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
Overview Acupuncture Trials on Pain Conditions Qigong/Tai-chi Trials on Pain Conditions Chinese herbal Trials on Pain Conditions
Effects of Acupuncture on Pain Management
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= 10.579). Published online September 10, 2012.doi:10.1001/archinternmed.2012.3654
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
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
Methods: Flowchart
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
RESULTS META-ANALYSIS
Osteoarthritis: Acupuncture is superior to usual care control Figure 1.A. Forest plots for the comparison of acupuncture with noacupuncture control
Chronic headache Acupuncture is superior to usual care control Figure 1.B. Forest plots for the comparison of acupuncture with noacupuncture control
Musculoskeletal pain: Acupuncture is superior to usual care control Figure 1.C. Forest plots for the comparison of acupuncture with noacupuncture control
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
Musculoskeletal pain and Shoulder pain: Acupuncture is superior to sham control Acupuncture vs Sham C. Musculoskeletal pain D. Shoulder pain
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
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.
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
Of 1,223 citations, 183 SRs met the inclusion criteria. Systematic reviews on acupuncture published January 2005 to March 2013
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
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
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
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
Effects of Tai chi/qigong on Pain Management
7 RCTs 348 patients Hip/knee OA Intervention (Tai Chi or Tai Chi/Qigong) IF=3.73
Complementary and alternative exercise for fibromyalgia: a meta-analysis Mist SD et al. J Pain Res (IF=2.24). 2013; 6: 247 260 Included studies: 16 Outcome measurement: FIQ total score or FIQ Pain Score Intervention: tai chi, qigong or yoga
Favors Qigong Favors Taichi
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.
A Randomized Trial of Tai Chi for Fibromyalgia Wang C. et al. N Engl J Med (IF=51.658) 2010; 363:743-754 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
12 weeks Tai Chi Control p-value >>> FIQ score 27.8 9.4 <0.001 Patient s global assessment score >> 2.5 0.6 0.002 Physician s global assessment score 1.0 0.02 0.02 PSQI score 3.6 0.7 0.001 6Minute walk test 60.6 16.3 0.007 SF36 score Physical component 8.5 1.4 0.001 Mental component 7.7 1.6 0.03 > >> >> >> >
24 weeks Tai Chi Control p-value FIQ score 28.6 10.2 <0.001 Patient s global assessment score Physician s global assessment score 2.4 0.7 0.001 0.5 0.6 0.02 PSQI score 4.2 1.2 0.007 6Minute walk test 49.8 23.2 0.12 SF36 score >>> Physical component 8.4 1.5 0.001 Mental component 8.5 1.2 0.009 >> > >> = >> >>
Conclusion: Tai chi may be a useful treatment for fibromyalgia and merits long-term study in larger study populations
Effects of Herbal Medicine on Pain Management
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): 825-36. 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). 2008 ;(2):CD005288. 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.
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