Evidence-Based Approach To Acupuncture in Integrative Medicine For Pain Management

Evidence-based approach to
acupuncture in integrative
medicine for pain management
Zhen Zheng BMed, PhD(Melb)
WHO Collaboration Centre for Traditional Medicine,

TCM Research Program, Health Innovations Research Institute,
& Discipline of Chinese Medicine, School of Health Sciences,
RMIT University, Melbourne, Australia
[email protected]
How does acupuncture work?
 www.youtube.com/watch?v=dhhdmahBQU8
Outline
 Multidimensional aspects of musculoskeletal pain

 Three problems of current pain management
 Acupuncture in pain management and evidence
 Strengths, weaknesses and current status


 How to use acupuncture in integrative medicine

Multidimensional aspects of
musculoskeletal pain
Social functioning Mental functioning Physical functioning
Anxiety Lack of sleep

Anger
Restless-
ness
Inactivity
Fear
Family issues
Social and Pain
financial & Disability
aspects
Fatigue Muscle
Depression Wasting
Comorbidity of chronic
musculoskeletal pain (Lu, Zheng, et al 2010)
Slide deleted. Unpublished data.

Pain management
Problem 1: Overuse of medications
(Pain and Policy Studies Group 2007)
Increased by 8 times Increased by 20 times

Morphine Oxycodone
Problem 2: Lack of long term benefit
(Jensen et al 2006 Eur J Pain 10: 423-33)
 Patients who were still on morphine

medications 10 years after a pain
management program had poorer QoL, were
more depressed, and adopted passive
strategies for pain management.
Problem 3: High cost (ABS 2004)
 In Australia, the cost of health conditions
 Cardiovascular diseases (11.2% of total allocated health

care)
 Nervous system diseases (9.9%).
 Chronic musculoskeletal conditions (9.5%)
Does acupuncture have the answer?
What can acupuncture do for chronic pain?
Is there any evidence supporting that
acupuncture
 can reduce the use of pain medications；
 provides long term relief (chronic pain)；and
 is cost-effective?
Level of evidence (Results of some studies
are more reliable and valid than those of others.)
SR of RCTs
•Clinical
studies RCTs
Controlled trials
•Classic
Uncontrolled data
literature
(case reports and series)
•Clinical
experience Experts’ opinions
•Cases
Animal studies Adapted from Ernst, E (1999)
Acupuncture for pain
(NIH 1998; JAMA 280: 1518-24; WHO 2002)
 World Health
Organization (WHO)
and National Institute
of Health (NIH) of USA
 Post-operative pain
 Musculoskeletal pain
 Headache
 Fibromyalgia.
Acupuncture for postoperative pain: Pain (1)
(Sun et al 2008 Br J Anaesth 101(2):151-60)
Pain reduction: Acu > standard therapy at 8 and 72 hours, but not at 24 hours.
Acupuncture for postoperative pain:
opioid medication use (2) (Sun et al 2008 Br J Anaesth
101(2):151-60)
Opioid medication use: Acu < sham Acu. Lesser as postoperative period extends.
Acupuncture for postoperative pain: Nausea and
vomiting (3) (Lee et al 2004 Cochrane)
Acupuncture for postoperative pain:
Australian position (4) (Macintyre et al 2010)
 Acute Pain Management: Scientific Evidence. 3rd
edition. Compiled by the Australian and New Zealand
College of Anaesthetists, endorsed by NHMRC
 Level 1 evidence (new)

 Acupuncture reduces postoperative pain as well as
opioid‐related adverse effects.

Acupuncture for chronic pain: German ARC,
ART and GERAC trials
 ARC: Randomized, comparative study (acu vs

non acu) (n = 50,000)
 ART: acupuncture, randomized trial (acu vs sham

acu vs wait list) (n= 1,200)
 GERAC: German acupuncture trials (acu vs sham

acu vs standard therapy) (n = 2,718)
 ASH: cohort study (n=300,000)

Acupuncture for chronic pain: response rate
Condition Real Acu Sham Acu Standard Wait list
(GERAC (GERAC therapy (ART)
ART) ART) (GERAC)
OA in the knee 53.1% 51% 29.1% 3%

52% 28%
Low back pain 47.6% 44.2% 27.2% 13%

54% 37%
Migraine 47% 39% 40% 15%

51% 53%
TTH 33% 27% Discontinued 4%

(amitriptyline)
46% 35%
Acupuncture for persistent non-specific low
back pain: UK and USA position
 National Institute for Health and Clinical
Excellence (NICE, UK) Clinical Guideline (2009)
Offer one of the following treatment options, an exercise
program, a course of manual therapy or a course of
acupuncture.
 American Pain Society Clinical Practice Guideline

(Chou 2007 Ann Inter Med 147:478-91).
Recommendation 7: For patients who do not improve
with self-care options, clinicians should consider the
addition of nonpharmacologic therapy with proven
benefits… for chronic or subacute low back pain, …
acupuncture ….
Acupuncture for low back pain: Australian
position on cost-effectiveness (NICM 2010)
 As a complement therapy to standard care,

acupuncture is a very cost-effective therapy.
Acupuncture for chronic pain:
Reduces opioid medication use:
A RCT (Zheng et al 2008 EJP 12:671-6)
Opioid comsumptions
(Morphine equivelant
600.0
450.0 39% reduction

mg/wk)
SEA
300.0
REA
150.0
25% reduction
0.0
Baseline Week 3 Week 6
Acupuncture for chronic pain:
reduces the use of pain medication – A SR
(zheng et al to be published)
 Slide deleted. Unpublished data.

Acupuncture for chronic pain: Quality of life- improves
physical functioning- A SR (Lu, Zheng et al 2010 ECAM)
Acupuncture for chronic pain: QoL- a delayed
effect on mental functioning – a SR (Lu, Zheng et al 2010
ECAM)
Electroacupuncture improves global well-
being of FM patients (Deare, Zheng et al, a Cochrane review,
under review)
Slide deleted. Unpublished data.

Acupuncture for pain management:
strengths
 Strong evidence supports

 A short-term effect of acupuncture for pain,
physical functioning and use of medications;

 Multidimensional effect
 Sleep, fatigue, well-being
 Being recognized by key health regulatory bodies in

the western countries
MRI imaging of the brain during acupuncture
Limbic
system
Real
Acu
Sham
Acu
Green – decreased activity Red/yellow-increased activity

Hy-hypothalamus; Nac-Nucleus accumbens; NA-amygdala;
(Wu, MT et al 1999)
SMA-supplementary motor cortex; MI-primary motor cortex)
Long-term: increased
MOR binding potential in
Real acu group
•the temporal pole
•The dorsal anterior cingulate

cortex
•the perigenual anterior

cingulate cortex
How to integrate acupuncture
into modern pain management?
Example 1– Acupuncture for tension
type of headache (TTH): evidence
Acupuncture
75
Reduction of TTH days (%)
CBT
50
0
6 weeks 12 weeks 3 months
after treatment
Weeks in therapy
Example 1 – Acupuncture for (TTH):
combined therapy – RMIT is
completing an NHMRC funded trial
Acupuncture
75
Reduction of TTH days (%)
CBT
Combined
50
0
6 weeks 12 weeks 3 months
after treatment
Weeks in therapy
Example 2: Acupuncture reduce
opioid medications use – RMIT is
completing an NHMRC funded trial
 Using Electroacupuncture to
 Reduce the use of opioid medication
 Reduce the side effects
 Reduce the withdrawal symptoms
Multidimensional aspects of
musculoskeletal pain
Social functioning Mental functioning Physical functioning
Anxiety Lack of sleep

Anger
Restless-
ness
Inactivity
Fear
Family issues
Social and Pain
financial & Disability
aspects
Fatigue Muscle
Depression Wasting
Acknowledgements
RMIT Pain research team Our collaborators
Prof Charlie Xue Prof Robert Helme; Prof Stephen
Dr Yanyi Wang Gibson-Uni Melb
Jessica Guo Prof Paul Martin; A/Prof Geoff
John Deare Littlejohn – Monash
David Lu Dr Carolyn Arnold – Caulfield
Alan Hao Dr Malcolm Hogg – RMH
Thank you! Questions?

[email protected]

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Evidence-based approach to

Zhen Zheng BMed, PhD(Melb)

WHO Collaboration Centre for Traditional Medicine,

 Three problems of current pain management

 Acupuncture in pain management and evidence

 Strengths, weaknesses and current status

 How to use acupuncture in integrative medicine

Anxiety Lack of sleep

Slide deleted. Unpublished data.

Increased by 8 times Increased by 20 times

 Patients who were still on morphine

 In Australia, the cost of health conditions

 Cardiovascular diseases (11.2% of total allocated health

 can reduce the use of pain medications；

 provides long term relief (chronic pain)；and

 Level 1 evidence (new)

opioid‐related adverse effects.

 ARC: Randomized, comparative study (acu vs

 ART: acupuncture, randomized trial (acu vs sham

 GERAC: German acupuncture trials (acu vs sham

 ASH: cohort study (n=300,000)

OA in the knee 53.1% 51% 29.1% 3%

Low back pain 47.6% 44.2% 27.2% 13%

Migraine 47% 39% 40% 15%

TTH 33% 27% Discontinued 4%

 American Pain Society Clinical Practice Guideline

 As a complement therapy to standard care,

450.0 39% reduction

 Slide deleted. Unpublished data.

Slide deleted. Unpublished data.

 Strong evidence supports

physical functioning and use of medications;

 Sleep, fatigue, well-being

 Being recognized by key health regulatory bodies in

Green – decreased activity Red/yellow-increased activity

•the temporal pole

•The dorsal anterior cingulate

•the perigenual anterior

Anxiety Lack of sleep

Thank you! Questions?

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