Journal of Chinese Medicine Number 85 October 2007

A Prospective, Randomised Control Trial of Acupuncture in Emergency Department

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A Prospective, Randomised Control Trial of Acupuncture for Select Common Conditions within the Emergency Department
Abstract
A trial was conducted among patients admitted to the Emergency Department of The Northern Hospital, Epping, Melbourne, Australia to assess the potential of acupuncture to reduce waiting times, reduce pain and satisfy the desire of patients to see complementary medicine within mainstream healthcare. 45 patients were randomly assigned to an acupuncture group (32) and a conventional treatment group (13). Comparison of the physiological parameters following treatment revealed no significant differences between the two groups (Table 3). These results demonstrate that acupuncture and conventional treatment are equally effective to reduce pain, however the acupuncture group received a significantly higher rate of patient satisfaction with the treatment. By: Carina Harkin & Robyn Parker Keywords: Acupuncture, electroacupuncture, emergency department, pain.

Introduction and literature review

cupuncture has been used to reduce pain in China for thousands of years. In more recent times there has been research in the West on the effectiveness of acupuncture for the treatment of pain. The quality and quantity of this evidence however, is insufcient to prove the efcacy of acupuncture. There is currently no literature on acupuncture within an emergency department situation. In regard to scientic trials, there is the obvious difculty of nding an appropriate placebo. To address this, some trials have used a sham needle1. This is where a supercial needling technique is used at non-acupuncture points. The problem with this is that these non-acupuncture points may still lie on a channel and of course the sun luo and fen luo, the little capillary network of vessels of the jingluo, connect the surface to the interior jingluo/channels and this may indeed induce a response. Other researchers have used a sham needle that does not penetrate the skin at all, and although it is apparently realistic (for the patient), since some acupuncture techniques only lightly stimulate the point, even this might be enough to exert an effect. Much experimental research has explored the mechanism behind acupuncture analgesia. Research indicates that acupuncture induces the formation of opioid-like peptides. An animal study found that electroacupuncture inhibits the release of stress-induced substance P through the activation

of descending serotonergic pathways meeting up with opioidergic systems.2 Some results, however, have been contradictory. For example, one study looking at acupuncture treatment for chronic pain syndrome found that the degree of symptom relief achieved with acupuncture correlated with an increase in plasma met-enkephalin and that plasma beta-endorphin concentrations were unchanged.3 However, another study in patients with recurrent pain who received electroacupuncture found increased endogenous opioid beta-endorphin in lumbar cerebrospinal uid CSF levels and no change in met-enkephalin levels.4 Another trial investigating the effects of acupuncture for chronic headache found that acupuncture results in a decrease of inammatory cytokines interleukin1, interleukin-6 and tumour necrosis factor alpha, TNF-alpha.5 One study investigating the immune effects of acupuncture in a group of 90 patients suffering from various painful disorders found a considerable increase in beta-endorphin levels of patients receiving acupuncture and that these remained high even 24 hours after acupuncture treatment.6 Other studies using electroacupuncture have indicated that a combination of two frequencies produces a release of all four opioid peptides. Enkephalin, beta-endorphin and endomorphin are released at a frequency of 2 Hz and dynorphin is released at 100Hz, therefore a combination of frequencies results in a maximum therapeutic effect.7,8

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A Prospective, Randomised Control Trial of Acupuncture in Emergency Department

Journal of Chinese Medicine Number 85 October 2007

Despite troubles with acupuncture research, acupuncture has become widely accepted in Western medical circles for the treatment of a number of conditions. Some of the strongest clinical evidence is for the treatment of dental and temporomandibular dysfunction pain, and research ndings are promising for idiopathic headaches, bromyalgia and osteoarthritis.9,10 With regard to pain from osteoarthritis, a trial to test the efcacy of acupuncture compared with minimal acupuncture and with no acupuncture in patients with osteoarthritis of the knee found that after eight weeks of treatment, pain and joint function were improved more with acupuncture than with minimal acupuncture or no acupuncture.11 Acupuncture is also well proven to treat painful conditions associated with pregnancy. A randomised controlled study found that acupuncture relieves pelvic and low-back pain in late pregnancy.12 Another randomised single blind controlled trial involving 386 pregnant women with pelvic girdle pain concluded that acupuncture complements standard treatment for the management of pelvic girdle pain during pregnancy and that acupuncture was superior to stabilising exercises.13 There are also studies that demonstrate acupuncture to be an effective alternative to pharmacological analgesia during labour.14 Recent studies indicate that 50% of Australians are using some form of alternative or complementary therapy every year.15,16,17 Patients are becoming increasingly suspicious of pharmacotherapy and more interested in natural remedies, feeling they receive more care from alternative health practitioners who take a more holistic approach to their patients health.18 In response to the increasing use of alternative therapies by the general public, the Australian Medical Association AMA issued a position statement on Complementary Therapies. In issuing this statement, Kerryn Phelps stated in the preamble: As evidence emerges that some complementary therapies are effective, it becomes ethically impossible for the medical profession to ignore them. Acupuncture has been practised for thousands of years and as such is arguably the most established alternative therapy. It has been embraced by the medical profession, with an estimated 20% of general practitioners utilising it.19 The Northern Hospital in Melbourne, Australia, has two acupuncture clinics in Ambulatory Care; these clinics take referrals from other subspecialties (e.g. general surgery) as well as from the community. Although these clinics are run by medical acupuncturists, this trial will be conducted by a traditional TCM practitioner. It is recognised that acupuncture offers a safe and effective alternative to pharmacotherapy. Acupuncture has long been listed on the Medicare Benets scheme as a rebatable item, and as quality research accrues, its efcacy is becoming more established.

Methods Study design Prospective, randomised controlled trial. Objectives Primary outcomes It is anticipated that following treatment the acupuncture group, as compared with the control group, will have a greater improvement in all of the parameters mentioned below: improved pain scores as measured by Visual Analogue scale, VAS a lowering of heart rate (HR), blood pressure (BP), respiratory rate (RR) satisfaction with the treatment

Subjects
Recruitment Patients presenting to the Emergency Department with conditions fullling the inclusion criteria (see below) will be offered the chance to participate in a trial of acupuncture versus conventional medical treatment. The selection of appropriate patients will be by the Emergency Physician on R.A.T. (Rapid Assessment Team) duty, as the current practice in the ED is for an Emergency Physician to perform the initial assessment of all patients presenting to the ED. Written informed consent will be obtained and then the patient will be randomised to receive either acupuncture or conventional medical treatment. An initial set of routine physiological observations (HR, BP, RR) and a pain score as indicated by a Visual Analogue Scale (VAS) of symptom severity will then be performed on all patients. Acupuncture group Patients randomised to receive acupuncture will be seen by the Acupuncturist in the General Practice After Hours Clinic (GPAHC) area for a consultation lasting 30-40 minutes. Following the treatment, at the point of discharge from the acupuncturists care, patients in this group will be briey assessed by the doctor rostered to the Fast Track clinic, which runs concurrently in the GPAHC. This doctor will ensure that the patient is able to be discharged from the care of the Emergency Department, and be provided with any correspondence/referrals/prescriptions as necessary. This doctor will also collect the second set of physiological observations (HR, BP, RR) and VAS needed as data for the trial, and administer a brief patient satisfaction survey. Conventional treatment (control) group Patients randomised to the control group will be seen by an Emergency Department doctor and receive the conventional medical treatment for their condition, at the discretion of the treating doctor. Discharge from the Emergency Department will also be by this doctor, after they have taken the second set of data (as above) for the trial.

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A Prospective, Randomised Control Trial of Acupuncture in Emergency Department

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Triage category

Description People who need to have treatment immediately or within two minutes are categorised as having an immediately lifethreatening condition. People in this group are critically ill and require immediate attention. Most would have arrived in Emergency Department by Ambulance. They would probably be suffering from a critical injury or cardiac arrest. People who need to have treatment within 10 minutes are categorised as having an imminently life-threatening condition. People in this group suffer from a critical illness or are in very severe pain. People with serious chest pains, difculty in breathing and severe fractures are included in this group. People who need to have treatment within 30 minutes are categorised as having a potentially life-threatening condition. People in this group suffer from severe illness, bleed heavily from cuts, have major fractures, or are dehydrated. People who need to have treatment within one hour are categorised as having a potentially serious condition. People in this group have less severe symptoms or injuries, such as a foreign body in the eye, sprained ankle, migraine or earache. People who need to have treatment within two hours are categorised as having a less urgent condition. People in this group have minor illnesses or symptoms that may have been present for more than a week, such as rashes or minor aches and pains. Extraneous variables These will be limited, as the trial will be conducted in a short period of time within the patients emergency department stay. Any medication that may be prescribed in addition to the acupuncture will only be prescribed after the nal assessment for the acupuncture trial is concluded. Materials Acupuncture needles 0.25 x 30mm, 0.25 x 40mm, 0.32 x 75mm, 0.30 x 30mm, 0.30 x 40mm, 0.30 x 75mm, 0.18 x 13mm, 0.18 x 25mm. Heat lamp TDP CQ 26/7. Electroacupuncture machine Hwato SDZ 2. Acupuncture procedures Differentiation of patterns Pain in Chinese medicine may be due to excess or deciency, exterior attack, interior disharmony, traumatic injury, heat or cold etc. The main patterns of disharmony and the guideline treatments are given in Table 1 below. Acupuncture technique and needle depth The treatment principle is to move qi and blood to alleviate pain. Patients will be differentiated according to TCM theory using tongue and pulse diagnosis and zangfu and channel pathology. Local and distal points will be chosen accordingly. For patients experiencing acute anxiety or who are new to acupuncture, treatment will begin using ear acupuncture. The points to be used are according to Above: The ve triage categories

3 4

Inclusion criteria Patients within triage categories 3,4 or 5, who present with the following acute conditions: Migraine headache Tension headache Torticollis Muscular back pain Acute musculoskeletal pain (excluding likely fracture) Hyperemesis gravidarum Chemotherapy-induced nausea and vomiting Anxiety/panic attack Viral upper respiratory tract infection Dysmenorrhoea Exclusion criteria Triage categories 1 and 2 Haemodynamic instability or suspected critical illness Acute, severe pain requiring parenteral narcotic analgesia Undifferentiated conditions where further investigations are needed Withdrawal criteria Anyone who develops needle phobia. Variables Independent variables Patients will be individually assessed and prescribed appropriate acupuncture according to TCM theories. Dependant variables These will include physiological observations (HR, BP, RR) and VAS as assessed by a triage nurse or doctor.

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A Prospective, Randomised Control Trial of Acupuncture in Emergency Department

Journal of Chinese Medicine Number 85 October 2007

Category

Pain symptom

Tongue

Pulse

Points (all reduced) Fengchi GB-20, Wangu GB-12, Dazhui DU-14, Fengmen BL-12, Lieque LU-7, Waiguan SJ-5 Qihai REN-6, Mingmen DU-4. Heat lamps were used instead of moxa. Quchi L.I.-11, Dazhui DU-14, Erjian M-HN-10, Waiguan SJ-5, Erjian L.I.-2, Neiting ST-44, Chize LU5, Zulinqi GB-41. Fenglong ST-40, Jianshi P-5, Lieque LU-7 Taichong LIV-3, Hegu L.I.-4, Ganshu BL-18, Qimen LIV-14, Zulinqi GB-41 Xuehai SP-10, Geshu BL-17, Dazhu BL-11

Wind

Sudden onset, migratory pain, upper body, wind-cold, wind-heat or wind-damp. Severe, xed, deep, stiffness better with warmth worse with cold Local redness, swelling and heat worse with heat better with cold (this is theoretical and not necessarily practical as most pain is better with heat) Dull ache, numbness, xed, heavy, swelling, distension

May be unchanged

Floating

Cold

White coat

Deep and slow

Heat

Yellow coat, red body

Floating and rapid

Damp

Thick greasy coat, Flabby, teeth marks

Slippery

Qi stagnation

Distension, migratory pain

Slightly purple

Wiry

Blood Stasis

Severe, sharp and xed pain

Dark purple

Full and choppy

Table 1: TCM patterns and treatments

the National Acupuncture Detoxication Association (NADA). The object is to increase endorphin levels quickly to relax the patient. In all cases I will open the four gates (Hegu L.I.-4 and Taichong LIV-3). In China there is a saying xuan mai, kai si guan, if the pulse is wiry, open the four gates. In reality however, the four gates are regularly used for the treatment of all pain regardless of the pulse, even in decient cases. From my experience a wiry pulse is always present in severe, debilitating pain. Appropriate supplementary points will then be chosen accordingly, i.e. a mixture of local and distal points according to point category and according to the patterns seen in Table 1. Needles will be inserted to the depth required to obtain a strong qi sensation (deqi). Strong reduction techniques will be used

locally and distal points will be tonied or reduced as required. Bleeding techniques at the jing-well points provide fast relief in excess conditions affecting the channels and will also be applied. Other points considered for acute pain include the xi-cleft points. An electroacupuncture device will be attached to the needles and the points stimulated for approximately 20 minutes. Studies using electroacupuncture have indicated that a combination of two frequencies produces a release of all four opioid peptides, enkephalin, beta-endorphin, endomorphin and dynorphin, resulting in a maximum therapeutic effect. Considering the main aim is to reduce pain and waiting times, electroacupuncture will be set on dense and disperse to increase the anodyne effect. A TDP heat lamp will be used over the affected area at an acceptable distance to further improve the effect

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A Prospective, Randomised Control Trial of Acupuncture in Emergency Department

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Conventional group Pain score (M SD) Respiratory rate (M SD) Heart rate (M SD) Systolic blood pressure (M SD) Diastolic blood pressure (M SD) 54.71 17.98% 18.75 2.51 / min 87.41 19.49 / min 140.12 29.16 mmHg 136.06 28.94 mmHg

Acupuncture group

64.39 24.07% 17.88 1.521 / min 77.22 16.32 / min 129.16 14.06 mmHg 129.41 26.74 mmHg

-1.460 0.926 1.964 1.586 0.791

0.151 0.359 0.056 0.120 0.433

of treatment, as is regular practice in China, even in conditions of excess heat. If applicable, I will also use what I call active puncture methods to conclude the treatment. These will mainly be used to treat back, neck and shoulder pain in particular. Examples are needling Houxi SI-3 or Luozhen M-UE-24, while getting the patient to perform gentle head rotations for wry neck. Another example for acute lower back pain is Yaotongxue N-UE-19 and Zanzhu BL-2 while the patient rotates and bends forwards, backwards and to the side. A further example using six channel theory is needling Waiguan SJ-5 of hand shaoyang to treat disorder affecting the upper portion of foot shaoyang, while the patient gently stretches. Table 1 shows examples of common TCM patterns and treatment for acute pain. Data management and statistical analysis. Data analysis SPSS 12.0 for Windows (November 2003) will be used for data management and analysis. Descriptive statistics (frequency, mean and standard deviation) will be used to examine participants demographic data, physiological parameters, effect of treatment and ED length of stay. The physiological parameters examined by the study will be pain score, heart rate, systolic and diastolic blood pressure and respiratory rate. The participant characteristics of the two groups (conventional treatment and acupuncture) will be compared to establish equivalence of the groups. Non-parametric data will also be compared using Chi square test for independence and t-tests will be used to compare parametric data. 20,21,22 T-tests will be used to compare test physiological parameters between and within the two groups of participants. Independent samples t-test will be used to compare the mean physiological parameters of both groups to establish equivalence of pre-treatment

parameters and examine the effect of treatment on post-test parameters.22,23,24 Paired samples t-test will be used to compare the pre-treatment and post-treatment physiological parameters within each group.22,23,24 Signicance will be indicated by a probability value of 0.05 or less. Ethical considerations A proposal will be submitted to the Ethics Committee of the Northern Hospital for approval. Timetable The trial will run for a period of four months from June 2003 October 2003. Results Group comparisons There were a total of 45 participants in the study. Of these, 32 were in the acupuncture group and 13 were in the conventional treatment group. The characteristics of the two groups were examined to determine if there were any statistically signicant differences in age, gender or pre-treatment physiological parameters. There were no signicant differences in the age or gender of both groups. The age of participants was 45.46 16.18 years for the conventional group and 40.25 14.68 for the acupuncture group, t (43) = -1.048, p = 0.300. Males accounted for 53.3% of the conventional group and 39.4% of the acupuncture group, (c2 = 0.814, df = 1, p = 0.367). There were no signicant differences in the pre-treatment physiological parameters of both groups (Table 2). These results demonstrate that there were no signicant differences between groups, indicating equivalence of the two groups. Effect of treatment The effect of treatment was examined using the following outcome measures: physiological parameters pain score as measured by VAS, respiratory rate, heart

Table 2: Pre-treatment physiological parameters

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A Prospective, Randomised Control Trial of Acupuncture in Emergency Department

Journal of Chinese Medicine Number 85 October 2007

Conventional group Pain score (M SD) Respiratory rate (M SD) Heart rate (M SD) Systolic blood pressure (M SD) Diastolic blood pressure (M SD) 32.81 21.68% 17.80 1.52 / min 76.50 12.95 / min 80.65 16.29 mmHg 76.25 12.72 mmHg

Acupuncture group

38.48 23.55% 18.03 4.00 / min 74.56 15.50 / min 78.42 14.06 mmHg 76.03 13.37 mmHg

-5.672 -0.215 0.429 0.496 0.054

0.422 0.830 0.670 0.622 0.957

Table 3: Posttreatment physiological parameters

rate, systolic and diastolic blood pressure), degree of effect reported by the patient, presence of side effects and ED length of stay. Conventional group Following treatment there were decreases in all physiological parameters examined in the conventional treatment group. There was 22.18 24.08% decrease in the pain score, t (15) = 3.685, p = 0.002. There were signicant reductions in heart rate (7.81 11.86, t (15) = 3.685, p = 0.002), systolic blood pressure (59.47 16.89, t (15) = 14.521, p < 0.001) and diastolic blood pressure (59.81 22.88, t (15) = 10.46, p < 0.001). There was also a non-signicant reduction in respiratory rate (1.13 2.23, t (15) = 2.369, p = 0.069). Acupuncture group The ndings for the acupuncture group were similar to those of the conventional treatment group. Again, there were decreases in all physiological parameters examined following treatment except respiratory rate. There was 25.90 17.64% decrease in the pain score, t (32) = 8.433, p < 0.001. There were signicant reductions in systolic blood pressure (50.74 12.20, t (32) = 23.150, p < 0.001) and diastolic blood pressure (53.37 22.10, t (32) = 13.66, p < 0.001). There was a non-signicant increase in respiratory rate (0.35 2.71, t (32) =-0.728, p = 0.472) and non-signicant reduction in heart rate (1.70 9.16, t (32) = 1.039, p = 0.307). Group comparisons Comparison of the physiological parameters following treatment revealed no signicant differences between the two groups (Table 3). These results demonstrate that acupuncture and conventional treatment are equally effective. Comparison of ED length of stay showed no signicant differences between the two groups. The ED length of stay was 238.93 82.48 minutes for the

conventional treatment group and 255.94 132.03 minutes for the acupuncture group. The self reported data collected from patients showed no signicant differences in the perceived effectiveness of the two treatments, the reported incidence of side effects or the willingness to have that treatment again. Positive effects of treatment were reported from 75.0% (n = 12) of the participants who were managed with conventional treatment and 84.4% (n = 27) of participants who underwent acupuncture (c2 = 0.615, df = 1, p = 0.433). Side effects were reported by 5.9% (n = 1) of the participants who were managed with conventional treatment and 18.2% (n = 6) of participants who underwent acupuncture (c2 = 1.410, df = 1, p = 0.235). The acupuncture side effects were minimal and related to pain reported at the needle site and insertion. Willingness to undergo the same treatment in the future was reported by 58.8% (n = 10) of the participants who were managed with conventional treatment and 81.8% (n = 27) of participants who underwent acupuncture (c2 = 3.083, df = 1, p = 0.0.79). Future research potential This trial could be continued in the Northern Hospital ED. A trial designed to determine if acupuncture, as compared to a control group, is also able to reduce rates of representation with the same condition. This type of trial could be applied to other departments within the public hospital system such as the orthopaedic, neurological and maternity wards. Given that the results have proven positive for the treatment of acute pain, this style of trial could be applied in frontline emergency relief situations with practitioners working alongside Westerns doctors with triage nurses. There is potential to experiment with other styles

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A Prospective, Randomised Control Trial of Acupuncture in Emergency Department

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of acupuncture treatment such as Dr. Zhus head acupuncture and hand/foot/nose acupuncture, as these are powerful techniques used in China in emergency situations when other methods fail.

Acknowledgements
With thanks to Professor Hongtao Dong and to Dr. Julie Considine (PhD); (RN, RM, BN, Emerg. Cert, Grad Dip Nsg, MN, FRNCA), Clinical Nurse Educator, Emergency Department, The Northern Hospital who did all the statistical analysis. With thanks to Carahealth Melbourne and Acuneeds Melbourne.
Carina Harkin is Australia's rst triple degree graduate in acupuncture, naturopathy and homoeopathy and mother of ve, currently Director of Studies and lecturer at the College of Naturopathic Medicine, Galway, and health columnist and practitioner in Galway, Ireland. [email protected] Robyn Parker is an Emergency Physician and qualied medical acupuncturist currently working at The Northern Hospital, Melbourne, Australia.

Discussion
Certain characteristics of Chinese medicine make it hard to t into experimental studies. In addition to placebo difculties it is sometimes difcult to equate diagnostic terminology. For example where the Western aetiology of torticollis is a detracted state of the cervical muscles resulting in torsion of the neck, TCM is likely to ascribe it to wind invasion resulting in stagnation of qi and blood in the affected channels. TCM may be in direct conict with modern scientic method in that its theory and practice involve integrating variables while current scientic research involves controlling and eliminating variables. Most doctors of Chinese medicine understand that TCM is more than science; it is a combination of art and science. There will always be difculty in conducting scientic trials in acupuncture that will satisfy both the medical fraternity and TCM doctors. This trial, however, is a good template for sound acupuncture research. The acupuncture was performed according to TCM theory and practice and points were varied according to presenting patterns of disharmony. The scientic data was collected in a controlled environment.

Footnotes
1 Witt C, Brinkhaus B, Jena S, Linde K, Streng A, Wagenpfeil S, Hummelsberger J, Walther HU, Melchart D, Willich SN. Acupuncture in patients with osteoarthritis of the knee: a randomised trial., Lancet. 2005 Jul 9-15; 366 (9480) 136-43. Takagi J, Sawada T, Yonehara N., A possible involvement of monoaminergic and opioidergic systems in the analgesia induced by electroacupuncture in rabbit., Jpn J Pharmacol. Jan 1996;70(1):7380. Kiser RS, Khatami MJ, Gatchel RJ, Huang XY, Bhatia K, Altshuler KZ, Acupuncture relief of chronic pain syndrome correlates with increased plasma met-enkephalin concentration., Lancet. Dec1983; 17; 2(8364): 1394-6. Clement-Jones V, McLoughlin L, Tomlin S, Besser GM, Rees LH, Wen HL. Increased beta-endorphin but not metenkephalin levels in human cerebrospinal fluid after acupuncture for recurrent pain., Lancet. Nov 1980; 1;2(8201):946-9. Jeong HJ, Hong SH, Nam YC, Yang HS, Lyu YS, Baek SH, Lee HJ, Kim HM. The effect of acupuncture on proinflammatory cytokine production in patients with chronic headache: a preliminary report., Am J Chin Med. 2003; 31(6):945-54. Petti F, Bangrazi A, Liguori A, Reale G, Ippoliti F, Effects of acupuncture on immune response related to opioid-like peptide., J Tradit Chin Med. Mar.1998; 18(1): 55-63.

Han JS, Acupuncture and endorphins., Neurosci Lett. May 6 2004; 361(1-3): 258-61. Ulett GA, Han S, Han JS. Electroacupuncture: mechanisms and clinical application, Biol Psychiatry; 1998 Jul 15; 44(2): 129-38. Berman, Brian M. Integrative approaches to pain management: how to get the best of both worlds, BMJ. 2003 Jun 14;326(7402):1320-1.

Conclusion
It was originally anticipated that the acupuncture group would have a greater reduction in pain scores, heart rate, blood pressure and respiratory rate than the control group and also nd a greater satisfaction rate with the treatment. On analysing the relationship between projected outcomes and actual outcomes, in hindsight, the projected outcomes were too optimistic. Most of the objectives in fact, were not met. The results do however demonstrate that acupuncture and conventional treatment are equally effective to reduce pain in the emergency department. The patient satisfaction rate or willingness to undergo the same treatment in the future for the acupuncture group was 81.8% compared with only 58.8% reported by the participants were managed with conventional treatment. This is an important factor as the results of this trial paved the way for Royal Melbourne Institute of Technology (RMIT) acupuncture students to provide treatment for pain relief in the emergency department of the Northern Hospital. The results show that trials of this nature need prioritisation within the public healthcare system to reduce the strain presently experienced as a result of an increasing and increasingly unwell population.
3

10 Soeken KL., Selected CAM therapies for arthritis-related pain: the evidence from systematic reviews: Clin J Pain.; 2004 Jan-Feb; 20(1): 13-8. 11 Witt C, Brinkhaus B, Jena S, Linde K, Streng A, Wagenpfeil S, Hummelsberger J, Walther HU, Melchart D, Willich SN., Acupuncture in patients with osteoarthritis of the knee: a randomised trial, Lancet. 2005 Jul 9-15; 366(9480) 136-43. 12 Kvorning N, Holmberg C, Grennert L, Aberg A, Akeson J, Acupuncture relieves pelvic and low-back pain in late pregnancy, Acta Obstet Gynecol Scand. 2004 Mar; 83(3): 246-50. 13 Elden H, Ladfors L, Olsen MF, Ostgaard HC, Hagberg H. Effect of acupuncture and stabilising exercises as adjunct to standard treatment in pregnant women with pelvic girdle pain: randomised single blind controlled trial, BMJ. 2005 Apr 2;330(7494):761. 14 Ramnero A, Hanson U, Kihlgren M. Acupuncture treatment during labour--a randomised controlled trial. BJOG; 2002 Jun; 109(6): 63744.

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15 E i s e n b e r g D M e t a l . , Unconventional Medicine in the United States: Prevalence and Patterns of Use, NEJM; 328(4), 1993 28 Jan; 2246-252. 16 Eisenberg DM et al., Trends in Alternative Medicine Use in the United State, 1990-1997: Results of a Follow-up National Survey, JAMA 280(18). Nov 11 1998; 15691575. 17 MacLennan AH, Wilson DH, Taylor AW., Prevalence and Cost of Alternative Medicine in Australia, Lancet, 347 (9001). Mar 2 1996; 569-573. 18 Astin J.A, Why Patients Use Alternative Medicine: Results of a National Survey, JAMA, May 20 1998; 1548-1553. 19 P i r o t t a M , C o h e n M , Complementary Therapies: Have they become mainstream in General Practice? MJA 172, Feb 7 2000; 105-109. 20 Brace, N, R Kemp, and R Snelgar. 2003. SPSS for Psychologists. 2nd ed. Hampshire: Palgrave McMillan. 21 Gravetter, F, and L Wallnau. 2000. Statistics for the Behavioural Sciences. 5th ed. Stamford:

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