CitkovitzC PS2016 ThursdayPM Presentation - Pacific College · – Body and scalp acupuncture styles, auricular ... – Gallbladder and San Jiao – channel trajectory, fascia? 10/11/16

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Post-StrokeAcupuncture:amanualfordiagnosisandtreatmentatacute,subacute andchronicstages

ClaudiaCitkovitzPhD,LAcDirectorofAcupunctureServicesNYULutheranMedicalCenter,BrooklynNY

PurposeofthisTalk

• PM- Toprovideastraightforwardreferencemanualforhowtohelpapatient,friendorlovedonewhosuffersastrokeorintracranialhemorrhage

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Outline• Clinicaloverviewofcommon strokesyndromes

– Therelationshipofbraininjuryand functionaldeficit• BasicAcupuncture Therapytoolbox

– Addressingstrokesyndromeswithorwithoutneedlesinhospital

– Bodyandscalpacupuncture styles,auricular,tui na• AManualfordiagnosis andtreatmentplanning

– Tipsfortalkingtohospitalstaffaboutacupuncture– Planningshort- andlong-termcare

INTEGRATIVECLINICALOVERVIEWOFCOMMONLYENCOUNTEREDSTROKESYNDROMES

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TheRelationshipofInjuryandDeficit

• Whichside?• Whichvessel/brainarea?

– Howbig/howdeep?• Whatfunctions arenormallyperformedbythatbrainarea?– Bleedvs Blockislessimportantatthispoint

Left brain, Right brain

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ChineseMedicinePerspective

Leftlesiondeficits• Dominantsideformost

– ‘Theheartison theleft’– speech,clarity,reason

– Adisproportionatenumberofcardiacembolismstrokessufferaphasia(CMheart)

• JillBTaylor’sexperience– Joy,freefromtyrannyofrationalmind

Rightlesiondeficits• Thinkyinfunctions ofcontinuity, spaceholding– Daodejing chapter‘wherethereisnothing,therethefunction is’(ofapot,window,wheel)

• Rightlesionpatientsoftensufferdepression

FronttoBack,YangtoYin

• AnteriortoDu20:– Prefrontalcortex– self-awareness,executive– Frontallobe– concentration,decisionmaking– Motorcortex,volitionalmovement

• PosteriorfromDu20:– Sensory (conscious butnotvoluntary)– Wernicke’s area(languagemeaning)

• Pons,Cerebellum,Medulla,Brainstem– Unconscious functions – balance,body functions

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For Reference: Functional Areas

Territories of the 3 Main Vessels

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MainVessels:UsefulOversimplificationforCMTreatment

• AnteriorCerebralArtery– KD/UB– UBChannel(toDu19ish)

• MiddleCerebralArtery– LV/GB;commonest– GBChannel(cortex/superficial lesions)– LiverChannel (lacunar/deeplesions)

• PosteriorCerebralArtery– deepdeficiency– DuChannel (withUB,Liver,Ren,Yin/Yangqiao)– Usuallyunderlying deficiency – jing,Qi, KD

Jiao Scalp Acupuncture

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MCA - superficial vs deep

• The MCA supplies the lateral convexity of the cerebral hemispheres which include parts of the temporal, frontal, parietal, and occipital lobes

• Deep branches of the MCA (M1) such as the Lenticulostriate branches supply Putamen, Caudate Nucleus, and the anterior limb of Internal Capsule

Peripheral (Cortical) vs Deep lesions

• At the cortex, neurons for different body parts are spaced farther apart.• Peripheral motor cortex lesions will produce contralateral monoparesis• Deep lesions that affect the internal capsule will produce contralateral hemiparesis

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Posterior Cerebral Artery

Branches of the PCA supply :• most of (1) midbrain (2) thalamus, and (3) subthalamic nucleus.• Anterior, posterior temporal, and parietooccipital branches, supply:

temporal lobes, medial and inferior occipital lobes of the cerebral cortex. • Calcarine artery supplies the primary visual cortex

Posterior Vessel Stroke Symptoms • Visual symptoms are a prominent feature:

– Sudden onset of bilateral signs, including ptosis, pupillary asymmetry or lack of reaction to light, and somnolence.

– Visual field loss, visual agnosia, disorders of color vision

• Memory impairment• Motor dysfunction

– Hemiballisumus is unique to PCA stroke• Central post-stroke pain syndrome

– Thalamus generates pain signal over entire affected side – excruciating

• Basilar Artery strokes affect pons– Quadriplegia, trunk weakness, ‘locked-in’ syndrome

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More Detail• Posterior Inferior Cerebellar Artery (PICA - blue)• Superior Cerebellar Artery (SCA - grey)

– superior and tentorial surface of the cerebellum.• Branches from vertebral and basilar artery supply

– medulla oblongata (light blue) – pons (green).

• Anterior Choroideal artery (AchA - aqua)– part of the hippocampus, – posterior limb of the internal capsule – extends upwards to an area lateral to the posterior part of the cella

media. • Lenticulo-striate arteries (LSA’s):

– lateral LSA’s (orange) = deep penetrating arteries of the middle cerebral artery (MCA): basal ganglia

– medial LSA' s (dark red) arise from anterior cerebral artery (usually the A1-segment).

• Anterior cerebral artery (ACA - red)– medial part of frontal and parietal lobe– anterior portion of corpus callosum, basal ganglia and internal

capsule.• Middle cerebral artery (MCA - yellow)

– cortical branches of MCA supply the lateral surface of the hemisphere, except for inferior part of the temporal lobe (pca).

• Posterior cerebral artery (PCA - light green)– Posterior thalamoperforating arteries branch off P1 segment and

supply blood to midbrain and thalamus.– Cortical branches of the PCA supply the inferomedial part of the

temporal lobe, occipital pole, visual cortex, and splenium of the corpus callosum.

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Visual Fields

• An injury on one side of the brain will cause deficits in both eyes.– Eg MCA -> contralateral homonymous hemianopia

• Monocular visual loss suggests an injury anterior to the optic chiasm.

Thalamus• “The major way station

of incoming sensation.” (Melvin Konner)

• Sensory information such as: visual input, touch, pressure, heat, cold, and pain all enter the thalamus, then is directed to its appropriate area in the cortex.

• Thalamic pain syndrome - unrelenting pain burning stinging while awake

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Cerebellar Stroke

The cerebellum controls many of our reflexes and much of our balance and coordination. A stroke that takes place in the cerebellum can cause:

•Coordination and balance problems, thus Dizziness, nausea and vomiting.•Alcohol affects cerebellar function. Cerebellar problems mimic movement of a drunk person•Nystagmus•Dysarthria: muscles of voice production and speech lack coordination so sudden irregular changes in volume and timing occur, i.e. scanning or staccato speech (words are broken into syllables).•Upper limbs: ataxia and intention tremor - best seen in movement directed towards a restricted target e.g. the finger–nose test•Dysdiadochokinesia i.e. slow, inaccurate, rapid alternating movements•Lower limbs: ataxia -best seen in the heel–knee–shin test.•Gait and stance ataxia- especially if the patient is asked to walk heel to toe, or to stand still on one leg.

Brain Stem or Vertebrobasilar Artery Stroke

• Strokes here are especially devastating. Controls all our involuntary, "life-support" functions, eg breathing rate, blood pressure, heartbeat. also controls eye movements, hearing, speech and swallowing.

• Since impulses generated in the brain's hemispheres must travel through the brain stem on their way to arms and legs, patients with a brain stem stroke may also develop paralysis in one or both sides of the body.

• Cranial nerve palsies – Diplopia, gaze palsies, nystagmus, vertigo, dysarthria and dysphagia

(sometimes hemispheric if patient hemiplegic) , other cranial nerve palsies (III-XII)

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Cranial Nerves

Whew!That’salot.

• Thismaterial ishereasareference– Shouldprovidecontextastowhat’s gonewrongwithagivenpatient,andwhatelsetolookfor

– Ifyouhaven’talready,saveacopytoyourphone• Asapracticalmatter,ourpatientsarrivewithlesionlocationandsyndromespre-diagnosed– Theframeworkfordiagnosis&treatment givenbelowallowsyouto‘treatwhatyousee’

– Mopupthebigspillsfirst,thenthinkitthroughmoredeeplywhenyouknowthepatientbetter

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REVIEWOFBASICDIAGNOSTICANDTREATMENTPRINCIPLESFORSTROKE

Recovery/RehabilitationSteps:

1. RegulatecranialQi/BloodflowDifferentiatehemorrhagic/ischemic stroke

2. Restorefunctionof‘Qimachine’– Cleanupacutemesses– Identifyandtreatunderlying constitutional

imbalances3. Identify,prioritizeandaddressdeficits

– Criticalfunctions first:shen, speech,swallowing– Motorfunction fromproximaltodistal

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1:RegulateCranialQi/Bloodflow

• Ischemicstroke:– Days2-7,BPhigh/stable,clearcytotoxicedema– Days7-21,clearvasogenic edema– Targetbloodflowtolesion,raiseclear/descend

turbid• Hemorrhagic stroke:

– Beforebleedingisstabilized(withcautionifatall): helplowerICP

– Oncestabilized,targetbloodflowtolesion,raiseclear/descend turbid,gentlymovebloodstasis

2:RestoreFunctionof‘QiMachine’

A. Cleanupacutemesses– Phlegmmistingorifices orharassinglung– Constipation/urinary retention(+/- UTI)– Fecaland/orurinaryincontinence

B. Identifyandtreatunderlyingconstitutionalimbalances

– Istherestillwind?(Usually not)– Howmuchblood stasis/howmuchphlegm?– Underlyingdeficiencies

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3:ID,Prioritize&AddressDeficits

A.Criticalfunctionsfirst:– Shen – ifnonverbal, lookforpresence,clear

eyes,recognizingfamily,reliableyes/no– Speech– differentiateaphasia(receivingand

usinglanguage)vs dysarthria(formingsounds)• Treatdysarthriaphysicallylikeswallowing

– Swallowing– freeupskywindowpoints• distinguishlips,tongue,upper/lowerthroat,

tight/lax/incoordinated/asymmetrical

3:ID,Prioritize&AddressDeficits

B.Motorfunctionfromproximaltodistal– Startwithbalanceandtrunkstability

• Balancemaybepoor, trunkmaybefloppyor leaning• Patientmay‘push’withgoodlegontobad

– Treatlowerextremityreturnfirst(it’smoreimportant;returnsfasterinMCAstrokeanyway)

• Glutes andhamstringsfirst,thenquads(especiallyvastus medialis tostabilize)

• Dorsiflexionmaynotreturn ->anklebrace

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3:ID,Prioritize&AddressDeficits

C:Upperextremityreturn• InMCAstroke,armlagsbehindlegandmay

notreturn– Returnisoftencomplicatedbylaxityofrotator

cuff->subluxation ->pain• Recoveryisgenerallyproximal->distal,but

mayjump– Lookforelevation,protraction/retractionfirst– Flexion returnsbeforeextension

TOOLBOXOFACUPUNCTURETHERAPIESFORPOSTSTROKECARE

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OurBasicAcupunctureToolbox

• Acupuncture(Zang-FuandChannelapproaches)– treatorgans,channels,constitution

• Jiaoscalpacu - mapslesionontoscalpsurface– Mostusefulformotordeficit,alsobalance– Vs Zhuscalpacu whichmapsbody ontoscalpsurface

• Oleson – mapslesionontoearlobe– Usetotargettreatment forinternalstructures,esp.thalamus,basalganglia

• Tui Na– physicallysupplementchannels,movebloodoutofLuo

Acupuncture– Zang-FuApproaches

• Inmostcases:– RestarttheQiMechanismandtransformphlegm– RegulatetheLiver(descendyangand/ornourishyin)– SupplementSPQi,KDyinand/oryang

• Also:– Heart: clearorifices;movebloodinluo;nourishZongQitorestorerhythm

– Lung: oftenfetteredbyphlegm,+/- heat, infection– Bladder:UTIoftenresultsfromurinaryretention– GallbladderandSanJiao– channeltrajectory,fascia?

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Acupuncture– ChannelApproaches• WangQing-ren modelofstrokepathology

– FilltheJing(mainchannels,emptyofQi)– CleartheLuo (collaterals,fullofstuckBlood)

• Coursesof3mainarteries– treatlocal/distal– MiddleCerebralArtery=GB– AnteriorCerebralArtery=UB– PosteriorCerebralArtery,smallervessels=usuallydeficiency,treatKDandextrachannels

• BalanceMethod(checkerboardyin/yang)– Cancirculatewhilesupplementing, lowneedlecount– Alternateyin/yangchannelspertx,1st tx bilateral!

TypicalBalanceTx forMCAStroke(plusDu20/24, legmotorareaLeftside)

• RightArm(AffectedSide,needle1st)– LI4/11/15,TH6– Canaddba xie withmotorline

• Leftarm(4th)– PC5/6

• RightLeg(3rd)– SP6/10– SP6deep/strongforblood stasis

• LeftLeg(lesionside,needle2nd)– ST36/40,GB34/40

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ScalpAcupuncture• JiaoShunfaMethod(ShanghaiText,Dr.Hao)

– Stimulatethebraintorebuildpathways• Mostusedforarm/legmotor/sensory• Alsousefulforbalance(cerebellum),speech(Broca’s,Wernicke’s)

• ZhuMingqing Method(Dr.Zhu)– BringsQiandawarenesstoaffectedareas

• Mapisipsilateral (vs Jiao’s)sogreattoalternate– NeedletechniqueisINFINITELY friendlier

• Earneedlesinseriesorchickenfeetalongthescalpline• Supplementwithlittlepushes,dispersewithlittlepulls

– Alsohas3jiao applicationsandspinemapforpain• Iseldomuse 3jiao butusepainallthetime,esp shoulder

Jiao Scalp Acupuncture

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ZhuSystem– BodyAreas

ZhuSystem– Shoulder/Hip

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Auricular

• TerryOleson hasmapsofbrainstructuresontotheear– Especiallyuseful fordeepstructures,eg Thalamus– 3rd Editionpicturesareeasiertoread– PerOleson, earseedsstronglystimulatedarenoweakerthanneedles

• Otherpointsareuseful– Constipation, insomnia, depression/anxiety,shoulder pain(allverycommon instroke)

Oleson – CorticalMap

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SubcorticalMap

Tui Na

• IuseittophysicallysupplementQiandmoveblood&fluids

• Alsoseemstohelprestore‘tensegrity’/awarenessoffascia– Shaking&rockingtechniques, cf Tragermethod

• Useonaffectedlimbs,shu points• Abdominalroundrubbingforconstipation

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PUTTINGITALLTOGETHER

1:RegulateCranialQi/Bloodflow

• Ischemicstroke:– Days2-7,BPhigh/stable,clearcytotoxicedema– Days7-21,clearvasogenic edema– Targetbloodflowtolesion,raiseclear/descend

turbid• Hemorrhagic stroke:

– Beforebleedingisstabilized(withcautionifatall): helplowerICP

– Oncestabilized,targetbloodflowtolesion,raiseclear/descend turbid,gentlymovebloodstasis

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Step1– Tx principlesandstrategies

*constitution!

2:RestoreFunctionof‘QiMachine’

A. Cleanupacutemesses– Phlegmmistingorifices orharassinglung– Constipation/urinary retention(+/- UTI)– Fecaland/orurinaryincontinence

B. Identifyandtreatunderlyingconstitutionalimbalances

– Istherestillwind?(Usually not)– Howmuchblood stasis/howmuchphlegm?– Underlyingdeficiencies

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2A–AcuteMesses

Step2B– constitutionalimbalances

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3:ID,Prioritize&AddressDeficits

A.Criticalfunctionsfirst:– Shen – ifnonverbal, lookforpresence,clear

eyes,recognizingfamily,reliableyes/no– Speech– differentiateaphasia(receivingand

usinglanguage)vs dysarthria(formingsounds)• Treatdysarthriaphysicallylikeswallowing

– Swallowing– freeupskywindowpoints• distinguishlips,tongue,upper/lowerthroat,

tight/lax/incoordinated/asymmetrical

Shen,SpeechandSwallowing

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3:ID,Prioritize&AddressDeficits

B.Motorfunctionfromproximaltodistal– Startwithbalanceandtrunkstability

• Balancemaybepoor, trunkmaybefloppyor lean• Patientmay‘push’withgoodlegontobad

– Lowerextremityreturnfirst(moreimportant;returnsfasterinMCAstrokeanyway)

• Glutes andhamstringsfirst,thenquads(especiallyvastus medialis tostabilize)

• Dorsiflexionmaynotreturn ->anklebrace

Balance/Stability,LowerExtremity

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3:ID,Prioritize&AddressDeficits

C:Upperextremityreturn• InMCAstroke,armlagsbehindlegandmay

notreturn– Returnisoftencomplicatedbylaxityofrotator

cuff->subluxation ->pain• Recoveryisgenerallyproximal->distal,but

mayjump– Lookforelevation,protraction/retractionfirst– Flexion returnsbeforeextension

UpperExtremityReturn(andPain)

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AFewAlternateLocations

• ShiXuemin– HT1– canapproachfromJian Qian with2”needle

• Firstreviewthelocationofthebrachialartery!J– SP6– posterioraspect,cangothrutoGB38!

• Strongstim todredgestaticbloodfromluo

• WangJu-Yi(viaJasonRobertson)– HT6– palpatedeeplyfornervycleftnearPC6

• Transverseinsertion,strongstim toclearluo =theorificesoftheheart

EmailtheseLinkstoYourself(ordownloadPDF’stoyourphone!)

• Soyouknowwheretheyareifyouneedtheminahurry– https://www.dropbox.com/sh/nuzhrab0diffl8x/AABtkVEjnAQEt4A7BeMGV4via?dl=0

• Fullmanualwith introductionanddescriptions– Forprintingandshowing tohospitalstaff– Notetheguidesareolder,morecomplex!– http://westminsterresearch.wmin.ac.uk/16057/

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Charts & Graphs Online

• Brain Structure & Functions: http://www.waiting.com/brainfunction.html

• Brain functions & deficits http://www.neuroskills.com/brain-injury/brain-function.php

• Arteries of the Brain & area supplied: • http://what-when-how.com/neuroscience/blood-supply-of-the-central-

nervous-system-gross-anatomy-of-the-brain-part-2/

• Aphasia and Apraxia at a Glance http://www.csuchico.edu/~pmccaffrey/CMSD636StudyGuide.pdf

• How to read a brain CT scan• http://www.slideshare.net/kunalmahajan50/basics-of-ct-head-by-dr-kunal-

mahajan

THANKYOU!!!!– JackMiller&PCOM– FrederickZamora