An old English fable concluded with this powerful moral: “In this world, the most important person is the person in front of you who needs your help, the most important thing is to help them, and the most important time is right now.”

Should not the mission statement of the health care industry read like this moral? Perhaps the best way to answer this rhetorical question is to review a few very interesting facts.

There is no question that modern medicine has been very successful treating a diverse array of health problems of “mechanical nature” such as cataracts, decayed teeth, damaged heart valves or degenerated hips, as well as numerous kinds of bacterial infections responsive to antibiotics. However, it has shown important limitations in the treatment of pain problems and chronic diseases, by stubbornly focusing on the pharmaceutical (and sometimes surgical) management of these conditions, ignoring the very important human factors involved in the experience of disease.

This “old science” approach is leading the health care systems of the most advanced nations in the planet, to the brink of bankruptcy. The “return on investment” in public health care is increasingly negative in dollars and sense, with the number one spender, the USA, as the worst example, already investing 17.6% of their GDP (or $8.233 per person) just to be ranked by the World Health Organization (WHO) number 38 in the list of health care systems among the 191 member countries (behind countries which spend only a few hundred dollars a year on health care). Canada is not in a much better situation as it invests over 11% of its GDP ($4.445 per person) to be ranked in that same WHO’s report the country with the 30th best health care. [Note: the WHO ranking information is from the year 2000, when that one time attempt to evaluate health care systems of all country members took place. As the results of this publication embarrassed many powerful countries the pressure and criticism was such that a study like that has never been repeated].

But there is one revealing statistic that cannot be suppressed and that debunks many of the health care myths created by the pharmaceutical and hospital industry in rich nations. It is the statistic regarding life expectancy. According to 2010 data, life expectancy was 76.2 years for a USA male versus 78.5 years for a Canadian male, or 80.3 for a Swiss, with Spain, Japan, Sweden and a few others above the 79.1 years mark. For USA females it was 81.1 years of life versus 83.1 for Canadian females, and almost 85 years for Swiss, with Japan and Spain now exceeding this number with 86.4 and 85.3 years of life expectancy respectively.

The corollary is simple: if the current mechanistic model of medicine, deeply rooted in a materialistic worldview, was an accurate reflection of how the body really works, then the health of the people treated with this system should be better than the health of the rest of mankind.

As this is not the case, we ought to conclude that there must be something important missing from the much talked about “evidence-based” recipe so narrowly used by many in our health care environment. What could that something be? And why are there still so many conventional doctors intensely annoyed by the existence of colleagues who practice a different kind of medicine, such as acupuncture practitioners? And why are the accomplishments of these complementary interventions often dismissed as a mere “placebo”?

The answers to these may be complex but not the obvious next question: if acupuncture was just a great placebo, would it not still be smarter to use it, particularly in cases of chronic and functional problems, rather than to keep spending billions of dollars in ineffective health care as the statistics provided above show?

Swedish doctor Thomas Lundeberg, editor of the journal Acupuncture and Related Therapies, said in a recent editorial: “…the practice of medical acupuncture may be considered as an art within the medical sciences. Its focus is the patient seeking help because of a health related problem. For medical acupuncture as an art, its chief and characteristic instrument is the human capacity. The therapist has the ability to listen, to empathize, to inform, to show compassion, in fact to be part of the treatment and to exercise ability to care for and treat.”

Good Swedish doctors and old English fables coincide: the best way of being part of the solution is to first stop being part of the problem. Acupuncture is trying hard, no wonder it starts and ends with A•C•U•R•E.

Canadian Chiropractor Magazine – April 2011

Is acupuncture a reasonably effective intervention for the treatment of pain? Advocates will tell you “Yes” and show you dozens of studies to support their enthusiastic claim. Detractors will tell you “No” and quickly add that based on randomized control trials and recent meta-analyses acupuncture is no better than placebo to treat pain. As a third answer, the 29 faculty members, and the more than 1,300 health professionals who have graduated from the McMaster University Contemporary Medical Acupuncture Program since 1999, will tell you simply that that has been the wrong question to ask. Why? Because pain is a complex individual experience impossible to evaluate accurately, and the common way of measuring the perception of pain in clinical trials (the Visual Analog Scale) has shown a very poor correlation with the potentially devastating loss of function and quality of life that pain sufferers experience every day. This alone makes most studies of no clinical value, regardless of their conclusions and methodological quality.

Looking for another approach, in the last few years several studies performed in England have evaluated the cost/benefit of acupuncture for the treatment of pain compared to conventional treatments for the same conditions. The conclusions were favorable to acupuncture. However, when confronted with these new positive results, the usual theoreticians of the evidence-based movement still maintained that it is “scientifically unclear” whether acupuncture can be considered an effective therapy for the treatment of pain.

How does this all affect the millions of pain patients worldwide that apparently benefit from acupuncture every day? Actually, it does not. Why? Because acupuncture seems to work for them, and they could not care less how acupuncture really works, as long as it keeps working for them, and they plan to continue using it, as they will tell you if you ask them as we did.

What is the position of the McMaster University Contemporary Medical Acupuncture Program on this debate? It is summarized as the title of this article Acupuncture for pain? No thanks. Does this mean literally not to use acupuncture for the treatment of pain? Hardly, as health care professionals trained through this program are among the most successful using acupuncture to treat people with pain problems. The answer? Neurofunctional acupuncture, an innovative clinical approach pioneered and systematized by the program.

A neurofunctional approach does not seek a single hypothetical source of pain; it investigates clinically the most common levels of dysfunction associated with complex pain problems, such as neurological, biomechanical, muscular, metabolic, and psychoemotional. Understanding and evaluation of these aspects allows the design of multidimensional treatment plans. Neurofunctional acupuncture interventions are used to facilitate modulation of neurological activity at multiple levels: autonomic (vascular, visceral and central), segmental somatic (propioceptive-motor, nociceptive), and supraspinal (autonomic, somatic, limbic system, cerebellum, etc.).

Neurofunctional acupuncture treatments are designed using a fully systematized practical modular approach (with local inputs, axial and trunk inputs, and systemic regulatory inputs). Clinical outcome measures used include multiple functional indicators.

Therefore, a neurofunctional acupuncture approach is fundamentally different from the “balancing the body’s energy” used by traditional acupuncturists and from the also oversimplistic evaluation of the central perception of pain tested in the randomized controlled trials of acupuncture in the last decade.

Neurofunctional acupuncture interventions do not aim at eliminating pain directly. The goal is to promote self-regulation of nervous system activity, facilitating up- and down-regulation processes such as the production and repair of myelin sheaths, the synthesis of protein-based nerve membrane ion channels, or the secretion and metabolism of neuropeptides.

Over the last forty years, hundreds of basic science studies in laboratories (using human and animal models) have shown the effects of acupuncture on many neurological, cellular, and metabolic processes. However, to date, no scientific neurofunctional acupuncture approach has been systematically tested other than in clinical practice by the faculty and graduates of the McMaster University Contemporary Medical Acupuncture Program.

In the future, only the use of such a scientific model, fully reproducible and based on a neurofunctional rational, will be able to reliably test the ability of acupuncture to influence the functions of the nervous system and answer whether this ability is clinically useful. Meanwhile patients still need to alleviate their pain and suffering. Should we continue to use acupuncture? Ask them. We did, and the answer was clear. Neurofunctional acupuncture for pain? Yes, thank you.

For more information about the McMaster University Contemporary Medical Acupuncture Program visit McMasterMedicalAcupuncture.com/ or call Valerie Cannon at 905-521-2100 x75175

Dr. Alejandro Elorriaga Claraco, MD (Spain) Director McMaster University Contemporary Medical Acupuncture Program.
Published in Hospital News March 2011.

By Chris O’Connor RMT, DO-MTP, Prov CMA

As an RMT I am always on the lookout for training programmes that will not only help to fulfill my CEU quota, but will also afford the opportunity to learn something valuable that will encourage me to become a better practitioner. I was introduced to Contemporary Medical Acupuncture by a class mate of mine during Osteopathic training. At the time I had limited knowledge of the practice of acupuncture, how it worked and its potential benefits. I decided to do some research about the differences between the various schools of thought regarding acupuncture.

For RMTs interested in this ancient healing art form, there is quite a wide range of education options available. For those wanting to add another professional title to their resume, five year training is available in Traditional Chinese Medicine (TCM). Programmes that focus strictly on acupuncture training for health care professionals are usually between two and three hundred hours and leave much of the TCM behind. Whether interested in the Traditional Chinese Medicine approach or the more ‘contemporary’ neuro-anatomical acupuncture, courses of varying lengths can be completed without interrupting your practice.

I chose the McMaster programme because of its careful focus on treatments for pain of musculoskeletal and visceral origin – treatments that have enjoyed clinically reliable and reproducible results. I was interested in the examination of musculoskeletal dysfunction, and further consideration of symptoms associated with abnormal autonomic nervous system activity and endocrine/exocrine dysfunction. The course, based on a whole body approach to treatment, embodies a philosophy shared by Massage, Osteopathic and Chiropractic schools alike.

My training in acupuncture began with an introduction to the safety standards and mechanisms of ‘pain free’ needle insertion. Rather than bombarding with a whirlwind of 400 traditional acupuncture points, the course delineated 181 of the most neurophysiologically relevant. Some of the first points needled, Governing Vessel 20 at the apex of the head for example, were carefully chosen for easy location and low risk of provoking discomfort. Initial classes include review of the anatomy and innervation of the extremities and axial skeleton. This review is the cornerstone for developing an understanding of how and why the needles work. Introductory lectures also discussed the well known auricular systems and important landmarks of the head and face.

The course included trips to the anatomy lab which were always inspiring and incredibly valuable for review of the acupuncture points and the clinically relevant underlying structures that can be treated with the needles. Practical classes made up the majority of any weekend providing the most meaningful learning tool and the best way to obtain clinical pearls from the variety of instructors. The student to instructor ratio was low allowing for strong group focus. Near onlookers gave students the chance to have specific questions answered and to quickly gain greater confidence in needling technique.

Contemporary Acupuncture teaches electrical stimulation as a tool for increasing the neuro-modulatory power of needling. Coupling the newly acquired knowledge of applied electrical stimulation with the solid review of the nervous system, we learned how to base our treatments on modulating the peripheral nerves from their spinal roots to their terminal ends. Rather than merely treating locally, we learned how to have far greater treatment results by treating along nervous pathways. Different electrical frequencies are used to treat different tissues. Joint capsules, ligaments and tendons can handle and benefit from higher frequencies, while muscle bellies and systemic regulatory points need the subtler, lower frequencies. Students are encouraged to follow up all acupuncture with manual treatment of the soft tissues and joints to allow for full integration of the treatment’s positive effects.

As a graduate of the McMaster CMA programme I have to mention how greatly I appreciated the practical and clinical aspects of the training. The strong foundation in neurophysiology and neuroanatomy acquired by the end of the program has been vital to the successful incorporation of acupuncture into my practice. Having the opportunity to work with other health professionals including physicians, chiropractors, physiotherapists, naturopathic doctors, athletic therapists, and nurses was invaluable. I came away from the course with a new understanding about how important cooperation will be to the future of health care and was encouraged to carry this multidisciplinary cooperative spirit into my treatment rooms.

Upon completion of the main course I carried on to attend several of the advanced training courses. These programmes offer a greater focus on the specifics of treatment and assessment of musculoskeletal disorders, TMJ dysfunction and the treatment of headaches and stress related problems. My training was so successful and my enthusiasm so great I am now proud to be the first RMT asked to be a full-time instructor for the course.

Acupuncture Training for RMTs in Ontario
In July, 2000 the College of Massage Therapists of Ontario (CMTO) granted its members the right to perform acupuncture during massage treatments. According to the World Health Organization acupuncture means, simply, to puncture with a needle but what does acupuncture mean to an RMT? Because acupuncture can be expected to benefit the soft tissues and joints of the body, it is accordingly considered an effective manipulation that falls within the guidelines of the Massage Therapy Act.

What training is required in order to be properly performing this new manipulation? To date, the CMTO has not published specific educational requirements for RMTs in Ontario wishing to integrate acupuncture into their practices. The College does require that prospective acupuncture training programs submit their full curriculum for review in order to establish that they fall within the standards of practice for the profession. A list of the approved acupuncture education programs can be found on the CMTO website, at www.cmto.com in the Standards and Regulations/Policies section.

As health practitioners we notice that every client responds in a unique way to treatment, no two are exactly alike. Broadening our scope of practice to include acupuncture lengthens the list of clients we can reach. As individuals we know that we all learn in different ways, and there are a variety of acupuncture courses available to accommodate learning and scheduling needs. The practice of peripheral nerve stimulation with acupuncture needles can be a valuable skill for practitioners to add to their ‘tool belt’ of complementary therapies. After enjoying the extremely successful integration of contemporary acupuncture into my massage practice, I would encourage others RMTs to pursue acupuncture training that meets their and their client’s needs.

Published by Massage Therapy Today, November 2009

Dr. Alejandro Elorriaga Claraco MD (Spain), Director McMaster University Contemporary Medical Acupuncture Program
Chris O´Connor, RMT, Instructor McMaster CMA Program

Introduction
In recent years, the McMaster Contemporary Medical Acupuncture for Health Professionals (CMA) Program has become an increasingly popular choice for RMTs in Ontario seeking acupuncture training. In July, 2000 the College of Massage Therapists of Ontario (CMTO) granted its members the right to perform acupuncture during massage treatments. Because acupuncture can be expected to benefit the soft tissues and joints of the body, it is accordingly considered an effective manipulation that falls within the guidelines of the Massage Therapy Act.

Acupuncture Training for RMTs in Ontario
To date, the CMTO has not published specific educational requirements for RMTs in Ontario wishing to integrate acupuncture into their practices. The College does require that prospective acupuncture training programs submit their full curriculum for review in order to establish that they fall within the standards of practice for the profession. A list of the approved acupuncture education programs can be found on the CMTO website, at www.cmto.com in the Standards and Regulations/Policies section.

Course Description
The McMaster Contemporary Medical Acupuncture for Health Professionals Program is an accelerated training program that consists of five weekend-units with Spring or Fall intake sessions. Upon completion, McMaster University’s CME department issues a certificate granting graduates 300 CME hours reflecting 126 contact hours and 174 hours of self-directed assignments.

Workshops constitute more than 70% of the contact time of the CMA program, and include: anatomy laboratory, problem-solving sessions, case management, point location, needling skills, and live case-study treatments.

The CMA program encourages the careful consideration of treatment principles over the memorization of specific protocols or treatment recipes. The course inspires confidence and competence by fostering a strong awareness of functional neuroanatomy and neurophysiology. Along with preparation for designing effective and safe acupuncture treatments for musculoskeletal pain and dysfunction, health professionals completing the clinically oriented program will understand acupuncture’s role in the management of systemic problems including fatigue, anxiety and poor digestion.

Curriculum Summary
Unit 1
The program starts with a comprehensive review of the neurophysiology of acupuncture and continues with the introduction of the original Contemporary Acupuncture ‘modular’ treatment approach. This is the foundation that allows clinicians with a good understanding of the neurophysiology, pathophysiology, and structural anatomy of a condition to integrate an acupuncture intervention into its management.

This Unit includes a review of current research in acupuncture, and a continually updated review of the literature regarding potential complications associated with acupuncture treatment. The first needling workshops and anatomy lab sessions also take place during this three day weekend.

Unit 2
The focus of this Unit is on the treatment of acute pain and upper extremity problems by integrating knowledge of functional neuroanatomy and pathophysiology of the locomotor system. Specific protocols and strategies for the treatment of common conditions of the joints and muscles of the upper extremity are studied in detail.

Unit 3
The focus of this Unit is on the treatment of pain of vertebral origin, including such common complaints as neck and low back pain. It also introduces participants to the integration of electro-acupuncture for the treatment of common states of dis-regulation.

Unit 4
The focus of this Unit is on the treatment of common chronic conditions such as myofascial pain, headaches, and chronic pain syndrome. Special techniques and protocols for the treatment of these conditions are studied.

Unit 5
Treatments for common conditions of the hip, knee, and ankle joints and soft tissue problems of the lower extremity are studied in detail in this Unit. Additional inputs and strategies for systemic regulation are also reviewed.

Evaluation
A practical point location and anatomy oral exam takes place at the anatomy laboratory during Unit 4. A clinical practicum with real patients takes place during Unit 5. Students are directed through a full evaluation and treatment of two patients in small groups of four. The results of these two exams are evaluated together with the results of four written exams from units 2-5, plus the homework portion. The overall evaluation determines the adequacy of the candidate to receive the final certificate of completion.

Conclusion
Since 1999, more than 800 health professionals have graduated from the McMaster CMA Program, including over 100 RMTs.
RMT graduates of the McMaster CMA program have commented in testimonials that they greatly appreciated the practical and clinical aspects of their acupuncture training. Many also noted that the strong foundation in neurophysiology and neuroanatomy that they had acquired by the end of the program has been vital to the successful incorporation of acupuncture into their massage practice.

Students have also appreciated the multidisciplinary collegiate environment at McMaster University and the opportunity to work with other health professionals including physicians, chiropractors, physiotherapists, naturopathic doctors, athletic therapists, and nurses. Graduates are encouraged to carry this multidisciplinary co-operation into practice.

The practice of peripheral nerve stimulation with acupuncture needles can be a valuable skill for health care professionals including RMTs to add to their complementary therapies. Due to its invasive nature and potential to damage internal viscera, it should only be practiced by well trained professionals with a very precise knowledge of anatomy and neurophysiology. The McMaster Contemporary Medical Acupuncture for Health Professionals Program provides a comprehensive modular approach to the development of competence in acupuncture. The program promises a balanced approach to acupuncture education that includes a firm foundation in theory carried through to the practical application of treatment.

by Alejandro Elorriaga Claraco, M.D. (Spain), Director McMaster Contemporary Medical Acupuncture Program, Hamilton, Ontario
and Rodrigo Garcia-Loyer, Odontologist, Director Cranio-Cervico-Mandibular Disorders Institute, Rio de Janeiro, Brazil
Hospital News – February 2009

Temporomandibular Disorders (TMD) are a group of conditions that cause pain and dysfunction in the jaw joint and its associated muscles. Some estimates suggest that over 10 million US citizens are affected. In a 2001 article, the Journal of the Canadian Dental Association revealed that the prevalence of TMD related symptoms in the Canadian population ranged from 5% to 15%, with peak prevalence between 20-40 years of age. The condition appears to be more common in women than in men.

TMD sufferers are one of the most difficult groups of chronic pain patients to treat successfully. There is not yet a universal gold standard treatment of TMD. In the US National Institutes of Health web site, there are 18 studies reported, either completed or in progress, related to the effectiveness of different interventions on the treatment of TMD. Studied interventions include several kinds of medication, joint injections, dental appliances, biofeedback, cognitive behavioral therapy, naturopathic medicine, chiropractic care, acupuncture, and even shamanic healing.

Currently, it is accepted that chronic pain of any kind is best managed by multimodal bio-psychosocial therapy, addressing the full range of physical, psychological and social components of the chronic pain in order to change beliefs, attitudes, coping style, dysfunctional behavior patterns, and activity levels.

It is within this bio-psychosocial treatment approach of TMD that acupuncture may play a valuable role mainly in alleviating the sensory component of the condition (pain experience) and in helping recondition the muscles that have been overworked due to joint and teeth imbalances and/or excessive grinding of the teeth due to stress.

In the last few years, there have been a number of studies showing the value of acupuncture in the management of TMD. Already in 1999, a systematic review of several previously published studies concluded that acupuncture might be an effective therapy for TMD, though further investigation was suggested.

In 2003, a study measuring the effect of integrating several interventions concluded that acupuncture treatment, in combination with splint therapy and trigger point injections, appeared to be effective for managing TMD.

A recent 2006 review of seven studies published in Sweden and one in the US, found also that acupuncture appears to be a suitable complementary treatment method in the management of cranio-mandibular dysfunction.

On the basis of another 2006 published randomized control clinical trial (in Austria), acupuncture can be recommended as acute treatment of cranio-mandibular disorders.

Another 2006 publication revealed that the results of using acupuncture in the treatment of temporomandibular dysfunction in a general dental practice are comparable to those obtained in clinical studies in university settings.

Finally, in a 2008 published randomized control trial, a group of 160 women TMD sufferers treated with acupuncture and naturopathic medicine showed significantly greater reduction of pain and psychosocial interference than a comparable group of women receiving state of the art specialty dental care.

As in any other area of health care, further ongoing research continues to be needed. However, based on the best available evidence (such as the one presented above) it is fair to state that acupuncture is a simple, relatively safe and potentially efficacious and useful modality in the integrated management of TMD.

How about the future? In the last few years, new insights in the understanding of TMD have led to the expansion of this syndrome into the term Cervico-Cranio-Mandibular Disorders (CCMD), a longer but more accurate descriptor of the multiple etiology and highly complex scope of the dysfunction experienced by this group of pain sufferers. This new clinical paradigm (CCMD) opens new therapeutic avenues for a more interdisciplinary management of these complex disorders to be developed in the next few years.

In conclusion, in order to be truly effective in dealing with TMD/CCMD, dental professionals need the help of manual therapy (chiropractors, massage therapists, osteopaths), psychotherapy, physiotherapy, naturopathic medicine, and acupuncture professionals.

Only integration of modalities and interdisciplinary work can bring complex chronic pain sufferers, such as the TMD/CCDM group, the relief and restoration of function that is the mission and goal of all health care professions.

For more information on the McMaster University Contemporary Acupuncture Program, please call Valerie Cannon at 905-521-2100 x75175 or visit McMasterMedicalAcupuncture.com/

by David Salanki, DC, Anthony Lombardi, DC, Michael Prebeg, DC, Lecturers and Clinical instructors, McMaster Contemporary Acupuncture Program

How many chiropractors could predict with certainty what our practice environment would look like 10 to 15 years into the future? Imagine for a moment traveling back in time, perhaps one hundred years or so, and envisioning the current mosaic of chiropractic techniques and procedures that we currently have available to us today. It would have been more than daunting, in fact, it would have been an impossible task for our forefathers to envision the current scope and direction of chiropractic practice. As practicing chiropractors, it is equally difficult for us to know what lies ahead as the chiropractic paradigm unfolds into the future. When we enrolled in our respective chiropractic colleges, as first year students, it never crossed our minds that acupuncture would be a part of our day- to-day chiropractic practices. Even more surprising would be the thought that we would someday, be sharing our coupled clinical chiropractic and acupuncture experience as lecturers and clinical instructors in the postgraduate division of one of Canada’s leading institutions responsible for educating medical doctors, dentists, chiropractors, physiotherapists and other regulated health professionals in Contemporary Acupuncture. The two themes that have taken our careers into this direction are the themes of this issue; the current research and the evidence based practice of acupuncture and continuing education.

For all of us, working in today’s competitive and complex health care environment makes continuing education much more than a mere administrative requirement by our licensing board; it is both an ethical and a professional duty we acquired the day we joined the ranks of committed contemporary chiropractors practicing in an evidence-based manner.

We all experience in our early years in practice, the excitement and enrichment that comes whenever we are exposed to new knowledge, a new chiropractic technique system or a new practice management tool. It is true that these experiences are exciting as they enrich our intellectual universe, but soon after we implement many of these so-called “clinical truths,” reality often sets in and offers a harsh way to evaluate—and fail—many of our theoretical approaches and techniques. Being frustrated by those patients that couldn’t be helped with all of the varied chiropractic techniques that we had available and despite our best-intentioned interventions, we had no choice but to challenge and expand our knowledge, and to look for new tools to be able to offer effective help to those who had put their trust on us and our skills.

Even though each of us had a very different kind of practice (from sports injuries, MVA and subluxation-based practice), all of us felt at some point the imperative need to have a more effective tool with which to treat pain and musculoskeletal dysfunction. Then, somehow we all found our way to the McMaster University Contemporary Acupuncture Program, and we have remained associated with it ever since.

After our extremely successful experience integrating contemporary acupuncture into our very different chiropractic practices, we all can state that continuing education programs of practical nature—offered by reputable teaching institutions—are the most cost effective way of accessing new knowledge and developing new skills.

We could now tell you about our significant income increase since offering contemporary acupuncture to our patients but we know you will be much more excited to find out about the many patients we have been able to help and about our greatly expanded ability to handle musculoskeletal pain and dysfunction as well as neurological problems.

We could also tell you about the competitive edge that contemporary acupuncture has given us over many of our colleagues and other practitioners but we know that you will care a lot more about the significantly better clinical outcomes we regularly achieve when treating our patients.

We could finally tell you that our practices are now recession and competition proof but instead we prefer to disclose to you our renewed passion and enthusiasm to both the chiropractic profession and our patients, as now we feel better equipped than ever to carry on our missions of helping others with a more specific functional approach and improved clinical efficiency.

From the beginning, we found the contemporary approach to be very easy to integrate in our practice. The language and the clinical concepts belong to the most updated body of knowledge on neurophysiology of pain and neuroanatomy, which greatly increases the acceptance of the intervention among patients and the ability to explain it to other health care professionals.

We are pleased as committed chiropractors all running very successful and busy practices to have the opportunity to give back to our profession by being involved in acupuncture-related teaching and research. On the formal academic side, our program, McMaster Contemporary Acupuncture Program for Health Care Professionals, provides a certificate for 300 CME hours, significantly above the 200 recommended by the WHO. As a result, the program has been recognized by the American Board of Medical Acupuncture and the American Academy of Medical Acupuncture among others, as well as it maintains institutional relationships with other university based programs abroad, and professional medical acupuncture associations in several countries.

For more information, visit McMasterMedicalAcupuncture.com/ or write us at acupuncturecourses@mcmaster.ca.

Published in Canadian Chiropractor Magazine

Dr. Alejandro Elorriaga Claraco, MD (Spain) Director McMaster University Contemporary Medical Acupuncture Program
Chris O´Connor, RMT, Instructor McMaster CMA Program

Introduction
In Sports Medicine, we are still far from understanding the amazingly complex and delicate neurological connections that make highly precise movements possible. In clinical practice, we need to oversimplify these millions of coordinated electrical impulses into a small number of measurable outputs in order to be able to approach the study of the dysfunctions of the musculoskeletal system of the athlete.

Although we usually intervene as a result of unpleasant neurological information experienced by the athlete (nociception, pain), we know that functional restoration, i.e. optimal movement patterns, is indeed our ultimate treatment goal. However, this quest for optimal motor function is full of pitfalls and difficulties due to the elusive nature of most of the sensory signalling generated by the locomotor system, such as proprioception and kinesthesia. Even nociceptive signals can be quite elusive as well as the brain sometimes is unable to interpret correctly the origin of a noxius stimulus from myofascial origin, e.g. trigger points and referred pain patterns.

Therefore, any therapeutic tool with a potential effect on musculoskeletal sensory and motor signals could be of great practical value for the clinician dealing with sports injuries and related problems. Contemporary acupuncture (or electro-acupuncture) is one of such a tool.

Contemporary acupuncture: neuro-reactive sites and neuromodulation
Contemporary acupuncture can be defined as a therapeutic method in which fine solid needles are inserted into specific neuro-reactive sites of the body for the purpose of inducing autonomic, sensory and/or motor neuromodulatory responses. Neuromodulation is the property of the nervous system to regulate its own activity in response to exogenous or endogenous stimuli, and is an integral part of the nervous system modus operandi, i.e. feedback mechanisms allow for finer modulation of efferent neurological responses as well as for filtering and selection of afferent neurological signals.

Neuro-reactive sites in general can be defined as any area of the body where there is somatic and/or autonomic sensory or motor innervation. These include skin, fascias, muscles, tendons, periosteum, joint capsules, ligaments, nerve trunks, arterial vessels, and peripheral neurovascular bundles. Specific (or preferential) neuro-reactive sites for contemporary acupuncture stimulation are associated with areas of the musculoskeletal system rich in specialized sensory receptors such as muscle spindles, Golgi tendon organs, ligament receptors, Paciniform and Ruffini’s receptors (joint capsules), deep pressure endings (within muscle belly), and free nerve endings (muscle and fascia). Also the motor nerves themselves are preferential targets for eletrostimulation through acupuncture needles.

Defined in this manner, the vast number of potential neuro-reactive or insertion sites available to contemporary acupuncture practitioners requires a great working knowledge of gross and functional neuroanatomy. A thorough technical description of these sites is beyond the scope of this overview article.

Neuromodulatory responses triggered by the insertion of acupuncture needles in the human body are now starting to be understood. In the last 35 years, we have learnt a great deal about the possible nature of these responses from studies in animal models. In recent years, the use of functional Magnetic Resonance Imaging has opened a new window into the understanding of the neurological responses to acupuncture in humans.

A great deal of the existing research in acupuncture has been devoted to the mechanisms of acupuncture analgesia. Nowadays, specific applications of acupuncture in the arena of sports medicine are beginning to be explored, and there are already preliminary studies of the effects of acupuncture on strength, aerobic conditioning, flexibility, and sport performance.

The author of this article has a personal experience of twenty years in the field of sports medicine having treated many thousands of athletes with injuries, as well as having developed a “performance care model” integrating acupuncture and manual interventions (soft tissue techniques) for the purpose of optimizing movement performance in physically active people. Some of this anecdotal evidence is shared with the reader in this article.

Contemporary acupuncture mechanisms: a neurological model
Contemporary Acupuncture interventions are based on a contemporary neurological model that allows for best integration of functional diagnosis and treatment interventions in sports medicine. In simple terms, contemporary electroacupuncture provides a physiological non noxius physical stimulus that triggers existing reflexes at the local tissue level, at spinal segmental level, and at supraspinal levels (brain stem, thalamus, and hipothalamus). An in depth review of these mechanisms is beyond the scope of this overview but a summary will be useful in order to understand the possible range of applications in sports medicine.

Physiological response to contemporary acupuncture interventions include: local tissue responses (vasodilation, release of nitric oxide, tissue healing), segmental modulation of nociceptive and proprioceptive signals (dorsal horn integrative and filtering mechanisms, spinal descending inhibitory systems), segmental modulation of autonomic and visceral signals (viscero-somatic, somato-visceral reflexes), and suprasegmental modulation of autonomic, endocrine & immune functions, as well as modulation of miscellaneous central functions such as those associated with the activities of the limbic system (neurological, neurohumoral, neuroendocrine, and neuroimmune responses).

The technical aspects related to each of those families of mechanisms will take several volumes to explore, and at the end we would not have a whole or acurate picture since this discipline is still in development. Therefore the rest of this article will simply focus on making some practical comments on the applications of contemporary acupuncture on sports medicine.

Contemporary Acupuncture and acute injuries
Acute injuries are easier to treat since the body responds mobilizing well known healing mechanisms that can be optimized by specific neurostimulation. The role of acupuncture at this stage is to tone down the high sympathetic activity triggered by the injury, both at the site of damage and centrally, as well as optimize the local healing mechanisms and reduce the motor inhibition and the discomfort from the tissue nociceptive activity. Though I am not aware of gold standard studies for this applications, my experience with hundreds of cases (plus hundreds more from colleagues in the sport world) allow me to state that well design contemporary acupuncture inputs are of great value in the recovery of acute injuries such as ankle sprains, muscle tears, or contusions. The most relevant mechanisms would be local and spinal segmental. In this respect, is worth noticing that some authors (Andersson and Lundeberg) have compared the physiologic benefits of sustained physical exercise with those of repeated acupuncture treatment due to the fact that both stimulate the same muscle afferents producing similar spinal segmental neuromodulatory responses.

Contemporary Acupuncture and subacute and chronic injuries
Effectiveness of acupuncture in subacute and chronic injuries will depend on the clinician’s ability to define the true levels of the dysfunction and to address them in a multilevel integrated manner. Having said that, many studies on the use of acupuncture on chronic musculoskeletal conditions (most of the time in non athletic populations) such as myofascial pain, low back pain, lateral epicondylitis, or knee osteoarthritis have shown promising results. Unfortunately, the uneven range of methodological and clinical quality of these studies precludes at the present time any definite judgment on the true value of acupuncture on these conditions.

For instance, in a study blood flow on the trapezius muscle improved in fibromyalgia patients with local acupuncture stimulation, but not on healthy controls, indicating a homeostatic effect which supports the notions above expressed of acupuncture being a physiological intervention.

Several controlled trials using acupuncture for back pain conclude that acupuncture has been shown to be superior to various control interventions, but not enough data are currently available to support its efficacy over sham acupuncture needling. Regarding lateral elbow pain, a Cochrane systematic review compiled in November 2001 reviewed the literature and determined that only four randomized controlled trials met their methodological search standards. Of the four, two showed a positive effect.

Likewise, four of seven studies on knee osteoarthritis found acupuncture to have a positive effect on pain, on the other three the effects were neutral. No studies reported acupuncture as having a negative effect on pain associated with knee osteoarthritis.
These reviews are provided with the references at the end of this article.

Contemporary Acupuncture and motor neuromodulation
The least know application of acupuncture in sports medicine relates to its ability to restore motor activity when this has been impaired due to motor inhibition secondary to segmental nociception or long standing somatic dysfunctions without clinical signs of pain. Abnormal proprioceptive information is often the underlying problem. In general, a great deal of proprioceptive information related to the control of movement in a given area is processed segmentally and intersegmentally, such as the reciprocal inhibition and autogenous inhibition reflexes. Therefore, the genesis of non noxious signals from the affected segment, preferably through electrical stimulation of motor nerves with acupuncture needles, could be a great way to restore segmental and intersegmental flow of proprioceptive information with the result of improved sensory-motor integration resulting in normalization of motor output in the segment.

Recently, a pilot study showed that in a group of individuals with chronic functional ankle instability, a single session of acupuncture electro-stimulation produced significant changes in strength, proprioception, balance, perceived discomfort, and the number of reported episodes of giving way, with all the improvements still remaining one month post treatment. The only explanation for this spectacular clinical improvement is the segmental normalization of sensory-motor activity with elimination of the prior regional motor inhibition.

Indeed, the author has provided segmental motor interventions thousands of times to both athletes and non athletes, and has found it to be the single most valuable therapeutic strategy in the treatment of movement disorders.

Discussion of the different techniques available to accomplish this is again beyond the scope of this article but as a quick summary they involve treating agonists and antagonistic muscles, involved joints, motor and sensory nerves, and affected spinal segments. The clinical results are often astounding as the ankle instability study shown, even producing at times improvement of athletic performance (best personal marks) due to the restoration of optimal sensory-motor integration, joint mechanics, and soft tissue mechanics.

Mid range and high frequencies (15-20 Hz and up) reinforce the segmental effects of these inputs, while low frequencies (2-4 Hz) engage supraspinal mechanisms in the neuromodulation of the segmental and intersegmental activities.

Miscellaneous applications of acupuncture in sports medicine
Muscle activity and potential changes in strength following acupuncture have been examined in one study. The investigators suggested that acupuncture is able to influence neuromuscular activity since electromyographic changes were detected after 15 minutes needling of the muscle belly. This coincides with this author’s experience as described above.

Ehrlic and Haber investigated the influence of acupuncture administered once per week over a 5-week period on anaerobic threshold and work capacity during exercise in healthy young, untrained males. At the end, individuals in the acupuncture treatment group had higher maximal exercise capacity and were able to perform higher workloads at the onset of blood lactate accumulation (OBLA) than individuals in the placebo group. Also, individuals who received acupuncture demonstrated lower heart rates than controls at various submaximal and maximal levels.

These results indicate once again the physiological and functional nature of the response to acupuncture treatment. Acupuncture is a functional intervention and not just a passive modality. There are still other areas of acupuncture in sports under investigation such as improving flexibility, speed, and coordination but insufficient data preclude any conclusions at this point.

Only clinician’s experiences and future studies will be able to elucidate the true value of all the many promising application of contemporary electro-acupuncture in sports medicine.

References
- Andersson S, Lundeberg T. Acupuncture—from empiricism to science: functional background to acupuncture effects in pain and disease. Med Hypoth 1995;45:271–81.
- Audette JF, Ryan AH. The role of acupuncture in pain management. Phys Med Rehabil Clin N Am 2004;15(4):749-72.
- Berman BM, Singh BB, Lao L, et al. A randomized trial of acupuncture as an adjunctive therapy in osteoarthritis of the knee. Rheumatology (Oxford) 1999;38:346–54.
- Ehrlic D., P. Haber. Influence of acupuncture on physical performance capacity and haemodynamic parameters. Am. J. Acupuncture 21(1):85. 1993.
- Elorriaga Claraco A. Electrical stimulation of acupuncture needles: an overview (part I). Acu-Press, Volume 5, Number 1, pp. 3-4, March 2004.
- Elorriaga Claraco A, Fargas-Babjak A. Neuromodulation, an emerging acupuncture paradigm: implications. Acu-Press, Volume 4, Number 1, pp. 4, February 2003.
- Ernst E, White AR. Acupuncture for back pain: a meta-analysis of randomized controlled trials. Arch Intern Med 1998;158:2235–41.
- Ezzo J, Hadhazy V, Birch S, et al. Acupuncture for osteoarthritis of the knee: a systematic review. Arthritis Rheum 2001;44:819–25.
- Green S, Buchbinder R, Barnsley L, et al. Acupuncture for lateral elbow pain. The Cochrane Databse of Systematic Reviews, Issue 3; 2002.
- Gustavsen G P, Elorriaga Claraco A, et al. A single segmental electroacupuncture treatment improves neuromuscular deficits in chronic functional ankle instability. Med. Sci. Sports Exerc. 35: No. 5, S357, May 2003.
- Konradsen L, Ravn JB, Sorensen Al. Proprioception at the ankle: the effect of anesthetic blockade of ligament receptors. J Bone Joint Surg Br 1993;75:433:36.
- Loaiza LA, Yamaguchi S, Ito M, Ohshima N. Electro-acupuncture stimulation to muscle afferents in anesthetized rats modulates the blood flow to the knee joint through autonomic reflexes and nitric oxide. Auton Neurosci 2002 May 31;97(2):103-9
- Margareta Sandberg, Lars-G. Lindberg, Bjorn Gerdle. Peripheral effects of needle stimulation (acupuncture) on skin and muscle blood flow in fibromyalgia. European Journal of Pain 8 (2004) 163–171.
- Mense S, Simons DG. Muscle pain: Understanding its nature, diagnosis and treatment. Philadelphia: Lippincott Williams & Wilkins; 2001. p. 205–88.
- Thomas W. Pelham, Laurence E. Holt, Robert Stalker. Acupuncture in Human Performance. Journal of Strength and Conditioning Research, 15(2), 266–271, 2001.
- Toma K., R.R. Conatser, R.M. Gilders, F.C. Hagerman.The effects of acupuncture needle stimulation on skeletal muscle activity and performance. J. Strength Cond. Res. 12(4):253–257 1998.
- van Tulder MW, Cherkin DC, Berman B, Lao L, Koes BW. Acupuncture for low back pain. The Cochrane Database of Systematic Reviews, Issue 3; 2002.

by Alejandro Elorriaga Claraco, MD (Spain), Director McMaster Contemporary Acupuncture Program and Angelica Fargas-Babjak, MD, Chair McMaster Contemporary Acupuncture Program

Whether acute or chronic, each pain problem is a personal experience with a unique combination of dysfunctions, sensory signals, and complex emotions. The main difference between acute and chronic pain is that in the latter tissue injury can no longer be used as the guiding model to explain symptoms. Instead, a neurobiological model that takes into account contributions by the peripheral and central nervous systems needs to be used. Processes such as peripheral and central sensitization are now key players in the maintenance of the sensory components of the pain problem. In addition, central processes related to the cognitive and affective dimensions of pain are also fundamental contributors to the experience.

Therefore, when dealing with a chronic pain problem, the challenge is to accurately define every level of dysfunction and to take a multi-level, multi-dimensional approach to correct as many affected mechanisms as possible. In these instances, one of the best therapeutic interventions available to clinicians and patients is contemporary acupuncture, a modality with a multi-level effect in the central nervous system.

Regarding the production of analgesia, acupuncture and electroacupuncture have shown to induce the release of numerous neurotransmitters and neuropeptides at different levels of the peripheral and central nervous system with modulatory effects on the transmission and processing of nociceptive signals. For instance, muscle pain studies by Professor C.H. Takeshige have demonstrated that there are at least two specific mechanisms involved in the production of muscle analgesia in response to acupuncture stimulation. One is the improvement of perfusion in the painful muscle mediated by autonomic vascular reflexes and the release of nitric oxide, the other is the activation of several endogenous pain inhibitory systems that act predominantly modulating nociceptive traffic at the spinal cord, and that involves the participation of several neurotransmitters such as serotonin and noradrenalin.

Based on a review of 228 basic research studies, professor Bruce Pomeranz has offered a theory of acupuncture analgesic effects based on specific neural pathways and neurohumoral responses, that complements the one proposed by professor Takeshige. Dr. Pomeranz proposes that acupuncture activates specific nerve fibers, such as small myelinated A-delta fibers and the type II-III muscle sensory afferents, that send impulses to the spinal cord that continue to supraspinal centers in the mid-brain, the hypothalamus, and the pituitary gland, triggering the release of different neuropeptides and neurohormones such as beta-endorphine, ACTH, and many more, with the overall effect of general modulation of pain and the regulation of several neuroendocrine and immune functions.

Some substances released in response to acupuncture stimulation, such as enkephalin, may help explain some of the observed effects of this therapy in the immune system. These simultaneous effects on the most important information systems of the body (nervous, endocrine, and immune systems) can be described with the contemporary term neuroimmunomodulation, which emphasizes the concept of the permanent intercommunication that exists among these systems. Possible mechanisms of neuroimmunomodulation associated with acupuncture include the potent anti-inflammatory effect of met-enkephalin, which may even prevent anaphylactic shock, or the enhancement of activity of natural killer cells and T cells by the different kinds of enkephalins.

Apart from its remarkable effects on pain and dysfunction of the locomotor system, there are also numerous documented effects of acupuncture on digestive function (motility and secretions), cardiovascular system (heart rate, blood pressure, etc.), gynecological and genitourinary systems, autonomic nervous system (xerostomia, nausea), limbic system (addictive behavior), mood control, especial senses, and a few others.

This impressive array of effects is due to the multilevel response — local, spinal segmental, and supraspinal — induced by the stimulation of specific neuroreactive sites with acupuncture needles and electricity. These neuroreactive sites are currently defined in anatomical terms and correspond with areas rich in sensory receptors such as neurovascular bundles on the limbs, sensory nerve trunks, muscle bellies, motor points, muscle-tendon junctions, teno-periosteal attachments, and joint capsules and ligaments.

In conclusion, contemporary acupuncture is a simple peripheral nerve stimulation technique that is used following a mechanism-based approach. This approach allows for better integration of electroacupuncture with other modalities for the benefit of pretty much any chronic pain sufferer. Response to treatment in these complex cases has to be evaluated in conjunction with the effects of the other interventions utilized.