Acupuncture treatment for palliative patients?

Gernot Ernst

Blefjell sykehus Kongsberg

Anestesi, Smerte- og palliativseksjon

• Introduction

• Scientific evidence

• Mechanisms

• Chinese medicine

• Examples

• Ongoing research in Kongsberg

History of acupuncture

• 200 v. Chr.: Huang Di Nei Jing (Han-dynasti), acupuncture needles at excavations

• 17. Jhdt.: de Bondt introduces acupuncture in Europa• 1816: Louis Berlioz• 1951: German association for acupuncture• 1972: Nixon in China• 1996: FDA: Acupuncture works and is safe (class II-

recommendation)• 1997: NIH: Acupuncture has scientific evidence and

should be accepted by physicians• 2004: 2 big studieswith more than 1000 pas (”gerac”):

back, knee) – verum-acupuncture not more effective than placebo, both better than controls

Indications for acupuncture (NIH 1997)

• Nausea (postop., chemotherapy, pregnancy)

• Tooth ache• Headache• Back pain• Fibromyalgia

• Dysmennorea• Epikondylitis• Carpal tunnel syndrome• Dependency syndromes• Asthma• Rehabilitation after

apoplectic insult

Scientific studies about acupuncture

Filshie/White 1998: left side: not randomized, right side randomized

Prophylaxis of migraine with acupuncture

Treatment success

Metoprolol 56-64%

Propanolol 32-43%

Flunarizin 42%

Dihydroergotamin 33%

Placebo 30%

Acupuncture 43-75%

Weinschütz et al 1996

Results of high quality RCTs

Syndrom Number of studies

Studies with positive result

Studies with negative result

Back Pain 8 3 5Osteoarthrosis 12 6 6Smoking 6 1 5Overweight 4 2 2Apoplectic insult 6 6 0

Acupuncture can help if something is perturbed, but not if something is

destroyed (e.g. cancer)

Side actions of acupuncture

• Weariness, heaviness, better sleep

• Stimulation, sensation of lightness

• Sensation of warmth

• Muscle relaxing

• Mood improving

• Increased appetite, improved digestion, improved urination

Adverse effects, complications

• Fainting

• Increased pain (rare)

• Local infections

• Minor bleedings, hematoma

• Organ damages (very rare)

• Allergic reactions (typ IV, extremely rare)

• Labour inducing ?Ernst 1994, Strzyz 1996, Ernst 2003

Mechanisms of action

• Anatomic places

• Gate-Control-Theory

• Release of endogene opioids

• Modulation of the serotoninergic system

• Induction of „Long term depression“

Anatomic places

• Many acupuncture points are at areas where vessel-nerve structures cross the fascia

• Similarities with trigger points

• Local immunologic effect through effects on sympathic fibers which innervate lymph nodes

Gate-Control-Teorie

• Blockade of secondary nociseptive pathways (A, C) due to concomitant stimulation of non-nociseptive pathways (A)

• Theoretical base for the contrairritation treatments• Has probably only effect during stimulation, but

no long term effect.• Involves GABA-Receptors, mediated through Aβ-

fibers

Release of endogene opioids

• Opiatantagonists can (partially) inhibit acupuncture analgesia

• Acupuncture has less effect in mice with a lower concentration of opioid receptors

• Acupuncture analgesis is increased when degradation of endogene opioids is blocked

• Cross tolerance with morphine• Emotional sideeffects partially similar to

endorphine

Modulation of the serotoninergic system

• Destruction of raphe nuclei in brainstem blocks acupuncture effects

• Acupuncture effect often better at paroxysmal pain• Acupuncture analgesia is diminished when

ascending serotoninergic pathways are blocked• Probably combined effect on noradrenergic and

serotoninergic pathways

Induction of „long term potentiation“

Long-term Depression

• Repeated use of acupuncture leads to decreased response of the second neuron at nociseptive stimulations

• Explains the lonbg time effect of acupuncture

• Additional effect through reduced „Long term-potentiation-effects“

Chinese medicine

• Traditionally based on the yin/yang principle and the five elements – different schools

• The body has symmetric ”meridians” which connect about 400 acupuncture points

• Classical: Pulse and tongue diagnostics, anamnesis description of the patient situation according to the five elements

• Chinese ”organs” are rather phenomenologic descriptions they do not fit to „western organs“ (e.g.: liver controls menstruation, kidney control finger nails

• Mythos is bigger than reality

Elements of chinese medicine

• Acupuncture

• Moxa

• Cupping (usually bloddless)

• Seven star hammer

• Massage

• Qigong, Tai Qi Chuan

• Medikaments

Acupuncture treatment

• Body acupuncture: usually 8 to 16 needles, symmetric, 20-40 minutes

• Ear acupuncture: needles, permanent needles or globes with plaster

• Moxa either with cigar or pieces of moxa on a acupuncture needle

• Cupping with or without needle, bloody or bloodless

Symptomer• Pain 70,3 %• Xerostomia 67,5 %• Lack of appetite 60,9 %• Frailty 46,8 %• Opstipation 44,7 %• Dyspnea 42,3 %• Nausea 36,2 %• Insomnia 34,2 %• Perspiration 25,3 %• Swallowing problems 23,2 %• Urination problems 21,3 %• Psychiatric symptoms 19,8 %• Vomiting 18,5 %• Itching, other skin problems 16,3 %• Diarrea 7,6 %N = 12438

Grond 1994

Symptomer• Pain 70,3 %• Xerostomia 67,5 %• Lack of appetite 60,9 %• Frailty 46,8

%• Opstipation 44,7 %• Dyspnea 42,3

%• Nausea 36,2

%• Insomnia 34,2

%• Perspiration 25,3 %• Swallowing problems 23,2

%• Urination problems 21,3

%• Psychiatric symptoms 19,8

%• Vomiting 18,5

%• Itching, other skin problems 16,3

%• Diarrea 7,6

%

N = 12438Grond 1994

Journal of clinical oncology 2003, 21: 4120-4126

Ear acupuncture for cancer pain (Alimi 2003)

• Cancer patients with neuropathic pain (!) and VAS > 30; 85% with constant pain, mean VAS 58

• Randomized, three groups: verum n=29 (with electical identification), placebo acupuncture n=30, no acupuncture n=31 (globes on placebo points)

• Assessed by a blinded observer

Results

• Verum acupuncture lead to a reduction of pain to 37 (placebo-acupuncture 55, Placebo”globes” 58)

Acupuncture for palliative patients: studies

• Short effect on dyspnea (Filshie 1996), no effect (Lewith 2004)

• Established effect in nausea (review: Weiger 2002)

• Pain: at some patients (bl.a. Alimi 2003)

• Xerostomia: some evidence (Rydholm 1999, Johnstone 2002)

Possible point combinations

• Opstipation: LI4, St25, SJ6• Diarrea: St37, St25• Anxiety: P6, Ren 14• Nausea: P6, St36, Ren12• Aerocolia: St 36, ev. Syvstjernehammer

between LI4 and S2• Sedation points: Du 20, Ex 6, H7, An mien

I,II, P6, UB62

Ongoing studies (Fatigue, Xerostomia)

• Treatment through nurses with a basic safety and technical training

• First treatments under supervision

• Each patient has a schedule and one who is responsible to follow the patient. This person does not treat the patient

Acupuncture for fatigue: inclusion criteria

– Terminated chemotherapeutic treatment or treatment pause

– Subjectice fatigue with negative effects on QoL– Cognitivily able to understand the strudy and to

give informed consent

Acupuncture for fatigue: exclusion criteria

• Clinical symptoms for immune suppression (spes: granulocytes < 1,5)

• Koagulation problems, thrombocytopeny• Relevant depression or anxiety• Anemia (Hb < 9) or frequent need for blood transfusions• Overdosage of medicaments, spec. Opioids or sedatives• Kacheksia• Clinical relevant infection• Dehydration• Detorriated electrolytes• Hypoxia• Clinical possibility for hormonal problems (e.g. Hypotyreodism)

Study structure

• One treatment per week• Same points (St36, Sp6, Ren 6, H7, K3,

K27)• Needles for 20-30 minutes• Evaluation after four treatments, after

treatment end, after one month and three months (ESAS og BFI through a none treating person)

St 36 (Zusanli)

• Lateral ved begynnelsen til tuberositas tibiae

Sp 6 Sanyinjiao

• 3 cun over medial malleolus, dorsal tibia

Ren 6 Qihai

• I midtlinjen, 1.5 cun under navlen

H7 Shenmen

• Ved håndleddsrynken, radial til første senen (m flexor carpi ulnaris)

K3 Taixi

• Mellom malleolus medialis og akillessene

K27 Shufu

• Under kragebenen, 2 cun lateral fra midtlinjen. Sett nålen skjev, ca. 1 cm (ikke mer!)

Acupuncture for xerostomia

• Inclusion: dry mouth with effects on QoL; Ability to give informed consent

• Exclusion: – Other effective treatment possibilities– Clinical symptoms for immune suppression (spes:

granulocytter < 1,5)– Coagulation problems, thrombocytopenia– Relevant depression or anxiety

Study structure

• To treatments per week

• Points: K6, L7, Ren17, Ren 23, Gb 20, SJ17

• Evaluation before treatment, after three weeks and one months after terminated treatment (ESAS and XI through a none treating person)

Punkter

K6 Zhaohai

• 1 cun under fremre kant til malleolus medialis

L7 Lieque

• Radial side til underarmen, 1.5 cun proximal fra håndleddsrynken

Ren17 Shanzhong

• Midten til brystbein, mellom brystvortene, 4. interkostalrom

Ren 23 Lianquan

• Mellom skjoldbruskkjertel og underkjevespissen (haken)

Gb 20 Fengchi

• Mellom m. Sternocleidomastoideus og trapezius

SJ17 Yifeng

• Bak øreflippen, foran processus mastoideus

Other goals of the two studies

• To test feasibility in a clinical setting

• To test if nurses and nurse assistants can use a simple treatment scheme with clinical relevant effects.