Lahey Clinic Acupuncture - Evidence Based Guidelines Jonathan Ammen, M.Ed., M.Ac., Lic.Ac. Acupuncture has been used increasingly in the United States and Europe since the 1960’s. Though acupuncture has historically been used for a wider range of illnesses this paper focuses on those for which a scientific evidence base has been established. Since the NIH Consensus Conference on Acupuncture in 1997 there has been great interest in acupuncture research. As of 2010, hundreds of mechanism studies and efficacy RCTs, have been completed. Likely mechanisms of action have been identified but are not discussed here and the evidence base for acupuncture efficacy is growing. Though efficacy research results are promising, the strength of evidence in some studies is limited by study design and sample size. Also, the puzzle of identifying satisfactory scientific controls when researching a medical procedure is only partially solved1. Our understanding of placebo controls has in fact been expanded through some acupuncture studies.2,3 With mounting evidence of acupuncture’s efficacy it is gradually being integrated into conventional healthcare. In most of the United States acupuncturists are licensed after three years of post graduate education with internship and passage of board certification examinations. In Massachusetts, acupuncturists are licensed by the Registration Board in Medicine as an independent medical specialty. Patients may access care with or without a physician’s referral. Lahey Clinic began offering acupuncture within the Community Group Practices in 1999 and in 2010 at the Sophia Gordon Cancer Center in Burlington. At Lahey, acupuncture is integrated with conventional care. A summary of the evidence for acupuncture efficacy is presented in table form below. The tables result from a review of the scientific evidence for acupuncture’s safety & efficacy, citations are generally limited to randomized controlled trials. Some information from case series or pilot studies is included only for conditions with which acupuncture has a long history of empirical success. The author is informed as an acupuncture researcher4,5,6, educator and by 30 years of clinical practice. Questions about acupuncture in relation to a patient? Jonathan B. Ammen, Lic.Ac. [email protected] Direct Line: 781 259 1165 1 (c) 2010 Jonathan Ammen updated 11/16/2010 Acupuncture - Evidence Based Guidelines Acupuncture is well tolerated and has an excellent safety record in adults7,8 and children.9 General Medicine - Acupuncture is effective for patients with: Condition Low back pain10,11 Chronic Shoulder Pain Post surgical pain15 Headache16 including migraine17,18 Lateral epicondyle pain19 Knee pain and function due to osteoarthritis20 Fibromyalgia pain fatigue and anxiety21 Dysmenorrhea22,23, infertility24,25 polycystic ovary syndrome26 Menopausal hot flashes27,28 Depression,29,30 depression during pregnancy31 Poor exercise tolerance in heart patients32 Bronchial asthma33,dyspnea34 Chronic obstructive Pulmonary Disease (COPD)35 Sleep apnea36 Findings, Recommendations & Comments Am College of Phys & Am Pain Soc - use for chronic or subacute low back pain.12 N Am Spine Soc - better relief and functional improvement than no treatment, add to other treatments for greater benefit than other treatments alone.13 Effective therapy in chronic shoulder pain. 15 treatments over 6 weeks are more effective than therapy with NSAIDs and physiotherapy. Therapeutic effect lasts for 3 mos.14 Comparable to 0.1 mg/kg IV morphine May enable reduction of medication May enable reduction of medication May be combined with physical therapy As part of comprehensive treatment approach Commonly used in Asia for wide range of GYN complaints Promising results, better placebo controls needed. One meta-analysis found acupuncture similar to antidepressants in major depressive disorder and post stroke depression. Ambulated 6 min walk distance was remarkably increased but no change in Cardiac ejection fraction or peak oxygen uptake. Improved lung function & reduced anxiety, acupuncture as an adjunct may enable medication reduction. Safe in children. Improved dyspnea on exercise. Apnea index, respiratory events & micro-arousals decreased. Hematology/Oncology - Acupuncture is effective for patients with: Condition Nausea & Vomiting of chemotherapy, pregnancy37 & perioperative38,39 Weight loss.40 Pain Oral & facial pain41,42,43 Cancer related pain, may enable reduced analgesic use. 44,45,46 Post Surgical pain47,48 Neck dissection pain, dysfunction & xerostomia.49 Joint pain & stiffness from aromatase inhibitors.50 Pain & limited ROM post axillary lymphadenectomy51 Immune Support Other cancer or cancer treatment symptoms xerostomia associated with radiotherapy.56 Dysphonia57 Inflammation associated with radiotherapy Vasomotor59,60 and depressive symptoms associated with antiestrogen therapy61, Vasomotor symptoms in men treated for prostate cancer.63 Weight loss, cough, chest pain, fever64 Fatigue associated with chemotherapy.65 Postoperative lymphedema 66 Anxiety, depression,67 post traumatic stress PTSD68 Findings, Recommendations & Comments Strong evidence Weight gain Post- surgical, myofascial pain, swallowing pain Clear benefit even when patients already under stable analgesic treatment. One trial – equal or better analgesia than conventional drugs over long term. Opiates may be reduced by peri-operative acupuncture. Significant reduction in symptoms versus usual care. Effective and well tolerated management strategy Treatment in this study begun 1 day post surgery. May enhance platelet count & prevented leukocyte decrease after radiation or chemotherapy.52, 53 Enhancement of leukocyte phagocytosis.54 Increased IL-2 level and NK cell activity55 Concurrent or after radiotherapy. Improved voice range, voice quality, and quality-of-life. rectitis58 studied, other tissues may be extrapolated. Equivalent to and more durable than Effexor62 also increased well being, energy, and in some cases libido. Frequency of and distress from hot flashes reduced, effect persisted 9 months. Weight gain, symptom relief, fewer side effects. Improvements in general & physical fatigue, activity & motivation Initiate treatment soon after surgery. Safe and effective management, PTSD symptom reductions maintained at least 3 months. 2 (c) 2010 Jonathan Ammen updated 11/16/2010 Endnotes: 1 Takakura N, Takayama M, Kawase A, Kaptchuk T,Yajima H. Double blinding with a new placebo needle: a further validation study. Acupuncture in Medicine, Sep2010, Vol. 28 Issue 3, p144-148; , 5p 2 Finniss DG, Kaptchuk TJ, Miller F, Benedetti F. Biological, clinical, and ethical advances of placebo effects. Lancet, ISSN: 1474-547X, 2010 Feb 20; Vol. 375 (9715), pp. 686-95; PMID: 20171404 3 Wasan AD, Kong J, Pham LD, Kaptchuk TJ, Edwards R, Gollub RL. The impact of placebo, psychopathology, and expectations on the response to acupuncture needling in patients with chronic low back pain. The Journal Of Pain: Official Journal Of The American Pain Society [J Pain], ISSN: 1528-8447, 2010 Jun; Vol. 11 (6), pp. 555-63 4 Kaptchuk T, Stason W, Davis R, et al. Sham device v inert pill: randomised controlled trial of two placebo treatments. BMJ (Clinical Research Ed.) [serial online]. February 18, 2006;332(7538):391-397. Available from: MEDLINE with Full Text, Ipswich, MA. Accessed November 8, 2010. 5 Avis N, Legault C, Coeytaux R, et al. A randomized, controlled pilot study of acupuncture treatment for menopausal hot flashes. Menopause (New York, N.Y.) [serial online]. November 2008;15(6):1070-1078. Available from: MEDLINE with Full Text, Ipswich, MA. Accessed November 8, 2010. 6 Schnyer R, Conboy L, Jacobson E, et al. Development of a Chinese Medicine Assessment Measure: An Interdisciplinary Approach Using the Delphi Method. Journal of Alternative & Complementary Medicine [serial online]. December 2005;11(6):1005-1013. Available from: Alt HealthWatch, Ipswich, MA. Accessed November 8, 2010. 7 Acupuncture: An Introduction. NCCAM Publication No. D404 Created December 2007 http://nccam.nih.gov/health/acupuncture/introduction.htm accessed 10/24/10 8 Lao L. Acupuncture practice, past and present: is it safe and effective? J Soc Integr Oncol. 2006 Winter;4(1):13-5. 9 Jindal V, Ge A, Mansky PJ. Safety and efficacy of acupuncture in children: a review of the evidence. J Pediatr Hematol Oncol. 2008 Jun;30(6):431-42. 10 Cherkin DC, Sherman KJ, Avins AL, et al. A Randomized Trial Comparing Acupuncture, Simulated Acupuncture, and Usual Care for Chronic Low Back Pain. Archives of Internal Medicine. 2009;169[9]:858–866. 11 Manheimer E, White A, Berman B, et al. Meta-analysis: acupuncture for low back pain. Annals of Internal Medicine. 2005;142(8):651–663. 12 Chou R, Qaseem A, Snow V, et al. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Annals Of Internal Medicine [serial online]. October 2, 2007;147(7):478-491. Available from: MEDLINE with Full Text, Ipswich, MA. Accessed November 16, 2010. 13 Ammendolia C, Furlan A, Imamura M, Irvin E, van Tulder M. Evidence-informed management of chronic low back pain with needle acupuncture. The Spine Journal: Official Journal Of The North American Spine Society [serial online]. January 2008;8(1):160-172. Available from: MEDLINE with Full Text, Ipswich, MA. Accessed November 16, 2010. 14 Molsberger A, Schneider T, Gotthardt H, Drabik A. German Randomized Acupuncture Trial for chronic shoulder pain (GRASP) - a pragmatic, controlled, patient-blinded, multi-centre trial in an outpatient care environment. Pain [serial online]. October 2010;151(1):146-154. Available from: MEDLINE with Full Text, Ipswich, MA. Accessed November 16, 2010. 15 Sahmeddini M, Farbood A, Ghafaripuor S. Electro-Acupuncture for Pain Relief After Nasal Septoplasty: A Randomized Controlled Study. Journal of Alternative & Complementary Medicine [serial online]. January 2010;16(1):53-57. Available from: Alt HealthWatch, Ipswich, MA. Accessed November 4, 2010. 16 Coeytaux RR, Kaufman JS, Kaptchuk TJ, et al. A randomized, controlled trial of acupuncture for chronic daily headache. Headache. 2005;45(9):1113–1123. 17 Diener HC, Kronfeld K, Boewing G, et al. Efficacy of acupuncture for the prophylaxis of migraine: a multicentre randomized controlled clinical trial. Lancet Neurology. 2006;5(4):310–316. 18 Endres HG, Diener HC, Molsberger, et al. Role of acupuncture in the treatment of migraine. Expert Review of Neurotherapeutics. 2007;7(9):1121–1134 19 Trinh KV, Phillips SD, Ho E, et al. Acupuncture for the alleviation of lateral epicondyle pain: a systematic review. Rheumatology (Oxford). 2004;43(9):1085–1090 20 Berman BM, Lao L, Langenberg P, et al. Effectiveness of acupuncture as adjunctive therapy in osteoarthritis of the knee: a randomized, controlled trial. Annals of Internal Medicine. 2004;141(12):901–910. 21 Martin DP, Sletten CD, Williams BA, Berger IH. Improvement in fibromyalgia symptoms with acupuncture: results of a randomized controlled trial. Mayo Clin Proc. 2006 Jun;81(6):749-57. 22 Witt CM, Reinhold T, Brinkhaus B, et al. Acupuncture in patients with dysmenorrhea: a randomized study on clinical effectiveness and cost-effectiveness in usual care. American Journal of Obstetrics and Gynecology. 2008;198(2):166.e1–166.e8. 23 Cho SH, Hwang EW. Acupuncture for primary dysmenorrhoea: a systematic review. BJOG. 2010 Apr;117(5):509-21. Epub 2010 Feb 17. 3 (c) 2010 Jonathan Ammen updated 11/16/2010 24 White AR. A review of controlled trials of acupuncture for women's reproductive health care. The Journal of Family Planning and Reproductive Health Care. 2003;29(4):233–236. 25 Manheimer E, Zhang G, Udoff L, et al. Effect of acupuncture on rates of pregnancy and live birth among women undergoing in vitro fertilization: systematic review and meta-analysis. British Medical Journal. Published online February 2008 26 Elisabet Stener-Victorin, Elizabeth Jedel, Per Olof Jansson and Yrsa Bergmann Sverrisdottir. Low-frequency electroacupuncture and physical exercise decrease high muscle sympathetic nerve activity in polycystic ovary syndrome. American Journal of Physiology - Regulatory, Integrative and Comparative Physiology, 2009; DOI: 10.1152/ajpregu.00197.2009 27 Venzke L, Calvert J, Gilbertson B. A randomized trial of acupuncture for vasomotor symptoms in post-menopausal women. Complementary Therapies In Medicine [serial online]. April 2010;18(2):59-66. Available from: MEDLINE with Full Text, Ipswich, MA. Accessed November 4, 2010. 28 Avis N, Legault C, Coeytaux R, et al. A randomized, controlled pilot study of acupuncture treatment for menopausal hot flashes. Menopause (New York, N.Y.) [serial online]. November 2008;15(6):1070-1078. Available from: MEDLINE with Full Text, Ipswich, MA. Accessed November 8, 2010. 29 Zhang Z, Chen H, Yip K, Ng R, Wong V. The effectiveness and safety of acupuncture therapy in depressive disorders: systematic review and meta-analysis. Journal Of Affective Disorders [serial online]. July 2010;124(1-2):9-21. Available from: MEDLINE with Full Text, Ipswich, MA. Accessed November 4, 2010. 30 Sun H, Zhao H, Zhang J, et al. [Effect of acupuncture at Baihui (GV 20) and Zusanli (ST 36) on the level of serum inflammatory cytokines in patients with depression]. Zhongguo Zhen Jiu = Chinese Acupuncture & Moxibustion [serial online]. March 2010;30(3):195-199. Available from: MEDLINE with Full Text, Ipswich, MA. Accessed November 4, 2010. 31 TCM acupuncture provides clinically relevant improvement in depression during pregnancy. FACT: Focus on Alternative and Complementary Therapies [serial online]. September 2010;15(3):230-232. Available from: E-Journals, Ipswich, MA. Accessed November 4, 2010. 32 Arnt V. Kristen, Boris Schuhmacher, Kathrin Strych, Dirk Lossnitzer, Hans-Christoph Friederich, Thomas Hilbel, Markus Haass, Hugo A. Katus, Antonius Schneider, Konrad M. Streitberger, Johannes Backs. Acupuncture Improves Exercise Tolerance of Heart Failure Patients - a Placebo-Controlled Pilot Study. Heart, 2010; DOI: 10.1136/hrt.2009.187930 33 Scheewe S, Vogt L, Minakawa S, Welle S, Stachow R, Banzer W. [Acupuncture in children and adolescents with bronchial asthma: a randomized controlled trial]. Deutsche Zeitschrift fur Akupunktur [serial online]. 2008;51(2):8-12. Available from: Cochrane Central Register of Controlled Trials, Ipswich, MA. Accessed November 4, 2010. 34 Jobst, Kim. A.1. A Critical Analysis of Acupuncture in Pulmonary Disease: Efficacy and Safety of the Acupuncture Needle The Journal of Alternative & Complementary Medicine; January 1995, Vol. 1 Issue: Number 1 p57-85, 29p 35 Suzuki M, Namura K, Ohno Y, et al. The Effect of Acupuncture in the Treatment of Chronic Obstructive Pulmonary Disease. Journal of Alternative & Complementary Medicine [serial online]. November 2008;14(9):1097-1105. Available from: Alt HealthWatch, Ipswich, MA. Accessed November 4, 2010. 36 Freiré A, Sugai G, Togeiro S, Mello L, Tufik S. Immediate effect of acupuncture on the sleep pattern of patients with obstructive sleep apnoea. Acupuncture in Medicine [serial online]. September 2010;28(3):115-119. Available from: Alt HealthWatch, Ipswich, MA. Accessed November 4, 2010. 37 National Cancer Institute: PDQ® Acupuncture. Bethesda, MD: National Cancer Institute. Date last modified 08/19/10. Available at: http://www.cancer.gov/cancertopics/pdq/cam/acupuncture/healthprofessional. pp 14-15 Accessed 10/10/10. 38 Korinenko Y, Vincent A, Cutshall SM, Li Z, Sundt TM 3rd. Efficacy of acupuncture in prevention of postoperative nausea in cardiac surgery patients. Ann Thorac Surg. 2009 Aug;88(2):537-42. 39 Ezzo JM, Richardson MA, Vickers A, Allen C, Dibble SL, Issell BF, Lao L, Pearl M, Ramirez G, Roscoe J, Shen J, Shivnan JC, Streitberger K, Treish I, Zhang G. Acupuncture-point stimulation for chemotherapy-induced nausea or vomiting. Cochrane Database Syst Rev. 2006 Apr 19;(2):CD002285. 40 Xia YQ, Zhang D, Yang CX, et al.: An approach to the effect on tumors of acupuncture in combination with radiotherapy or chemotherapy. J Tradit Chin Med 6 (1): 23-6, 1986. 41 Lao L, Bergman S, Hamilton GR, et al. Evaluation of acupuncture for pain control after oral surgery: a placebo-controlled trial. Archives of Otolaryngology—Head & Neck Surgery. 1999;125(5):567–572. 42 Shen Y, Younger J, Goddard G, Mackey S. Randomized clinical trial of acupuncture for myofascial pain of the jaw muscles. Journal Of Orofacial Pain [serial online]. 2009 Fall 2009;23(4):353-359. Available from: MEDLINE with Full Text, Ipswich, MA. Accessed November 8, 2010. 43 Sertel S, Herrmann S, Greten H, et al. Additional use of acupuncture to NSAID effectively reduces post-tonsillectomy pain. European Archives Of Oto-Rhino-Laryngology: Official Journal Of The European Federation Of Oto-Rhino-Laryngological Societies (EUFOS): Affiliated With The German Society For Oto-Rhino-Laryngology - Head And Neck Surgery [serial online]. June 2009;266(6):919-925. Available from: MEDLINE with Full Text, Ipswich, MA. Accessed November 8, 2010. 44 National Cancer Institute: PDQ® Acupuncture. Bethesda, MD: National Cancer Institute. Date last modified 08/19/10. Available at: http://www.cancer.gov/cancertopics/pdq/cam/acupuncture/healthprofessional. pp 12-14 Accessed 10/10/10. 4 (c) 2010 Jonathan Ammen updated 11/16/2010 45 Alimi D, Rubino C, Pichard-Léandri E, Fermand-Brulé S, Dubreuil-Lemaire M-L, Hill C. Analgesic Effect of Auricular Acupuncture for Cancer Pain: A Randomized, Blinded, Controlled Trial Journal of Clinical Oncology, Vol 21, Issue 22 (November), 2003: 4120-4126 46 Deng G, Cassileth B, Cohen L, Gubili J, Johnstone P, Kumar N, Vickers A. Integrative Oncology Practice Guidelines. Journal of the Society for Integrative Oncology, Vol 5, No 2 (Spring), 2007: pp 65–84 47 Naoki Kotani, M.D., Hiroshi Hashimoto, M.D., Yutaka Sato, M.D., Daniel I. Sessler, M.D., Hideki Yoshioka, M.D., Masatou Kitayama, M.D., Tadanobu Yasuda, M.D.,§ Akitomo Matsuki, M.D._Preoperative Intradermal Acupuncture Reduces Postoperative Pain, Nausea and Vomiting, Analgesic Requirement, and Sympathoadrenal Responses Anesthesiology 2001; 95:349 –56 48 Sahmeddini M, Farbood A, Ghafaripuor S. Electro-Acupuncture for Pain Relief After Nasal Septoplasty: A Randomized Controlled Study. Journal of Alternative & Complementary Medicine [serial online]. January 2010;16(1):53-57. Available from: Alt HealthWatch, Ipswich, MA. Accessed November 4, 2010. 49 D. Pfister, A. Vickers, G. Deng, J. S. Lee, D. Garrity, N. Lee, D. Kraus, A. Shaha, J. Shah, B. R. Cassileth. Acupuncture for pain and dysfunction after neck dissection: preliminary results of a randomized controlled trial. J Clin Oncol 26: 2008 (May 20 suppl; abstr 6016) 50 Crew KD, Capodice JL, Greenlee H, Brafman L, Fuentes D, Awad D, Yann Tsai W, Hershman DL. Randomized, blinded, sham-controlled trial of acupuncture for the management of aromatase inhibitor-associated joint symptoms in women with earlystage breast cancer. J Clin Oncol. 2010 Mar 1;28(7):1154-60. Epub 2010 Jan 25. 51 He JP, Friedrich M, Ertan AK, et al.: Pain-relief and movement improvement by acupuncture after ablation and axillary lymphadenectomy in patients with mammary cancer. Clin Exp Obstet Gynecol 26 (2): 81-4, 1999. 52 National Cancer Institute: PDQ® Acupuncture. Bethesda, MD: National Cancer Institute. Date last modified 08/19/10. pp 1112 Available at: http://www.cancer.gov/cancertopics/pdq/cam/acupuncture/healthprofessional. Accessed 10/10/10. 53 Wu B, Zhou RX, Zhou MS. Effect of acupuncture on immunomodulation in patients with malignant tumors Zhongguo Zhong Xi Yi Jie He Za Zhi 16 (3): 139-41, 1996. 54 Zhou RX, Huang FL, Jiang SR, et al. The effect of acupuncture on the phagocytic activity of human leukocytes. J Tradit Chin Med 8 (2): 83-4, 1988 55 Wu B, Zhou RX, Zhou MS. Effect of acupuncture on interleukin-2 level and NK cell immunoactivity of peripheral blood of malignant tumor patients. Zhongguo Zhong Xi Yi Jie He Za Zhi 14 (9): 537-9, 1994. 56 Peter A. S. Johnstone, M.D., M.A. Richard C. Niemtzow, M.D., Ph.D., M.P.H. Robert H. Riffenburgh, Ph.D. Acupuncture for Xerostomia. CANCER February 15, 2002 / Volume 94 / Number 4 57 A Randomized Treatment-Placebo Study of the Effectiveness of Acupuncture for Benign Vocal Pathologies. Journal of Voice [serial online]. March 2006;20(1):144-156. Available from: E-Journals, Ipswich, MA. Accessed November 4, 2010. 58 Zhang ZH. Effect of acupuncture on 44 cases of radiation rectitis following radiation therapy for carcinoma of the cervix uteri. J Tradit Chin Med 7 (2): 139-40, 1987. 59 Deng G, Vickers A, Yeung S, et al.: Randomized, controlled trial of acupuncture for the treatment of hot flashes in breast cancer patients. J Clin Oncol 25 (35): 5584-90, 2007. 60 Frisk J, Carlhäll S, Källström AC, et al.: Long-term follow-up of acupuncture and hormone therapy on hot flushes in women with breast cancer: a prospective, randomized, controlled multicenter trial. Climacteric 11 (2): 166-74, 2008. 61 Porzio G, Trapasso T, Martelli S, et al. Acupuncture in the treatment of menopause-related symptoms in women taking tamoxifen. Tumori 88 (2): 128-30, 2002 Mar-Apr. 62 Walker et al. Acupuncture Versus Venlafaxine for the Management of Vasomotor Symptoms in Patients With Hormone Receptor-Positive Breast Cancer: A Randomized Controlled Trial. Journal of Clinical Oncology, 2009; DOI: 10.1200/JCO.2009.23.5150 63 Frisk J, Spetz AC, Hjertberg H, et al. Two Modes of Acupuncture as a Treatment for Hot Flushes in Men with Prostate CancerA Prospective Multicenter Study with Long-Term Follow-Up. Eur Urol : , 2008. 64 Xia YQ, Zhang D, Yang CX, et al.: An approach to the effect on tumors of acupuncture in combination with radiotherapy or chemotherapy. J Tradit Chin Med 6 (1): 23-6, 1986. 65 Molassiotis A, Sylt P, Diggins H. The management of cancer-related fatigue after chemotherapy with acupuncture and acupressure: a randomised controlled trial. Complement Ther Med 15 (4): 228-37, 2007. 66 Kanakura Y, Niwa K, Kometani K, et al. Effectiveness of acupuncture and moxibustion treatment for lymphedema following intrapelvic lymph node dissection: a preliminary report. Am J Chin Med 30 (1): 37-43, 2002. 67 O'Regan D, Filshie J. Acupuncture and cancer. Auton Neurosci. 2010 Oct 28;157(1-2):96-100. 68 Michael Hollifield, Nityamo Sinclair-Lian, Teddy D. Warner, and Richard Hammerschlag, "Acupuncture for Posttraumatic Stress Disorder: A Randomized Controlled Pilot Trial." The Journal of Nervous and Mental Disease, June 2007. 5 (c) 2010 Jonathan Ammen updated 11/16/2010