An Evaluation Of Acupuncture Treatment In A Podiatry Clinic

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An Evaluation Of Acupuncture Treatment In A
Podiatry Clinic

• A dissertation submitted for the award of MSc in
  Clinical Practice For Healthcare Practitioners
  University of Salford 2003
• Ramzana Anwar MSc DPodM SRCh

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Aim

• to evaluate the effectiveness and benefits of
  podiatric-acupuncture treatment for a variety of
  medical conditions that cause chronic lower limb
  pain that presented in a podiatry clinic

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Objective

• To evaluate if acupuncture as a pain management
  tool is an effective adjunctive treatment for
  podiatry
• Very little research currently in podiatry (Price
  2001, BJP)

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Background

• Complimentary medicine is increasingly popular
  for treating many conditions.
• Acupuncture is the most popular complimentary
  therapy and has been subjected to more research
  than any other complimentary therapy (Mason et
  al, 2002 BMJ Vol 235)

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Background continued.

• 3 leading audits Thomas M 1997 Handy J 1998 and
  Stellon AJ 2001 in primary care have shown that
  acupuncture treatment is effective for a variety
  of conditions , and appears cost effective by not
  only reducing prescribing but also referrals to
  secondary care.
• More NHS trusts are looking to see whether
  acupuncture should be funded in primary care not
  only because of its possible clinical and cost
  effectiveness but also to satisfy patients
  request for this type of treatment. (House of
  Lords Select Committee Comp Med 2000)

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My involvement

• Multidisciplinary team working in a GP fund
  holding practice initiated my interest. There was
  a demand from GP to offer some form of pain
  management for numerous referrals of patients
  with chronic lower limb pain.
• Sent on a appropriate acupuncture course aimed at
  Doctors and Allied health professionals in 1998

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Validation

• Society Of Chiropodists and Podiatrists now have
  several validated courses on Acupuncture
  treatment and we are insured to practice
  acupuncture as an adjunctive therapy if you
  undertake a validated course.
• (www.scpod.org)

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Chinese Approach Historical background

• Acupuncture is stimulation of special points in
  the body usually by inserting fine
  needles.Originating in the Far East 2000 years
  ago. Original form based on principals of
  traditional Chinese Medicine, on the Daoist
  concept of yin and yang. Illness s seen in terms
  of excesses or deficiencies in various exogenous
  and endogenous pathogenic factors, and treatment
  is aimed at restoring balance.

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Western Approach Historical background

• Western Acupuncture concept acupuncture points
  correspond to physiological and anatomical
  features such as peripheral nerve junctions and
  diagnosis is made on purely conventional terms.
• Trigger points used this is an area of
  increased sensitivity within a muscle, which is
  said to cause a characteristic pattern of
  referred pain in a related segment of the body.
  The 2 approaches overlap considerably.

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How Does It Work

• Effects of acupuncture on pain partially
  explained within a conventional physiological
  model. Vickers and Zollman 1999 state that
  acupuncture is known to stimulate Alpha delta
  fibres entering the dorsal horn of the spinal
  cord- these mediate segmental inhibitions of pain
  impulses carried in the slower unmyelinated C
  fibres. This explains why acupuncture needles in
  one part of the body can affect pain sensation in
  another region. Also known to stimulate release
  of endogenous opioids and other neurotransmitters
  such as serotonin.

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Study Design

• Evaluation is carried out by 2 methods.
• - Retrospective audit- 59 patients were referred
  by their GP for acupuncture treatment for chronic
  lower limb pain who failed to respond to standard
  pharmacological treatment over a 2 year period .
  47 subjects completed their rx and were included
  in the audit.
• - using a validated health outcome questionnaire
  MYMOP (Measure Yourself Medical Outcome
  Profile)(Patterson C 1996, BMJ 312) to evaluate
  the long-term effectiveness of acupuncture. 47
  questionnaires sent out to all 47 subjects, 26
  returned completed.

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Audit

• All subjects at 1st appointment full
  biomechanical assessment, full medical history
  and provision of simple insoles/orthoses as per
  diagnoses. Acupuncture offered at 2nd appt if
  pain not subsiding. Pain measured using visual
  analogue scale. VAS well known valid outcome
  measure (Price D et al, 1994 Pain 56)
• Pre-acupuncture VAS pain score
• VAS 48 hours
• VAS after 7 days
• VAS after completion of 6 treatments.

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Audit
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Types of Standard Rx Prescribed
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Age Bands of subjects
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Audit of VAS scores
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Diabetic Painful Neuropathy
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Heel Pain
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Metatarsalgia
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Tibial Shinsplints (N1) Osteoarthritis (N5)
Sciatica (N2)
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Data analysis for audit- Friedman Test

• Ranks

• Test Statistics

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Data analysis

• Friedman stat test using SPSS stat package
• For audit at 3(df) chi square is 125.973
• P 0.00lt 0.01 highly significant.
• Further analysis of VAS using Wilcoxen signed
  ranks test as post hoc test to see if there is a
  diff where does it lie? Results show diff highly
  signif between pre vas and after 6 rx. Not sig
  between pre acupunc and after 48 hours.

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Results- overview follow up MYMOP QUESTIONNAIRE

• All 47 patients follow up quest to evaluate long-
  term benefits of acupuncture treatment.
• 26 (55.3) returned completed.
• MYMOP consists of 4 items each scored by the
  patient on a seven point scale
• first 2 scales 2 sympt that were most imp prior
  to Rx .
• 3RD is an activity of daily living that is being
  disrupted/prevented.
• 4th general feeling of well being.
• 5th any new symp since rx.
• Lastly patients asked what rx currently and what
  would be rx of choice. Profile score calculated
  as mean of scored items.

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MYMOP Measure Yourself Medical Outcome
Profile. Choose one or two symptoms that bothered
you the most before you had your acupuncture
treatment. Write them on the dotted lines. Now
consider how bad each symptom has been, over the
last week, and score it by circling your chosen
number. SYMPTOM 1.. 0 1
2 3 4 5
6 As good as it
As bad

could be
as it
could
be SYPMTOM 2 0 1
2 3 4 5 6 .
As good as it
As bad as could
be it
could be   Now choose one activity of daily
living that your problem prevented you from
doing. Score how bad it has been in the last
week   ACTIVITY I cannot. 0 1
2 3 4 5 6
.. As good as it
As bad as it
.. could be
could be   WELL-BEING
how would you 0 1 2 3
4 5 6 rate your general
feeling of As good as it
As bad as it
Well-being
could be
could be   If an important new symptom
has appeared you may describe it and mark how bad
it is below.   Otherwise do not use this
line   SYMPTOM 3. 0 1 2
3 4 5 6 .
As good as it
As bad as it could be
could be   The
treatment/ help I am having for this problem is
(please include anyone, or anything, that you
have used to try and help this problem since you
completed your acupuncture treatment also what
treatment would you choose if you had a
choice.   .
.        
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MYMOP RESULTS
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ANALYSIS

• 26 replies, 19 f, 7 m. All subjects indicated
  reoccurrence of original symptoms apart from 1
  who had tibial shin splints. 5 subjects indicated
  presence of a new symptom 18 indicated they would
  like a second course of acupuncture rx as they
  felt an improvement in their well-being and
  general health.

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Discussion

• Evaluation- by retrospective audit shows
  significant reduction in vas score acupuncture is
  an effective adjunctive therapy in podiatry
  especially in hp oa .
• Evaluation- by questionnaire reoccurrence of
  original symptoms although not as severe long
  term improvement in well being request for 2 nd
  course of acupuncture.short duration of effect.
• Methodology critique randomised control trial
  gold standard future research eliminate placebo
  effect. Mymop questionnaire very useful should be
  completed before and after rx. Should quantify
  reduction of medication if any.

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Implications Of Practice

• Useful therapeutic inexpensive pain management
  adjunctive therapy.Additional rx modality.change
  my rx planning.
• Remarkably safe, not time consuming, meets
  demands from patients for effective pain
  management away from polypharmacy.
• Course of rx should be adapted to medical
  condition and whether it is acute or chronic no
  standard formula.

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Future Research

• Hope evaluation encourages my colleagues to
• Use acupuncture as an adjunctive therapy
• Develop evidence based research in
  podiatric-acupuncture.
• Collaborate with other AHPS who use acupuncture
  as an adjunctive therapy.

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Thank you