By Marissa GraceLatin: Acus (needle) Punctura

Values Assessment: Continuum…….

Cognitive Objectives

• List 3 stated benefits of acupuncture. • Define sham acupuncture.• Describe what Qi is. • Identify the most significant adverse effect

related to safety and explain what it was related to.

• Explain which treatment application (Back pain, OA of the Knee, or PONV) has the most evidence of benefits based on results, strengths and limitations.

Origins

• Trace back more than 2000 years in China• 6th Century spread to Korea and Japan • 8th and 10th Century trade into Vietnam • 16th Century Western France by Jesuit

missionaries • 1972- Visit to China from President Nixon-

– Member of US Press Corps with emergency appendectomy received acupuncture.

– Experienced shared with New York Time

Stated Benefits

• N/V after chemotherapy

• Back Pain• Osteoarthirtis• Preop surgery pain• Addiction• Stroke• Headache• Menstrual Cramps

• Tennis elbow• Fibromyalgia• Asthma• Carpal Tunnel

Techniques and Practices

• Sham acupuncture

• Okibari - Japanese style

• Moxibustion

• Cupping

• Electroacupuncture (EA)

Needles• Needles made of flint, thorns of plants, bamboo

slivers or bone • Very fine and flexible about 1/2in (0.6cm) to 1 ½

in (38cm)• Attract or disburse energy along meridians• FDA approved needles by use of licensed

practitioners in 1996. Sterile, non toxic, single use only

Tools of the Trade http://www.lhasaoms.com/

Traditional Chinese Medicine

• Qi: Life force, vital energy behind all physiological processes.– warms body, pathogen protection, promotes

growth– Meridian network system – Disruption of flow results in illness– Mechanism of Qi still mysterious

Traditional Chinese Medicine

• Meridians– Term for each of 20 pathways through body

for flow of qi, accessed through acupuncture points

– 12 main and 8 secondary– Up to 2000 points along meridian complex – Points regulate different areas of the body

Theory

• Stimulation of the nervous system to release chemicals in the muscles, spinal cord, and brain. – Beta-endorphin

• Analgesia.

• Placebo effect.

Is acupuncture safe? A systemic review of case reports

Lao L, et al. Alt Therapy in Health and Med Jan/Feb 2003:9,1:72-83

• Method– 202 cases reported (40% from US) from

1965-1999,

– First hand reports included, case reports

Is acupuncture safe? A systemic review of case reports

Lao L, et al. Alt Therapy in Health and Med Jan/Feb 2003:9,1:72-83

• Results– Infection: Hepatitis 80% (94cases/35

years)• Needles not cleans/ repeated use/ inadequate Needles not cleans/ repeated use/ inadequate

sterilizationsterilization

– Internal Organ/tissue injury

– Fewer complications after 1988: no further Hepatitis reports.

– 20% of practitioners with no recognized qualifications

Acupuncture for back pain: A meta-analysis of randomized controlled trials.

Ernst, Arch of internal Med. 1998;158:20:2235-2241

• Methods– Randomized controlled trials of acupuncture of back

pain in humans– 377 subjects, mostly with chronic poor prognosis back

pain – Consulted by 6 experienced acupuncturists– 12 studies included (9 suitable for meta-analysis)

• Conclusion– Insufficient evidence to state whether superior to

placebo– Long term effect of back pain with acupuncture

uncertain

Acupuncture for back pain: A meta-analysis of randomized controlled trials.

Ernst, Arch of internal Med. 1998;158:20:2235-2241

Randomized trial comparing traditional medical acupuncture, therapeutic massage, and self-care education for chronic low back pain. Cherkin DC, Eisenberg D, Sherman KJ et al.

Archives of internal medicine. 2001; 161, 8: 1081-1088.

• Design– Only 17% of invited Washington State Group Health

HMO patients participated (262 patients, age 20-70 years).

– Ten acupuncture or massage visits in a 10 week period.

– 95% of patients w/ Follow-up after 4, 10, and 52 weeks.

• Symptoms and dysfunctions assessed • Results

– F/U with 95% of participants– massage is an effective short-term treatment for

chronic low back pain with benefits to last at least 1 year

Randomized trial comparing traditional medical acupuncture, therapeutic massage, and self-care education for chronic low

back pain. Cherkin DC, Eisenberg D, Sherman KJ et al. Archives of internal medicine. 2001; 161, 8: 1081-1088.

• Results – If acupuncture has a positive effect it seems

to be during the first 4 weeks with limited improvement thereafter.

• Strengths- randomized design, involvement of therapist with protocol development, and high compliance rate.

• Limitations -absence of control group, restriction of single form of acupuncture (TCM), possibility of atypical therapists, use of protocols that excluded treatments often used by some TCM acupuncturist.

Osteoarthritis

• OA most prevalent form of arthritis

• Common site is knee joint and a leading cause of disability in the elderly

• Acupuncture for OA is a therapeutic approach common in Asian societies

A randomized trial of acupuncture as an adjunctive therapy in osteoarthritis of the knee

Berman BM, et. al. Rheumatology 1999;38: 346-354

• Design

– 73 patients from the Baltimore area (average age 65 years).

– Inclusion criteria ≥ 50 older Dx of OA ≥ 6 months, moderate pain in knee most days in the last month, taking analgesic or anti-inflammatory agents for pain control at least one month.

– protocol included TCM treatment for Bi syndrome which uses local and distal points on channels that cross the area of pain

A randomized trial of acupuncture as an adjunctive therapy in osteoarthritis of the knee

Berman BM, et. al. Rheumatology 1999;38: 346-354

– Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)

– The patient’s scores were determined at 0, 4, 8 and 12 weeks during trial.

• Results– the acupuncture group with about 34% ↓ on WOMAC

at week 4 and 42% at week 8. – There were no significant changes in the control

group from baseline to week 12. – Limitations noted lack of placebo control group.

Effectiveness of acupuncture as adjunctive therapy in osteoarthritis of the knee: a randomized, controlled trial. Berman BM, Lao L, Langenberg P, et al. Annals of Internal

Medicine. 2004

• Design– Reduce pain/improve function among patients

with knee OA as compared to both sham acupuncture and education control groups

– 8 week intense acupuncture treatment, followed by an 18 week tapering regime

– 570 participants– Assessments conducted at baseline, 4, 8, 14,

and 26 weeks

Effectiveness of acupuncture as adjunctive therapy in osteoarthritis of the knee: a randomized, controlled trial. Berman

BM, Lao L, Langenberg P, et al. Annals of Internal Medicine. 2004

• Results– True acupuncture groups improvement from baseline

was significantly greater than the sham control group at weeks 8 (P=0.01), 14 (P=0.04), 26 (P=0.009)

– Most believe they received true acupuncture at both times, suggesting the sham acupuncture to be a credible blinding strategy

• At 4 weeks 67% of the true acupuncture group and 58% of sham believed they were receiving true acupuncture (P=0.06) and at 26 weeks 75% in acupuncture group and 58% in sham (P=0.003).

The use of nonpharmacologic techniques to prevent postoperative nausea and vomiting (PONV): A meta-

analysis Lee A, Done M. Anesthesia and analgesia. 1999. 88:6: 1362-1369.

• Design– Stimulation of wrist at pericardium (P6)– Systemic review 24 randomized controlled

trials (1679 patients)• Nonphamacologic- acupuncture, electroacupuncture,

transcutaneous electrical nerve stimulation, acupoint stimulation and acupressure

– Measured incidence of nausea, vomiting or both after surgery 0-6h (early) or 0-48h (late)

The use of nonpharmacologic techniques to prevent postoperative nausea and vomiting (PONV): A meta-

analysis Lee A, Done M. Anesthesia and analgesia. 1999. 88:6: 1362-1369.

• Results – Pediatric studies failed to show significant

benefit.– Antiemetic use in preventing early or late

PONV in adults was comparable to the non-pharmacologic techniques.

– Significant reduction of early vomiting in nonpharm. group compared with placebo w/in 6h of surgery for adults.

The use of nonpharmacologic techniques to prevent postoperative nausea and vomiting (PONV): A meta-

analysis Lee A, Done M. Anesthesia and analgesia. 1999. 88:6: 1362-1369.

• Limitations– Combining different non-pharmacologic techniques.

• May have different effects to prevent PONV

– Optimal methods of applying techniques unknown. – Length of treatment (5min- 7days)– No statistical heterogeneity

• Conclusions– Further RCT with better study methodology needed in

adults. – Mechanism for prevention of PONV not established.

Values Assessment: Continuum……./ Questions????