knees up mother brown! marion richardson. the st albans and harpenden acupuncture knee clinic

Knees Up Mother Brown!Knees Up Mother Brown!

Marion Richardson

The St Albans and Harpenden The St Albans and Harpenden Acupuncture Acupuncture Knee ClinicKnee Clinic

Why acupuncture?Why acupuncture?

An ancient art

Well tried & tested

Cost effective

Patient choice

A last ditch attempt

Local practitionersSafe

Cost-effectivenessCost-effectiveness

Lindell (1999)o patients in GP settingo acupuncture OR hospital OP referral or procedureo acupuncture costs significantly less o average saving/patient £232

No UK studies specifically focussing on knee pain but back pain study (Thomas et al, 2005) incremental QALY costs compared favourably with other NHS approved treatments

Reinhold et al (2007) Eur J Health Economics o Acupuncture + usual care cost effective in OA knee

Why acupuncture?Why acupuncture?

An ancient art

Well tried & tested

Cost effective

Patient choice

A last ditch attempt

Local practitionersSafe

SafetySafety

Yamashita et al (2006)o No serious adverse events reportedo Minor side effects – worsening of pain,

haematoma, dizzinesso May be unrelated to physiological action of

acupuncture per seWhite (2007) Evidence from UK

o Negligible risk in hand of competent practitioners

Why acupuncture?Why acupuncture?

An ancient art

Well tried & tested

Cost effective

Patient choice

A last ditch attempt

Local practitionersSafe

Eastern or Western therapy?Eastern or Western therapy?

Dampness in the spleen meridian?

OR

Osteoarthritis of the knee?

Why OA knee?Why OA knee?

Common Debilitating Older population with co-

morbidity NSAIDs can be harmful +

lack of evidence of long-term effectiveness

Surgery may be suboptimal , has relatively high rates of complications and is expensive - £5633 (PBC tariff 2008/9)

Is there research evidence?Is there research evidence? Large cohort, high quality RCTs

o Vas et al (2004) Acupuncture vs a sham needle – better for pain, improved function and decreased use of diclofenac

o Berman et al (2004) – Acupuncture improved function and pain relief compared with sham acupuncture and education control groups

o Witt C et al 2005 - Acupuncture significantly better than sham for pain and disability

Systematic Review (White et al, 2007) Acupuncture significantly superior to sham and to no intervention in improving pain and function in severe OA knee

How are patients referred?How are patients referred?Via MSK CATSClear criteria

o maximum tolerated analgesiao woken at night o restricted walking distance (eg 100 m)

Contacted by MSK CATS ES physioOffered acupuncture & choice of surgeryAppointment made by surgery

The clinics The clinics

Nurse ledInitial personal consultation‘Trial’ session of acupunctureGroup clinicTreatment protocolAssessment using MYMOP

The clinics The clinics

Nurse ledInitial personal consultation‘Trial’ session of acupunctureGroup clinicTreatment protocolAssessment using MYMOP

The clinics The clinics

Nurse ledInitial personal consultation‘Trial’ session of acupunctureGroup clinicTreatment protocolAssessment using MYMOP

The clinics The clinics

Nurse ledInitial personal consultation‘Trial’ session of acupunctureGroup clinicTreatment protocolAssessment using MYMOP

Treatment protocolTreatment protocol

4 sessions at weekly intervalsReassess and either

o continue with manual acupunctureo add electroacupuncture and reassess

Treatments at extending intervalsMYMOP assessment at 6 monthsMaintenance every 6 weeks or less

frequently

Treatment protocolTreatment protocol

4 sessions at weekly intervalsReassess and either

o continue with manual acupunctureo add electroacupuncture and reassess

Treatments at extending intervalsMYMOP assessment at 6 monthsMaintenance every 6 weeks or less

frequently

Is it working?Is it working?

Numbers treated to end of Augusto 63 patients (44F, 19M)o 98 knees (35 both)o Age range 48 - 93

Numbers still being treatedo 52 patientso 80 knees

Success contd.Success contd. Those referred back to MSK CA(T)S

o 1 worse after treatmento 6 insufficient symptom reliefo 1 wanted surgery (despite considerable improvement)

o 1 initial improvement not maintainedo 2 repeated DNAo 1 problems getting to surgeryo 1 GP disapproved of acupuncture!

Success contd.Success contd. Saving money?

o 1 TKR = 282 treatmentso 28 patients for first 6 monthso 35 patients a year AT LEAST longer term

o Both knees = 1 treatment o 12 knees maintained for 1 year and avoiding TKR =

an annual saving against tariff of £67,356 Other potential savings

o OPD consultationso Physiotherapy interventionso Medications

MYMOP scoresMYMOP scores

Overall score (max 24, min 0)o Pain (0-6)o Stiffness (0-6)o Activity (0-6)o Wellbeing (0-6)

Drugs for conditionImportance of cutting down

MYMOP scores difference at MYMOP scores difference at 4 weeks4 weeks

01234567

89

10

Worse -1 -3 -5 -7+ -14+

What are the perceived benefits?What are the perceived benefits?

Reduce the demand for outpatient, inpatient and day case treatment and so either save the cost of those activities and/or reduce waiting times

Reduce the need for operative interventions especially knee surgery

Reduce referrals to the West Herts physiotherapy service and thereby reduce waiting times

Promote a Secondary to Primary shift of care in line with the aims of government, Investing in Your Health and PCTs

Enhance patient choice and ensure a service that is locally accessible to patients in line with the stated aims of the government and local health economy

Reduce expenditure on medication

Let the patients speak…Let the patients speak…

“In 2003 I was diagnosed with severe osteoarthritis in both knees and was told that the condition would deteriorate and my only recourse was painkillers and eventually replacement knees. The provision of acupuncture on the NHS has transformed this prognosis. Acupuncture eased the pain and discomfort to such an extent that I was able to take up regular exercise to strengthen my muscles. Nowadays, I rarely take painkillers and the flexibility in both knee joints has improved dramatically.

Attending the acupuncture clinic in the GP’s surgery is beneficial for several reasons: the surgery is local; the acupuncture is given as part of a treatment programme particular to each patient’s medical history; the patient has confidence that the acupuncturist is well-trained and has a medical background and patients feel more comfortable in familiar surroundings. Group sessions are therapeutic in encouraging patients to share their experiences.I feel privileged and lucky to have benefitted from acupuncture on the NHS and hope that it will continue and its availability become widespread throughout the country.” Valerie Lucien 18 August 2008

AcknowledgementsAcknowledgements

Dr Jonathan Freedman, Parkbury House Pam Richmond – Nurse Acupuncturist Drs James Ferguson, Michael Cannell, Andy Cohen –

the Midway Surgery St Albans Dr Mike Cummings - BMAS Medical Director Dr Saul Berkovitz - Consultant RLHH Katrina Power – Commissioning Lead West Herts PCT Dr Mark Bevis – MSK CATS GP Lead Sally Allan – Extended Scope Practitioner MSK CATS

Any questions?Any questions?