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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

slide2
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)
slide6

Scientific studies about acupuncture

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

side actions of acupuncture
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
adverse effects complications
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

mechanisms of action
Mechanisms of action
  • Anatomic places
  • Gate-Control-Theory
  • Release of endogene opioids
  • Modulation of the serotoninergic system
  • Induction of „Long term depression“
anatomic places
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
gate control teorie
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
release of endogene opioids
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
modulation of the serotoninergic system
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
long term depression
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“
chinese medicine
Chinese medicine
  • 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
Elementsof chinese medicine
  • Acupuncture
  • Moxa
  • Cupping (usually bloddless)
  • Seven star hammer
  • Massage
  • Qigong, Tai Qi Chuan
  • Medikaments
a cupuncture treatment
Acupuncture 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
  • 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

slide30

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

ear acupuncture for cancer pain alimi 2003
Ear 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
Results
  • Verumacupuncture lead to a reduction of pain to 37 (placebo-acupuncture 55, Placebo”globes” 58)
a cupuncture for palliative patients studie s
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)
possible point combinations
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
ongoing studies fatigue xerostomia
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
acupuncture for fatigue inclusion criteria
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
acupuncture for fatigue exclusion criteria
Acupuncture for fatigue: 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
  • 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)
  • Lateral ved begynnelsen til tuberositas tibiae
sp 6 sanyinjiao
Sp 6 Sanyinjiao
  • 3 cun over medial malleolus, dorsal tibia
ren 6 qihai
Ren 6 Qihai
  • I midtlinjen, 1.5 cun under navlen
h7 shenmen
H7 Shenmen
  • Ved håndleddsrynken, radial til første senen (m flexor carpi ulnaris)
k3 taixi
K3 Taixi
  • Mellom malleolus medialis og akillessene
k27 shufu
K27 Shufu
  • Under kragebenen, 2 cun lateral fra midtlinjen. Sett nålen skjev, ca. 1 cm (ikke mer!)
acupuncture for xerostomia
Acupuncture for xerostomia
  • 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
  • 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)
k6 zhaohai
K6 Zhaohai
  • 1 cun under fremre kant til malleolus medialis
l7 lieque
L7 Lieque
  • Radial side til underarmen, 1.5 cun proximal fra håndleddsrynken
ren17 shanzhong
Ren17 Shanzhong
  • Midten til brystbein, mellom brystvortene, 4. interkostalrom
ren 23 lianquan
Ren 23 Lianquan
  • Mellom skjoldbruskkjertel og underkjevespissen (haken)
gb 20 fengchi
Gb 20 Fengchi
  • Mellom m. Sternocleidomastoideus og trapezius
sj17 yifeng
SJ17 Yifeng
  • Bak øreflippen, foran processus mastoideus
other goals of the two studies
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.
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