Summer Newsletter - August 2009


Enhancing Research Education in Acupuncture Schools: The Oregon College of Oriental Medicine (OCOM) was among the first CAM colleges awarded an NCCAM 4-year grant to enhance research education in their curricula. OCOM’s initiative, "Acupuncture Practitioner Research Education Enhancement" (APREE), will end this fall with a dissemination workshop to the Council of Colleges of Acupuncture and Oriental Medicine. This workshop will highlight APREE’s successes and lessons learned. The major goal of APREE has been to impact the culture of OCOM such that research literacy, an evidence-informed perspective, and the ability to participate in research become increasingly accepted as necessary and desirable skill sets for contemporary practitioners of acupuncture and Oriental medicine (AOM).

The NIH/National Center for Complementary and Alternative Medicine (NCCAM) perspective that research is a bridge between CAM and conventional medicine has led to an expansion of the Center’s traditional roles of funding research and training of researchers. NCCAM is also currently funding CAM colleges to enhance research education in their curricula (Kreitzer & Sierpina, 2008). These R25 research education grants -- designed as partnerships between CAM and biomedical institutions -- are aimed at strengthening an evidence-informed practice model for the broad base of future CAM providers.

An early accomplishment of the Acupuncture Practitioner Research Education Enhancement (APREE) at OCOM grant was the creation of a set of 9 research literate practitioner competencies, which have served to guide curriculum development and evaluation of student learning (Lasater et al, 2009). As we began to introduce research appreciation into the curriculum we recognized that faculty training was essential to support development of information access and research evaluation skills, as well as research-related content for non-research courses. APREE’s central approach to faculty development was a seminar-style Research Scholars Program in which selected faculty formed a learning community with research and pedagogy experts (Hammerschlag et al, 2008). As a final project, each Research Scholar created a learning activity to introduce a research perspective into their Chinese medicine or biomedicine course syllabus (Lasater et al, 2009).

Building a research culture at the college has also included creation of a Research Grand Rounds, in which invited CAM researchers present the challenges of designing and implementing research projects, a student-initiated Research Club and a Student Research Conference, at which the top-selected student research practicum projects are presented.

A key lesson learned from APREE is that introducing a research perspective was most successful when presented as one of several types of evidence to be considered (including clinical experience, classic and modern texts and patient preferences) in the clinical decision making process. We also found that piquing student interest in research leads to the need to develop means of responding to student requests to participate in research projects.

As research literacy begins to be integrated into AOM curricula, an increasing number of practitioners are learning the language and issues of research, beginning to participate in the design of research studies and becoming interested in attending and contributing to conferences of the Society for Acupuncture Research. For additional experiences of how research appreciation and content have been introduced into an AOM college curriculum, see the NCCAM U19-grant funded programs developed at the New England School of Acupuncture (Wayne et al, 2008a,b).

Hammerschlag R, Lasater K, Salanti S, Fleishman S (2008) Research scholars program: A faculty development initiative at the Oregon College of Oriental  Medicine. J Altern Complement Med 14(4):437-443.

Kreitzer MJ, Sierpina VS (2008) NCCAM awards grants to CAM institutions to enhance research education. Explore 4(1):74-76.

Lasater K, Salanti S, Fleishman S, Coletto J, Jin H, Lore R, Hammerschlag R (2009) Learning activities to enhance research literacy in a CAM college curriculum. Altern Ther Health Med 15(4):46-54.

Wayne PM, Pensack LY, Connors EM, Buring JE, Davis, RB, Schachter SC, Hrbek A, Kaptchuk TJ, Andrews, SM (2008a) Increasing research capacity at the New England School of Acupuncture: Building grants management infrastructure. Altern Ther Health Med 14(1):56-64.

Wayne PM, Buring JE, Davis RB, Andrews SM, St. John M, Conboy L, Kerr CE, Kaptchuk TJ, Schachter SC (2008b) Increasing research capacity at the New England School of Acupuncture through faculty and student research training initiatives. Altern Ther Health Med 14(2):52-58.

Acupuncture Clinical Trials Highlights: In a recent trial published in the Archives of Internal Medicine 169(9), 858 May 2009, "A randomized trial comparing acupuncture, simulated acupuncture, and usual care for chronic low back pain"1 Dan Cherkin and colleagues compared acupuncture, simulated acupuncture, and usual care for chronic low back pain to explore three important questions in relation to this common condition:  1) Is acupuncture more effective than usual medical care alone; 2) is real acupuncture is more effective than simulated (noninsertive) acupuncture; and 3) is individualized acupuncture more effective than standardized acupuncture.

Participants (n=638) diagnosed with chronic low back pain (cLBP), were randomized to one of four groups: individualized acupuncture, standardized acupuncture (expert panel prescribed protocol), simulated acupuncture (standardized acupuncture points stimulated with a toothpick), or usual medical care. Participants received 8 treatments over 7 weeks and the primary outcomes, back-related dysfunction (Roland-Morris Disability Questionnaire) and symptom bothersomeness (0-10 scale), were assessed at 8, 26 and 52-weeks.

Results indicate that all three acupuncture treatments significantly outperformed usual care, with no differences between acupuncture groups. Based on the results the authors concluded: "For clinicians and patients seeking a relatively safe and effective treatment for a condition for which conventional treatments are often ineffective, various methods of acupuncture point stimulation appear to be reasonable options…" yet state "…for cLBP, tailoring needling sites to each patient and penetration of the skin appear unimportant in eliciting therapeutic benefits."

Looking at each of the 3 stated goals, some points are worth highlighting:

Aim 1 (Is acupuncture more effective than usual medical care alone?)

1) Yes, acupuncture is more effective than usual care alone for cLBP. Participants in the acupuncture groups not only demonstrated substantial benefits in dysfunction and symptoms but the effects were long-lasting at the 26 & 52-week follow-up visits.

2) A more relevant framework is to determine if acupuncture is at least as effective as usual medical care, but with less side effects and cost-savings.

a. In support of this, participant-reported use of medications for back pain was significantly reduced in the acupuncture groups as compared to usual care.

Aim 2 (Is real acupuncture more effective than simulated acupuncture?)

1) No, the effects therefore may be due to "non-specific" treatment effects.

a. The authors cite studies of "placebo-effects" tied to patient-practitioner interaction and the increased "placebo" effect with various sham interventions; e.g. larger effect with sham surgery vs. placebo pills.

i. As an aside, recent studies in biomedicine report the inability of vertebroplasty to outperform placebo for the treatment of back pain due to osteoporotic fractures.2, 3 It’s doubtful that these findings will lead to the cessation of vertebroplasty being recommended, in fact many commentaries are being published that call into question the validity of the results. The findings by Cherkin et al should be viewed in a similar light, resulting in further inquiry into the mechanisms of action for acupuncture.

2) An alternative explanation is that the set of acupoints deemed most important for the treatment of cLBP can be effectively stimulated without the insertion of acupuncture needles.

b. Cherkin et al appropriately refer to this intervention as simulated not sham acupuncture and cite the use of blunted needles as means of treatment dating back 2,000 years. Would the finding have been the same if the protocol called for acupressure at this set of acupoints?

i. An RCT comparing acupressure to physical therapy for the treatment of cLBP suggests the answer would be yes.4

Aim 3 (Is individualized acupuncture more effective than standardized acupuncture?)

1) No, it appears that the standardized set of acupoints developed for this trial is as effective as individualized acupuncture protocols for cLBP.

c. This finding may or may not translate to:

i. Other acupuncture point protocols for cLBP;

ii. Other chronic pain conditions;

iii. Conditions outside of the realm of chronic pain, e.g. depression.

The study by Cherkin et al raises important questions regarding the use of acupuncture for chronic low back pain in the clinical setting. As such, we echo the conclusions regarding the need for further study to determine the relative contributions of an acupuncture treatment. As a means of assessing theses contributions we suggest a focus on the effects of both specific & non-specific needling effects and specific & non-specific non-needling effects, as recently proposed by Dr. Helene Langevin (see diagram 1).


Reference List

  1. Cherkin DC, Sherman KJ, Avins AL et al. A randomized trial comparing acupuncture, simulated acupuncture, and usual care for chronic low back pain. Arch Intern Med 2009; 169(9):858-866.
  2. Buchbinder R, Osborne RH, Ebeling PR et al. A randomized trial of vertebroplasty for painful osteoporotic vertebral fractures. N Engl J Med 2009; 361(6):557-568.
  3. Kallmes DF, Comstock BA, Heagerty PJ et al. A randomized trial of vertebroplasty for osteoporotic spinal fractures. N Engl J Med 2009; 361(6):569-579.
  4. Hsieh LL, Kuo CH, Lee LH, Yen AM, Chien KL, Chen TH. Treatment of low back pain by acupressure and physical therapy: randomised controlled trial. BMJ 2006; 332(7543):696-700.

Insights into Acupuncture Mechanisms: A new study published in the journal Neuroimage 2009 Sep;47(3):1077-85. Epub 2009 Jun 6, examined whether Traditional Chinese acupuncture and placebo (sham) acupuncture exerted different effects on mu-opioid receptors (MORs).

It has been known for decades that acupuncture’s analgesic effects are mediated in part by the release of endogenous opioids1. This mechanism has been shown to be operative in placebo analgesia and has caused some critics to believe that acupuncture may be no different than a placebo. In a recent paper by Harris et al.2, this hypothesis was tested directly in chronic pain patients diagnosed with fibromyalgia. 20 patients underwent opioid positron emission tomography (PET), a neuroimaging technique that can provide specific information on the activation of opioid receptors. PET imaging was done prior to and following nine acupuncture or sham acupuncture treatments. Interestingly the authors find that although acupuncture and sham acupuncture elicited a similar amount of pain relief, their effects on opioid receptors were markedly different. Sham acupuncture evoked the release of endogenous opioids, a mechanism involved in the "placebo effect", whereas acupuncture increased the opioid receptor binding strength. Furthermore following acupuncture, patients with greater increases in receptor binding had greater reductions in pain. These data suggest that although the clinical effects of acupuncture and sham acupuncture may be similar, their underlying mechanisms are not.

  1. Stux, G., Hammerschlag, R. 2001. Clinical Acupuncture: scientific basis. New York: Springer.
  2. Harris RE, Zubieta JK, Scott DJ, Napadow V, Gracely RH, Clauw DJ. Traditional Chinese acupuncture and placebo (sham) acupuncture are differentiated by their effects on mu-opioid receptors (MORs). Neuroimage. 2009 Sep;47(3):1077-85. Epub 2009 Jun 6.

Moxibustion Research Highlights: An innovative study "Moxibustion for treating menopausal hot flashes: a randomized clinical trial" recently published in Menopause 2009 Jul-Aug:16(4):660-5, compared two types of moxibustion (14 sessions) to a wait list control in 51 women with menopausal hot flashes. The protocol was supported by evidence from clinical experts (Moxa 1) or published literature (Moxa 2). Statistically significant difference in severity (overall, P = 0.006; Moxa 1, P = 0.002; and Moxa 2, P = 0.0076) and frequency (Moxa 1, P < 0.0001; Moxa 2, P = 0.0017) of hot flashes was found between the treatment groups and the control after 4 weeks. In addition, there was a statistically significant difference in Menopausal-Specific Quality of Life Scale (MSQL) scores between treatment group Moxa 2 and the other groups (P = 0.0008). The study was conducted by Drs. Ji-Eun Park and Sun-Mi Choi, researchers in the Korea Institute of Oriental Medicine in collaboration Jongbae Park, SAR board member.

New Methodological Developments in Traditional Chinese Medicine Research was the theme of the Third Annual International Symposium on Evaluation of Clinical Trial Methodologies, Applications, Design, and Frontiers of Data Analysis. The Symposium was held in Beijing, China, June 25-28, 2009. SAR Border member, Dr. Lixing Lao, former SAR board member Dr. Karen Sherman, and NCCAM officer Dr. Laura Lee Johnson were among the invited keynote speakers. The symposium was made possible by a grant from NCCAM (R13AT005399); Dr. Xiao-Hua Andrew Zhou, Ph.D, from the University of Washington, School of Medicine served as PI and Dr. Lixing Lao, from the University of Maryland School of Medicine served as co-PI. Summaries of the presentations will be published in a special issue of the journal "Statistic in Medicine."

CAM Use and Costs, Results and Controversies of a New Survey: A new report based on data from the 2007 National Health Interview Survey, reveals that 38 percent of adults use some form of complemenrary and alternative medical treatment for health and wellness or to treat a variety of diseases and conditions1. http://nccam.nih.gov/news/2009/073009.htm

In this study CAM accounted for approximately 1.5 percent of total health care expenditures ($2.2 trillion²) and 11.2 percent of total out-of-pocket expenditures (conventional out-of-pocket: $286.6 billion² and CAM out-of-pocket: $33.9 billion¹) on health care in the United States. The most commonly used interventions included herbal supplements, meditation, chiropractic, and acupuncture with an estimated 3.1 million adults in the United States using acupuncture within the prior year-- a 47% increase from the 2002 NHIS estimate3.

The report, when compared to the Eisenberg, 1997 survey4 seems to indicate a significant reduction in visits to CAM practitioners. Is this really so? John Weeks from the Integrator Blog reanalyzed the data on his own and offers interesting commentary. The controversial report has spurred numerous commentaries from prominent people in the field. Check out the conversation and decide for yourself.

http://www.theintegratorblog.com

These findings raise important questions for the field of CAM. Is the practice of CAM decreasing in the US. Will we see greater or fewer numbers of patients turning to CAM therapies in the wake of the country’s recent recession? What is the major drive for patients to seek CAM? Is more cost effective, more efficacious, or both? See another recent blog addressing these and other questions:

http://blog.naturalstandard.com/natural_standard_blog/2009/08/americans-spend-billions-on-cam.html

  1. Nahin, RL, Barnes PM, Stussman BJ, and Bloom B. Costs of Complementary and Alternative Medicine (CAM) and Frequency of Visits to CAM Practitioners: United States, 2007. National health statistics reports; no 18. Hyattsville, MD: National Center for Health Statistics. 2009.
  2. Office of the Actuary, Centers for Medicare and Medicaid Services, National Health Expenditure Data for 2007. U.S. Department of Health and Human Services. Available at: www.cms.hhs.gov/NationalHealthExpendData/02_NationalHealthAccountsHistorical.asp#TopOfPage.
  3. Barnes PM, Bloom B, Nahin RL. Complementary and alternative medicine use among adults and children: United States, 2007. Natl Health Stat Report. Dec 10 2009(12):1-23.
  4. Eisenberg DM, Davis RB, Ettner SL, Appel S, Wilkey S, Van Rompay M, Kessler RC. Trends in alternative medicine use in the United States, 1990-1997: results of a follow-up national survey. JAMA. 1998 Nov 11;280(18):1569-75. follow-up national survey. JAMA. 1998 Nov 11;280(18):1569-75.

Acupuncture Translational Tools: The Acusensor, developed by Stromatec is a device designed to unobtrusively and objectively quantify the force and motion profile of an acupuncture needling interaction. Currently in the last stages of the engineering phase with funding from an SBIR NCCAM grant (R44AT002021), clinical evaluation will begin this fall to assess the device’s ability to quantify differences between styles (e.g. TCM vs. Japanese) and types (e.g. tonifying vs. sedating) of needling techniques.Stromatec is an exciting medical research and development new company focusing on innovative sensor and diagnostic technologies for the CAM health care market owned by SAR board members Robert Davis and Helene Langevin.

 

Information and links were accurate at the time the newsletter was published.

 


 
 
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