Specific effects and expectation of Acupuncture treatment
اسلاید 1: www.tabaye.ir
اسلاید 2: Specific effects and expectation of Acupuncture treatment A trial utilising PET imagingDr P WhiteDr G LewithDr J ParienteProf R Frackowiac
اسلاید 3: BackgroundEffectiveness vs Efficacy for acupunctureOften large treatment effectsNeck pain trialWhite, Lewith, Prescott (2004), Annals of internal Medicine
اسلاید 4: Neck pain - methodAcupuncture versus MTNSOutcomes:-Pain (VAS)-Credibility (B & N)-QoL (general and disease specific)-A range of movement-Analgesic intakeBaseline, treatment, short (3) and long (12) term follow-up.
اسلاید 5: Mean pain scores from baseline to week 12Acupuncture versus MTNS, 12% differenceP = 0.01, 95% confidence intervals, 3-21%Neck pain - resultsThe specific effect of acupuncture is statistically significantly different to placeboThis may be clinically significant but not in our studyThe specific effect of acupuncture is about 4 times smaller than the non-specific effect
اسلاید 6: BackgroundNeed to tease apart specific and non-specific effectsMany different controls have been used? Physiological effect of acupuncture
اسلاید 7: Possible specific effects on healthy subjects - stimulation of GB37 (leg) & GB43 (foot) causes activation of visual & auditory cortex (Cho 2000) (fMRI)Different areas become functional with ‘deqi’ vs needle stimulation in normal subjects (Hsieh 2001) (fMRI)Placebo and Expectation (Dopamine release) may influence experience of pain (Wager 2004) (Fuente-Fernandez 2002)Functional Imaging and Acupuncture
اسلاید 8: Functional Imaging and AcupuncturePlacebo analgesia shares mechanisms with opioid analgesia (Petrovic 2002)PAG involved in higher cortical pain control (Tracey 2002)Acupuncture induces PAG activity (Liu 2004) and modulates limbic system (Hui 2000)
اسلاید 9: QuestionsDoes real acupuncture have a specific effect?Is there a physiological/therapeutic response to the streitberger needle and how does this compare to that of real acupuncture? Is the observed therapeutic effect of acupuncture and placebo due to the patient’s belief that there will be an effect?
اسلاید 10: MethodSingle blindCrossoverRandomised to order of treatment- Real acupuncture- Streitberger- Overt placeboPatients – OA first MCP joint, any age, no other major pain or illness.
اسلاید 11: Streitberger Needle
اسلاید 12: OutcomesPrimaryComparison of brain activation mapsSecondaryNeedle sensation (Jongbae Park 2002)Credibility (Borkevec and Nau 1972)HCAMQ (Hyland, Lewith, Westoby 2003)Pain (100mm VAS)
اسلاید 13: Consent, history/ assessment/ questionnaires, insert cannula, MRI scanRandomisationReal AcupunctureStreitberger PlaceboOvert PlaceboBaseline PET scanManipulate (4 mins)Manipulate and scan (8 mins)Apply needle (0 minutes)Scan only (16 mins)Remove needle (23.5 mins)Scan only (24 mins)Scan only (32 mins)Continues as per ‘Real acupuncture’Continues as per ‘Real acupuncture’Apply needle (0 minutes)Insert needle (0 mins)Flow chart of PET procedure
اسلاید 14: Results14 patients (F=11, M=3)Right handed8= pain in left thumbMean age=59 (S.D.=5.7) (Range 48-63)4 patients had experience of acupuncture
اسلاید 15: Credibility (2 p values) Real and Streitberger = similar credibilityReal and Overt = significantly differentStreitberger and Overt = ?different (less so)
اسلاید 16: Skin penetration14 subjects for RA & SN, 1 subject for OPWas the treatment realNo sig diff for RA & SN, both were sig diff to OPSensationAll 3 had similar sensations (although RA tended to elicit slightly stronger sensations followed by SN)Other confounders HCAMQExperienceOrderPainNo effect on outcome
اسلاید 17: Hyperactivation of the insula ipsilateral to the intervention – not found on the other two interventionsReal Acupuncture vs Streitberger needle (specific acupuncture effect).
اسلاید 18: Painful stimulusArea of activation in the contralateral insula
اسلاید 19: Real & Streitberger vs Overt placebo (Expectation)A – Rostral part of anterior cingulate cortex & midbrain periaqueductal gray; B - dorsolateral prefrontal cortex are both activated over and above OP. They are part of the expectation/reward systemAB
اسلاید 20: InterpretationAcupuncture has a specific physiological effect – not linked to pain/ sensation of the procedureExpectation has a mediating effect on the physiological response to a physical stimulus Streitberger needle is fundamentally different from RA and might be an inert control (or at least a physiologically less effective treatment). It only affected sensory areas
اسلاید 21: The next phase?Further investigation of the physiological effect of skin prick – is it inert?
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