Q/marketing/insignia guidelineswww.aacp.org.uk

Session 1

Origins and Evolution of Acupuncture

Learning Outcomes

By the end of the session you should be able to demonstrate

➢ a basic knowledge of the origins of acupuncture

➢ a basic knowledge of its adoption into Western culture

➢ an appreciation of the concepts associated with traditional Chinese acupuncture (TCA)

➢ an understanding of the evolution of the Western medical model

Discuss

➢ the acceptance of acupuncture within main stream medicine

➢ the current state of the evidence

AcupunctureLatin ‘acus’ – needle ‘punctura’ - a pricking

• Taoism

• Yin and Yang

• Qi

• Meridians

1st Century AD ‘Nei Ching’

Traditional Chinese Acupuncture –Diagnosis

( association between environment and symptoms)

Include:►Bi Syndrome ►5-elements

• Chen Chiu Chia I Ching –

Acupoints on meridians

• Sun Simiao – the cun© The Seirin Pictorial Atlas of Acupuncture

Not just a Chinese medicine

Japan

Korea

‘Otzi’ Tyrolean Iceman tattooed ‘points’

Dofer et al. (1999) A medical report from the stone age? The Lancet354:1023-1025.

Ch’ing dynasty – decline of acupuncture in China coincides

with translation into the West (17th Century)

European missionaries visiting China

1822 great plague in China - millions died . Acupuncture practice prohibited as a result. Western medicine encouraged.

Mao Zedong and resurgence of acupuncture in China

Post second world war population growth 900 million (2015)

Nixon visits China 1972

Surgery with acupuncture analgesia(hyperlink to video)

Development of acupuncture in the West

Referred Pains from Muscle. Kellgren JH. Br Med J. 1938 Feb 12;1(4023):325-7

Travell (1940’s) & Simons (1980’s)

Myofascial Trigger Points

Trigger points and acupuncture points for pain: correlations and implications.Melzack R, Stillwell DM, Fox EJ.Pain. 1977 Feb;3(1):3-23. Review

Felix Mann (1970’s)

Challenged the construct of acupuncture points‘dry needling'

Acupuncture anaesthesia. Mann F. Lancet. 1973 Sep 8;2(7828):563-4

Modern day advances in radiological and laboratory techniques – are they advancing our understanding of acupuncture?

Trends in acupuncture research

Nix

on

’s v

isit

f-MR

I

NC

CA

M in

US

RC

T’s

f-MR

I

Global trends and performances of acupuncture research.Han JS, Ho YS.Neurosci Biobehav Rev. 2011 Jan;35(3):680-7.

Trends in acupuncture research

Global trends and performances of acupuncture research.Han JS, Ho YS. Neurosci Biobehav Rev. 2011 Jan;35(3):680-7

Acupuncture within Physiotherapy

➢ 2000 - House of Commons select committee in science and technology

➢ 2008 - Statutory regulation

➢ 2015 - AACP Evidence and Commissioning Resource

➢ NICE guidelines

➢ Cochrane database

Should GPs commission acupuncture for the treatment of musculoskeletal pain conditions?

Q/marketing/insignia guidelines www.aacp.org.uk

Session 2

Neurological Mechanisms Local Effects and Segmental Analgesia

Learning outcomes

By the end of the session you should be able to demonstrate

➢ a basic understanding of the local neurophysiologicalmechanisms associated with acupuncture analgesia

➢ a critical understanding of the evidence used to support acupuncture analgesia at a local and segmental level

➢ an awareness of Western medical theoretical models used to explain acupuncture points and meridians

Location of acupuncture points

➢Approx.361 along 14 meridians, plus extra points

➢ No specific distinguishing features – evidence of reduced electrical impedance unconvincing

Electrical properties of acupuncture points and meridians: a systematic review. Ahn AC et al. Bioelectromagnetics. 2008 May;29(4):245-56.

© The Pictorial Atlas of Acupuncture

How do you think acupuncture works in relieving pain?

Neuropeptidese.g. Calcitonin gene-related peptide

Substance P

Neurokinin A

Local effectsa) chemical

© Dr Liz Tough

Causing vasodilation and increased vascular permeability

‘Weal and flare’

Release of:

Bradykinin from plasma protein

Serotonin from platelets

Potassium ions from plasma

Histamine from mast cells

Inflammatory exudate

Local effects

Effects of acupuncture on skin and muscle blood flow in healthy subjects.Sandberg et al Eur J Appl Physiol. 2003 Sep;90(1-2):114-9.

Peripheral opioid analgesia➢ Local endorphins and their receptors have been found on

nociceptive afferents in inflammatory conditions1

Endorphins are secreted from inflammatory cells post injury.

Increased synthesis of endorphin receptors at the dorsal root ganglion2.

Local effects

1Peripheral opioid analgesia.Stein C, Machelska H, Binder W, Schäfer M. Curr Opin Pharmacol. 2001 Feb;1(1):62-5. Review 2 Acupuncture mechanisms for clinically relevant long-term effects--

reconsideration and a hypothesis.Carlsson C. Acupunct Med. 2002 Aug;20(2-3):82-99. Review.

Peripheral opioid analgesia occurs some days after injury1 - Increase in endorphin levels and receptors observed at injury site a few days after injury

Local effects

1Peripheral opioid analgesia. Stein C, Machelska H, Binder W, Schäfer M. Curr Opin Pharmacol. 2001 Feb;1(1):62-5. Review 2 Acupuncture mechanisms for clinically relevant long-term effects-

reconsideration and a hypothesis. Carlsson C. Acupunct Med. 2002 Aug;20(2-3):82-99. Review.

TheoryAcupuncture induces an injury = increase in local endorphins few days later. Could explain why some patients report pain relief 2-3

days post treatment2

Local effectsb) electrical

Action potential A δ fibres

Needle insertion and manipulation stimulates Aδ fibres in skin; type II &III in muscle

White A, Cummings M, Filshie J (2008) An Introduction to Western Medical Acupuncture. Churchill Livingstone

Segmental analgesia

© 2008 Elsevier Limited

White A, Cummings M, Filshie J (2008) An Introduction to Western Medical Acupuncture. Churchill Livingstone

Segmental analgesia

© 2008 Elsevier Limited

Acupuncture stimulation of A δ fibres activates intermediate cells to produce

enkephalin which ‘blocks’ nociceptive input from C-fibres

Evidence that acupuncture needling influences A δ fibres (type II type III afferent)

Needle sensation ‘de qi’

NumbnessTingling type II afferent stimulation

HeavinessMild ache type III afferent stimulation

Pomeranz B (1997) Scientific basis of acupuncture. In Basics of Acupuncture Fourth Ed. Springer.

A study on the receptive field of acupoints and the relationship between characteristics of needling sensation and groups of afferent fibres.

Wang et al. Sci Sin B. 1985 Sep;28(9):963-71

Afferent nerve fibers and acupuncture.Kagitani et al. Auton Neurosci. 2010 Oct 28;157(1-2):2-8. Review

➢ Spinal segment that supplies a joint also supplies the muscles around it

➢ Needle the muscles to affect nociceptive pain originating from other structures in and around the joint

Clinical application of segmental acupuncture

Clinically - know tissue innervation

It’s complicated!

Consider the patients pain

Persistent pain and central sensitisation

➢ Reduced mechanical threshold, and increased responsiveness to suprathreshold stimulus (i.e. touch perceived as pain) and an expansion of the receptive fields of WDR neurones in the dorsal horn

➢Mildly painful stimulus of afferent A-δ fibres in the same segment has been shown to induce long term depression (of synaptic strength) in the spinal cord resulting in pain relief 1,2

➢ However, mildly painful stimulus can induce long-term potentiation, if WDR cells are influenced by descending excitatory influences, resulting in an increase

in pain. Can make chronic pain patients worse.

Supporting evidence of long-term depression (LTD) in the dorsal horn comes from experiments on rats1. Low-frequency stimulation of afferent Adelta-fibersinduces long-term depression at primary afferent synapses with substantia gelatinosa neurons in the rat.Sandkühler et al. J Neurosci. 1997 Aug 15;17(16):6483-91

2. Long-term depression of C-fibre-evoked spinal field potentials by stimulation of primary afferent A delta-fibres in the adult rat. Liu et al. Eur J Neurosci. 1998 Oct;10(10):3069-75

Acupuncture's painkilling secret revealed: it's all in the twist actionTwist of a needle damages cells and triggers release of anti-inflammatory chemical adenosine, US scientists find•Ian Sample, science correspondent •The Guardian, Monday 31 May ‘10 •Article historyAcupuncture 'meridians' match main nerve pathways scientists believe.

Adenosine A1 receptors mediate local anti-nociceptive effects of acupuncture.Goldman et al. Nat Neurosci. 2010 Jul;13(7):883-8.

Behind the headlines

Neural acupuncture unit: a new concept for interpreting effects and mechanisms of acupuncture. Zhang et al. Evid Based Complement Alternat Med. 2012;2012:429412.

Is accuracy of point location important?

i) The neural acupuncture unit (NAU) – a theoretical construct

Classification of NAU Location

Muscle spindle rich Around 60% of acupuncture points are located in muscle

Cutaneous receptor rich Hands, feet, face, (sensory homonculus)

Tendon organ rich Around joints, wrist, elbow, knees, ankles

ii) Connective tissue – mechanical transduction

Relationship of acupuncture points and meridians to connective tissue planes.Langevin et al. Anat Rec. 2002 Dec 15;269(6):257-65.

Electrical impedance along connective tissue planes associated with acupuncture meridians. Ahn et al. BMC Complement Altern Med. 2005 May 9;5:10.

Local Effects and Segmental Analgesia

Summary

➢ Effects of piercing the skin – local physiological response

➢ Stimulation of A-δ fibres – segmental pain inhibition

➢ Consider the patient’s pain – long term potentiation versus long term depression

➢ Specificity of point location

➢ NAU

➢ Connective tissue planes

Task

➢Summarise acupuncture’s effect at a local level

➢Describe to the person next to you ‘how acupuncture is believed to work’ in a way that a lay person or patient would understand

Session 3

Safety of Acupuncture

Learning outcomes

By the end of the session you should be able to demonstrate a knowledge and understanding of

➢ the evidence of acupuncture safety

➢ possible adverse events

➢ contraindications and precautions

Discuss

➢ the importance of anatomical knowledge

➢ the importance of co-morbidity

Survey data

Survey of adverse events following acupuncture (SAFA): a prospective study of 32,000 consultations. White A, et al. BMAS and AACP. British Medical Acupuncture Society and Acupuncture Association of Chartered Physiotherapists. Acupunct Med. 2001 Dec;19(2):84-92No major adverse event; 7% minor adverse events

❖ A prospective survey of adverse events and treatment reactions following 34,000 consultations with professional acupuncturists.

MacPherson H, et al Acupunct Med. 2001 Dec;19(2):93-102Similar outcome to White et al.

❖ Systematic review of adverse events following acupuncture: the Japanese literature. Yamashita H et al Complement Ther Med. 2001 Jun;9(2):98-104. Review.

Behind the headline

Acupuncture - a treatment to die for? Ernst E. J R Soc Med. 2010 Oct;103(10):384-5.

Dozens killed by incorrectly placed acupuncture needles

Professor of complementary medicine calls for adequate training for all acupuncture practitioners after survey reveals punctured hearts and lungs among causes of death over past 45 years

Mis-interpretation in the press

Punctured organs and infection as a result of failure to sterilise needles were among the causes of death after acupuncture

Ian Sample, science correspondent guardian.co.uk, Monday 18 October 2010 17.21 BST Article history

www.aacp.uk.com

Severity Definition

Mild Reversible, short lived and does not seriously inconvenience the patient

Significant Needs medical attention or interferes with the patient’s normal activities

Serious Requires hospital admission or prolongation of existing hospital stay, or results in persistent or significant disability/incapacity or death

Mild events

➢sharp pain at needle site

➢bleeding and subsequent bruising

➢nausea

➢fainting

➢light headed

➢drowsy

➢aggravation of symptoms(include all in patient information for consent)

www.aacp.uk.com

Condition or Organ Number reported Comment

Lung and pleurae 54 Pneumothorax, one haemothorax

Heart and pericardium 9 Cardiac tamponade

Blood vessels 10 e.g. compartment syndrome, DVT, occlusion popliteal artery.

Brain, spinal cord 12 Penetration of medulla/brain stem; transverse myelopathy

Reported serious traumatic events

Reduce the risk –consider underlying co-morbidity

A thin woman with muscular rheumatism in her back underwent acupuncture for the first time with needles inserted in both sides of her back, close to the spine. She developed increasing shortness of breath and collapsed at home and died. Post mortum showed a needle track through the third left intercostal space, a collapsed left lung, a tiny puncture in the visceral pleura, severe bilateral vesicular emphysema, chronic bronchitis, and lower thoracic osteoarthritic changes. Though pneumothorax is a recognised complication of acupuncture,' it is unlikely to be fatal in a healthy person but coexistent lung disease would increase the hazard.-D J GEE,Departmentof Forensic Medicine, St James's University Teaching Hospital, Leeds LS9 7TF. (Accepted 13 December 1983)

Case Report 1 - Pneumothorax

Pneumothorax after acupuncture. Ritter HG, Tarala R. Br Med J. 1978 Aug 26;2(6137):602-3.

Arteriogram revealed popliteal aneurysm

Case Report 2 – Pseudoaneurysmpopliteal artery

61-year-old woman, longstanding osteoarthritis in both knees. About 6 months earlier, she had undergone a single session of acupuncture for pain associated with the osteoarthritis. During that treatment, multiple needle punctures had been administered around the left knee and along the medial aspect of the lower left thigh. She had experienced sharp pains in her leg and demanded that the needles be removed. The pain subsided after the treatment, and she did not notice any abnormality in her left leg at that time. Two months later and four months before presentation at hospital she had felt a sudden shooting pain in her left thigh while she was sitting in a chair; the pain radiated from the thigh to the lower leg.

Pseudoaneurysm of the popliteal artery: a rare sequela of acupuncture.Kao CL, Chang JP. Tex Heart Inst J.2002;29(2):126-9.

Psoas abscess formation after acupuncture in a hemodialysis patient. Kim JW, Kim YS. Hemodial Int. 2010 Jul;14(3):343-4

Case Report 3 – Psoas abscess

A 53-year-old female patient presented with a 2-day history of acute left lower quadrant abdominal pain and fever. She had been maintained by haemodialysis for 6 months due to chronic renal failure from diabetes mellitus via a permanent tunnelled catheter. Fifteen days before, she slipped down and developed lower back pain without external wound. Three days before admission, she underwent acupuncture of both sides of her lower back. After completion of the treatments, she experienced a chilling sensation and right lower quadrant abdominal pain for 2 days.

Psoas abscess caused by acupuncture? Kim et al. Hemodial Int. 2010 Oct;14(4):526-7

Reduce the risk – know your anatomy

Development of postdural puncture headache following therapeutic acupuncture using a long acupuncture needle. Jo et al. J Korean Neurosurg Soc. 2010

Feb;47(2):140-2. Epub 2010 Feb 28

Be aware of anatomical anomalies

•Scapula foramen

•Foramen sternale

Acupuncture needle removed from lung of former South Korean president The former president of South Korea was admitted to hospital with a bad cough only to end up on the operating table to remove an acupuncture needle from his right lung.

The needle was removed from the bronchial tube of former President RohTae-woo's right lung Photo: EPA 1:48PM BST 03 May 2011

Doctors are puzzled how the

needle ended up in his lung,

and acupuncturists

say that none of their procedures

involved penetrating the lung.

Reduce Risk1. Select appropriate patients – be aware of co-morbidity

2. Infection • Sterile needling technique (handling)• Use disposable single use needles

3.Traumatic event • Know your anatomy• Use appropriate length needle and angle of insertion

✓Report any adverse events ✓Reflect on your practice✓Alter practice accordingly✓Learn from your mistakes

Do not become complacent as acupuncture becomes more routine

Good practice eliminates serious adverse events

Review of 13 studies➢4 million treatments

➢11 serious events reported

➢ None fatal

White (2006) The safety of acupuncture – evidence from the UK. Acupuncture in Medicine 24 [Suppl]: S53-S57

Patient safety incidents from acupuncture treatments: A review of reports to the National Patient Safety Agency. Wheway J, Agbabiaka TB, Ernst E.

Int J Risk Saf Med. 2012 Jan 1;24(3):163-9

The majority (95%) of the incidents were categorised as low or no harm.

Recent retrospective survey of NHS acupuncture practice

Hidden perils of acupuncture: Lost needles, punctured lungs and fainting among NHS horror stories. PUBLISHED: 00:50, 5 September 2012. Read more: http://www.dailymail.co.uk/health/article-2198441/NHS-horror-stories-Hidden-perils-acupuncture-lost-needles-punctured-lungs.html#ixzz264JDNeiR

The Headline

Behind the headline

“Acupuncture…in skilled hands is one of the safer forms of medical intervention”

(Vincent 2001)

Discussion

➢Contraindications

➢Precautions (refer to Practical Work Book)

➢Information and informed consent

➢Examples from your own work place

www.aacp.org.uk

AACP Safe Practice Guidelines. (V3 2017 AACP)

Integrating Evidence-Based Acupuncture into Physiotherapy for the Benefit of the Patient.

Session 4

Neurological Mechanisms 2. Supraspinal Analgesia, Affective and

Autonomic Effects.

Learning outcomes

By the end of the session you should be able to demonstrate

➢ a basic knowledge of the neurological mechanisms associated with acupuncture analgesia

➢ a critical understanding of the evidence used to support acupuncture analgesia at a supraspinal level

➢ Hypothalamus – Arcuate nucleus termination for some Aδ (type II & III) afferent fibres stimulated by acupuncture

➢ PAG is activated by β-endorphin, released from nerve fibres descending from arcuate nucleus

➢ PAG receives input from limbic system

➢ Two main descending inhibitory pathways from the PAG

Descending inhibitory pain control

1. Release of serotonin at intermediate cells in dorsal horn stimulates intermediate cells to release met-enkephalin inhibits substantia gelatinosa (SG) cells, adding to segmental inhibition

2. Release of noradrenalin throughout the dorsal horn (every segmental level) direct inhibition of post-synaptic membrane of transmission cells

White et al.(2008) An Introduction to Western Medical Acupuncture. Chapter 5.

SG lamina II & III

Descending pathways

Increased beta-endorphin but not met-enkephalin levels in human cerebrospinal fluid after acupuncture for recurrent pain. Clement-Jones V, McLoughlin L, Tomlin S, Besser GM, Rees LH, Wen HL. Lancet. 1980 Nov 1;2(8201):946-9. [seminal paper]

Abstract

Low-frequency electroacupuncture effectively alleviated recurrent pain in 10 patients. Basal levels of beta-endorphin and met-enkephalin in the lumbar cerebrospinal fluid (CSF) of these patients were not different from those in pain-free control subjects. After electroacupuncture in the patients with pain CSF beta-endorphin levels rose significantly in all subjects, but met-enkephalinlevels were unchanged. These results suggest that the analgesia observed after electroacupuncture in patients with recurrent pain may be mediated by the release into the CSF of the endogenous opiate, beta-endorphin.

Clinical research findings

1. Neuromodulators: opioid peptidesWhite et al 2008 An Introduction to Western Medical Acupuncture

Peptide Main site Receptor

β-endorphin Midbrain, PAG (pituitary)

μ & δ

Met-enkephalin Dorsal horn of spinal cord μ & δ

Dynorphin Brainstem and spine к

Orphanin Widespread μ

Acupuncture causes the releases of enkephalin in the spinal cord and β-endorphine in the brain

Key Commentator Ji-Sheng Han Neuroscientist Peking University

Han J, Terenius L (1982) Neurochemical basis of acupuncture analgesia. Annual Review of Pharmacology and Toxicology. 22:193-220 [seminal paper]

Han JS (2011) Acupuncture analgesia: Areas of consensus and controversy. Pain.S41-48

Number of experimental studies in which naloxone is injected post acupuncture to evaluate if the analgesic effects are lost – naloxone blocks μ-receptors

Other proposed mechanisms

➢ Oxytocin

➢ Gene expression leading to cumulative response of acupuncture (opioid peptides)

➢Diffuse noxious inhibitory control - very strong stimulus; analgesia

short lived; consideration in animal experimentation

➢ Cholecystokinin – opioid antagonist associated with anxiety and identified

in laboratory studies when acupuncture exposure exceeds 45 minutes

The limbic system is involved in aspects of processing and responding to pain

Includes:

Amygdala

Hippocampus

Anterior cingulate cortex (ACC)

Insula

Prefrontal cortex

Nucleus accumbens

Affective component of pain

Is the patients description of their pain an ‘emotional’ one?

Review of f-MRI studies on healthy pain free volunteers

Identify:

➢ Amygdala & hippocampus decreased activity during acupuncture stimulation

➢ Strong stimulus and eliciting sharp pain can reverse effect

Evidence of acupuncture’s influence on the limbic systemAcupuncture, the limbic system, and the anticorrelated networks of the brain.Hui et al. 2010 Oct 28;157(1-2):81-90.

Increased expectation of acupuncture’s effectiveness produces greater activity in prefrontal cortex, ACC and mid-brain than low or no expectation

Expectancy and belief modulate the neuronal substrates of pain treated by acupuncture.Pariente et al. Neuroimage. 2005 May 1;25(4):1161-7

Evidence of the influence of expectation

PET study on patients with OA thumb

Autonomic effects of acupuncture

➢ Needle insertion produces an immediate sympathetic response in the related spinal segment, and in the long term - widespread , sustained decrease in sympathetic tone

➢ Response seems related to strength of stimulus➢ Low frequency electrical stimulation decreases sympathetic tone, high

frequency increases it ➢ Could explains acupuncture’s influence on conditions such as IBS & irritable

bladder

• Measured heart rate variability & blood pressure• Needled either LI4 or ear point• Results indicated increased parasympathetic activity = clinically relaxation/calm

Effect of sensory stimulation (acupuncture) on sympathetic and parasympathetic activities in healthy subjects. Haker E et al. J Auton Nerv Syst. 2000 Feb 14;79(1):52-9

Examples of further research

Autonomic effects of acupuncture

Brain correlates of phasic autonomic response to acupuncture stimulation: An event-related fMRI study. Napadow et al. Hum Brain Mapp. 2012 Apr 14.

Specific acupuncture sensation correlates with EEGs and autonomic changes in human subjects. Sakai et al. AutonNeurosci. 2007 May 30;133(2):158-69

Inflammation is part of the pathophysiological process in many kinds of disease

Acupuncture and Inflammation

The anti-inflammatory effect of acupuncture may be an important mechanism by which it achieves some of its effects

Bradnam, L.V. and Phty, D., 2010. Clinical Reasoning for Western Acupuncture. Acupuncture in manual therapy. Edinburgh: Churchill Livingstone, pp.1-7.

Supraspinal, affective and autonomic effectsSummary

• Descending inhibitory pain control

• Role of oxytocin and gene expression

• Emotional component of pain (pain description)

• Effect of expectation

• Autonomic changes

gentle needle stimulation inhibits sympathetic

strong, or painful stimulus stimulates sympathetic

Task

➢Summarise the mechanisms which are thought to be involved in acupuncture analgesia

➢Describe to the person next to you ‘how acupuncture is believed to work’ in a way that a lay person or patient would understand

www.aacp.org.uk

Session 5

Acupuncture for Chronic Low Back Pain

Learning outcomes

By the end of the session you should be able to demonstrate

➢ a critical understanding of the NICE guidelines for LBP

➢ an appreciation of the strength of the evidence for acupuncture with LBP

Discussion➢Understand the evidence and ways to reason use of acupuncture

in case of chronic low back pain.

Prevalence and Impact

• LBP affects 1 in 10 adults (Newton 2015)

• Leading cause of disability

• Responsible for;

– 37% of all chronic pain in men and

– 44% in women (Health Survey England 2011)

• Economic cost £12 billion per annum (Maniadakis & Gray 2000)

Nice Guidelines (May 2009) ‘LBP: early management of persistent non-specific low back pain’

Recommendations for acupuncture

“ Consider offering a course of acupuncture needling comprising up to a maximum of 10 sessions over a period of

12 weeks”(for LBP> 6 weeks & <12 months duration)

2016 recommendations;

“Do not offer acupuncture for managing non-specific low back pain with or without sciatica”

The explanation by NICE:

Nice Rationale:

►No clear difference in pain or function between real and sham acupuncture

►Acupuncture is a passive treatment►Cost implications►Recognised that there was a large body of evidence

showing acupuncture superior to usual care, but only up to 4/12

►Also recognised that there was no evidence that exercise or manual therapy is superior to sham

• Paracetamol – effective above placebo or sham? No. Recommended? Yes, recommended in some scenarios along with opioid, but no specific efficacy demonstrated.

• Opioids – effective above placebo or sham? No. Recommended? Yes, recommended along with paracetamol, but no specific efficacy was demonstrated.

• Exercise or Yoga – effective above placebo or sham? No. Recommended? Yes.• Cognitive therapy – efficacy above sham? No. Recommended?

Yes, recommended as part of a package of care.• Acupuncture – efficacy above sham? Yes, “Clinically important” improvements above

sham/minimal acupuncture for pain reduction and quality of life (including physical function, physical role limitation, vitality). Recommended by the guidelines? No.

“GDG considered that other treatments reviewed in this guideline had specific and clinically important treatment effects beyond contextual effects and that these should be prioritised for the use of healthcare

resources.”

“We feel that NICE have failed to properly evaluate the comparison between acupuncture treatment and other treatments commonly used for these conditions. Many of the studies referenced, compare acupuncture to sham-acupuncture, a clinically irrelevant comparison as this is not viewed as an appropriate placebo. By doing so, we feel that NICE have not assessed the effectiveness of acupuncture in a clinically relevant manner”.

The AACP Response

“the GDG decision-making process behind the recommendations against acupuncture—while supporting common conventional treatments for LBP and sciatica—is inconsistent and lacks sufficient evidence-based justification.”

Trinh et al. Medical Acupuncture (2017), 29 (1)

Response of Renowned Medical professionals

Your thoughts…….

►NICE generally considered research comparing intervention to sham;

What are the pros and cons of this?

► Acupuncture v sham trials for LBP consistently produce similar outcomes - why is this?

► If acupuncture is no better than sham for LBP does our point selection matter?

Published 2015

Examples of Evidence AACP Publication

Footnote: describe sham acupuncture interventions

1. Systematic review

Acupuncture and dry-needling for low back pain. Furlan et al. Cochrane Database Syst Rev. 2005 Jan 25;(1):CD001351.

Summary of papers

➢35 RCTs

➢3 ‘acute’ LBP

➢Acupuncture versus sham acupuncture – 4 studies

Conclusion

➢Insufficient evidence on effectiveness of acupuncture for acute LBP

➢One study compared acupuncture with no treatment–some evidence for pain relief at short-term follow-up

➢Acupuncture combined with conventional therapy better than conventional therapy alone

➢Pooled analysis (meta-analysis) of 4 sham controlled trials (n=314) short-term pain relief but not maintained

1. Acupuncture in patients with chronic low back pain: a randomized

controlled trial. Brinkhaus et al. Arch Intern Med. 2006 Feb 27;166(4):450-7

Adults with chronic LBP (> 6 months) Total n=301

Conclusion. Acupuncture was more effective than no treatment in reducing pain, but there was no statistically significant difference

between minimal (sham) and true acupuncture at the end of treatment (8 weeks)

Group 1 - Acupuncture (n=141)12 x 30 min sessions, twice a week for 4 weeks then once a week for 4 weeks

Group 2 - Minimal acupuncture (n=70) Same as Group 1 but with non-acupuncture points needled superficially, away from region of pain

Group 3 - No treatment (waiting list control) (n=74)

2. Five Individual RCTs

2. German Acupuncture Trials (GERAC) for chronic low back

pain: randomized, multicenter, blinded, parallel-group trial with 3 groups.Haake et al. Arch Intern Med. 2007 Sep 24;167(17):1892-8.

Adults with chronic LBP (> 6 months) Total n=1161

Conclusion. The effectiveness of acupuncture at reducing pain, either genuine or sham, was almost twice that of conventional therapy at 6

months follow-up

Group 1 - Acupuncture (n=387) 10 x 30 min, twice a week - 14 to 20 points manual stimulation

Group 2 - Sham acupuncture (n=387) Same as group 1 except non-acupuncture points with no stimulation

Group 3 - Conventional treatment (n=387) physiotherapy and exercise

2. Five Individual RCTs

3. Pragmatic randomized trial evaluating the clinical and

economic effectiveness of acupuncture for chronic low back pain.Witt et al. Am J Epidemiol. 2006 Sep 1;164(5):487-96

Adults with chronic LBP (> 6 months)

Conclusion. Acupuncture combined with usual care produces a clinically relevant reduction in pain compared with usual care

alone at 3 months follow-up

Group 1 - Acupuncture plus routine care (n=1549); up to 15 sessions (mean 10); 75% receiving 5-10 (over 3 months)

Group 2 - Routine care (n=1390)

Additional group - Non-randomised acupuncture group (n =8,537)

2. Five Individual RCTs

4. Longer term clinical and economic benefits of offering acupuncture

care to patients with chronic low back pain. Thomas et al. Health Technol Assess. 2005 Aug;9(32):iii-iv, ix-x, 1-109

Adults with LBP 4 - 52 weeks

UK based study n=241

Group 1 - Acupuncture (n=160) delivered by TCM acupuncturist; up to 10 sessions over 3 months (average 8 sessions) plus GP usual management for LBP

Group 2 - GP usual management for LBP (n=80)

2. Five Individual RCTs

Profile of the acupuncture treatment

Acupuncture for low back pain: traditional diagnosis and treatment of 148 patients in a clinical trial. MacPherson et al. Complement Ther Med. 2004 Mar;12(1):38-44.

Conclusion. Acupuncture is significantly more effective in reducing pain in the long-term than usual care alone

➢ Average number of treatments 8 ➢ Average number of points needled 9 ➢ Average treatment duration 20 mins➢ Frequency Once a week➢ Most commonly used points

BL23 and Huatuojiaji points (HJJ) at L4 and L5➢ Other local points – BL 23, 25,26,28,30,32,34,52,53,54. HJJ L2. GV 3,4. Shiqizhui

& Yaoyan extra points➢ Additional points – GB 30 & 34. KI 3. BL 11,17,17. BL62 & SI3 combined

5. Acupuncture in patients with acute low back pain: A multicentre

randomised controlled clinical trial.Vas et al. Pain. 2012 Sep;153(9):1883-9

Adults with acute LBP (< 2 weeks duration) Total n = 275

Group 1 – Acupuncture at genuine acupuncture points plus conventional treatment (n=68). 5, 20 min sessions over 2 weeks

Group 2 – Sham acupuncture – genuine acupuncture at non-acupuncture points plus conventional treatment (n=68). 5, 20 min sessions over 2 weeks

Group 3 – placebo acupuncture – blunt non-penetrating needle at genuine acupuncture points plus conventional treatment (n=69). 5, 20 min sessions over 2 weeks

Group 4 – Conventional treatment (n=70) – analgesic and anti-inflammatory drugs

Conclusion. All acupuncture groups significantly more effective than conventional treatment. Patients responded best to genuine

acupuncture, but no statistically significant difference between the 3 groups at end of treatment

2. Five Individual RCTs

Acupuncture for chronic LBP; a meta analysis of 13 RCT’s.Xu et al. The American Journal of Chinese Medicine (2013) 41 (1), 1-9

Conclusion. Compared with no treatment, acupuncture achieved better outcomes in terms of pain relief, disability

recovery and better Qol. Acupuncture is an effective treatment for LBP.

3. Meta Analysis of RCTs

Thomas et al (2005) included economic evaluation quoted in

the NICE guidelines

“ One NHS based costs per QALY analysis indicates that we can be 90% certain that acupuncture is cost-effective compared with usual care at 24 months”

Attrition rate. Acupuncture: n=147 at 12 month follow up; n=123 at 24 month follow-up. Usual care n= 68 at 12 months; n=59 at 24 months

Footnote: This study was powered for 12 month primary outcome

Will you still offer

acupuncture for LBP?

If so, how will you justify

this?

“Healthcare professionals are expected to take it fully into account when exercising their clinical judgement. However, the guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient”

NICE 2016 General Terms and Conditions

….on ‘guidelines’ in general:

What do you take into account when

choosing the patient and the points?

Clinical reasoning

• What effects can acupuncture have on Chronic Low Back Pain?

– Locally?

– Segmentally?

– Centrally?

• Which Low Back Pain patients do we want which effects on?

Mechanisms Chronic Low Back Pain;It’s complicated!

• Release of neuropeptides;

– CGRP, Substance P, Neurokinin A, Adenosine, Bradykinin, Serotonin, Potassium, Histamine

• Vasodilation

• Increased vascular permeability

• Increased local endorphins and receptors

Local Effects

White et al (2008)

• Stimulation of A-Delta fibres (skin) and type II&III afferents (muscle)

• Synapse in SG of spinal cord

• Enkephalin released by intermediary cells block C fibres from firing

Segmental Effects

Modulation of Limbic system;– Emotional and cognitive aspects of pain i.e.

behaviour, expectation, attention, fear and memory

Oxytocin;– Improved wellbeing

Autonomic changes;– Initial increased SNS– Long term increased PNS

Hormonal regulationImmune response

Central Effects

• Reduce other symptoms associated with back pain

• Enhance patients’ feelings of control and ability to cope

• Reduce patients’ fear and avoidance of physical activity

• Reduce patients’ catastrophising about pain

• More flexible convenient appointment times, cheaper (low cost private sector clinics, costs associated with attending hospital-based clinics)

Bishop et al (2012)https://eprints.soton.ac.uk/364162/

Targets for Intervention

Acupuncture for Chronic LBP –Summary

• Acupuncture combined with conventional therapy appears better than conventional therapy alone

• Acupuncture appears to be significantly more effective in reducing pain in the long-term than usual care alone

• There is no statistically significant difference between ‘sham’ and true acupuncture at the end of treatment

Q/marketing/insignia guidelines www.aacp.org.uk

Session 6

Acupuncture for neck pain and headache – The evidence

Learning outcomes

By the end of the session you should be able to demonstrate

➢a critical understanding of the current evidence on acupuncture for neck disorders

➢a critical understanding of the current evidence on acupuncture for migraine prophylaxis

➢an awareness of a Western clinical construct associated with head and neck pain (myofascial trigger points)

Acupuncture for neck disorders.Trinh et al. Cervical Overview Group. Cochrane Database SystRev. 2006 Jul 19;(3):CD004870. Review

1. Neck pain

➢No trials investigating acute/sub-acute neck pain

➢10 RCTs chronic neck pain (>6 month history) Total n = 661 participants

➢2 v ‘sham acupuncture’ (Birch 1998; White 2000)

➢3 v active treatment (mobilisation/massage/traction) (David 1998; Irnich 2001;Loy 1983)

➢4 v inactive treatment (sham TENS and sham laser) (Petrie 1983; Petrie 1986;Irnich 2002;White2004)

➢1 v waiting list (Coan 1982)

Summary

Ideally there should be at least six acupuncture sessions

Additional relevant research for neck pain

Tension neck syndrome treated by acupuncture combined

with physiotherapy: a comparative clinical trial (pilot study).

França et al. Complement Ther Med. 2008 Oct;16(5):268-

77

CONCLUSION: The data suggested that acupuncture effect may facilitate and/or enhance physiotherapy performance in musculoskeletal rehabilitation for tension neck syndrome

The optimized acupuncture treatment for neck pain caused by cervical spondylosis: a study protocol of a multicentre randomized controlled trial. Liang et al. Trials. 2012 Jul 9;13(1):107.

This Chinese study aims to evaluate the effects of an optimised acupuncture treatment in real practice compared with sham and

shallow acupuncture therapy.

On going research for neck pain

On going research for whiplash

Dry needling and exercise for chronic whiplash - a randomised controlled trial. Sterling M et al. BMC Musculoskelet Disord. 2009 Dec 18;10:160

Acupuncture for tension-type headache. Linde et al. Cochrane Database Syst Rev. 2009 Jan 21;(1):CD007587.

2. Tension-type headache

➢ 11 RCTs Total n = 2317 participants

➢ 2 v no treatment or routine care

➢ 6 v sham acupuncture

➢ 4 v other preventative treatments (physiotherapy/relaxation)

(some trials included more than 2 arms)

Summary

Outcome: pain intensity

1. Acupuncture versus no acupuncture

Outcome: n headache days

2. Acupuncture versus sham ‘placebo’

Outcome: pain intensity

Outcome: n headache days

2. Acupuncture versus sham ‘placebo’

“Three of the four trials comparing acupuncture with physiotherapy, massage or relaxation had important methodological or reporting shortcomings. Their findings are difficult to interpret, but collectively suggest slightly better results for some outcomes in the control groups”.

3. Acupuncture versus physiotherapy

“… acupuncture could be a valuable non-pharmacological tool in patients with frequent episodic

or chronic tension-type headaches”.

Linde et al (2009) Cochrane Pain, Palliative and Supportive Care Group

Other effective non-pharmacological treatments

Subjective well-being in patients with chronic tension-type headache: effect of acupuncture, physical training, and relaxation training. Söderberg et al. Clin J Pain. 2011 Jun;27(5):448-56

Acupuncture for migraine prophylaxis. Linde et al. Cochrane Database Syst Rev. 2009 Jan 21;(1):CD001218.

3. Migraine prophylaxis

➢ 22 RCTs Total n = (4419) participants

➢14 v sham control

➢6 v no preventative treatment or routine care

➢4 v active treatment (physiotherapy/relaxation)

(some trials included more than 2 arms)

Summary

Outcome: pain intensity

Acupuncture versus sham ‘placebo’

Even 'fake' acupuncture reduces the severity of headaches and migrainesReview of published studies finds improvement in headache symptoms whether or not needles were placed correctly, suggesting a powerful placebo effect

•Ian Sample, science correspondent •guardian.co.uk, Wednesday 21 January 2009

Acupuncture can help people who suffer from headaches and migraines, even when the needles are put in the "wrong" place, according to a major review of medical studies

➢ Trials varied considerably in their quality, methods, interventions (particularly for sham), patients, times when the treatment was administered, and outcomes measured… difficulty in interpreting the results, particularly for answering the question of acupuncture vs sham

➢ Unclear if usual care includes migraine drugs

➢ Any interpretation that acupuncture is better than drugs should be made with caution – more research is required comparing the two

➢ The review does not suggest or conclude that acupuncture is as effective as analgesia and other treatments for acute, severe headache

http://www.nhs.uk/news/2009

Review by NHS Knowledge Service

Headaches

Diagnosis and management of headaches in young people and adults

Clinical Guideline 150

Methods, evidence and recommendations September 2012

http://guidance.nice.org.uk/CG150

Commissioned by the National Institute for

Health and Clinical Excellence 2012

Treatment of tension-type headache and migraine prophylaxis – the evidence.

The review group decided that only evidence from verumacupuncture compared to a sham procedure would be considered.

This they said was … “To be consistent across protocols, wherever a placebo or equivalent existed, this has been used as the comparator for the reviews in this guideline. This also enables indirect comparisons with RCTs of pharmacological treatments”.

Recommendations

Discuss the benefits and risks of treatment with the person, taking into account the person’s preference, comorbidities, risk of adverse events and the impact of the headache on their quality of life.

Parameters for the recommendations

Tension-type headaches - experienced on 15 or more days a month

Migraine – includes episodic, chronic and pre-menstrual migraine

If both topiramate and propranolol are unsuitable or ineffective, consider…

First offer

➢ Topiramate or propranolol according to the person’s preference, comorbidities and risk of adverse events.

➢Advise women of childbearing potential that topiramate is associated with a risk of fetal malformations and can impair the effectiveness of hormonal contraceptives.

➢ Gabapentin (up to 1200 mg per day) or

➢ A course of up to 10 sessions of acupuncture over 5 to 8 weeks.

➢ Each session of acupuncture should last at least 30 minutes, preferably at a frequency of two sessions a week.

The original cost-effectiveness model developed for this guideline showed

that acupuncture costs on average £273 over 6 months while beta-blockers

cost £90.

We can reduce the cost of acupuncture by treating patients in a group

setting

For both migraine and tension type headache prophylaxis

Hyperlink https://www.nhs.uk/livewell/headaches/pages/migrainerealstory.aspx

Patient’s experience of acupuncture for migraine headache

Myofascial Trigger Points and Headaches

(MTrPs to be covered in detail in session 9 and 10)

Wall & Melzack 1984 Textbook of Pain in Baldry PE Acupuncture ,Trigger Points and Musculoskeletal Pain. Third Edition. Elsevier. Churchill Livingstone

Upper Trapezius headache

© Dr Liz Tough

Acupuncture for neck and head pain –Summary

• Mechanical neck pain acupuncture more effective than a sham intervention

• Radiculopathy acupuncture more effective than waiting list• May enhance effectiveness of physiotherapy in tension type

neck pain• Valuable non-pharmacological tool in patients with frequent

episodic or chronic tension-type headaches – recommended by NICE

• Can be a useful alternative to drug management for migraine prophylaxis – recommended by NICE

• Muscular referral – tender points and trigger points

Q/marketing/insignia guidelines

www.aacp.org.uk

Session 7

Treatment Dose

Learning outcomes

By the end of the session you should be able to demonstrate

➢ an understanding of the factors which might contribute to ‘acupuncture dose’

➢ an understanding of how point selection may influence treatment response

➢an awareness of factors (other than the needle) which may influence a persons response to acupuncture

DiscussionHow could you define an ‘adequate dose’ of acupuncture?

What might constitute dose?

Definition for the dose of acupuncture needling:

“ The physical procedures applied in each session, using one or more needles, taking account of the patient’s resulting perception (sensory, affective and cognitive) and other responses (including motor). The dose may be affected by the state of the patient (e.g. nervous, immune and endocrine systems); different doses may be required for different conditions”

Defining an adequate dose of acupuncture using a neurophysiological approach--a narrative review of the literature. White A et al. Acupunct Med. 2008 Jun;26(2):111-20.

The needle and needling

“The dose required to treat different health conditions will vary depending on the intended mechanism of the effect, e.g. whether local, segmental, extrasegmental or central. Some conditions e.g. migraine or fibromyalgia, probably require several mechanisms to be activated if treatment is to effective; and some conditions…may require a different dose according to the degree to which the nervous system is sensitised in a particular patient”

Definition for the dose of acupuncture needling:

Defining an adequate dose of acupuncture using a neurophysiological approach--a narrative review of the literature. White A et al. Acupunct Med. 2008 Jun;26(2):111-

20.

What is an adequate dose, or the optimal dose of acupuncture?

Example formed by expert consensus

Evidence from RCTs on optimal acupuncture treatment for knee osteoarthritis--an exploratory review. Vas J, White A. Acupunct Med. 2007 Jun;25(1-2):29-35.

“…we define acupuncture as adequate if it consisted of at least 6 sessions, at least 1 per week, with at least 4 points needled for each painful knee for at least 20 minutes, and either needle sensation (de qi)achieved in manual acupuncture, or electrical stimulation of sufficient intensity to produce more than minimal sensation.”

Acupuncture treatment for chronic knee pain: a systematic review.White A et al. Rheumatology (Oxford). 2007 Mar;46(3):384-90.

Neck pain treatment with acupuncture: does the number of needles matter? Ceccherelli et al. Clin J Pain. 2010 Nov-Dec;26(9):807-12

Small group of patients (n=36) with cervical myofascial pain

“The number of needles, 5 or 11, seems not to be an important variable in determining the therapeutic effect when the time of stimulation is the same in the two groups”

In the absence of scientific evidence on optimal dose of acupuncture, adopt a clinical reasoning model which is based on

theoretical concepts

Layering Technique

Lynley Bradnam. A proposed clinical reasoning model for Western acupuncture J of AACP .Jan 2007: 21-30

Location of points needled

Sensory homunculus

Theory- stimulating points on the upper limb, face and to a lesser extent on the lower limbs should activate a larger area of the sensory cortex than other points which should then induce a greater response

Location of points needled

Points distal to elbows and knees

➢Have a larger peripheral nerve plexus – less stimulation, stronger central response?

➢Have a greater sympathetic innervation – more efficient at modulating response?

➢More superficial (hands and feet) – connective tissue and periosteum stimulated - greater sensory input into the CNS?

Concept of ‘Big Points’ Bradnam L. A pathway of progression for Western acupuncture: Using the power of the brain. J of AACP July 2003:27-33

Checklist – what do you want

➢ Peripheral effects?

➢ Segmental/spinal effects?

➢ Supraspinal effects?

➢ Sympathetic outflow?

➢ Central sympathetic effects?

➢ Immune effects?

Bradnam L . A proposed clinical reasoning model for Western acupuncture J of AACP Jan 2007:21-30

Yes

• Needle close to injury

• Stimulate gently to maximise

local effect.

• Superficial tissues – low-frequency, low-intensity electro-acupuncture to reduce sympathetic tone and aid blood flow

No

• Needle away from injured tissue

Peripheral (local) effects

• Yes

➢ Local points anatomically near to damaged tissue

➢ Or points away from damaged tissue with same segmental innervation

➢ If selecting a muscle with the same myotome, chose one in which there are tender points

• No

➢ Needle tissues with a different segmental nerve supply to damaged tissue

Segmental/spinal effects

Acute nociceptive pain

➢ Fewer needles in segment

➢ Minimal stimulation

Chronic nociceptive pain

➢ More needles in segment

➢ Plus - distant point in affected segment or a point in a bordering segment

➢ Add layer – spinal point that relates to same segment

➢ Rx time 10-20 minutes

• Yes

➢ Extrasegmental points & ‘big points’ of the hand and feet

➢ Strong stimulation to activate descending inhibitory systems from the hypothalamus, and DNIC

➢ Rx time 20-40minutes

• No

➢ Segmental points only

➢ No ‘big points’

➢ Moderate stimulation

➢ Rx time 10-15 minutes

Supraspinal effects

• Yes➢ Choose segmental level of tissue

you want to influence and needle BL points. Head and neck (T2-T4); upper limb (T5-T9); lower limb (T10-L2)

➢ Plus – distant point in tissues with the same sympathetic segmental supply as tissue you want to influence

➢ Needle strongly for at least 10 minutes to increase sympathetic flow, or gently to decrease flow

Sympathetic outflow –condition not improving with somatic treatment

Central sympathetic effects

• Yes

➢ Autonomic nervous system controlled by the hypothalamus; stimulated in same manner as analgesic supraspinal effects. Choose large points on the hands and feet, and stimulate strongly for 20 to 40minutes

What factors might influence a patients response to acupuncture?

Patient ‘phenotype’

1. Genetics

➢ Differences in opioid peptide metabolism and receptor activity?

➢Variations in enzyme enkephalinase activity in the spinal cord?

Traditional Chinese acupuncture and placebo (sham) acupuncture are differentiated by their effects on mu-opioid receptors (MORs). Harris RE et al. Neuroimage. 2009

Sep;47(3):1077-85.

Pharmacology of enkephalinase inhibitors: animal and human studies. EhrenpreisS.Acupunct Electrother Res. 1985;10(3):203-8

2. Physical appearance

‘Acupuncture time line’ model Pearce L. How long? How deep? How many? Making a reasoned choice from the myriad

approaches to acupuncture. J AACP July 2006: 32-37.

Blue eyes, fair/pale skin, blonde/ginger hair, skin that flares when scratched,allergies, sensitive to medication

Strong reactor Slow reactor

Darker skin, dark/brown eyes, tolerant to sun, require higher dose medication

Patient characteristics and variation in treatment outcomes: which patients benefit most from acupuncture for chronic pain? Witt et al. Clin J Pain. 2011 Jul-Aug;27(6):550-5.

Patients' characteristics that enlarged the acupuncture effect were • being female (P = 0.028), • living in a multi-person household (P = 0.002), • failure of other therapies before the study (P = 0.049), • former positive acupuncture experience (P = 0.005).

Physician characteristics and variation in treatment outcomes: are better qualified and experienced physicians more successful in treating patients with chronic pain with acupuncture? Witt et al. J Pain. 2010 May;11(5):431-5.

“PERSPECTIVE: In this analysis, physician characteristics such as training did not influence patients' outcome after acupuncture, suggesting that formal training parameters have only a limited influence on treatment effect. Other skills such as the therapeutic relationship, which are difficult to measure, may probably play a more important role and should be taken into consideration.”

Chinese male practitioners produce the best outcome –Observational study in Australia in 1980’s

Perception of Practitioner

“…the effect of acupuncture clearly involves much more than needle insertion and manipulation…”

“…If the specific needle stimulation is not the critical factor in treatment then future research should explore other aspects of acupuncture”

To be continued…

Session 8