acupuncture for pain - guildford advanced courses€¦ · acupuncture for pain slide 5 what is...

Acupuncture for Pain

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Acupuncture for pain relief

Dr Graham Leng


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Plan

Definitions

Use of acupuncture in Palliative Care in the UK

Evidence Base – does it work?

Mechanisms – how does it work?

Training and resources


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What is acupuncture?

Acus = needle

Punctura = to puncture


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What is Western Medical Acupuncture?

Western medical acupuncture is a therapeutic modality involving the insertion of fine needles

It is an adaptation of Chinese acupuncture using current knowledge of anatomy, physiology and pathology, and the principles of evidence based medicine

Acupunct Med 2009;27:33-35


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Use of acupuncture in Palliative Care

UK Palliative Care Survey Acupunct Med 2013;31:16–22

On-line questionnaire

263 emails

141 responses = 54%


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59%(N=76)

41%(N=53)

Results


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Where acupuncture was not available


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‘The lack of evidence in support of acupuncture prevents greater use of acupuncture in our palliative care service’

Strongly agree 5

Agree 28

Neutral 25

Disagree 52

Strongly disagree 12

Don’t know 4

51%

26%


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'If funding and a suitable practitioner were available, acupuncture would be a useful addition to our service'

73% agree or strongly agree


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Evidence Base

Cancer pain – 2 systematic reviews with meta-analyses

Hu – Evid Based Complement Alternat Med 2016

Chiu – Eu J Cancer Care 2017

Chronic pain – 2 individual patient meta-analyses

Vickers – Arch Intern Med 2012

Vickers – J Pain 2018


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Evidence Base

Nausea/vomiting – 3 Cochrane reviews, one other systematic review

Breathlessness – systematic review in COPD

Hot flushes – 3 systematic reviews, 2 meta-analyses

Dry mouth – 3 RCTs

Fatigue – meta-analysis

CIPN – systematic review

Aromatase inhibitor induced arthralgia - meta-analysis


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Non-palliative care evidence base

Low back pain – Cochrane review

OA knee – systematic review and meta-analysis

Neck pain – large RCT, Cochrane review

Shoulder pain – 2 RCTs

Migraine – Cochrane review, NICE guidelines

Tension type headaches – Cochrane review, NICE guidelines

Overactive bladder – 1 narrative review, 6 RCTs


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Systematic Review – Hu 2016

Cancer pain, 20 RCTs, 1639 patients

Acupuncture plus drug therapy is more effective than conventional drug therapy alone

Improved pain reduction

Shortened onset time to pain relief

Longer duration of analgesic time

Improved QoL

Acupuncture alone not superior to drug therapy


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Acu + drug therapy vs drug therapy alone


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Systematic Review – Chiu 2017

Cancer-related pain

Due to cancer, surgery, chemo, radiotherapy

29 RCTs, 2213 patients

Acupuncture is effective in relieving cancer-related pain, particularly malignancy-related and surgery-induced pain

Overall effect size -0.45

Cancer pain effect size -0.71

(small 0.2 – medium 0.5 – large 0.8)


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Cancer pain


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Vickers 2012 / 2018

Individual patient meta-analysis

39 RCTs, 20827 patients

Chronic non-malignant pain

Acupuncture superior to sham control -0.2 SDs

Superior to no acupuncture control by -0.5 SDs

15% reduction in treatment effect at 1 year


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Mechanisms

Neurotransmitters eg endorphins

Segmental effects

Heterosegmental effects

Wind-up / neuronal plasticity


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Neurotransmitters


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requires stimulation of an intact nervous system

is blocked by;

local anaesthesia of the tissue being stimulated

nerve section or nerve damage

naloxone and six other opiate antagonists

antibodies to endorphins

microinjection of naloxone or endorphin antibodies

lesioning the periaqueductal grey

Acupuncture analgesia

is not blocked by dextro-naloxone

is subject to cross-circulation effects

is associated with a rise in mRNA for proenkephalin


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Segmental effects

C-fibres

Aδ fibres

Local effectsCGRP, NGFSub P etc

ThalamusSomatosensory cortex

Met-encephalin


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Heterosegmental effects

Collaterals in midbrain run from Thalamus and SSC to Periaquaductal Grey (PAG)

B-endorphin & met-encephalin in PAG

Descending inhibition –5HT and Noradrenaline (concentrated at the segment stimulated)


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Wind up

Chronic pain

Central sensitisation

Increased pain response

Allodynia Hyperalgesia Hyperpathia

NMDA receptors


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Guidelines

Guidelines for providing acupuncture treatment for cancer patients – Filshie 2006

National Guidelines for the Use of Complementary Therapies in Supportive and Palliative Care 2003

Foundation for Integrated Health and NCPC

Safety Aspects of Acupuncture in Palliative Care – Filshie 2001


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Guidelines

Narrative literature reviews

More recent higher quality evidence

Recommend use in pain and a range of other symptoms

Safety aspects discussed

References in handouts


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Use in Palliative Care

Pain

Cancer-related pain

If myofascial component to pain

For ‘difficult’ pain eg neuropathic pain

For treatment-related pain

eg scar / CIPN / aromatase inhibitor arthralgia

If pain partially/poorly responsive to opioids

For patients sensitive to drug side effects

Patient wishes to avoid increases in medication


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Use in Palliative Care

Non-pain

Nausea

Dyspnoea

Hot flushes

Dry mouth

Overactive bladder

Anxiety

Fatigue


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Adverse events

Two Prospective studies

66000 treatments by 652 UK acupuncturists

Minor adverse events 10%

Tiredness 3%

Bleeding / bruising 3%

Aggravation of symptoms 2%

Pain at needling site 1%

Significant events in 0.1%

Fainting, forgotten needle, forgotten patient

No Serious adverse eventsWhite A. 2006 Acupunct Med


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Cautions in palliative care

Spinal Cord Compression

Vertebral mets – RTX first

Skin mets / local tumour

Lymphoedema

Or axillary surgery / RTX

Pneumothorax

Frail / cachexic patients

Anticoagulants

Chemotherapy / Haematology patients

Neutropenia – avoid indwelling needles

Thrombocytopenia –avoid vigorous needling


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Training in acupuncture

British Medical Acupuncture Society

Training for health professionals

Foundation Course

Special topic days

Palliative Care, Back pain, Headache, Osteoarthritis, Electroacupuncture,Women’s health, Pregnancy & Childbirth

Scientific meetings


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Resources

Elsevier


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Thank you

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acupuncture for pain - guildford advanced courses€¦ · acupuncture for pain slide 5 what is...

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