Acupuncture for Hemophilia Patients in Chronic Pain.

Angela Lambing, MSN, NP-C, 1 Dr. Vinay Varma, 2 Beth Kohn L.Ac., M.T.O.M, Dipl.Ac, Dipl.CH , 1 Dr. Suresh Hanagavadi 2 1 Henry Ford Health System, Detroit, MI 2 Karnataka Hemophilia Society, India

Statement of the Problem

   Chronic pain due to end stage arthritis for hemophilia patients presents ongoing issues resulting in exploration of non standard therapies for pain management Acupuncture has proved successful in osteoarthritis and non-malignant pain. Pain management involves a multimodal approach

Objectives

 This study seeks to:   a) Document a decrease in hemarthritic joint pain after acupuncture treatments b) Demonstrate minimal bleeding risk during acupuncture.

Review of the Literature

Minimal literature related to hemophilia  Wallny TA, Brackmann, HH, Gunia G, WIlbertz P, Oldenberg J, Kraft CN. (2006). Successful pain treatment in arthropathic lower extremities by acupuncture in haemophilia patients. Haemophilia. 12(5); 500-2.

 10/12 pts showed improvement   Average VAS reduced from 6.8/10 to 5/10 No side effects were observed

 Rosted P & Jorgensen V. (2002). Acupuncture used in the management of pain due to arthropathy in a patient with haemophilia. 20(4); 193-5.

Acupuncture medicine.

 Case report – 38 yr old severe hemophilia A, with joint pain; knees, elbows, ankles   On factor prophylaxis; received factor prior to tx Previous right knee synovectomy     5 tx for the knee with reported significant reduction in pain Repeat acupuncture every 3 months Close collaboration with hemophilic clinic Use of qualified acupuncture specialists

Method

      Convenience sample Prospective study Dual study between Twinning partners:    Henry Ford Health System, Detroit, MI Karnataka Hemophilia Society, Karnataka, India Utilized certified acupuncturists Inclusion Criteria     > 18 years of age Hemophilia Reported chronic pain Severe Joint hemarthrosis as identified by the HTC Michigan subjects – factor replacement > 15% level (per IRB requirements) India residents – no factor prior to treatments

Acupuncture points

 Acupuncture treatment plan  Twice per week x 4 weeks; weekly for remaining 6 weeks Primary acupuncture points:  Du 20, LI 4, Liv 3, Gb 34, Sp 6, LI 11, St 35, Kid 3, Shen Men Ear Point     Specific Knee pain:  Secondary points: Xi yan, Heding, Liv 8, Sp 10 Specific Ankle pain:  Secondary Points: St 41, Gb 40, Sp5 Specific Lower back pain:  Secondary Points: Ub 23, Du 4 Specific Elbow Pain:  Secondary Points: Lu 5, Sj 5

Method

  Measured pain scores using:    Visual analog scale: 0 – 10   Average daily pain Highest level  Lowest level Types of pain medications utilized Number of pain pills taken/day Quality of Life (QOL)  Standard SF-36

Method

     Signed consent per IRB protocol Cost of acupuncture sessions covered Mileage covered for travel to each session Patients were instructed to report any bleeding issues Acupuncturists identified any post procedural bleeding issues.

Results

   19 HFH hemophilia pts signed up to participate  Only 6 completed the study citing travel & work restrictions 3 hemophilia pts completed study in India Total of 9 pts completed study    6 severe hemophilia 2 moderate hemophilia 1 mild hemophilia

Demographics

  Ethnicity:  3 India   4 Caucasian 2 Afr American Education:  4 college    2 secondary school 2 technical school 1 grade school: gr 8    Marital Status   7 married 2 single Age: 28 – 63 yrs  Ave age 45 years Work  4 full time    3 disabled 1 student 1 retired

Pt #1 #2 #3 #4 #5 #6 #7 #8 #9

Pain level reports: VAS 0-10

Pre treatment 4.0

4.0

8.0

5.0

6.0

4.0

4.0

10.0

4.0

Post Treatment 4.0

2.0

6.0

1.0

4.0

4.0

4.0

5.0

2.0

Pain med pre 1 x week 1 x week 3-4 x day 1-2 x day 1-2 x day 1-2 x day < 1 x day 3-4 x day 1 x week Pain med post 1 x month None 3-4 x day < 1 x day 1-2 x day 5-6 x day <1 x day 3-4 x day 1 x month

SF-36; QOL scores

Variables Physical Functioning Social functioning Physical problem Emotional problem Mental health Energy/Fatigue Pain Health perception Health change Pre acupuncture 23.0

52.50

0 60.0

76.8

42.0

33.3

43.8

50.0

Post acupuncture 30.0

70.0

0 73.3

82.4

43.0

44.4

43.8

65.0

Pre Acupuncture Post Acupuncture

Pre Acupuncture Post Acupuncture

Limitations

   Very small sample size Duration of therapy program proved a barrier to enrollment Additional objective data to confirm improvement would have been helpful  Joint measurements

    

Conclusions

No bleeding experienced:   With any subject After every treatment session  Factor vs no factor pre treatment 6/8 pts reported decrease in VAS pain scores 7/9 QOL domains improved Alternative therapies: acupuncture may provide some benefit to chronic pain patients with hemophilia in a multimodal approach Larger randomized studies are needed