Diagnostic Acupuncture/Manual

Therapy Exam (DAPE)

CVMA Program

October, 2012

Tim Holt, DVM

Diagnostic Acupuncture/Manual

Therapy Exam (DAPE)

Derived from a Japanese approach to acupuncture

Emphasizes palpation of tissue to arrive at a diagnosis of organ, joint, or muscle imbalance

Assists to identify local tissue swelling, pain, changes in texture, heat, and lack of motion.

– Segmental Dysfunction (SDF)

Findings may indicate local or referred

The DAPE

No diagnosis off of one reactive point

Put the entire picture together with multiple reactive points and clinical presentation/complaint

Advantages include – Ease of exam

– Body palpation

– Evaluation of trigger points

– Identifying Segmental dysfunction (SDF)

– Guidance to biomechanical relevance to dysfunction elsewhere in the body

DAPEUtilizes pressure, palpation and touch of over 200 diagnostic acupuncture points for reactivity

An accumulation of input from many including but not limited to Dr. Peggy Fleming, Dr. Marvin Cain, Dr. Phillip Rogers, Dr. Pam Muhonen, Dr. Kevin Haussler, Dr. Allen Schoen, and me

This exam is only a guideline for further evaluation

To Perform the DAPE

Use any type of blunt object (needle case) to apply pressure along the body

Use about three pounds of pressure when doing the exam in a uniform manner

If sensitivity is found stop and apply direct pressure to that point to better evaluate

See Movie

Location of

Diagnostic Acupuncture Points

Schoen, A. Veterinary Acupuncture:

Ancient Art to Modern Medicine. Mosby, St. Louis, MO, 2001

Many references available with much variability

Chi Institute

www.tcvm.com

Myofascial Pain Syndrome

Trigger Points

MPS develops as a result of the activation of C afferent Nociceptors at trigger point sites in muscle

The pain may be abolished by means of stimulating cutaneous and subcutaneous A delta nerve fibers with dry needles

Flishie & White, Medical Acupuncture: A Western Scientific Approach. Churchill

Livingstone, London, 1998Robinson, Narda. Veterinary Acupuncture Course Notes, Colorado State University, 1999-2007.

Trigger Point

Hyperirritable point within a muscle

Can be locally painful or have a characteristic referred pain

Possibly caused by:– excess release of acetylcholine from

dysfunctional motor endplate

– abnormal contracting regions of the motor endplate or muscle tissue

– spontaneous electrical activity of muscle

Trigger Point Therapy

Palpate trigger points (TP)

TP’s are easy to treat and results are good

Look for TP’s away from primary site of pain,

Trigger point at SI-9, deltoid and triceps area

– Lumbo-sacral pain

– Sacroiliac pain

– Coxofemoral pain

– Pelvic/sacral pain

SI-9

Common Equine

Trigger Points

Triceps brachii, infra/supraspinatus, Deltoids,

Extensor carpi radialis, Trapezius,

Brachiocephalicus, Gluteus medius, Iliocostalis

lumborum, Longissimus, Multifidus, Quadriceps

femoris, Semitendinosus-membranosus, Psoas

major, Iliacus, Iliopsoas, and Biceps femoris

Treatment of trigger points

– Acupuncture, manual therapy techniques at point and

joint around point

Trigger Points

Doing the DAPE

To record an objective pressure sensitivity an algometer can be used

The algometer also allows non-bias evaluation following therapy, that day or later exam

Wagner pain test algometer

800-345-4188

http:www.paintest.com

Algometer use

Apply pressure with

algometer

monitoring pressure

Observe for pain reaction record reading

LI-18Ipsilateral forelimb, foot

BL-19, BL-20, BL-21Ipsilateral hock, stifle, lateral

hip, stomach (ulcers),

GI motility, local muscle

pain, saddle fit

DAPE sweeping motion

SI-9shoulder, pelvic pain

BL-39, BL-40hock, stifle

SI-9 Is often a region of intense

trigger points and can be very sensitive, use caution

Reactive Points

Identify regions of segmental dysfunction

Identify a sensitive or painful response to pressure– Muscle fasciculation's

– Tail swishing

– Biting, kicking, rearing, collapse

– Mild changes in posture

Use caution not to diagnose normal panniculus response for a sensitive reaction

Reactive Points

A true reactive point will be seen at the point of pressureMuscle fasciculation away from the pressure is not a responseA reactive point may be reactive for a number of reasons including– Local pain

– Trigger point

– Saddle fit issues

– Somatovisceral reflex response

– Referred pain

– Compensatory pain

DAPE

evaluation of

ST-7

ST-7- Local TMJ

- Unilateral positive

- Teeth

- Unilateral positive

- Pelvic pain- Unilateral negative- Bilateral positive

Right side Neg. Left side Neg.

Bilateral Pressure Positive Head Going Up

Evaluating Space Between

Caudal Ramus and Cranial Wing C-1

- Personality???

- Pathology??

Palpating for trigger

Point, Infraspinatus

muscle

Isolating point for treatment:

- Muscle spindle cell work

- Pressure

- Manual therapy

- Acupuncture

- Massage

- Heat

- Anti-inflammatories

Muscle Spindle Cell

Receptor that has the greatest influence on central nervous system integrity

Designed to register changes in muscle length and joint movement

The muscle groups that have the most fine motor control have the largest number of muscle spindle cells

Neck vs. gluteus

Muscle Spindle Cell

3-12 small intrafusal fibers anchored at the polar ends of the receptor

Large diameter 1a afferent nerve fibers that wrap around the central region of the intrafusal fibers

Gamma motor neurons that innervate the polar ends of the intrafusal fibers

Muscle Spindle Cell

Relaxing the muscle spindle cell

treating the tight muscle or trigger point

- Isolate trigger point or tight pathological muscle group

- Hard inwardpressure into muscle

Relaxing Muscle Spindle Cell

- Inward pressure

thumbs push together

- Contracts muscle

spindle cell

- Relaxes alpha motor

neuron

- Muscle relaxes

- Do opposite to tone up

muscle

Another means of treating

tight sore muscles or trigger points

Myofascial rolling

Specific Vertebral Regions of Pathology

and Common Presentations

L-1—L-4

– Chronic colic, renal disease, saddle pain

L-4—6

– Trigger points, soft tissue pain

Intertransverse Joints

– DDx SI pain, hunched back, loss of performance

L-S

– Loss of speed and performance, extreme pain non block-able, unable to drop in rear

Specific Vertebral Regions of Pathology

and Common Presentations

T-18—L-1– Chronic colic

T-15– Increase in symptoms associated with heart, lung,

pericardium, local pain, and rib issues

T-11,12,13– TMJ, cribbing, ulcers

T-3,4,5,6,7– Refusal to jump

– Tripping

– Non blockable lameness

Questions

References

1. Schoen, A. Veterinary Acupuncture: Ancient Art to Modern Medicine. Mosby, St. Louis, MO, 2001

2. Filshie and White. Medical Acupuncture: A Western Scientific Approach. Churchill Livingstone, London, 1998

3. Gatterman, Meridel. Foundations of Chiropractic Subluxation. Mosby, St. Louis MO. 1995

4. Kamen, Daniel. Animal Chiropractic, Learn the Methods Seminar. 1995

5. Veterinary Manual Therapy Course Notes, Colorado State University. 2001

6. Giniaux, Dominique. Advanced Equine Veterinary Manual Therapy, Colorado State University, 2001.

7. Robinson, Narda. Veterinary Acupuncture Course Notes, Colorado State University, 1999-2007.

8. Schwartz, Cheryl. Four Paws Five Directions, Celestial Arts Publishing, Berkeley, California, 1996.

9. Kendall, Donald. Dao of Chinese Medicine, Oxford University Press Inc., New York, 2002

References (Continued)

10. Maciocia, Giovanni. The Foundations of Chinese Medicine,Longman Singapore Publishers (Pte) Ltd, Singapore, 1989. 11. DeStefano, Carl and Martin, Dan. Course Notes: Applied Kinesiology I & II, May 2002.12. Denoix, Jean-Marie and Pailloux, Jean-Pierre. Physical Therapy and Massage for the Horse, second edition, Trafalgar Square Publishing, North Pomfret, Vermont, 2001.13. Giniaux, Dominique. What the Horses Have Told Me, Xenophon Press Cleveland Heights, Ohio, 1996.14. Haussler, Kevin, ed. The Veterinary Clinics of North America –Equine Practice – Back Problems, W.B. Saunders Company, Philadelphia, Pennsylvania, April 199915. Fleming, Peggy, Equine Atlas of Acupuncture Loci, Florida Equine Acupuncture Center, Dade City Florida.