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 Hanagavadi2 1Henry Ford Health System, Detroit, MI 2Karnataka 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) Rosted P & Jorgensen V. (2002). Acupuncture used in the management of pain due to arthropathy in a patient with haemophilia. Acupuncture medicine. 20(4); 193-5. 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: Quality of Life (QOL) 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: Education: Marital Status Age: 28 – 63 yrs 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

Pain level reports: VAS 0-10 Pt Pre treatment Post Treatment Pain med pre Pain med post #1 4.0 1 x week 1 x month #2 2.0 None #3 8.0 6.0 3-4 x day #4 5.0 1.0 1-2 x day < 1 x day #5 #6 5-6 x day #7 <1 x day #8 10.0 #9

SF-36; QOL scores Variables Pre acupuncture Post acupuncture Physical Functioning 23.0 30.0 Social functioning 52.50 70.0 Physical problem Emotional problem 60.0 73.3 Mental health 76.8 82.4 Energy/Fatigue 42.0 43.0 Pain 33.3 44.4 Health perception 43.8 Health change 50.0 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