What acupuncture can and cannot do for arthritis?

1. What acupuncture can and cannot do for arthritis? June 25, 2009 Wei Huang MD, PhD Birmingham/Atlanta GRECC Atlanta VAMC Emory University

2. Purpose • Provider education on the use of acupuncture as a complementary alternative therapy in arthritic conditions.

3. Review the effects of acupuncture in treating osteoarthritis (degenerative), rheumatoid arthritis (inflammatory), and gout (metabolic); • Determine when and how to refer a patient with arthritis for acupuncture.  

4. Osteoarthritis

5. Osteoarthritis • Over 20 million people in the United States live with osteoarthritis • Radiographically, 30% individuals of age 45-65, and more than 80% over age 70 are affected • Second most common cause of permanent incapacity among people over age 50 • Most common: knees, followed by hips, spine, feet, hands • Knee OA is one of the five leading causes of physical disability in the non-institutionalized elderly • Pain usually is the initial and principal source of morbidity

6. Current Treatments Surgery CSI, hyagan, Prescription pain meds Over the counter medications, dietary supp Physical therapy, proper brace use, TENS Weight loss, activity modification, topical heat/cold, topical analgesic cream, shoe modification/insert, coping

7. Why consider acupuncture? • Medication side effects • Polypharmacy in the elderly • Inconclusive effects of a lot of modalities • Patients not accepting invasive procedures • Potential benefits of acupuncture over other modalities • Minimal and no long term adverse reactions • Not invasive procedure to perform in the office • Less costly than surgery

8. Any research evidence for the effects of acupuncture in osteoarthritis?

9. Acupuncture for knee and hip OA • Witt et al. (2006-2008) • Recruitment from July 2001 to July 2004 • Age > 40yo (average [SD] 61.8 [10.0]); radiographic evidence of osteophyte; disease duration > 6m; at least 15 days with pain in the past 30 days • 3 groups: non-randomized (n=2726); randomized to immediate acupuncture (n=322); randomized to delayed acupuncture (n=310) • Knee OA 57.1%; hip OA 14.5%; both 28.4%

10. Witt et al. (cont.) • Intervention: • Individualized acupuncture up to 15 sessions in 3 months (average 10.7+3.9x, 76.6% 5-10 sessions) • Needle acupuncture only • Manual manipulation only • All three groups continue to receive any additional conventional treatments • 1417 study physicians in Germany • Outcome measures: • WOMAC indexes of pain, stiffness and function • SF-36 total score and physical/mental subscales • Baseline, after 3 months, after 6 months

11. Witt et al. (cont.) - Results • At 3 month, there were significant improvements in WOMAC pain, stiffness, function, and SF-36 physical component scores in patients with knee and/or hip OA who were randomized to receive immediate acupuncture, as compared to controls who were randomized to have delayed treatments. Only SF-36 mental component score did not differ significantly b/w groups. • There were no significant differences in all scores between patients who received acupuncture treatments, randomized or non-randomized

12. Witt et al. (cont.) - Results • At 6 month, there were no significant differences b/w all groups • No difference in delayed treatments • Treatment effects lasted for at least 3 months post-intervention

13. Witt et al. (cont.) - Results • Other interesting findings: • Subgroup analysis showed significantly more pronounced improvements in patients of: • younger age, • higher baseline physical or mental quality of life, and • higher baseline WOMAC indexes • Physician participants: 1% of primary care physicians in Germany, at least 140 hours of certified acupuncture education; years of clinical experience varied; treatment regimen varied – reflected well of real world general practice --- no significant influence on the outcome measured in this study

14. Witt et al. (cont.) - Cost analyses • 489 subjects completed cost-effectiveness analysis (acupuncture n=246; control n=243) • Mean overall costs incurred by acupuncture patients during the treatment period were €1,204.15 with additional costs of acupuncture (€35/session), as compared to €734.66 in control patients • However, QALYs (quality adjusted life year) was gained in acupuncture group • Acupuncture for knee osteoarthritis in females was more cost-effective than males; • No gender difference in hip osteoarthritis

15. Limitation of the study • Neither physicians nor patients were blinded • No sham treatment control • Heterogeneous patient sample: age, area of involvement

16. SCEGM/Hartford Pilot Study (preliminary) - Huang, Bliwise, Carvenale, Kutner • Supported by SCEGM/Hartford Foundation and Birmingham/Atlanta GRECC • Acupuncture for knee OA in elderly • Standardized treatment protocol • Sham control, double blinded • Treatment of pain, sleep or both

17. Huang et. al. (cont.) – baseline demographics • N=24 • Average age 72 yo • Average duration of knee pain 10.8 yrs • Average PSQI score 10.5 • 4 randomized groups: true sleep sham pain, sham pain true sleep, true pain true sleep, sham pain sham sleep

18. Huang et al. (cont.) - Results • Subjects who received true acupuncture for knee pain and/or for poor sleep, compared to subjects who received only sham treatments, had more improvement in pain ratings (P=0.03) and PSQI scores (P=0.04). • True versus sham acupuncture for knee pain was associated with improved SF-36 ratings of general health (P=0.03) and vitality (P = 0.04). • True versus sham acupuncture for poor sleep was associated with improved SF-36 ratings of social functioning (P=0.03).

19. Acupuncture for severe knee OA - Tillu et al. 2002 • 60 patients on waiting list for total knee replacement surgery • Allocation into acupuncture group and control group with matched age and gender • Standardized acupuncture regimen weekly for 6 wks • Outcome measures: • Hospital for Special Surgery scores (pain, function, muscle strength, joint ROM, flexion deformity, knee instability) • 50 meter walk • 20 steps climbing • Pain score (VAS)

20. Tillu et al. (cont.) - Results • Acupuncture group significantly improved in all outcomes; control group significantly worsened in all outcomes after 2 months • 3 subjects in acupuncture group (10%) requested suspension of surgery due to the improvements of their symptoms • Limitation of the study: non-randomized, not blinded

21. Acupuncture for OA (Summary) • For knee OA, strong research evidence supports the use of acupuncture for symptom relief and quality of life improvement, including in elderly patients and in those with severe joint pathology; • For hip OA, acupuncture can be recommended for a trial of pain relief; • For other OA, the evidence is not clear yet.

22. Other types of arthritis

23. Rheumatoid Arthritis • In addition to arthritic pain as in osteoarthritis, rheumatoid arthritis also presents with: • Increased morning stiffness (>1hr) • Multiple joints involvement including small joints: pain, swelling • Increased ESR, CRP

24. Acupuncture for RA • Moxibustion in combination with needles • Bee needle and bee venom therapy • Acupoint injections • Fire needle

25. Review by Wang et. al. (2008 Arthritis and Rheumatism) • Search in 12 databases from 1806 to March 2008 • Both Chinese and English literature • Selection criteria: randomized controlled trials, ACR dx criteria, clear outcome measures • 8 studies (536 subjects) included from 4 countries (Canada, UK, Brazil, China) 1974-2007

26. Review on acupuncture for RA (cont.) • 4 against sham control: placebo needles (3), superficial acupuncture • 4 against active control: MTX IM injection, indomethacin (2), diclofenac ointment • All with pain assessments, 6 also with ESR and CRP – 3 sham and 3 active control • Mean study duration: 11+ 6 wks (range 4-22wks) • Mean number of acupuncture sessions: 42 + 62 (range 1-180)

27. Review on acupuncture for RA (Cont.) • 6 studies (4 active control, 2 sham control) showed significant reduction of pain compared to controls (decrease of tender joint count by 1.5 to 6.5) • 4 studies (3 active control, 1 sham control) showed significant reduction of morning stiffness (-29 minutes); however, no significant difference from controls • 5 studies (3 active control, 2 sham control) showed significant reduction in ESR (-3.0mm/hr); 3 studies (2 active control, 1 sham control) showed significant reduction in CRP (-2.9mg/dl); 1 study (active control) showed significant reduction in both ESR and CRP • Swollen joint counts – no difference between intervention and control groups

28. Acupuncture for RA (summary) • Limited studies suggest the use of acupuncture for improving RA symptoms and possible some inflammatory indexes. • Results are not conclusive.

29. Gouty Arthritis • Metabolic • Uric acid crystal deposition in the joint(s) • Inflammation: redness, swelling, sharp pain

30. Acupuncture for gouty arthritis • Ma 2004 • N=72 (42 experimental; 30 control) • Randomized (how?), no blinding • Exp: Acupuncture daily x 10 (one course) – total#? • Control: allopurinol 100mg bid-tid; Ibuprofen 200mg tid if painful arthritis • Outcome measures: clinical improvements of symptoms and signs (detail?); serum uric acid, creatinine, BUN; 24hr urinary protein content • Time points: baseline, one month after treatments

31. Ma (cont.) • Results: • Excellent response (disappearance of symptoms and signs, with all lab tests normalized): 45.2% vs. 20%; • Effective response (improvement of symptoms and signs and lab tests): 50% vs. 43.3%; • Failed response (no obvious improvement of symptoms and signs with no obvious change in lab tests): 4.8% vs. 36.7% • Total effective rate: 95.2% vs. 63.3%

32. Ma (cont.) • Results (cont.) • In the acupuncture group, all lab tests were improved (p<0.01); while • In the control group, only serum uric acid level was improved (p<0.05) without changes in BUN, creatinine or urine protein.

33. Acupuncture for Gout (Summary) • Limited clinical trials suggest beneficial use of acupuncture in patients with gouty arthritis and abnormal renal functions.

34. Summary (I)Acupuncture Effects in Arthritis • Proven pain control • Probable cost effective for improving QoL • Possible improvements in other related symptoms, laboratory inflammatory indicators • Proven in knee osteoarthritis, esp. cost effective in female patients • Probable in hip osteoarthritis • Possible in other areas/types of arthritis

35. What acupuncture has not be proven to do … • To reverse structural damages • To slow down disease progression • To reduce healthcare cost

36. When and how to refer patients for acupuncture treatments?

37. Summary (II)Treatment Recommendation (When…) Surgery CSI, hyagan, Prescription pain meds Over the counter medications Acupuncture, Physical therapy, proper brace use, TENS Weight loss, activity modification, topical heat/cold, topical analgesic cream, shoe modification/insert, coping

38. How … • Know the resources at your facility/area • Know the credentialing process at your state • Build a referral network

39. Something your patients may ask you about … • Side effects profile for acupuncture • Relative contraindications

40. Common adverse reactions • Usually minor: Local bleeding, bruise, achiness/pain • About 3% with strong reactions to needling: vagovagal reaction, increased pain for 24-48hours

41. Rare complications • Pneumothorax • Nerve injury • Blood vessel penetration KNOW THE ANATOMY!!!

42. Relative contraindications • Skin infection (not in the same area where needle will be inserted) • Bleeding disorder/on Coumadin with high INR • Valvular heart disease (no semipermanent needles) • Pacemaker, cardiac arrhythmia, epilepsy (no electroacupuncture) • SCI with injury level higher than T6 (risk for autonomic dysreflexia) • Pregnancy (not in certain spots) • On moderate to large amount of opioids

43. Contact Information • For information about this specific presentation please contact Wei Huang, MD, PhD at whuang4@emory.edu • For any questions about the monthly GRECC Audio Conference Series please contact Tim Foley at tim.foley@va.gov or call (734) 222-4328 • To evaluate this conference for CE credit please obtain a ‘Satellite Registration’ form and a ‘Faculty Evaluation’ form from the Satellite Coordinator at you facility. The forms must be mailed to EES within 2 weeks of the broadcast.

44. Q&A Thank You!