Auricular acupuncture for pain relief after total hip arthroplasty – a randomized controlled study (2022)

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Pain

Volume 114, Issue 3,

April 2005

, Pages 320-327

Abstract

Auricular acupuncture (AA) is known to be effective in treatment of various pain conditions, but still there have been no randomized controlled studies of AA for treatment of acute postoperative pain. Therefore we tested whether AA of specific points is superior to sham acupuncture for complementary analgesia after total hip arthroplasty in a patient–anesthesiologist–evaluator–analyst blinded study. The patients were randomly allocated to receive true AA (lung, shenmen, thalamus and hip points) or sham procedure (4 non-acupuncture points on the auricular helix). Permanent press AA needles were retained in situ 3 days after surgery. Postoperative pain was treated with intravenous piritramide (opioid receptor agonist with analgesic potency of 0.7 compared with morphine) using a patient-controlled analgesia (PCA) pump. The time to the first analgesic request, the amount of postoperative piritramide via PCA and pain intensity on a 100-mm visual analogue scale (VAS-100) were used to evaluate postoperative analgesia. Intraoperative anesthetic requirement, incidence of analgesia-related side effects, inflammation parameters and success of patients' blinding were also recorded. Fifty-four patients (29 AA and 25 controls) completed the study. Piritramide requirement during 36h after surgery in AA group was lower than in control: 37±18 vs. 54±21mg; mean±SD; P=0.004. Pain intensity on VAS-100 and incidence of analgesia-related side effects were similar in both groups. The differences between the groups as regard patients' opinions concerning success of blinding were not significant. Findings from our study demonstrate that AA could be used to reduce postoperative analgesic requirement.

Introduction

Effective relief of acute pain has been associated with increased patient satisfaction in addition to shortened hospital stays and decreased morbidity and mortality (Ballantyne et al., 1998, Tsui et al., 1997).

Despite a better understanding of the pathophysiology of pain, the pharmacology of analgesics and the development of numerous analgesic techniques, many patients continue to experience distressing pain after elective surgery. A recent review of 165 papers, including nearly 20,000 patients, has shown that 29% still experienced moderate pain and 11% severe postoperative pain (Dolin et al., 2002). Even when patient-controlled analgesia (PCA) was used, which is considered to satisfy the individual patients' analgesic demand, the incidence of moderate pain was 35.8% and that of severe pain was 10.4%. Moreover, systemic opioids administered via PCA pumps can cause numerous side effects such as respiratory depression, decreased intestinal motility, nausea, vomiting and itching, which can all lead to decreased life quality after major surgery and may result in significant morbidity and even mortality (Ashburn et al., 1994, Ballantyne et al., 1998, Schug and Torrie, 1993). In order to achieve better postoperative pain relief, various complementary non-pharmacological analgesic techniques, including acupuncture, have been tested (Chen et al., 1998, Kotani et al., 2001, Lao et al., 1999).

Auricular acupuncture (AA), an old chinese therapeutic technique, is reported to be effective in treatment of pain syndromes of various origins (Alimi et al., 2003, Simmons and Oleson, 1993, Vorobiev and Dymnikov, 2000). AA was first introduced into clinical western medicine by Nogier (1972), who empirically identified AA points.

In the last decade AA found its place as a complementary technique in perioperative medicine. Randomized controlled trials (RCT) have shown AA to decrease preoperative anxiety in patients scheduled for ambulatory surgery (Wang et al., 2001), reduce anesthetic requirement in healthy individuals (Taguchi et al., 2002) and relieve chronic pain in cancer patients (Alimi et al., 2003). To our knowledge, there has been no RCT assessing AA effectiveness in relief of acute postoperative pain. Designing control procedures in acupuncture studies is difficult (Usichenko et al., 2003b). A placebo using non-inserted needles has been reported to be a valid control procedure for evaluation of postoperative analgesic effect of acupuncture (Lao et al., 1999). However, it does not account for the non-specific physiological response of intradermal needle penetration, which has been reported in experimental and clinical studies to have analgesic properties (Le Bars et al., 1979, Lewith and Machin, 1983). To investigate whether the acupuncture has any specific effects beyond the physiological reaction of needle penetration, the control group should always receive sham acupuncture, defined as a needle insertion either into sites other than traditional points or meridians, or into inappropriate acupuncture points (White et al., 2002).

(Video) Suburban Hospital Grand Rounds 1/11- Medical Acupuncture in Clinical Practice

Therefore we performed the following study to test whether the AA of specific points is superior to sham acupuncture for complementary analgesia after total hip arthroplasty (THA).

Section snippets

Study design and randomization

This prospective randomized patient–anesthesiologist–evaluator–analyst blinded, sham acupuncture controlled study was approved by the local ethics committee. It was performed at the Departments of Anesthesiology and Orthopedic Surgery, University of Greifswald, Germany, from November 2002 to September 2003. Sixty-one patients scheduled for elective THA performed under general anesthesia were enrolled in the study.

The preoperative anesthesiologic evaluation along with the patients' randomization

Patients characteristics

Sixty-one out of 75 patients who initially agreed to take part in this study met the inclusion criteria and were randomized. The groups were well balanced for age, weight and gender (Table 1). All patients in this study were Caucasians who had never previously received AA. Fifty-four patients completed the study: 29 patients in AA group and 25 in the control group. The difference between the study groups regarding withdrawal rate was not statistically significant. One patient from the control

Analgesic properties of AA

Auricular acupuncture applied to specific acupuncture points appeared to be more effective than sham acupuncture in reducing postoperative piritramide requirement after elective THA. In order to obtain reliable results in pain measurement using PCA requirement, the piritramide titration was adjusted to achieve similar pain values on VAS (McQuay and Moore, 1999). We found the mean reduction of VAS to be 44mm, 36h after THA procedure in both groups. Although it was slightly higher than the

Conclusion

Findings from our study demonstrate that AA could be used to reduce postoperative analgesic requirement. Further large-scale randomized investigation of this treatment modality comparing it with standard therapy and placebo acupuncture (non-inserted needle) appears to be necessary.

Acknowledgements

The authors thank M. Groth for discussion of study design, the personnel of the University Hospital of Greifswald and the patients who participated in this study.

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      Two studies directly examine the effect of AA on PONV. Other studies examine the effect of AA on postoperative pain, while including PONV as secondary data.6,11,28,31 The model for this project is described in a 2003 prospective randomized controlled trial.6

      Postoperative nausea and vomiting (PONV) affects more than 30% of surgical patients. Auricular acupuncture (AA) has been shown to decrease the incidence of PONV in select populations.

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      More risk factors for PONV were present in the AA group (P<.001). Both groups experienced a less-than-expected rate of PONV. Similar rates were shown between groups for PONV, postanesthesia care unit length of stay, and opioid consumption. Patient satisfaction was 96% with AA. The AA group was treated with less antiemetic medication (P < .001), yet PONV rates remained similar.

      A multimodal approach treating patients at risk for PONV is recommended. Administration of multiple antiemetics may result in unnecessary cost or unfavorable side effects when effective and less costly alternatives exist. AA is a viable treatment for PONV, considering cost and patient satisfaction.

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