Integrative Medicine on Pain Management Is There Any

Transcription

1 Integrative Medicine on Pain Management Is There Any Evidence? Lixing LAO, MB, PhD Professor and Director of School of Chinese Medicine, The University of Hong Kong

2 Overview Acupuncture Trials on Pain Conditions Qigong/Tai-chi Trials on Pain Conditions Chinese herbal Trials on Pain Conditions

3 Effects of Acupuncture on Pain Management

4 Acupuncture for Chronic Pain -- INDIVIDUAL PATIENT DATA META -ANALYSIS Andrew J. Vickers, DPhil; Angel M. Cronin, MS; Alexandra C. Maschino, BS; George Lewith, MD; Hugh MacPherson, PhD; Nadine E. Foster, DPhil; Karen J. Sherman, PhD; Claudia M. Witt, MD; Klaus Linde, MD; for the Acupuncture Trialists Collaboration Arch Intern Med (IF= ). Published online September 10, 2012.doi: /archinternmed

5 Background Although acupuncture is widely used for chronic pain, there remains considerable controversy as to its value Determine the effect size of acupuncture for 4 chronic pain conditions: back and neck pain, osteoarthritis, chronic headache, and shoulder pain

6 Methods Literature search: MEDLINE, the Cochrane Collaboration Central Register of Controlled Trials, the citation lists of systematic reviews. Identification of eligible RCTs Collection, checking, and harmonization of raw data Individual patient data meta-analysis

7 Methods: Flowchart

8 RESULTS SYSTEMATIC REVIEW Control groups Sham RCTs No-acupuncture control groups a. needles inserted superficially b. sham acupuncture devices c. non-needle approaches varied usual care

9 RESULTS META-ANALYSIS

10 Osteoarthritis: Acupuncture is superior to usual care control Figure 1.A. Forest plots for the comparison of acupuncture with noacupuncture control

11 Chronic headache Acupuncture is superior to usual care control Figure 1.B. Forest plots for the comparison of acupuncture with noacupuncture control

12 Musculoskeletal pain: Acupuncture is superior to usual care control Figure 1.C. Forest plots for the comparison of acupuncture with noacupuncture control

13 Osteoarthritis and Chronic headache: Acupuncture is superior to sham control Acupuncture vs Sham A. Osteoarthritis B. Chronic headache Figure 2. Forest plots for the comparison of true and sham acupuncture

14 Musculoskeletal pain and Shoulder pain: Acupuncture is superior to sham control Acupuncture vs Sham C. Musculoskeletal pain D. Shoulder pain

15 Results META-ANALYSIS Effect sizes are large Effect sizes are larger for the comparison between acupuncture and no-acupuncture control than for the comparison between acupuncture and sham: 0.37, 0.26, and 0.15 in comparison with sham vs 0.55, 0.57, and 0.42 in comparison with no-acupuncture control

16 CONCLUSION Acupuncture is superior to both no-acupuncture control and sham acupuncture for the treatment of chronic pain. The total effects of acupuncture, include both the specific effects, nonspecific physiologic and psychological (placebo) effects. Acupuncture is effective for the treatment of chronic pain and is therefore a reasonable referral option.

17 Evidence Map of Acupuncture January, 2014 Hempel et al. VAESP Project #05-226; 2013 Evidence-based Synthesis Program (ESP) U.S. Department of Veterans Affairs

18 Of 1,223 citations, 183 SRs met the inclusion criteria. Systematic reviews on acupuncture published January 2005 to March 2013

19 In three VA (Department of Veterans Affairs) priority areas: Pain (N=65) Wellness (N=44) Mental health (N=20) Other (N=48) AE (N=6) Hempel et al. Evidence Map of Acupuncture. VAESP Project #05-226; 2013

20 Pain-related indications 證明無效證據不明確可能有療效有療效 Hempel et al. Evidence Map of Acupuncture. VAESP Project #05-226; 2013

21 肥胖 Wellness-related indications Hempel et al. Evidence Map of Acupuncture. VAESP Project #05-226; 2013 Evidence of no effect Unclear evidence Evidence of a potential positive effect 證明無效證據不明確可能有療效有療效 Evidence of a positive effect

22 Mental health-related indications 證明無效證據不明確可能有療效有療效 Hempel et al. Evidence Map of Acupuncture. VAESP Project #05-226; 2013

23 Effects of Tai chi/qigong on Pain Management

24 7 RCTs 348 patients Hip/knee OA Intervention (Tai Chi or Tai Chi/Qigong) IF=3.73

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26 Complementary and alternative exercise for fibromyalgia: a meta-analysis Mist SD et al. J Pain Res (IF=2.24). 2013; 6: Included studies: 16 Outcome measurement: FIQ total score or FIQ Pain Score Intervention: tai chi, qigong or yoga

27 Favors Qigong Favors Taichi

28 Favors Yoga Conclusion: The level of research has been moderately weak to date, but most studies report a medium-to-high effect size in pain reduction. Given the lack of adverse events, there is little risk in recommending these modalities as a critical component in a multimodal treatment plan, which is often required for fibromyalgia management.

29 A Randomized Trial of Tai Chi for Fibromyalgia Wang C. et al. N Engl J Med (IF=51.658) 2010; 363: Design: Randomized controlled trial Intervention (12 weeks): 1) Tai chi group (n=33) 2) Control intervention group (wellness education and stretching, n=33) Assessments: baseline, 12 and 24 weeks Outcome measurements: Primary: Fibromyalgia Impact Questionnaire (FIQ) score Secondary: SF-36

30 12 weeks Tai Chi Control p-value >>> FIQ score <0.001 Patient s global assessment score >> Physician s global assessment score PSQI score Minute walk test SF36 score Physical component Mental component > >> >> >> >

31 24 weeks Tai Chi Control p-value FIQ score <0.001 Patient s global assessment score Physician s global assessment score PSQI score Minute walk test SF36 score >>> Physical component Mental component >> > >> = >> >>

32 Conclusion: Tai chi may be a useful treatment for fibromyalgia and merits long-term study in larger study populations

33 Effects of Herbal Medicine on Pain Management

34 Few high quality RCTs on Chinese herbal medicine for pain management A systematic review and meta-analysis on the use of TCM compound kushen injection for bone cancer pain. Yanju B et al. Support Care Cancer (IF=2.649). 2014; 22(3): This systematic review showed positive but weak evidence of CKI for bone cancer pain because of the poor methodological quality Future rigorously designed RCTs are required. Chinese herbal medicine for primary dysmenorrhoea Zhu X et al. Cochrane Database Syst Rev (IF= 5.785) ;(2):CD The review found promising evidence supporting the use of Chinese herbal medicine for primary dysmenorrhoea; however, results are limited by the poor methodological quality of the included trials.

35 Some presented research projects were/are funded by: The National Center for Complementary and Alternative Medicine (NCCAM), National Institutes of Health (NIH) Grant #: RO1 AT00010 The National Center for Complementary and Alternative Medicine (NCCAM), National Institutes of Health (NIH) Grant #: R24 AT001293