Yoon Hang Kim, MD MPH

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Integrative MedicineScientific Basis for
Acupuncture

• Yoon Hang Kim, MD MPH
• Dean of Integrative Medicine
• Program in Integrative Medicine
• AIMC Berkeley
• www.aimc.edu

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• AIMC Berkeley
• Program in Integrative Medicine
• Clinical Services
• Problem Based Team Approach
• Education
• Public, Students, Professionals
• Consulting
• Professionals Institutions

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Vision

• Imagine a world - oriented toward healing rather
  than disease, where physicians believed in the
  natural healing capacity of human beings, and
  emphasized prevention above treatment.
• In such a world, doctors and patients would be
  partners working toward the same ends.

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Integrative Medicine

• Integrative Medicine is healing-oriented medicine
  that takes account of the whole person (body,
  mind, and spirit), including all aspects of
  lifestyle.
• It emphasizes the therapeutic relationship and
  makes use of all appropriate therapies, both
  conventional and alternative.
• www.integrativemedicine.ariazona.edu
• PIM U of Arizona

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Integrative Medicine

• Integration
• Mastery
• Independence
• Interdependence
• Synergy

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Evidence

• What is evidence?
• Kochs Postulates
• Case Study, Case Series, RCT, Meta-analysis
• RCT randomizes known and unknown confounding
  factors ? LIMITATIONS

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Essence of Science

• What is science?
• Reliability and Validity
• Reliability ability to repeat and to produce
  predictable results
• Validity - Truth

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Effectiveness Efficiency

• Efficiency Reduces unnecessary expenditure
  (waste) of time, energy, and other resources.
• Effective Ensures achievement of desired
  outcome
• Example Asian Martial Arts
• Minimum effort ? Maximum result
• Effective and Efficient

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Simplicity and Complexity

• Simplicity and Linear Progression
• Science and Technology is based on Cartesian
  model of repeatability and predictability.
• Complexity and Non-Linear Evolution
• The idea of complexity is more accepted in
  business, science, and in medicine.

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Complex System

• A complex system is a self-organizing collection
  of multiple parts that interact in interrelated,
  interdependent, and unpredictable ways.

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Example of Complexity Theory Network Theory

• Living networks manifest as small worlds tied
  together into modular, interactive networks by
  weak ties, weak links, or interactive
  relationships between clusters of more-strongly
  interconnected parts or nodes.
• Tao of Physics

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Linearity and Western Medicine

• Most of Medicine today developed in response to
  challenged faced over a century ago.
• Infectious Disease follow linear patterns and
  responds to linear interventions such as
  antibiotics
• Chronic Disease which account for most of the
  problems in medicine follow complex pattern
  i.e. Cancer

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Synergy Paradigm Shift

• Synergy in Complexity Science often can defy
  explanation in a linear world.
• New principles in physics unlocked previously
  impossible amount of energy from small mass
  following Einsteins famous formula E mc

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Terminology

• Traditional Chinese Medicine
• Oriental Medicine
• Medical Acupuncture
• Medical Acupuncture is an integrative approach to
  acupuncture drawing from strengths of Western
  medicine and classic Chinese medicine.

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Discovery of Acupuncture Scientific Basis
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History

• Acupuncture is an ancient Chinese medical
  procedure involving insertion and manipulation of
  needles at any of more than 360 points in the
  human body.
• Acupuncture needles dating from 4,000 years ago
  have been found in China. The first needles were
  stone later, bronze, gold, or silver were used,
  and today needles are usually made of steel.

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Complexity and Chinese Medicine

• Chinese Medicine is developed from a macroscopic
  view that a human being is a reflection of cosmos
  or universe.
• Taoism is the basis of principles of Chinese
  Medicine
• Balance of Yin and Yang
• Balance of Five Phases of Energy

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Chinese Medicine Paradigm

• Yin and Yang
• Black and White
• Five Phases
• Color
• Emphasis on Macroscopic Energetics

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Yin-Yang Diagram
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Five Phases Matrix
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Five Phases Emotional Matrix
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Chinese Paradigm

• Acupuncture was developed in response to the
  theory that there are special meridian points on
  the body connected to the internal organs and
  that vital energy flows along the meridian lines.
• According to this theory, diseases are caused by
  interrupted energy flow, and inserting and
  twirling needles restores normal flow.

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Kidney Meridian Example
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Acupuncture Point vs. Sham
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Evidence

• In 1998 a National Institutes of Health (NIH)
  panel reviewed scientific studies of acupuncture
  and concluded that the technique effectively
  relieves nausea and vomiting caused by
  chemotherapy and surgical anesthesia.
• Good evidence also suggests that acupuncture
  relieves nausea during pregnancy and pain after
  dental surgery.

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Neurotransmitter Theory

• The needles may trigger the release of
  endorphins, which inhibit pain signals by
  blocking their pathway through the spinal cord.
• Studies show that placing acupuncture needles
  causes a rise in the level of endorphins in the
  spinal fluid.
• Acupuncture analgesia is at least partly
  reversible by naloxone.

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Neurotransmitter Theory

• Acupuncture stimulates nerve fibers in the muscle
  which send impulses to the spinal cord and
  activates spinal cord, midbrain, and
  hypothalamus-pituitary to cause analgesia
• Neurotransmitters implicated include enkephalin,
  dynorphin, GABA, monamines, serotonin, and
  norpinephrine.

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fMRI Study

• Z H Cho at UC Irvine
• I. Positive Control
• II. Intervention 1
• III. Intervention 2
• IV. Negative Control

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Cochrane Reviews

• Multiple Modalities on Evidence Based Medicine
  Including Acupuncture
• www.cochrane.org

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Acupuncture

• Review Papers Authored
• Depression
• OA Knee Pain
• Back Pain
• Cocaine Addiction
• www.bayintegrative.com

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Acupuncture for Headache

• Vickers et al. BMJ. 2004
• RCT Efficacy Analysis
• Acupuncture leads to persisting, clinically
  relevant benefits for primary care patients with
  chronic headache, particularly migraine.
  Expansion of NHS acupuncture services should be
  considered.
• Wonderling et al. BMJ. 2004
• RCT Cost Benefit Analysis
• 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.

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Acupuncture for Knee OA Pain

• US 2003 Technology Assessment
• The Centers for Medicare and Medicaid Services
  (CMS) has commissioned a Technology Assessment
  from The Agency for Healthcare Research and
  Quality (AHRQ) to review the evidence regarding
  the use of acupuncture for osteoarthritis.

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Acupuncture for Knee Pain

• Vas et al. BMJ Nov 2004 329 1216.
• Acupuncture plus medication is more effective
  than placebo acupuncture plus medication for the
  symptomatic treatment of osteoarthritis of the
  knee.

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Acupuncture for Knee Pain

• Berman et al. Ann Intern Med 2004141901-910.
• The impact of Bermans study is best described by
  Stephen E. Straus, MD, Director, National Center
  for Complementary and Alternative Medicine, NIH
• For the first time, a clinical trial with
  sufficient rigor, size, and duration has shown
  that acupuncture reduces the pain and functional
  impairment of osteoarthritis of the knee. These
  results also indicate that acupuncture can serve
  as an effective addition to a standard regimen of
  care and improve quality of life for knee
  osteoarthritis sufferers.

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Measuring Pain
The most reliable indicator of the existence pain
and its intensity is the patients description.
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Case History

• A patient with fibromyalgia
• Pre-tx statement
• Conventional tx statement
• Morbidity of fibromyalgia
• Post-tx statement

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Pre-treatment

• Over two years ago I was diagnosed with
  fibromyalgia. At the time I was in so much pain
  I couldn't hold down a job and my music studies
  at SDSU suffered incredibly.

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Conventional tx

• The doctors I went to told me there was no cure
  for fibromyalgia,only various treatments.
• Several lifestyle changes had to be made- getting
  at least 8 hours of sleep, daily exercise, a
  healthy diet, etc.
• I also tried low dosages of anti-depressants to
  help me sleep. These had such strong adverse side
  affects for me that I stopped taking them to look
  for alternative forms of treatment.

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Morbidity of Fibromyalgia

• I was still in such overall pain (most especially
  in my legs) that in the summer of 2000 I was
  using a walker and began looking for a
  wheelchair.

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Post-Treatment

• My body responded to treatments immediately.
  After about four or five weekly visits, I could
  go most of the week being pain-free. This time
  eventually increased to two weeks and more.

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Physician Contributions to Acupuncture

• Ear Acupuncture
• Neuroanatomic Acupuncture
• PENS Percutaneous Electrical Nerve Stimulation
• IMS Intramuscular Stimulation
• STOP AB2152!
• Taking acupuncture out of scope of practice for
  physicians

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Yoon Hang Kim MD 408.310.2678 Acupuncture
Integrative Medicine College ykim_at_aimc.edu www.ai
mc.edu