صفحه 1:
ey طبايع
صفحه 2:
3
Specific effects and
expectation of
Acupuncture
treatment
A trial utilising PET imaging
Dr P White
Dr G Lewith
صفحه 3:
Background
٠ Effectiveness vs Efficacy for
acupuncture
* Often large treatment effects
* Neck pain trial
- White, Lewith, Prescott (2004),
Annals of internal Medicine
صفحه 4:
Neck pain - method
Acupuncture versus MTNS
Outcomes:
- Pain (VAS)
- Credibility (B & N)
- QoL (general and disease specific)
- A range of movement
- Analgesic intake
Baseline, treatment, short (3) and long (12)
term follow-up.
صفحه 5:
Neck pain - results
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*The specific effect of acupuncture is statistically
significantly different to placebo
*This may be clinically significant but not in our
study
*The specific effect of acupuncture is about 4
times smaller than the non-specific effect
صفحه 6:
Background
* Need to tease apart specific and
non-specific effects
* Many different controls have been
used
¢ ? Physiological effect of
acupuncture
صفحه 7:
Functional Imaging and
Acupuncture
* Possible specific effects on healthy
subjects - stimulation of GB37 (leg) &
GB43 (foot) causes activation of visual &
auditory cortex (Cho 2000) (f{MRI)
۰ 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)
صفحه 8:
Functional Imaging and
Acupuncture
* Placebo 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)
صفحه 9:
Questions
* Does 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?
صفحه 10:
Method
Single blind
Crossover
Randomised to order of treatment
- Real acupuncture
- Streitberger
- Overt placebo
Patients - OA first MCP joint, any age,
no other major pain or illness.
صفحه 11:
Streitberger Needle
صفحه 12:
Outcomes
Primary
* Comparison of brain activation maps
Secondary
* Needle sensation (jongbae Park 2002)
* Credibility (Borkevec and Nau 1972)
* HCAMQ (Hyland, Lewith, Westoby 2003)
¢ Pain (100mm VAS)
صفحه 13:
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صفحه 14:
Results
¢ 14 patients (F=11, M=3)
* Right handed
* 8= pain in left thumb
¢ Mean age=59 (S.D.=5.7) (Range
48-63)
٠ 4 patients had experience of
acupuncture
صفحه 15:
Credibility (y2 p values)
Streitberger Overt
01 02 Ql Q2
RA 0.20 | 0.53 | 0.003 | 0.003
SN - - 0.07 0.05
Real and Streitberger = similar credibility
Real and Overt = significantly different
Streitberger and Overt = ?different (less so)
صفحه 16:
Skin penetration
- 14 subjects for RA & SN, 1 subject for OP
Was the treatment real
- No sig diff for RA & SN, both were sig diff
to OP
Sensation
- All 3 had similar sensations (although RA
tended to elicit slightly stronger sensations
followed by SN)
Other confounders
No effect on
outcome
- HCAMQ
- Experience
- Order
- Pain
صفحه 17:
Real Acupuncture vs
Streitberger needle
(specific acupuncture
effect).
Hyperactivatio
n of the insula
ipsilateral to
the
intervention -
not found on
the other two
interventions
صفحه 18:
Painful
stimulus
Area of
activation in
the
contralateral
insula
صفحه 19:
Real & Streitberger vs Oj
placebo (Expectatio
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 system
صفحه 20:
Interpretation
¢ Acupuncture has a specific physiological
effect - not linked to pain/ sensation of the
procedure
¢ Expectation 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
صفحه 21:
a The next phase?
* Further investigation of the
physiological effect of skin prick -
is it inert?