Specific effects and expectation of acupuncture treatment a trial utilising pet imaging
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Specific effects and expectation of acupuncture treatment. A trial utilising PET imaging. Dr P White Dr G Lewith Dr J Pariente Prof R Frackowiac. Background. Effectiveness vs Efficacy for acupuncture Often large treatment effects Neck pain trial

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Specific effects and expectation of acupuncture treatment a trial utilising pet imaging

Specific effects and expectation of acupuncture treatment. A trial utilising PET imaging

Dr P White

Dr G Lewith

Dr J Pariente

Prof R Frackowiac


Background
Background trial

  • Effectiveness vs Efficacy for acupuncture

  • Often large treatment effects

  • Neck pain trial

    • White, Lewith, Prescott (2004), Annals of internal Medicine


Neck pain method
Neck pain - method trial

  • 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.


Neck pain - results trial

Mean pain scores from baseline to week 12

Acupuncture versus MTNS, 12% difference

P = 0.01, 95% confidence intervals, 3-21%

  • 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


Background1
Background trial

  • Need to tease apart specific and non-specific effects

  • Many different controls have been used

  • ? Physiological effect of acupuncture


Functional imaging and acupuncture
Functional Imaging and Acupuncture trial

  • 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 acupuncture1
Functional Imaging and Acupuncture trial

  • 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)


Questions
Questions trial

  • 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?


Method
Method trial

  • 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.



Outcomes
Outcomes trial

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)


Flow chart of PET procedure trial

Consent, history/ assessment/ questionnaires, insert cannula, MRI scan

Randomisation

Real Acupuncture

Streitberger Placebo

Overt Placebo

Baseline PET scan

Apply needle (0 minutes)

Apply needle (0 minutes)

Insert needle (0 mins)

Manipulate (4 mins)

Continues as per ‘Real acupuncture’

Continues as per ‘Real acupuncture’

Manipulate and scan (8 mins)

Scan only (16 mins)

Remove needle (23.5 mins)

Scan only (24 mins)

Scan only (32 mins)


Results
Results trial

  • 14 patients (F=11, M=3)

  • Right handed

  • 8= pain in left thumb

  • Mean age=59 (S.D.=5.7) (Range 48-63)

  • 4 patients had experience of acupuncture


Credibility 2 p values
Credibility trial (2 p values)

Real and Streitberger = similar credibility

Real and Overt = significantly different

Streitberger and Overt = ?different (less so)


  • Skin penetration trial

    • 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

    • HCAMQ

    • Experience

    • Order

    • Pain

No effect on outcome


Real Acupuncture vs Streitberger needle (specific acupuncture effect).

Hyperactivation of the insula ipsilateral to the intervention – not found on the other two interventions


Painful stimulus acupuncture effect).

Area of activation in the contralateral insula


A acupuncture effect).

B

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 system


Interpretation
Interpretation acupuncture effect).

  • 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


The next phase
The next phase? acupuncture effect).

  • Further investigation of the physiological effect of skin prick – is it inert?


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