14/06/2013

Metaanalysis measurestheoveralleffectsize
Levelsofevidence

MedicalAcupunctureEvidence:
ScientificandEffective.
Dr.IanRelf

Level1
evidence
5001000
people:
Manytrials
added
together

MBBS,BScHons,MSc(Monash/PHH),DipRACOG,
FRACGP,FAMAC
ResearchFellowMelbourneUniversity
MentorMonashUniversityPostGradAcupuncture
BoardmemberArthritisVictoria

Goldstandard
10,000+
peopletreated/trialsadded

1trial20people

2012 Overallanalysishighlypositive
17,922patients

Acupuncture MSKPain
Back&NeckPain

AcupunctureforChronicPain
Metaanalysispositive

Comparedwithnoacupuncturecontrols;
theeffectsizeswere0.55,0.57,and0.42standarddeviationsforbackandneck
pain,osteoarthritis,andchronicheadache,respectively.

AndrewJ.Vickersetal JAMA ArchInternMed.PublishedonlineSeptember10,2012.

doi:10.1001/archinternmed.2012.3654

LancetBoxplot Chowetal2009

Level1 NeckPain
Lancet2009 Laseracupuncture
Efficacyoflowlevellasertherapyinneckpain:asystematicreview.
RobertaTChow,MarkIJohnson,RodrigoABLopesMartins,JanMBjordal

16RCTs(820patients)
RRforpainimprovementof405 (274598)
Acute&chronicneckpain
Conclusions
Laser LLLT reducespainimmediatelyinacuteneckpain
Chronicimprovementneckpainlasting>5mo

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Laser/needles genericeffectsPain
system&tightmuscles

4yearsofKneepain Army
$Costestimate
4years@64K/yr+oncostsadd1/3+medical+legal
>$400,000
EarlyLaser=$7000(10Tx$2K+4weeks(5K)&RTW)
Actual12moTx RTWwaspossibleat3months
Couldrunat12months.

USArmedservices

ProfJoeHelms
USA

Cortisone
Injections
problematic

Medicalacupuncture?
WesternMedicine+Acupuncture.
Acupunctureworksthroughthenerves.

Lancet TENNISELBOW

2010Nov20;376(9754):175167.Epub2010Oct21.Analysis 3824trials HighqualityRCTs

Normalizesthephysiologicalresponsetoinjury.

reducedpainintheshortterm,
BUT thiseffectwasreversedatintermediateandlongterms.

Generaleffectsonpainsystem,muscles&
ligaments,hormonal,autonomicnerves.

Summary cortisonedetrimentalinlongterm.

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Shoulderpain Recommendedtreatment:
Overall analysisof32trials.
HealthTechnolAssess.2012;16(11):1264.
Managementoffrozenshoulder restriction
ofmovement :asystematicreviewof32
trials.
Therewaslimitedclinicalevidenceontheeffectivenessof
exercise,cortisoneandphysiotherapyorsurgicalreleasefor
frozenshoulderproblems.

Hip,back&knee
injuries time
Cantmoveproperly
Time weekspassby
Nosignificantimprovement
Takes Antiinflams,valium,painkillers.
Medicalisation Whatdidthedocsaycantdo
anythingtillwegetascan.Gotafewbulging
discssoundsbadmateMightneedsurgery
Moretimepasses stillnoeffectivetreatmenthas
beengiven.

Truckdriver bilatfrozenshld+neck+headaches

Medication problematic?

Medicationeffectdoesntlast.
Painsystemnottreated.
Muscle&finenerveinjurynottreated.
Ligamentinjurynottreated.
Timepasses

Psychologychanges

10minsafterfirsttreatment5mwlaser

NeckMovement Immediatelywithfirsttreatment(2yrs)

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Wheelchair phantom

BMJ.2004Mar27;328(7442):744.Epub2004Mar15.
Acupunctureforchronicheadacheinprimarycare:large,
pragmatic,RCTtrial.
VickersAJ,etal

2xdislocation+surgery>laseracu

18yrsofpostconcussionheadache

401patientsTxfor12monthsvsUSUALCare.
Headachescoreat12mo 34%reductionof16.2,SD13.7,
n=161,34%(22.3,SD17.0,n=140,16%reductionfrom
baseline).
Differencebetweenmeansis4.6;P<0.0002.
22fewerdaysofheadache
15%lessmedication(P=0.02),
25%fewervisitstogeneralpractitioners(P=0.10),
15%fewerdaysoffsick(P=0.2).

Level1 PerioperativeAcupuncture

Postbacksurgery Panadolonly

BrJAnaesth2008Aug;101(2):15160
Acupunctureforpostoperativepain:
Asystematicreviewof 15RCTs.

SignificantlyLess
Pain&Opiates5 10mg
S/ESedation/Pruritis/Dizziness/Urinary
retention.
RR=>0.6(>0.2sig)

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Level1 HeadacheAcu

OPIATES NationalPrescribingServiceNPS (DOHA)

AnaesthAnalg.2008 ;107(6):203847
Systematicreviewof 31RCTs.

1300+deathsinAustraliaperyear

SignificantlyLess medication
Painintensity,frequency
&physicalfunction,responserate.

Uptoonethirdofpatientsprescribedopiatesfor
nonmalignantpainwillexhibitaberrantdrugtaking
behavior.
Operatingvehicleswithdrugs?
Acuteexacerbationsofpersistentpain
Thereisasignificantoverlapbetweenpersistentnon
cancerpainandsubstanceabusedisorder.

H/AIntensity(MeanDiff:8.54,95%:15.52,1.57)
H/AFrequency(MeanDiff0.70,95%CI1.38,0.02)
PhysicalFunction(4.16,95%CI:1.33,6.98)

Laserandpostmastectomy
lymphoedemamobilitygrip

LaserAcupunctureadvantages

Safe&lowcoststraightintotreatment
HighLevelscientificevidence
Treatsmultipleaspectsofpatientproblems:
Pain,muscles,sleep,anxiety/depression,
hormonalchange.

JSurgRes.2011Jan;165(1):8290.Epub2010
Postmastectomylymphoedema&laser
DoubleblindRCTtrialN=50

CONCLUSION:
Lasereffectivein93%
Reducingthelimbvolume,
shouldermobility&handgripstrength

Anti InflammatoryNSAIDS
Morbidity&Mortality

Kneepaintrial
Kneepain
community

GORD 10%GPvisits
EstimatingprevalenceofcommonchronicmorbiditiesinAustraliaStephanieA
Knox,ChristopherMHarrison,HelenaCBrittandJoanVHendersonMedJAust
2008;189(2):6670.

NSAIDS 350+deathsinAustralia.
Upto16,000/yeardeathsinUSA.
IncreasesCVDriskupto80%Voltaren
RecurrentGORD morbidity
NoLongtermusefuleffects
Clinicaleffectivenessisverylow,exceptinInflammatoryarthritis(5%popn.)

$600KNHMRCClinicalResearchTrial 282patienttreatmentscompletedacrossVictoria

Needles

Laser
ON

Laser
OFF

External
Fromtrial
kneepain

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Physio/Chiro/PainClinics
problematic

Kneepain

ViscosupplementationforKneeOsteoarthritis
SystematicReviewandMetaanalysis:
Data 89trialsinvolving12,667adults.
Conclusion:
Viscosupplementationisassociatedwithasmalland
clinicallyirrelevantimprovement
increasedriskforseriousadverseevents.

Evidence loweffectiveness
Notversatile
Timeconsuming
Singletherapy/notdiagnostic/variability
Usedwidelybecauseworkforceisavailable
PainClinicstraditionallyopposedto
acupuncture

Highlyskilleddoctors
wellintentioned
treatmentsloweffectiveness.

CardiaceffectsofAcupuncture

CortisoneInjectionsproblematic loweffectiveness
NSAIDS failsthelongtermtestin95%&dangerous
Painkillers nolongtermeffects
Musclerelaxants Valium noteffective addictive

YouarejokingofCourse!

Drugsdontlast.

Dontusuallytreattherealproblem.

Cardiacreperfusion
Acupunctureeffects
Yangetal2010 RCT,N=60,dailyTx
5daysprevalvereplacement.
Sig cardiactroponinIlevelsafterreperfusion
Sig intensivecareunitstaytime.
Conclusion Electroacupuncture pretreatment
mayreducethedegreeofischaemicreperfusion
injuryinpatientsundergoingvalvereplacement.

Angina Acupuncture
Xuetal2005
RCT,N=70Acu1/dayover10days
Patientswithintractableanginapectoris
Acupuncture+medicationsvs.controlgroups
SIGSymptomaticandECGchanges
89%and63%inthetreatmentgroup
60%and31%inthecontrolgrouprespectively
astatisticallysignificantdifferencebetweenthegroups
Theincidenceofacuteheartattackandsuddendeathwas6%inthe
treatmentgroupand20%inthecontrolgroup
Conclusion:Acupuncture,incombinationwithmedication,iseffectivein
thetreatmentofintractableanginapectoris.

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Acupunctureimprovesexercisetoleranceofpatients
withheartfailure:aplacebocontrolledpilotstudy

Heart.2010Sep;96(17):1396400.doi:10.1136/hrt.2009.187930.Epub 2010Jun15.Acupuncture
improvesexercisetoleranceofpatientswithheartfailure:aplacebocontrolledpilotstudy.Kristen
AV,SchuhmacherB,StrychK,LossnitzerD,FriederichHC,HilbelT,HaassM,KatusHA,Schneider
A,StreitbergerKM,BacksJ.SourceDepartmentofCardiology,UniversityofHeidelberg,
Heidelberg,Germany.

METHODS:17stablepatientswithCHF(NewYorkHeartAssociationclassIIIII,ejectionfraction
<40%)receivingoptimisedheartfailuremedicationwererandomisedintoaverumacupuncture
(VA)andplaceboacupuncture(PA)group.Cardiopulmonaryfunction,heartratevariabilityand
qualityoflifewereexplored.
RESULTS:Noimprovementsofthecardiacejectionfractionorpeakoxygenuptakewereobserved,
buttheambulated6minwalkdistancewasremarkablyincreasedintheVAgroup(+32+/7m)
butnotthePAgroup(1+/11m;p<0.01).
Accordingly,postexerciserecoveryaftermaximalexerciseandtheVE/VCO(2)slope,amarkerof
ventilatoryefficiency,wereimprovedafterVAbutnotPA.Furthermore,heartratevariability
increasedafterVA,butdecreasedafterPA.The'generalhealth'scoreand'bodypain'scoreofthe
qualityoflifequestionnaireSF36tendedtobeimprovedafterVA.

CONCLUSION:Acupuncturemaybecomeanadditionaltherapeuticstrategytoimprovethe
exercisetoleranceofpatientswithCHF,potentiallybyimprovingskeletalmusclefunction.

(Continued)CVA
AcupunctureIntervention

290patients;
onecaseintheinterventiongroupdied,andtwocasesinthecontrolgroupdiedfromthe
disease(p=0.558).
ResAcurelapse6/144,
VsControl 34/143patientshadrelapse(<0.001).
BI6mo 70.25 20.37and57.43 19.61(p<0.01).
At4weeksAcupuncture
NationalInstituteofHealthStrokeScale(NIHSS),(4.15 2.032vs.6.35 3.131,p<0.01).
TheChineseStrokeScale(CSS)(9.40 4.51vs.13.09 5.80,p<0.001).
6mo StrokeSpecificQualityofLifeScale(SSQOL)(166.63 45.70)thanthecontrolgroup
(143.60 50.24;p<0.01).
Results clinicallyrelevantdecreaseofrelapseat6moresuscitatingacupuncture.Also
improveselfcareabilityandqualityoflife;
Scales gradedneurologicalexaminationassessingconsciousness,eyemovements,visual
fields,motorandsensoryimpairments,ataxia,speech,cognitionandinattention.

Depression Acu Lasertrial+

JAffectDisord.2013Jun;148(23):17987.doi:
10.1016/j.jad.2012.11.058.Epub 2013Jan
19.Laseracupuncturefordepression:A
randomised doubleblindcontrolledtrial
usinglowintensitylaserintervention.Quah
SmithI,SmithC,CrawfordJD,RussellJ.

CVA AcupunctureIntervention
AmJChinMed. 2012;40(4):68593.
Acupunctureinterventioninischemicstroke:arandomizedcontrolled
prospectivestudy.
ShenPF,KongL,NiLW,GuoHL,YangS,ZhangLL,ZhangZL,GuoJK,XiongJ,
ZhenZ,ShiXM.
Source
TheFirstAffiliatedHospitalofTianjinUniversityofTCM,Tianjin300193,
China.
Abstract
290patientsaged4075yearsoldwithfirstonsetofacuteischemicstroke
(morethan24hoursbutwithin14days)treatedwithstandard
treatments,
TheRCTresuscitatingacupuncturevs.shamacucontrol.
PrimaryoutcomemeasuresBarthelIndex(BI),relapseanddeathuptosix
months.

Depression Acu vs Fluoxetine

JAltern ComplementMed.2013May6.[Epub aheadofprint]Effects ofElectroacupuncture onDepressionand
theProductionofGlial CellLineDerivedNeurotrophic FactorComparedwithFluoxetine:ARandomized
ControlledPilotStudy.

Approximately30%40%ofpatientswithdepressionhave
onlyapartialresponsetoavailablepharmacologicaland
psychotherapeuticinterventions.
EAandfluoxetine hadsimilarcurativeeffectsonDD
patients.EAhadafasteronsetofaction,betterresponse
rate,andbetterimprovementratethanfluoxetine.Both
fluoxetine andEAtreatmentrestoredthenormal
concentrationofGDNFintheserumofDDpatients.
Conclusion:EAtreatmentfordepressionisaseffectiveasa
recommendeddoseoffluoxetine.However,EA
demonstratesanadvantageintheregulationofthe
productionofGDNFcomparedwithfluoxetine.

Lowlevelvisiblelight(LLVL)irradiationpromotes
proliferationofmesenchymal stemcells.
LasersMedSci.2012Sep25.[Epub aheadofprint].Lipovsky A,
OronU,GedankenA,LubartR.SourceIsrael.
AbstractMesenchymalstemcells(MSCs)wereisolatedfromthe
bonemarrow,andlightirradiationwasappliedatenergydensities
of2.4,4.8,and7.2 J/cm(2).
IlluminationoftheMSCsresultedinalmosttwofoldincreasein
cellnumberascomparedtocontrols.Elevatedreactiveoxygen
speciesandnitricoxideproductionwasalsoobservedinMSCs
culturesfollowingilluminationwithbroadbandvisiblelight.The
presentstudyclearlydemonstratestheabilityofbroadband
visiblelightilluminationtopromoteproliferationofMSCsinvitro.
Theseresultsmayhaveanimportantimpactonwoundhealing.

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Inductionofautologous mesenchymal stemcellsin

thebonemarrowbylowlevellasertherapyhas
profoundbeneficialeffectsontheinfarcted ratheart.
LasersSurg Med.2011Jul;43(5):4019.doi:10.1002/lsm.21063.
TubyH,MaltzL,OronU.SourceDepartmentofZoology,TheGeorgeS.WiseFacultyofLifeSciences,
TelAvivUniversity,TelAviv69978,Israel.
AbstractBACKGROUNDANDOBJECTIVES:Theadultmammalianheartisknowntohaveaverylimited
regenerativecapacityfollowingacuteischemia.Inthisstudyweinvestigatedthehypothesisthat
photobiostimulationofautologousbonemarrowderivedmesenchymalstemcells(MSCs)by
lowlevellasertherapy(LLLT)appliedtothebonemarrow(BM),maymigratetotheinfarcted
areaandthusattenuatethescarringprocessesfollowingmyocardialinfarction
(MI).MATERIALSANDMETHODS:SpragueDawleyratsunderwentexperimentalMI.LLLT(GaAlAs
diodelaser,powerdensity10mW/cm,for100seconds)wasthenappliedtotheBMofthe
exposedtibiaatdifferenttimeintervalspostMI(20minutesand4hours).Shamoperated
infarctedratsservedascontrol.
RESULTS:Infarctsizeandventriculardilatationweresignificantlyreduced(76%and75%,respectively)
inthelasertreatedrats20minutespostMIascomparedtothecontrolnontreatedratsat3
weekspostMI.
Therewasalsoasignificant25foldincreaseincelldensityofckit+cellsintheinfarctedareaofthe
lasertreatedrats(20minutespostMI)ascomparedtothenonlasertreatedcontrols.
CONCLUSION:TheapplicationofLLLTtoautologousBMofratspostMIoffersanovelapproachto
induceBMderivedMSCs,whichareconsequentlyrecruitedfromthecirculationtotheinfarcted
heartandmarkedlyattenuatethescarringprocesspostMI.