Acupuncture for Acupuncture for Hemophilia Patients in Hemophilia Patients in

Chronic Pain.Chronic Pain.Angela Lambing, MSN, NP-C, Angela Lambing, MSN, NP-C, 11

Dr. Vinay Varma, Dr. Vinay Varma, 22

Beth KohnBeth Kohn L.Ac., M.T.O.M, Dipl.Ac, L.Ac., M.T.O.M, Dipl.Ac,

Dipl.CHDipl.CH , , 11

Dr. Suresh HanagavadiDr. Suresh Hanagavadi22

11Henry Ford Health System, Detroit, MIHenry Ford Health System, Detroit, MI22Karnataka Hemophilia Society, IndiaKarnataka Hemophilia Society, India

Statement of the ProblemStatement of the Problem Chronic pain due to end stage arthritis Chronic pain due to end stage arthritis

for hemophilia patients presents for hemophilia patients presents ongoing issues resulting in exploration ongoing issues resulting in exploration of non-standard therapies for pain of non-standard therapies for pain managementmanagement

Acupuncture has proved successful in Acupuncture has proved successful in osteoarthritis and non-malignant pain. osteoarthritis and non-malignant pain.

Pain management involves a Pain management involves a multimodal approachmultimodal approach

ObjectivesObjectives

This study seeks to: This study seeks to: a) Document a decrease in hemarthritic a) Document a decrease in hemarthritic

joint pain after acupuncture treatmentsjoint pain after acupuncture treatments b) Demonstrate minimal bleeding risk b) Demonstrate minimal bleeding risk

during acupuncture.during acupuncture.

Review of the LiteratureReview of the Literature

Minimal literature related to hemophiliaMinimal literature related to hemophilia Wallny TA, Brackmann, HH, Gunia G, WIlbertz Wallny TA, Brackmann, HH, Gunia G, WIlbertz

P, Oldenberg J, Kraft CN. (2006). Successful P, Oldenberg J, Kraft CN. (2006). Successful pain treatment in arthropathic lower pain treatment in arthropathic lower extremities by acupuncture in haemophilia extremities by acupuncture in haemophilia patients. patients. Haemophilia. 12(5); 500-2. Haemophilia. 12(5); 500-2. 10/12 pts showed improvement 10/12 pts showed improvement Average VAS reduced from 6.8/10 to 5/10Average VAS reduced from 6.8/10 to 5/10 No side effects were observedNo side effects were observed

Rosted P & Jorgensen V. (2002). Rosted P & Jorgensen V. (2002). Acupuncture used in the management Acupuncture used in the management of pain due to arthropathy in a patient of pain due to arthropathy in a patient with haemophilia. with haemophilia. Acupuncture Acupuncture medicine. medicine. 20(4); 193-5. 20(4); 193-5. Case report – 38 yr old severe hemophilia Case report – 38 yr old severe hemophilia

A, with joint pain; knees, elbows, anklesA, with joint pain; knees, elbows, ankles On factor prophylaxis; received factor prior to On factor prophylaxis; received factor prior to

txtx Previous right knee synovectomyPrevious right knee synovectomy 5 tx for the knee with reported significant 5 tx for the knee with reported significant

reduction in painreduction in pain Repeat acupuncture every 3 monthsRepeat acupuncture every 3 months Close collaboration with hemophilic clinicClose collaboration with hemophilic clinic Use of qualified acupuncture specialistsUse of qualified acupuncture specialists

MethodMethod Convenience sampleConvenience sample Prospective studyProspective study Dual study between Twinning partners:Dual study between Twinning partners:

Henry Ford Health System, Detroit, MIHenry Ford Health System, Detroit, MI Karnataka Hemophilia Society, Karnataka, IndiaKarnataka Hemophilia Society, Karnataka, India Utilized certified acupuncturistsUtilized certified acupuncturists

Inclusion CriteriaInclusion Criteria > 18 years of age> 18 years of age HemophiliaHemophilia Reported chronic painReported chronic pain Severe Joint hemarthrosis as identified by the HTCSevere Joint hemarthrosis as identified by the HTC

Michigan subjects – factor replacement > 15% Michigan subjects – factor replacement > 15% level (per IRB requirements)level (per IRB requirements)

India residents – no factor prior to treatmentsIndia residents – no factor prior to treatments

Acupuncture pointsAcupuncture points Acupuncture treatment planAcupuncture treatment plan

Twice per week x 4 weeks; weekly for remaining 6 Twice per week x 4 weeks; weekly for remaining 6 weeksweeks

Primary acupuncture points:Primary acupuncture points: Du 20, LI 4, Liv 3, Gb 34, Sp 6, LI 11, St 35, Kid 3, Du 20, LI 4, Liv 3, Gb 34, Sp 6, LI 11, St 35, Kid 3,

Shen Men Ear Point Shen Men Ear Point Specific Knee pain:Specific Knee pain:

Secondary points: Xi yan, Heding, Liv 8, Sp 10Secondary points: Xi yan, Heding, Liv 8, Sp 10 Specific Ankle pain:Specific Ankle pain:

Secondary Points: St 41, Gb 40, Sp5Secondary Points: St 41, Gb 40, Sp5 Specific Lower back pain:Specific Lower back pain:

Secondary Points: Ub 23, Du 4Secondary Points: Ub 23, Du 4 Specific Elbow Pain:Specific Elbow Pain:

Secondary Points: Lu 5, Sj 5Secondary Points: Lu 5, Sj 5

MethodMethod

Measured pain scores using:Measured pain scores using: Visual analog scale: 0 – 10Visual analog scale: 0 – 10

Average daily painAverage daily pain Highest levelHighest level Lowest levelLowest level

Types of pain medications utilizedTypes of pain medications utilized Number of pain pills taken/dayNumber of pain pills taken/day

Quality of Life (QOL)Quality of Life (QOL) Standard SF-36Standard SF-36

MethodMethod

Signed consent per IRB protocolSigned consent per IRB protocol Cost of acupuncture sessions coveredCost of acupuncture sessions covered Mileage covered for travel to each Mileage covered for travel to each

sessionsession Patients were instructed to report any Patients were instructed to report any

bleeding issuesbleeding issues Acupuncturists identified any post Acupuncturists identified any post

procedural bleeding issues.procedural bleeding issues.

ResultsResults 19 HFH hemophilia pts signed up to 19 HFH hemophilia pts signed up to

participateparticipate Only 6 completed the study citing travel & Only 6 completed the study citing travel &

work restrictionswork restrictions 3 hemophilia pts completed study in 3 hemophilia pts completed study in

IndiaIndia Total of 9 pts completed studyTotal of 9 pts completed study

6 severe hemophilia6 severe hemophilia 2 moderate hemophilia2 moderate hemophilia 1 mild hemophilia1 mild hemophilia

DemographicsDemographics

Ethnicity: Ethnicity: 3 India3 India 4 Caucasian4 Caucasian 2 Afr American2 Afr American

Education:Education: 4 college4 college 2 secondary school2 secondary school 2 technical school2 technical school 1 grade school: gr 81 grade school: gr 8

Marital StatusMarital Status 7 married7 married 2 single2 single

Age: 28 – 63 yrsAge: 28 – 63 yrs Ave age 45 yearsAve age 45 years

WorkWork 4 full time4 full time 3 disabled3 disabled 1 student1 student 1 retired1 retired

Pain level reports: VAS 0-10Pain level reports: VAS 0-10PtPt Pre Pre

treatmetreatmentnt

Post Post TreatmenTreatmentt

Pain Pain med premed pre

Pain Pain med med postpost

#1#1 4.04.0 4.04.0 1 x week1 x week 1 x month1 x month

#2#2 4.04.0 2.02.0 1 x week1 x week NoneNone

#3#3 8.08.0 6.06.0 3-4 x day3-4 x day 3-4 x day3-4 x day

#4#4 5.05.0 1.01.0 1-2 x day1-2 x day < 1 x day< 1 x day

#5#5 6.06.0 4.04.0 1-2 x day1-2 x day 1-2 x day1-2 x day

#6#6 4.04.0 4.04.0 1-2 x day1-2 x day 5-6 x day5-6 x day

#7#7 4.04.0 4.04.0 < 1 x day< 1 x day <1 x day<1 x day

#8#8 10.010.0 5.05.0 3-4 x day3-4 x day 3-4 x day3-4 x day

#9#9 4.04.0 2.02.0 1 x week1 x week 1 x month1 x month

SF-36; QOL scoresSF-36; QOL scores

VariablesVariables Pre acupuncturePre acupuncture Post acupuncturePost acupuncture

Physical Physical FunctioningFunctioning

23.023.0 30.030.0

Social functioningSocial functioning 52.5052.50 70.070.0

Physical problemPhysical problem 00 00

Emotional problemEmotional problem 60.060.0 73.373.3

Mental healthMental health 76.876.8 82.482.4

Energy/FatigueEnergy/Fatigue 42.042.0 43.043.0

PainPain 33.333.3 44.444.4

Health perceptionHealth perception 43.843.8 43.843.8

Health changeHealth change 50.050.0 65.065.0

Pre Acupuncture

Post Acupuncture

Pre Acupuncture

Post Acupuncture

LimitationsLimitations

Very small sample sizeVery small sample size Duration of therapy program proved Duration of therapy program proved

a barrier to enrollmenta barrier to enrollment Additional objective data to confirm Additional objective data to confirm

improvement would have been improvement would have been helpfulhelpful Joint measurementsJoint measurements

ConclusionsConclusions No bleeding experienced:No bleeding experienced:

With any subjectWith any subject After every treatment sessionAfter every treatment session Factor vs no factor pre treatmentFactor vs no factor pre treatment

6/8 pts reported decrease in VAS pain scores6/8 pts reported decrease in VAS pain scores 7/9 QOL domains improved7/9 QOL domains improved Alternative therapies: acupuncture may Alternative therapies: acupuncture may

provide some benefit to chronic pain provide some benefit to chronic pain patients with hemophilia in a multimodal patients with hemophilia in a multimodal approachapproach

Larger randomized studies are neededLarger randomized studies are needed