More on Munger's Mental Models and Acupuncture

My post yesterday was a riff on Charlie Munger and his use of mental models. Why is this of interest? I am searching for workable models to use for acupuncture and thereby improve its efficacy. I also think that the models for Western Medicine are breaking down in various ways and to varying degrees. They are still the best we have, but they are inadequate and have been corrupted by moneyed interests to boot.
Example:
At the ISAMS conference, I presented a poster on Heart Rate Variability and its correlation with clinical outcomes in my private practice clinic. Professor Longhurst was interested in the poster in so much as he came over a number of times to argue with me. He has done yeoman's work on hypertension and cardiac health and acupuncture. His argument was that since I used manual and not electroacupuncture, I was not getting a sustained stimulation so I couldn't draw any conclusions. His argument makes sense according to his mental model; i.e that acupuncture works by stimulating nerves under the meridian. My models say that that's part of it, but after reading a textbook on Immunology and the Skin describing what happens when one gets a sunburn, I would posit that there are cascades of immunological healing effects that happen with the tiny injury of placing of a needle. (This is the model that could account for the non-specific needling effects seen with acupuncture.) Also, as I've written about repeatedly on this blog and in my research I think that the decrease in the stress response can account for the variety of conditions treated by acupuncture from panic attacks to allergy to sciatica.
Models are extremely important, because without them how can we improve outcomes? When it comes to Longhurst's model it worked in this study on hypertension, but to use electroacupuncture routinely in the clinic, especially for musculoskeletal pain can lead to severe aggravation of symptoms, which, naturally enrages the patients. Not good clinically nor for business... Electroacupuncture is used on lab animals all the time and they don't seem to be enraged, but maybe they have a stronger placebo effect?? I kid.
The mental models used in Traditional Chinese Medicine, also do their best to make sense of health and healing in their own ingenious way and have structured their models completely differently than the models of Western Medicine. It is a struggle to use models that don't fit with our models, but on the other hand there is a constraint of thinking in only using the traditional models again and again if they are failing. For failing models you need look no further than Avastin, temporal artery surgery for stroke prevention, or stents to name a few.
More on my practice here.

Treating Hypertension (High Blood Pressure) in the Acupuncture Clinic

This is the abstract from a study on hypertensive patients from Professor John Longhurst's lab. It is a sort of summary of his findings discussed here and here.
A few comments... He uses electroacupuncture because he says it's easier to make it standard across patients. This was something I noticed repeatedly at the conference: most researchers are using electroacupuncture. I had a few different discussions with Dr. Longhurst, and he thinks that if you don't do electroacupuncture, you're really not stimulating because the stimulus goes away during the session. I don't agree with that. I think that the needles provoke a "micro-injury" just by being there and work just fine, even if you don't repeatedly stimulate them. Manual acupuncture, without electro, is my standard operating procedure. I use electro acupuncture if I'm following a specific protocol, for example for infertility or PCOS, or in musculoskeletal cases where the patient has reached a "plateau." I hardly ever start with electrical stimulation because of the tendency for it to aggravate the condition and the patient. I would never have the heart to do electrical stimulation at P6, as they do in this study. It's such a sensitive spot, I will try their other choice of LI11 and LI10 which is equally effective according to their work.
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Acupuncture Treatment of Hypertension
John C. Longhurst, MD, PhD and Peng Li, MD, Department of Medicine, University of California, Irvine
Heart disease in both men and women has become the major cause of death and disability in both developed and developing countries. Coronary atherosclerosis, the leading cause of heart disease, has a number of risk factors that increase its incidence. These include hypertension, hypercholesterolemia, diabetes mellitus, family history, obesity, physical inactivity and chronic stress. Hypertension, in particular, is reversible if patients are treated early and blood pressure is lowered to normal levels. Although a number of drug therapies have been shown to be valuable in lowering this risk factor, many patients do not take medications faithfully because of their common side effects and need for daily dosing. As such, there is a strong rationale developing alternative regimens to control blood pressure. One such therapy is acupuncture. Acupuncture is a form of integrative medicine that has substantial evidence demonstrating its mechanisms of action to lower sympathetic outflow, one of the major causes of elevated blood pressure. For example, studies in our laboratory show that, through an opioid mechanism in the brain stem, acupuncture can lower reflex elevations in blood pressure. Furthermore, we have shown that low frequency, low intensity electroacupuncture at some acupoints, such as P5-P6 and S36-S37, is most effective in lowering elevated blood pressure for prolonged periods of time. In the last decade several studies have been conducted showing that acupuncture is capable of lowering blood pressure to a small extent for the period of time during which it is applied. Although these studies indicate a possible role for acupuncture in treating hypertension, they have been confounded by use of a variety of different acupoints, some of which may not have strong cardiovascular actions, use of manual acupuncture, which unlike electroacupuncture cannot be standardized between patients, the use of very frequent acupuncture, which because of patient incompliance could limit success for long-term treatment, and the absence of regular follow-up, which does not provide an understanding of the duration of acupuncture’s action. To overcome these obstacles, we have embarked on a program of treatment of patients with mild to moderate hypertension using 30 min of low intensity (2 mA), low frequency (2 Hz) electroacupuncture at P5-P6 and S36-S37, a modality and site of action that we have shown has the greatest action on sympathetic outflow and elevated blood pressure in our experimental studies. Furthermore, all patients were off antihypertensive medications for the duration of the study and agreed to acupuncture treatment once weekly for an eight week period with a further follow-up for an additional eight weeks to determine acupuncture’s duration of action. Ambulatory automated blood pressure monitoring demonstrated that both average and 24 hour peak systolic and mean arterial blood pressures were lowered by electroacupuncture after 4-6 weeks of therapy by as much as 11-18 mmHg and that the duration of action of lasted for up to 4 weeks after termination of acupuncture in 73% of individuals treated. Conversely, 69% of a group of control hypertensive subjects treated at LI6-LI7 and GB37-GB39 (cardiovascular inactive acupoints demonstrated in our experimental studies), , did not demonstrate any change in blood pressure. These studies, guided by our results in experimental studies, suggest that low intensity and low frequency electroacupuncture applied once weekly at 2 acupoints demonstrated to have a strong influence on sympathetic activity after 4-6 weeks demonstrate a profound and prolonged antihypertensive response in many patients with mild or moderate hypertension. Additional work is needed to determine the optimal frequencies of repetitive stimulation during the initial period of intervention as well as during follow-up therapy for reinforcement of the blood pressure lowering action of acupuncture. Supported by grants from the NIH, HL063313 and HL072125-10, the Dana and Adolph Coors Foundations.

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Neuro Pathways in cardiovascular electroacupuncture response

Technical article looking at low frequency electroacupuncture in cats at P5 and P6 and the brain circuits responsible for the cardiac sympathoinhibition. Cardiac sympathoinhibition is another way to say a decrease in the stress response. The last blog post was looking at overall increased sympathetic tone in PCOS patients. This particular treatment at P5 and P6 might help to further decrease sympathetic tone in addition to the protocol described by Stener-Vitorin.
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Nucleus raphe pallidus participates in midbrain-medullary cardiovascular sympathoinhibition during electroacupuncture.
Am J Physiol Regul Integr Comp Physiol. 2010 Nov;299(5):R1369-76. Epub 2010 Aug 18.
Li P, Tjen-A-Looi SC, Longhurst JC.

Susan Samueli Center for Integrative Medicine, Department of Medicine, School of Medicine, University of California, Irvine, Irvine, California 92697-4075, USA. pengli@uci.edu
Abstract:
We have shown that electroacupuncture (EA) inhibits sympathoexcitatory rostral ventrolateral medulla (rVLM) neurons and reflex responses following activation of a long-loop pathway in the arcuate nucleus and ventrolateral periaqueductal gray (vlPAG). Additionally, EA at P 5-6 acupoints (overlying the median nerve) activates serotonin-containing neurons in the nucleus raphé pallidus (NRP), which, in turn, inhibit rVLM neurons. Although direct projections from the vlPAG to the rVLM exist, it is uncertain whether an indirect pathway through the NRP serves an important role in vlPAG-rVLM cardiovascular modulation. Therefore, the splanchnic nerve (SN) was stimulated to induce cardiovascular sympathoexcitatory reflexes, and EA was applied at P 5-6 acupoints in a-chloralose-anesthetized cats. A single-barreled recording electrode was inserted into the NRP or rVLM. Microinjection of DL-homocysteic acid (DLH) into the vlPAG increased the NRP neuronal response to SN stimulation (5 ± 1 to 12 ± 2 spikes/30 stim). Likewise, EA at P 5-6 for 30 min increased the NRP response to SN stimulation (3 ± 1 to 10 ± 2 spikes/30 stim), an effect that could be blocked by microinjection of kynurenic acid (KYN) into the caudal vlPAG. Furthermore, the reflex increase in blood pressure induced by application of bradykinin to the gallbladder and the rVLM cardiovascular presympathetic neuronal response to SN stimulation was inhibited by injection of DLH into the vlPAG, a response that was reversed by injection of KYN into the NRP. These results indicate that EA activates the vlPAG, which excites the NRP to, in turn, inhibit rVLM presympathetic neurons and reflex cardiovascular sympathoexcitatory responses.