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


Acupuncture treatment for palliative patients

  • 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)


Acupuncture treatment for palliative patients

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


Results of high quality rcts

Results of high quality RCTs


Acupuncture can help if something is perturbed but not if something is destroyed e g cancer

Acupuncture can help if something is perturbed, but not if something is destroyed (e.g. cancer)


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


Induction of long term potentiation

Induction of „long term potentiation“


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

  • Pain70,3 %

  • Xerostomia67,5 %

  • Lack of appetite60,9 %

  • Frailty46,8 %

  • Opstipation44,7 %

  • Dyspnea42,3 %

  • Nausea36,2 %

  • Insomnia34,2 %

  • Perspiration25,3 %

  • Swallowing problems23,2 %

  • Urination problems21,3 %

  • Psychiatric symptoms19,8 %

  • Vomiting18,5 %

  • Itching, other skin problems16,3 %

  • Diarrea 7,6 %

N = 12438

Grond 1994


Acupuncture treatment for palliative patients

Symptomer

  • Pain70,3 %

  • Xerostomia67,5 %

  • Lack of appetite60,9 %

  • Frailty46,8 %

  • Opstipation44,7 %

  • Dyspnea42,3 %

  • Nausea36,2 %

  • Insomnia34,2 %

  • Perspiration25,3 %

  • Swallowing problems23,2 %

  • Urination problems21,3 %

  • Psychiatric symptoms19,8 %

  • Vomiting18,5 %

  • Itching, other skin problems16,3 %

  • Diarrea 7,6 %

N = 12438

Grond 1994


Acupuncture treatment for palliative patients

Journal of clinical oncology 2003, 21: 4120-4126


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)


Punkter

Punkter


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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