Acupuncture

1. Acupuncture

2. Much higher among patients with chronic medical conditions (much higher among patients who see doctors a lot) The 1% actively using acupuncture still translates to more than 2 million Americans.Much higher among patients with chronic medical conditions (much higher among patients who see doctors a lot) The 1% actively using acupuncture still translates to more than 2 million Americans.

3. Acupuncture One part of the ancient, rich system of Traditional Chinese Med, generally combined w/ Chinese herbs Yin-Yang - opposing forces in the body. Goal of acupuncture is to restore their balance. Qi - Life energy. Runs along channels (meridians). Acupuncture relieves blockages, improves flow Overarching goal: rebalance, redistribute Yin-Yang and allow Qi to flow more freely. Western Acup � needles only (without Chinese herbs) Acupuncture is really just one part of the ancient, rich system of Traditional Chinese Medicine generally combined with Chinese herbs and moxibustion � which I�ll tell you about in a minute But first, some key concepts yin-yang qi It�s a rather recent development in the US to practice acupuncture alone without Chinese Herbs Acupuncture is really just one part of the ancient, rich system of Traditional Chinese Medicine generally combined with Chinese herbs and moxibustion � which I�ll tell you about in a minute But first, some key concepts yin-yang qi It�s a rather recent development in the US to practice acupuncture alone without Chinese Herbs

4. what makes Traditional Chinese Medicine difficult to study is that these formulations are very individualized - so hard to do double blind randomized controlled trials. So the studies that are most clearly considered the most rigorously scientificly sound tend to test the needles in isolation, using a sham acupuncture procedure as a control. But that does raise the question about whether this reductionist approach to studying acupuncture might miss the efficacy of the whole package. what makes Traditional Chinese Medicine difficult to study is that these formulations are very individualized - so hard to do double blind randomized controlled trials. So the studies that are most clearly considered the most rigorously scientificly sound tend to test the needles in isolation, using a sham acupuncture procedure as a control. But that does raise the question about whether this reductionist approach to studying acupuncture might miss the efficacy of the whole package.

5. Large RCT in the Annals (Berman, 2004) Patients (n=570) were randomized into three arms: 1) true acup 2) sham acup 3) control - educ only Elaborate sham acupuncture: pressure on random points - without skin puncture. 2 months of full treatment, followed for 6 months. Successful blinding (equal number guessed they got �sham� in both arms). So now let�s look at some data Until just a year ago, the data was scant and not very compelling But at the end of 2004, this large, very carefully performed trial was published in the Annals ~ almost exactly 10% in both groups ~ < say at the very end > Note: that this was Western acupuncture - needles only So now let�s look at some data Until just a year ago, the data was scant and not very compelling But at the end of 2004, this large, very carefully performed trial was published in the Annals ~ almost exactly 10% in both groups ~ < say at the very end > Note: that this was Western acupuncture - needles only

6. 1) True 2) Blinded sham 3) No treatment Look how much better sham was than no treatment (placebo is HUGE) But true was signif better than sham and remember they tested for blinding so they did successfully tease out placebo And found good evidence that accupuncture worked for OA of the knee ------------------------- baseline = 9 (scale 0-20) � this finding does not fit with the standard neuropeptide release theory � in which pain scores should start to improve right away � although if early subtle changes in pain made people more active and more activity resulted in the trend over time1) True 2) Blinded sham 3) No treatment Look how much better sham was than no treatment (placebo is HUGE) But true was signif better than sham and remember they tested for blinding so they did successfully tease out placebo And found good evidence that accupuncture worked for OA of the knee ------------------------- baseline = 9 (scale 0-20) � this finding does not fit with the standard neuropeptide release theory � in which pain scores should start to improve right away � although if early subtle changes in pain made people more active and more activity resulted in the trend over time

7. Two large high quality studies done in Germany, both published in 2005. One studied patients with migraine HA�s (n=302). Other studied patients with tension HA�s (n=270). Patients were randomized to receive: true acupuncture vs. �sham� needling vs. wait list. �Sham� needling involved superficial / minimal needling of non-acupuncture points Talk about is acupuncture there different than acupuncture here (especially in terms of herbs)Talk about is acupuncture there different than acupuncture here (especially in terms of herbs)

8. These numbers are for end of 12 weeks of treatment Improvement persisted in the 2 acupuncture groups out to one year - - peristent benefit continued to be about the same in the true acupuncture vs. sham groups These numbers are for end of 12 weeks of treatment Improvement persisted in the 2 acupuncture groups out to one year - - peristent benefit continued to be about the same in the true acupuncture vs. sham groups

9. These numbers are for end of 12 weeks of treatment Improvement persisted in the 2 acupuncture groups out to one year - - peristent benefit continued to be about the same in the true acupuncture vs. sham groups These numbers are for end of 12 weeks of treatment Improvement persisted in the 2 acupuncture groups out to one year - - peristent benefit continued to be about the same in the true acupuncture vs. sham groups

10. Acupuncture Randomized Trial Group Almost identical trial design Talk about the differences between the acupuncture in the German studies vs. the British study Acupuncture Randomized Trial Group Almost identical trial design Talk about the differences between the acupuncture in the German studies vs. the British study

11. Large high quality study done in Germany, published in 2007. 1162 patients with LBP > 6 months (mean duration of back pain 8 years) Pts were randomized to get: true acupuncture vs. �sham� needling vs. usual care. �Sham� needling involved superficial / minimal needling of non-acupuncture points Talk about is acupuncture there different than acupuncture here (especially in terms of herbs)Talk about is acupuncture there different than acupuncture here (especially in terms of herbs)

12. These numbers are for end of 12 weeks of treatment Improvement persisted in the 2 acupuncture groups out to one year - - peristent benefit continued to be about the same in the true acupuncture vs. sham groups These numbers are for end of 12 weeks of treatment Improvement persisted in the 2 acupuncture groups out to one year - - peristent benefit continued to be about the same in the true acupuncture vs. sham groups

13. Other high quality RCTs of acupuncture Fibromyalgia: true acupuncture no better than sham acupuncture � both improved a lot from baseline - no observation arm Assefi et al. Ann Intern Med 2005;143:10 LBP: a very large NIH - funded RCT based in Seattle will be published within next few months Pretty dismal really Here are 3 well-controlled trials (all used good sham procedures) 2 negative - one minimal effect But it does look like acupuncture for OA really does stand outPretty dismal really Here are 3 well-controlled trials (all used good sham procedures) 2 negative - one minimal effect But it does look like acupuncture for OA really does stand out

14. Past 4 years: there�s suddenly good evidence that people with OA + chronic headaches + low back pain + (maybe fibromyalgia?) get significantly better after receiving acupuncture. Always better than baseline, always better than observation only group These were large well-funded studies, with rigorous methodology, registered ahead of time so not worried about publication bias. Talk about is acupuncture there different than acupuncture here (especially in terms of herbs)Talk about is acupuncture there different than acupuncture here (especially in terms of herbs)

15. BUT: positive effects (which persisted for many months after treatment ended) were not too different in patients who got various forms of well-blinded sham (such as �minimal needling� to distant non-acupuncture points). Although in the one large OA trial the �true acupuncture� group did slightly better than a well-blinded �non-insertion� pressure-like sham group. Talk about is acupuncture there different than acupuncture here (especially in terms of herbs)Talk about is acupuncture there different than acupuncture here (especially in terms of herbs)

16. Positive physiologic effects of �minimal needling� or �pressure sham�? Is there such a thing as a �non-accupuncture point�? �Placebo response�? Certainly some part of it. May also be important benefits of TCM-based acupuncture that we�re missing (Chinese diagnostics / individualization of tx plan) May be too complex to tease out placebo � we may need to rely on whole systems trials Talk about is acupuncture there different than acupuncture here (especially in terms of herbs)Talk about is acupuncture there different than acupuncture here (especially in terms of herbs)