?What acupuncture can and cannot do for arthritis

?What acupuncture can and cannot do for arthritis

اسلاید 1: www.tabaye.ir

اسلاید 2: What acupuncture can and cannot do for arthritis?June 25, 2009Wei Huang MD, PhDBirmingham/Atlanta GRECCAtlanta VAMCEmory University

اسلاید 3: PurposeProvider education on the use of acupuncture as a complementary alternative therapy in arthritic conditions.

اسلاید 4: Review the effects of acupuncture in treating osteoarthritis (degenerative), rheumatoid arthritis (inflammatory), and gout (metabolic);Determine when and how to refer a patient with arthritis for acupuncture.  

اسلاید 5: Osteoarthritis

اسلاید 6: OsteoarthritisOver 20 million people in the United States live with osteoarthritisRadiographically, 30% individuals of age 45-65, and more than 80% over age 70 are affectedSecond most common cause of permanent incapacity among people over age 50Most common: knees, followed by hips, spine, feet, handsKnee OA is one of the five leading causes of physical disability in the non-institutionalized elderlyPain usually is the initial and principal source of morbidity

اسلاید 7: Current TreatmentsWeight loss, activity modification, topical heat/cold, topical analgesic cream, shoe modification/insert, copingPhysical therapy, proper brace use, TENSOver the counter medications, dietary suppCSI, hyagan,Prescription pain medsSurgery

اسلاید 8: Why consider acupuncture?Medication side effectsPolypharmacy in the elderlyInconclusive effects of a lot of modalitiesPatients not accepting invasive proceduresPotential benefits of acupuncture over other modalitiesMinimal and no long term adverse reactionsNot invasive procedure to perform in the officeLess costly than surgery

اسلاید 9: Any research evidence for the effects of acupuncture in osteoarthritis?

اسلاید 10: Acupuncture for knee and hip OAWitt et al. (2006-2008)Recruitment from July 2001 to July 2004Age > 40yo (average [SD] 61.8 [10.0]); radiographic evidence of osteophyte; disease duration > 6m; at least 15 days with pain in the past 30 days3 groups: non-randomized (n=2726); randomized to immediate acupuncture (n=322); randomized to delayed acupuncture (n=310)Knee OA 57.1%; hip OA 14.5%; both 28.4%

اسلاید 11: Witt et al. (cont.)Intervention:Individualized acupuncture up to 15 sessions in 3 months (average 10.7+3.9x, 76.6% 5-10 sessions) Needle acupuncture onlyManual manipulation onlyAll three groups continue to receive any additional conventional treatments1417 study physicians in GermanyOutcome measures: WOMAC indexes of pain, stiffness and functionSF-36 total score and physical/mental subscales Baseline, after 3 months, after 6 months

اسلاید 12: Witt et al. (cont.) - ResultsAt 3 month, there were significant improvements in WOMAC pain, stiffness, function, and SF-36 physical component scores in patients with knee and/or hip OA who were randomized to receive immediate acupuncture, as compared to controls who were randomized to have delayed treatments. Only SF-36 mental component score did not differ significantly b/w groups. There were no significant differences in all scores between patients who received acupuncture treatments, randomized or non-randomized

اسلاید 13: Witt et al. (cont.) - ResultsAt 6 month, there were no significant differences b/w all groupsNo difference in delayed treatmentsTreatment effects lasted for at least 3 months post-intervention

اسلاید 14: Witt et al. (cont.) - ResultsOther interesting findings:Subgroup analysis showed significantly more pronounced improvements in patients of:younger age,higher baseline physical or mental quality of life, andhigher baseline WOMAC indexesPhysician participants: 1% of primary care physicians in Germany, at least 140 hours of certified acupuncture education; years of clinical experience varied; treatment regimen varied – reflected well of real world general practice --- no significant influence on the outcome measured in this study

اسلاید 15: Witt et al. (cont.) - Cost analyses489 subjects completed cost-effectiveness analysis (acupuncture n=246; control n=243)Mean overall costs incurred by acupuncture patients during the treatment period were €1,204.15 with additional costs of acupuncture (€35/session), as compared to €734.66 in control patientsHowever, QALYs (quality adjusted life year) was gained in acupuncture groupAcupuncture for knee osteoarthritis in females was more cost-effective than males;No gender difference in hip osteoarthritis

اسلاید 16: Limitation of the studyNeither physicians nor patients were blindedNo sham treatment controlHeterogeneous patient sample: age, area of involvement

اسلاید 17: SCEGM/Hartford Pilot Study (preliminary) - Huang, Bliwise, Carvenale, KutnerSupported by SCEGM/Hartford Foundation and Birmingham/Atlanta GRECCAcupuncture for knee OA in elderlyStandardized treatment protocolSham control, double blindedTreatment of pain, sleep or both

اسلاید 18: Huang et. al. (cont.) – baseline demographicsN=24Average age 72 yoAverage duration of knee pain 10.8 yrs Average PSQI score 10.54 randomized groups: true sleep sham pain, sham pain true sleep, true pain true sleep, sham pain sham sleep

اسلاید 19: Huang et al. (cont.) - ResultsSubjects who received true acupuncture for knee pain and/or for poor sleep, compared to subjects who received only sham treatments, had more improvement in pain ratings (P=0.03) and PSQI scores (P=0.04). True versus sham acupuncture for knee pain was associated with improved SF-36 ratings of general health (P=0.03) and vitality (P = 0.04). True versus sham acupuncture for poor sleep was associated with improved SF-36 ratings of social functioning (P=0.03).

اسلاید 20: Acupuncture for severe knee OA - Tillu et al. 200260 patients on waiting list for total knee replacement surgeryAllocation into acupuncture group and control group with matched age and gender Standardized acupuncture regimen weekly for 6 wksOutcome measures: Hospital for Special Surgery scores (pain, function, muscle strength, joint ROM, flexion deformity, knee instability)50 meter walk20 steps climbingPain score (VAS)

اسلاید 21: Tillu et al. (cont.) - ResultsAcupuncture group significantly improved in all outcomes; control group significantly worsened in all outcomes after 2 months3 subjects in acupuncture group (10%) requested suspension of surgery due to the improvements of their symptomsLimitation of the study: non-randomized, not blinded

اسلاید 22: Acupuncture for OA (Summary)For knee OA, strong research evidence supports the use of acupuncture for symptom relief and quality of life improvement, including in elderly patients and in those with severe joint pathology;For hip OA, acupuncture can be recommended for a trial of pain relief; For other OA, the evidence is not clear yet.

اسلاید 23: Other types of arthritis

اسلاید 24: Rheumatoid ArthritisIn addition to arthritic pain as in osteoarthritis, rheumatoid arthritis also presents with:Increased morning stiffness (>1hr)Multiple joints involvement including small joints: pain, swellingIncreased ESR, CRP

اسلاید 25: Acupuncture for RAMoxibustion in combination with needlesBee needle and bee venom therapyAcupoint injectionsFire needle

اسلاید 26: Review by Wang et. al. (2008 Arthritis and Rheumatism)Search in 12 databases from 1806 to March 2008Both Chinese and English literatureSelection criteria: randomized controlled trials, ACR dx criteria, clear outcome measures 8 studies (536 subjects) included from 4 countries (Canada, UK, Brazil, China) 1974-2007

اسلاید 27: Review on acupuncture for RA (cont.)4 against sham control: placebo needles (3), superficial acupuncture4 against active control: MTX IM injection, indomethacin (2), diclofenac ointmentAll with pain assessments, 6 also with ESR and CRP – 3 sham and 3 active controlMean study duration: 11+ 6 wks (range 4-22wks)Mean number of acupuncture sessions: 42 + 62 (range 1-180)

اسلاید 28: Review on acupuncture for RA (Cont.)6 studies (4 active control, 2 sham control) showed significant reduction of pain compared to controls (decrease of tender joint count by 1.5 to 6.5)4 studies (3 active control, 1 sham control) showed significant reduction of morning stiffness (-29 minutes); however, no significant difference from controls5 studies (3 active control, 2 sham control) showed significant reduction in ESR (-3.0mm/hr); 3 studies (2 active control, 1 sham control) showed significant reduction in CRP (-2.9mg/dl); 1 study (active control) showed significant reduction in both ESR and CRPSwollen joint counts – no difference between intervention and control groups

اسلاید 29: Acupuncture for RA (summary)Limited studies suggest the use of acupuncture for improving RA symptoms and possible some inflammatory indexes. Results are not conclusive.

اسلاید 30: Gouty ArthritisMetabolic Uric acid crystal deposition in the joint(s)Inflammation: redness, swelling,sharp pain

اسلاید 31: Acupuncture for gouty arthritisMa 2004N=72 (42 experimental; 30 control)Randomized (how?), no blindingExp: Acupuncture daily x 10 (one course) – total#? Control: allopurinol 100mg bid-tid; Ibuprofen 200mg tid if painful arthritisOutcome measures: clinical improvements of symptoms and signs (detail?); serum uric acid, creatinine, BUN; 24hr urinary protein contentTime points: baseline, one month after treatments

اسلاید 32: Ma (cont.)Results:Excellent response (disappearance of symptoms and signs, with all lab tests normalized): 45.2% vs. 20%; Effective response (improvement of symptoms and signs and lab tests): 50% vs. 43.3%;Failed response (no obvious improvement of symptoms and signs with no obvious change in lab tests): 4.8% vs. 36.7%Total effective rate: 95.2% vs. 63.3%

اسلاید 33: Ma (cont.)Results (cont.)In the acupuncture group, all lab tests were improved (p<0.01); whileIn the control group, only serum uric acid level was improved (p<0.05) without changes in BUN, creatinine or urine protein.

اسلاید 34: Acupuncture for Gout (Summary)Limited clinical trials suggest beneficial use of acupuncture in patients with gouty arthritis and abnormal renal functions.

اسلاید 35: Summary (I) Acupuncture Effects in ArthritisProven pain controlProbable cost effective for improving QoLPossible improvements in other related symptoms, laboratory inflammatory indicatorsProven in knee osteoarthritis, esp. cost effective in female patientsProbable in hip osteoarthritisPossible in other areas/types of arthritis

اسلاید 36: What acupuncture has not be proven to do …To reverse structural damagesTo slow down disease progressionTo reduce healthcare cost

اسلاید 37: When and how to refer patients for acupuncture treatments?

اسلاید 38: Summary (II) Treatment Recommendation (When…)Weight loss, activity modification, topical heat/cold, topical analgesic cream, shoe modification/insert, coping Physical therapy, proper brace use, TENSOver the counter medicationsCSI, hyagan,Prescription pain medsSurgeryAcupuncture,

اسلاید 39: How …Know the resources at your facility/areaKnow the credentialing process at your stateBuild a referral network

اسلاید 40: Something your patients may ask you about … Side effects profile for acupunctureRelative contraindications

اسلاید 41: Common adverse reactionsUsually minor: Local bleeding, bruise, achiness/painAbout 3% with strong reactions to needling: vagovagal reaction, increased pain for 24-48hours

اسلاید 42: Rare complicationsPneumothoraxNerve injuryBlood vessel penetrationKNOW THE ANATOMY!!!

اسلاید 43: Relative contraindicationsSkin infection (not in the same area where needle will be inserted)Bleeding disorder/on Coumadin with high INRValvular heart disease (no semipermanent needles)Pacemaker, cardiac arrhythmia, epilepsy (no electroacupuncture)SCI with injury level higher than T6 (risk for autonomic dysreflexia)Pregnancy (not in certain spots)On moderate to large amount of opioids

اسلاید 44: Contact InformationFor information about this specific presentation please contact Wei Huang, MD, PhD at whuang4@emory.eduFor any questions about the monthly GRECC Audio Conference Series please contact Tim Foley at tim.foley@va.gov or call (734) 222-4328To evaluate this conference for CE credit please obtain a ‘Satellite Registration’ form and a ‘Faculty Evaluation’ form from the Satellite Coordinator at you facility. The forms must be mailed to EES within 2 weeks of the broadcast.

اسلاید 45: Thank You!Q&A