1. Acupuncture on chronic pain management: Hong Kong service model Dr Regina Choi Associate Consultant Kowloon East Cluster Pain Mangement Centre United Christian Hospital Hong Kong

2. Hong Kong is a place where the Chinese and Western culture meet and mix Our beliefs and practice in seeking health care Our mode of practice of acupuncture Some service models on acupuncture practice Any hurdles coming for “integration” of care? What are the ways forward? What is

3. Hong Kong is a mixing bowl for Western and Chinese culture It is a dynamic, open to world city

5. what was the attitudes to traditional chinese medicine and western medicine of the people in hong kong?

6. Attitudes Of Hong Kong chinese to traditional chinese medicine :survey and cluster analysis Objectives - determine whether within a cohort of Hong Kong out-patients, any definable subtypes exist based on their attitudes to traditional Chinese medicine and Western medicine E Mok et al. Complementary Therapies in Medicine 2003 ;11: 103-9

7. What were the results? Total of 503 respondents in 3 major clinics while they were in waiting area for clinic service, all are Chinese aged > 18 yrs 67% female, 55% education level college or above,over representation of subjects between ages of 20-29 (43%)

8. Extent of beliefs and trust to traditional chinese medicine compared to western medicine VariablesMeanSD TCM restorative effect3.660.52 TCM fewer side effect3.780.58 TCM therapeutic effect 3.40.69 TCM prioritised2.890.79 Subtotal of TCM superior scores 3.450.45 WM quality and facilities 3.680.59 WM efficiency of treatment and effects 3.770.59 Subtotal of WM superior scores 3.710.49 Chinese-Western Medical Beliefs Scale (1-5) VariablesMeanSD TCM physician3.40.84 WM physician3.80.75 Trust Score (1-5) Score range 1 ( very disagree) to 5 ( very agree) Score range from 1(not at all) to 5 ( very much)

9. Different practitioners practising acupuncture in Hong Kong Acupuncture practitioners in Hong Kong Western medicine practitioners with acupuncture qualifications, practising “dry needling “ Physiotherapists with recognised qualifications Traditional Chinese Medicine Practitioners- prescribing herbs, acupuncture

10. Western medicine practitioners practice Numerous Western medicine practitioners are qualified Chinese medicine practitioners Some have certain qualifications on acupuncture/Chinese herbs Practice acupuncture based on literature, chinese medicine diagnosis

11. hong kong physiotherapy association ltd - acupuncture & integrative medicine specialty group (AIMSG) Conduct lectures and courses regularly on topics on acupuncture Run diploma course on acupuncture for physiotherapists Run practical courses in Mainland China Responsible for accreditation of acupuncture qualifications and experience for physiotherapists

12. chinese medicine practitioners According to Chinese Medicine Council of Hong Kong, currently there are > 6000 Chinese Medicine practitioners in Hong Kong ( Data 4/2011) They take up about 20% of the medical consultations in Hong Kong ( data from Chinese Medicine Council of Hong Kong 2001)

13. Hospital Authority Chinese Medicine (CM)Department runs 18 CM centres, with bilateral mode of collaboration model with non- government organisations/local universities Provide different modalities of treatment including chronic pain acupuncture treatment

14. Integrated Practice Model

15. INtegrated Chinese and Western Medicine treatment centre Mission The medical and health services of Tung Wah aim at providing Western and Chinese health care services to the community, as well as expanding services which fall out of the current public health system to cater for the specific needs of the community through the collaboration with the Government and institutions from both public and private sectors.

16. TWGHS INtegrated Chinese and Western Medicine treatment centre It started to operate since 2006 Runs day centre, to provide herbal soup, acupuncture to terminal cancer patients Runs out-patient clinics Under planning, to provide service to inpatients with predefined clinical treatment protocols

17. TWGHS INtegrated Chinese and Western Medicine treatment centre Disease with predefined treatment protocols - Stroke trigeminal neuralgia Facial Palsy Parkinson’s Disease Low Back Pain Osteoporosis Asthma (paediatric cases)

18. TWGHS INtegrated Chinese and Western Medicine treatment centre There will be chinese medicine practitioners and western medicine practitioners in charge of case Joint consultation may be facilitated

19. What about acupuncture and chronic pain management?

20. Kowloon east cluster(KEC) pain management centre hong kong Incorporated acupuncture service since year 2000, provided by physiotherapists and pain physicians with appropriate qualification in acupuncture Chinese Medicine practitioners started to offer acupuncture service since 2009

21. Our chinese medicine clinic setting

22. pain managment centre United christian hospital hong kong Free assessment by Chinese medicine practitioners in multidisciplinary new case clinic Case conference after new case session among pain physician,pain nurse, clinical psychologist and chinese medicine practitioners patient consented - additional followup to receive acupuncture /herb treatment Patient not consented- To be reviewed subsequent FU, may be referred back to chinese medicine practitioners or physiotherapists for acupuncture

23. Outcome measures on effects of chinese medicine on our pain patients

24. The survey was carried out from the period of May 2009 to July 2010. Patients received acupuncture treatment by chinese medicine practitioners 2 sets of questionnaires, pre-treatment and post- treatment ( after 10 sessions and sent by mail ), based on Brief Pain Inventory (BPI) were collected A survey on out-patient chinese medicine service in KEC pain management centre

25. 37 patients completed the 1st set of questionnaire, with response rate of 84% on 2nd set. Regions of pain complaint include LBP, neck, limbs, TMJ. They may receive physiotherapy at the same time

26. Pain intensity and effects Pain intensity Mean pain score (S.D.) Median pain score Highest over past 4 weeks 7.23 (1.813)8 Lowest over past 4 weeks 4.3 (1.950)4 Average over past 4 weeks 5.86 (1.866)6 Now5.97 (2.195)6 Item Mean score (S.D.) Median score Daily activities5.83(2.679)7 Mood5.97 (2.125)6 Walking5.52 (2.706)5 Physical exertion6.42 (2.446)7 Interpersonal relationship 4.45 (3.150)5 Sleep6.45 (2.488)7 Enjoyment of life6.10 (3.045)7 Concentration5.90 (2.587)5 Appetite4.16 (3.067)4 Pain intensity perceived by patients on a numerical rating scale of 0 to 10 Effect of pain on various aspects of functioning on numerical rating scale of 0 to 10

27. comparision on Pain intensity perceived by patients before and after acupuncture treatment Pain intensity Mean pain score (SD) after acupunctur e Median pain score after acupunctur e Mean pain score (SD) before acupuncture Median pain score before acupunctur e p-value for paired Student’s t-test Highest over past 4 weeks 6.29 (2.224)77.23 (1.813)80.045 Lowest over past 4 weeks 3.90 (2.587)44.30 (1.950)40.487 Average over past 4 weeks 5.22 (2.217)55.86 (1.866)60.200 Now 5.26 (2.516)55.97 (2.195)60.235

28. COmparision on effects of pain on various aspects of functioning before and after acupuncture Item Mean score (SD) after acupuncture Median score after acupuncture Mean score ( SD) before acupuncture Median score before acupuncture p-value for paired Student t- test Daily activities5.00 (2.933)55.83 (2.679)70.118 Mood4.68 (3.092)55.97 (2.125)60.034 Walking4.42 (2.975)55.52 (2.706)50.038 Physical exertion5.48 (2.682)66.42 (2.446)70.026 Interpersonal relationship4.01 (3.609)34.45 (3.150)50.511 Sleep5.16 (3.216)56.45 (2.488)70.017 Enjoyment of life5.48 (3.305)66.10 (3.045)70.233 Concentration4.94 (3.076)55.90 (2.587)50.057 Appetite3.84 (2.979)34.16 (3.067)40.541

29. All respondents( n= 37) had acupuncture as mainstay of treatment 3 patients also use herbs on top of acupuncture Satisfaction score (0-10) rated after 10 sessions of treatment (mean 7.322, SD 2.372)

30. CAn we “integrate” Chinese medicine and western medicine ?

31. attitudes to traditional Chinese Medicine amongst western trained doctors in China Survey conducted in Shenyang, Northern China 177 respondents from 4 major centres. 98% respondents have some theoretical and practical Chinese medicine training Consensus that TCM ( mainly herbal medicine ) was useful and safe in treating chronic and intractable disease Harmsworth K et al. Soc. Sci Med 2001 ; 52(1) : 149-53

32. Current Situation in Hong kong Majority of western medicine trained doctors are not familiar with theories and practice of chinese medicine Fear of potential interactions of herbs, complications of acupuncture Chinese medicine comprise different philosophy, but researches lay ground on its practice

33. Way forward......

34. Promotion & governing of Chinese Medicine by various levels Hospital Authority Chinese Medicine Service Hong Kong Association for Integration of Chinese-Western Medicine / Hong Kong Chinese Medicine Council

35. Targets Quality Service delivery Information & Research (computerised Chinese Medicine Information System) Training & Education Pharmacology & toxicology Collaboration between Western Medicine & Chinese Medicine, with protocol based practice Chinese medicine hospital

36. We are going ahead......