EBP Proposal Project for Acupuncture: An Evidence-Based Practice Proposal

Abstract

The EBP Proposal project proposed acupuncture as an alternative to adjunct standard medication therapy in pain management of osteoarthritis (OA) amongst women aged 55 years and above. The clinical question is, “In women above 55 year old suffering from osteoarthritis of the lower back, how does acupuncture compared to the adjunct standard medication therapy decrease pain within 6 months?” the aims of the study are; Suggestion for acupuncture therapy for Osteoarthritis patients, Symptom management of OA, Pain alleviation for the OA patients, Improving functional status especially on the joint performance as well as enabling easy and painless movement by the patient, and Controlling disease progress. The paper reviewed, synthesized and summarized different studies from various databases with a span of less than five years. The project will apply quasi-experimental study design by use of a randomized controlled trial of the acupuncture therapies on the sample population of women beyond 55 years with osteoarthritis. Some of the instruments that will be used in the study include chart audit to track changes from the onset of the study to the end, and 100mmVisual Analog Scale (VAS) for measuring pain.

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Acronyms

Part1- Introduction

The identified practical issue the paper will address is the osteoarthritis in women above the age of 55 years. The Evidence-based practice (EBP) project will be present acupuncture as a pain management method on a patient whom has problems with osteoarthritic pain. Many people suffer from osteopathic pain which involves the joint. The cartilage or cushion between joints becomes swollen and stiff due to the break down causing pain. The major factor causing OA consist of excess weight, injury or overuse and genes, and other developmental issues. At least 80 percent of the people over 55 will show x-ray symptoms of Osteoarthritis in at least one joint (Cherniack & Cherniack, 2013). Before 55, Osteoarthritis is common in men. However, after 55 it becomes more common in women (Pelletier, 2010). Pain management is the challenge to these patients. Treatment options include medication, surgery, and therapy. The frequency of the disease calls for the adoption of alternative therapeutic approach in management. Given that it is a chronic illness, development of customized solutions for patients has enabled substantial benefits in the control of the disease. The EBP will majorly focus on acupuncture as a pain management method to osteoarthritis of the lower back for women aged 55 years and above.

People suffering from OA and seek pain relief outside the mainstream medicine have the option of acupuncture. According to Bahrami-Taghamaki et al (2014), acupuncture for thousands of years have been practiced and plays a significant role in pain relief. Using this treatment method, acupuncturists relieve pain by inserting slender metallic needles at specific points on the body. In their study, Manyanga et al (2014) elaborated that well inserted needle produce a signal that travels to the brain along the spinal cord. This triggers a release of enkephalins and endorphins which are transmitters that reduce pain sensation. Similarly, other studies suggest that inserting the acupuncture needle triggers cortisol production. Cortisol is a hormone that assists in controlling inflammation. Relief of pain is a matter of great concern to patients that suffer from OA and therefore detection of difference in results on the 100mmVisual Analog Scale (VAS) line is regarded as a change that is important clinically to patients having chronic pain.

Aim of project:

This project seeks to introduce acupuncture as the efficient, affordable and sustainable pain management solution for osteoarthritis in women over 55 years old. The paper hope to achieve the following improved outcomes:

1. Suggestion for acupuncture therapy for Osteoarthritis patients.
2. Symptom management of OA
3. Pain alleviation for the OA patients
4. Improving functional status especially on the joint performance as well as enabling easy and painless movement by the patient
5. Controlling disease progress

PICOT Question

In women above 55 year old suffering from osteoarthritis of the lower back (P), how does acupuncture (I) compared to the adjunct standard medication therapy (C) decrease pain (O) within 6 months? (T).

(P)- Population: The population will comprise of women aged 55 years and above who are ailing from OA of lower back.

(I)-intervention: Acupuncture treatment method will be given to the subjects.

(C)- Comparison: In the study, adjunct standard medication therapy will be used. The control group would be given adjunct standard medication therapy as a comparative treatment.

(O)- Outcome: Pain alleviation and increased joint functionality from the subjects under acupuncture treatment. This will be measured using 100mmVisual Analog Scale (VAS) that will be administered before treatment and after 6 month acupuncture treatment.

(T)-Time: The outcome will be measured after 6 months.

Significance

Adoption of acupuncture treatment method is of importance to manage the effects and suffering of OA patients. There have been several identified harmful effects of Non-steroidal Anti-inflammatory Drugs (NSAIDs). There are over 12,000 hospitalizations and 2,000 deaths related to NSAIDs complications in the country annually (Pelletier, 2010). Acupuncture is therefore the best alternative to adjunct standard medication therapy. In females above the age of 55 years and above, the body is on a declining scale for most of its biological functions. With respect to the toxicity and unsafe side effects of adjunct standard medication therapy, it is recommendable that this age group of women turns to proven alternative methods such as acupuncture (Cherniack & Cherniack, 2013). The cost of acupuncture is significantly lower than the standard options. Most of the procedures are simple and do not require sophisticated medical equipment for activities such as surgery (Pelletier, 2010).

Part 2- Evidence Review and Synthesis

Search of information is one of the most essential parts of carrying out an effective research on any topic. In order to get the most relevant literature for Evidence Based Practiced, it is quite paramount to have access to some of the most reputable search sites such as ProQuest (South’s Online Library), PubMed, Medline, among others. In order to have access to the most recent publications, I filtered my search to ensure that I only accessed peer-reviewed academic journal articles.

In carrying out appraisal using the Rapid Clinical Appraisal Tools, it mainly aimed at identifying some of the most evident methodological flaws found in the literature as well as providing consumers of specific research evidence with the opportunity to ensure they make highly informed decisions on the quality of the given research evidence. The Rapid Appraisal tool that was used in the appraisal included mixed research methods that were aimed at helping understand the entire article from different perspectives. The article that was used in the appraisal was White, A., Richardson, M., Richmond, P., Freedman, J., & Bevis, M. (2012). Group acupuncture for knee pain: evaluation of a cost-saving initiative in the health service, Acupuncture Medicine, 30, 170-175 from NCBI and in addition to other articles. In order to fully understand the concepts that were appraised in the article, it is quite essential to note the evaluation table and the search tracker template provided in Appendix 1 and 2

Summary of “Keeper” studies

There is a wealth of clinical literature supporting the usefulness of the acupuncture in the treatment of elderly patients suffering from osteoarthritis. Although most of the study shows that more research is needed to ascertain the efficiency of these drugs, they have also found that these traditional techniques have the same effectiveness in terms of reducing pain, but more efficient in terms of their tolerance towards adverse effect. These studies reveal the effectiveness of the acupuncture in treating chronic pain.

For example, Bahrami-Taghamaki et al (2014) argued that with the recent increased awareness of the acupuncture’s benefits for the management of chronic back pain by both the patients and professionals, the technique can be adjusted to become more beneficial than before. As a result, the authors compared the effectiveness of the regular acupuncture with a modified one which has been added confluent acupoints, which is a modification linked to the day time period in time technique acupuncture by conducting a randomized controlled trial using sixty patients from Beijing China. The authors randomly grouped the patients into two individuals to take acupuncture. The control group received the regular acupuncture (RA) while the test group (TA) received regular acupuncture together with acupuncture in confluent points related to time. To determine the changes between the two groups, the authors measured pain score using the Visual Analog Scale (VAS). The results revealed that the pain in the test group decreased from 69.6 ± 7.9 to 11.8 ± 4.9, and for the control group it reduced from 69.2 ± 8.0 to 15.7 ± 10.0 at a probability 0.001. The authors concluded that routine acupuncture with time method acupuncture was more effective and more beneficial to individual with chronic low back pain than the regular acupuncture.

Another study supporting the use of acupuncture in the treatment of chronic pain is a study by Iloth et al (2014). The authors argue that although there is evidence showing that acupuncture is an effective method in the management of chronic pain, it is not clear which method is the most effective. With this claim, the author evaluated the efficacy of trigger point acupuncture and associated it with sham acupuncture in the treatment shoulder pain and function using patients with chronic shoulder pain using randomized 18 patients (15 women and three men aged between 42 and 65 years) into two groups. The patients were neurological healthy and also had non-radiating shoulder pain. The first group received trigger points for muscle while the second group received the sham acupuncture for the same muscle each group received five sessions and outcomes were measured using the VAS and Shoulder function used Constant-Murley Score (CMS). After five weeks of treatment, the pain decreased, and shoulder functionality increased significantly at TrP (P=0.001). Furthermore, the comparison of the two areas using the outcome curve showed a significant difference between the two group (P=0.024). The results affirmed that TrP therapy is more effective for chronic shoulder pain than sham acupuncture treatment.

Manheimer et al (2015) also conducted a systematic review to show the efficacy of acupuncture in the treatment of low back pain. The data extracted were those related to pain, functionality, overall improvements, return to work, as well as analgesic consumption. The meta-analysis analyzing the effectiveness of acupuncture in treatment of short-term chronic pain revealed that acupuncture is more effective than sham treatment. However, the analysis did not show any conclusive analysis for acute low back pain. Additionally, there was also no conclusive of the efficacy of acupuncture compared with other therapies.

Further, a study by Manyanga et al (2014) evaluated the utility of acupuncture in the management of osteoarthritis. The study argues that previous trials have shown conflicting results, and some systematic reviews may have overstated the benefits of acupuncture. However, to provide credible evidences of the benefits of acupuncture, the authors examined two separate controlled trials of up to 2014 from different databases and pooled data expressed as mean differences with a confidence interval of 95%. The analysis of pain intensity by duration showed that there was greater pain reduction for a time greater than four weeks. The results led to the conclusion that acupuncture resulted in significant reduction of pain, improved functionality, as well as the quality of life.

Finally, the study by White et al (2012) provides a trial showing the effectiveness of acupuncture using patients with knee osteoarthritis which would otherwise be referred to an orthopedic surgeon. The authors evaluated the outcomes of the service’s year operations and the patients’ outcome at the end of 2010. Using patients’ data from the referral centers, as well as acupuncture clinics, and also attendance data and MYMOP symptoms and well-being of the patients, the author evaluated the effectiveness of the service and compared with possible outcomes from surgical intervention. The authors concluded that acupuncture was a practical alternative low-cost service for knee surgery services when treating knee osteoarthritis. The cost consequences showed an estimated saving of per year £100 000.

As a result, it is clear that there enough evidence showing that acupuncture is an effective method in the treatment of pain management. The research demonstrates that acupuncture is effective in reducing pain, improving functionality, as well as enhancing the quality of life for patient suffering due to different conditions.

Part 3- Purpose of the project

Clinical questions

The first clinical question is “In women above 55 suffering from osteoarthritis, can acupuncture compared to the adjunct standard medication therapy decrease pain over a 6 month period?”

The second clinical question is “After the implementation of the intervention will there be any improvement in the outcomes among the patients, and what some of the outcomes expected are and how will they be determined or measured?”

The purpose of this project is to bring forward an efficient, affordable and sustainable pain management solution for osteoarthritis in women over 55. The detailed purposes for the study include:

1. Suggestion alternative medication that is accupunure. This purpose is to identify the available acupuncture solutions for Osteoarthritis patients.
2. Symptom management- This project seeks to suggest methods that can be used in identification and control of OA symptoms for new patients. This helps the patients to seek help at the earliest possible opportunity and control the disease as it progresses in its stages.
3. Pain alleviation- This aim is to completely manage the pain suffered by the patient or to significantly reduce the pain to within manageable levels. Pain is a major challenge to Osteoarthritis patients that results in the reduced functioning of the patient’s joints. Management of pain would thus play a significant role in keeping the life of the patient comfortable.
4. Improving functional status- Improving this aims at increasing the joint performance as well as enabling easy and painless movement by the patient. Through this, the disease will have a minimal effect on the life and daily activities of the patient
5. Controlling disease progress- It is important to manage the progress of the disease and spread to other body joints. Managing the development of the disease ensures optimal functionality for the patients over a longer time.

Part 4: Methods

Study design

The clinical question of the study hints to the quasi-experimental study by use of a randomized controlled trial of the acupuncture therapies on the sample population of women beyond 55 years with osteoarthritis. It is quasi-experimental study design because it introduces evidence-based change of practice into a practical setting.

Procedure/intervention

For patients with knee osteoarthritis, they will lay first supine with a pillow under their knees for the treatment of the posterior aspect. The needles for treatment will be 3cm, 30 gauge strong dispensable filiform stainless steel needles. The deepness of the needle insertion will depend on the thickness of the skin and subcutaneous fatty tissues at the acupuncture points. In addition, the patients will be involved in exercises in the form of stretching or regular walking around the health center or at their homes for those receiving home-based care (Frontera, Slovik & Dawson, 2006). In addition, there will be an initial physiological examination to ascertain the state of patients health-wise before, during and after the six months. After the treatment session (6 months), a survey will be conducted to obtain information relevant to help in the intervention or not to their state or illness.

One group of participants will get administered with acupuncture intervention by qualified acupuncturists, while the other group will be administered using for the standard adjuvant treatment by qualified health professionals. Then, a comparison of the result from each of the two groups of providers will enable the researcher assess the accuracy and practicality of the evidence gathered from the literature review that acupuncture offers a better solution to pain problem in women over 55 years with osteoarthritis.

Setting

The study will be set at the health facilities serving the patients who meet the topic criteria according to verified medical records by the sample population, the health providers.

Instruments/scales and measurement of outcomes

The researcher will use a chart audit to track changes from the onset of the study to the end. The chart audit will enable the researcher and the sample population to identify differences in the levels of achievements between the onset of the study and the end thereby giving the kind of accuracy and practicality of using the acupuncture intervention for pain relief among women over 55 years old with osteoarthritis. VAS will also be used to measure pain levels among the women over 55 years suffering from arthritis

Confidentiality

The free will of patients will be sought by use of consent forms after thorough explanation of the study contents as required by the Institutional Research Board (IRB). Also, the free will of the health care providers to introduce the new intervention into their practice will be affected from free will evidenced by given consents and guided by use of theoretical models of behavior change and evidence-based nursing practice implementation. Besides, other ethical consideration like integrity and confidentiality of the patients will be observed by use of pseudonyms and coded data (Manyanga et al, 2014)..

Data collection

Johns Hopkins nursing evidence-based practice model (JHNEBP) will be used as the vehicle to guide the nursing change and process in the study in addition to current applications of Prochaska’s trans-theoretical model of behavior change as a means of effecting behavior change among the health provides to be used as the sample population. Nursing skills will be improved as measured by the patient outcomes using the JHNEBP model enabling cost-effectiveness and improved patient satisfaction. Prochaska’s trans-theoretical model of behavior change, on its part, will ensure that the sample population of heath care providers caring for women over 55 years old with osteoarthritis implement a change in practice as part of their behavior change.

Aligning stakeholders

A stakeholder is a person who has interest in a particular project and benefits from it. The stakeholders whom will be involved in this project include clinician, staff nurses, consultant, nurse coordinator and nurse director. They will all played different and important roles in the process of implementing the project. When new evidence is implemented into practise, women above 55 suffering from osteoarthritis would be a part of the stakeholders.

The Gathering Point Community Acupuncture, being the project owner, would have the privilege of benefiting from the success of implementation of evidence-based practice (EBP) project within its premises. The nurse director is the chief decision maker and supervised all the aspects of the project. He will be responsible for ensuring that the team adhered to established project standards, methodologies, processes, tools, policies and procedures (Grisham, 2010). He will be in charge of administering the program, training and coaching the employees on acupuncture therapy. Finally, he will also ensure that quality is maintained throughout the project so that efforts to improve quality would meet or surpass the needs or expectations of customers respectively.

The nurse coordinator is important in the project for collection, analyzing, organizing and distributing information about the EBP project and include but not limited to ISO 9001. Moreover, he is the reporting generator. Through his computer literacy, he generated reports about the project and to other stakeholders of the projects. The consultant on other hand offered assistance in training, providing advice on quality improvement aspects and ensured the new ideas were introduced to enable the project to be a part of the changes in the field (Binder, 2011).

The main purpose of staff nurses is to assist in the care of the women whom are suffering from osteoarthritis. On the other hand, the clinician will be providing the healthcare recommendations on osteoarthritis. Finally, the nursing director will ensure the smooth running of the project by providing a conducive legal environment and supplying necessary resources to run the project.

Part 5- Data Analysis

Expected Outcomes to be analyzed and how they will be analyzed

The intervention seeks to improve the current conditions of the patients, and hence the outcomes expected will assist in determining the effectiveness of the treatment. The various patients will show different changes after implementation of the study in other words; there will be variations in the pain levels. In the process, data on the various patients in regard to the intervention will be obtained. Most of the changes after implementation of the intervention will be physical, thus, data may be collected through observation. For instance, patients will be in a position to walk with minimal assistance or support, while others will not require any assistance in order to walk due to significant levels of pain. As such, information can be obtained through observation hence it will be integral in collecting such information. In addition, a t-test will be done to compare the effectiveness of the intervention among the patients affected in various parts of the body. The t-test will be used to measure dependent variables like natural therapies, physical activity, weight management or surgery. The analysis of variance, on the other hand, will be used to measure the independent variables which include level of pain and muscle strength.

Statistical analysis relating the data collection tools to be used

Some of the data collection tools will be through interviews, questionnaires, or observation of the patient before and after the intervention. The expected outcomes from the intervention will provide data/information which will be analyzed and later on interpreted. The information obtained from the various categories of patients, depending on the affected body parts will be analyzed statistically. The analysis will incorporate utilization of the paired t-test which will assist in determining the effectiveness of the intervention (Hill, 2012). There will also be an analysis of variance to examine the categories of patients. Additionally, the collected data will not only be analyzed using descriptive measures but also run through other tests to ascertain the correlation of the variables from the patients against the expectation of the adopted expectation of the adopted intervention.

The types of demographic data you plan to report on your participants

The participants have different attributes or features which can be used to differentiate them. Demographic data to be reported will be composed of age, income level, education level, geographical location, sex, race, gender, and religion. The demographic data regarding the participants will assist in knowing how they will affect or are affected by both the dependent and independent variables. Hence, they are integral in the analyzing of data and also for interpretation purposes. The demographic variables will be analyzed by conducting a t-test for comparative purposes and how they affect the study.

Conclusion

When it comes to health making choices physiotherapists and patients bring a range of values, preferences, experiences and skills. The practice of EBP is based on patients’ preferences and knowledge, and physiotherapists’ clinical skills.

Regarding systematic reviews, it is evident that exercise tends to lower pain and enhance function in patients. Nonetheless, there is no enough proof that acupuncture ultimately diminishes pain and that psycho-educational interventions improve psychological results.

Among physiotherapists, the most significant aim for the treatment of osteoarthritis is to lower pain and increase muscular strength. Physiotherapists are responsible for providing exercise, massage and stretching treatments for patients. Characteristics of patients cannot define the differences in clinical practice and acupuncture was linked with having searched medical databases to assist in answering the clinical question.

References

Bahrami-Taghamaki, H., Liu, Y., Azizi, H., Khorsand, A., Esmaily, H., Bahrami, A., & Zhao, B.X. (2014). A Randomized, Controlled Trial of Acupuncture for Chronic Low-Back Pain. Alternative Therapies in Health and Medicine, 20(3).

Binder, J. (2011). Global project management: Communication, collaboration and management across borders. Aldershot, Eng: Gower.

Cherniack, P., & Cherniack, N. S. (2013). Alternative medicine for the elderly. Berlin: Springer.

Grisham, T. W. (2010). International project management: Leadership in complex environments. Hoboken, N.J.: John Wiley & Sons.

Iloth, K., Saito, S., Sahara, S., Nartoh, Y., Imai, K., & Kitakoji, H. (2014). Randomized Trial of Trigger Point Acupuncture Treatment for Chronic Shoulder Pain: A Preliminary Study. Journal of Acupuncture and Meridian Studies, 7(2), 59-64.

Manheimer, E., White, A., Berman, B., Forys, K., & Ernst, E. (2015). Meta-Analysis: Acupuncture for Low Back Pain. Annals of Internal Medicine, 142 (8).

Manyanga, T., Froese, M., Zarychanski, R., Abou-Setta, A., Friesen, C., Tennenhouse, M., & Hay, B. (2014). Pain management with acupuncture in osteoarthritis: A systematic review and meta-analysis. BMC Complementary and Alternative Medicine, 14: 312. Retrieved from http://www.biomedcentralcom/1472-6882/14/1312

Odom, S. L., Brantlinger, E., Gersten, R., Horner, R. H., Thompson, B., & Harris, K. R. (2013). Research in special education: Scientific methods and evidence-based practices. Exceptional children, 71(2), 137-148.

Pelletier, K. R. (2010). The Best Alternative Medicine. New York: Simon & Schuster,

Roberts, P. (2011). Effective project management. London, UK: Kogan Page.

White, A., Richardson, M., Richmond, P., Freedman, J., & Bevis, M. (2012). Group acupuncture for knee pain: evaluation of a cost-saving initiative in the health service. Acupuncture Medicine, 30, 170-175. Doi: 10.1136/acupmed-2012-010151

Appendices

Appendix 1

Search Tracker

Appendix 2

Evaluation Table

Evaluation Table

Synthesis Table

Herman Bailey

With a student-centered approach, I create engaging and informative blog posts that tackle relevant topics for students. My content aims to equip students with the knowledge and tools they need to succeed academically and beyond.