Neurofunctional Blueprints Transcripts for Tempe, January 2015.pdf

 

 

 

Neurofunctional Acupuncture Blueprints Video Series    

The  Complete  Transcripts           By  Dr.  Alejandro  Elorriaga  Claraco  

  Copyright  2014  by  Alejandro  Elorriaga  Claraco.  All  rights  limited,  specifically   reproduction  or  distribution  is  prohibited.  This  is  a  personal  licensed  product  for  a   single  user,  and  has  been  granted  as  part  of  the  course  material  package  provided  to   the  participants  in  the  Neurofunctional  Meridians  Dissection  Program,  February  3-­‐7, in  USA,  to  be  exclusively  used  by  each  participants  for  personal   study  and  review  of  the  Neurofunctional  Acupuncture  Blueprints  Video  Series.  

 

 

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System overview Hi. My name is Alejandro Elorriaga Claraco. I’m the director of the McMaster University Contemporary Medical Acupuncture Program and I’m here to present to you an overview of the neurofunctional acupuncture blueprints. Neurofunctional electro-acupuncture treatments are the example, the model, to design your functional treatments for a number of problems, mainly problems of musculoskeletal pain and dysfunction and of general regulation. What’s a blueprint? A blueprint, as you know, is what architects and engineers use as a plan, guideline (model, template) in order to build something. That’s exactly the intention with these blueprints. It’s not a cookbook recipe. It’s a set of guidelines that will assist the practitioner to arrive at the most effective treatment following the tenants of neurofunctional treatment. So let’s build the model up from a blank page beginning. For those of you unfamiliar with the neurofunctional model it’s a simple understanding of the relationship between the peripheral parts of the body and the nervous system. As you well know, the organization of the nervous system consists of a brain and associated organs centrally such as the cerebellum, the limbic system, etcetera. A brain stem connecting to a spinal cord and from there, peripheral nerves arriving at the [innervated] structures. In this case we are concerned with the structures of the neuro-musculoskeletal system: the muscles, the joints, the tendons and the peripheral nerves that control the movement at the peripheral level. The neurofunctional model consists of understanding the traffic of information from the periphery to the central nervous system and from the central nervous system to the periphery. In this traffic which we can term afferent in the direction of the central nervous system and efferent on the direction from the nervous – central nervous system to the periphery. Due to embryological development there’s a natural station in between the periphery and the central nervous system, the brain particularly, which is the spinal cord. The spinal cord is the natural crossroad where information from both ends is processed and modulated. We can represent this by drawing a transfer [scat] of the spinal cord with the anterior horn, posterior horn, where the different afferent, efferent connections take place. I have a better diagram to show you some of the traffic of information and we can use it if the camera can zoom in to show the different levels. This diagram portrays the normal traffic of impulses from the peripheral structure to the spinal cord in which depending on the type of fiber that carries that afferent information, the processing [of the signals] is different. Some, particularly, the information from the so-called C fibers, C unmyelinated fibers which form free nerve endings as well as A delta fibers also forming free nerve endings. These are the – they’re represented here, the free nerve endings. And then we have another type of nerve fiber represented by this encapsulated organ which would be the A beta fibers and this would be thick, myelinated

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[fibers] with their own encapsulated receptors, while the A-delta and C fibers will be free nerve endings with no encapsulated receptors. Nerve fibers specialize in the transmission of certain kind of information. As you know, C fibers are in charge of temperature, pressure, of coarse pressure, as well as what is called nociception. Nociception is any signal that expresses threat to the tissue whether chemical threat, mechanical threat, thermal threat. So C fibers and A-delta fibers are nociceptive fibers and they are the only ones that can convey a threatening message to the central nervous system, while A beta fibers are devoted to proprioception, the communication between mechanoreceptors of many kinds and the central nervous system for defined regulation of movement. For instance, the information from the muscle spindles, from the Golgi tendon organs, the Pacinian corpuscles, etcetera. And these fibers cannot transmit nociceptive information. This specialization of the nervous system obviously has an evolutionary origin. The most abundant fibers in the body are the C fibers. Up to 70 percent of all the fibers in the body are C fibers and on evolutionary terms, the myelin sheath came later and the hierarchization of processing of signals has respected this evolution in such a way that information from A-beta fibers is processed preferentially and at much higher speed than information from C fibers. This naturally occurring modulation of information that we can see in this blow up of a dorsal horn makes possible to stop some of the nociceptive signals before they reach upper levels of the central nervous system. This is what has been termed the gate control theory and is not a theory, it’s a physiological reality and a lot more complex than this simplification, a schematic simplification. But enough for us to know that the category of information that the peripheral nervous system conveys to the central system is processed differently and has influence on how the nociceptive information is processed. This is one of the core principles of neurofunctional acupuncture. Understanding that if we send signals from the same segment or arriving to the same segment in the spinal cord and these signals are non-noxious, not nociceptive signals, then the spinal cord is going to modulate the entry of nociceptive signals. And this is a beneficial strategy not just with needles, acupuncture needles, but also with other means to stimulate a beta fiber like warmth, light touch, etcetera. So this is the first level of neuromodulation that can be accomplished based on the design of the information processing and management in the central nervous system. The next level is more complex and has to do with different relay stations that the nociceptive fibers stop at before they reach their final destination on the thalamus. This contralateral ascendant tracts are all spino something; spinoreticular, spinothalamic. The final destination being the thalamus and from there the nociceptive signals will be spread out through the somatosensory cortex and other areas of the brain in order for the brain to process the full meaning of the signal. For our purposes it’s enough to know that the entry of these nociceptive signals and posterior processing with influence, [regulatory] influence on the segment

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that originated the signal, produces additional modulatory mechanisms that can be promoted by different strategies. One modulatory mechanism would involve the sending inhibitory tracts with no adrenaline and serotonins as the neurotransmitters. Other mechanisms will involve processing within the spinal cord with secretion of endogenous opioids such as dynorphin and enkephalin. These mechanisms can be specifically optimized using electro acupuncture and this has been well researched. For instance, there is a 125Hz stimulation that promotes the modulation of the segment through the stimulation of the descending inhibitory mechanisms, noradrenergic and serotoninergic. Also, in our blow-up of the segment, we see that A beta fibers do not follow the same trajectory as the C fibers or A delta fibers. Instead, the A beta fibers continue up towards the brain stem and the brain through the so-called dorsal column nuclei. And before they enter the dorsal column nuclei, they give off collateral branches that also inhibit the entry of nociceptive impulses. The neurotransmitter associated with this modulatory mechanism is GABA, gamma amino butyric acid. And this can be preferentially stimulated with an electrical current of 80Hz. So we see that some of the knowledge developed in the last decades have helped us predominately trigger modulation of nociceptive signals by stimulating one of the particular mechanisms that nature has put in place. This is the core of neurofunctional acupuncture. Neurofunctional acupuncture is nothing but the stimulation of the peripheral nervous system with a fine solid needle and electricity for the purposes of modulating the activity of the nervous system, particularly the nociceptive pathways as well as the central mechanisms involved in the regulation of autonomic nervous system activity, sympathetic activity and also neurohumoral responses that are involved in the inflammatory response and neuroendocrine responses that affect the hypothalamus, pituitary access and the effector organs such as the adrenal gland. This in a nutshell is the foundation of neurofunctional. Therefore, the blueprint, the first blueprint that we use in neurofunctional acupuncture is a blueprint that is functionally related to these levels of modulation inherent to the nervous system. In a simple three-category model, we have processes that take place locally, processes that take place at the segment, segmentally, and processes that take place above the spinal cord supraspinally. And those three sets of processes are the three main categories of response that we seek when we use neurofunctional acupuncture. Again, today our goal is to talk about the blueprint but briefly just for the benefit of those not familiar with our system, locally so we have – let me go back and forth. We have neurofunctional levels of a given problem. Neurofunctional levels refer to anything on the afferent pathway that’s related to the problem. And in simple neurostructural terms, a problem can be defined always in neurological, segmental dimension meaning which spinal cord segment supplies the territory that’s in trouble. This is called a segmental relationship, and in this case a peripheral segmental relationship.

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So the categories of relationship of a problem with the nervous system are segmental when the problem and the nerve or the level of the spinal cord are connected or extrasegmental when they’re not. So we can simply define – redefine every body part into a segmental relationship with the spinal cord and a non-segmental relationship. So the segmental relationship would be based in several [soup] categories that relate to the type of tissues that are preferentially innervated by a segmental level of the spinal cord and this category of tissues due to embryological development are well established. One refers to the skin, the next refers to the muscle and the third one refers to the deeper hard tissues such as the periosteum and the joints. And these have been termed dermatomal, myotomal and sclerotomal categories. So a given problem, pain in the elbow, will have a dermatomal level which would be the spinal segment that supplies the skin over the area where the pain is perceived. It’ll have a myotomal level, segmental level, which would be the spinal segment that supplies the muscles on the affected area and the same with the sclerotomal level. Obviously this relationship is not direct. It’s through the intervention of a peripheral nerve that can be the same for the three levels or it can be different. On the girdles these levels are typically different. For instance, let’s do the shoulder as the quintessential example of this. In the shoulder we have a dermatomal level that is – that’s the shoulder. The dermatomal level is a C4 meaning the C4 spinal segment provides the actions that innervate the skin of the shoulder. And we’ll see which peripheral nerves carry that. The myotomal level is a C5 meaning the majority of the actions that supply the muscles over the – on the deltoid are from C5. And finally, the sclerotomal level is typically a C6. Now, segmental innervation is not an absolute and all these segments should be interpreted as plus two levels above and two levels below contributing to the same segment but the predomination innervation is the one we highlighted. And now to the peripheral nerves. The dermatomal innervation C4 origin will be via the supraclavicular nerves. So supraclavicular nerves from the cervical plexus. Well, the C5 myotomal innovation would be via the axillary nerve which is a brachial plexus. And the sclerotomal will be supplied by miscellaneous nerves such as the axillary and the suprascapular also from the brachial plexus. So this concept of segmental innervation being a complex mixture of these three soup categories is very important when using a neurofunctional acupuncture blueprint because depending on the target tissue, we have to go to different levels sometimes of the spinal cord. In more peripheral parts the innervation is a little bit more coincidental on the same segment. The same spinal segment may supply simultaneously the dermatomal, myotomal, sclerotomal level. So back to our neurofunctional acupuncture general blueprint. We are just simply talking about the categories of relationship between a given problem and

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the nervous system. So the first category is that okay, the problem area is associated with certain segments or it’s not. Now, when it’s associated with certain segments this association that we just described can be through what is called peripheral nerves which are peripheral nerves formed by anastomosis of the anterior divisions of the spinal nerves. The spinal nerves divide into anterior and posterior branches. The anterior branches are called anterior primary rami and these form plexuses such as the cervical plexus, the brachial plexus, the lumbar plexus, then the sacral plexus and those form peripheral nerves such as the axillary, suprascapular or sciatic nerve. Then we have segments from and these are segments from C1 to the coccygeal nerve except for the anterior primary rami that form the intercostal nerves between T1 and T12, the supracostal nerve and then the iliohypogastric, ilioinguinal, that they are L1 nerves. So we have a first category, very important category of relationship between problem areas and the nervous system which is determined by two levels. Which segment of the spinal cord supplies that area? That’s the first relationship and that can be also made or expressed in terms of peripheral nerve. Which peripheral nerves supplies this tissue? And this is a peripheral segmental relationship. Now, if we go back to the spinal cord and to the two divisions, the anterior and posterior rami, we can also reach the posterior primary rami on the paravertebral musculature. This rami don’t form plexuses. They are independent branches that innervate all the intrinsic musculature of the back and they stem from the C1 to the coccygeal branches. And these posterior primary rami can be – can form another segmental somatic relationship. So we have two ways of accessing the same spinal segment. One through the peripheral nerve, a peripheral segmental relationship; two: through the posterior primary rami that belongs to the same spinal segment as the peripheral nerve that supplies the problem part. This can further be subdivided into the same categories which is described for the peripheral tissues. So you can go to the posterior primary rami to treat a shoulder problem at the C4 level because of a dermatomal neuropathy, for instance, or you can go to the C5 level because you want to influence the myotome or you can go to a C6 level because you want to have an influence on the sclerotomal. So this is the first subdivision of categories for neurofunctional acupuncture; peripheral segmental and a spinal segmental always through the posterior primary rami but also in the trunk through the anterior primary rami between the T1 and the supracostal nerve T12 and also for the abdominal wall through the iliohypogastric, ilioinguinal nerves at the L1 segmental level. Neurofunctional relations, there are four, can happen at a peripheral segmental level via the peripheral nerves, can happen at the posterior primary rami on the paravertebral musculature at the levels corresponding to the same dermatome, myotome or sclerotome.

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To make matters a little more complex, we should remember that the vasculature of the musculoskeletal system and the visceral system receives independent innervation provided by the sympathetic nervous system. The sympathetic nervous system exists in the intermediate dorsal lateral column of the spinal cord between T1 and L2. Therefore, the vessels of the different areas have a segmental origin that topographically is different from the dermatomal, myotomal and the sclerotomal levels. There’s not an official denomination for this sympathetic vascular level but I call these areas reflex vascular sympathetic areas because that’s where the preganglionic neuron, the first of the two neurons that will finally innervate the arteries or small arterioles, it starts at that level. So now we have an additional category of segmental relationship. We have the so-called segmental autonomic. So we have the segmental somatic, the relationship that corresponds to the dermatome, myotome, sclerotome and now we have the segmental autonomic. That can be on the sympathetic side, a side just described between T1 and L2. And we need to know simply where those preganglionic neurons are going to go which in the case of the innervation of the vessels of the head, neck and upper extremity, these neurons from T1 to T5, these preganglionic neurons are going to synapse with postganglionic neurons on the cervical ganglia on the lateral aspect of the neck, superior cervical ganglion, middle cervical ganglion when it exists. An inferior cervical ganglion which usually anastomosis with the superior thoracic forming the stellate ganglion and from there the neurons will proceed to innervate the vessels of the shoulder, rest of the upper extremity and head and neck. Therefore, if we want to treat the elbow as we explained before, it’s not enough – or the shoulder. It’s not enough to go to the segmental somatic levels. We must pay attention to what’s happening with the segmental reflex vascular sympathetic levels. In this case T1 to T5 or in the case of the lower extremity T10 to L2. And the inclusion of these segments in the treatment of problems in this area by itself produces superior results in our neurofunctional model and this is part of the blueprint. So the blueprint is always going to have a peripheral segmental level via peripheral nerves. Is going to have a spinal segmental level that will have a double category, segmental somatic at the levels corresponding to the dermatomal, myotomal, sclerotomal and segmental autonomic at the sympathetic level for the vessels. If we are treating visceral problems sometimes we’ll have a parasympathetic level of innervation which in this case will be S2 to S4 when we are dealing with organs from the descending column, the prostrate, the bladder and the genital organs. So that would be a reflect parasympathetic level. All viscera, most of them have double innervation, sympathetic, not only vascular but also glandular and the smooth muscle, the motility of the smooth muscle is regulated by the interplay between sympathetic from L1 – from T1 to L2 and parasympathetic via the vagus nerve which exits the cranium through the foramen magnum and then forms different plexuses like the cardio plexus, etcetera, and innervates everything up to the level of the transfer column and from there down the S2/S3/S4 spinal levels of parasympathetic innervation provide.

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So once again, the neurofunctional blueprint, first blueprint, is determined by the relationship between the problem however we want to define it, structurally, topographically or functionally, and the spinal segments associated with the problem. This is the first level. So let’s paint here once again a [transfer scat] of the spinal cord and a spinal nerve which we can’t include there but I’ll do a dorsal root ganglion. This would be the anterior root, posterior root. And this would be the spinal nerve and then the anterior and posterior divisions of the spinal nerve. There it is. So this would be spinal nerve anterior and posterior division. So we are talking about this relationship, the segment, and this relationship the anterior rami forming peripheral nerves and the posterior rami just innervating the paravertebral musculature. So going back to your first category of neurofunctional blueprint, all problems have a segmental dimension that’s reachable through anterior and posterior primary rami, peripheral nerves and posterior rami. And this posterior rami at the segmental somatic and the segmental autonomic, particularly the reflex vascular sympathetic level. And then the rest of the relationship between a problem and the nervous system has to be independent of the segments, independent of the topography, extrasegmental. So still, we can put needles in areas that are not directly related neurologically to the problem but that are going to have certain effect on the central nervous system that is going to be beneficial. What could this effect be? Well, we saw how information from C fibers and A delta fibers enter the posterior horn and then continue via several spinal, [aspinall] cerebral pathways all the way to the thalamus. Once it’s reached that level the neurological signals are transformed into neurohumoral impulses and now release of certain substances such as ACTH, adrenal cortical tropic hormone, are released in several spinal fluid and they reach the bloodstream and they have an effect at a distance. So there are neurohumoral effects that reach beyond the brain that have been triggered by the stimulation of a specific segment. This segment doesn’t need to be related to the problem in order to benefit from this mechanism. For instance, two examples from the literature would be group of patients with shoulder pain, they were treated with a needle on the trunk of the common fibularis nerve which is non-segmentally related to this area. If these patients benefited from this stimulation it’s because this nerve took a signal to the central nervous system and from there produce a neurohumoral response that helped modulated the perception of pain associated with nociceptive activation of the shoulder. Same, another group of patients, in this case elbow pain, treated with the same strategy. Stimulation here on the common fibularis nerve and also the treated group experienced benefit. These are extrasegmental relationships and these are extrasegmental inputs that can be also included in a neurofunctional acupuncture blueprint. So at the most basic level, a neurofunctional acupuncture blueprint consist of a combination of segmental and extrasegmental inputs. The extrasegmental input doesn’t need to be there all the time. The segmental input doesn’t need to be there all the time as the two examples I just referred to demonstrate.

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Therefore, the very basic neurofunctional acupuncture blueprint just tell us that you can reach the central nervous system and the supraspinal parts of the central nervous system, the brain, you can reach it through the affected segments or through any other nerve which is testimony of the interrelationship of all the innervated areas of the body and the integration of signals that take place, particularly not just at the spinal cord but at the reticular formation and later on in the centre – in the processing centres of the brain. So now with this basic understanding of global neuro function, we can proceed and discuss in detail what the neurostructural possibilities that are given to us by the neurofunctional model. So the second level of blueprint that I like to present to you today refers to which structures that are innervated and are related to the problem can be addressed by the acupuncture needles and the electricity. So I call that neurostructural related substrates or relevant innervated structures. And here we have a rich array of structures that we can call upon and that they are all the basic structures that form the musculoskeletal system, better depicted by this beautiful drawing where we see the representation of the joint here represented by this combination of humoral, ulnar humoral joint, and the prime movers such as this idealized, you know, biceps brachii with antagonistic muscle depicted as well, these triceps, and all the neurovascular bundles. It’s not a precise anatomical depiction. It’s just a representation of the elements that form the neuro musculoskeletal system which is the basis of the organ that allows us to produce movement as output. So let’s go one by one and review the categories of neurostructural substrates. The first one, the joints, are diverse. You can reach the nervous system related to the joint via the capsule as represented here, number 15 – number 14, I believe. Number 14. You can reach by stimulating a ligament or by inserting a needle into the capsule, an intra-articular insertion. Also you can if you know where they are, stimulate directly an articular nerve such as this one represented here by this branch. So the joint is reachable by capsules, ligaments or articular nerves and these are all part of the general blueprint. The muscle tendon is so richly innervated by – particularly by myelinated nerves that in an encapsulated particular structure such as the muscle spindles here represented, such as the Golgi tendon organs here represented, such as the Pacinian corpuscles or other [mechanical] receptors that are abundant along the tendon at the tendon periosteal attachment and on the fascia that anchors the muscle tissue to the interstitial tissues. So how can we reach the muscle tendon unit? We have a variety of avenues. We can go to the motor nerves directly. It’s been represented here, I believe, by either the motor point here. Number one is the motor point. Or if we follow later on the motor nerve is represented somewhere like here. You can put also needles in the belly of the muscle which is where the concentration, highest concentration of muscles spindles occur, and that will have definitely a positive effect as we discussed on the diagram that I’m going to put back so we’re aware of the segmental mechanisms that myelinated fibers trigger with the pre

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synaptic inhibition of nociceptive fibers via secretion of GABA. That’s one of the mechanisms in addition to facilitate the segmental motor function. So apart from the motor nerves and the motor points and the spindles in the belly, we can go to the muscle tendon junction where we have the Golgi tendon organs which also are coupled, function with the control, motor control of the antagonistic muscles, same with the spindles. So the agonist, antagonist play necessary for the coordination of movement takes place at the spinal segment. Once again, we go back time and again to the concept that the spinal segment is the natural regulator of afferent, efferent information, in this case sensory afferent and motor efferent not just to a given muscle but also between agonist, antagonist synergistic stabilizers, etcetera. In addition, we can go to the tenoperiosteal attachment such as here, number eight, where we have a variety of receptors, [vagal] receptors as well as sympathetic fibers that are in the periosteum associated with the vessels of the periosteum. We can as well sometimes go to abnormal areas of neurological hyperactivity called trigger points represented here by this red area that oftentimes correspond to motor points but not always. These trigger points can also be bands, taut bands, not just a specific point. And sometimes can be physically perceived as fibrous tissue or hypertonic tissue. We can also go to miscellaneous [vagal] receptors. So the muscle is – and the muscle tendon one of the if not the most available access to the central nervous system by the acupuncture needles and that’s why there’s such a variety of insertion sites within this structure. And this is important part of our neurofunctional blueprint. So we can talk to the joints, talk to the muscles or go directly to the peripheral nerve trunks which is the summary of all of the above. So depending on which nerve we go, an articular nerve or a motor nerve, we will have an influence on the whole segment. The same applies to the nerves that accompany vessels like here which is a common occurrence, neurovascular bundles, artery, nerve and vein or veins. And important neurofunctional bundles are well known from antiquity to be excellent stimulation sites for modulation of pain. In addition, we have soft tissue interfaces as a miscellaneous category that also in our neurofunctional blueprint gives us preferential access to the nervous system. For instance, abnormal tissue such as tears or later on scars can be the target of the acupuncture needles. The area between adjacent muscles such as these four needles in this fascial plane where adhesions may take place, where biochemical changes may take place as well as on other fascia surface – superficial fascia or deeper fascia and adjacent overlapping muscles that change direction and then may suffer adhesions in between. So we have a miscellaneous category of soft tissues that we can also include in our neurofunctional blueprint and not just – important to mention not just material structure but also just targeting the biochemical environment is important. Biomechanical environment sometimes changes when prolonged irritation of a C fiber triggers the well-known phenomenon of neurogenic inflammation that produces plasma extravasation and the accumulation of

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abnormal substances in the vicinity of the nerve creating a bad biochemical environment that prevents the proper function of the nerve and also with changes metabolically at the tissue level. This is what we call trophic changes and can be easily seen in many cases of chronic neck pain, shoulder pain, upper extremity pain. This accumulation of bad tissue on the C7/T1 vertebrae that can be palpitated. Well, that could be the target also of the acupuncture needles with the goal of changing the chemical environment which has been proven in research that is an immediate consequence of needling. As soon as the needle enters the tissue there is a disturbance of the existent biochemical milieu with immediate changes in an array of substances from substance P, vascular active intestinal peptide, the local cytokines, certain interleukins, tumor necrosis factor alpha, etcetera. And this is a wonderful category of insertions on the neurofunctional blueprint. So summarizing, we have so far two general categories of blueprints. One that refers simply to the relationship between the problem and the nervous system. So segmental inputs or extrasegmental inputs. And within the segmental inputs relationship that’s direct with the tissue via peripheral nerves, peripheral segmental inputs, or that’s indirect by going to the segment associated with the tissue stimulating the posterior primary rami at that level either at the segmental somatic level, dermatomal, myotomal and sclerotomal [unintelligible 00:47:48] or going to the origin of the vascular sympathetic supply of innervation of the vessels of that area. So this is the first blueprint. Second blueprint is neurostructural and now refers beautifully summarized in this diagram – refers to the ability to reach the segment and to reach certain areas of the muscular – neuro musculoskeletal system by going to specifically innervated areas, many of which supplied by encapsulated receptors and thick myelinated fibers that have preferential processing at the spinal cord including miscellaneous soft tissue inputs that are going to add the ability to influence local metabolic and biochemical phenomena, not just segmental modulation. So we have the ability to produce local changes as well as segmental and supraspinal changes. [End of recorded material 00:49:07]

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2. Inputs and Approaches Section I. Neurosegmental (00:06:06) On the first category of blueprints the simple one that reflects the relationship between the problem and the spinal cord, we can extend the blueprint to a structural functional classification of inputs according to where the needles are going to be inserted. And the first category of that general blueprint is what we call local inputs. Anything that is locally related to the problem and it doesn’t matter if we define this relationship as purely structural or topographic. There’s pain perceived over a certain area even if there is no demonstrable structural damage there. Or it simply is a territory supplied by a given nerve and the problems is on this nerve and not on the territory as it could have been with compression or rotation of the sciatic nerve and then pain will occur down the S1/S2 segments. So the first category of inputs is local inputs or peripheral segmental inputs. The second category as we explain will be to stimulate the paravertebral musculature, the posterior primary rami between C1 and the coccygeal nerve. If we try to stimulate the same segment as the dermatomal, myotomal, sclerotomal levels of the problem. If on the other hand what we’ve tried to do is to stimulate the sympathetic nervous system indirectly by going to the segment that contains the preganglionic sympathetic neurons of the vascular network that supplies that, then we can use this so-called vascular sympathetic homunculus where we can see represented from T1 to L2 the totality of the body and where we can see that to have an effect on the head, neck, upper extremities we should stimulate T1 to T5 to have an effect on the trunk, T6 to T9 to have an effect on the lower extremities, pelvic girdle, lower back, T10 to L2. This is extremely important, this sympathetic homunculus because oftentimes the control of the vasomotor tone is the determinate. So if we only go to the segmental somatic level, let’s say we have an elbow problem and we go to the C6 level and we omit the T3 level where oftentimes is the actual problem, we will not modulate the activity of these neurons and therefore we will not modulate the vasomotor tone and we will not change the environment and we will not promote healing. So again, we have a second category of axial inputs which can be subdivided in segmental somatic and segmental reflex vascular sympathetic which would be these levels. In addition, if we were treating viscera we would have to use the visceral homunculus which has different levels for different organs which we’re not going to discuss. I just want to point out that there’s another reflex visceral sympathetic level and then another one not represented here that will include the S2/S4 sacral levels of paravertebral innervation of the lower viscera as well as the levels of the innervation of the vagus nerve. Between T1 and T12, the supracostal nerve, the anterior rami don’t form independent nerves and we can stimulate if we wish directly these nerves at the intercostal spaces, mostly for local purposes.

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information, in this case sensory afferent and motor efferent not just to a given muscle but also between agonist, antagonist synergistic stabilizers, etcetera. In addition, we go to the tendon periosteal attachment such as here, number eight, where we have a variety of receptors, many receptors as well as sympathetic fibers that are in the periosteum associated with the vessels of the periosteum. We can as well sometimes go to abnormal areas of neurological hyperactivity called trigger points represented here by this red area that oftentimes correspond to motor points but not always. These trigger points can also be bands, taut bands, not just a specific point and sometimes can be physically perceived as fibrous tissue or hypertonic tissues. We can also go to miscellaneous mechanoreceptors. So the muscle is – and the muscle tendon one of the if not the most available access to the central nervous system by the acupuncture needles and that’s why there’s such a variety of insertion sites within this structure and this is important of our neurofunctional blueprint. So we can talk to the joints, talk to the muscles or directly to the peripheral nerve trunks which is the summary of all of the above so depending on which nerve we go, an articular nerve or a motor nerve, we will have an influence on the whole segment. The same applies to the nerves that accompany vessels like here which is a common occurrence, neurovascular bundles, artery, nerve and vein or veins. And important neurofunctional bundles are well known from antiquity to be excellent stimulation sites for modulation of pain. In addition, we have soft tissue interfaces as a miscellaneous category that also in our neurofunctional blueprint gives us preferential access to the nervous system. For instance, abnormal tissue such as tears or later on scars can be the target of the acupuncture needles. The area between adjacent muscles such as these four needle sin this fascial plane where adhesions might take place, where biochemical changes might take place as well as on other fascia surface – superficial fascia or deeper fascia and adjacent overlapping muscles that change direction and then may suffer adhesions in between. So we have a miscellaneous category of soft tissues that we can also include in our neurofunctional blueprint and not just – important to mention. Not just material structure but also just targeting the biochemical environment is important. Biochemical environments sometimes changes when prolonged irritation of a C fiber triggers the well-known phenomenon of neurogenic inflammation that produces plasma extravasation and the accumulation of abnormal substances in the vicinity of the nerve creating a bad biochemical environment that prevents the proper function of the nerve. And also with changes metabolically at the tissue level. This is what we call trophic changes and can be easily seen in many cases of chronic neck pain, shoulder pain, upper extremity pain. This accumulation of bad tissue on the C7/T1 vertebrae that can be palpated. Well, that could be the target also of the acupuncture needles with a goal of changing the chemical environment which has been proven in research that is an immediate consequence of needling. As soon as the needle enters the tissue there is a disturbance of the existent biochemical milieu with immediate changes in an array of substances from substance P, vasoactive intestinal peptide, the local cytokines, certain interleukins, tumour and the [crosses] factor alpha, etcetera. And this is a wonderful category of insertions on the neurofunctional blueprint.

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2. Inputs and Approaches Section II. Neurostructural (00:10:31) We can proceed and discuss in detail what the neurostructural possibilities that are given to us by the neurofunctional model. So the second level of blueprint that I’d like to present to you today refers to which structures that are innervated and are related to the problem can be addressed by the acupuncture needles and the electricity. So I call that neurostructural related substrates or relevant innervated structures. And here we have a rich array of structures that we can call upon and that they are all the basic structures that form the musculoskeletal system, better depicted by this beautiful drawing where we see the representation of the join here represented by this combination of humoral, ulna humoral joint, and the prime movers such as this idealized, you know, biceps brachii with antagonistic muscle depicted as well, these triceps, and all the neurovascular bundles. It’s not a precise and anatomical depiction. It’s just a representation of the elements that form the neuro musculoskeletal system which is the basis of the organ that allows us to produce movement as output. So let’s go one by one and review the categories of neurostructural substrates. The first one, the joints, are diverse. You can reach the nervous system related to the joint via the capsule as represented here, number 15 – number 14, I believe. Number 14. You can reach by stimulating a ligament or by inserting the needle into the capsule, an intraarticular insertion. Also you can, if you know where they are, stimulate directly an articular nerve such as this one represented her by this branch. So the join is reachable by capsules, ligaments or articular nerves and these are all part of the general blueprint. The muscle tendon is so richly innervated by – particularly by myelinated nerves that end in encapsulated particular structures such as the muscle spindles here represented, such as the Golgi tendon organs here represented, such as the Pacinian corpuscles or other mechanical receptors that are abundant along the tendon at the tendon periosteal attachment and on the fascia that anchors the muscle tissue to the interstitial tissues. So how can we reach the muscle tendon unit? We have a variety of avenues. We can go to the motor nerves directly. It’s been represented here, I believe, by either the motor point here. Number one is the motor point. Or if we follow later on the motor nerve is represented somewhere like here. You can put also needles in the belly of the muscle which is where the concentration – highest concentration of muscle spindles occur and that will have definitely a positive effect as we discussed on the diagram that I’m going to put back so we’re aware of the segmental mechanisms that myelinated fibers trigger with the presynaptic inhibition of nociceptive fibers via secretion of gaba. That’s one of the mechanisms in addition to facilitate the segmental motor function. So apart from the motor nerves and the motor points and the spindles in the belly we can go to the muscle tendon junction where we have the Golgi tendon organs which also are couple – function with control, motor control of the antagonistic muscles, same with the spindles. So the agonist, antagonist play necessary for the coordination of movement takes place at the spinal segment. Once again, we go back time and again to the concept that the spinal segment is the natural regulator of afferent, efferent

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information, in this case sensory afferent and motor efferent not just to a given muscle but also between agonist, antagonist synergistic stabilizers, etcetera. In addition, we go to the tendon periosteal attachment such as here, number eight, where we have a variety of receptors, many receptors as well as sympathetic fibers that are in the periosteum associated with the vessels of the periosteum. We can as well sometimes go to abnormal areas of neurological hyperactivity called trigger points represented here by this red area that oftentimes correspond to motor points but not always. These trigger points can also be bands, taut bands, not just a specific point and sometimes can be physically perceived as fibrous tissue or hypertonic tissues. We can also go to miscellaneous mechanoreceptors. So the muscle is – and the muscle tendon one of the if not the most available access to the central nervous system by the acupuncture needles and that’s why there’s such a variety of insertion sites within this structure and this is important of our neurofunctional blueprint. So we can talk to the joints, talk to the muscles or directly to the peripheral nerve trunks which is the summary of all of the above so depending on which nerve we go, an articular nerve or a motor nerve, we will have an influence on the whole segment. The same applies to the nerves that accompany vessels like here which is a common occurrence, neurovascular bundles, artery, nerve and vein or veins. And important neurofunctional bundles are well known from antiquity to be excellent stimulation sites for modulation of pain. In addition, we have soft tissue interfaces as a miscellaneous category that also in our neurofunctional blueprint gives us preferential access to the nervous system. For instance, abnormal tissue such as tears or later on scars can be the target of the acupuncture needles. The area between adjacent muscles such as these four needle sin this fascial plane where adhesions might take place, where biochemical changes might take place as well as on other fascia surface – superficial fascia or deeper fascia and adjacent overlapping muscles that change direction and then may suffer adhesions in between. So we have a miscellaneous category of soft tissues that we can also include in our neurofunctional blueprint and not just – important to mention. Not just material structure but also just targeting the biochemical environment is important. Biochemical environments sometimes changes when prolonged irritation of a C fiber triggers the well-known phenomenon of neurogenic inflammation that produces plasma extravasation and the accumulation of abnormal substances in the vicinity of the nerve creating a bad biochemical environment that prevents the proper function of the nerve. And also with changes metabolically at the tissue level. This is what we call trophic changes and can be easily seen in many cases of chronic neck pain, shoulder pain, upper extremity pain. This accumulation of bad tissue on the C7/T1 vertebrae that can be palpated. Well, that could be the target also of the acupuncture needles with a goal of changing the chemical environment which has been proven in research that is an immediate consequence of needling. As soon as the needle enters the tissue there is a disturbance of the existent biochemical milieu with immediate changes in an array of substances from substance P, vasoactive intestinal peptide, the local cytokines, certain interleukins, tumour and the [crosses] factor alpha, etcetera. And this is a wonderful category of insertions on the neurofunctional blueprint.

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2. Inputs and Approaches Section III. Neurobiomechanical (00:05:14) We reviewed in detail the neurostructural dimensions of possible local insertion sites, mostly of – most these insertions are used to the regulation of nerves that are association with the problem. But we have a third and very important blueprint or a strategy that consists of going to the neuro biomechanical level. And this neurofunctional biomechanically related structures. So now not only we have the ability to select a structure for its direct relationship with relevant nerves or relevant spinal segments, now we can do the same but with a biomechanical criteria. Since the neuro musculoskeletal system operates as a unit or at least operates as a set of supra units like the upper extremity, the girdles, the lower extremity, there are neuro musculoskeletal tissues that work in action together. For instance, joins along the same kinetic chains is a good strategy and is a third blueprint to include distal and proximal joints. If someone presents with an elbow problem or a knee problem it’s been sufficiently demonstrated that most of the time the primary problem is not the intermediate join in the extremity which architecturally has quite a restricted range of possibilities and is there just to transfer movement in a specific manner. Therefore, when you have a knee problem or an elbow problem most of the time the distal and the proximal articular segments are at the core of the problem. Particularly for patella femoral pain problem, research has proven now that hip treatment produces the best results, not treatment of the alignment of the patella, the tracking the patella or even the motor activity of the vastus medialis. It’s the hip. Once the hip problem is treated, the knee disappeared – the pain in the knee disappears. So very important concept as well as the muscles. The muscles operate not in individualities but as at the minimum a group of muscles with related functions, definitely agonist and antagonist, operates in a coordinated manner. All muscles requites stabilization so there is stabilizer muscles. Many muscles are supported by synergistics, by the action of synergistics, and then we have kinetic chain or equivalent contemporary concepts such as the anatomy trains or the myofascial chain or the myotatic unit all indicating that beyond a single muscle we – and beyond a single nerve there is cooperation among adjacent segments because obviously most of these muscles oftentimes are supplied by adjacent segments so C5/C6/C7 for the muscles of the shoulder. However, there are exceptions around the pelvic girdle where you can find something that is an L2/L3/L4 operating with an L5/S1/S2 and that is a fair amount of difference in the segments. So the muscles need to be included as well as the joints that are not directly related to the problem but are biomechanically related. And the same with peripheral nerves that for whatever reason are connected with the problem area whether at the somatic level or at the sympathetic level. And that would include, for instance, treatment of the scalene when these muscles are impingent on the roots of the brachial plexus and they’re segmentally related with the part that now is affected by that compression and that neuro dysfunction but they need to be included because they are connected. In this case it’s a non-segmental connection. Examples of segmental connection would involve paravertebral muscle, muscles that are at the somatic level or the sympathetic level. So

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you need to treat the cervical segments when there are associated problems of the shoulder or upper extremity the same way that you need to treat the thoracolumbar junction when there are associated problems of the lower extremity. [End of recorded material 00:05:14]

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2. Inputs and Approaches Section IV. Segmental Analysis (00:07:57) A problem can be analysed segmentally in three different dimensions. We can have a problem defined solely by the dysfunction that – the movement dysfunction. So we can have a problem. This is segmental analysis, important for the application, proper application of the neurofunctional blueprints. So the segmental analysis of the problem will have three levels. We’ll have one dimension that is purely functional defined by movement, for instance no pain by movement. So which movement is impaired? Which joint or joints are involved? Which muscles are in charge of those movements and which peripheral nerves supply those muscles? So with a simple analysis of movement dysfunction, for instance shoulder abduction we can quickly determine which joint. Well, in this case the glenohumeral joint together with the acromioclavicular and the scapular thoracic and which muscles we can define, the deltoid. We can define the supraspinatus, the stabilize of the scapula and which nerves, the axillary nerve for the deltoid, the suprascapular for the supraspinatus and the serratus interior for the scapula and the dorsal scapula nerve, etcetera. So with a simple functional analysis we can already come up with a number of peripheral nerves which immediately will translate in a number of options whether we go directly to the nerve or we go to the muscles that we just mentioned or to the joints that we just mentioned. This is a functional – the first analysis, segmental analysis is functional and it gives us peripheral nerve. But the peripheral nerves also come from segments. So it gives us immediately a segmental level. A segmental somatic and a segmental sympathetic – vascular sympathetic because we know which dermatomal, myotomal, sclerotomal supplies this nerve supply and we also know which vessels are supplying these joints and these muscles. So we can just – analyzing functionally without knowing anything about the state of the structures, we can select local inputs, peripheral segmental inputs, and we can select posterior primary rami. We can select axial inputs associates with the two levels, segmental somatic, segmental autonomic or reflex vascular sympathetic. That is the first level of segmental analysis. The second level of segmental analysis is a pure topographic analysis. Topographic analysis in pain problems is simply which cutaneous nerve and/or which dermal are involved in the pain perception. Whether this is accurate from the structural standpoint or not it’s irrelevant. It’s another way of analysing segmentally and then we will put together all the analysis, the functional analysis, the topographic which again allows us to select a peripheral, segmental or local input and an axial segmental, spinal segmental, other segmental, somatic. And finally, we have a third segmental analysis which is a structural. Now it’s not neurostructural. Now it’s [unintelligible 00:04:43] whenever it’s possible and whenever there is a structure that we can identify as the origin of the nociception. So this is going to give us again a peripheral nerve and an associated spinal segment. -1-

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So these three, this triple approach, functional, topographical and structural can serve the neurofunctional acupuncture practitioner to define specifically the inputs used in this blueprint. And the end of each analysis we have a peripheral segmental input and a spinal segmental input. And if we do this analysis with every single problem we’ll see that oftentimes each analysis overlaps. So in the case of this patient with the problem of the shoulder that I just described, at the functional level we determined that segments C4/C5/C6 were involved. We determined peripheral nerves, axillary, suprascapular. Let’s put them here. Axillary, suprascapular and dorsal scapular, long thoracic and a few others. Anyway, and C4/C5/C6 predominant. If we do a topographic analysis that individual may have pain anteriorly, posteriorly or over the shoulder. That is going to be a C4 and it’s going to be a supraclavicular nerve involvement. So that’s a little addition but it’s still overlapping our analysis and the dermatomal level C4. And structurally no matter what, we palpate there we are going to find that it is either a C4/C5 or C6 and we’re going to see well there is the joint, the glenohumeral joint, the capsule, the tendon of the biceps, the tendon synovia. The innervation again is going to come via these peripheral nerves, maybe the muscular cutaneous as well. So no matter how we analyse the problem functionally, topographically or structurally, we are going to be able to generate similar inputs at the both peripheral segmental level and at the spinal segmental level. And now it’s a matter of refining the analysis of each particular problem to arrive at a more precise blueprint and this is what we’ll do in the following segments. [End of recorded material 00:07:57]

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3. Acute Injuries (00:25:04) In this segment we’re going to talk about the neurofunctional acupuncture blueprint for the treatment of acute injuries. One of the most rewarding experiences for a practitioner is to deal with an acute injury because in this particular instance we are just there with nature cooperating in the naturally occurring mechanisms that will lead to the repair of the tissue. Therefore, the first blueprint is to remember the flow of events on the socalled tissue model where we have an acute inflammatory phase that occurs as soon as the injury takes place and that lasts a variable 72 hours or up to a few more days. Almost immediately following the injury there is an activation of numerous cellular processes all of which can be termed proliferation phase which is going to go to the five day mark and it’s going to transition the inflammation into a repairing and cleaning of the area. And finally there is a process that starts shortly after proliferation started producing the new materials to repair the tissue which will go now all the way to many, many months which is the remodelling. Remodelling can take up to 18 months. Eighteen months as it’s been researched with patients after anterior cruciate ligament reconstruction surgeries. This is the inflammatory phase, inflammation. And the green one is proliferation. So this is important to know when we get the injury where we – how can we best support nature. And in a normal course of action, the injury should result in a repairing which functionally should be adequate although structurally the repairing will never be the same. As you know, collagen based tissues can be repaired but they cannot be replicated. The new tissue is called scar tissue and scar tissue has different structural aspect and mechanical properties and one of the goals of the treatment is to minimize the formation of scar tissue so the scar tissue is just necessary to produce the bridging between the disturbed – the disrupt parts and also to promote the proper remodelling of this collagen. So let’s see once we have clarity on the underlying processes that nature set up – sets up after an injury how can we best support the body. So let’s start with a blueprint which will be very, very simple and effective. In a semi schematic we have here a nicely modelled figure. I’m just going to create a semi schematic figure. A ribcage here, a spinal cord, pelvic girdle and the extremities. And we don’t have a lot of room so I’m going to put the arms bent. And here definitely we don’t have much room for the feet but we’re going to take some artistic licence and draw them anyway. So no matter where the injury occurred … And I’m going to prepare the model for some of the inputs that we’re going to use. So wherever the injury occurs and we’re going to use the example of a limb, maybe an elbow injury, maybe a hip injury or any other, maybe a knee injury. It can be even a low back strain or a neck or a fracture. So regardless of where the injury is the first goal in our blueprint, the number one goal is to modulate sympathetic activity because the occurrence of the injury triggers and alarm reaction that is like the fight or flight response. And the first thing we need to do is to tone down that hyperactivity which is going to amplify, magnify whichever nociception is coming from this area to the brain. Obviously all these areas will be sending messages to the brain, to the spinal cord, and our goal is to tone down the

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general state of arousal of the central nervous system by toning down the sympathetic nervous system. How can we accomplish that? Well, we can accomplish that using several strategies. So first goal is to decrease sympathetic activity. And we can accomplish that by putting a needle on the ear. That would be one of the first strategies. This will trigger the release of central endorphins and we have two preferential areas, one is the trigeminal nerve or fifth cranial nerve territory. The other is the concha which is the territory of the tenth cranial nerve or vagus. So no need to be highly specific. Just going to these areas is going to help tone down. A very good and first – that would be the very first insertion site to tone down central sympathetic activity which has research to support it is this traditional point here between the nose and the upper lip called the philtrum. So this is the classical insertion site, Governing Vessel 26 or Du Mai 26. And in animal models it was demonstrated that the stimulation of this point produces stabilization of the system that allowed these animals and their – whatever stress the experimenters causing them, it may be the suppression of breathing by clamping the trachea or something similar and the group of animals where the Governing Vessel 26 was assimilated, they were able to maintain their vital constance for much longer. So it can be considered a resuscitation point or an emergency stabilization point and this would be the number strategy. It doesn’t need to be done with a needle, it can be done with a finger, with a nail. It can be done with a sharp object. And it can be used in instances of vasovagal reactions as well as in any acute pain due to an injury state or even an acute pain of any kind. This plus the ear, that would be an excellent first line of action to modulate sympathetic and central activity. Another not as powerful but also utilized strategy by some is a needle on top of the head on the traditional Governing Vessel 20 on the area between the two [interparietal sutures] and in the area of the transition between the top of the head and the posterior aspect of the head. Governing Vessel 20 which also there’s research with magnets showing beneficial effects on the serotonergic pathways and definitely worthwhile, very simple to perform and not painful at all. So general central sympathetic modulation would be the first goal. How can we also expand that goal and number two would be the same goal but now regional. Now we want to decrease sympathetic tone regionally. Why? Because the shock, the state of shock of the vascular system requires some intervention. Of course we can use ice. Still a valuable, very good physical mean to facilitate modulation of local nociceptors and well as produce vessel constriction. But if all you have is needles we can also do the same, attempt the same with needles. And the strategy here is to use one of the distal insertion sites that has proven to have the ability of modulate the regional sympathetic activity such as liver three on the foot or large intestine four on the head, better represented in our diagram here. So we can use large intestine four on the head, liver three on the foot and leave them there by themselves or add something of a category of extrasegmental inputs that have proven to be valuable to modulate central activity such as the insertion site on the common fibular nerve that corresponds to the traditional gallbladder 34.

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So whether the injury has taken place on the lower or the upper extremity this is an extrasegmental input. So we can add number three, something extrasegmental. Also the first insertions were extrasegmental to the problem. So this is a difference between acute, sub-acute and chronic where the acute, yes, we’re going to do something locally but we’re going to use broad array of strategies to reach the central nervous system in an extrasegmental fashion whether the ear input, the Governing Vessel 26 or Governing Vessel 20 or the extrasegmental input gallbladder 34. In addition to the distal point on the extremity. Better if using the extremity of the injury. And then we can even add electrical stimulation to these needles because they are not directly over the injury area and we can connect this too at a frequency of one to 4Hz that is going to produce a supraspinal neurohumoral modulation of pain perception as well as a delay response neuroendocrine that will help facilitate the modulation of the activity of the adrenal gland and the subsequent normalization of the cortisone secretion. All this delayed response will add to the acute effects, neurological effects that we’re going to trigger. So we’ve produced central sympathetic modulation. We’ve produced regional sympathetic modulation. We’ve added something extrasegmental. And now locally what can we do, what should we do? Well, there are a couple of strategies that we can combine. The first one is a very old strategy and we just rename it in a more contemporary language and I would call this a contention approach because the idea is to contain the cellular processes so the effects of the injury don’t spread further than necessary. So this contention approach is a simple inserting the needles in healthy tissue. So that is the only condition. This tissue needs to be healthy. Healthy doesn’t mean that cannot be edematous or with a hematoma because the blood doesn’t make the tissue unhealthy. You can put needles through a hematoma provided you understand that underneath there is healthy tissue and that the tear is elsewhere. This contention approach just needs to be surrounding the unhealthy tissue as close as possible but always staying in healthy tissue. As the healing progresses the needles can be progressively approached to the scar area. And that seems to facilitate local cellular mechanisms and this seems to – this contention approach seems to work not only for acute injuries but also for some other processes such as some skin problems where putting the needles has some sort of local cellular effect that facilitates the metabolic processes and facilitates fighting whatever phenomena are occurring there. So contention approach very valuable and obviously no electricity used for several days because the tissue already is hyperactive and the only goal is to calm down what’s going on here, not to add more. However, we can use electricity and we use electricity very effectively distally at the systemic – at the regional sympathetic points but also distal or proximal nerve tracts that are associated with the affected area. So if we have the knee here, we have the femoral nerve. We can include a femoral nerve stimulation at the inguinal region at the classical spleen 12. We can go to the saphenous nerve as distal as the medial aspect of the patella crual region and, you know, stimulating other things. And we can pass electricity here at one to 4Hz and that would be beneficial for anything that’s in between. Following the rule of no pain this is extremely safe. It’s not going to irritate what is in the middle. And we do that with all sorts of different injuries, articular injuries or muscle injuries as I have represented here. -3-

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For instance, strain on the back. We can put needles above, on the segments above and we can do the same on the same ones below and we don’t need to go to the area that’s sore, hypertonic or there’s a high discomfort getting there. So nerve [trunk] above nerve – distally nerve [trunk] approximately with or without electricity. That’s an excellent strategy. And finally, we can complement this or substitute sometimes. Let’s say there’s a fracture. Now we have a fracture that requires fixation and requires a cast. So now we have no access to the area. Well, we can always reach the segment, the spinal segment going to the contralateral side to the relevant nerves that are going to tell that spinal segment that there’s no need to keep the area under extreme neurological activity because now things are under control. And that is going to contribute to the normalization of the traffic, afferent, efferent traffic at the segment which is at the core of preventing many problems such as ankyloses, such as arthrofibrosis or other problems that happen when we have immobilization on one body part. So going to the contralateral healthy side whether we were able to put something on the affected side or not is by itself an extremely valuable strategy. So summarizing: When we have an acute injury we have a number of strategies at our disposal and I’ll start with the diagram. We have the ability to tone down central sympathetic tone by stimulating specific insertion sites along the midline which is rich in anastomosis. So this area is very rich in sympathetic innervation as well as cranial nerves of such value like the trigeminal and the vagus nerve. So this GV20, GV26, shaman point in the concha, that is very, very valuable as a strategy to modulate central sympathetic activity. Number two: Modulate regional sympathetic activity. Now we want the limb, the affected limb or the area to normalize vasomotor tone. For that we choose the distal arterial and then work because that’s where we have best access to the sympathetic nervous system unless the injury is right there of course. And those distal points can be combined or can be mixed with nonspecific extrasegmental inputs that are well known for modulating central activity such as the common fibular nerve at the neck of the fibula, the traditional gallbladder 34. So we can connect some of these stimulation sites and that will produce that regional modulation. In addition, locally we can use a contention approach by inserting needles not very deep into healthy tissue, not necessarily devoid of hematoma or edema but healthy tissue nonetheless. And this strategy will allow us to limit the effects of the extra cellular activity that has been started by the injury. And finally, we can use nerves above and below the injury, healthy nerve trunks that will modulate the segment. Whether we do that on the site of the injury or we do that on the contralateral side when we can’t reach the affected site or we combine both it’s a very valuable strategy. Now, this is our general blueprint and what we do, we evolve the treatment. As the acute emergency situation becomes more of a recovery situation, we don’t need to use this modulation of central sympathetic. We maintain the contention approach for as long as we feel there is extra cellular activity and we refine the selection of relevant nerve trunks and particularly work the kinetic chain and the other blueprint strategies that we’ve described elsewhere. -4-

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Some of you may ask well, how about segmental input, inputs going to the posterior rami at the relevant somatic or reflex sympathetic vascular levels and the answer is it’s possible to add this. If the problem is neck or back definitely we will use that, but for extremities it doesn’t seem to add in the first sessions any additional value. And the reason may be that the nervous system is enough stimulated with the injury plus all the other inputs and the posterior rami do not seem to be of much – as much value as in sub-acute and chronic conditions. However, it can always be done at a later time once we’ve toned down that first sympathetic tone. So as you can see, in our approach, neurofunctional approach, we’re not trying initially to suppress pain. That is going to happen as the local nociceptors come down and is still bombarding the spinal cord. So that’s the best pain management strategy is to limit the amount of inflammation and to facilitate the proper proliferation and remodelling with three connective tissue motion particularly related to the peripheral nerves that are in the area. The last thing we want after an injury is scars that are disorganized that involve peripheral nerves and that interfere with the neuro biomechanics of the area. That would be the cause of chronic problems that will be much harder to treat at a later time. So this is the goal: Support the naturally occurring mechanisms. Inflammation is good if it’s limited and if followed by proliferation and remodelling of the newly formed collagen based tissues. For other acute situations that are pain related but not injuries, we have elsewhere a different blueprint that will describe that. [End of recorded material 00:25:04]

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4. Lower Extremity Section I. Ankle Sprain (00:31:37) In this segment we are going to review the treatment of a typical injury, ankle sprain. And following the same blueprint that we’ve established for the neurofunctional approach, we are going to target local tissues as well as relevant nerves that supply the affected tissues as well as other relevant levels of the nervous system. In general, our neurofunctional levels consist of peripheral nervous system, spinal segmental level with subdivisions into segmental somatic and segmental autonomic, the innervation of the vessels which is an important dimension in injuries as the vessels with vasoconstrict and we will want a better modulation of the vasomotor tone. And also, we have supraspinal level which for this particular case we are not going to use in general as this is a very structural injury. Then neurostructural dimensions that we typically involve in treatment of this injury include joints, affected joints which in this case will be the talocrural joint between the fibula, the tibia and the talus. We would also include the subtalar joint between the talus and the calcaneus. We may as well have to include the superior tibia fibular joint because the mechanism of the talocrural joint also regulated by the behaviour of the superior tibia fibular joint. And then we may in certain cases have to include the additional midtarsal joints or even more distal depending on the involvement in the injury. We can target the capsules. We can target ligaments which in this case by definition an ankle sprain is a tear or a strain on one or several of the following ligaments; anterior talofibular ligament represented here by this single line, the talocalcaneal, the posterior talofibular ligament as well as this deep ligament represented here, deep to the belly of the extensor hallucis brevis and extensor digitorum brevis and that’s the interosseous talocalcaneal ligament. Actually, the most important ligament in our experience in the treatment of this problem because it’s the one that more often gets missed and the one that has been associated with chronic functional ankle instability. Then we can include muscles and tendons which in this case the main muscle tendon unit would be the peronei, peroneus longus, peroneus brevis or fibularis longus and brevis depending on the year of the nomenclature. But also the extensor brevis of the toes and the big toe, the extensor longus of the same two set of structures. On the other side the tibialis anterior, the tibialis posterior and the muscles that produce the plantar flexion, the flexors of the toes, the flexor of the big toe and the triceps surae, the soleus and gastroc. Within those muscles we have a number of targets that we will discuss elsewhere including the belly, the motor nerve, the motor point, etcetera. We can also target peripheral nerve trunks. Particularly with this nerve trunks are associated with either the joints or the muscles or both. And in this case we have represented here the most commonly associated nerves with a problem which we’re going to target and include from lateral to medial, from posterior to anterior. We have the sural nerve represented here behind the fibula and behind the tendon of the peroneal,

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the peronei. That’s the sural nerve which supplies the lateral skin of the foot. Then we have the medial – intermediate dorsal cutaneous nerve which is a branch of the peroneal – of the fibularis, super – superficial fibularis nerve. And the other branch is the thick one represented here. That’s the medial dorsal cutaneous nerve. So medial and intermediate are both branches of the superficial peroneal nerve. Then the sural nerve laterally and finally the saphenous nerve which supplies the medial aspect of the fact. And there are anastomosis among these nerves and several anatomical variations. These nerves although cutaneous the majority of them, they also provide articular branches and that’s why they’re important. As well as neuropathy has been described after sprains due to neurapraxia and damage of these nerves. Deep to the tendons of the extensor hallucis longus and the extensor digitorum, we have the trunk, the distal part of the deep fibularis nerve which is going to supply the skin on the “V” between the big toe and the second toe but also supplies articular branches for this area, for the talocrural and the midtarsal joints. So in addition, we have motor branches that innervate the anterior – the dorsiflexors and tibialis interior, the extension digitorum longus, the extensor hallucis longus and that’s the deep fibular nerve which we can find here at the level of the fibular neck. And then we have the tibial nerve on the other side that supplies the plantar flexors and that we can address from the medial side. So peripheral nerve trunks, neurovascular bundles and then we have a miscellaneous soft tissue interfaces and [plasminos] associated peripheral nerves that we can involve in the treatment of any soft tissue injury and that includes scars. In this case not applicable. Abnormal biochemical environment. Very applicable in this case because there’s going to be swelling, there’s going to be edema and we want to limit the extension of the damage of that as well as in chronic cases the trophic changes that accompany some of those peripheral nerve neurogenic inflammatory behaviour. And then we have miscellaneous areas related to soft tissue where adjacent planes are not sliding properly or overlapping planes of soft tissue are not moving properly or nerves are passing through osteofibrous tunnel or [unintelligible 00:07:44] and they are irritated at that point. It may happen to the superficial fibularis nerve here on the lateral aspect of the leg distally where the nerve pierces the fascia. So our examination is going to determine which of these categories are applicable and this is what we’re going to do. And finally, at the third level of neurofunctional selection we have biomechanically related structures, particularly kinetic chain or any of the contemporary equivalents of the kinetic chain, the myofascial chain, the myotatic chain, the anatomy trains, any structurally related structure. So joints, distal and proximal joints. So if you have restrictions on the metatarsophalangeal joints that going to affect the metatarsal joints, it’s going to affect the talocrural and the subtalar, the superior tibofibula we mentioned, the rotation of the tibiofemora, etcetera. So joints on the kinetic chain very important. Muscles on the kinetic chain because we may have a deficit on a particular muscle and the problem being the stabilizer proximally or the antagonistic muscle that is excessively hypertonic is a producing a reflex inhibition, etcetera. We have to evaluate the whole kinetic chain as well as any peripheral nerve that’s segmentally connected including those which have an autonomic sympathetic connection which may include nerves that supply viscera and that we can indirectly access through axial inputs. -2-

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We’re going to briefly sketch the treatment plan. As this is a demonstration there’s be no particular value assessing. Needless to say, in a real situation we would be assessing very precisely the involvement of the structures that we just mentioned, the articular involvement, the muscle involvement and the peripheral nerve involvement. Depending on the timing of the treatment, we’ll be focusing more in containing the initial inflammation or promoting better proliferation and definitely trying to have control motion that will provide a better collagen reorganization over time. So without getting into many details, just keeping the general blueprint the goal is to neuro modulate any relevant peripheral nerve pathway that influences what’s happening after the injury. And this involves a first line of work. This is the left side and we have the fibula. We have the talus and we have the calcaneus underneath. And without judging which particular ligament, the anterior talofibular ligament, the talocalcaneal, all the posterior talofibular and the definitely the interosseous talocalcaneal ligament. Without getting into a major discussion on the pathomechanics let’s assume that most sprains affect at least these two and miscellaneous soft tissues associated with the capsule or capsules of these joints. So the first thing we’re going to see is a edema surrounding these areas depending on the timing. And the first approach that we’re going to follow is a containment approach. It’s a simple technique where we will insert needles on healthy tissues surrounding the injured tissue and if possible the insertion sites should have neurofunctional significance. Meaning we can simultaneously stimulate local tissue activity as well as we can simultaneously send signals through relevant nerves and that will give us more than one physiological response. So if we were treat this case and the injury had involved interior talofibular and the interosseous talocalcaneal and this was already several days older, we could put still some needles surrounding the edema. There is no representation of that. But we could select any appropriate insertion site. Whether it coincides with a classic acupuncture point or not is not necessary. We can sural nerve. That would be an appropriate selection and in this case it coincides with a traditional acupuncture point called bladder 60 as you know very well. There it is, bladder 60. This is a little off the most common edematous area but it’s a good anchor and definitely affects one of the main nerves that we want to influence. We can look for spaces left between the tendons and between the different bony surface interfaces and we can go to classical ones again, classic points on the anterior talocrural joint or distally. Let’s choose a point on a soft tissue that’s very easy to identify, the belly of the extensor digitorum brevis and extensor hallucis brevis. This is a commonly seen area of edema and is very close to the access to the sinus tarsi or where the interosseous talocalcaneal ligament is and it’s a very good insertion site to help them pass electricity through these needles or to leave it there just to influence the local cellular activity. Another possible insertion site could be located above or below the tendons of the peronei. In this case depending on the timing, I think if it’s early I would choose an insertion site distal to the lateral malleolus and below the tendon of the peronei and you can that bladder 60 to prime because there’s a classical insertion site here that is called bladder 62 and we can recycle the nomenclature. However, the intention and the target correspond to the sural nerve rather than to a meridian. -3-

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Now we have already three. If it was really, really acute we would need more. We can eventually walk our inputs closer and closer to the injured tissue and eventually our – one of our favourite insertion sites here is going to be gallbladder 40, right, targeting the interosseous talocalcaneal ligament. So I’m going to perform that insertion already which I would hold for several days after the sprain has occurred because we don’t want to irritate possible cellular activity on the area when it’s on the inflammatory period. On the inflammatory period we just surround the area with the needles and then we approximate the needles to the injured site as the inflammatory phase subsides. So now, in addition to just containing the local inflammation we want to affect the vasomotor tone of the area which is best accomplished by involving any of the distal arterial networks that are rich in sympathetic fibers. In this case a major classical acupuncture point right along the dorsal is pedis artery and the distal arterial network here, liver three. This is a very, very good strategy for this and any other acute injury. We do something that has been proven to neuromodulate regionally the activity of the sympathetic nervous system which is going to help normalize the vasomotor tone. And because it’s far from the injury it’s also a great insertion site to connect electricity with something that is proximal to the injured area. In this case one of our most common connections is believe liver three and what we mentioned before, the trunk of the common fibularis nerve or the deep fibularis nerve as it passes by the neck of the fibula. So we go to the neck of the fibula. Here fibular head, fibular neck anteriorly and then this insertion site which corresponds with the classical gallbladder 34 and is proven to have a supraspinal effect is going to be a great couple with liver three to neuromodulate sympathetic activity in the whole territory. So we can connect these two even in the acute stages. I don’t have any hesitation doing this because we are going to use a gentle one or 2Hz stimulation and painless so that shouldn’t affect the inflammatory reaction in a negative way. So I’m going to turn on my stimulator and I may see activity of the peronei if I have connected the – contacted the nerve or I may not see it. In this case it’s not critical. If I really want to see it, I would pursue a re-insertion until I get it. Do you feel that? Is that okay. Male Voice: Yes. So it’s not – we’re not getting motor vehicle. It’s not a problem. We are going to leave the stimulation there just to pass electrons through the area and help the tissues continue with whatever phase, inflammatory phase, proliferation phase the injury is at this moment. Along the same lines we would like to have input on – maybe directly on the peronei or on the antagonistic muscles. The peronei are dorsiflexions, dorsiflexors and [evertors], therefore plantar flexors and invertors such as the tibialis posterior would be an appropriate complement, particularly down the road, to assure that there is a balanced motor activity between the important pronosupinator muscles. As an additional example of how to reach simultaneously these muscles and the peripheral nerves that we described such as the intermediate dorsal cutaneous nerve, we can go exactly four to six finger breadths above the lateral malleolus anterior to the

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fibular and then look for a comfortable insertion site on the belly of the peroneus tertius if that exists or the belly of the extensor digitorum longus. So that’s also an area that is approximately above the gallbladder 39 traditional. We are just looking for comfortable insertion sites that simultaneously modulate activity on muscles and peripheral nerves. Of course palpation is the ultimate judge of what the most appropriate insertion site is and therefore careful palpation of all these nerve branches, careful palpation of these ligaments and careful palpation of the muscles involved is the most important criteria when it comes to decide where to put the needles. Again, as treatment progresses, we would like to see more motor activity. We would like to use more electricity. Let’s do one connection between the insertion site we just performed and an antagonistic insertion here along the tibial nerve. So I’m going to go another four finger breadths above the medial malleolus and I’m going to go posterior to the medial tibial margin. In that case that’s a traditional insertion site, spleen six. But I’m not looking for the traditional site. I’m looking for a target which is the end of the tibialis posterior and oftentimes I expect like now a little motor response. And I could, if I wish to do so, use my monopolar electrical stimulator to ascertain the accuracy of this insertion. So I can just test and see whether there is any motor activity. There. There is motor activity. We can see eversion so that is fibularis brevis or it could even be peroneus tertius which is an additional inconstant muscle that is associated with extensor digitorum. And then I can try the – I see that I got a little bit of the flexor digitorum which confirms that I have the two nerves that I wished to target, the deep fibularis nerve and the tibial nerve. So that’s a perfect example of how to cover the neurological territory that we desired. It doesn’t need to be more specific than this because this sites are going to send messages to the spinal cord that going to help normalize activity in the segments associated with the kinetic chain of the – from the knee to the tip of the toes. Let’s turn this stimulator on. We may see a little bit of movement. Again, it’s not necessary to have a lot. I can see a little bit of flexion. It’s enough. At this point recapping, what’s important is that we are covering all the relevant neurofunctional and neurostructural territory. And then additional input will have to do with the particulars of the injury, how it took place and what specific soft tissue interfaces may have affected. If we want to go to the talocrural joint we can do so in a very good manner. Between the tendons of the extensor, hallucis longus and the extensor digitorum. At that level the talocrural joint is very accessible and in the depth of that insertion site we have the trunk of the deep fibularis nerve. Also, we are affecting the capsule of the talocrural joint. This is a very good way of normalizing activity on this particular articular territory. So this one, talocrural joint and deep fibularis nerve plus –which is the traditional stomach 41 plus gallbladder 40 which targets the interosseous talocalcaneal ligament, the most commonly associated ligament with chronic functional ankle instability as I mentioned. And the miscellaneous insertions that target the other structures. We could at other time or after the first part of the treatment put our subject on the prone position and then target the tibial nerve from the popliteal fasso. Perhaps being more specific targeting the plantar flexors if we feel that there is a deficit there. And we -5-

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could in chronic conditions do a so-called axial input where we would target the lower part. So the relevant segments at the somatic level are L4/L5/S1. So those segments would be in the lower back of the back being it’s usually L4 and this being the sacrum. Okay? And then we could target the segmental vascular sympathetic level which coincides with the T10/L2, thoracolumbar junction. And the way we would do it is by putting a couple of needles on each side. We cross them and clip with the same alligator of the electro stimulator. So this would be the segmental vascular sympathetic reflex area, T10/L2. And the L4 to S1 would be there and we could do the same here, one needle, one needle, one needle. And this would be the segmental somatic area, reflex area, because these levels are the one that innervate the somatic structures, thermatomal, myotomal, sclerotomal on the area. We would connect this at a low frequency. So we can connect this negative to positive and here negative to positive or in any other fashion. And this input would be the socalled – that would be the spinal segmental input or axial for short, axial input. And it would be a great complement to this peripheral segmental or local input either on the lateral and anterior aspects of the leg or including as well the posterior as we mentioned including perhaps the tibial nerve and the popliteal fossa and the rest of the innervated structures by the tibial nerve. So this would be a very, very comprehensive that can only be improved by adding something suprasegmentally if we believe that’s necessary. And that would be something on the territory of the head and ears particularly. We can use areas of the ears such as shaman or in the concha or the vagus nerve, vagus nerve at concha. And we can add miscellaneous input that could contribute to the modulation of central supraspinal structures. That again provided that we see the need in chronic conditions, not for acute. I don’t think we need to do that. So this has been our blueprint for the treatment of ankle sprains. We like to refer as usual to our master blueprint of the local structures that can be targeted with acupuncture needles that include articular related structures, muscle related structures, neurovascular bundles and distal arterial networks. Plus miscellaneous soft tissue interfaces such as injured tissue, planes between adjacent muscles like represented here, or even areas of abnormal neurological activity like trigger points or here we have represented needles on this more whitish area which is the fascia itself for biochemical or neurological changes. So this is our master blueprint and what we’ve done here is just to apply this knowledge to our understanding of the pathomechanics and the neuromechanics of the injury. [End of recorded material 00:31:37]

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4. Lower Extremity Section II. Articular Problems (00:51:26) In the next segment we are going to review the neurological function blueprint for the treatment of articular problems of the lower extremity. The general blueprint for the treatment of articular problems can be summarized in the neurostructural approach. We are going to somehow ignore the exact structural dimension of the joint and we are going to appeal to the nervous system in order to modulate the metabolic and neural activity of the area. Therefore, the neurostructural approach is effective regardless of the state of the joint from modulate arthritic changes to more advanced deterioration of the joint. The neurostructural approach has two levels. The first one refers to the articular nerves. We can always send messages through articular nerves in order to modulate their activity and the activity of the nociceptive pathways that will tell the brain that the joint is okay even if it structurally is not. How do we neuromodulate articular nerves? Well, articular nerves according to Hilton’s Law and the neurologists from many years ago, it comes from two sources, motor nerves that innervate the muscles that move the joint and cutaneous branches that innervate the skin that covers the joint. Those are the two sources of articular innovation. With this knowledge then the neurostructural approach becomes neurofunctional by virtue of the involvement of the prime movers or the muscles that move the joint. Now we are going to be able to select any muscle that participates in the movement of the joint as a source of neurological information to modulate articular function. And we’ll see that in each of the three main articular complexes on the lower extremity. In addition, we can always appeal to the receptors that innervate directly the joint structure such as the capsule, the ligaments or the synovia, intra-articular insertion. The innervation of the joint is very rich in proprioception. We have numerous receptors in the capsule, in the ligaments, mechanoreceptors that tell the brain about the speed of motion and the degree of tension of those tissues. And then we also have rich intraarticular innervation, the synovia sites A and B. And we have nociceptors as well that are spread out through the different tissues. So this combination, articular nerves plus the joint structure and the articular nerves by themselves when we can identify them or via the prime movers is the neurostructural, neurofunctional approach. With this blueprint we’re going now to proceed to review each of the three main joint complexes of the lower extremity. We have the hip joint complex which is the femoroacetabular joint particularly but also associated with the mechanics of the lumbosacral and sacroiliac areas that we are not going to include in the discussion but they are present. Then the knee complex which is mainly the tibiofemora joint plus the articulation of the femoral patella articulation. And then the ankle complex which consists of the talocrural joint between the tibia, the fibula and the talus and then the subtalar joint between the talus and the calcaneus and a number of other joints, the

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calcaneocuboid, the talocalcaneal, etcetera, with cuneiforms that also affects the mechanics. But we’re going to focus on the talocrural and subtalar. So let’s start with a hip joint. Here is a summary of the function of the hip joint. Briefly, I will review this perhaps with a model and quickly establish which are the best access to the joint. So the hip joint has extension that’s provided by the gluteus maximus which is innervated by the inferior gluteal nerve. On the anterior aspect we have flexors that flex the joint and that include the iliopsoas, the pectineus, the rectus femoris and the sartorius, muscles that cross the joint line. And that they are provided by the femoral nerve one way or another and also anterior rami of the lumbar plexus. We have abduction which is the separation of the joint from the midline and the adductors are the tensor fascia latae, the gluteus medius here represented and the gluteus minimus underneath. And these muscles are all supplied by the superior gluteal nerve. So we have inferior gluteal nerve, superior gluteal nerve and femoral nerve so far. On the inner aspect of the thigh we have the adductors, the adductor longus, adductor brevis, adductor magnus, the half of the adductor magnus devoted to abduction. And that is all supplied by the obturator nerve. Also the gracilis participates in the abduction. And then we have some degree of rotation, external rotation which is provided by these deep muscles that we can see in the gluteal fossa, the gemelli – the piriformis, the gemelli, the obturator internus and then on the other side the obturator externus. That is not represented here, and the quadratus femoris that is deep to this tendon of the gluteus maximus. These are supplied by different branches mostly associated with inferior gluteal nerve and independent branches for the quadratus femoris and for the obturator internus. And this is the summary of all the possible neurological structures that provide one way or another articular innervation. We don’t know exactly how much articular innervation from each of these but we know that if we use this neurofunctional approach the articular function is going to improve greatly including the improvement of the discomfort in cases of pain associated with arthritic changes. So let’s see in our model some of the main nerves and how to access from this collection. I’m going to bring some needles and we will proceed to indicate what the best access for them. On the anterior aspect of the hip we have the neurovascular bundle that consist of the femoral vein, femoral artery and femoral nerve from medial to lateral. We can use the palpation of the femoral artery as a landmark and then we can go lateral to the [pulsation] and we will have the needle very close to the trunk of the femoral nerve. The femoral nerve has seven branches including the main cutaneous branch for the medial aspect of the leg, the saphenous, an important branch for the knee. And we can stimulate these branches variably dependent on the landing of the needle. It’s not necessary to product a major motor activation of the quadriceps but sometimes it’s possible. We’ll going to use a little bit of electricity. In this case we haven’t had any major motor activation but it’s mostly cutaneous. It’s fine.

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We are going to if we want include additional stimulation sites along the femoral nerve in the vicinity. We could if we wish to go to the iliopsoas between the inguinal ligament and the sartorius. There’s a space that will allow us to get to the iliopsoas. We can go to the pectineus between the pulsation of the artery and the tendon and muscle of the adductor longus. The pectineus forms the floor of the femoral triangle here. And all these would be a femoral nerve influence stimulation. If we want to double the needle that’s another technique we use often when we haven’t achieved the full motor activation that we were looking for. We can always add another needle and we have mainly sensory stimulation. I can feel that through my fingers. We’ll leave it there for now. Now, the second nerve that’s accessible in this area is the obturator nerve. The obturator nerve also from the same levels as the femoral nerve, L2/L3/L4, anterior division of the anterior primary rami of L2/L3/L4 and the femoral nerve posterior division of the anterior primary rami L2/L3/L4. So they are both from the same exact segmental origin. So the obturator nerve exited the pelvis through the obturator foramen. The obturator membrane covers the obturator foramen and there’s a space left for the nerve and then divides into two branches, an anterior branch that we can see here in a discontinued trace to represent that it’s posterior to the adductor longus and then a deep branch that will go to innervate the adductor magnus, adductor fibers. The anterior fibers will stimulate but will innervate the adductor longus, the adductor brevis, the gracillis as well as they will send an articular branch to the knee joint. So this is an important insertion site both for the knee joint as well as the hip joint. In addition there is an area of the skin supplied by cutaneous branches, cutaneous fibers from the obturator nerve. The idea is simply to put the needle through the muscle tendon junction of the adductor longus to reach the anterior branch. They are classical insertion sites here, liver ten, liver 11, but we just target the nerve. Same here there are traditional insertion sites, spleen 12, but we just target the femoral nerve and we use the artery as the landmark. So here typically it’s easier than it was for the femoral nerve to produce a motor activation and I’m just going by the drawing and not by the feeling which is what it’s going to give me there. So there is the motor activity of the adductor. So we have these two main nerves and then we have represented some cutaneous branches, the lateral femoral cutaneous nerve that exits the pelvis under the inguinal ligament and often between the sartorius attachment and the ligament, sometimes pierces the sartorius and supplies the skin over the lateral aspect of the thigh as far down as the knee. We have also anterior branches, cutaneous branches from the femoral nerve and then we had the big sensory fibre is the saphenous nerve. We can see here the [unintelligible 00:13:23] branch, main branch, and then the nerve continues down to supply all the medial aspect of the leg all the way to the medial aspect of the foot. So we can see that the femoral nerve really can be influential in the treatment of knee, ankle and hip. So the same insertion site will serve as for the three years. Same with the obturator nerve for the knee as well as the hip. If we want to add areas where these nerves may overlap – if we look here we have the sartorius intersecting with the adductor longus. And that area which is a classical liver nine is a good area to have an

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influence on both nerves which can be used for problems on the knee, problems on the hip which we know that oftentimes are related – are associated. The technical approach that we use – we have lots of insertion sites that we can select. Here we’re showing some of the interior ones. Later we’ll show the posterior ones. We don’t need to use every one of them. We just need to touch the main nerves. So once again to make sure that we have an input, blueprint should include the femoral nerve. It should include the superior gluteal nerve which we’ll do on the prone position. It should include the obturator nerve which we already have and it should include the inferior gluteal nerve. In addition, we can as well go to the paravertebral area and stimulate sacral nerves to influence all the deep gluteal musculature. We can go to the posterior primary rami, S1/S2/S3/S4. And we can go also to the posterior rami of the L2/L3/L4/L5/S1 to influence the segment. The only nerve that we haven’t mentioned that’s not motor for any of these muscles but because of its size and presence will send some articular branches is the sciatic nerve. Again, on the prone position we’ll see how we can reach this nerve. Taking advantage of the position of the model and the relationship, intimate relationship between the hip and the knee in terms of articular innervation, I’m going to move to the knee joint to come back later on to the three joints on the prone position. The knee complex is a simpler biomechanical function. It has extension and flexion and some rotation between the tibia and the femur. Extension is provided by the combined action of the four bellies of the quadriceps, the rectus, the vastus medialis, vastus lateralis and intermedius and the sartorius which also crosses the joint and it’s been represented here. That is all femoral nerve territory and we can get this femoral nerve here at the exit of the pelvis at the spleen 12 classical or we can get it in any area innervated by the femoral nerve such as the motor point of the vastus medialis for instance. Again, there are classical acupuncture points in the area such as a spleen ten. We are not going by traditional measurements. We are going – there. I just saw a twitch response so I know that I stimulated the motor point of the vastus medialis which is what I was looking for and we can see the contraction of the muscle very, very nice. This is one of the best possible responses to our needling and it’s almost guaranteed that is going to be a broad neuromodulation motor and sensory on the area with many benefits short term and longer term. So this is an important area and it’s femoral nerve. We can also go to the other side for the flexion, the hamstrings as well as the complex of the gastrocnemius and the popliteus that cross the joint. The popliteus involve also in rotation and that would be sciatic nerve branches as well as the tibial nerve for the gastrocnemius and we’ll see that on the other side. Going back to our neurofunctional blueprint not only motor branches are important which they are the number one target for our acupuncture needles, we have the cutaneous branches as well, particularly when the nerve is well known to provide articular innervation such as the saphenous in this case. So the saphenous can be stimulated after it’s left the area here at the junction of the shaft of the tibia with the medial condyle and this is the classical insertion site, the spleen nine. We can also involve the nerve before the area and this would be the origin of the popliteus as well. At that level we have the origin on the posterior aspect of the

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tibia. We can palpate sometimes branches of the saphenous that have suffered trophic changes and we can just needle the area of the changes in order to produce biochemical environment changes. If we palpate sources of nociception which may be related to the ligaments such as here, the medial quadrilateral ligament, tibial quadrilateral ligament or tender spots along the joint line depending on the degree of arthritic changes, we can also do insertions on the joint line or on this area. So here the ligament is a good target because it has more receptors than other area. Of course it’s a shallow insertion that doesn’t need to go too deep because you have the meniscus there. So these are additional strategies. Now, a caveat. We don’t ever needle a join that is inflamed or that is actively suffering an autoimmune process such as rheumatoid arthritis or psoriatic arthritis or microcrystal arthritis. We will wait until the inflammation comes down before we go to treat locally. These treatments are for joins that are in a state of not inflammation even if they are degenerated and even if they are painful. Pain is not an obstacle to treat a joint directly putting needles on the capsule or the ligament but synovitis, inflammation is a contrary indication because we will irritate further the structures that are producing the excess synovial fluid and we’ll irritate the nociceptors and we will not accomplish the goal of improving articular function. So the knee joint is accessible along the midline. You can go on the sides of the patellar tendon, patellar ligament and on the joint line. You can put the needle to the coronoid ligament of the – that joins the meniscus. There are areas with relatively rich innervations. Now here it is. This would be now an intra-articular insertion. And the bursa tissue is not a target but we don’t have any concerns. There are not problems in the literature described if the needle goes through the bursa tissue. This corresponds to classical acupuncture points, extra median point on this side and the stomach 35 on this side. There are nerves in the joints that come from distal branches. The development is such that the nervous system continues to grow and then it has to send branches back to the joint. In this case there’s an important branch from the common fibularis nerve that with a [unintelligible 00:22:56] tibial – anterior tibial artery comes from the area of stomach 36 from the area of the origin of the tibialis anterior. From here it comes to the joint. So this would be a very important local insertion site for the treatment of knee problems apart from the classical functions. So if we go here to the tibial tuberosity lateral one finger and there is the belly, the origin of the tibialis interior and deep in that location we have the recurrent anterior tibial artery and recurrent peritoneal nerve articular branch. So that would be an important articular nerve. So the knee is easy to cover. You would have insertions below, insertions above and indeed the classical protocol that has been tested in some randomized controlled trials. It involves exactly a pattern very similar to the one I’m just creating here. We have a spleen ten, a [bath] medially, stomach 34, a [bath] laterally, a stomach 36 below laterally, spleen nine below medially. I’m not totally familiar with that protocol but for sure those four classical insertion sites which we know they are femoral nerve, lateral femoral cutaneous nerve plus femoral nerve, recurrent peritoneal articular nerve plus deep peritoneal nerve for the tibialis anterior, the saphenous nerve here and even -5-

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posterior tibial nerve at the popliteus and at the soleus origin which is what is in the depth of this region. So this plus points on the capsule through this classical knee eyes, the eyes of the knee, and some other tender sites. I would recommend to add the proximal trunks of the obturator and the femoral nerve as well for the knee as a more comprehensive protocol. And again, we have the posterior access to the flexors that we do in the prone position. So the third area is the very complex ankle region which has the talocrural and the subtalar joint and depending on which joints we prefer to isolate it’ll be flexion extension through the talocrural and then a complex combination of movements at the subtalar that can be summarized into the pronation and supination or a pronation also called eversion and supination called inversion. So the participation of the anterior muscles on dorsi flexion and the anterior muscles also participate in aversion. That’s – you can look at the movements in isolation or combined. So let’s do it in isolation. Dorsi flexion. We have the anterior compartmental muscles, tibialis interior, extensor hallucis longus, extensor digitorum longus. And this is all deep fibularis nerve innervation. Flexion. We have the triceps surae which is innervated by the tibial nerve and then we also have the peronei which are supplied by the superficial perineal nerve. So they produce plantar flexion. And also the deep compartmental muscles, the tibialis posterior, the flexor digitorum longus and the flexor hallucis longus participate and these muscles are all supplied by the tibial nerve, same as the gastroc and soleus. So from the knee down basically the two main nerves are going to be the superficial and deep perineal nerves, branches of the common fibularis and the tibial nerve, the two main motor nerves. Inversion, eversion. When the foot is taken into supination which is also inversion, everything that produces plantar flexion and inversion participates. So that would be once again the triceps surae, the tibialis posterior and even those – those would be the main, even the posterior – the muscles of the deep posterior compartment like the flexor houses and the flexor digitorum. So the movement that we call supination is basically a function of the tibial nerve. And this is an important reminder for us. Tibial nerve, anything that produces problems with supination. And for pronation which is the opposite movement, pronation will then take the side of the foot up. That would be the peronei pulling from here and the muscles such as the extensor, hallucis longus extensor, digitorum longus. So it would be – and the peroneus tertius when it exists which is an extra muscle that is attached to the extensor digitorum longus. It’s all a superficial and deep peroneal nerve. So we have this pronation, supination or eversion, inversion that are the interplay between the superficial peroneal and deep peroneal. So the common fibularis nerve and the tibial nerve. And these trunks can be found proximal to the area. We can go to the popliteal fossa for the tibial nerve and we’ll see that in the prone position. We can go to the fibular head and fibular neck and try to stimulate there the trunk of the common fibularis nerve. So really, the knee is influenced by the hip and it influences the mechanics of the ankle and the foot. It’s always in the kinetic chain the preceding joint neurologically and biomechanically influences the function of the following joint.

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In terms of more detailed selection of insertion sites, we can go to the motor points of any of the muscles. We can go to the trunk of the tibial nerve here on the medial aspect of the talocrural region. That would be the classical kidney three. We can go above, classical spleen six or other classical insertion sites, or we can just go posterior to the medial tibial margin looking for the tibial nerve at any point we know it is easy to find such as five or six finger breadths from the medial malleolus is one of our preferred access to stimulate the tibialis posterior. So there it is. There it is. Tibialis posterior producing – participating in that movement that we call inversion or supination. Now we can access directly the talocrural joint here on the anterior aspect of the region between the tendons of the extensor hallucis longus and extensor digitorum. We can see the trunk of the deep fibularis nerve which comes with anterior tibial artery that now becomes the dorsalis pedis and this gives us access to the anterior capsule of the talocrural joint. Also, we’ll see later on from a different angle how there’s a branch, a motor branch from the deep fibularis nerve that supplies the little muscle in front of the sinus tarsi, the combination of the extensor hallucis brevis and extensor digitorum brevis. And that’s an important detail because the motor nerve can be stimulated sometimes from this area. At any rate, this is a great capsular point as well as addresses the trunk of the nerve and it can go intra-articular. That’s one of the best accesses to the talocrural. You can also go medial to the tendon of the extensor hallucis into the joint or lateral to the tendon of the extensor digitorum. Let’s just see if we’ve achieved any motor activity. Not in this particular one. It’s okay because it was a capsular point so we are satisfied with it. The main point to access the talo, the subtalar joint is the access of the sinus tarsi, distal to the lateral malleolus and proximal to the belly of those two little muscles I just described, extensor hallucis brevis and extensor digitorum brevis. And this would be an insertion that would target the interosseous talocalcaneal ligament which is rich in mechanoreceptors and we will also demonstrate that in the prone position from a lateral view that will be more accessible. So this segment has demonstrated different accesses to the main nerves that provide articular branches for the hip joint, the knee joint complex and the ankle complex. And the summary of the nerves, femoral and obturator for the hip, femoral and obturator as well for the knee. Very shared common innervation. And then additional nerves from the common fibularis for the knee which is also a main nerve for the ankle complex and then the saphenous nerve from the femoral nerve still have a direct influence on this area and supplies some articular branches. So the cutaneous branches are the last ones that we need to be aware of although rarely we target them as specifically as we do with the motor branches but here there are in no particular order. We have the saphenous that we already mentioned passing by the medial aspect of the talocrural region, the medial aspect of the knee and coming all the way from the origin of the femoral nerve. We have the branches of the superficial peroneal or fibularis nerve here represented. The medial – the intermediate dorsal cutaneous nerve, medial dorsal cutaneous nerve and intermediate dorsal which supply all the dorsum of the foot. And the best way of affecting these branches would be to go to the trunk of the nerve up here. Then we have the sural nerve on the lateral aspect that we will demonstrate in a different position. And those are the main cutaneous here.

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Here we have the anterior femoral cutaneous nerve, the lateral femoral cutaneous nerve branches that come from the hip region. And on the posterior side we will mention the posterior femoral cutaneous nerve, the main one for the posterior aspect of the leg, and the sural nerve, the same one that will end up laterally will cover most of the posterior aspect of the leg. So we’ll now just move our model and demonstrate all the posterior accesses. Now we’re going to proceed to access the three lower extremity main joint complexes from the prone position. We have reviewed the nerves on the prior segment and all we have to do is to find the access to those nerves. On the posterior aspect of the hip complex we can access the nerves related to the extensor muscles which – and the adductor muscles which were the inferior gluteal nerve for the gluteus maximus and the superior gluteal nerve for the gluteus medias, gluteus minimus and tensor fascia latae. For these deeper structures we need longer needles and due to the thickness of the local musculature. Landmarks involve the posterior superior iliac spine and the circle hiatus that determine the level of S2 to S4. Approximately at the level of S2/S3 and four, five, six finger breadths depending on the size of the area, we can access the superior gluteal nerve represented here in yellow. This one would be more superficial than the inferior gluteal nerve. This is an L4/L5/S1 segmental level. Now we have the inferior gluteal nerve approximately at the same distance from the midline at the level of the sacrococcygeal joint S4 and the first coccygeal vertebrae. So here where we can see is common area for the inferior gluteal nerve and the origin of the sciatic nerve under the piriformis. The sciatic nerve is going to continue all the way and pass posterior to the hip joint on top of the quadratus femoris that would be found here under the tendon of the fascial attachment of the gluteus maximus. So the sciatic nerve also can be accessed here at the level of the quadratus femoris. This is [unintelligible 00:38:04] here so the quadratus femoris would be approximately at this level. So we could go here or we can go in the middle of the gluteal area not to expect to really hit the sciatic at that level but close enough to have an influence on the articular branches and to have an influence on the hip joint. So we can insert the third needle and test with our monopolar electrical stimulator and see which muscles we have reached with this landmarks and insertions. So I will proceed now to test. This coincide with some traditional acupuncture points but the way we do it we are targeting exactly these structures so I’m not going to mention that the traditional bladder 53, 54, gallbladder 30 because the land marking will be different and for a different purpose. So here it is, superior gluteal nerve. I get a slight contraction actually of the gluteus medius so I got it. There it is. Superior gluteal nerve producing a contraction of the gluteus medius, inferior gluteal nerve producing a contraction of the gluteus maximus, some fibers. And for the sciatic, really I got more the inferior gluteal nerve now proper. Here it is producing a very vigorous contraction of the gluteus maximus and perhaps some of the muscles deep inside which is the piriformis and lower down the gemelli and the obturator internus. So here we are. All very effective insertion sites. We’ve also represented some of the cutaneous nerves that supply the area from the branch of the iliohypogastric nerve that

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covers this area to the posterior rami of L1/L2/L3 forming the superior cluneal nerves or the medial division or the lateral division of the S2/S3/S4 which form the medial cluneal nerves. So this would give us all the necessary access to the main nerves in the posterior hip. Finally, we can also do an intra-articular capsular insertion. This is a very big joint. We can access posteriorly anywhere above the insertion of the capsule and we can go to the posterior capsule through this area. We can go to the lateral capsule through the tensor fascia latae. We would do on a lateral recumbent position what I’m representing here by this longer needle. So we can go through the tensor fascia latae, anterior fibers of the gluteus medius and – or deeper. Perhaps sometimes the gluteus minimus and then the capsule of the joint. It’s very accessible and very safe from the lateral aspect. So this is for the hip joint. Now we follow the sciatic nerve. The sciatic nerve is going to continue along the posterior aspect of the thigh and it’s going to divide into its two main components, the common fibularis nerve that we can see here represented following the medial border of the tendon, muscle of the biceps femoris and then wrapping around the neck of the fibula. The common fibularis, there are four, is an important nerve for the knee, not just when it passes by here but as we mentioned in a prior segment when it gives off a recurrent peroneal articular nerve that goes together with a recurrent branch of the anterior tibial artery. We can obviously reach this nerve trunk from any of these positions. It’s so superficial that we don’t need a needle to locate it. All we have to do is go to the bone, go to the posterior aspect and then even though the nerve hides fairly well – I’m going to go not by the drawing but my own palpation. We are going to see that stimulation at this level just with the electrical stimulator produces activation of the different branches of the common fibularis nerve. So we can see both dorsi flexion and eversion. So this is to prove that the position of the nerve is easily accessible on this area. We can also stimulate the tibial nerve which is the other branch of the sciatic and that one goes with the popliteal artery and bisect the popliteal fossa. The limits of the popliteal fossa are the biceps femoris above and lateral, the semitendinosus, semimembranosus complex above and medial. And then the two tendons of the gastrocnemius muscles below, lateral and medial. So we bisect this popliteal crease into two. That would be the artery and now we go slightly lateral in order to find the nerve and also to avoid the artery. There have been few reports in the literature of complications by piercing this artery. Once again, the goal here would be to affect not just the nerve for the knee purposes but anything below the knee. So it can be used for problems of the joints of the ankle complex. So let’s see what we got here. And we didn’t get any motor activity. Once again better to go by palpation than by the drawing. So here were have a contraction of the gastrocnemius. There it is. And therefore we could connect this now with distal points for the treatment of the ankle. Remember the concept of the kinetic chain and how one of the strategies of the blueprint strategies that we use in neurofunctional acupuncture is always to address the whole kinetic chain. From the posterior aspect we have several ways of stimulating the common fibularis nerve, the tibial nerve and then if we wish to do so we could also go to the popliteus, to

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the motor point avoiding the neurovascular bundle either medially or laterally in a technique that we’re not going to demonstrate but that we use regularly in our clinical practice. Finally, we have from this position the access to the remaining nerves, articular nerves that may affect the complex, the subtalar and the talocrural joints. We mentioned the sinus tarsi. We can see the sinus tarsi perfectly represented here anterior to the belly of the extensor hallucis brevis and extensor digitorum brevis, anterior to the lateral malleolus. This is the tarsi and from here the needle should go in two centimetres with no resistance. There it is. Perfect. Three, four centimetres. So you can see the needle has gone approximately four centimetres in the sinus tarsi in a painless insertion demonstrating that there is a significant space between the talus and the calcaneus on the lateral aspect. And that space is partially occupied by the interosseous talocalcaneal ligament that is frequently the source of abnormal nociception and that gets injured in ankle sprains. So this is gallbladder 40 or a sinus tarsi insertion site. We see the representation of the sural nerve with its terminal branches that also we can stimulate at the classical acupuncture point here, bladder 60. And we can stimulate as we did with the perineal nerve by just using the pointer plus feeling the nerve trunk and in this case the patient will feel a sensory sensation down the territory of the nerve. It won’t have any motor activity. Or we can use the needle as we do in classical approach and connect this bladder 60 with any of these other points. As a general strategy, we can also combine in any of the joints the local points with a regional sympathetic regulatory point such as liver three here or even at gallbladder 34 as a general extrasegmental input in this case for the – not for the knee. That would be segmental. But for the hip and for the ankle as well. So that summarized the approach that we’ve termed neurostructural that includes stimulation of the most relevant articular nerves by going to the most important prime movers and combining that with cutaneous branches when appropriate and by targeting the adjoining structure as well when appropriate. So final demonstration of how to expand this concept, this neurofunctional concept, is to go to those motor points of the movers of the joint when that particular mover is thought to be involved because the mechanism of injury involved that muscle or now the deficit observed on the gait analysis or the manual examination indicates the weakness of that muscle. So if we wanted to stimulate the flexor hallucis longus we would go here on the lateral aspect of its insertion under the soleus and we would make it jump. That would be helpful not for the ankle complex but more distally but for the mechanics of the inner aspect of the foot. It’s just one simple demonstration of how to profit from the knowledge of motor innervation of the muscles and the anatomical relationships between the joints and the muscles. So we can see the movement of the big toe there and also partially of the toes. So this knowledge of where the nerves, the motor nerves go and where the motor points are is going to enhance our ability. Same thing we did here on the gluteal area with a

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motor activation of the gluteus maximus. We can do the same for the hamstrings. We can do the same for the biceps femoris, semitendinosus, semimembranosus, gastrocnemius, soleus, even popliteus as mentioned before. So this has been the summary presentation of the neurofunctional acupuncture blueprint for the treatment of the articular dimension of any problem. I can be primarily a problem with the joint or it can a movement disorder that involves the joint. And this neurostructural, neurofunctional approach has proven to be very effective. Finally, it would be necessary in chronic conditions to add the segmental axial input in order to modulate the whole dermatomal, myotomal, sclerotomal as well as the reflex sympathetic vascular levels. So T10/L2 in general for any problem of the lower extremity and then we can add from L1 to S2 any level that we think should be included because of the somatic relationship. So eight needles on the back is usually a good input to add at low frequency together with these local inputs that we just described. [End of recorded material 00:51:26]

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5. Upper Extremity Section I. Shoulder Problems (01:12:02) In the next segment we are going to review the neurofunctional acupunctural blueprints for the treatment of shoulder problems. This is a very complex area and therefore is going to take a little more in-depth review of the neurostructural anatomy to understand the foundation of our blueprint. We use three main blueprints, the first one being the neuroanatomical one consisting of local inputs, axial inputs and extrasegmental inputs that have been defined elsewhere. As a brief reminder, local inputs are any peripheral, segmental structures or nerves related to the problem. Axial inputs are any spinal, segmental levels that are associated with the problem via the posterior primary rami, both at the segmental somatic levels, dermatome, myotomes, sclerotome, and at the segmental autonomic, particularly the reflex vascular sympathetic level. These two levels can be expanded using blueprints number two and three which we have defined elsewhere as a neurostructural approach and a neuromechanical approach. Neurostructural approach, which is reflected here, is the combination of structures such as joints, articulations, nerve trunks and muscles that participate in the dysfunction. And this neurostructural definition allows us to select a vast array of targets for our acupuncture needles. At the same time, the definition of the dysfunction in precise segmental terms, dermatomal, myotomal and sclerotomal, allows for the selection of the axial inputs which have two levels, as mentioned before. Segmental somatic, which in the shoulder region goes from C1 to T1, not as much neurologically, as there is no C1 direct supply to the shoulder, but their anatomical structures such as some of the scalenus muscles and the levator scapulae that have their origin at C1. So C1 to T1, or C2 to T1, are the segmental somatic levels. And then the segmental autonomic or reflex vascular sympathetic levels go from T1 to T5, the origin of the preganglionic neurons that supply the vessels of the head, neck and upper extremity. Therefore, the neurostructural blueprint allows us to select local and axial inputs as well as the neuromechanical analysis of the kinetic chain can help to select distal inputs that will be either neurofunctionally related to the problem by sharing segment, so anything distal to the extremity that is of C7, C8, T1 dimension will have an influence on the shoulder because of the segmental somatic common origin. But also from a biomechanical standpoint, the joints distal to the shoulder have an influence on how the shoulder operates, particularly when they are actions that involve the whole extremity, such as hitting a tennis ball with a racket or doing any other thing with that full extremity. Some of these distal inputs can be deducted or inferred by this neuromechanical analysis, some can be taken from traditional empirical information that has proven to help on the modulation of nociception and sympathetic activity on the whole limb. And we’ll discuss those insertion sites later on. Finally, our blueprint number one, our three-level segmentally-related inputs, or nonsegmentally-related inputs, extrasegmental inputs is a category that has less value for shoulder problems but can be included when appropriate. Less value because the shoulder is a very structural regional with complex biomechanics and neuromechanics, but the central nervous 1 Copyright 2014 by Dr. Alejandro Elorriaga Claraco

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system, as in any other condition, chronically can suffer changes and can contribute to the control of the inflammation, to the control of the somatosensory cortex processing of the sensory signals that come from the different structures of the shoulder and therefore there is value in adding something extrasegmental when necessary. So we’re going to use our model for the demonstration of the selection of the inputs and then the demonstration of a blueprint treatment. This is not a detailed analysis of the neuromechanics of the shoulder. It’s a demonstration of a blueprint that targets the main neurostructures, joints, articulations, nerve trances and muscles that are involved in the normal mechanics of the shoulder. We’ll start with the anterior aspect and we’ll review what are the main components of the blueprint from the articular, muscular and neurological standpoints. Before that, the end result of the analysis and selection of the insertion site will be supported by the use of electricity. Electricity will be an important part of every treatment and the blueprint for the use of the electricity will consist of four electrodes put across the area that want to influence, something anteriorly, something posteriorly, something proximal, something distal. And then electricity will pass through the affected area and therefore will be a form of stimulation to all the nerve endings involved in the problem, even if we don’t know with precision what these nerve endings are, the value of electricity is that you can treat in a broad manner. And this is what the blueprint is until we proceed to analyze the problem in more detail biomechanical terms, which is beyond the scope of this presentation on blueprints. So on the [tier] aspect, we have access to some of the most important elements on the neurostructure of the shoulder. We have access to the external clavicular joint, acromialclavicular joint and glenohumeral joint between the scapula and the head of the humerus. These are three joints that need to work in coordinated fashion for the shoulder to have its full function. In addition there are a number of articulations which are not true bone-to-bone connections but they are sliding interfaces, the most important one being the scapulothoracic articulation between the scapula on the back and the rib cage that slides without being connected to the underlying bones. There are other articulations less know or less discussed but equally important. For instance the subacromial deltoid articulation, the space between the deltoid and above the capsule which is occupied by the subacromial deltoid bursa, can be considered an articulation because if there are adhesions that prevent the sliding of those planes the whole mechanics of the glenohumeral joint will be altered. There are other articulations that I’m not going to discuss, but some authors have mentioned, particularly the coracoacromial ligament complex and the structures underneath. Everything needs to slide properly for the compound movement to allow the positioning of the hand on the space, which is the ultimate function of the shoulder. So a scapular glenohumeral joint, acromioclavicular, sternoclavicular and the other articulations operate in conjunction to allow the extremity to operate properly. Now, what’s important to know from the pure neurofunctional standpoint, neurostructural, is what is the articular innervation of the joints? We have a simple two-way approach to the treatment of the joints. We can put needles directly into the capsules or ligaments of the joints, such as we will have here. The capsule of the acromioclavicular joint easy to access, or even the 2 Copyright 2014 by Dr. Alejandro Elorriaga Claraco

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capsule of the - and the ligaments of the sternoclavicular, easy to access. And the glenohumeral on the posterior aspect as well, easy to access. This is one direct approach. The second approach, the indirect approach to the joint, is to go to the nerves that supply the joint. And for that we go back to our Hilton’s Law that tells us articular branches come from nerves that supply the skin that covers the joint, or and from the motor branches that innervate the muscles that move the joint. Therefore, if we know their cutaneous innovation and we know the prime movers of the joint we know which origin the articular nerves have. And here we’ve represented several important that we need to always consider on the treatment of shoulder problems. The first one is a set of three branches that come from the cervical plexus at the level of the laryngeal prominence at the posterior border of sternocleidomastoid, we see the exit of several branches of the cervical plexus, the lesser occipital nerve, greater auricular nerve, transverse cervical nerve and the big trance of the supraclavicular nerves, C3, C4 segmental origin, anterior primary rami. Here we have the three distinct branches. The first one, the medial supraclavicular nerves supply the skin over the sternoclavicular joint, therefore providing branches to the sternoclavicular joint. The middle intermediate supraclavicular nerve, has a territory that includes the acromioclavicular joint and the skin over this area. So this is all a C4, the infraclavicular region is a C4 dermatome, and the peripheral nerves that supplies these fibres are the supraclavicular nerves. And the third nerve is the post-lateral supraclavicular nerve that supplies the area over the angle of the acromion and the top of the shoulder. Then lower down we are going to have, represented here as well, the cutaneous branch of the axillary nerve that supplies this patch of skin. But the whole top of the shoulder is a territory for the supraclavicular nerves. Therefore, this exit here, this insertion site can be used for any problems of the shoulder where we have an involvement of any of the three joints that we mentioned. Therefore in any shoulder problem we can use it. And that coincides with the classical insertion site, the small intestine 16. So once again the level of laryngeal prominence, posterior border of the sternocleidomastoid, and not a very deep insertion because above 1cm we can encounter the nerve trance. This is a local input even though the needle is not on any of the structures, but it’s on the nerve that supplies the structure and that’s why it’s a neurostructural approach. In addition, we could put needles on the capsules or ligaments of these joints as we mentioned. This would be one important part of the blueprint, the cutaneous nerve. Let’s represent the small intestine 16 here on the lateral aspect of the neck as our first contribution to the blueprint. It’s not compulsory to use everything that we’re going to mention. This is just a construction of a treatment that makes sense from the neurostructural standpoint. Again, regardless of the specific neuromechanics of the problem or the patho-physiological processes that have taken place underneath, such as degeneration of the joints, etc., our approach is targeting the nervous system. It’s not targeting the structure, it’s targeting the vascular system, the sympathetic nervous system as well and the effect on the metabolism of everything in the area. It’s therefore a neurofunctional approach even though we’re using a neurostructural logic to find the best insertion sites to communicate our message to the nervous system. 3 Copyright 2014 by Dr. Alejandro Elorriaga Claraco

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We have therefore the first level of innervation of the joints, which are the cutaneous nerves that supply the skin that covers the joint. The second level is the motor nerves that innervate the prime movers. So let’s review the main prime movers of the glenohumeral joint in particular because the sternoclavicular and the acromioclavicular joints are here to allow rotation and sliding of the clavicle so that scapula has an anchor when sliding over the ribcage and it doesn’t go off on any tangent and allows therefore the action of the muscles that go from the trance to the humerus, which include the so-called rotator cuff muscles, supraspinatus, infraspinatus, suprascapularis, teres minor and others such as the latisimus dorsi, the teres major, etc. And the big deltoid here represented. So the glenohumeral joint, which is a universal joint with infinite degrees of movement that can be summarized along with three planes of the space, it has prime movers that include first this big muscle that participates in every direction. It does flexion, it does extension, it does abduction and is the deltoid muscles. The deltoid muscle is innervated by the axillary nerve. The axillary nerve is one of the two branches of the posterial core together with the radial nerve, and it comes from the quadrangular space around the posterior aspect of the glenohumeral region and it wraps around deep to the deltoid, innervating - providing several motor points to the deltoid. That would be the first nerve to think about when dealing with glenohumeral joint problems. Then - unless write them down as we discuss them. So we have axillary nerve. We also have a deeper - the nerves that supply those muscles, some of the muscles I mentioned, particularly the important supraspinatus and infraspinatus. The supra and infraspinatus muscles that end up mixing with the fibres of the capsule of the glenohumeral joint are stabilizers that allow the rotation of the humeral head without the humeral head being pushed against the acromial ceiling, and therefore allow for the clearing, part of the mechanism that allows for the clearing of this osseous arch. The innvervation of these two muscles is through the suprascapular nerve. The suprascapular nerve we will see afterwards when we turn our model around, it ends up in the infraspinatus fossa. So let’s write it down. Suprascapular nerve. These would be the two most important nerves on the articular supply of the glenohumeral joint. Axillary suprascapular, together with the supraclavicular that is the cutaneous branch that covers the area. At the same time, the axillary nerve is also - and both the axillary and the suprascapular are going to contribute to the acromioclavicular joint innervations. We have of course many other muscles that participate in the movements of the glenohumeral joint. We have the big anterior pectoralis major and underneath, the pectoralis minor, which participate in anything that approaches the humerus to the limb, whether [across] a deduction from this position, from elevation, from the resting position. It’s a little bit of internal rotation from external rotation. Also deep there on the suprascapular fossa, the [suprascapularis] muscle participates in the internal rotation or the recovery from abduction. So these anterior muscles are supplied by branches such as the medial and lateral pectoral nerves, every easy to access here. And oftentimes the presence of hypertonicity on the shoulder with bad posture that involves hunching forward, anterior forward head and increased kyphosis of the thoracic spine, tightening 4 Copyright 2014 by Dr. Alejandro Elorriaga Claraco

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of the pec minor is necessary to open up the fascia by treating, relaxing these muscles, treating the trigger points, stimulating these nerves to restore the normal flow of information between these muscles and the central nervous system, the spinal cord. So as part of the blueprint I would recommend always to do something on this quadrant. And that something can combine two of the criteria we just mentioned. We can try to target simultaneously the territory let’s say of the supraclavicular nerves. So we’re going to go through the skin. That’s accomplished by that. Then deeper, the trance of the suprascapular nerve, which can be found at the infraclavicular fossa, this triangular space between the anterior deltoid border of the deltoid and the lateral fibres of the clavicular fibres of the pectoralis major. So in this triangle, called the intraclavicular fossa, on the depth we have the suprascapular notch that is being closed by the superior transverse scapular ligament, and that serves for the suprascapular nerve to come from anterior to posterior to reach the supraspinous fossa and from there going around the root of the spine of the scapula to innervating infraspinatus on the infraspinous fossa. So in the depth of this fossa is the suprascapular nerve, and this is one of the inputs that we can include in our blueprint. We can also substitute that by either one of the official acupuncture points such as Line 1 that would target the pectoralis minor, not represented here, from the coracoids to the third, fourth and fifth ribs. And that’s also an excellent anterior anchor for the electrical stimulation. Or we can select a trigger point of the many - on the area clavicular fibres of the pectoralis major, sternum fibres or even anterior deltoid, or even trying to go to the coracobrachialis, now innervated by the musculocutanea. So something from this area will help to anchor the electrode that will go here. So let’s represent a couple of the insertion sites, here, Line 2, infraclavicular fossa, Line 1 to the pecoralis minor innervated by the lateral and medial pectoral nerves. This would be the best summary of anterior inputs, but we can also, as I mentioned, go to the anterior deltoid or to the coracobrachialis here on this area. In addition in this region we have a very important muscle that attaches to the inferior aspect of the clavicle and that often - and it goes from there to the first costochondral joint. I’m talking about the subclavius. The subclavius muscle, represented here on our model, going to the first costochondral joint is a stabilizer of the sternoclavicular joint, but at the same time when hypertonic may restrict the free rotation, the free sliding of this joint, particularly after trauma of the shoulder it oftentimes - the clavicle remains restricted. The acromioclavicular joint prevents the proper movement of the scapula and the glenohumeral joint starts complaining because it doesn’t have the freedom to operate properly. And the symptom appears to be a glenohumeral dysfunction, while in actuality the dysfunction is the mechanics of the clavicle and the subclavius is at the core of it. The subclavius is supplied by a nerve directly from the upper trance C4, C5, C6 levels and is an important nerve because it has consistent connections described by the German anatomist between the phrenic and this nerve. And therefore, embryologically it has some connections with the important diaphragm, which is an interesting connection, something that is not usually thought in practice that has a connection, the subclavius and the diaphragm.

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So if we want to add this as our stimulation, we have the technique described elsewhere very safe when properly done, mid-clavicular line, aiming laterally, superiorly and posteriorly and going about 1, 1 1/2cm, that only takes going through the clavicular fibres of the pectoralis major. And that will, in a few seconds of the stimulation with the monopolar stimulator, will restore the tone and will restore the flow of information between the C4, C6 level and the corresponding spinal segments. So this is our main general discussion of the anterior aspect. We have also represented the sterno plato mastoid just to point out the connection with the supraclavicular nerve trance. And also we have the trapezius, which will come to the one-third, outer third of the clavicle and then will go to the spine of the scapula as well. So this territory is a spinal accessory nerve territory in addition of being a supraclavicular nerve for the skin. So it is may be a good idea to evaluate whether there is a trigger point associated with this 11th cranial nerve, a spinal accessory nerve, and the typical trigger point takes place in the middle of the muscle on the top of the shoulder. So anybody with the same postural dysfunction that we described before, a lot of tension in the shoulder, that is prone to develop this trigger point. Treating trigger points as part of the blueprint is a good idea because it will deactivate abnormal information that’s now blocking the regular traffic of afferent information, and this would be the number-one trigger point in humans described by Janet Travell, the trigger point on the upper trapezius. And that corresponds with the trajectory of the spinal accessory nerve, which supplies innervation to both the sternocleidomastoid and the trapezius. And that is another muscle that could be treated with local technique, shallow needling when necessary. The sternocleidomastoid is oftentimes ignored in the treatment of shoulder problems but you can see the connection between the head via the mastoid process and the girdle, because one tendon attaches to the [maneuvering] the sternum, the other to the clavicle, and therefore is a connector between the head and the girdle. And anything that goes from the head to the girdle is potentially a valuable neurostructural target for our acupuncture needles. And this is I believe, the big review of the anterior aspect. Let’s go now to the proximal distal on the lateral aspect. Proximally we have access to the trapezius, which was mentioned, the upper trapezius, the most superficial. And then we have access to the supraspinous fossa. The supraspinous fossa is, if we can see here, it’s posterior to the clavicle, anterior to the spine of the scapula. And all we need to know is that the floor of the fossa is parallel to the floor, and therefore the direction of insertions that attempt to reach this floor need to be perpendicular to the floor. So cranial to caudal, and not angled according to the surface. So every needle that we use in this area, which aims to the supraspinatus muscle, needs to be inserted in this direction. But anatomically we can summarize it all in the supraspinatus muscle and the suprascapular nerve at the supraspinous fossa. And we can use 1, 2, 3, 4 needles, whatever we consider necessary. Very important access and one of the best anchors for a proximal [structor]. So we can add that to our treatment here. We did the trigger point of the trapezius and now we are doing one needle, supraspinatus and suprascapular nerve. That represents all that. But the patient is of course the ultimate judge of what is the best insertion site rather than doing it intellectually as we are discussing now. 6 Copyright 2014 by Dr. Alejandro Elorriaga Claraco

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And now we need the posterior anchors for these anterior needles. And we’re going to proceed to change sides and also literally to change sides of the table so we can access now the posterior structures. What we’ve represented here is the scapula with the deeper muscles, the second layer of muscles. We’ve eliminated the trapezius and now we see the levator scapulae, the rhomboid minor and major, which all go from the axial skeleton to the scapula, and then we’ve represented also the infrapinatus in the infraspinous fossa. And we’re going to briefly discuss which targets posteriorly which are several. First, we can repeat a representation of what we just discussed on the other side, which is anything on the supraspinous fossa is a suprascapular nerve. And this would be a classical - for instance the small intestine 12. The nerve, which we’ve represented here which dotted lines, we see the nerve coming - the infraspinous branch of the suprascapular nerve coming to the innervation of the infraspinatus. So we can put a needle on this branch to double the effect on the nerve. And here we would have ... anywhere in the fossa. We can look for a trigger point, we can look for ... the motor point. We just simply go to the middle of the fossa. So this would be a huge attachment or anchor for the posterior aspect that would fulfill the criteria of influencing one of the two major nerves that have an influence on the glenohumeral joint. Traditionally there is a small intestine insertion that we can call prime just to represent the broadness of it. We can also go directly to the capsule of the glenohumeral joint and we can do that by going along the posterior axillary fold. We can go all the way to the spine of the scapula, come back a little bit and then insert a needle that will go through the deltoid, which will be axillary nerve. We’ll go through the infraspinatus, which will be suprascapular nerve, and then we will finish in the capsule. So in one single insertion we cover everything, including the supraclavicular nerves on the surface. So here, in one single area we have every neurological structure from the C3 to the C6 sclerotomal levels. In one single insertion we cover four levels, three, four, five, six. This is one of the best insertions, and that corresponds to the traditional insertion site of small intestine 10, performed anatomically as described aiming towards the capsule and touching the capsule. We can also another insertion site that will target the two nerves represented here. We have represented the radial nerve going down the arm behind the triceps and we have represented as well the axillary nerve, this dotted line, with the cutaneous branch. These are the two terminal branches of the posterior cord and we can put a needle in between the two branches below the quadrangular space and above where the radial nerve passes under the teres major. This insertion site would be one finger-breadth above the inferior border of the posterior axillary fold and it would go through the long head of the triceps and then through the teres major. So we’ll stimulate the skin, supraclavicular nerves again. We will stimulate radial, instead axillary, now would be radial, which is the same level at the segments of the spinal cord. And then we would go through the teres major innervated by the inferior suprascapular nerve, lower suprascapular nerve. So this would be an additional radial nerve input and the lower suprascapular nerve. We can also insert both and cross them together, and then we cover six nerves and at least five segments in one simple input. That’s the beauty of a neurofunctional approach. 7 Copyright 2014 by Dr. Alejandro Elorriaga Claraco

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Now, in addition to the area related to the glenohumeral joint and the muscles that move the joint, we have the articulation of the scapula, the scapulothoracic articulation. So the muscles that anchor the scapular are also of great value when it comes to modifying this activity. If the scapula is not sliding properly then the glenoid cannot position itself on a space in the glenohumeral joint cannot move properly. Important muscles attaching on the scapula include the levator scapulae, the rhomboid minor and the rhomboid major, all occupying the medial border and superior angle. And they’re all innervated by the same nerve, the dorsal scapular nerve. So the dorsal scapular nerve, which is the first nerve of the pars supraclavicularis of the brachial plexus and it goes through the scalenus posterior. It receives fibres from C4, C5 predominantly. Maybe C6, but C4, C5. C5 would be the predominant, and it usually is under the levator. And then it goes under the rhomboids and it runs along the medial border of the scapula. The nerve can be reached on the side of the neck behind the scalenus medius, because that’s piercing it and we can find it there. Or we can go directly to these muscles and do trigger points or tenoperiosteal trigger points such as the attachment of the levator, very common, or along the medial border. So this is a really good area to have an effect on the dorsal scapular nerve and the mechanics of the scapulorthoracic articulation. Also, on the other side, invisible to our eye, of this border, we have the attachment of the serratus anterior that goes from the first rib to the ninth rib with its three fascicles. That is supplied by the long thoracic nerve. The long thoracic nerve is the second nerve on the pars supraclavicularis, and it comes directly from C5, C6, C7, long thoracic nerve. It also pierces the scalenus medius but in this case anteriorly. And then it crosses over the ribs and it ends up on the side of the ribcage, mid-axillary line, it goes all the way to the lower slips of the serratus anterior. Extremely important muscle that is going to facilitate the scapular position above 90 degrees of abduction. If we don’t have proper function of the serratus anterior we won’t be able to do elevation of the shoulder. We would be able with the trapezius just to reach to this level but we won’t be able to do this. And of course if we have a total palsy of this, the scapula will wing and we’ll have a winged scapula, which is a common nerve to suffer neuropathy by viral infection that lasts several months, will describe the Parsonage-Turner Syndrome. [Low] thoracic nerve that we can reach easily on the side of the thorax. Harder to reach, also on the other side is the subscapularis muscle and the upper subscapular nerve. I would say impossible to reliably reach this nerve. Possible to reach the fossa with a careful technique similar to the trigger-point injection used by Travell but that we will not demonstrate today but can be included as well in a finer neurostructural treatment. I think with these inputs that cover the main nerves involved in the neuromechanics of the shoulder on the posterior aspect, we have enough input. And then we can combine these all with the axial input that, as we mentioned, can target segmental somatic levels up to the level of C7 and segmental autonomics or reflex vascular sympathetic levels, which should target the T1 and all the way to the T3, T4. No necessary to go to the T5. 8 Copyright 2014 by Dr. Alejandro Elorriaga Claraco

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And we can sometimes omit the somatic level. I would not omit the reflex vascular sympathetic. In our treatment I’m going to put, to represent this input, two needles at the T1, T3. I’m going to do it unilaterally because of convenience but in regular treatments we use bilateral approach. We can treat the patient on either lateral recumbent position or prone first, supine second. We can also treat seated. Not recommended because of the possibility of evasive vagal reaction. It’s just more difficult. The patient has to be seated and can’t lean back, can’t relax. It’s not a pleasant treatment. So we’re going to treat our patient now with a blueprint derived from this discussion, and we’re going to do it on a lateral recumbent. As part of the blueprint, number-one consideration is patient’s comfort. If we don’t have a properly relaxed patient, if we don’t have access to the areas that we want to needle in a relaxed manner, we won’t be able to select the neurostructural targets with precision. So our first-always obsession is with patient comfort. We have the needles. I will bring the regular alternate current stimulator to do the connections that we described and I will bring a monopolar stimulator to test some of the insertions that we discussed in the prior segment. In a regular treatment, methodologically speaking, we would put the needles for this away from our body. In that fashion our hands will never encounter the needles that have already been inserted, and we’ll finish with everything that’s closer to our body. If we need to change positions we will do so. I would start with maybe the small intestine 16 as the summary of representation of all the cutaneous contribution to the articular supply. So I landmark laryngeal prominence, posterial [order] of the sternocleidomastoid and then not too deep of an insertion, approximately 1cm, is not a motor point. Therefore I would not try to elicit any kind of muscle contraction in this case. Now we will proceed to insert one of the two needles that we - or two insertion sides that will target the medial lateral pectoral nerves. So if we go to the infraclavicular fossa and either there the line two, or I’m going to select a muscle point because we like muscles as interfaces for the needles, as we have there on our master poster. We see how many neurostructures the muscle contains, from the motor nerve to special mechanical receptors, muscle spindles, and all those can be stimulated by one single insertion into the muscle. Therefore the muscle is the numberone, other than nerve trances when there’s a specific reason for it, is the number-one target, a neurostructural target for our acupuncture needles. We can test with the monopolar stimulator whether we’ve accomplished. I think we’ve accomplished connection, and it is very close to the nerve because the stimulator is barely on, and we can contractions. So this is great. But definitely this is the goal. So we can just leave this needle as represented and all the needles we discussed previously. Now we’ll use a proximate approach. I’ll go to the suprascapular fossa, and I would just go to the middle of the, the motor point of the supraspinatus, and that will represent every possible insertion proximal. So we are now going to connect this to a distal point on the territory of the axillary nerve. Since we are targeting the glenohumeral joint, I could go to a capsular point but I’m going to do that on the posterior aspect and insert the needle as we explain on small intestine 9 Copyright 2014 by Dr. Alejandro Elorriaga Claraco

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10, one of the best stimulation sites for the reasons we discussed. So I’m going to here maybe look for a trigger point or a motor point on the anterior deltoid. There it is. We’ll leave it there. So let me put the last position posteriorly. We need longer needles in general for that task. Maybe not in this case. Maybe we could manage with a 40, maybe a 50, but we’ll use a 75. It doesn’t have to go all the way. And I’m going to make sure that I landmark properly. I go to the spine of the scapula, posterior axillary fold, I touch the spine, I come back, feel the depression and then go into a posterior/anterior direction. So here it is. The needle goes through the deltoid first, then touches the - or goes through the infraspinatus, gently, and then I feel the resistance of the capsule, so I’ve accomplished my goal, and I stay there. This is the access we use to inject contrast in the joint when we are doing an arthrogram and therefore is very well-known anatomical access to the glenohumeral joint, which the traditional acupuncture practitioners call the small intestine 10. Now I’m going to connect the electrodes and then I’m going to discuss the addition of distal points. As explained several times in this series, the connections could be done in any fashion due to the fact that these are alternate current stimulators. Therefore, electrodes come from each of the electrodes. However, for the purpose of supporting the intention of the practitioner I’m going to connect the anterior point with the posterior point, which also coincides with the polarity of the human body, more negative on the front and on the back. And also I’m going to connect the distal point to the proximal following the polarity of the human body, which is again more negative on the distal part. The blueprint is we’re targeting the main neurostructures and also we are adding elements that improve the biomechanics. And speaking of the third level of blueprint, which is the neuromechanical approach, blueprint number three, which oftentimes obviously overlaps with blueprint number two, the neurostructural, consists of anything that - not directly at the local level, but biomechanically is connected to the problem. So anything on the upper extremity can have a double influence. Structural, biomechanical, as well as neurological on the shoulder. Since our first goal always is to modulate sympathetic activity, it’s fair to add always one distal point classical insertion site on the motor point of the first interosseous dorsalis, the so-called large intestine 4, that’s always a good addition in order to neuromodulate sympathetic activity on the whole extremity. Then we have the first interosseous dorsalis supplied by the ulnar nerve, and the ulnar nerve is from the medial cord of the brachial plexus and gives have of the median nerve and the ulnar nerve and some of the cutaneous branches that cover all the medial aspect of the arm and the forearm, the medial brachial cutaneous nerve, the medial antebrachial cutaneous nerve. So a very important territory is covered just by going here. And if the needle goes deep enough we can even affect the median nerve via one of the thinner muscles. At any rate, this is the ideal distal stimulation site to produce regional sympathetic modulation and therefore providing an additional stimulus to the T1 to the T5. So even those there is no somatic innervation T1, T5 here, by stimulating sympathetic fibres on the distal arterial network, we are also going to have an effect on the axial level T1, T5. And you can see that with one single needle we are coming from C5 to T5 by taking into consideration the different relationship. So this one needle, almost ten segments, and such is the power of some 10 Copyright 2014 by Dr. Alejandro Elorriaga Claraco

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distal insertion sites. If we didn’t have any other insertion sites on the extremity and we wanted to put electricity here, we could use either the one that is already there or we can select another one. I’m going to go to the muscle-tendon junction of the supraspinatus muscle, which I will access through this large intestine 16 insertion site, and then I would use a stimulator and connect the two sites, negative distally to represent the actual polarity of the human body, which is more negative distally, and positive proximally even though they’re both negative and positive, as already explained, alternate current. And then we will turn on all the needles at 1 - 2.5 Hz, a very slow, comfortable stimulation that is going to add an extrasegmental or central factor into the equation. By using electricity, we are guaranteeing that the extrasegmental effect occurs. And electricity produces a neurocentral response. So now we have a combination with very simple design of neurostructural criteria, neuromechanical criteria and this neurocentral criteria. We have effect on the somatic nervous system, we have effect on the autonomic nervous system. We thought having a detailed knowledge of the pathomechanics of the problem, we are able to provide a neuromodulation that could be extremely to the patient, not just at the nociceptive level, decreasing the pain experience, but also at the true functional levels, improving everything neurologically and vascularly on the region. So we will now proceed to show the treatment from the other side. Now we are displaying the other side of the treatment, the posterior aspect, and we see the insertion site on the posterior capsule of the glenohumeral joint with the needle vibrating gently due to the electrical stimulation. And once again in this single insertion we are stimulating the posterior or lateral supraclavicular nerves, represented here. We are stimulating the axillary nerve, represented here, by going through the deltoid. We are stimulating the suprascapular nerve, represented here, by going though fibres of the infraspinatus, and we are reaching the sclerotomal level, the capsule of the glenohumeral joint. One single needle. We said that we could also combine this insertion site with a small intestine 9, or the way we defined it before a needle that will go through the long head of the triceps, the teres major, and therefore simultaneously will have effect on the radial nerve, lower suprascapular nerve. And now we can clip the electrode to both needles, and that way we cover more territory without needing more electrical stimulation. We also said that it’s possible to specifically deactivate a trigger point on the infraspinatus, on the infraspinous fossa, or we can add insertions that will target the dorsal scapular nerve such as the tenoperiosteal attachment of the levator, which is a common place for nociception, particularly when the mechanics of the spacula are heavily involved in the problem, or we can go an stimulate the rhomboid minor/major through motor points or try to target the trance of the dorsal scapular nerve. So we can target individual muscles. We can target the trance of the nerves that supply the muscles. Dorsal scapular nerve for levator scapulae, rhomboid minor, rhomboid minor, or suprascapular nerve for supraspinatus, infraspinatus. Those are the main nerves. The only one that we’re not able to represent here is the long thoracic nerve that supplies the serratus anterior, and that would be stimulated here on the side of the thorax and it would be done by putting the

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needle flat, threading the needle along the skin parallel to the plane of the ribs so with zero risk of pneumothorax, as this is a subcutaneous insertion. So these are other additions to the blueprint according to the presentation. We haven’t mentioned but we will now, that as part of the neuromechanical approach we can target anything that goes from the region to the next joint. For instance the bicep muscle. The biceps, which is not just an elbow flexor but is a muscle that crosses the glenohumeral joint, the long head of the biceps, therefore is both an elbow and a shoulder muscle. We could go to either the belly of the biceps, the long head laterally here, or we can target the musculocuteaneous nerve that supplies the coracobrachialis, the biceps and the brachialis and the skin of the distal aspect of the forearm, the lateral antebrachial cutaneous nerve. So the biceps could be a good addition to this blueprint based on neuro biomechanical considerations. Same applies to the long head of the triceps that both extends the elbow and also inserts above the joint line on the infraglenoid tubercle, and therefore participates in the movement of the glenohumeral joint. So biceps and triceps, they both connect in a physical manner, the glenohumeral joint with the elbow complex, and therefore they are good additions to the blueprint. That’s an example of how to combine the three blueprints, or rather the two blueprints that help us in the selection of the inputs. From a general blueprint that’s purely neurofunctional, local, axial and extrasegmental, we’ve arrived at a very detailed neurostructural and neuromechanical input with neurocentral component provided by electricity. This is a great way of covering all the relevant neurofunctional dimensions without needing a detailed anatomical diagnosis. This is an example of the axial input for any problem of the upper extremity, whether lateral epicondylar or median nerve-related or anything else. And a neurofunctional standard blueprint axial input will consist of two components, a segmental somatic anywhere above the C8 root, which is the end of the brachial plexus, and a segmental autonomic reflex vascular sympathetic, which will be from T1 to T5. And the most important obviously is the second one, as the first one I would select, and oftentimes I limit my input to those levels, two needles bilaterally. However, it’s also beneficial when the lower segments of the cervical spine are involved to also do that. So in this case we are going to go from approximately C5, and we use a [parvertivial] insertion that’s about one finger-breadth lateral to the spinous process. I felt quite a bit of resistance there. I have to palpate - yeah, because the drawing is not now accurate. This one is better. And then I’m going to do the segmental autonomic. We’ll have the first one between T1 and T2, approximately 1cm because remember, we have to pass through the extrinsic musculature of the back, the trapezius represented here, and then the rhomboid, and the serratus posterior superior because we need to reach the iliocostalis in order to be in contact with the posterior primary rami or otherwise we are not going to have a beneficial effect on the sympathetic nervous system. Here once again, this is the spinous process, one finger-breadth and here we go, and then we will connect. I’m going to do just one side and we will connect those needle to an electrical stimulator and we will do that bilaterally, and that would be the first input that we typically perform in most patients. So a segmental somatic and a segmental autonomic reflex vascular 12 Copyright 2014 by Dr. Alejandro Elorriaga Claraco

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sympathetic, bilaterally at a low frequency, 1 to 2 Hz during about ten minutes. That will prepare the whole traffic of nervous impulses between the upper extremity, the shoulder girdle and the spinal cord and will help normalize the abnormal activity that is taking place there secondary to whichever injury or chronic process was taking place. So this is the first part of every treatment of chronic condition for the shoulder upper extremity. [End of recorded material 01:12:02]

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5. Upper Extremity Section II. Lateral Epicondylar Problems (00:39:02) In this segment we are going to discuss the neurofunctional acupunctural blueprint for the treatment of lateral epicondylar problems. We will avoid the terminology epicondylitis because of in time, epicondylantia, which is a pure descriptive term, is more appropriate and there is no demonstrable inflammatory component. Therefore we’ll remain faithful to that terminology. Lateral epicondylar pain or lateral epicondylantia. The first blueprint we always discuss is our general neurofunctional blueprint with a local [opera-forensic mental] input, an axial or a spinal-segmental input and extra-segmental input. The elbow region and associated functional areas can be described anatomically as included joints of the elbow, the joints of the carpus that move the wrist and also it can include the joints of the glenohumeral region and the whole shoulder girdle, as that is part of the mechanics of the arm. From the neurostructural perspective that we always use to select the local input, we can start the analysis of the problem as usual with neurofunctional perspective movements that are involved in the pathology in the presentation of the problem. And they include flexion, extension, pronation, supination, as well as wrist dorsiflexion which involves carpal - radiocarpal joint as well as mid-carpal joint. So there, a good number of joints involved since pronosupination requires a coordinated action of three joints, the radio-humeral, the superior radioulnar and the inferior radioulnar. And therefore the complexity of the biomechanics of the elbow is sufficient to make the approach quite complex despite the reduced physical size of the area. Humeroradial joint, proximal radioulnar, distal radioulnar, radiocarpal and midcarpal, those would the most important joints. And regarding the muscles that provide the motion for these joints will include muscles that go from the humerus to the radius or the ulnar, sometimes even from the chest wall as the short head of the biceps or the scapula as the long head of the biceps. And those go from there to the radius and the ulnar. So we have physical linkage between the three segments, the three mobile segments of the upper extremity, and that makes the elbow a unique functional area, anatomically and neurologically. The muscles therefore are involved in elbow flexion. We have brachialis and biceps. We have elbow extension, mostly a function of the triceps and the inconnus, and then we have flexion on neutral pronosupination, function of the brachioradialus and the extensor carpi radialis longus and we have a number of muscles that provide the motor activity for wrist dorsiflexion, namely, apart from the extensor carpi radialis longus, the extensor carpi radialis brevis, the extensor digitorum, the extensor digiti minimi and extensor carpi ulnaris. Those would be all muscles acting on this joint and attaching anatomically on the lateral epicondyle of the humerus, which is the usual area for the pathological, pathomechanical changes at the structural level. Although in a neurofunctional model we are very concerned about the involvement of the many nerves that participate in the innervation of those structures.

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But at the patho-physiological level it’s important to point out that oftentimes we find degenerative tendinosis at the attachment of the common tendon that occurs at the lateral epicondyle, and this common tendon involves the extensor carpi radialis brevis, the extensor digitorum represented here, the extensor carpi ulnaris underneath the extensor digiti minimi. So those four muscles, and we also have one of the two origins of the supinator. This is all taking place at the lateral epicondyle, so no surprise with such an array of different muscles pulling from that area, that irritation and inflammation acutely, and then a chronic inflammatory infiltrate is common. However, the symptoms as usual occur because of the nerve involvement and the important thing to know is which nerves supply these muscles and which nerves supply the joint. The joints are supplied by two sources by the cutaneous branches that innervate the skin that covers the joint and by the motor nerves that innervate the muscles that move the joint. In this case, the cutaneous innervation we have represented here. This continuous yellow nerve is the posterior antebrachial cutaneous is a branch of the radial nerve - cutaneous branch of the radial nerve. We also have represented here as a solid line the muscular cutaneous nerve, terminal branch, which is the lateral and the brachial cutaneous nerve. So we have two cutaneous branches, sometimes overlapping in the territory. And those two, as they cross the joint, can give off articular branches. So we can act on the tranco musculocutaneous nerve higher up on the arm between the biceps and the brachialis. We can even go to the coracobrachialis on the anterior aspect of the shoulder. Once again, their anatomical connections between the shoulder and the elbow. We have represented here also the most important nerve in this pathology, which is the radial nerve. The [tranco] of the radial nerve, after passing along the spiral groove, it pierces the lateral septum and goes lateral to the biceps and the brachialis and here gives off several branches for the muscles that attach above the lateral epicondyle, the brachioradialis, the extensor carpi radialis longus, and then the nerve branches into two terminal branches. The first one, the motor branch, is the posterior interosseous nerve, approximately three finger breadths distal to the lateral epicondyle. They are at the level of the supinator. Between the supinator and the extensor al carpi radialis brevis is the arcade of Frohse, and there the nerve passes and pierces that space and continues as the posterior interosseous nerve all the way to the carpus, innervating all the extensor muscles of the wrist, and then providing articular branches for this joint. Therefore it’s an extremely important nerve. There is weakness typically of wrist dorsiflexion, sometimes there is inability to full extend the fingers when there’s an involvement of this nerve. So we need to involve this nerve and this will become the number-one input in neurostructural treatment of lateral elbow pain. The second branch of the radial nerve we’ve represented here along the medial edge of the brachioradialis and continues along the radius to innervate the dorsum of the V of the hand over the first and the second metacarpals, which are represented here by these branches over the first interosseous dorsalis muscle. Therefore, radial nerve is the master nerve of the lateral epicondylar problems and we can not only reach the nerve distally, as we can do here at the first interosseous dorsalis, the cutaneous branch, we can reach the nerve in different insertions that we’ll discuss in a minute over the lateral aspect of the forearm.

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But we can also go to the proximal aspect of the limb and get the radial nerve as early as its exit under the teres major and before it dives deep to the long head of the triceps and then to continue deeper against the humerus along the spiral groove. We can get it here at the septum where the nerve pierces the septum, so therefore whether we analyze the problem from an articular perspective, a muscular perspective or a neurological perspective, all points towards the radial nerve and specifically towards the posterior interosseous nerve. And structurally everything points towards the extensors, the common extensor, the extensors of the wrist. There are four movements of the hand involved and are important. And also everything points towards the participation of the supinator and the antagonistic muscle, which is the pronator teres. So we need to include in the treatment the stimulation of the median nerve, whether directly over the tranc or at the pronator teres. And here we have a list of the nerves we just discussed, the radial nerve, tranc, or the posterior interosseous nerve, the median nerve for the pronator teres, if we decide to go there, and then the cutaneous branches, the posterior cutaneous nerve of the forearm, the lateral antebrachial cutaneous nerve branch of the muscular cutaneous. With this we are well equipped and we have numerous insertion sites that I will discuss one by one in a second. Then, the addition of the spinal segmental level in the treatment, the axial input, will involve the C5, C8 segments, which they go from the shoulder, C5, C6, C7, C8. We could even include T1 because of the wrist extension. So those would be the segmental somatic levels. Therefore we will go to those vertebral levels and will stimulate the posterior primary rami at these levels. And then the segmental reflex vascular sympathetic level at the T1, T5 we can add a couple of needles bilaterally in order to facilitate the modulation of the sympathetic nervous system at these levels. From a practicalist standpoint, this treatment being confined to a limb, to an extremity, is easier because we can position the patient as is being done here, exposing most of the area that we need to access and then we can proceed with a blueprint that touches the most relevant neurostructural levels we just described. Depending on the history, depending on the findings we will favour a little more one approach or another, but basically we are going to have to address a radial nerve territory to matter what. One specific intervention that we may need to include at some point would be the treatment of trigger points, or tight bunts that may have developed associated with this muscle, particularly the extensor carpi radialis brevis. So sometimes we can find a very tight, tender snappy band here and we can use one of the techniques that we have to deactivate these trigger points. The inline technique, where we will put four needles on the tight band and then connect electricity cross two-and-two needles and put electricity and make the muscle fatigue, contract and finally relax. We can also use a two-needle technique, another good technique to deactivate trigger points, in this case we have two electrodes to the two needles that go into the trigger point, and it’s been proven to be empirically a very effective technique to deactivate trigger points with no known reason why two needles would work better than one with electricity. But it seems to work better. These are special interventions as well as tenoperiosteal [packing] at the attachment of the common extensor to stimulate the local cellular activity, which is a technique now improved further by certain practitioners who have - who use a galvanic current through the acupuncture 3 Copyright 2014 by Dr. Alejandro Elorriaga Claraco

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needle and the guided ultrasound and proceed to electrolize the tissue, the chronic inflammatory infiltrate on the lateral epicondyle, which allows then the neovascular activity and the new regeneration of the cells. Sometimes this technique has been combined with injection of growth factors or local cytokines and other structures that are going to stimulate cellular growth. Sometimes injection of plasma - extract of plasma or PRP injections have been utilized for the same purpose. So there’s a strong local component all located on the lateral epicondyle. Sometimes I’ve used the two-needle technique right on the epicondyle with a frequency ranging from 2 Hz to 125 Hz. Every ... of these interventions is an attempt to modify the stagnant cellular activity, which is the representation of the chronic inflammatory infiltrate. There is no regeneration, there is no positive cellular changes, just a chronic inflammatory infiltrate with low-quality granulation tissue and no proper vascularisation. And that irritates, changes the biochemical environment, irritates nociceptors on some of these structures, periosteum, tandems - capsule of the joint and dad nociception makes the brain produce inhibition of these muscles and therefore produce the functional incapacity that is the structural-neurological connection between these elements. The good news is that restoration of normal neuromotor function by itself can reduce the processing of nociceptive signals and the spinal cord decreasing the dysfunction and the symptom. So let’s see how we can execute a blueprint treatment for a lateral epicondylar problem. I would prioritize the radial nerve over other structures. Therefore I would always try to the posterior interosseous nerve. I would landmark at the lateral epicondyle and then I would go about three fingers breadth and then try to reach the nerve between the extensor carpi radialis brevis and the supinator. Definitely we may have [touched] a cutaneous branch ... is that burning a little bit, or? Okay, we can always use the monopolar stimulator to check whether what we’ve had is contact with a nerve. Is that too strong? Let’s re-position because our goal is always a painless needling, and since I want to electrically stimulate this needle I need to be very comfortable. So I will double-check. Is that better now? Okay, and we’ll leave it there. As the goal, the main goal in any treatment, acute or chronic, is always the modulation of sympathetic activity, one of the first needles - perhaps the first or second one should also go to the distal insertion on the dorsum of the hand where we can modulate sympathetic tone. The traditional large intestine 4 here, and the mid-level of the shaft of the second metacarpal in the belly of the first interosseous dorsalis. Again, this is a radial nerve territory ... and is also the motor point of the first interosseous dorsalis. Not a favoured insertion because it could be quite tender, so I’m going to reposition the needle. Let me know if that’s better there. So I’m just repositioning the needle, maintaining appropriate stabilization of the area and proof positive that we need to be very gentle on our technique, since a neurofunctional approach we don’t want to trigger more nociception. We are trying modulate nociception, therefore we need the insertions to be comfortable, okay? So we’ll leave it there. It is well on the belly. That’s fine. This one can be documented as a posterior interosseous nerve insertion or as a large intestine 10 prime. I will refer the traditional insertion sites but in our methodology we are targeting specific nerves.

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Now it would be useful to include some of the structure that had been innervated by the radial nerve above the posterior interosseous’ independent existence. And those include the supinator muscle, the extensor carpi radialis, longus, brevis and the brachioradialis. All those muscles have been supplied by branches that are above the elbow, therefore if we believe that there is an involvement of the supinator, as commonly is the case, then we must go to the track of the radial nerve approximately, or to the supinator muscle directly here on the lateral aspect of the elbow distal to lateral epicondyle. The supinator has a double origin. The supinator at the ulnar crease supinator crease of ulnar at the lateral epicondyle and at the radial humeral - radial ligament. And from there it goes over the radius to attach on the other of the radial so it’s able to pull the bone and roll in it, and producing that supination. It’s a very particular arrangement of the fibres of the supinator. It’s relatively simple then to reach it, so we can use the ulnar as a landmark. We can go from the ulnar towards the radius, and before we reach the radius, or as we reach the radius there, we should be on the motor point of the supinator. It’s a shallow insertion, there it is. And there it is. I felt the muscle jumping. We had a twitch response. That is the best possible corroboration of what we’re doing. I will very briefly put a very gentle electrical stimulation just to feel the muscle jumping. I feel it under my finger and that’s enough to confirm that I’m where I need to be. We can do these needle one by one with the monopolar stimulator or, since we need a fair amount of stimulation, as it’s trying to achieve changes in a chronic condition, then we will be better off using the regular stimulators. And here we can connect distal points with some of the promixal points. As discussed elsewhere, the connections just represent an intention and a polarity. So the intention is to pass electricity through the affected area. The polarity of the human body is negative more distally than proximally. I would to cross the joints. I would like to have something above the joint for that connection, and then I would like to connect this area with something that radial nerve tranc proximal, and that way we are crossing the area twice, at least with the cables. In actuality, electrons are going to be deployed from each of the insertion sites. So I will insert a needle on the traditional acupuncture point at small intestine 9 along the triceps - the long head of the triceps. That’s ... our model is a little sensitive but she has some pathology in the area so there is a degree of sensitization that needs to be expected in any patient with any chronic condition. Therefore it’s a good example of a real live situation and we need to accommodate the technique to the situation. As stated above it would good to go here just - let’s say the area is quite sensitive, which is the case. We don’t want to go in this case directly to the radial humeral joint, which we could in another situation. Instead, we are going to just try to intercept that the tranc of the radial nerve as the radial nerve goes from posterior to anterior, pierces the septum. And then I have something for my distal needle, and then I can use the other circuit as a bridge between these two ... and the tranc of the radial nerve. That’s too tight? Okay, so we can select one of the two there and then we can add more electricity if we need to do so, but this represents what we’re trying to accomplish. We are passing electricity along radial nerve territory. We’re passing electricity along the physical location of the most common [estrecal], the mention of the problem, which is the lateral epicondyle, the common extensor 5 Copyright 2014 by Dr. Alejandro Elorriaga Claraco

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tendon, and we are involved in the radial nerve from the posterial aspect of the shoulder. We could - we’ll leave this here as the example. We’ll use our model here. We could equally try to reach the joints by going to the anterior aspect of the radiohumeral joint, traditional insertion side along 5, which is located along the medial border here of the brachioradialis at the level of the antecubital fossa, is the trajectory of the - both the musculocutaneous nerve, the terminal branch, the lateral antebrachial cutaneous nerve, and deeper, the radial nerve. So it’s simultaneously - it’s an insertion site that keeps as the two important nerves for the supply of articular branches as well as direct contact with the capsule. It’s quite comfortable. Insertion is not a particularly uncomfortable one and it’s valuable when the sensitivity of the patient allows to do so. We could equally go into the annular ligament between the lateral aspect of the radius and the lateral epicondyle. That could be part of a packing technique or a technique to stimulate the local cellular activity. And then at the pure neurofunctional level, we could single every of the extensor muscles and then go to the motor points of the extensor carpi radialis brevis here at the junction of the outer third of the one-third for proximal and the one-third distal. We could go to the one-third of the forearm looking for the motor points of the extensor digitorum or lower to look for the extensor carpi ulnaris. And we could do those with the monopolar stimulator or we could connect that to a circuit like this. Having said that, we need to do something else. It’s not enough to target the relevant structures because the reason the body cannot - have not been able to regenerate the damaged tissue is become something at the metabolic level was not working in the first place. And that something typically is some sort of segmental dysfunction at the reflex-sympathetic levels at the T1, T4. Oftentimes we find that a chronic epicondylar problem is associated with chronic segmental dysfunction of the upper thoracic spine, which can be found by palpation, careful palpation that will demonstrate changes into the soft tissues at the subcutaneous level and could demonstrate restrictions and mobility could demonstrate tenderness. And therefore the inclusion of those segments in the examination and the treatment are very important. So any case of lateral epicondylar pain we also do an axial input. The axial input can precede this or sometimes we can put just unilaterally. It’s better to have a two-part treatment where we will put four needles along the C6 to the T4, and that way we cover the segmental somatic and the segmental autonomy. And after that first input we can then turn the patient around, so the first input will cover from C4 to T4, and then the second input will then ... the second input will then be done on the lateral recumbent and could include the tranc of the radial nerve and the joints and muscles associated with elbow extension, pronation, supination wrist dorsiflexion. Lateral epicondylar problems are difficult to treat because the local changes are sometimes difficult, if not impossible, to revert. Other techniques that we can integrate in this treatment include lidocaine injections include obviously the surgical resection of that tissue, or in recent years the electrolysis of the back issues and their guided ultrasound use in acupuncture, a needle procedure called EPI®, E-P-I, intratissular percutaneous electrolysis. And with that, we have a chance to regenerate the tissue and we stop the nociception. But even with that, we need to restore normal neuromotor activity and normal efferent activity on the affected segments.

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In some instances we will include, as part of the same treatment or another treatment, the antagonistic side and we’ll work on the flexors and we’ll work median nerve, depending on the activities that this individual is involved in. And we will make sure that the shoulder, as a biomechanical entity, is working properly and is not transferring some of the work of absorbing and this person’s reaction forces to the elbow. A strong shoulder, like a strong hip, protects the distal joint. Healthy knee requires healthy hip. Healthy elbow requires healthy shoulder. And finally, remember that the brachial plexus origin is on the spinal nerves on [TRMI] between C5 and T1, and therefore on the scalene between the scalenus anterior medius and the lateral aspect of the neck, we can sometimes find the dimension of the problem that was missing and which is the irritation of some of these nerve roots there. And that can be addressed with acupuncture manual techniques. So C5 to T1 laterally, biomechanically, the shoulder girdle neurostructurally, the radial nerve territory, the pronosupination and elbow flexion extension and the wrist dorsiflexion. Those are the complex dimensions of the symptoms that seem to be originated just by the tissues locally, but the experience has proven to us that has all these more broad and complex dimension. Extrasegmental inputs on the blueprint of lateral epicondylar problems can be included when the situation advises to do so. There are two different strategies for extrasegmental. If the main goal is just to modulate nociception, then you can go to the points on the ear, on the head that are going to produce central release of endorphins and accomplish the goal. They’ll be a simple stimulation of the concha for the vagus nerve participation in the modulation of inflammation and pain in general that are germinal area here on the upper part of the ear. So a couple of points would do it, and points on the head on different parts which have that central effect. However, there is another strategy that’s not as obvious but it’s of great value, and it’s the stimulation of the reflex adrenal region of the T10-L2. Why? Because the patient with a chronic condition, whether lateral epicondylar pain or back pain is always going to have a stress component and the stress component is going to be positively influenced by stimulation of this reflex area as well as the ear, so I would include, in addition the segmental somatic, segmental reflex vascular sympathetic, I would include these extrasegmental inputs that will add to the modulation of inflammation and the modulation of central processing of pain, neurohumoral processes. And I would use the same exact extrasegmental inputs for median nerve compression syndrome or any other chronic situation. This is an example of the axial input for any problem of the upper extremity, whether lateral epicondylar or median nerve-related or anything else. And a neurofunctional standard blueprint axial input will consist of two components, a segmental somatic anywhere above the C8 root, which is the end of the brachial plexus, and a segmental autonomic reflex vascular sympathetic, which will be from T1 to T5. And the most important obviously is the second one. That’s the first one I would select, and oftentimes I limit my input to those levels, two needles bilaterally. However, it’s also beneficial when the lower segments of the cervical spine are involved to also do that. So in this case we are going to go from approximately C5, and we use a [par-vertical] insertion that’s about one finger breadth lateral to the spinous process. I felt quite a bit of resistance there. 7 Copyright 2014 by Dr. Alejandro Elorriaga Claraco

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I have to palpate, yeah, because the [drawing] is not now accurate. We’ve moved our model so I’m going to reposition that. This one is better. That’s ... and then I’m going to do the segmental autonomic. We’ll have the first one in between T1 and T2, approximately one centimeter, because remember we have to pass through the extrinsic musculature of the back. The trapezius is not represented here, and then the rhomboid and the serratus posterior superior because we need to reach the ileocostalis in order to be in contact with the posterior primary rami or otherwise we are not going to have a beneficial effect on the sympathetic nervous system. Here once again, this is the spinous process, one finger breadth, and here we go. And then we will connect. I’m going to do just one side and we will connect those needles to an electrical stimulator and we will do that bilaterally. And that would be the first input that we typically perform in most patients. So a segmental somatic and a segmental autonomic reflex vascular sympathetic bilaterally at a low frequency, 1 to 2 Hz during about 10 minutes, that will prepare the whole traffic of nervous impulses between the upper extremity, the shoulder girdle and the spinal cord and will help normalize the abnormal activity that is taking place there, secondary to whichever injury or chronic process was taking place. So this is the first part of every treatment of chronic condition for the shoulder upper extremity. [End of recorded material 00:39:02]

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5. Upper Extremity Section III. Median Nerve Problems (00:27:41) In this segment we are going to review the neurofunctional acupunctural blueprint for the treatment of median nerve-related problems. I prefer that terminology to the more common carpal tunnel syndrome that assumes a specific pathomechanical origin of the median nerve pathology, while in actuality research has shown that there is a complex set of problems, including central changes in the brain as a result of prolonged neuro dysfunction on the median nerve. This is a unique situation where the nerve becomes the structure to be targeted. The neurofunctional blueprint, our blueprint number one, always includes the local input, the axial input and the extrasegmental input when appropriate. The local input is what level of peripheral segmental connection varies with a problem, and it can be defined as a neurostructural approach, and the axial input is neurofunctional based on the neurostructural. We can add a neuro-biomechanical approach in which not directly related to segmental structures have - they’re included in an extension of the neurostructural approach, which in this case is less applicable than in other conditions. Finally, the extrasegmental input have the goal of modulating central activity for two purposes. For purposes of pure neuromodulation of the pain experience of the neuromatrix, and secondly to support the system, the adrenal gland in particular, so the energy available for the patient is increased and lack of sleep that produces additional problems may improve, etc. So it’ll have a neuro-metabolic dimension. In this case they are all valuable, particularly because some cases of median nerve-related problems are metabolic in nature. As we know, the carpal tunnel syndrome in more frequent in diabetic people as well as during pregnancy secondary to the retention of liquids. So what are our targets for the local input? Well in this case we have a very specific target, the median nerve. And this specificity is structural but it can also be anatomically defined as inter-neural, things that happen inside the nerve, and perineural. Of course things that happen inside the nerve are outside the reach of our intervention but we can modify the perineuralist pace through electroacupuncture and manual techniques. And this is a unique opportunity to use this approach. Then non-specifically, any target that contributes to the so-called irritation of the median nerve will be a good neurostructural target. So any joints that anatomically along the pathway of the median nerve, any muscles, any neurovascular bundles that may be associated - in this case the brachial artery and other structures - and the soft tissues as well, include the scars from prior surgeries, etc. Axially, and that includes - we’ll review in a second our model, all these anatomical dimensions. The axial input at the segmental-somatic level includes obviously the brachial plexus, C5 to T1 because those are the levels of the median nerve. However, we will also include C1 to C4 because the neck, which is the physical origin of the cervical plexus is as well associated with the C1, C4 via the supraclavicular nerves for instance. Or the anterior primary rami that supply muscles of the neck, including the scalene that are at the core sometimes of the irritation of the median nerve.

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And finally the extrasegmental autonomic levels, the reflex vascular sympathetic at the T1, T5, and the extrasegmental that we briefly explained, consisting of either needles on the ear, needles on the head or the input for the adrenal system. So in a brief review of the main areas where the median nerve can get in trouble using the more mechanistic metaphor, although it’s clear that there’s a metabolic [in] general component, hydroelectrolytic balance problems, microvascular problems that can affect the median nerve and definitely people with axial problems at the cervical-thoracic junction and upper thoracic or more prone to suffer median nerve-related problems, which is often bilateral, proving the case that we’re presenting of the relationship between the nerve complaints and the state of the segments of the spinal cord and associated arterial structures that are associated with the median nerve. So in a brief evaluation of the trajectory of the median nerve from the roots of the C5, T1 here between the scalenus anterior and medius at the passage of the divisions of the brachial plexus under the clavicle. Or already under the pectoralis minor with the axillary artery where the median nerve is already formed, there along the medial aspect of the arm passing through the two bellies of the pronator teres and then dividing into the anterior interousseous nerve, which goes to innervate the flexor pollicis longus and pronator quadratus and the radial aspect of the flexor digitorum superficialis. Then the nerve can also be - this is the second branch, the median nerve proper, goes between the tendons of the flexor carpi radialis and palmaris longus and then passes through the carpal or under the ligament that formed the carpal tunnel and innervates the thinner muscles as well as the skein over the palmar aspect of the first three digits. So this nerve has motor fibres from the pronator, the flexor of the thumb, the pronator quadrates and all the flexors, excluding the flexor carpi ulnaris, which is supplied by the ulnar nerve. And then it supplies the thinner muscles and then it has a palmar branch represented here as it continues the line that supplies the skin over this area. But it stems from the nerve above the carpal tunnel so it’s necessary to have paresthesia on this territory to say that someone has a carpal tunnel, because you can have a true carpal tunnel and no paresthesias in the branch above is already being given off. So that’s why this terminology that assumes that all the problems are there is not appropriate. So what would be the targets other than the nerve itself along this trajectory? Obviously the nerve can be - and it’s reachable at the level of the antecubital fossa immediately medial to the pulsation of the brachial artery. So the nerve becomes now medial to the artery, so we go to the [bicis] aponeurosis, we palpate for the artery and we go medial. And that’s the traditional pericardium 3 and is the trance of the median nerve with its two terminal branches, the anterior interosseous and the median nerve proper. Then it’s reachable anywhere along the trajectory bisecting the dorsal aspect of the forearm, and definitely there’s a traditional insertion site three finger-breadths above the palmar wrist crease, which is pericardium 6. That’s quite a shallow insertion and it’s very reachable there, this is an excellent access for acupressure or pressure with devices that are either mechanical, electrical or magnetic that have been devices for the management of nausea and motion sickness. This is the traditional pericardium 6. The carpal tunnel itself can be a target. Pericardium 7 or [unintelligible 00:09:44] of the [hard] 7, the needle can be put there over the transverse carpal ligament.

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So we have the nerve itself as a target reachable in areas that are well known. In addition, and according to our non-specific approach, anything, any joint, any muscle that is associated with this trajectory could be a target. For instance we can have an individual with anterior forward posture of the shoulders with compression of the neurovascular bundle under the pectoralis major secondary to excessive tightness from typing, from having that position. So then the pectoralis minor would become one main target of the needle. The joints, even from the posterior aspect that will help reposition the whole girdle could be a target, so stimulating the rhomboids via the dorsal scapular nerve could be an indirect approach, and so on and so forth. So the analysis of the underlying condition is as important as a mere symptom-based approach. The blueprint again has been represented here by the trajectory of the nerve and everything biomechanically, anatomically or neurologically associated with the nerve. And oftentimes the best approach definitely is not to go to the nerve directly but to have an effect on the most proximal dimensions of the problem, specifically at the upper thoracic spine. The upper thoracic, the stimulation of the posterior primary rami produces neuromodulation of sympathetic nervous system, which facilitates the oxygenation, the vascular supply of the nerve, and that oftentimes is very beneficial. If [dippling] clavicular fractures with abnormal callouses, narrowing of the space there or tightness of the pec minor or tightness on the scalene, then it’s possible to work on this. So this upper part, even though the symptom is distal, it’s more important in my experience to produce a non-specific improvement of the environment of the nerve. If they’re intra-neural processes, that is going to be a different story and we’re going to need to do everything possible and then hope that the body can access that level and modify. So we have numerous acupuncturist strategies from direct stimulation of the [transverse] processes of C5, C6, C7 here affecting the scalenus medius, the line 2 or the muscle tendon junction of the pectoralis minor. That can be easily accomplished here and stimulation with a monopolar stimulator. And we can also put needles on the pronator teres. It’s one of my favourite targets since we’ve described it double-crunch syndrome where the nerve is thought to be compressed on the antecubital fossa and on the carpal tunnel. So this double-crunch syndrome that the surgeons are operating nowadays by releasing both the carpal tunnel and the pronator teres passage, we can mimic what the surgeon does with the scalpel, and with the needles we can try to relax the pronator teres. And it could be a very effective approach. The nerve is sandwiched between the flexor digitorum superficialis and profundus, that the profundus does the distal phalanx flexion and the superficialis the proximal interphalangeal, we can go for the motor points here. And then for the rest we can use manual techniques that will reorganize connective tissues along the whole trajectory of the nerve. And this comprehensive approach seems to have the best results. We’re going to proceed now to just demonstrate a few of these insertions, and obviously for these treatments we would need two time interventions, one for the back inputs for the segmental somatic/segmental autonomic, and that can be accomplished on one of the massage chairs where patients can lean comfortably forward, putting the head in a proper support, and sometimes even

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possible in that position to do some of the distal trajectory as well as the neck. If all you have is a treatment table then it requires definitely one prone position and then one supine position. So we going to just demonstrate the supine position and will ask our model to lie back. It’s important to have proper support of the forearm. It’s not ideal to have a full extension of the elbow, so in an ideal situation we will have something to support like that so there’s no tension along here. The same, if we’re going to do insertions on the neck we would need a relaxed position with proper access, particularly if we’re going to work on the neck. So here we have full access, even with the extension, and in this case the use of electricity needs to be carefully considered. Electricity for the axial component is very beneficial. However, electricity along the nerve itself could irritate the nerve and could have a negative effect on the modulation of nociception. So I don’t advise to put direct electricity over the nerve, particularly on the distal part, and I use electricity on the muscles, such as the pectoralis minor or the pronator teres that are associated with the nerve, and that’s the two insertions that I’m going to demonstrate now. So if use electricity of course very gentle and at a frequency that doesn’t exceed the 124 Hz, particularly if in a case of chronic median nerve syndrome. So let’s start with the most proximal, the pectoralis minor. The landmark is the coracoids process. We would go by palpation. These cases are very, very easy to identify. The tightness, the contribution of the pectoralis minor and then there it is, is the muscle tendon junction. You can feel the rather tendonous part. I don’t know if we’re going to get the - therefore a contraction. So once again you can always do a gentle manual stimulation, which I typically do with these patients on the first sessions until the sensitization is subsided. It will take tension from the neck. Our model also has real issues with the neck and the upper thoracic and therefore it doesn’t have a specific median nerve symptom but there is a clear sensitization of all the pathways, so we will refrain from using electricity. In this case, as I said, the most important input would be the axial input, and we will limit this to specific areas that have been identified as being contributors. So if the pronator muscle has been identified as being tight and we want to relax it, we can proceed. There it is. That’s a very well-tolerated needle in general and one of the safest to start a treatment. Pronator pectoralis major and minor, nothing necessary in between in general between the shoulder and the elbow. There are typically no major areas of constriction because the nerve and the artery travel freely, not compressed. And then from here to the carpal tunnel, manual techniques oftentimes are better than needling of the nerve because the retractions of the tissue respond better to gentle manual. However, I’d had some cases where I achieve significant benefit by doing a one-time needle on either the carpal tunnel - I remember a couple of cases - or the pericardium 6 areas. So there is value in every approach. It’s hard to give a certain guideline of what to do or not to do. My first approach is to calm down the sympathetic activity and to take out the general tension on the anterior aspect of the area and there just identify specific areas that can respond to my manual interventions and work the soft tissues. This is one complex situation where I combine both electroacupuncture with manual techniques, and I find that that is the best combination.

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In other instances of other syndromes, acupuncture can often be the single intervention that will make the difference. In this case it varies. I have cases where I was very successful with acupuncture. I have cases where I was not that successful. So truth be told, it’s a complex syndrome as you can see, involvement from the scalene to the carpal tunnel and requires a multidimensional approach. Metabolic needs to be changed because it’s at the core many times, and then the tension of the soft tissues need to be modified. The sympathetic needs to be modulated and in general the biomechanics of the whole extremity need to be improved. So postural changes, ergonomic changes - when people have carpal tunnel because they carry like [weighters] or weighters as they carry something repeatedly in this position with a nerve stretch or typists who are using short-range movements all day long. That requires work on the faschia. That requires work all along. And that is going to give us the key. By changing the perineural and then promoting the changes of the intraneural, which at the end are the origin of the symptoms. The fibres that will mediate the complaints of the median nerve will be not the actions of the median nerve necessarily, whether sensory or motor, but the little branches that supply the nerve itself called the nervi nervorum. Those are the real culprits of the symptom, not the absence of the median nerve. Which can be involved as well, and we can have motor deficits and we can have sensory deficits on the territory. But if pain is the most dominant syndrome then I would say it’s more a factor of the stimulation of the nervi nervorum that supply the nerve itself. And of course we have the vasa nervorum, the vessels that supply the nerve that can be affected because of the sympathetic nervous system. These regulations - and that makes this syndrome uniquely complex because we have the segmental somatic - the somatic nervous system involved but we have the sympathetic nervous system involved as well. So our advice is to take this broad approach, multidisciplinary and not purely anatomical, as every dimension can contribute. Not to say that sometimes a resolution of the syndrome is a surgical release of the ligament. Whether that was primarily the pathology or not, it seems in many instances to allow the nerve to recover from whichever internal process was happening, and we’ve seen many successful surgeries of median nerve compression syndrome or carpal tunnel. Particularly when the proximal aspect of the problem is released in these double-crash syndromes. This is an example of the axial input for any problem of the upper extremity, whether lateral epicondylar or median nerve-related or anything else. And a neurofunctional standard blueprint axial input will consist of two components. A segmental somatic anywhere above the C8 root, which is the end of the brachial plexus, and a segmental autonomic reflex vascular sympathetic, which will be from T1 to T5. And the most important obviously is the second one, as the first one I would select. And oftentimes I limit my input to those levels, two needles bilaterally. However it’s also beneficial when the upper segments or the lower segments of the cervical spine are involved to also do that. So in this case we are going to go from approximately C5, and we use a [parva tibial] insertion that’s about one finger-breadth lateral to the spinous process. I felt quite a bit of resistance there. I have to palpate, yeah, because the drawing is not now accurate with - move our model, so I’m going to reposition that. This one is better. And then I’m going to do the segmental autonomic. We’ll have the first one in between T1 and T2, approximately 1cm because remember we have 5 Copyright 2014 by Dr. Alejandro Elorriaga Claraco

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to pass through the extrinsic musculature of the back, the trapezius not represented here, and then the rhomboid and the serratus posterior superior because we need to reach the ileocostalis in order to be in contact with the posterior primary rami or otherwise we are not going to have a beneficial effect on the sympathetic nervous system. Here once again this is the spinous process, one finger-breadth and here we go. And then we will connect. I’m going to do just one side, and we will connect those needles to an electrical stimulator and we will do that bilaterally. And that would be the first input that we typically perform in most patients. So a segmental somatic and a segmental autonomic reflex vascular sympathetic bilaterally at a low frequency, 1 to 2 Hz during about ten minutes. That will prepare the whole traffic of the nervous impulses between the upper extremity, the shoulder girdle and the spinal cord and will help normalize the abnormal activity that is taking place there secondary to whichever injury or chronic process was taking place. So this is the first part of every treatment of chronic conditions for the shoulder upper extremity. [End of recorded material 00:27:41]

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6. Lower Back Section I. Low Back Pain Treatment (00:56:48) In this segment we are going to discuss the neurofunctional acupuncture blueprint for the treatment of low back problems, one of the most common clinical presentations in practice. Our neurofunctional blueprints can be generated using three different approaches that combined will form the inputs that we’ll demonstrate. The first one is a general neurofunctional segmental approach. We will select inputs according to the relationship between the problem and the innervation. This relationship can be established structurally or topographically simply going by the area. So it’s necessary to know well the dermatomal innervation, myotomal innervation and sclerotomal innervation as well as the peripheral nerve pathways in order to determine the relationships between a given problem and the central nervous system. This is what we call our categories of local inputs or peripheral segmental and they once again refer to the dermatomal, myotomal and sclerotomal levels and the so-called axial and trunk inputs that refer to the level of segmental innervation that correspond to those areas mentioned before but that in this case are connected by the posterior primary rami that innervate the paravertebral musculature. So the peripheral segmental input goes to a peripheral nerve. The axial and trunk input goes to a posterior primary rami or one of the intercostal nerves or one of the subcostal nerves or iliohypogastric, ilioinguinal on the interior abdomen. And then we can select inputs that have no segmental connection with the problem, so-called extrasegmental inputs and that are going to target the central nervous system in a nonspecific manner. This is our first level of blueprint. For the treatment of back problems we need to select local inputs and axial trunk inputs that are related to the problem. So we need define the problem in neurostructural dimension which is our blueprint number two. Neurostructural dimension refers to the combination of joints, muscle, tendons, peripheral nerves, peripheral neurovascular bundles and miscellaneous soft tissue interfaces and related soft tissue areas with the problem. So in order to have a neurostructural dimension, we need to define which joints, which muscles, which peripheral nerves. Low back pain is an extremely broad and complex subject. So keeping it relatively simple, the joints that can be involved in the genesis of low back pain include intervertebral joints, the zygapophysial joints, the sacroiliac joint. They are basically those joints, also the lower part of the attachment between the ribs and the thoracic spine can generate as well nociception that is perceived in the low back. The low back is a broad area between T9/T10 and the end of the coccyx. That is a low back. So these joints will be included in the neurostructural dimension. They are not all accessible, particularly without guided imagery such as ultrasound, but we know that they contribute to the problem.

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Then we have muscles and tendons. This is where neurofunctional acupuncture is going to have easier access because the muscles are all accessible. They are layered in multiple layers and they’re extrinsic muscles of the back which have not been represented here such as the latissimus dorsi. And then there are intrinsic muscles of the back that have been represented here such as the first layer of erector spine. Here we see the iliocostalis muscle. We see the longissimus and then we’ll have the spinalis here. And underneath we’ll have the multifidus, the rotatores and the intertransversarii and we’ll have splenius muscles, semispinalis in other areas of the back. So intrinsic muscles of the back are supplied by posterior primary rami all the way from the first C1 spinal nerve to the lowest of the spinal nerves at the coccygeal level. Peripheral nerves, there are four. In this case coincide with the nerves, the axial inputs because the back is an axially related structure. In this case we don’t have peripheral nerves from plexuses. We only have posterior primary rami supplying these structures which makes our task somehow easier. And finally, we have miscellaneous soft tissue related areas which can include scars from surgery, scars – the surgery can be a surgery for back problems, hemilaminectomy, laminectomy, etcetera. The surgery may be related to a visceral problem, kidney problem. Very frequently we see big scars here. This would be one level of connective tissue that we need to include in our treatment. Of course scars on the other side may have a role as well such as the C-section scars frequent in women and particularly back pain that has started after delivery by C-section it’s important to address those scars, appendectomy scars. Any scar on the trunk will be relevant as a potential source of nociception, direct nociception or indirect tension that produces nociception elsewhere. We have also areas such as frequently over the posterior superior [iliac] spine that have suffered trophic changes that are biochemically altered and therefore any nerves in the area are abnormally activated, any nociceptors. It is important to treat these abnormal trophic areas and that’s part of the blueprint from the neurostructural standpoint. Going back to the neurofunctional segment of the blueprint, important to point out that the vessels that supply the blood with the oxygen and nutrients to all the structures that we just mentioned, articular structures, muscle structures, peripheral nerves, all these vessels, arterial network, are supplied by sympathetic neurons that are at different levels than the somatic neurons that supply the structures. These sympathetic neurons have two way – a two neuron pathway that starts at the spinal cord between T10 and L2 intermediolateral column and from there the neurons go and connect with [preganglionic] and from there the neurons go to the vessels. So the levels of T10/L2 are reflex sympathetic vascular levels in relation to the lower back and the whole lower extremities because the spinal cord ends around L2 in the adult. All the segments that supply all the somatic levels up to the S1/S2/S3/S4, they’re condensed between the T10 and L2 vertebral levels. Therefore, this becomes an extremely important reflex area and I would say the number one target and the number one input in a neurofunctional blueprint for the treatment of back problems. And we’ll start writing T10/L2, our first level. Then we have a neuro biomechanical level which involves the same categories of the structures as the neurostructural but not directly related to the symptom. In this case it -2-

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would be anything on the lower extremity, on the kinetic chain. Any alterations on the gait secondary to abnormal mechanics of the foot or the ankle region, knee problems is going to affect the way forces arrive to the lower back and are absorbed and dispersed by these tissues, therefore it’s going to have an influence. Particularly on the pelvic girdle we see motor deficits of the big extensor, the gluteus maximus is going to overload the paraspinals and is going to transfer load to these smaller muscles therefore overloading them and producing nociception. So it’s very important to treat anything on the kinetic chain that is going to have a direct or indirect effect. In this case it’s both direct effect and indirect effect. Direct effect because many of the structures here share segmental innervation with the lower back. This would be an S2 dermatome for instance and that would be on this area which is commonly one of the symptomatic areas. So combining neurostructural directly related to the problem with neuro biomechanical directly and indirectly related to the problem we can design very specific local inputs or as specific as possible even in the presence of a structural disruption or structural problems that are not changeable, for instance, an osteoarthritic joint, for instance the result of a surgical repair with a fusion of a segment that can no longer be mobilized, etcetera. The neurofunctional approach allows us to design treatments that will modify nervous system activity regardless of the state of the structure. And that requires now a simplification, useful simplification. In addition to these levels we are going to use extrasegmental points that will for the chronic condition be along the extremity and we will explain which levels and why. Or for acute problems could be on the head, on the hands, on other parts of the body, extrasegmental inputs. I’m going to discuss the blueprint for sub-acute and chronic conditions. So in this case I’m going to write down the main targets for our local inputs. Local inputs should include the following nerves. First, remember the local inputs equal segmental somatic inputs. And remember also that we said that we need to add as axial inputs the segmental vascular sympathetic at the T10 and L2. So this could be our first input. Four needles, T10/L1 or T11/L2 bilaterally. That could be our first input combined with a segmental somatic depending on the perceived origin of the pain. If it’s intervertebral joints of certain level, L4 and 5, L5/S1, we will do that. We will put needles there. That would be the basic blueprint. So we will have the needles at the segmental sympathetic, reflex vascular sympathetic. We would have four needles at the segmental somatic levels if they are different or clearly identified. With this we cover a broad area from T10 to typically L5. This is a good approach because regardless of the pathophysiology of the problem we are going to be modulating activity on relevant nerves. Now, particular details on the innervation of the back include the understanding that the level of L2 the spinal cord ends and therefore all the remaining nerves, L3/L4/L5/S1, etcetera, required to go distally to find their exit and therefore we have – in the spinal canal below L2 what we have is a collection of spinal nerves. No longer we have a spinal cord. There’s no spinal cord in the adult beyond L2. These spinal nerves will exit and we can see for instance here on our model how the posterior primary rami of L1/L2/L3 form the superior culneal nerves. They pierce the fascia of the lower back and they pass over the ilia crest and they supply the skin over this area. The posterior rami of L4/L5, they don’t have cutaneous dimension. We see a representation of other -3-

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posterior rami, T12/T11/T10 with a lateral and a medial division. These cutaneous branches and this could be cutaneous as well as motor. There are motor branches for every level for the intrinsic musculature. All we have to do to reach those branches is to insert a needle right at that level. And that typically is selected based more on palpation than on symptom presentation because low back can be perceived in many different areas. It can be concentrated over the posterior superior [iliac] spine. It can go across the whole low back. It can be concentrated over the sacrum. Different individuals experience different low back patterns. Therefore the best policy, the best blueprint should be to always include levels from T10 to L5. Not to forget the sacral levels since the multifidus origin is over this sacral foramina and this sacral foramina have the posterior rami of S1/S2/S3 with a lateral division forming the inferior or the medial culneal [left] nerves and the medial division that supplies this multifidus. So not to be ignored the fact that the sacral levels of innervation also affect the intrinsic musculature of the back. This would be all the direct approach to the muscles related directly with the mechanics of the vertebral column. And we will proceed after we finish with our review to insert the needles. So we should in addition to the intrinsic muscles of these levels, the posterior primary rami from these levels for the purposes of both somatic modulation anywhere from L2 distal or from autonomic modulation between T10 and L2, autonomic and somatic both, apart from this local input we should add electricity. Electrical stimulation of the needles is going to add a signal that as we review elsewhere is going to reach the brain and produce a nonspecific response, neurohumoral response that’s going to be beneficial for the control of inflammation as well as for the control of general sympathetic activity. Therefore, electricity adds a valuable stimulus to the needle. One to 4Hz is the preferred frequency. In specific cases we can increase the frequency to 80Hz to stimulate presynaptic inhibitory gabaminergic neurons or we can use a 15 to 30 Hz to promote spinal secretion of encephalin, endorphin , other substances. However, a low frequency seems most of the time sufficient to provide the additional benefit at the neurohumoral level. Having said that, back problems are much more from the biomechanical standpoint than problems of the intervertebral joints. Indeed, research supports the idea that the back is more the victim than the cause of the problem. The victim of a combined weakness of the posterior chain, the [antigravity] chain that has to constantly fight gravity and which involves joints from the interphalangeal joints of the toes all the way to the intervertebral joints of the occipital-atlantal joint. So that is the whole antigravity chain. If there are areas in the antigravity chain that are weak, then the transfer of reaction forces to other regions is going to overload structures that are not prepared to take that. In this case the main area that we see in practice is inhibited and it’s not contributing to this work on the posterior chain is the big gluteus maximus as well the additional extensor and stabilizer, the gluteus medias and the gluteus medius underneath. These muscles are supplied by two nerves, superior gluteal nerve for the gluteus medius, gluteus minimus and also tensor fascia lata and the inferior gluteal nerve for the gluteus maximus. These two nerves stem from the pelvis above and below the level of the piriformis muscle. That would be the piriformis muscle here above superior gluteal -4-

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nerve, below the inferior gluteal nerve plus the big sciatic nerve that is going to later on split into the two components, common fibularis nerve and tibia nerve. Therefore the activation, the stimulation of these nerves in every low back problem has proven in our experience to be an extremely effective manner of restoring biomechanical function, neuro motor function along the posterior chain. Therefore, a typical low back pain treatment blueprint at the local level would look something like this. We could start with eight needles that we refer to. We would landmark the T10 by going to the inferior margin of the ribcage which coincides with the level of L2 and then we can count two levels above, L2/L1/T12/T11/T10. Three – three, four levels above. And therefore, from T10 to L2 we have the reflex vascular sympathetic area. We would insert the needles about one finger breadth from the midline because our goal is to stimulate the medial division of the posterior primary rami as this division has proven to have more sympathetic fibers and a relationship with the sinuvertebral nerve which innervates zygapophysial joint and other structures often involved in the nociception, the genus of the nociception in low back problems. So here it is. The needle goes through the extreme thick muscles. So the back first layer and then it lands in the longissimus or if we go a little more lateral iliocostalis. I would make sure I cover this level unless there is a specific segmental problem lower. I would put from T10 to L2/L3 my eight needles, four and four bilaterally. So this is the first input that routinely acute chronic first treatment or many treatments we utilize. In addition to the reflex sympathetic vascular dimension there is another reason for using this input and this is the intimate relationship between these levels and the most important endocrine gland, the adrenal gland. Since any person who has any overload of the adrenal gland because of chronic stress will experience difficulty with the anabolic processes it’s important to stimulate these levels trying to promote a better function of the adrenal gland. So patients with low back problems present typically with fatigue. Patients with fatigue suffer low back pain more often than people with full energy and therefore this becomes the golden mile of the back at the level of T10/L2 because of the reflex relationship with the adrenal gland where the steroids, hormones are synthesized, where the mineralocorticoid and metabolism also is controlled by the hormones secreted there, where cortisol involved in the control of inflammation is secreted and even where the kidney is there, erythropoiesis takes place and the ability to supply oxygen. So all general functions of the body depend heavily on the function of the adrenal gland. And this simple reflex stimulation is no universal panacea but is a great jump start for a system that’s still functional but is not functioning at the available levels. We will complete the circuit so we can wire the – put the wires with the electrons and see how the real treatment looks like. Exactly like this. Very simple input but potentially very beneficial. Nonspecific but very, very beneficial for the autonomic and endocrine dimensions of the problem. We’re not searching nociceptive sources at the muscle, tendon, ligament, joint. We’re looking for neuromodulation at the most relevant somatovisceral, visceral somatic levels which are the connections between information from the musculoskeletal system and the viscera at those levels related to the adrenal gland.

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In addition to these needles, we can target specific structures that are innervated by making receptors and have proven practice to be of great value. Structures at just the posterior sacroiliac ligament or the ligament that connects the transfer process of L4 with the ilia crest, the transverse – the iliotransverse lumbar ligament. Also it’s possible to go in between the spinous processes and stimulate the supraspinal and intra spinous ligament. Ligaments are of great value. It’s difficult and according to the literature not possible without guided imagery but it can attempted to go to the capsule of the sacroiliac joint at the level of the medial aspect of posterior superior [liga] spine and aiming obliquely posterior and lateral. At any rate, will be through the fibers of the posterior sacroiliac ligament and will have neuro modulatory effect on that area. And a final caveat, never to use this capsular structures when there is sacroiliitis that is associated with any of the connective [apathies] that typically present, ankyloses, spondylitis or similar. This is a very good complement to our other neurofunctional input. We need just one stimulator in order to cover the eight needles because we can clip two needles together. That’s what was represented there at the board. And here we have. We alternate the polarity. It doesn’t make any difference. These stimulators are alternate current. Electrons come from each of the electrodes therefore the visual display is no representation of the direction of the current. The current goes everywhere from each of the needles as electrons are dispersed from each alternatively. So they cover the whole area. We could cross the cables. We could put the two blacks one side, the two reds, it would make no difference. Electrons will come from all the needles. So this is the first input. I would use a low frequency, turn it on and leave it there for 12, 15 minutes. At the same time, I would like to target these two very important nerves, superior gluteal nerve, inferior gluteal nerve. For that we need longer needles since these nerves are deeper buried into the – or covered. Buried into the gluteus maximus, the inferior gluteal nerve and covered by it the superior gluteal nerve. So let’s go to the inferior gluteal nerve. At the level of the sacrococcygeal joint six, seven finger breadths from the midline there imagining that we are targeting the [unintelligible 00:30:29] piriformis foramen. We can insert this 75 needle and we can always with the monopolar stimulator assess that we have contacted the nerve. In this case we don’t get any motor response so we may be a little bit too low. I’m going to change the angle of the needle. I think we’ve contacted something. There it is. And we should some motor … I feel the motor activity is not very strong. Let’s see the next needle. We aim to the superior gluteal nerve, the level of S2/S3, again about six finger breadths for the trunk and then if we wish to do so we will add needles along the trajectory. So we can always double this insertion, this a little further laterally aiming towards the gluteus medius, maybe even the minimus. And we can add another one more for the outer fibers of the gluteus maximus. And putting four needles is quite [inefficient] because at least two of these needles should produce motor activation. We’re going to recycle this stimulator and show how the connections could be. Same idea. Two needles together. It makes no difference. It’s just to save electrodes. And then we’re going to turn this on and see if we can get any activity. And we can see the motor activity there. Not too strong. We’ll ask our patient is that okay? Female Voice: Yeah. -6-

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Not too strong. And then – so this is – we can turn it off now. This is the basic pattern for the initial input, blueprint for the low back pain. Make sure we cover the T10/L2. Make sure we activate all the gluteal musculature. In addition, if there is specific nerves that we want to target related to the intrinsic musculature such as the multifidus, if we are dealing with more sacral pain associated with an accident or delivery that can involve a structure such as the posterior sacroiliac ligament or the sacraltuberous ligament or the multifidus here, then by all means we could and we should target those nerves. You can feel the foramina, guess the foramina and there is no danger aiming towards the exit of the sacral nerve. Since we practice a painless needling technique and we don’t aggressively manipulate the needle there is no contraindication. As long as there is no pain, no discomfort, the needle is not going to cause any harm. So we can do that as well as use the same inputs when we’re dealing visceral problems that are associated with the same segment. So any viscera supplied by the parasympathetic, by S2/S4 such as the descending column, the uterus, the ovaries, the prostrate, the bladder, can be stimulated by putting needles at this level, S2/S3/S4. Any viscera, kidney, adrenals, transverse colon that are supplied by these segments can be [reflex] stimulated by putting the needles in the same exact area. And sometimes patients present with a combination. Women with dysmenorrhea have low back problems. Women with pelvic pain, they have back pain as well. Both sides are part of the same neurological equation and when we turn our patient to the other side we will see how to influence the same segments from the anterior rami, from the subcostal nerve, from the peripheral nerves such as the iliohypogastric, ilioinguinal and even the femoral nerve that we can include in these treatments. We can also see in the drawing that beyond the intrinsic musculature of the back we have a wall musculature which consists of three layers, the internal oblique we can see in the depth of this triangular space, the external oblique and of course underneath the transversus abdominis. And even deeper we’ll have here the quadratus lumborum that will go from the ilia crest to the costal margin. All those muscles can be included in a treatment of back problems. Sometimes a small hemipelvis, a postural problem can produce trigger points in any of these muscles. These trigger points have been well described by [Traval] and can be found in her books, the pattern. And they can be treated with acupuncture needles with or without electricity depending on the trigger point. If we find a trigger point in any area we just target the trigger point which oftentimes coincides with a motor point and we can treat the trigger point with a monopolar stimulator. We can test and then we can just treat it. We can inject lidocaine in the trigger point. We can inject saline. There are different methods to treat the trigger points. But definitely some back problems are associated with trigger points. The trigger point may not be the primary cause but is now the cause of the symptom. Obviously the trigger point has been produced by something else, some dysfunction that needs to be evaluated and treated if at all possible by appealing to the third blueprint level not to be forgotten, the neuro biomechanical level. It’s a very good indirect approach. Sometimes we don’t focus on the back other than this thoracolumbar reflex area and the posterior chain and we focus on improving the mechanics of the lower extremity. We put patients in programs that strengthen the legs. And by strengthening the legs the back receives better support and that seems to be in clinical practice one of the best approaches, better than chasing pain at the local level where so many structures can be at one time activated and nociceptors being sending

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information but it’s not relevant information from the standpoint of the dysfunction that is at the core of the problem. Now, there’s also great value in using reflex distal points that are well known to modulate activity, nociceptive activity in the low back. Some of them have clear segmental connections with the low back so it’s no mystery. At the minimum, any insertion site that has an artery such as the popliteal fossa, the traditional bladder 40, such as the posterior tibial artery, here at the classical kidney three, they both are going to have a connection, segmental connection with the T10/L2 reflex vascular sympathetic level. In addition, at the somatic level the nerves on these areas at the popliteal fossa, the tibial nerve is going to have a segmental relationship with anything from the L4 to the S3 level. And the same with the tibial nerve here which is the same nerve just in a different location. So we see that selecting distal stimulation sites that are neurovascular in nature produces a double gain because we not only modulate activity at the somatic level, but also we add a modulation, very important modulation of the sympathetic nervous system that is also at the core of many dysfunctions. Improper oxygen supply, by improper control of the vascular – of the vasomotor tone is one of the main problems. If we take an infrared thermography of a chronic low back, we will see cold areas, areas of the deep tissue that are not properly vascularized and that are not receiving enough oxygen for a proper metabolic activity. In addition to these distal points which can be two per leg bilaterally … So we could use the trunk of the tibial nerve at the popliteal artery on the posterior aspect of the knee. It can be also the kidney three on the medial aspect of the talocrural joint. A substitute for this could be the traditional spleen six which is the same nerve trunk but a few centimetres above. It could be for acute conditions, the sural nerve at the traditional insertion site bladder 60 which has proven to have a good neuro modulatory effect of nociception in acute conditions. It can be the trunk of the common fibularis nerve at the level of the fibula whether posterior or anterior. That has proven as well to have a valuable supra segmental, supraspinal effect. Again, these points can be connected to a stimulator at a low frequency. We are just for illustration purposes using one leg to the other. That could be done as well. There is no contraindication to do it this way. It just would need more electricity. And we would do it bilaterally. This will add an extrasegmental component. So at the core strategy of the blueprint is the use of low frequency electrical stimulation because that guarantees that the central nervous system is going to have a neuroendocrine, neurohumoral response that’s going to be very beneficial for the whole system. At the patient level the pain is just one component of the problem. Fatigue and sleeping problems, mood disorders, etcetera, is also part of the equation and can be beneficially affected by these extrasegmental inputs. So the basic extrasegmental input is just the use of electricity anywhere because by virtue of using the electricity we’re stimulating the brain and associated areas. So on posterior side as well, we could oftentimes include a hip treatment if this low back is associated with hip dysfunction which is a common condition and elsewhere

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we’ve described how to approach this articular dimension we just mentioned here that should be done, can be done as part of the same treatment. This position allows us to treat comfortably for the 15, 20 minutes that these bigger inputs require. However, should not be the only position of treatment because there are extremely valuable neurological and muscular structures on the other side that at the functional level can add a lot to the equation. For instance, at the core of a functionally deficit in the low back is sometimes the weakness of the abdominal muscles, particularly the deep abdominal muscles, transversus abdominis and the obliques. Also the pelvic diaphragm very frequently damaged during delivery is critical in the maintenance of the proper pressure that allows the proper function of the intrinsic muscles of the back and needs to be retrained and sometimes repaired surgically when it’s been damaged. So there are a number of biomechanical related issues that need to be addressed and acupuncture, our neurofunctional acupuncture blueprint can be expanded by adding the structures on the other side and we will do that in the next segment. An important part of the neurofunctional acupuncture blueprint for the low back and a not very well known strategy but very effective is the inclusion of the abdominal wall on the treatment. That stimulates all the neuro motor function of the abdominal wall muscles as well as provides additional neuromodulation for the – some of the most commonly involved segments in the low back problems as we discussed elsewhere, particularly the involvement between T10 and L2. We have here a summary of the main abdominal muscles that we are going to include in the input. The least valuable perhaps is the rectus abdominis and the most valuable are the transversus abdominis internal oblique and external oblique also gets involved. Innervation is provided by the intercostal nerves at different levels, T5 to T12 for both rectus abdominis and external oblique and then internal oblique according to different books from T8 or T10 to T12 which coincides with the critical reflex area for the adrenal glands as well as branches of the L1 from the lumbar plexus, the iliohypogastric and ilioinguinal nerves that also supply the transversus abdominis as well as the genital femoral nerve which is another L1 related segment and the T7/T12. So basically the lower part of the T spine, the anterior rami, as well as the upper part of the lumber plexus. The strategy is simple. Needles will be inserted trying these muscles. Penetrate the abdominal muscles at different levels. The muscles – some of the nerves come above the ribcage. I like to concentrate on the segment between the ribcage and the ilia crest because that’s the safe insertion. I use four needles on each side. Sometimes I double to eight needles if I really need a broader stimulation. And the goal is to have contraction of either the external oblique, the internal oblique, the transversus or all of the above. And rarely, I seek contraction of the rectus. But also, in cases of motor inhibition or diastasis after delivery, pregnancies, delivery, stimulating the rectus abdominis can be a good strategy to neuromodulate the segments. The representation of certain nerves here. We have the iliohypogastric nerve with the lateral branch. The ilioinguinal nerve would be inferior and deeper and travel along the inguinal canal. And these are just the motor branches of the lower thoracic nerves, the subcostal nerve, the T11, and these are the cutaneous branches. -9-

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So the goal is to get the needle through at least two or three of the layers of the abdominal. I like to start with the midaxillary line and palpate a little bit where the transition of the wall takes place. And there from the subcostal margin to the ilia crest, I thread the needle obliquely passing through several levels. If I feel at the end of the insertion an elastic resistance, I know I may have reached the fascia transversalis which is exactly what I want to do because I’m going to stimulate all the layers, external oblique, internal oblique. I move the insertion a little bit anteriorly just keeping with the silhouette of the abdominal wall there coming towards the iliac crest and trying to include the iliohypogastric nerve in the equation. The ilioinguinal nerve is not possible to directly stimulate as it inside the ligament. Let’s see what we’ve accomplished with those two pairs of needles. So I hook them to the stimulator and then using a low electric frequency, I see whether I’ve accomplished any motor activity. I don’t see any movement. There it is. Slight movement. Now, do you feel that? Is that okay? Not too strong. There it is. So we see the internal oblique because it’s pulling the abdominal wall in that direction. And that would be a successful stimulation. You don’t feel the external oblique yet. It’s all the internal oblique here. That’s not too strong? Female Voice: It’s alright. Okay. So if we want to add a second line, I would proceed along the same line approximating the attachment of the external oblique on the rectus, perhaps keeping it a little further away to make sure what we include the motor branches because otherwise the motor branches have ended at that level. So perhaps we should go back a little bit. And since we’re using several needles, one or more are going to stimulate the desired motor nerves. It’s not particular difficult to obtain that response. Just make sure the needle goes through all the layers and here we are. And then we’ll check the second with the same or we can combine. We can combine the stimulation of these needles with these needles but just for the testing purposes we’re going to see if we’ve accomplished the same or different. That too strong? Female Voice: [unintelligible 00:52:02] So we see how this is a transversus because there’s no movement on the superficial and you can see the other needles vibrating because the fascia is being pulled by the contraction of the transversus abdominis deep there. So this is a very good response, an ideal response, and we can combine the stimulation. See how the needles go out so easily? It’s a really comfortable insertion and it’s because of the oblique direction. If you wish to go perpendicular, particularly for the rectus – so you’re looking now for the motor stimulation. We go to the middle of the belly of the rectus and we’ll try to seek contraction. We can see that faster with the monopolar stimulator. We didn’t accomplish that here. Let’s try again and perhaps a little closer. The motor point of the rectus is in the middle of the belly. So we will … We don’t see a contraction there and we’re going to then reconsider the palpation without using the drawing which is more distracting than helpful and I think we may be better off there. A little contraction but we’re not getting a full contraction. As usual, motor stimulation

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may require several needles along the same line and that’s how usually we get contraction by covering enough territory. As I said, the value of the rectus is lesser than the value of the obliques but still it has a good potential value. Let’s see what we’ve accomplished with these needles. And we don’t see. Do you feel it? Yup. So we don’t see the stimulation. However, if it was just for the purpose of neuromodulation of the segment that would be enough but I prefer to see the muscles contracting as is most of the time the case with external, internal obliques and transversus. So needles on the abdominal wall from the margin of the ribcage to the anterior superior [liga] spine will stimulate the lower branches of the thoracic interior intercostal nerves, the subcostal nerves and then the iliohypogastric and the ilioinguinal nerves, indirectly the ilioinguinal, directly the iliohypogastric, and that will have a great modulatory effect on the T10/L1 segment which is critical apart from the good neuro motor modulation that will add to the biomechanics of the back. Therefore, I advise to include in the blueprint of the treatment of low back anterior abdominal wall stimulation as well as the stimulation of the femoral nerve for the purposes of normalizing the iliopsoas activity as well as work on the kinetic chain on the anterior aspect the same fashion we did on the posterior aspect. And only then we will cover the three levels of the blueprint that we established, the neurofunctional level, the neurostructural level and the neuro mechanical level which all combine plus the modulation of visceral activity and the modification of the diet sometimes and the modification of the behavioural pattern will produce the better results. It’s not a treatment that can be done simply addressing nociceptive information. It has to be a global treatment with a very strong local component designed following this three level blueprint that we present. [End of recorded material 00:56:48]

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6. Lower Back Section II. Abdominal Inputs (00:11:46) An important part of the neurofunctional acupuncture blueprint for the low back and a not very well known strategy but very effective is the inclusion of the abdominal wall on the treatment. That stimulates all the neuro motor function of the abdominal wall muscles as well as provides additional neuro modulation for the – some of the most commonly involved segments in the low back problems as we discussed elsewhere, particularly the involvement between T10 and L2. We have here a summary of the main abdominal muscles that we are going to include in the input. The least valuable perhaps is the rectus abdominis and the most valuable are the transversus abdominis, internal oblique and external oblique also gets involved. Innervation is provided by the intercostal nerves at different levels. T5 to T12 for both rectus abdominis and external oblique and then internal oblique according to different books from T8 or T10 to T12 which coincides with the critical reflex area for the adrenal glands as well as branches of the L1 from the lumbar plexus, the iliohypogastric and ilioinguinal nerves that also supply the transversus abdominis as well as the genital femoral nerve which is another L1 related segment and the T7/T12. So basically the lower part of the T spine, the interior rami, as well as the upper part of the lumbar plexus. The strategy is simple. Needles will be inserted. Try in these muscles penetrate the abdominal muscles at different levels. The muscles – some of the muscles come above the ribcage. I like to concentrate on the segment between the ribcage and the ilia crest because that’s the safe insertion. I use four needles on each side. Sometimes I double to eight needles if I really need a broader stimulation. And the goal is to have contraction of either the external oblique, the internal oblique, the transversus or all of the above. And rarely, I see contraction of the rectus. But also in cases of motor inhibition or diastasis after delivery – pregnancies, delivery, stimulating the rectus abdominis can be a good strategy to neuromodulate the segments. The representations of certain nerves here. We have the iliohypogastric nerve with the lateral branch. The ilioinguinal nerve would be inferior and deeper and travel along the inguinal canal. And these are just the motor branches of the lower thoracic nerves, the supracostal nerve, the T11, and these are the cutaneous branches. So the goal is to get the needles through at least two or three of the layers of the abdominal. I like to start with the midaxillary line and palpate a little bit where the transition of the wall takes place. And there from the supracostal margin to the ilia crest, I thread the needle obliquely passing through several levels. If I feel a the end of the insertion an elastic resistance, I know I may have reached the fascia transversalis which is exactly what I want to do because I’m going to stimulate all the layers, external oblique, internal oblique. I move the insertion a little bit anteriorly just keeping with the silhouette of the abdominal wall there coming towards the iliac crest and trying to include the iliohypogastric nerve in the equation. The ilioinguinal nerve is not possible

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to directly stimulate as it is inside the ligament. Let’s see what we’ve accomplished with this two pairs of needles. So I hook them to the stimulator and then using a low electric frequency, I see whether I’ve accomplished any motor activity. I don’t see any movement. There it is. Slight movement now. Do you feel that? Is that okay? Not too strong? There it is. So we see the internal oblique because it’s pulling the abdominal wall in that direction and that would be a successful stimulation. You don’t feel the external oblique. Yeah, it’s all the internal oblique here. That’s not too strong? Female Voice: It’s alright. Okay. So if we want to add a second line, I would proceed along the same line approximating the attachment of the external oblique on the rectus, perhaps keeping it a little further away to make sure that we include the motor branches because otherwise the motor branches have ended at that level. So perhaps we should go back a little bit. And since we are using several needles, one or more are going to stimulate the desired motor nerves. It’s not particularly difficult to obtain that response. Just make sure the needle goes through all the layers and … Here we are. And then we’ll check the second with the same or we can combine. We can combine the stimulation of these needles with these needles. But just for the testing purposes we’re going to see if we’ve accomplished the same or different. That too strong? Female Voice: [unintelligible 00:07:0] So we see how this is the transversus because there is no movement on the superficial and you can see the other needles vibrating because the fascia is being pulled by the contraction of the transversus abdominis deep there. So this is a very good response, an ideal response, and we can combine the stimulation. See how the needles go out so easily? It’s a really comfortable insertion and it’s because of the oblique direction. If you wish to go perpendicular, particularly for the rectus, so you’re looking now more for the motor stimulation, we go to the middle of the belly of the rectus and we’ll try to seek contraction. We can see that faster with a monopolar stimulator. We didn’t accomplish that here. Let’s try again and perhaps a little close. The motor point of the rectus is in the middle of the belly. So we will … We don’t see a contraction there and we’re going to then reconsider the palpation without using the drawing which is more distracting than helpful and I think we may be better off there. A little contraction but we’re not getting a full contraction. As usual, motor stimulation may require several needles along the same line and that’s how usually we get contraction by covering enough territory. As I said, the value of the rectus is lesser than the value of the oblique but still it has a good potential value. Let’s see what we’ve accomplished with these needles. And we don’t see … Do you feel it? Yup. So we don’t see the stimulation. However, if it was just for the purpose of neuro modulation of the segment that would be enough, but I prefer to see the muscles contracting as it’s most of the time with external, internal obliques intersperses. So needles on the abdominal wall from the margin of the ribcage to the anterior superior iliac spine will stimulate the lower branches of the thoracic interior intercostal nerves, the subcostal nerves and then the iliohypogastric and the ilioinguinal nerves, indirectly

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the ilioinguinal, directly the iliohypogastric, and that will have a great modulatory effect on the T10/L1 segment which is critical apart from the good neuro motor modulation that will add to the biomechanics of the back. Therefore, I advise to include in the blueprint of the treatment of low back anterior abdominal wall stimulation as well as the stimulation of the femoral nerve for the purposes of normalizing the iliopsoas activity as well as work on the kinetic chain on the anterior aspect the same fashion we did on the posterior aspect. And only then we will cover the three levels of the blueprint that we establish. The neurofunctional level, the neurostructural level and the neuro mechanical level which all combine plus the modulation of visceral activity and the modification of the diet sometimes and the modification of the behavioural pattern will produce the better results. It’s not a treatment that can be done simply addressing nociceptive information. It has to be a global treatment with a very strong local component designed following this three level blueprint that we present. [End of recorded material 00:11:46]

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