Hovedpine og akupunktur
Hovedpine er et stort problem, men heldigvis respondere mange patienter på akupunktur. har vi videnskabeligt belæg for anvendelse af akupunktur ved hovedpine?
Problemet bliver belyst i to undersøgelser, netop offentliggjort i British Medical Journal.
Cost effectiveness analysis of a randomised trial of acupuncture for chronic headache in primary care
David Wonderling, lecturer in health economicsAndrew J Vickers, assistant attending research methodologistRichard Grieve, lecturer in health economicsRob McCarney, research officer
BMJ. 2004; 328: 747
Objective To evaluate the cost effectiveness of acupuncture in the management of chronic headache.
Design Cost effectiveness analysis of a randomised controlled trial.
Setting General practices in England and Wales.
Participants 401 patients with chronic headache, predominantly migraine.
Interventions Patients were randomly allocated to receive up to 12 acupuncture treatments over three months from appropriately trained physiotherapists, or to usual care alone.
Main outcome measure Incremental cost per quality adjusted life year (QALY) gained.
Results Total costs during the one year period of the study were on average higher for the acupuncture group (£403; $768; {euro}598) than for controls (£217) because of the acupuncture practitioners' costs. The mean health gain from acupuncture during the one year of the trial was 0.021 quality adjusted life years (QALYs), leading to a base case estimate of £9180 per QALY gained. This result was robust to sensitivity analysis. Cost per QALY dropped substantially when the analysis incorporated likely QALY differences for the years after the trial.
Conclusions Acupuncture for chronic headache improves health related quality of life at a small additional cost; it is relatively cost effective compared with a number of other interventions provided by the NHS.
Acupuncture for chronic headache in primary care: large, pragmatic, randomised trial
Andrew J Vickers, assistant attending research methodologist Rebecca W Rees, research officer Catherine E Zollman, general practitionerRob McCarney, research officerClaire M Smith, senior trials coordinatorNadia Ellis, lecturerPeter Fisher, director of researchRobbert Van Haselen, deputy director of research BMJ. 2004; 328: 744
Objective To determine the effects of a policy of "use acupuncture" on headache, health status, days off sick, and use of resources in patients with chronic headache compared with a policy of "avoid acupuncture."
Design Randomised, controlled trial.
Setting General practices in England and Wales.
Participants 401 patients with chronic headache, predominantly migraine.
Interventions Patients were randomly allocated to receive up to 12 acupuncture treatments over three months or to a control intervention offering usual care.
Main outcome measures Headache score, SF-36 health status, and use of medication were assessed at baseline, three, and 12 months. Use of resources was assessed every three months.
Results Headache score at 12 months, the primary end point, was lower in the acupuncture group (16.2, SD 13.7, n = 161, 34% reduction from baseline) than in controls (22.3, SD 17.0, n = 140, 16% reduction from baseline). The adjusted difference between means is 4.6 (95% confidence interval 2.2 to 7.0; P = 0.0002). This result is robust to sensitivity analysis incorporating imputation for missing data. Patients in the acupuncture group experienced the equivalent of 22 fewer days of headache per year (8 to 38). SF-36 data favoured acupuncture, although differences reached significance only for physical role functioning, energy, and change in health. Compared with controls, patients randomised to acupuncture used 15% less medication (P = 0.02), made 25% fewer visits to general practitioners (P = 0.10), and took 15% fewer days off sick (P = 0.2).
Conclusions Acupuncture leads to persisting, clinically relevant benefits for primary care patients with chronic headache, particularly migraine. Expansion of NHS acupuncture services should be considered.
Hvordan søger man på Medline
Vi kender alle problemet, vi sidder med en patient med en sjælden sygdom og vil gerne vide mere herom. Medicinsk Kompendium har efterhånden nogle år på bagen, så hvad gør man så? Man søger på Medline, og det er slet ikke så svært.
Jeg vil ikke forsøge at give anvisning på avancerede søgning, men kun på en helt basal søgning.
Der er mange måder at starte søgningen på. Man kan enten gå ind på Ugeskrift for Lægers hjemmeside og klikke på Links. Der kommer så en række links, herunder pub med, som man klikker på, og s¨å er man inde på siden. Man kan også anvende google og blot skrive pubmed. Der kommer nu en hel række matching sites. Man vælger den øverste Entrez Pubmed, og klikker på den, så er man inde på siden.
Øverst er der en tom rubrik, hvor man skriver sine søgeord. Hvis vi fx vil søge på akupunktur og tennis albue, skriver vi acupuncture and tennis elbow og klikker på go.
Vi kan nu se, at der er 34 artikler, der matcher denne søgning, heraf er de første 20 på side 1 og de resterende 14 på side 2.
I margenen på denne oversigtsside ser man nogle firkantede kasser. Hvis kassen er tom betyder det, at der ikke er noget abstrakt. Hvis der er nogle streger betyder det, at der er et abstrakt. Hvis der er flere sider, der ligger oven på hinanden betyder det, at hele artiklen kan læses og udskrives direkte. Imidlertid er det ikke alle sider der er gratis.
Hvis man vil læse abstraktet eller hele artiklen klikker man på den firkantede kasse, så kommer abstraktet op på skærmen.
Naturligvis kan man indstille søgningen til at være begrænset til kun at indeholde artikler på engelsk, kun at indeholde randomiserede kontrollerede undersøgelser, etc., men det er ikke hensigten med denne lille vejledning.
God læselyst
Udvalgte abstrakts fra Medline
Tennisalbue - opdatering 1-7-2004
Rehabilitation for patients with lateral epicondylitis: a systematic review.
Trudel D, Duley J, Zastrow I, Kerr EW, Davidson R, MacDermid JC.
J Hand Ther. 2004 Apr-Jun;17(2):243-66.
The purpose of this systematic review was to determine the effectiveness of conservative treatments for lateral epicondylitis and to provide recommendations based on this evidence. Five reviewers searched computerized bibliographic databases for articles on the conservative treatment of lateral epicondylitis from the years 1983 to 2003. A total of 209 studies were located; however, only 31 of these met the study inclusion criteria. Each of the articles was randomly allocated to reviewers and critically appraised using a structured critical appraisal tool with 23 items. Treatment recommendations were based on this rating and Sackett's Level of Evidence. This review has determined, with at least level 2b evidence, that a number of treatments, including acupuncture, exercise therapy, manipulations and mobilizations, ultrasound, phonophoresis, Rebox, and ionization with diclofenac all show positive effects in the reduction of pain or improvement in function for patients with lateral epicondylitis. There is also at least level 2b evidence showing laser therapy and pulsed electromagnetic field therapy to be ineffective in the management of this condition. Practitioners should use the treatment techniques that have strongest evidence and ensure that studies findings are generalized to patients who are similar to those reported in primary research studies in terms of patient demographics and injury presentation.
Comparison of the effectiveness between manual acupuncture and electro-acupuncture on patients with tennis elbow.
Tsui P, Leung MC.
Acupunct Electrother Res. 2002;27(2):107-17.
This is a single-blinded randomized controlled trial to compare the relative effectiveness between manual acupuncture (MA) and electro-acupuncture (EA) on the patients with chronic tennis elbow. Twenty patients recruited in the study were first introduced into control group for 2 weeks waiting period. Then, they were randomly assigned into either MA or EA group for acupuncture treatment. The acupuncture points of GB34 and ST38 were used in both treatment groups. In the MA group, the needle was retained for 20 minutes after the Deqi sensation obtained. In the EA group, electrical stimulation with 4 pulses/second frequency was applied and treatment lasted for 20 minutes. After 6 treatments within 2 weeks duration, significant differences were observed between groups favoring the electro-acupuncture in relation to pain relief (Pain visual analogue scale) and pain free hand grip strength (PFG). This study showed that electro-acupuncture is superior to manual acupuncture in treating patients with tennis elbow.
Acupuncture for tennis elbow: an E-mail consensus study to define a standardised treatment in a GPs' surgery.
Webster-Harrison P, White A, Rae J.
Acupunct Med. 2002 Dec;20(4):181-5.
Acupuncture is a possible alternative treatment for tennis elbow in general practice. Rigorous investigation of its effectiveness is needed by means of a randomised controlled trial. Before undertaking a trial, a consensus is required on the best treatment protocol. Therefore, a modified Delphi Process was undertaken by e-mail, consisting in three iterative rounds. Fourteen acupuncture trainers initially reported details of their normal treatment that were then incorporated into a treatment plan. This was circulated once for further suggestions and finally for agreement. Consensus was achieved from all 14 participants who responded to the third round.
Interventions in chronic pain management. 3. New frontiers in pain management: complementary techniques.
Braverman DL, Ericken JJ, Shah RV, Franklin DJ.
Arch Phys Med Rehabil. 2003 Mar;84(3 Suppl 1):S45-9.
This self-directed learning module highlights complementary and alternative therapies that are often used by patients seen in the typical physiatric practice. This article contains information on acupuncture and its use to treat low back pain, recent therapeutic approaches to lateral epicondylitis, movement therapies appropriate for the osteoporotic patient, and spa therapies. Scientific literature and standards of clinical practice in these areas have been reviewed to put forth the most recent recommendations regarding these diagnoses and therapeutic interventions. OVERALL ARTICLE OBJECTIVES: (a) To familiarize the physiatrist with complementary techniques that are increasingly popular in the United States and (b) to identify when therapies, such as acupuncture, movement therapies, bodywork, and the like, may be integrated into a comprehensive treatment approach for common physiatric clinical scenarios.
Rehabilitation for patients with lateral epicondylitis: A systematic review.
Trudel D, Duley J, Zastrow I, Kerr EW, Davidson R, Macdermid JC.
1: J Hand Ther. 2004 Apr-Jun;17(2):243-66.
Canadian Forces Base Kingston, Ontario, Canada.
The purpose of this systematic review was to determine the effectiveness of conservative treatments for lateral epicondylitis and to provide recommendations based on this evidence. Five reviewers searched computerized bibliographic databases for articles on the conservative treatment of lateral epicondylitis from the years 1983 to 2003. A total of 209 studies were located; however, only 31 of these met the study inclusion criteria. Each of the articles was randomly allocated to reviewers and critically appraised using a structured critical appraisal tool with 23 items. Treatment recommendations were based on this rating and Sackett's Level of Evidence. This review has determined, with at least level 2b evidence, that a number of treatments, including acupuncture, exercise therapy, manipulations and mobilizations, ultrasound, phonophoresis, Rebox, and ionization with diclofenac all show positive effects in the reduction of pain or improvement in function for patients with lateral epicondylitis. There is also at least level 2b evidence showing laser therapy and pulsed electromagnetic field therapy to be ineffective in the management of this condition. Practitioners should use the treatment techniques that have strongest evidence and ensure that studies findings are generalized to patients who are similar to those reported in primary research studies in terms of patient demographics and injury presentation.
Anti-inflammatory actions of acupuncture.
Zijlstra FJ, van den Berg-de Lange I, Huygen FJ, Klein J.
Mediators Inflamm. 2003 Apr;12(2):59-69.
Acupuncture has a beneficial effect when treating many diseases and painful conditions, and therefore is thought to be useful as a complementary therapy or to replace generally accepted pharmacological intervention. The attributive effect of acupuncture has been investigated in inflammatory diseases, including asthma, rhinitis, inflammatory bowel disease, rheumatoid arthritis, epicondylitis, complex regional pain syndrome type 1 and vasculitis. Large randomised trials demonstrating the immediate and sustained effect of acupuncture are missing. Mechanisms underlying the ascribed immunosuppressive actions of acupuncture are reviewed in this communication. The acupuncture-controlled release of neuropeptides from nerve endings and subsequent vasodilative and anti-inflammatory effects through calcitonine gene-related peptide is hypothesised. The complex interactions with substance P, the analgesic contribution of beta-endorphin and the balance between cell-specific pro-inflammatory and anti-inflammatory cytokines tumour necrosis factor-alpha and interleukin-10 are discussed.
Akupunktur og tennisalbue - en audit
I akupunkturnyt maj 2004 gjorde vi rede for de forskellige videnskabelige undersøgelser man kan lave. Ligeledes blev vor nuværende viden om akupunkturs anvendelse ved behandling af tennisalbue fremlagt.
Cochrane analysen konkluderede: " Akupunktur har en kortvarig effekt på tennisalbue, men der hersker uklarhed om en eventuel langtidseffekt"
Vi kører for tiden en audit om anvendelsen af akupunktur ved behandling af tennisalbue, men der er lang vej endnu, før vi har de ønskede 100 rapporter.
At lave en sådan audit som enkeltperson er næsten umulig, men hvis vi løfter i flok, bliver det hurtigt til noget, så fat computeren og send mig en mail på Prosted@aol.com , og du får tilsendt en diskette med det relevante registreringsskema.
Vi er vidende om, at en deltagelse i en sådan audit tager lidt ekstra tid, men vi beder dig ikke om at lave 20 registreringer. Hvis I alle laver 2-3 registreringer, når vi hurtigt det magiske tal på 100.
Med denne viden er vi klar til næste trin på raketten, den randomiserede kontrollerede undersøgelse, som vi håber kan løbe af stablen i slutningen af 2004.
Hvis akupunktur skal anerkendes som en ligeværdig medicinsk specialitet, er det os der må skaffe beviset for dens berettigelse - så kære kollega, lad os smøge ærmerne op og komme i gang - send mig en mail allerede i dag og du er med i undersøgelsen.
Palle Rosted
