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????