1. 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……………..

2. 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.

3. 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)

4. Stated Benefits N/V after chemotherapy Back Pain Osteoarthirtis
Preop surgery pain
Addiction
Stroke
Headache
Menstrual Cramps
Tennis elbow
Fibromyalgia
Asthma
Carpal Tunnel

5. 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).

6. 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 Sterile, non toxic, single use only

7. 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.

8. 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

9. 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.

10. 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??

11. 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 ,
First hand reports included, case reports

12. 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……….

13. Acupuncture for back pain: A meta-analysis of randomized controlled trials. Ernst, Arch of internal Med. 1998;158:20:
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.

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

15. 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:
Design
Only 17% of invited Washington State Group Health HMO patients participated (262 patients, age 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

16. 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:
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.

17. 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

18. 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:
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

19. A randomized trial of acupuncture as an adjunctive therapy in osteoarthritis of the knee Berman BM, et. al. Rheumatology 1999;38:
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

20. 9 points 5 local, 4 distal

21. 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.

22. 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

23. 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 :6:
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)

24. 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 :6:
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

25. Limitations Conclusions
The use of nonpharmacologic techniques to prevent postoperative nausea and vomiting (PONV): A meta-analysis Lee A, Done M. Anesthesia and analgesia :6:
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.

27. Values Assessment: Continuum……./ Questions????
I would not be willing to try acupuncture…… unsure…….I would be wiling to try (or have tried) acupuncture……………..