acupuncture treatment for palliative patients? gernot ernst blefjell sykehus kongsberg anestesi,...
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Acupuncture treatment for palliative patients?
Gernot Ernst
Blefjell sykehus Kongsberg
Anestesi, Smerte- og palliativseksjon
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• Introduction
• Scientific evidence
• Mechanisms
• Chinese medicine
• Examples
• Ongoing research in Kongsberg
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History of acupuncture
• 200 v. Chr.: Huang Di Nei Jing (Han-dynasti), acupuncture needles at excavations
• 17. Jhdt.: de Bondt introduces acupuncture in Europa• 1816: Louis Berlioz• 1951: German association for acupuncture• 1972: Nixon in China• 1996: FDA: Acupuncture works and is safe (class II-
recommendation)• 1997: NIH: Acupuncture has scientific evidence and
should be accepted by physicians• 2004: 2 big studieswith more than 1000 pas (”gerac”):
back, knee) – verum-acupuncture not more effective than placebo, both better than controls
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Indications for acupuncture (NIH 1997)
• Nausea (postop., chemotherapy, pregnancy)
• Tooth ache• Headache• Back pain• Fibromyalgia
• Dysmennorea• Epikondylitis• Carpal tunnel syndrome• Dependency syndromes• Asthma• Rehabilitation after
apoplectic insult
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Scientific studies about acupuncture
Filshie/White 1998: left side: not randomized, right side randomized
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Prophylaxis of migraine with acupuncture
Treatment success
Metoprolol 56-64%
Propanolol 32-43%
Flunarizin 42%
Dihydroergotamin 33%
Placebo 30%
Acupuncture 43-75%
Weinschütz et al 1996
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Results of high quality RCTs
Syndrom Number of studies
Studies with positive result
Studies with negative result
Back Pain 8 3 5Osteoarthrosis 12 6 6Smoking 6 1 5Overweight 4 2 2Apoplectic insult 6 6 0
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Acupuncture can help if something is perturbed, but not if something is
destroyed (e.g. cancer)
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Side actions of acupuncture
• Weariness, heaviness, better sleep
• Stimulation, sensation of lightness
• Sensation of warmth
• Muscle relaxing
• Mood improving
• Increased appetite, improved digestion, improved urination
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Adverse effects, complications
• Fainting
• Increased pain (rare)
• Local infections
• Minor bleedings, hematoma
• Organ damages (very rare)
• Allergic reactions (typ IV, extremely rare)
• Labour inducing ?Ernst 1994, Strzyz 1996, Ernst 2003
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Mechanisms of action
• Anatomic places
• Gate-Control-Theory
• Release of endogene opioids
• Modulation of the serotoninergic system
• Induction of „Long term depression“
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Anatomic places
• Many acupuncture points are at areas where vessel-nerve structures cross the fascia
• Similarities with trigger points
• Local immunologic effect through effects on sympathic fibers which innervate lymph nodes
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Gate-Control-Teorie
• Blockade of secondary nociseptive pathways (A, C) due to concomitant stimulation of non-nociseptive pathways (A)
• Theoretical base for the contrairritation treatments• Has probably only effect during stimulation, but
no long term effect.• Involves GABA-Receptors, mediated through Aβ-
fibers
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Release of endogene opioids
• Opiatantagonists can (partially) inhibit acupuncture analgesia
• Acupuncture has less effect in mice with a lower concentration of opioid receptors
• Acupuncture analgesis is increased when degradation of endogene opioids is blocked
• Cross tolerance with morphine• Emotional sideeffects partially similar to
endorphine
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Modulation of the serotoninergic system
• Destruction of raphe nuclei in brainstem blocks acupuncture effects
• Acupuncture effect often better at paroxysmal pain• Acupuncture analgesia is diminished when
ascending serotoninergic pathways are blocked• Probably combined effect on noradrenergic and
serotoninergic pathways
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Induction of „long term potentiation“
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Long-term Depression
• Repeated use of acupuncture leads to decreased response of the second neuron at nociseptive stimulations
• Explains the lonbg time effect of acupuncture
• Additional effect through reduced „Long term-potentiation-effects“
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Chinese medicine
• Traditionally based on the yin/yang principle and the five elements – different schools
• The body has symmetric ”meridians” which connect about 400 acupuncture points
• Classical: Pulse and tongue diagnostics, anamnesis description of the patient situation according to the five elements
• Chinese ”organs” are rather phenomenologic descriptions they do not fit to „western organs“ (e.g.: liver controls menstruation, kidney control finger nails
• Mythos is bigger than reality
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Elements of chinese medicine
• Acupuncture
• Moxa
• Cupping (usually bloddless)
• Seven star hammer
• Massage
• Qigong, Tai Qi Chuan
• Medikaments
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Acupuncture treatment
• Body acupuncture: usually 8 to 16 needles, symmetric, 20-40 minutes
• Ear acupuncture: needles, permanent needles or globes with plaster
• Moxa either with cigar or pieces of moxa on a acupuncture needle
• Cupping with or without needle, bloody or bloodless
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Symptomer• Pain 70,3 %• Xerostomia 67,5 %• Lack of appetite 60,9 %• Frailty 46,8 %• Opstipation 44,7 %• Dyspnea 42,3 %• Nausea 36,2 %• Insomnia 34,2 %• Perspiration 25,3 %• Swallowing problems 23,2 %• Urination problems 21,3 %• Psychiatric symptoms 19,8 %• Vomiting 18,5 %• Itching, other skin problems 16,3 %• Diarrea 7,6 %N = 12438
Grond 1994
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Symptomer• Pain 70,3 %• Xerostomia 67,5 %• Lack of appetite 60,9 %• Frailty 46,8
%• Opstipation 44,7 %• Dyspnea 42,3
%• Nausea 36,2
%• Insomnia 34,2
%• Perspiration 25,3 %• Swallowing problems 23,2
%• Urination problems 21,3
%• Psychiatric symptoms 19,8
%• Vomiting 18,5
%• Itching, other skin problems 16,3
%• Diarrea 7,6
%
N = 12438Grond 1994
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Journal of clinical oncology 2003, 21: 4120-4126
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Ear acupuncture for cancer pain (Alimi 2003)
• Cancer patients with neuropathic pain (!) and VAS > 30; 85% with constant pain, mean VAS 58
• Randomized, three groups: verum n=29 (with electical identification), placebo acupuncture n=30, no acupuncture n=31 (globes on placebo points)
• Assessed by a blinded observer
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Results
• Verum acupuncture lead to a reduction of pain to 37 (placebo-acupuncture 55, Placebo”globes” 58)
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Acupuncture for palliative patients: studies
• Short effect on dyspnea (Filshie 1996), no effect (Lewith 2004)
• Established effect in nausea (review: Weiger 2002)
• Pain: at some patients (bl.a. Alimi 2003)
• Xerostomia: some evidence (Rydholm 1999, Johnstone 2002)
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Possible point combinations
• Opstipation: LI4, St25, SJ6• Diarrea: St37, St25• Anxiety: P6, Ren 14• Nausea: P6, St36, Ren12• Aerocolia: St 36, ev. Syvstjernehammer
between LI4 and S2• Sedation points: Du 20, Ex 6, H7, An mien
I,II, P6, UB62
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Ongoing studies (Fatigue, Xerostomia)
• Treatment through nurses with a basic safety and technical training
• First treatments under supervision
• Each patient has a schedule and one who is responsible to follow the patient. This person does not treat the patient
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Acupuncture for fatigue: inclusion criteria
– Terminated chemotherapeutic treatment or treatment pause
– Subjectice fatigue with negative effects on QoL– Cognitivily able to understand the strudy and to
give informed consent
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Acupuncture for fatigue: exclusion criteria
• Clinical symptoms for immune suppression (spes: granulocytes < 1,5)
• Koagulation problems, thrombocytopeny• Relevant depression or anxiety• Anemia (Hb < 9) or frequent need for blood transfusions• Overdosage of medicaments, spec. Opioids or sedatives• Kacheksia• Clinical relevant infection• Dehydration• Detorriated electrolytes• Hypoxia• Clinical possibility for hormonal problems (e.g. Hypotyreodism)
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Study structure
• One treatment per week• Same points (St36, Sp6, Ren 6, H7, K3,
K27)• Needles for 20-30 minutes• Evaluation after four treatments, after
treatment end, after one month and three months (ESAS og BFI through a none treating person)
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St 36 (Zusanli)
• Lateral ved begynnelsen til tuberositas tibiae
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Sp 6 Sanyinjiao
• 3 cun over medial malleolus, dorsal tibia
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Ren 6 Qihai
• I midtlinjen, 1.5 cun under navlen
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H7 Shenmen
• Ved håndleddsrynken, radial til første senen (m flexor carpi ulnaris)
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K3 Taixi
• Mellom malleolus medialis og akillessene
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K27 Shufu
• Under kragebenen, 2 cun lateral fra midtlinjen. Sett nålen skjev, ca. 1 cm (ikke mer!)
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Acupuncture for xerostomia
• Inclusion: dry mouth with effects on QoL; Ability to give informed consent
• Exclusion: – Other effective treatment possibilities– Clinical symptoms for immune suppression (spes:
granulocytter < 1,5)– Coagulation problems, thrombocytopenia– Relevant depression or anxiety
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Study structure
• To treatments per week
• Points: K6, L7, Ren17, Ren 23, Gb 20, SJ17
• Evaluation before treatment, after three weeks and one months after terminated treatment (ESAS and XI through a none treating person)
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Punkter
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K6 Zhaohai
• 1 cun under fremre kant til malleolus medialis
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L7 Lieque
• Radial side til underarmen, 1.5 cun proximal fra håndleddsrynken
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Ren17 Shanzhong
• Midten til brystbein, mellom brystvortene, 4. interkostalrom
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Ren 23 Lianquan
• Mellom skjoldbruskkjertel og underkjevespissen (haken)
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Gb 20 Fengchi
• Mellom m. Sternocleidomastoideus og trapezius
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SJ17 Yifeng
• Bak øreflippen, foran processus mastoideus
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Other goals of the two studies
• To test feasibility in a clinical setting
• To test if nurses and nurse assistants can use a simple treatment scheme with clinical relevant effects.