Values Assessment: Continuum……. By Marissa Grace Latin: Acus (needle) Punctura Values Assessment: Continuum……. Back Pain, arthirtis, Addiction, Headache – daily discomforts that may be remedied by acupuncture. I would not be willing to try acupuncture…… unsure…….I would be wiling to try (or have tried) acupuncture……………..

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. http://www.faqs.org/nutrition/A-Ap/Alternative-Medicines-and-Therapies.html

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 One of the oldest and most commonly used medical procedure in the world (4)

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) is no intention to stimulate acupuncture points, Okibari, is a Japanese style technique where the needles are left in the points for some time. , Moxibustion is the combustion of plant material to warm specific points at or near the surface of the body and cupping involves placing a small heated cup on the body to create a vacuum and can be used along withacupuncture (13). In Moxibustion, burned dried and aged mugwort (a medicinal plant) on the meridian point may be used (16). Electroacupuncture (EA) is the stimulation of acupuncture point with electrical current and is thought to be more effective for pain relief than manual stimulation (9).

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/ Our signature brand is SEIRIN, providing painless acupuncture for over 25 years. Federal Law (USA) restricts TENS, EMS and MicroCurrent devices to sale by or on the order of a licensed physician. Electro-therapy devices are sold only to qualified practitioners. Effectiveness is dependent on patient selection. Keep out of reach of children.

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 Discrepancies in number of points.

Theory Stimulation of the nervous system to release chemicals in the muscles, spinal cord, and brain. Beta-endorphin Analgesia. Placebo effect. Painkiller, type of Chemicals??

Method 202 cases reported (40% from US) from 1965-1999, 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

Internal Organ/tissue injury 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 Average 6 cases/ year among 22 countries A pneumothorax is collection of air or gas in the space surrounding the lungs. Pneumothorax 26 cases Okibari: Needles inserted permanently, r/t spinal injuries 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 The trials included were heterogeneous in terms of study population, type of acupuncture used, outcome measure used, and length of follow up; heavy biases towards positive results where negative trials may not have been published.

Acupuncture for back pain: A meta-analysis of randomized controlled trials. Ernst, Arch of internal Med. 1998;158:20:2235-2241 Details about Quality rating scores- adequacy of acupuncture, randomizes, blinding, drop-outs. What is odds ratio?

Ten acupuncture or massage visits in a 10 week period. 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. Other treatment herbs, oriental massage.

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

73 patients from the Baltimore area (average age 65 years). 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 Electrical stimulation for 20 minutes used

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. WOMAC- which is a validated, multidimensional self-report scale to assess pain, stiffness and physical function of OA of the knee

9 points 5 local, 4 distal

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 Electrical stimulation was provided at knee points at a low frequency for 20 minutes.

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). For the sham control the treatment was modified with a combination on insertion and noninsertion procedures without electrical stimulation as well as use of a shield to participants could not observe procedure. This study was improved from the 1999 trial related to use of credible sham acupuncture group and inclusion of nonpharmacologic education as a second control and suggests an important role in the adjunctive therapy for treating OA of the knee

Design Stimulation of wrist at pericardium (P6) 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)

Results Pediatric studies failed to show significant benefit. 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. Placebo considered sham point or no tx

Limitations Conclusions 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???? I would not be willing to try acupuncture…… unsure…….I would be wiling to try (or have tried) acupuncture……………..