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Complementary and Alternative Medicine CAM

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					 Acupuncture for
  low back pain


     Hugh MacPherson
   Senior Research Fellow
Department of Health Sciences
     hm18@york.ac.uk
                                1
Numbers of practitioners
   50,000 Complementary & Alternative (CAM)
   practitioners*

   10,000 acupuncture practitioners - approx
     2500 doctors (BMAS)
     2500 physios (AACP)
     2500 acupuncturists (BAcC)
     2500 Chinese shop practitioners
       (unregulated)
*House of Lords Report
DEPARTMENT OF HEALTH SCIENCES
Effectiveness gaps in primary care

    Based on survey* of GP perceptions (n=78)
      Musculoskeletal           95%
      Depression                45%
      Eczema                    36%
      Chronic pain              32%
      Irritable bowel           32%

*Fisher 2004

DEPARTMENT OF HEALTH SCIENCES
Why use the randomised controlled trial
(RCT) for evidence of effectiveness?

    Key reasons are:

      Control for natural history of the disease
      (people tend to recover anyway)

      Attribute change to intervention
      (minimise bias)

DEPARTMENT OF HEALTH SCIENCES
Comparing pragmatic and explanatory RCT

       Explanatory RCT                 Pragmatic RCT
    experimental                   routine
    efficacy                       effectiveness
    acute conditions               chronic conditions
    placebo controlled             real world comparison
    standardised Tr                individualised Tr
    high internal validity         high external validity


   DEPARTMENT OF HEALTH SCIENCES
 Acupuncture versus sham acupuncture
              short-term (<6 weeks outcome)




                                              6

Source: Manheimer et al Ann In Med 2005
    Acupuncture versus no treatment
             short-term (<6 weeks outcome)




Source: Manheimer et alSAnn In Med 2005
  DEPARTMENT OF HEALTH CIENCES
    Acupuncture versus no treatment
              long-term (>6 weeks outcome)




Source: Manheimer et alSAnn In Med 2005
  DEPARTMENT OF HEALTH CIENCES
              Overall improvement




Source: Manheimer et al Ann In Med 2005

    DEPARTMENT OF HEALTH SCIENCES
GERAC randomised controlled trials
           LBP                              OA Knee




                                  Scharf et al, Ann Int Med 2006
  DEPARTMENT OF HEALTH SCIENCES
sham intervention vs. no treatment




              Hrobjartsson A, Götzsche P. Cochrane Library 2006
                ART Mig: Linde K. et al. JAMA 2005;293:2118
 DEPARTMENT OF HEALTH SCIENCES D et al. BMJ 2005;331:376
                ART TTH: Melchart
            ART LBP: Brinkhaus et al. Arch Intern Med 2006;166:450
                  ART OAK: Witt et al. Lancet 2005;366:136
            The UK perspective

Health Technology Assessment’s call
 for proposals – 1997:

 “Does acupuncture have long term
  effectiveness in the management of
         pain in primary care? ”


DEPARTMENT OF HEALTH SCIENCES
We set out to test the hypothesis
that….

…. primary care patients in the UK with
persistent low back pain, when referred for
up to 10 acupuncture sessions, gain more
relief from pain than those offered usual
management only, for equal or less cost.



DEPARTMENT OF HEALTH SCIENCES
Inclusion/exclusion

  INCLUSION: Patients aged 20 to 65
  with current episode at least 4 weeks
  duration

  EXCLUSION: A current episode of
  back pain of more than 12 months
  duration, possible serious spinal
  pathology
DEPARTMENT OF HEALTH SCIENCES
DEPARTMENT OF HEALTH SCIENCES
            Baseline demographics
                            Acupuncture   Control
                              (n=159)     (n=80)

Age ( mean years)               42          44
Female                          62%        58%
Full-time work                  52%        56%




DEPARTMENT OF HEALTH SCIENCES
            Baseline demographics
                            Acupuncture   Control
                              (n=159)     (n=80)

Age ( mean years)                42         44
Female                           62%       58%
Full-time work                   52%       56%


Unable to work due                7%        0%
to LBP                          (n=11)     (n=0)


DEPARTMENT OF HEALTH SCIENCES
      Acupuncture treatments provided

  Average 8 treatments per patient,
  usually weekly
      Average 10 needles per treatment
      Individualised point selection
      Auxiliary techniques and advice




DEPARTMENT OF HEALTH SCIENCES
Underlying principles of
acupuncture


  Diagnosis of imbalance
  Catalyst for change
  Leads to self-healing
  Goal of longer-term impact




DEPARTMENT OF HEALTH SCIENCES
Treatments received during 3 three months




 DEPARTMENT OF HEALTH SCIENCES
SF-36 Bodily Pain score at 3 months:
adjusted for baseline



                    Diff = 5 pts
                     P = 0.129




DEPARTMENT OF HEALTH SCIENCES
SF-36 Bodily Pain score at 12 months:
adjusted for baseline

                                Diff = 6 pts
                                 P = 0.111




DEPARTMENT OF HEALTH SCIENCES
SF-36 Bodily Pain score at 24 months:
adjusted for baseline

                                      Diff = 8 pts
                                       P = 0.003




      Source: Thomas et al BMJ 2006

DEPARTMENT OF HEALTH SCIENCES
          Practitioner approach
          (based on interviews)


     a complex intervention
     individualised care
     new understandings
     actively involving patients
     a long term approach

DEPARTMENT OF HEALTH SCIENCES
At randomisation:
“Do you believe that acupuncture can
help your low back pain?”

                                SF-36 Bodily Pain at 24 months
                                    (adjusted for baseline)


                         N      Acupuncture       Usual care

      “Yes”             127         66

“Don’t know”/ “No”       55         71




DEPARTMENT OF HEALTH SCIENCES
At randomisation:
“Do you believe that acupuncture can help
your low back pain?”

                                 SF-36 Bodily Pain at 24 months
                                     (adjusted for baseline)


                         N       Acupuncture       Usual care


       “Yes”             127         66                 63


“Don’t know”/ “No”       55          71                 53



 DEPARTMENT OF HEALTH SCIENCES
     Worry about back pain at 24 months
          (compared to baseline)




               Diff. between groups P<0.001
DEPARTMENT OF HEALTH SCIENCES
       Heterogeneity of acupuncturists




DEPARTMENT OF HEALTH SCIENCES
           NHS and total social costs
               (mean cost/patient at 24 months)
                           Acupuncture        Comparison
                              group             group


  Total NHS                    £425              £282
  costs                   (£215 for initial
                           acupuncture)
  Total social                   £1465          £1604
  costs



  Estimated cost per QALY gained = £4,241
  Source: Ratcliffe EALTH SCIENCES
DEPARTMENT OF Het al BMJ 2006
                  Conclusions

 The evidence suggests that acupuncture is
  effective for low back pain
 In primary care in the UK, a short course of
   individualised acupuncture confers clinical
   and cost benefits at 24 months
 The evidence supports appropriate
  commissioning of acupuncture for low back
  pain in primary care

DEPARTMENT OF HEALTH SCIENCES
Acknowledgements re back pain trial


 NCCHTA                         Research Team
                                 Kate Thomas (PI)
 Patients
                                     Lucy Thorpe
 Acupuncturists                      Mark Roman
                                    Julie Ratcliffe
 Patient representative               John Brazier
 David Laverick                        Mike Fitter
                                  Mike Campbell
                                    Ann Morgan
 Advisory Board
                                       Liz Oswald
 Trevor Sheldon (chair)
                                 Helen Wilkinson
 Sally BellSyer
                                       Jon Nicholl
DEPARTMENT OF HEALTH SCIENCES

				
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