Foundation in Acupuncture - Essay Example

Literature Review: Foundation in Acupuncture Introduction Acupuncture is an old practice originated in China, where acupuncture has been being practiced for a period of over 2000 years. Although, reports have proved its utility in different clinical conditions, especially those which are not amenable to conventional allopathic management despite sufferings the patients may go through. It is to be remembered that despite its use and increasing use in the current times, its use remains controversial and often viewed as a part of oriental culture rather than an established branch of medical practice. The main reason for this has been stated to be lack of evidence. In fact, the confusion about acupuncture in current medical literature reflects the difficulty of studying acupuncture through randomised controlled trials, since it is difficult to blind a subject or investigator as to whether or not the subject was receiving the needle stick. Sham acupuncture will always have some effects since it intercepts some peripheral nerves, so a control is difficult to establish in different conditions. Moreover, acupuncture traditionally is used in chronic conditions, late in the course of the disease. This makes getting a statistical result difficult to obtain. Despite these drawbacks, considerable evidence from literature has accumulated which can serve as evidence in favour of its use in clinical practice (Gaw et al., 1975). Literature Review In this literature review, contemporary literatures on use of acupuncture in a chronic disease, osteoarthrosis will be critically reviewed in order to create an evidence base for clinical practice. Osteoarthritis is a disease of the knee joints with destruction of articular cartilages leading to pain and restriction of motion. There is no known cure for this disease in conventional medicine, and the goals of management are control of pain, improvement of function and health-related quality of life with avoidance of toxicity out of therapeutic agents (Kwon et al., 2006). Ernst (1997) identified in his systemic review on acupuncture for osteoarthritis in any joint, and seven reported a positive result and six, negative results. Of the positive studies, the majority failed to control for placebo effects. Of the five placebo-controlled studies, four found no difference between the effect of acupuncture and the effect of sham. As with neck pain, it is unclear whether the clinical benefits which many patients experience from acupuncture are a specific or a nonspecific response. This indicates, there is no definite conclusion about the utility of acupuncture in this disease, and more research and evidence are necessary (Ernst, 1997). In TCM, the indications for acupuncture, osteoarthritis is viewed as lack of strength in both feet, lower legs, and knees, numb, aching, and painful. There is occasional sensation of muscular hypertonicity and cramping, impaired movement. The treatment principles are to warm the channels and scatter cold, to move the qi and relax tetany. The treatment offered is Jing Gu (Bl 64), Cheng Shan (Bl 57), Cheng Jin (Bl 56), and Shang Qiu (Sp 5) (Takeda and Wessel, 1994). For this purpose, three studies were located, and they will be reviewed below. Berman et al. (1999) investigated the efficacy of acupuncture as an therapy of adjunct for relief of pain and dysfunction in elderly patients with knee osteoarthritis. They performed this study in a randomised controlled trial design involving 73 patients with symptomatic osteoarthritis of the knee. This was a comparative study between standard care and standard care and acupuncture. The measures utilised in this study were self scoring by the patients of their knee disease with WOMAC scores and Lesquesne indices at baseline and at 4, 8, and 12 weeks of therapy. It was found that patients randomised to acupuncture improved on both these scores in comparison to standard treatment alone group at 4 and 8 weeks, although there was a slight decline in response noticed after cessation of the treatment after 12 weeks without any adverse effects. The authors concluded that acupuncture is a safe and effective adjunctive therapy for knee osteoarthritis (Berman et al., 1999). Foster et al. (2007) investigated the effects of adjunctive acupuncture to exercise therapy for pain reduction in patients with knee osteoarthritis. This study was designed as a multicentric randomised controlled trial in 37 physiotherapy centres accepting referrals from primary care physicians in London. For this study, 352 adults over age 50 were recruited, who had clinical diagnosis of knee osteoarthritis. The interventions were advice and exercise in 116 patients as opposed to exercise plus true acupuncture in 117 patients and exercise plus nonpenetrating acupuncture in 119 patients. The outcome measures were decided to be changes in the WOMAC scores at 6 months with secondary outcomes being improvement in function, pain intensity, and unpleasantness of pain at 2 weeks, 6 weeks, six months, and 12 months. Statistical analysis of the data revealed that compared to advice and exercise alone, there were small but statistically significant improvements in pain intensity and unpleasantness at 2 and 6 weeks, although there was no discernible improvement in the WOMAC scores. Thus it could be concluded that the addition of acupuncture to a course of advice and exercise in patients with knee osteoarthritis does not provide any additional benefits on the pain scores despite having some improvement in subjective feeling (Foster et al., 2007). Williamson et al. (2007) evaluated the effects of standardised Western acupuncture on functional ability and pain in a group of 181 patients with severe osteoarthritis awaiting total knee arthroplasty. This study was conducted in a three-arm, assessor-blind, randomised controlled trial. The interventions were acupuncture for 6 weeks, physiotherapy for 6 weeks, as opposed to standardised advice. The outcomes were measured through Oxford Knee Score Questionnaire and the secondary outcomes were a 50-m timed walk and duration of hospital stay following the surgery. Although there were no baseline differences between groups, at 7 weeks, there was a 10% reduction on OKS in the acupuncture group in comparison to the control group. This indicates when treated with acupuncture, patients with severe knee osteoarthritis can achieve short term improvement in symptoms, although in the long run, these are not evident (Williamson et al., 2007). The comparison of these studies can be tabulated below Berman, BM., Singh, BB., Lao, L., Langenberg, P., Li, H., Hadhazy, V., Bareta, J., and Hochberg, M., (1999). A randomized trial of acupuncture as an adjunctive therapy in osteoarthritis of the knee. Rheumatology; 38: 346 - 354. Group number/type Trial type RCT Needling method Yanglinquan (GB 34), Yinlinquan (Sp 9), Zusanli (St 36), Dubi (St 35(, extra point Xiyan. The distal points were Kunlun ( UB 60), Xuanzhong (GB 39), Sanyinjiao (Sp 6), and Taixi (kid 3) Needling parameters I inch, 34-gauge, 0.22 mm needles inserted to 0,4 to 0.6 inches. De Qi sensation verified by the patient. Two electrodes were attached to the needles at local points Dubi and Xiyan with stimulation of 1 ms duration for 20 mins. Outcome measures Self scoring by the patients of their knee disease with WOMAC scores and Lesquesne indices at baseline and at 4, 8, and 12 weeks of therapy. Foster, NE., Thomas, E., Barlas, P., Hill, JC., Young, J., Mason, E., and Hay, EM., (2007). Acupuncture as an adjunct to exercise based physiotherapy for osteoarthritis of the knee: randomised controlled trial. BMJ; 335: 436. Group number/type Trial type RCT Needling method For each individualised treatment session between six and 10 acupuncture points from 16 commonly used local and distal points were selected. Local points were Sp 9, Sp 10, St 34, St 35, St 36, Xiyan, Gb 34, and trigger points. Distal points were LI 4, TH5, Sp 6, Liv 3, St 44, Ki 3, BI 60, andGb 41. Needling parameters Sterilised disposable steel needles (300.3 mm) were used; the depth of insertion was between 5 mm and 25 mm, depending on the points selected. Needles were manipulated to achieve the de qi sensation. The protocol permitted 25 to 35 minutes between insertion of the last needle and stopping treatment. Outcome measures The outcome measures were decided to be changes in the WOMAC scores at 6 months with secondary outcomes being improvement in function, pain intensity, and unpleasantness of pain at 2 weeks, 6 weeks, six months, and 12 months. Williamson, L., Wyatt, MR., Yein, K., and Melton, JTK., (2007). Severe knee osteoarthritis: a randomized controlled trial of acupuncture, physiotherapy (supervised exercise) and standard management for patients awaiting knee replacement. Rheumatology; 46: 1445 -1449. Group number/type Trial type RCT Needling method For each individualised treatment session between six and 10 acupuncture points from 16 commonly used local and distal points were selected. Local points were Sp 9, Sp 10, St 34, St 35, St 36, Xiyan, Gb 34, and trigger points. Distal points were LI 4, TH5, Sp 6, Liv 3, St 44, Ki 3, BI 60, andGb 41. Needling parameters The needles (1 inch, 0.25 gauge) were inserted and de chi achieved where possible, and left in situ for 20 min. Outcome measures The outcomes were measured through Oxford Knee Score Questionnaire and the secondary outcomes were a 50-m timed walk and duration of hospital stay following the surgery. Summary and Conclusion From this literature review, it is evident that acupuncture has a therapeutic role in management of osteoarthritis. Even those studies which fail to elicit a therapeutic benefit; this may be used as an adjunct to conventional therapy at least in advanced cases as a safe alternative that can enhance patient's pain sensation and displeasure during the early phase of therapy. At present evidence is lacking as to whether these can be used as a single modality of therapy, and for that, further research is mandated. Reference List Berman, BM., Singh, BB., Lao, L., Langenberg, P., Li, H., Hadhazy, V., Bareta, J., and Hochberg, M., (1999). A randomized trial of acupuncture as an adjunctive therapy in osteoarthritis of the knee. Rheumatology; 38: 346 - 354. Ernst E., (1997). Acupuncture as a symptomatic treatment of osteoarthritis. A systematic review. Scand J Rheumatol.;26:444-7. Foster, NE., Thomas, E., Barlas, P., Hill, JC., Young, J., Mason, E., and Hay, EM., (2007). Acupuncture as an adjunct to exercise based physiotherapy for osteoarthritis of the knee: randomised controlled trial. BMJ; 335: 436. Gaw AC, Chang LW, and Shaw LC., (1975). Efficacy of acupuncture on osteoarthritic pain. A controlled, double-blind study. N Engl J Med.;293:375-8. Kwon, YD., Pittler, MH., and Ernst, E., (2006). Acupuncture for peripheral joint osteoarthritis: A systematic review and meta-analysis. Rheumatology; 45: 1331 - 1337. Takeda W and Wessel J. (1994). Acupuncture for the treatment of pain of osteoarthritic knees. Arthritis Care Res.;7:118-22. Williamson, L., Wyatt, MR., Yein, K., and Melton, JTK., (2007). Severe knee osteoarthritis: a randomized controlled trial of acupuncture, physiotherapy (supervised exercise) and standard management for patients awaiting knee replacement. Rheumatology; 46: 1445 - 1449. Read More