By Marissa Grace Latin: 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 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 sterilization

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 antiinflammatory 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 patients 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 metaanalysis
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)
Nonphamacologicacupuncture, 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 metaanalysis
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 nonpharmacologic 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 metaanalysis
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????