Download What acupuncture can and cannot do for arthritis?

What acupuncture can and
cannot do for arthritis?
June 25, 2009
Wei Huang MD, PhD
Birmingham/Atlanta GRECC
Atlanta VAMC
Emory University
Purpose
 Provider education on the use of acupuncture
as a complementary alternative therapy in
arthritic conditions.
 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.
Osteoarthritis
Osteoarthritis
 Over 20 million people in the United States live with
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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
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
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
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Minimal and no long term adverse reactions
Not invasive procedure to perform in the office
Less costly than surgery
Any research evidence for the
effects of acupuncture in
osteoarthritis?
Acupuncture for knee and hip OA
 Witt et al. (2006-2008)
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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%
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
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
Witt et al. (cont.) - Results
 At 6 month, there
were no significant
differences b/w all
groups
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No difference in
delayed treatments
Treatment effects
lasted for at least 3
months postintervention
Witt et al. (cont.) - Results
 Other interesting findings:
 Subgroup analysis showed significantly more
pronounced improvements in patients of:
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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
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
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Acupuncture for knee osteoarthritis in females was
more cost-effective than males;
No gender difference in hip osteoarthritis
Limitation of the study
 Neither physicians nor patients were blinded
 No sham treatment control
 Heterogeneous patient sample: age, area of
involvement
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
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
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).
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:
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Hospital for Special Surgery scores (pain, function,
muscle strength, joint ROM, flexion deformity, knee
instability)
50 meter walk
20 steps climbing
Pain score (VAS)
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
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.
Other types
of arthritis
Rheumatoid Arthritis
 In addition to arthritic pain as in osteoarthritis,
rheumatoid arthritis also presents with:
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Increased morning stiffness (>1hr)
Multiple joints involvement including small
joints: pain, swelling
Increased ESR, CRP
Acupuncture for RA
 Moxibustion in combination
with needles
 Bee needle and bee venom
therapy
 Acupoint injections
 Fire needle
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) 19742007
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 422wks)
 Mean number of acupuncture sessions: 42 +
62 (range 1-180)
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
Acupuncture for RA (summary)
 Limited studies suggest the use of
acupuncture for improving RA symptoms and
possible some inflammatory indexes.
 Results are not conclusive.
Gouty Arthritis
 Metabolic
 Uric acid crystal deposition
in the joint(s)
 Inflammation: redness, swelling,
sharp pain
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
Ma (cont.)
 Results:
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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%
Ma (cont.)
 Results (cont.)
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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.
Acupuncture for Gout (Summary)
 Limited clinical trials suggest beneficial use of
acupuncture in patients with gouty arthritis
and abnormal renal functions.
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
What acupuncture has not be proven to
do …
 To reverse structural damages
 To slow down disease progression
 To reduce healthcare cost
When and how to refer patients for
acupuncture treatments?
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
How …
 Know the resources at your facility/area
 Know the credentialing process at your state
 Build a referral network
Something your patients may ask you
about …
 Side effects profile for acupuncture
 Relative contraindications
Common adverse reactions
 Usually minor: Local bleeding, bruise,
achiness/pain
 About 3% with strong reactions to needling:
vagovagal reaction, increased pain for 2448hours
Rare complications
 Pneumothorax
 Nerve injury
 Blood vessel penetration
KNOW THE ANATOMY!!!
Relative contraindications
 Skin infection (not in the same area where needle will
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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
Contact Information
 For information about this specific presentation
please contact Wei Huang, MD, PhD at
[email protected]
 For any questions about the monthly GRECC Audio
Conference Series please contact Tim Foley at
[email protected] 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.
Q&A
Thank You!