Akupunktur en spydspiss for forskning og aksept innen KAM

Transkript

1 Akupunktur en spydspiss for forskning og aksept innen KAM Terje Alræk PhD Akupunktør, Forsker Faglig ansvarlig for Norge-Kina samarbeidet innen TCM NAFKAM, Universitetet i Tromsø

2 TCM Chinese herbal medicine minerals animal products Acupuncture many different styles Tuina, Tai qi, Qi gong Lifestyle advice according to TCM theory Slide no. 2

3 Omfanget av TCM i Kina 2526 sykehus viet TCM alene (3.8%) sengeplasser ansatte (medical workers) 95% av VM sykehus har TCM avdelinger TCM sykehusene behandlet 200 mill pasienter (poliklinisk 1994) 2,5 mill inneliggende Slide no. 3

4 Omfanget av TCM i Kina TCM leger VM leger Leger som behersker begge deler (tall fra 1994) Slide no. 4

5 Bruk av aku i Norge 1997 Totalt 1/3 av befolkningen har brukt KAM 31% prøvd aku (Aarbakke) % av bef. Har brukt KAM forrige år, 9% aku (Opinion A/S) 2003 KAM brukt ved 28 norske sykehus, 19 tilbød aku (Salomonsen et al.) ,7% av leger praktiserer aku ,8 av legene henviser til aku The importance of reliability and validity in the evaluation of traditional Chinese medicine Terje Alræk, Slide no. 16 Slide no. 5

6 Bruk av aku i Norge II Akupunktur er den KAM behandlingsform flest leger er blitt behandlet med, praktiserer selv, henviser til eller samarbeider med. NOU 1998;2:punkt The importance of reliability and validity in the evaluation of traditional Chinese medicine Terje Alræk, Slide no. 16 Slide no. 6

7 Adverse events from acupuncture Norheim AJ. Komplikasjoner ved akupunkturbehandling Litteraturstudie for årene Tidsskr Nor Laegefor 1994;114: Norheim AJ. Adverse effects of acupuncture: a study of the literature for the years J Altern Complement Med 1996;2: Slide no. 7

8 Adverse events from acupuncture Incidence of minor side effects 14 out of treatments (White et al., 2001) Comparable results from treatments given by TCM acupuncturists (MacPherson et al,. 2001) Among patients treated by acupuncture, 6936 (7.10%) reported minor adverse effects (Melchart et al., 2004) Acupuncture is a safe form of treatment in the hands of well-qualified therapists Slide no. 8

9 Adverse events from acupuncture Traumatic complications pneumotorax cardiac tamponade infections fainting and convulsions Slide no. 9

10 Ways to evaluate TCM Systematic reviews/meta analysis RCT Qualitative research Observational designs Anecdotal Slide no. 10

11 The Princess effect! Her Royal Highness Märtha Louise warmly recommend women to use acupuncture during the birth process. Slide no. 11

12 The Norwegian Minister of Health receiving acupuncture treatment in China Slide no. 12

13 Anecdotal evidence 1,3 billion Chinese can t be wrong? Stories from individuals with similar illnesses who have used the treatment. Slide no. 13

14 RCTs Siden 1970 (fram til 2002) ca 500 RCTs Halvparten placebo kontrolerte Pragmatiske studier som sammenligner akupunktur med konvensjonell behandling eller akupunktur i tilegg til konvensjonell behandling mot standard annerkjent behandling Slide no. 14

15 RCTs Kina ca RCTs????? Slide no. 15

16 Systematic reviews Akupunktur mot kvalme + Akupunktur mot tannsmerter + Fibromyalgi, hodepine, slitasjegikt,astma, kroniske lave ryggsmerter Akupunktur mot div. Rusavhengighet Akupunktur mot tinnitus Slide no. 16

17 An empty and happy feeling in the bladder Qualitative study Explored experienced health changes in cystitisprone females Reported on an open-ended free text questionnaire In all 46 women reported back 7 reported no change at all Material consists of 39 free text assesments Slide no. 17

18 An empty and happy feeling in the bladder The following conceptual categories were found: Better pressure during voiding, and more complete emptying of the bladder I felt a happiness and emptiness as if there was no more pressure from the bladder. Slide no. 18

19 An empty and happy feeling in the bladder The following conceptual categories were found: More energy, reduced stress level and better sleep I felt I had more energy, wanted to do more, and my body is more relaxed. Slide no. 19

20 Model Validity Assesses the likelihood that the research has adequately addressed the unique theory and therapeutic context of the CAM system in question. Slide no. 20

21 Validitet via brobygging (?) Model validity: TCM versus western medicine Different, incompatible models TCM models: no known pathophysiological correlate How to validate, an example Slide no. 21

22 A TCM model by recurrent cystitis Emotional disturbances Damp Heat in Urinary Bladder Liver Fire Heart Fire Stagnation of Liver Qi Kidney XU Qi,Yin,Yang Stagnation of Damp Kidney Yin XU Kidney Qi XU Deficient San Jiao Spleen Yang XU Kidney Yang XU Impaired Jin Ye circulation Lung Qi XU External Damp and Cold Slide no. 22

23 Sentralt i tradisjonell kinesisk medisin er å se sammenhenger mellom alle tegn og symptomer som pasienten presenterer. Målet er å se et mønster i de symptomene pasienten viser og de tegn legen observerer bl.a. via tunge og puls. The importance of reliability and validity in the evaluation of traditional Chinese medicine Terje Alræk, Slide no. 16 Slide no. 23

24 Recurrent cystitis - a medical model Anxiety Adrenergic tension Parasympath. inhibition Tension in pelvic muscles + inner sphincter -detrusor Voluntary deferred voiding Functional residual urine Cystitis Slide no. 24

25 STRICTA STandards for Reporting Interventions in Contolled Trials of Acupuncture H. MacPherson, A. White, M. Cummings, K. Jobst, K. Rose, R. Niemtzow Complement Ther Med 2001;9: Slide no. 25

26 STRICTA Acupuncture rationale Style of acupuncture Rationale for treatment syndrome patterns segmental levels trigger points individualisation if used Literature sources to justify rationale Slide no. 26

27 STRICTA continued Treatment regimen Number of treatment sessions Frequency of treatment Needling details Co-interventions Slide no. 27

28 STRICTA continued Practitioner background Duration of relevant training Length of clinical experience Expertise in specific condition Slide no. 28

29 STRICTA continued Control intervention(s) Intended effect of control intervention and its appropriateness to research question and, if appropriate, blinding of participants active comparison minimally active penetrating or nonpenetrating sham inert Slide no. 29

30 Evidence from lab science Measurable (valid) and replicable (reliable) physiological effects of acupuncture endorphins and enkephalins stress hormones rabbit and cerebrospinal fluid functional magnetic resonance imaging (fmri) this list could continue and continue Slide no. 30

31 Moderne forståelse av akupunktur Akupunkturanalgesi blokkeres av nalaxone Humoral (væskebasert)-overføring av analgesi via cerebrospinal væske Nevro-kjemisk fysiologi endogene opioider The importance of reliability and validity in the evaluation of traditional Chinese medicine Terje Alræk, Slide no. 16 Slide no. 31

32 Moderne forståelse av akupunktur Akupunktur analgesi settes igang ved stimulering av tynne nerver i muskler som sender impulser til ryggmargen. Så blir 3 nerve senter (ryggmarg, midthjerne og hypofyse) aktivert til å frigjøre transmitter substanser som blokkerer smerte impulser. The importance of reliability and validity in the evaluation of traditional Chinese medicine Terje Alræk, Slide no. 16 Slide no. 32

33 Moderne forståelse av akupunktur Den nevrologiske forskningen på akupunktur bidrar signifikant til den vitenskapelige forståelsen av utøvelsen av akupunktur men er forløpig til liten nytte i klinisk hverdag. The importance of reliability and validity in the evaluation of traditional Chinese medicine Terje Alræk, Slide no. 16 Slide no. 33

34 Viktig å ta hensyn til The biomedical need to standardize treatments creates an uncertainty about whether we are studying acupuncture appropriately Slide no. 34

35 Viktig å ta hensyn til The variability in acupuncture styles creates ambiguity about whether we are studying the right style Slide no. 35

36 Vi (aku forskere?) er klar over Respons på Aku behandling kan være kompleks og multifaktoriel Nature of the disease Attitude to acupuncture The points needed Manipulation of needles Patient s prior experience with acupuncture Expectations and beliefs Slide no. 36

37 Overall conclusion THERE IS MORE TO TCM ACUPUNCTURE THAN A WEEKEND COURSE! Slide no. 37