Acupuncture treatment for palliative patients
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Acupuncture treatment for palliative patients?. Gernot Ernst Blefjell sykehus Kongsberg Anestesi, Smerte- og palliativseksjon. I ntroduction Scientific evidence Mechanisms Chinese medicine Examples Ongoing research in Kongsberg. History of acupuncture.

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Acupuncture treatment for palliative patients

Acupuncture treatment for palliative patients?

Gernot Ernst

Blefjell sykehus Kongsberg

Anestesi, Smerte- og palliativseksjon


  • Introduction

  • Scientific evidence

  • Mechanisms

  • Chinese medicine

  • Examples

  • Ongoing research in Kongsberg


History of acupuncture
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-acupuncturenot more effective than placebo, both better than controls


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

Indications for acupuncture (NIH 1997)


Scientific studies about acupuncture

Filshie/White 1998: left side: not randomized, right side randomized


Prophylaxis of migraine with a c upun c tur e
Prophylaxis of migraine with acupuncture

Weinschütz et al 1996




Side actions of acupuncture
Side actions of acupuncture something is destroyed (e.g. cancer)

  • Weariness, heaviness, better sleep

  • Stimulation, sensation of lightness

  • Sensation of warmth

  • Muscle relaxing

  • Mood improving

  • Increased appetite, improved digestion, improved urination


Adverse effects complications
Adverse effects, complications something is destroyed (e.g. cancer)

  • 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


Mechanisms of action
Mechanisms of action something is destroyed (e.g. cancer)

  • Anatomic places

  • Gate-Control-Theory

  • Release of endogene opioids

  • Modulation of the serotoninergic system

  • Induction of „Long term depression“


Anatomic places
Anatomic places something is destroyed (e.g. cancer)

  • 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


Gate control teorie
Gate-Control-Teorie something is destroyed (e.g. cancer)

  • 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


Release of endogene opioids
Release of endogene opioids something is destroyed (e.g. cancer)

  • 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


Modulation of the serotoninergic system
Modulation of the serotoninergic system something is destroyed (e.g. cancer)

  • 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


Induction of long term potentiation
Induction of „long term potentiation“ something is destroyed (e.g. cancer)


Long term depression
Long-term Depression something is destroyed (e.g. cancer)

  • 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“


Chinese medicine
Chinese medicine something is destroyed (e.g. cancer)

  • Traditionally based onthe yin/yang principleand the five elements – different schools

  • The body has symmetric ”meridians” which connect about 400 acupuncture points

  • Classical: Pulseandtongue diagnostics, anamnesis description of the patient situation according to the five elements

  • Chinese ”organs” are ratherphenomenologic descriptions they do not fit to „western organs“ (e.g.: liver controls menstruation, kidneycontrolfinger nails

  • Mythos is bigger than reality


Element s of chinese medicine
Element something is destroyed (e.g. cancer)sof chinese medicine

  • Acupuncture

  • Moxa

  • Cupping (usually bloddless)

  • Seven star hammer

  • Massage

  • Qigong, Tai Qi Chuan

  • Medikaments


A cupuncture treatment
A something is destroyed (e.g. cancer)cupuncture treatment

  • Body acupuncture: usually 8 to 16 needles, symmetric, 20-40 minutes

  • Ear acupuncture: needles, permanent needlesor globes with plaster

  • Moxa either with cigar or pieces of moxa on a acupuncture needle

  • Cupping with or without needle, bloody or bloodless


Symptomer
Symptomer something is destroyed (e.g. cancer)

  • 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


Symptomer something is destroyed (e.g. cancer)

  • 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


Journal of clinical oncology 2003, 21: 4120-4126 something is destroyed (e.g. cancer)


Ear acupuncture for cancer pain alimi 2003
Ear something is destroyed (e.g. cancer)acupuncture for cancer pain (Alimi 2003)

  • Cancer patients with neuropathicpain (!) and VAS > 30; 85% with constant pain, mean VAS 58

  • Randomized, three groups: verum n=29 (with electical identification), placeboacupuncture n=30, no acupuncture n=31 (globes on placebo points)

  • Assessed by a blinded observer


Result s
Result something is destroyed (e.g. cancer)s

  • Verumacupuncture lead to a reduction of pain to 37 (placebo-acupuncture 55, Placebo”globes” 58)


A cupuncture for palliative patients studie s
A something is destroyed (e.g. cancer)cupuncture 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)


Possible point combinations
Possible point combinations something is destroyed (e.g. cancer)

  • 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


Ongoing studies fatigue xerostomia
Ongoing studies (Fatigue, Xerostomia) something is destroyed (e.g. cancer)

  • 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


Acupuncture for fatigue inclusion criteria
Acupuncture for fatigue: something is destroyed (e.g. cancer)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


Acupuncture for fatigue exclusion criteria
Acupuncture for fatigue: something is destroyed (e.g. cancer)exclusion criteria

  • Clinical symptoms for immune suppression (spes: granulocytes < 1,5)

  • Koagulation problems, thrombocytopeny

  • Relevant depression oranxiety

  • 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)


Study structure
Study structure something is destroyed (e.g. cancer)

  • 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)


St 36 zusanli
St 36 (Zusanli) something is destroyed (e.g. cancer)

  • Lateral ved begynnelsen til tuberositas tibiae


Sp 6 sanyinjiao
Sp 6 Sanyinjiao something is destroyed (e.g. cancer)

  • 3 cun over medial malleolus, dorsal tibia


Ren 6 qihai
Ren 6 something is destroyed (e.g. cancer) Qihai

  • I midtlinjen, 1.5 cun under navlen


H7 shenmen
H7 something is destroyed (e.g. cancer) Shenmen

  • Ved håndleddsrynken, radial til første senen (m flexor carpi ulnaris)


K3 taixi
K3 something is destroyed (e.g. cancer) Taixi

  • Mellom malleolus medialis og akillessene


K27 shufu
K27 something is destroyed (e.g. cancer) Shufu

  • Under kragebenen, 2 cun lateral fra midtlinjen. Sett nålen skjev, ca. 1 cm (ikke mer!)


Acupuncture for xerostomia
Acupuncture for xerostomia something is destroyed (e.g. cancer)

  • Inclusion: dry mouthwith 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


Study structure1
Study structure something is destroyed (e.g. cancer)

  • 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)


Punkter
Punkter something is destroyed (e.g. cancer)


K6 zhaohai
K6 something is destroyed (e.g. cancer) Zhaohai

  • 1 cun under fremre kant til malleolus medialis


L7 lieque
L7 something is destroyed (e.g. cancer) Lieque

  • Radial side til underarmen, 1.5 cun proximal fra håndleddsrynken


Ren17 shanzhong
Ren17 Shanzhong something is destroyed (e.g. cancer)

  • Midten til brystbein, mellom brystvortene, 4. interkostalrom


Ren 23 lianquan
Ren 23 Lianquan something is destroyed (e.g. cancer)

  • Mellom skjoldbruskkjertel og underkjevespissen (haken)


Gb 20 fengchi
Gb 20 Fengchi something is destroyed (e.g. cancer)

  • Mellom m. Sternocleidomastoideus og trapezius


Sj17 yifeng
SJ17 Yifeng something is destroyed (e.g. cancer)

  • Bak øreflippen, foran processus mastoideus


Other goals of the two studies
Other goals of the two studies something is destroyed (e.g. cancer)

  • To test feasibility in a clinical setting

  • To test if nurses and nurse assistants can use a simple treatment scheme with clinical relevant effects.


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