Acupuncture treatment for palliative patients?

1. Acupuncture treatment for palliative patients? Gernot Ernst Blefjell sykehus Kongsberg Anestesi, Smerte- og palliativseksjon

2. Introduction • Scientific evidence • Mechanisms • Chinese medicine • Examples • Ongoing research in Kongsberg

3. History of acupuncture • 200 v. Chr.: Huang Di Nei Jing (Han-dynasti), acupuncture needles at excavations • 17. Jhdt.: de Bondt introduces acupuncture in Europa • 1816: Louis Berlioz • 1951: German association for acupuncture • 1972: Nixon in China • 1996: FDA: Acupuncture works and is safe (class II-recommendation) • 1997: NIH: Acupuncture has scientific evidence and should be accepted by physicians • 2004: 2 big studieswith more than 1000 pas(”gerac”): back, knee) – verum-acupuncturenot more effective than placebo, both better than controls

5. Nausea (postop., chemotherapy, pregnancy) Tooth ache Headache Back pain Fibromyalgia Dysmennorea Epikondylitis Carpal tunnel syndrome Dependency syndromes Asthma Rehabilitation after apoplectic insult Indications for acupuncture (NIH 1997)

6. Scientific studies about acupuncture Filshie/White 1998: left side: not randomized, right side randomized

7. Prophylaxis of migraine with acupuncture Weinschütz et al 1996

8. Results of high quality RCTs

9. Acupuncture can help if something is perturbed, but not if something is destroyed (e.g. cancer)

10. Side actions of acupuncture • Weariness, heaviness, better sleep • Stimulation, sensation of lightness • Sensation of warmth • Muscle relaxing • Mood improving • Increased appetite, improved digestion, improved urination

11. Adverse effects, complications • Fainting • Increased pain (rare) • Local infections • Minor bleedings, hematoma • Organ damages (very rare) • Allergic reactions (typ IV, extremely rare) • Labour inducing ? Ernst 1994, Strzyz 1996, Ernst 2003

12. Mechanisms of action • Anatomic places • Gate-Control-Theory • Release of endogene opioids • Modulation of the serotoninergic system • Induction of „Long term depression“

13. Anatomic places • Many acupuncture points are at areas where vessel-nerve structures cross the fascia • Similarities with trigger points • Local immunologic effect through effects on sympathic fibers which innervate lymph nodes

14. Gate-Control-Teorie • Blockade of secondary nociseptive pathways (A, C) due to concomitant stimulation of non-nociseptive pathways (A) • Theoretical base for the contrairritation treatments • Has probably only effect during stimulation, but no long term effect. • Involves GABA-Receptors, mediated through Aβ-fibers

15. Release of endogene opioids • Opiatantagonists can (partially) inhibit acupuncture analgesia • Acupuncture has less effect in mice with a lower concentration of opioid receptors • Acupuncture analgesis is increased when degradation of endogene opioids is blocked • Cross tolerance with morphine • Emotional sideeffects partially similar to endorphine

16. Modulation of the serotoninergic system • Destruction of raphe nuclei in brainstem blocks acupuncture effects • Acupuncture effect often better at paroxysmal pain • Acupuncture analgesia is diminished when ascending serotoninergic pathways are blocked • Probably combined effect on noradrenergic and serotoninergic pathways

17. Induction of „long term potentiation“

18. Long-term Depression • Repeated use of acupuncture leads to decreased response of the second neuron at nociseptive stimulations • Explains the lonbg time effect of acupuncture • Additional effect through reduced „Long term-potentiation-effects“

19. Chinese medicine • Traditionally based onthe yin/yang principleand the five elements – different schools • The body has symmetric ”meridians” which connect about 400 acupuncture points • Classical: Pulseandtongue diagnostics, anamnesis description of the patient situation according to the five elements • Chinese ”organs” are ratherphenomenologic descriptions they do not fit to „western organs“ (e.g.: liver controls menstruation, kidneycontrolfinger nails • Mythos is bigger than reality

22. Elementsof chinese medicine • Acupuncture • Moxa • Cupping (usually bloddless) • Seven star hammer • Massage • Qigong, Tai Qi Chuan • Medikaments

28. Acupuncture treatment • Body acupuncture: usually 8 to 16 needles, symmetric, 20-40 minutes • Ear acupuncture: needles, permanent needlesor globes with plaster • Moxa either with cigar or pieces of moxa on a acupuncture needle • Cupping with or without needle, bloody or bloodless

29. Symptomer • Pain 70,3 % • Xerostomia 67,5 % • Lack of appetite 60,9 % • Frailty 46,8 % • Opstipation 44,7 % • Dyspnea 42,3 % • Nausea 36,2 % • Insomnia 34,2 % • Perspiration 25,3 % • Swallowing problems 23,2 % • Urination problems 21,3 % • Psychiatric symptoms 19,8 % • Vomiting 18,5 % • Itching, other skin problems 16,3 % • Diarrea 7,6 % N = 12438 Grond 1994

30. Symptomer • Pain 70,3 % • Xerostomia 67,5 % • Lack of appetite 60,9 % • Frailty 46,8 % • Opstipation 44,7 % • Dyspnea 42,3 % • Nausea 36,2 % • Insomnia 34,2 % • Perspiration 25,3 % • Swallowing problems 23,2 % • Urination problems 21,3 % • Psychiatric symptoms 19,8 % • Vomiting 18,5 % • Itching, other skin problems 16,3 % • Diarrea 7,6 % N = 12438 Grond 1994

31. Journal of clinical oncology 2003, 21: 4120-4126

32. Ear acupuncture for cancer pain (Alimi 2003) • Cancer patients with neuropathicpain (!) and VAS > 30; 85% with constant pain, mean VAS 58 • Randomized, three groups: verum n=29 (with electical identification), placeboacupuncture n=30, no acupuncture n=31 (globes on placebo points) • Assessed by a blinded observer

34. Results • Verumacupuncture lead to a reduction of pain to 37 (placebo-acupuncture 55, Placebo”globes” 58)

35. Acupuncture for palliative patients: studies • Short effect on dyspnea (Filshie 1996), no effect (Lewith 2004) • Established effect in nausea (review: Weiger 2002) • Pain: at some patients (bl.a. Alimi 2003) • Xerostomia: some evidence (Rydholm 1999, Johnstone 2002)

36. Possible point combinations • Opstipation: LI4, St25, SJ6 • Diarrea: St37, St25 • Anxiety: P6, Ren 14 • Nausea: P6, St36, Ren12 • Aerocolia: St 36, ev. Syvstjernehammer between LI4 and S2 • Sedation points: Du 20, Ex 6, H7, An mien I,II, P6, UB62

37. Ongoing studies (Fatigue, Xerostomia) • Treatment through nurses with a basic safety and technical training • First treatments under supervision • Each patient has a schedule and one who is responsible to follow the patient. This person does not treat the patient

38. Acupuncture for fatigue: inclusion criteria • Terminated chemotherapeutic treatment or treatment pause • Subjectice fatigue with negative effects on QoL • Cognitivily able to understand the strudy and to give informed consent

39. Acupuncture for fatigue: exclusion criteria • Clinical symptoms for immune suppression (spes: granulocytes < 1,5) • Koagulation problems, thrombocytopeny • Relevant depression oranxiety • Anemia (Hb < 9) or frequent need for blood transfusions • Overdosage of medicaments, spec. Opioids or sedatives • Kacheksia • Clinical relevant infection • Dehydration • Detorriated electrolytes • Hypoxia • Clinical possibility for hormonal problems (e.g. Hypotyreodism)

40. Study structure • One treatment per week • Same points (St36, Sp6, Ren 6, H7, K3, K27) • Needles for 20-30 minutes • Evaluation after four treatments, after treatment end, after one month and three months (ESAS og BFI through a none treating person)

41. St 36 (Zusanli) • Lateral ved begynnelsen til tuberositas tibiae

42. Sp 6 Sanyinjiao • 3 cun over medial malleolus, dorsal tibia

43. Ren 6 Qihai • I midtlinjen, 1.5 cun under navlen

44. H7 Shenmen • Ved håndleddsrynken, radial til første senen (m flexor carpi ulnaris)

45. K3 Taixi • Mellom malleolus medialis og akillessene

46. K27 Shufu • Under kragebenen, 2 cun lateral fra midtlinjen. Sett nålen skjev, ca. 1 cm (ikke mer!)

47. Acupuncture for xerostomia • Inclusion: dry mouthwith effects on QoL; Ability to give informed consent • Exclusion: • Other effective treatment possibilities • Clinical symptoms for immune suppression (spes: granulocytter < 1,5) • Coagulation problems, thrombocytopenia • Relevant depression or anxiety

48. Study structure • To treatments per week • Points: K6, L7, Ren17, Ren 23, Gb 20, SJ17 • Evaluation before treatment, after three weeks and one months after terminated treatment (ESAS and XI through a none treating person)

49. Punkter

50. K6 Zhaohai • 1 cun under fremre kant til malleolus medialis