presented to our practise. When I moved here in the Netherlands, Rexa, she was one of my first patients, her German Shepherd dog that had been diagnosed with severe osteoarthritis of the hips when she was 4 years of age. She also had lumbosacral sclerosis, spondylosis in various regions along the She couldn't tolerate NSAIDs, so that was not a help for her.

And they had tried homeopathics without any help. When she presented, she was on the devil's claw mixture and included, including some glucosamine chondroitin sulphate, but currently, when she presented to me, she was barely able to walk and it was one of those. Last desperate, hopes that she would be able to have a decent quality of life.

And then the last little patient we'll talk about is Sid, a 1.5 year old state female, British short hair. Prior to presentation for acupuncture, she had been diagnosed with feline allergic bronchitis and was treated with Motorin and doxycycline with minimal response.

So my colleague had recommended a belamethasone inhaler in addition to the Motorin, and the owner was reluctant because the cat was so young. So on presentation for acupuncture, she was still having severe problems, which basically her biggest thing was extreme shortness of breath. At 1.5 years of age, she could not walk across the living room without having to stop and catch her breath.

So extreme shortness of breath. So these are the, the patients that stimulated me to pursue acupuncture. And either Western medicine had done everything that they could do on a very good level.

That absolutely nothing wrong with Western medicine, but it, they had, in some of these patients, the Western medicine wasn't enough. For other patients, it was a, a choice of the owner, that they wanted to try something other than Western medicine, a lifelong use of steroids because of the age of the of. So these are the patients that stimulated me to pursue something else.

The goals for this presentation are to very kind of give you some idea that there are some similarities between Western and Chinese medical theory. They're not quite as different as a lot of people think. And to explain the purpose of acupuncture very, very briefly, but to focus mainly on the scientific mechanisms of past studies, but there are some very current interesting studies that are going on and hopefully by the end of the presentation, it gives some of you the idea of That maybe this is an option to integrate acupuncture into your Western medical practise either if you pursue training, I do have some, areas where you can get training that are listed on the last slide for the presentation, but also maybe just to encourage you, maybe not to pursue the training yourself, but to seek out trained acupuncturists in your area and work with those people to truly provide an integrative approach to veterinary health.

So Western medical theory, the early days, this is a picture of Hippocrates, right, considered the father of modern medicine, lived around 460 to 370 BCE and at that point in history, disease was felt to come from Evil spirits or from the divine, in all forms in all areas of the world. In Chinese medicine at that history, also there was a change from disease having a shamanic cause to being caused from natural causes, so not from the divine, but something inherently that was going on with the body. And Hippocrates also had the same .

Idea and what he did is he systemized systematised collection of data from patients. So he systematised a manner of collecting information from patients, and then he made a clinical diagnosis from this. His style of medicine was called humorism or humeralism, which actually dominated Western medical thinking for about 2000 years.

In humeralism, they felt that there were 4 humours of the body. The, the names for these in Greek medicine were blood, yellow bile, black bile, and phlegm. But possible origins for this concept could be found in ancient Egyptian medicine or from Mesopotamia.

This was also supported by the Persian physician. Yeah, you also see this in Ayurvedic medicine where you have 4 different, humours or 4 different characteristics that they use in Ayurvedic medicine. So it's not just foreign to Chinese medicine, but you see this even in Western medical history, and balance or imbalance of these humours was reflected in physical as well as mental health or disease.

So these were the balance of these humours was important for not only the physical condition of an individual, but also the mental condition of an individual. Now, with the advent of modern medical research of the 19th century, this theory obviously is not as popular as it once was, but it does give us some valuable information to think of things in a bit more of a global perspective sometimes. When you look at the schools of thought that were at that time of Hippocrates, you had the Koan or the Hippocratic school, and then you had the Canadian schools.

And the Colan schools looked at patterns of disease, and this is very similar to what we see with with Chinese medicine thinking. Able to make connections between various clinical signs and symptoms and then treated that individual pattern. So it's more of an individual based.

Diagnosis and treatment strategy, and they actually achieved great success. The Canadian school is more interested in making a specific diagnosis of a clinical sign or a symptom, but oftentimes the, the problem that this could have is that it failed to recognise the connections between different clinical signs that they may have one general cause. So the Chinese medicine actually follows a little bit more closely to the hippocrite.

Where we look at, try to achieve a diagnosis that can explain a myriad of clinical signs or symptoms. So it's basically a pattern diagnosis based on these imbalance of what are called humours or what we called humours in, in Greek medicine. And you look at the quality, you look at the quantity, their balance, their circulation, the distribution, and your treatment focuses on rebalancing those humours.

Now, in Chinese medical theory, the humours are termed or translated into vital or fundamental substances, and those vitamin fundamental substances are called qi, blood, body fluids, essence, and spirit. Now just a really quick, very, very brief translation of these fundamentals. It's probably the most widely used terminology and probably the most widely mistranslated and misunderstood.

It was translated by a gentleman, a sinologist, a French sinologist named Soleil Dumont, and he translated it to vital energy. So then there's a concept that exists that she only talks about energy, something very non-tangible, something very etheric. But what I'd like to do is bring this down just a little bit to earth and give you the translation that she really translates to metabolism, physiology, and neurologic function.

If you can think about that as what she is in the body. I think that makes it a little bit more tangible for Western trained veterinarians. Normal metabolism, the normal physiology of the organs, normal neurologic function, both in the peripheral nervous system as well as the Blood, it just means blood.

It's just that red substance that flows within the vascular system, bringing oxygen and nutrients to every tissue of the body, to every cell of the body. When we talk about body fluids, we're talking about body fluids, tears, sweat, serum, intracellular, as well as well as well as extracellular fluids. Translated to the DNA basically who we are, what makes us, what makes a human a human, what makes a dog, what makes a camel a camel, so it's our genotypes.

It's also the genotypic expression of the genotypes that make an individual. Who he or she is. And when you start talking about essence and you start talking about DNA, one of the things you have to recognise is epigenetics.

Acupuncture actually has been able to, has been shown to change the epigenetic expression. So acupuncture is not gonna change the genotype of somebody, but it can change the epigenetic epigenetic expression for an individual. And then when we talk about spirit, we're actually talking about the mind, psyche, or the behaviour of an individual.

So when you look at these fundamental substances in Chinese medicine, if you can keep these, Western translations in mind, it makes acupuncture a little bit more tangible on a scientific basis because there is a there is a load of scientific information that's more good research that's being done every day to show how physiological level in the body. So when we talk about acupuncture, acupuncture basically comes from Chinese medical theory, and they use the penetration of needles into the body to effect a change in the flow, distribution, and production of these fundamental substances. So now Chinese medical theory developed a system of channels and points to do a number of things.

You have to remember that 234 1000 years ago, we didn't have microscopes. We didn't have electron microscopes for sure. We didn't have blood chemistry.

CBC machines. There are a lot of things that we just couldn't explain. Looking at what we have the availability to look at now.

So they developed a series of channels that could explain various normal physiologic processes, how the body worked on a physiologic basis, the, the working between how muscles and joints would, would work. The ability for us to maintain a normal movement, we would see that as proprioceptors. We would see that as, aferent and eer information coming from the periphery, going to the brain, the brain modulating that information and then bringing that information back out to the muscles and the joints of the body.

So, even musculoskeletal problem or musculoskeletal aspects of Of body function, but also internal organ function, being able to understand how food was digested and how we could transform what we ate into products that we could be that could be used by the body. The channels also explained pathologic responses of the body. So when we come in contact with a virus, a cold, how the body responds to that invasion of an external pathogenic factor.

Now they didn't know what viruses or bacteria were, but they had the concepts of the diseases that they could cause. The channels also gave us connections of the body. So when we look at the the channels, you see the exterior trajectories, you have to keep in mind that there are also internal trajectories of these of these channels which connect the internal organs to the outside part of the body through these connections, and on the external trajectories is where you're gonna find the acupuncture points and then by accessing these acupuncture points.

This allowed practitioners to reestablish balance and health, not only in the external environment but also on the internal environment, helping to maximise organ function or to balance organ function, helping with things like gastrointestinal motility. There are a number of points that, and we'll talk about that a little bit later in the presentation. That have been shown to have an effect on the gastrointestinal motility.

So the needles were used to balance these vital substances, keeping in mind that chi is one of those vital substances, which if you if you keep in mind that translation, it's normal metabolism, normal physiology, and normal neurologic function. So the needles were used to help balance these vital substances, their quality, their quantity, circulation, and distribution. When we look at the scientific evidence, we, there's plenty to demonstrate how acupuncture has an effect on reducing pain and inflammation.

That's some of the easiest research to, to do with acupuncture. We also know that acupuncture influences hormones and neurotransmitters, and it enhances and or re-establishes blood circulation. So we'll talk about some of these scientific effects of acupuncture.

Just to be sure that everybody is, is kind of on the same page, it does rely on an intact nervous system. There is a very strong correlation with acupuncture points and the nervous system. When you look at, this is a study that was done in humans probably 2 or 3 decades ago, but, 99.7% of that found in proximity to the peripheral nerves.

Close to 94% had a relation to superficial nerve in the skin, and over 50% had a relationship to deeper nerves. So the there is a lot of correlation between acupuncture points and the nervous system, and for a long time, the channels of acupuncture were trying to find channels of acupuncture. They were correlated with the nervous system.

Which in part is true, but we have better, I think a better template for that now. When you look at the morphologic features of the acupuncture points, they are 3 dimensional structures, they're not two dimensional. Histologically, what you see is a vertical column of loose connective tissue which is surrounded concentrically by thicker, more dense connective tissue of the skin, but also of the sub within this column, so you'll you'll see a, a vertical column of loose, very supple connective tissue, and within that column you see free nerve ending.

There's generally a single small artery and a vein, and there's often a lymphatic vessel. The acupuncture points oftentimes also have a very high concentration of mass cells as well. When you look at electron microscopy, it shows that there's microvesicles and perineural cells in a contact zone between the sympathetic nerve engines and the blood vessels.

So in a very small area, you have some very complex networks that we're gonna be taking advantage of when we when we explain how things work, when we insert the needle. What's interesting with the acupuncture points is that they are also areas of lower electrical resistance, 7 to 70 kg versus 200 to 2000 kg which you see in the surrounding tissue. And if you look again histologically at the anatomy of an acupuncture point, the skin directly over the centre of the acupuncture point will actually be slightly thinner than the surrounding skin.

So there's actually electrical as well as anatomic differences in the acupuncture acupuncture points versus surrounding skin tissue. Acupuncture points also have a very strong correlation with capillaries, close to 85% of our acupuncture points are associated with arteries and veins. 71% of those with a major blood vessel, and hemo acupuncture was especially common in early veterinary acupuncture.

Chemo acupuncture is that there are many points that were directly over blood vessels and those blood vessels were punctured with what we would consider, you know, similar to a hypodermic needle, and those points were bled. There is a very high concentration of small blood vessels at the centre of acupuncture points. And there is a microvascular supply of acupuncture points, which is significantly higher than corresponding control areas.

So anatomically, the acupuncture points are a distinct entity that we can find anatomically in the body. Now, we're gonna be talking about neurophysiology because it's one of the main How acupuncture. So just to kind of give a review of those afferent nerves that we, we talk about, these are the, the nerve fibres that are gonna be important in the use of acupuncture and the delivery of an acupuncture stimulation to the central nervous system.

We have our A beta fibres, which are myelinated sensory and motor fibres. They deliver non-pay sensory information. They are also important for the proprioceptive information that enters the central nervous system.

We have our A-delta fibres which are thinly myelinated, and they deliver no susceptive as well as non-nosoceptive information. They are also mechanical receptors and deliver thermal receptor information. Primarily the feeling of heat.

They also help to mediate touch and pressure. They are found in skin as well as the fascia, and because of their thin myelination, they deliver that first pain response. We have our C fibres which are non-myelinated, and they are strictly responsible for delivering no susceptive information, so painful information.

Because they are non-myelinated, they are the slowest conducting fibres in the in the axon, and they are also responsible for some of our moana receptor information and the thermal receptor, they are responsible for the reception of cold information. And they mediate because of their non-myelination, they mediate a slow pain response. So how does acupuncture play a role in all of this?

When we insert a needle, it actually creates a local trauma that is going to incite local tissue and chemical. I already alluded to, acupuncture points have a high concentration of mast cells, so when you insert that needle into the acupuncture point, you will get a disruption of mast cell, . Integrity, so you're gonna get a release of histamine.

That in turn is gonna create a cascade of inflammatory molecules. Bradykinin, substance P, prostaglandin E is gonna be released. So you have a local area of inflammation that is created.

You also have sensory nerve endings in these acupuncture areas. So you're gonna get a stimulation of A beta, ADelta, and C fibres stimulated by these, not only by the mechanical insertion of the needle, but by the chemical mediators that are released. And this follows a pain pathway.

So a lot of the early research that was done with acupuncture looked at the pain pathways from the neuro of the neurologic system. When we look at our local effects, we'll talk about local effects first because we have local segmental and super segmental effects of acupuncture. When you, traumatise.

And most of our points are in or near muscles, and the muscle releases adenosine. Adenosine is an important neurotransmitter that has been. It actually binds to the receptors on the A1 axions, so immediately it decreases local pain perception at the site.

One of the other very important things that adenosine does, and this is amazing, is it binds to the receptors of the epithelium of blood vessels, which triggers the secretion of nitric oxide from the endothelial cells of the blood vessels. Nitric oxide is a very potent vasodilator that travels throughout the throughout the vascular system. It is one of the most important neurotransmitters, you put it that way.

That is responsible for the microcirculation. And if we're talking about chronic diseases such as osteoarthritis, we have, one of the most important things that we need to do is to encourage that good microcirculation to the synovial membranes and to the joint areas, to help with joint health. One of the things that we know of with all of our NSAIDs and also with our steroidal medications at this point.

All of them blocked the production of nitric oxide. I'm sure most of you are following the coronavirus, the COVID-19, situation. One of the things that was just announced today on the Dutch news was the use of nitric oxide to help with the thrombic events of COVID-19, which is a part of the pathology of COVID-19.

And a lot of the the patients that are struggling medically and those that have died of the COVID-19, it's not because of your typical pneumonia problems that you see, it's actually because of thrombic events that are occurring in the lungs themselves or elsewhere in the body, including in the brain. So they are using nitric oxide as a molecule that can help with the circulation and prevent thrombic effects of COVID-19. Acupuncture can also help with this.

I'm just in, in general, not for COVID-19 patients, although I would, I would think if you could do it safely, it would be a good idea. But in the patients that have chronic disease. You also have the release of calcitonin gene-related peptide when you stimulate the ergo receptors within muscles, CGRP is also called vasodilator locally and systemically, and it has the trophic effect of increasing the growth of blood vessel epithelium.

So one of the areas that this can be very important in is in wound healing and also ischemic conditions. So the the results that you get locally and systemically just from the insertion of the needle is locally you have improved circulation, better profusion of tissues, nutrition and oxygen to local tissues, muscle relaxation, you have the benefit of wound healing or helping with wound healing. Immune cells are brought to the area because the, the circulation is improved and waste products are removed from an area again because of improved circulation.

Systemically, because of the release of nitric oxide and cal calcitonin gene related peptide, you have a systemic improvement in circulation. So not only does it help with local circulation, but you also have a systemic effect. You also have decreased pain perception because of the attack.

Immediately start decreasing pain perception on a systemic level. Because of that, you're gonna get some muscle relaxing and you're relaxation, and you're also gonna have a stimulation of the immune system. So this is just the local, with local effects of inserting the acupuncture needle.

Now, yeah, as I alluded to before, a nervous system, an intact nervous system is required for the best results. What we have seen is that if you inject local anaesthetic into acupuncture points that actually negates the analgesic effect. So propagated sensations of acupuncture can also be blocked by the use of cocaine, opiates, and naloxone, and sometimes even pressure.

So this all of this indicates the role of the neuro nervous system and neurotransmitters in acupuncture. Two of the most difficult things for us to treat with acupuncture are pain from diabetic neuropathies because the nerve is actually dying back from the elevated glucose and degenerative myelopathy in our veterinary patients because we're having degeneration of the myelin sheet. So, again, just to give you an indication how important an intact nervous system is to the effects of acupuncture.

When we talk about pain reduction now we're gonna we already discussed some of the local effects. Now we're gonna talk about segmental and super segmental effect and briefly touch about talk about the. Visceral effects of acupuncture.

The first really kind of groundbreaking theory of how acupuncture might work in the control of pain was presented by Malta and Wall in 1965. He control theory. Now, within the substantial gelatinosis of the laminate to the second lamina of the the the grey matter and the dorsal horn.

Only one type of impulse is allowed to connect with the second order neuron that projects a signal to the thalamus. The thalamus is gonna be where a lot of information is integrated. So within that that substantial gelatinosa, only one type of impulse is able to connect with a second order neuron, which actually then projects that information to the brain.

If you again remember our Our afer nerves. We have our A beta which is the fastest transmission of the action potential, and this delivers innocuous or non-painful information. A delta are responsible for medium transmission, but they give noxious as well as innocuous information.

Keeping in mind that it's only slightly less than 75% carry non-painful information. So even our ADelta fibres which carry painful information, most of them carry non-painful information. Both of these fibres travel faster.

They deliver the action potential faster than our C fibres. So their theory proposed that the information from A beta and ADelta fibres would reach the inter neurons first, effectively blocking the nosoceptive information from the C fibres. Furthermore, if you remember that you have the list hours tracks in this.

This non-noxious information would be spread parasegmentally, so a few segments cranial and a few segments caudal to the area where the the spinal nerves actually come into the spinal cord. So keeping in mind that if we're following the pain pathways, because acupuncture will follow the pain pathways, with the stimulation of an acupuncture point, you start getting local modulation of pain signals at the spinal cord level. Therefore, you're gonna be able to generate a different efferent signal.

If A betas and non-nxious A-Delta fibres are giving Non-painful information to that area of the spinal cord. The effect that you're gonna get with Eer information is that the muscles are going to be able to relax. We all know that if there's chronic pain, there's gonna be muscle tension and there's gonna be muscle contraction.

If we are able to institute the information from A beta and A and non-nxious Adelta fibres into a local area, now we start getting muscle relax, relaxation. One of the positive effects of that is is that you're gonna have improved circulation to the area innervated by those efferent axons, OK? This is something that can actually be enhanced with electroacupuncture, which we'll touch on in a little bit.

Now, in 1968, Melzack and Casey modified this theory to include super segmental influence. They theorised that there had to be some other way other than just a direct influence with the spinal cord segments that acupuncture was having an effect on mediating pain. So they came up with.

Theory of a descending inhibitory controlled pathway, and this has since borne out to be true with with research into neurophysiology. So we're gonna talk about 3 important tracts, the spinal thalamic tract, the spinal reticular tract, and the. When you look at the spinal thalamic tract, this primarily is composed of Adelta and C fibres.

These innervate on the lamina one of the dorsal horn, or sorry, when your A delta and your C fibres come in, they innervate in the first lamina of the dorsal horn, and these are gonna activate the neurons of the neospinal thalamic tract, which is the the tract that we see in animals. This neospinal thalamic tract actually ascends to the thalamus, which there at that point, that information is actually relayed into the cortex and the limbic system. Now, via the limbic system, You have innervation, you have stimulation of the pituitary gland, which is stimulated to release beta endorphins into the blood circulation.

In time you also have innervation into the arcuate nucleus, which stimulates beta endorphins into the brain stem into the central the cerebrospinal fluid itself, having an effect on the brain stem. So in effect, what you start with this information is endogenous pain mediation with beta endorphins, not only locally into the to the central nervous system, but also systemically into the bloodstream. So this is our endogenous pain mediation.

We look at the spinal reticular tract. This is no susceptive input information into the reticular formation, which is located in the pond. And then this in turn relays that information up into the thalamus, and the thalamus, it it diffusely projects this information into the cortex.

So the spinal reticular tract is an important track for bringing no susceptive input into. As well as the reticular. The reticular information is important because it starts to act as a hub for our inhibitory mechanism for pain control.

The last track that we look at is the spinal mesencephalic tract, which delivers sensory and no susceptive signals. So not just painful but also sensory perception. This terminates in the midbrain, and the midbrain is an important area where information is gathered and relayed to the dorsal horn.

So you have, you have a lot of information that's coming into the midbrain, into the the reticular formation, into the per. Periaqueductal brain area and you also have information that's coming from the cerebral cortex back down into the midbrain. So in the midbrain area, there's a lot of information that is gathered that's coming from the periphery, but that is also coming from the cortex.

As we look at all these functions together, various nuclei are gonna give rise to descending neurons that terminate in the lamina 2 and lamina 4 areas of the dorsal horn. So we kind of walk this through because now we're looking at how the body controls our perception of pain, which is necessary for survival. We cannot be constantly walking around in pain, so obviously the body has to have a way of modulating that pain, not only from a segmental level in the spinal column, but also from a central region from the brain.

So one of the more important, one of the first important nuclei that we talked about one of important areas is the periaqueductal grey. The midbrain and in the periaqueductive way, this is a source of endorenergic neurons, so neurons that secrete in. We also have the nucleus raft Magnus, which is located in the medulla, and this is a source of serotonergic neurons.

You also have in the medulla, the nucleus reticularis per gigantic cellularis, which is responsible for no adrenergic or no epinephrinergic neurons secreting. And our last area that's important is the locus eruleus, which also secrete is also a source of no adrenergic neurons. The bottom line is that from these four major areas in the midbrain and in the lower brain, You had in the brain stem.

You actually have nerves that are generated that travel back down to the spinal cord and Terminate in the 2nd and the 4th lamina of the dorsal horn, inhibiting the excitatory neurons. So from these 4 sources, you basically have secretion of serotonin and norepinephrine. These are our two big neurotransmitters that go back down to the dorsal horn and actually influence our interneurons.

So when we look at this super segmental summary, one, you have beta endorphins that are released into the blood and into the cerebral spinal fluid from the pituitary and the arcuate nucleus. You also have beta endorphin, norepinephrine, and serotonin inhibitory fibres from the midbrain which descend. They synapse neurons located in the dorsal horn.

That's what you're gonna, that's what you see depicted over the side of your screen. They release encephalin and diorphan, and those those molecules are gonna bind to the opiate receptors on the pain ferrets, ferrets. Basically what you have is pre-synaptic inhibition of the Adelta and the C fibres.

So when we look at our control of pain. From the segmental level, you have A beta and Adelta, no susceptive fibres that come into the segmental regions of the spinal cord, blocking the inflammation from the C fibres. That's one area of pain control from acupuncture.

You also have super segmental effects of acupuncture where it stimulates nerves that are generated from the central nervous system in the midbrain and the brain stem that come back down and also innervate in the dorsal horn of the spinal cord, stimulating the release of enceflon, which then again bind to interneurons. And that again basically blocks the signal from the C fibres being able to transmit more painful information up to the brain. The Mass effect of this is that locally, those eer fibres that are coming from that area of the dorsal heart or from the ventral heart in the same spinal cord segment are going to have relaxation effect on the muscles and the tissues distal to that site.

So you get better circulation and you have muscle relaxation and better motor function of an area secondarily. Additionally, in the pituitary gland is also gonna secrete ACTH which stimulates the release of cortisol. So with this, with this system in understanding how the system works, not only do you get it a systemic endogenous pain modulation with the secretion of endorphins, and and diorphins, but you also have decreased inflammation due to the release of cortisol.

Now, we do use electroacupuncture sometimes with with painful patients and a lot of times I don't, I don't want to spend too much time on the electroacupuncture because a lot of times you can get very good effects just with a single with grindingly alone or just the insertion of. But electroacupuncture, if you're reading any kind of research papers, looking at acupuncture and the effects of acupuncture, they will use electroacupuncture as a standard technique, primarily because you can quantify the stimulation that you're giving and it it's gonna be the same kind of stimulation between researchers. So, excuse me me, makes acupuncture a much more standardised approach.

Low frequency stimulation will actually activate ADelta and C fibres. So when you're doing acupuncture or electroacupuncture, you basically use a very small microcurrent to stimulate the acupuncture points between the leaves, and it is, you basically use a strong enough current to where it is comfortable for the patient. So you want to activate the A-Delta non-nosoceptive fibres and avoid actually stimulating the, the ADelta painful fibres as well as the C fibres.

When you activate the A-Delta non-noxious stimulate or non-noxious fibres, you activate central nervous system regions which help to block and modulate pain perception. So electroacupuncture can be a very valuable. A tool to use in patients that have significant pain.

One of the areas that I've used it a lot is in patients that have intervertebral disc disease. With high frequency stimulation, this will actually stimulate that segmental analgesia. That's the segmental analgesia that we talk about that occurs in the spinal cord segments themselves.

What has been found between low frequency and high frequency electroacupuncture is that oftentimes the combination of these is the best. Low frequency, which is anywhere from 10 to 2 to 10 Hz, you have pain relief, you also have increased pain threshold, and you have the secretion of encephalin and beta endorphins. With high frequency stimulation, which is between 80 and 100 hertz, you also get pain relief.

It does not increase the threshold. You have a stim you have the release of dimorphine, so another, cau. Opiate agonist, and you also have stimulation of the serotonin and norepinephrine fibres of that dorsolateral tract.

So you have the activation of the descending inhibitory systems. So basically with low and high frequency, you get the best of both worlds. This, it can be helpful for early onset pain control, but will also give you longer pain control management.

So there's a nice reference down there for you, acupuncture and endorphins, which was in the neuroscience letters from El Xavier a few years back in 2004, but it gives you a very nice summary of the research going into being able to isolate the different neurotransmitters that are released with electroacupuncture stimulation. We also have visceral influence of acupuncture. There are many referred visceral pain patterns that we are aware of in people.

You know, McBurnie's point for appendicitis, heart attack, you have the left arm, back, and neck, you don't really see, you don't really have pain over the chest. It seems to come down to the periphery along the arm. All of us are familiar with the brain freeze from eating ice cream or drinking cold beverages too quickly.

You have the abdominal cramping with inflammatory bowel disease and the low back pain with kidney. So we are aware of these visceral, you know, these pain markers of something that's going on on the inside of the body. And so we can take advantage of that connection also with acupuncture.

Acupuncture is also gonna have an effect on the viscera via the autonomic nervous system. On the left side of your screen, what you're seeing is, you know, kind of way of the lumbar spinal cord and the sacral spinal cord where you see sympathetic fibres that are gonna be synapsing in that symp sympathetic chain ganglia and also where you can have them. Merging into the column mesenteric ganglia and the pelvic plexus, which gives us influence over in this instance, you know, the urinary bladder, the colon, the rectum, our reproductive organs.

But keep in mind the sympathetic chain ganglia goes along, it resides along the whole ventral aspect underneath the the spinal column and you have other ganglia, you know, the cranial mesenteric ganglia, you have the, the, ganglia that are in the chest region that is gonna influence all of your internal organs. So if you look over on the right hand side of your screen, you see some acupuncture channels that we use. One of the major ones that goes down right along the, the middle of the back is called the governing vessel, and this can have a very direct influence over this or just locally.

On each side of the spinal column, you see the bladder what we call the bladder channel. And you see that there are With insertion of needles into either the governing vessel or the bladder channel, you can have direct influence over the segmental regions of the spinal cord. Which is going to influence the autonomic nervous system in that area, the primarily the the sympathetic nervous system, but when you look at the lumbar plexus, and the sacral plexus, we also have influence over the parasympathetic influence into the pelvic plexus and influence over the colon, the rectum, and the bladder.

So this is just a depiction of the, the sympathetic system is in red, the parasympathetic system is in blue. And if you look, if you keep in mind that picture of the governing vessel channel and the bladder channel, you can see that using those two channel systems we're gonna have a local effect on the autonom. Nervous system because of the connections of these efferent nerves coming into the spinal cord segments and then affecting a change of the aferent nerves or the the efferent nerves that are leaving the spinal cord and having effect into the sympathetic chain ganglia as well as the ganglia that we see within the body cavity itself.

When we look at the neural mechanisms of acupuncture, there have been some nice studies that have been done on the gas gastric motility. Interestingly enough, these were, this was a study using acupuncture points on the forelimbs and the hind limbs, and it was showed, it was able to show that this evoked a moderate gastric. Utility, so it improved gastric motility by increasing discharges of the vagus nerve.

Now these are points that were used on the limbs, on the forelimb and the hind limb, but it showed that they were still having an effect on the vagus nerve, which helped to increase gastric motility. They used also a stimulus to acupuncture points that were located on the abdomen, so locally on the abdomen, and stimulation of these points actually resulted in decreased motility of the gastrointestinal system. When they denervated the splint nerves, this abolished the inhibitory gastric response, when they did a vagotomy that increased the inhibitory gastric response.

So this study was a very nice study showing, demonstrating the influence of acupuncture on the GI motility, either increasing it or decreasing it based on the points that were used. There's also a nice study that showed that acupuncture activation of the brain stem modulated the imbalance between sympathetic activity and parasympathetic activity. So opioids released from the periaqueductal grey, which we haven't spoken about.

Involved in mediating the anti anti-emetic as well as the anti-nociceptive effects of acupuncture, so those are betalo. Oxytocin, released from the perventricular nucleus, mediated the anti-stress and also further anti-osciceptive effects of acupuncture. So the conclusion of this study was that acupuncture may be effective in patients with functional GI disorders because of its effects, not only on GI motility and visceral pain, but also that anti-stress and anti-emetic effect that you can have from acupuncture of certain points.

There's also an increasing role or increasing understanding of the role of the vagus nerve and inflammation. This is a nice summary that was written by Tracy in 2002, talking about the inflammatory reflex within the vagus nerve. The vagus nerve has a self-control mechanism to deal with to deal with inflammation of the visceral organs.

What they found in the study was that if there is inflammation of the viscera, that inflammation actually stimulates nearby sensory receptors of the vagus nerve. That impulse travels up the vagus nerve, and when that nerve impulse reaches the medulla oblongata, those impulses are relayed back along the motor fibres to the inflamed areas. Acetylcholine is released from the motor neurons and it actually suppresses the release of inflammatory, cytokinide, one of the most important ones being tumour necrosis factor.

So the vagus nerve in and of itself has an inflammatory feedback loop that when it detects inflammation of the viscera, it automatically triggers a response to release acetylcholine. To decrease inflammatory responses of in within the viscera. We can take advantage of this.

There was a study that was done in 2016, so not. Where there was they manually stimulated acupuncture, stimulation of stomach 36. Stomach 36 is a very important point on the limb.

It is located in the cranial tibialis muscle just lateral to the end of the tibial crest and is actually considered a motor point. It's actually where the, the nerve innervates the muscle directly, directly. What they showed with manual stimulation of stomach 36 is that it decreased the production of tumour necrosis factor alpha.

Tumour necrosis factor alpha, messenger RNA and protein levels were also down regulated, and they were able to demonstrate this manual stimulation of this acupuncture point generated CPOs induction in the dorsal vagal complex nema. CFOs is a marker of neurologic activity, so it basically indicated that there is vagal nerve stimulation. Histochemical studies also verified that the neural circuits within the dorsal veal complex were involved in mediating that acupuncture stimulation signal into the vagus nerve.

So here is a point that's on the distal hind limb. It's on the stomach channel, which may give you an indication that it may have an effect on gastrointestinal motility, and that is one of the, the main functions at this point is it's often used for stomach issues, you know, chronic chronic gastritis, as well as chronic inflammatory bowel disease. It's actually probably one of the most common points that is used in acupuncture for both human and veterinary species.

Some interesting new research that's been going on is acupuncture stimulates the migration of stem cells. This was a study using electroacupuncture which promoted the differentiation of mesoinal stem cells and the regeneration of nerve fibres, and it helped to establish a partial functional recovery after spinal cord injury. So for any of you who are using stem cells and in some specialty practises, I know this is becoming more and more common.

Acupuncture and electroacupuncture can actually further enhance the effects of stem cells. So definitely something to be considered as an ancillary integrative treatment for some of these patients. Lawrence Johnston, who is a, one of the doctors at the Institute spinal cord injury in Iceland, also, We cited some recent studies that treatment with electroacupuncture combined with bone marrow derived stem cell transportation, restored more function than either treatment by itself.

So again, it seems to be a synergistic effect which is very, very nice where we can use for acupuncture in combination with. Newest, one of the newer things that we have for regeneration of tissue. There was a study that was also done in using stem cells to treat hip dysplasia in dogs, and it was a study that, very nice study that was done comparing the use of autologous derived fresh stromal vascular fraction, adult stem cells with allogeneic allergen.

Allogenetic stem cells are gonna be derived from adipose tissue from a donor dog. So what was interesting, they injected the stem cells into three acupuncture points of dogs with hip dysplasia that was unresponsive to conventional therapy. The points for bladder 54, gallbladder 29, and gallbladder 30, which for those of you who don't do any acupuncture, probably doesn't mean much, but these three points are found in close proximity to.

The hip joint itself. Every dog showed improvement with this injection. This is the only treatment that was done.

They did see more positive results in the dogs that had the autologous derived stem stem cells, but the allogeneic stem cells also showed benefit and it also showed that these could be safely used. So this is something for the future for us. So getting back to to kind of wrap this up, getting back to these clinical cases, can acupuncture really make a difference and did acupuncture really make a difference?

I think I hope I'm giving you enough scientific information. To show that there is strong clinical or there's strong research evidence that shows that acupuncture can work. But for me, it always depends on how my patients are gonna respond to a treatment therapy.

So, When we look at Smokey, our little 6 month old kitten, when he presented to our hospital, I had actually discovered a second lesion. So he not only had a lesion on the left hind limb, but he also had a second lesion over the dorsal aspect of the lower lumbar spine, crossing over the caudal aspect of the spinal cord and cau. He was at presentation still unable to walk.

He did have deep pain that was present, present, which was fantastic, and that is also always a good indicator. He had exaggerated patellar reflexes, which would be an upper motor neuron sign, but he had no faecal or urinary control, so a lower motor neuron sign. Unable to urinate, but he did have overflow urination.

The rest of the physical exam was completely normal. So after discussing treatment options with the owner, it was decided that we would the kidney. The second lesion under anaesthetic and that I would start acupuncture after surgical treatment of the, of the wound.

Now, Western medical diagnosis, this is a severe trauma to the lumbar spinal cord, cardioquina, and he has. Chinese medical diagnosis is the same thing. We just have a different way of looking at it.

We would say it's a severe chi and blood stagnation in the channels, OK? Keeping in mind chi is normal neurologic function, which he doesn't have, OK? So anaesthetic, that was our, you know, Aceromazine premed with ketamine valium induction and maintained with halothane.

That was our standard protocol at the time, routine debribe and closure of all wounds. At the end of surgery, I started acupuncture. The points that I used.

And you don't have to know where these are. If you look over on the right hand side of your screen, you're going to see where the points are located. Bladder 23, bladder 28, you can see one is a little bit, it's gonna be cranial to the lumbosacral area, one is caudal to the lumbosacral area where the lesion.

Bladder 40, which is in the opal fossa, and then stomach 36, a point that we've talked about in the craniotibial. I did, I treated all points bilaterally, and I did electroacupuncture from bladder 23 to 28 bilaterally. Dense and dispersed, so I used low frequency, 2 Hz per second, combined with 80 Hz per second.

Low frequency combined with high frequency stimulation, and I did that for about 10 minutes. And I also did connected bladder 40 to bladder 40 across the body. On recovery from anaesthetic, he was able to walk in the cage.

His defecation was normal. He still had incomplete urinary control. I was pretty happy with that.

I don't think my surgical skills were pretty good, but I don't think they were that good, so I have to attribute that recovery. I did release them the next day with antibiotics and a prescription for urethyline and dibenzole to help. I enhanced that urinary function.

I rechecked the kitten one week later, the lesions were healed, kittens doing super at home, urination and defecation were completely normal, and a surprise bonus for me, the owner had never filled the prescription for the ureline or the dibenzoline at the pharmacy cause she thought it was gonna be too expensive. So with one acupuncture treatment, this kitten regained complete normal function of the hind limbs as well as urinary and faecal control. Our friend Rocky with the ruptured lumbar discs, 3 months post-surgery, still not being able to use as high limbs, faecal and urinary in.

His first visit for acupuncture, he did have pain per perception, which again is a very good indicator. He did have decreased conscious proprioception in both hind limbs, so we would look at this as an obstruction of qi and a pattern diagnosis. He had an advanced atrophy of all the hind limbs.

This is just because of disuse. He had no faecal, no urinary control, limited faecal control. This would be considered a chi deficiency in Chinese medicine, lack of neurologic function.

He was very painful along the back from bladder 17 to bladder 23, which basically spans from the 7th thoracic vertebra all the way down to the 2nd, between the 2nd and 3rd lumbar vertebrae. So a lot of pain, even though he's had surgery 3 months prior, he still is locally painful here. When we have pain in Chinese medicine, we consider that a stagnation of qi and blood.

So, the treatment strategy for him was to basically get things moving along the spinal cord, and move the chi and blood, free that obstruction, and free the the relieve the chi stagnation. So again, I used a combination of dry needles and electroacupuncture. I saw him once weekly for 4 treatments and then I think 3 more treatments.

The points that I use, and again you're gonna see these show up on the right side of your screen. I use bladder 17, which is at thoracic 17, T7 level, bladder 18, bladder 23, bladder 40, which is again that point in the polial fossa, bladder 60, which is just proximal to the. To In the in the web between the calcaneusarsus.

And then I use small intestine 3 which is on the forelimb. You're not gonna see that. I also use gallbladder 34.

Lateral aspect of the knee and then another point called spleen 6 or. I also use some other points that are on the hind feet and then what I did is I used electroacupuncture points on, electroacupuncture on points that were basically basically spanning the surgical scar. So those points you see highlighted in blue.

After 4 weekly treatments, he was able to try and scratch his ears. I was regained after the first treatment, and after the 2nd or 3rd treatment, he regained urinary incontinence. After 2 months, he was able to walk, swim, and had virtually a normal life.

His gait was still a little bit weak, but he continued to improve. Swimming was one of his favourite things to do. So obviously a rewarding case.

. And one of the things that I wanna say about Rocky, he had, he was treated beautifully. He had the team of surgeons that he had were great. His primary care veterinarian was a super super person, but Western medicine just could not do anything for him anymore.

Establish a normal way of life for him. Last two little patients, Rexa, our, our dog with horrible, horrible osteoarthritis. Her physical exam when I first saw her.

She had a very dull, dry hair coats. Her pulses were very, very deep, very slow. She was very, very weak.

She had extreme muscle atrophy. The atrophy on her hind limbs and over her pelvic region was so bad that you could actually palpate the bony osteoarthritic changes of her hip. Had absolutely no muscle.

And the reason they were so desperate is that now she was starting to have weakness in the forelimbs. So she had some tension in the thoracic area. You can probably imagine that for a number of years, she's been trying to compensate with the forelimbs and because she was so weak in the hind limbs.

So she was a very, very fragile patient. And as I said, I was kind of their last hope. If she didn't respond to what I was gonna do, then they were gonna have to euthanize her.

I treated points again, it probably doesn't matter for the purpose of, of this lecture, which points I use. Some of them very similar to what I used in Rocky and also in But I also use some points that help to release the ileosoas muscle as well as the diaphragm. These are important structural muscles that help maintain that integrity.

I did put her on an herbal formula which also helps to to move tin blood. It also actually increases the production of nitric oxide within the, the vascular system, so it helps with that microcirculation. Luckily, I saw her one week later and she had been very relaxed at the treatment.

She slept well and after the treatment she was walking better and she even wanted to play with her ball. So luckily, Rexa got to live with us a little while longer. We continued with the acupuncture and herbal support support for an additional 4 years, and she was actually euthanized at 12, 12.5 years of age, so she did.

Those are our musculoskeletal patients, but what about that kitty with the lung condition? OK, Sid, our 1.5 year old stayed female, and as I said, she was so, compromised with her lung function that she could not walk across a room without having to stop and catch her breath.

So these are the radiographs from typical alveolar. And as I said, when I look at these patients, not being able to breathe properly, not being able to move, this would be considered a chi deficiency, I think in anybody's book. Again, if you think of chi, normal metabolism, normal physiology, lung physiology is not able to function.

The spleen pancreas is a very important organ for our digestive system. This gives us the nutrients that we need in order to feed ourselves, to feed our tissues. So a Chinese pattern diagnosis for her was a lung and spleen qi deficiency.

Basically what I did for her is I used points to benefit the lung and benefit the circulation of blood and therefore oxygen to the whole body. These are the points that I used. I also put on her, put her on an herbal formula called Ban Be the lung powder.

The following week she was approved. I treated her twice more, 2 weeks apart in the month of December, and she was scheduled to bring the cat back in in the middle of January, but she forgot the cat cause the cat was doing fine. And Sid has never needed any further acupuncture treatment, nor has she needed any further medications.

So, in summary, you know, you can see that acupuncture has developed from Chinese medical theory, which is different from Western medical theory, but not completely in our early origins. Despite that different origin, there is a tremendous number of scientific studies that show the neurophysiological effects. What I tried to stress is the influence that acupuncture has on pain.

A lot of times these are the patients that are gonna be most rewarding to treat. They're gonna be the most commonly, . They will respond most quickly to acupuncture.

So if you're thinking about incorporating acupuncture in your, your practise, they're gonna give you the most rewards very quickly. And you, I hope that you've been able to see that it can be an aid to Western medical treatment. It doesn't need to be one or the other.

It can be a very valuable tool as an integrated modality. On the right hand side of your screen, there's Information about where you can get further training. ADA is the Association of British Veterinary Acupuncturists.

They have a 4 day introductory course that is offered twice a year. I know that that's gonna be introduced, again in October of this year. They will have a session and IIS is the International Veterinary Acupuncture Society, that's the organisation that I'm most involved in, and depending on where you take the course, there's courses offered in various countries.

Spanning anywhere from 140 to 190 hours of veterinary acupuncture instruction, and it gives you more in-depth instruction not only about, a little bit more about the neurophysiology, but a lot more about the Chinese medical influence or understanding of how acupuncture works and how you can use that to treat your patients. I know we've got a little bit over time. I hope that's OK.

If you have any questions, my, email address was listed on the first slide. If you have any questions, please don't hesitate to contact me. Just let me know in the subject that you had done the the webinar vet introductory lecture so that I know how to address the.

I wish all of you a good evening and a good weekend, and I hope all of you stay healthy and that your loved ones stay healthy through this interesting period of history that we're living through right now. Thank you very much.