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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 neuro-modulation 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 electro-acupuncture 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.

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.

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

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.

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

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

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