How Researchers Reached The Flawed Conclusion That Acupuncture Doesn’t Help With Knee Pain

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How Researchers Reached The Flawed Conclusion That Acupuncture Doesn’t Help With Knee Pain By MARYGRACE TAYLOR SEPTEMBER 30, 2014
The effects of acupuncture on knee pain

Picture this scenario: An adult plagued with chronic headaches seeks relief by popping ibuprofen a few times a week. The meds help. Then she decides to stop taking them. And when she does, the pain creeps back.

Surprised? Not exactly. The last thing you’d deduce from this imaginary experiment is that ibuprofen doesn’t help with headaches. But that’s basically what researchers suggested about needle and laser acupuncture’s effect on chronic knee pain in a new JAMA study.

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In the clinical trial, 282 adults age 50 and older with chronic knee pain were randomly assigned to needle or laser acupuncture treatments or a sham laser acupuncture treatment. After 12 weeks, participants who received the acupuncture reported modest improvements in pain. Then the treatments stopped, and nine months later, the participants had knee pain again. This, weirdly, led the researchers to conclude that acupuncture just doesn’t offer relief from chronic knee pain.

Sounds confusing, right? Save for undergoing surgery, most chronic pain problems can never really be permanently solved. Even for treatments that make the discomfort vanish, it tends to come back once said treatment stops. That’s sort of a given. “Acupuncture can be used as pain management, but it doesn’t necessarily heal the pain permanently,” says Michelle Goebel-Angel, licensed acupuncturist at Chicago’s Raby Institute for Integrative Medicine at Northwestern.

There’s more. The researchers of this small study posit that having a larger sample size might have yielded more significant results. Which is exactly what experts uncovered in 2012 meta-analysis of nearly 18,000 patients, which found that needle acupuncture does help with osteoarthritis, as well as other types of chronic pain.

Still, like many treatments, acupuncture doesn’t have the same effect on everyone. But it’s absolutely worth trying, and tends to be the type of thing where the benefits accumulate over time (as in, longer than 12 weeks). “When patients feel the relief, they believe it,” says Goebel-Angel. “And that opens a new level of healing—the spiritual aspect of healing.”

MORE: 12 Odd Pain Relief Tricks That Work

Tags: NEWSDOCTORS & MEDICINEHEALTH HABITS & MISTAKES

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Acupuncture for knee osteoarthritis: reply by Hinman et al still denies real benefits for patients

• Adrian R White, Honorary University Fellow ; Mike Cummings,Plymouth University

http://acupmed.bmjjournals.com/content/33/1/86/reply

We thank Hinman and her colleagues for their considered reply to our letter. We accept that our approach was more informal than their response, but in our defence, we were writing originally for the audience of a general journal, rather than for methodologist and statisticians.

The main point we wished to make concerns the decision to power a study without any reference to previous literature or pilot data within the setting adopted. Of course it seems superficially justified to adopt a minimum change that you wish to measure (in this case a difference over sham of 1.8 on a 10 point scale), but if this difference has never been achieved in previous research it seems odd to invest so much unless the intention was to provide evidence of a lack of effect for acupuncture and laser acupuncture. More….http://acupmed.bmjjournals.com/content/33/1/86/reply

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Can Acupuncture Treat Knee Pain? Ge Nan, PhD, Yong Ming Li, MD, PhD

http://www.acupuncturetoday.com/…/can_acu_treat_knee_pain.p…

Can Acupuncture Treat Knee Pain?

Ge Nan, PhD, Yong Ming Li, MD, PhD

Recently an article in Journal of the American Medical Association concluded that “neither laser nor needle acupuncture conferred benefit over sham for pain or function” among older chronic knee pain patients. (JAMA, 2014;312:1313)

We, the practitioners of acupuncture and more broadly Traditional Chinese Medicine (TCM), believe this conclusion is premature. There has been several thousand years of acupuncture practice in history. Acupuncturists’ observation, patients’ feedback, many previous clinical trials, as well as basic researches, all suggest that acupuncture could effectively treat knee pain.

There are several flaws in the design of this article, which we will itemize and address below. In general, the key reasons are 1) the lack of an appropriate sham needle control in the trial, 2) poorly designed protocol and insufficient power of test, and 3) exaggerated data interpretation.

This study demonstrates better effectiveness of needle acupuncture over no treatment control.
This is consistent with observations in previous clinical trials and real clinical practice. Logically, this does not argue against needle acupuncture as a potential therapy for treating chronic knee pain.
The primary goal of this trial is to determine the efficacy of laser treatment, not needle acupuncture, in treating chronic knee pain, as clearly evidenced by authors own trial protocols and publications.
A negative result is concluded from the data, that is, laser treatment was shown not to be better than sham laser treatment or needle acupuncture.
The final conclusion of this study states: both needle acupuncture and laser treatment are not better than sham laser treatment, thus acupuncture should not be recommended for patients with chronic knee pain.
This conclusion is ungrounded, and quite frankly does not make sense. Sham laser treatment is not a valid control for needle acupuncture, thus the comparison is invalid.
The acupuncture protocol in this trial is poorly designed and does not reflect real clinical practice and management of patients with knee pain.
Acupuncture point selection, acupuncture dose and frequency, time course, and evaluation points was not optimal.
Among 282 patients participated in this trial (about 70 per group), with variable health conditions, only 54 patients completed needle acupuncture treatment (less than 1 treatment per week, for 12 weeks).
This small sample of patients does not provide enough statistical power to test the difference between acupuncture and sham treatments.
Twelve months is too long a time-peirod for a second point of follow-up, considering the treatment concluded at the end of 12-week.
Moderate or severe chronic knee pain occurs naturally among older patients. A more appropriate follow up regimen would be frequent survey over a shorter time period.
The author over emphasized the strength of Zelen design and ignored its limitation.
Despite randomization in the beginning, the usage of Zelen design in this study is not appropriate. For example, different treatment groups are not equally blinded during the trial, which will exert variable placebo or even nocebo effects and eventually lead to unfair among-group comparisons. Furthermore, 19% of the patients that refused needle acupuncture were analyzed as receiving the treatment. This is not an accurate comparison by any means.
This trial includes patients older than 50 years with moderate or severe chromic knee pain and the potential benefit effect of acupuncture on younger patients or older patients with mild knee pain cannot be ruled out.
Since publication, there have been a lot of debates around the efficacy of needle acupuncture. The investigators of this trial appeared on several public interviews to promote their negative findings on acupuncture and recommend their physical therapies to the patients. However, based on above analysis, we think the conclusion of this trial is premature and editors of JAMA should re-evaluate this report.

Summary of 2014 Australian Acupuncture Trial
Figure 1: Summary of 2014 Australian Acupuncture Trial for Knee Pain: The trial was originally designed to test laser treatment using needle acupuncture as a positive control (reference treatment). However, after collecting undesired results that the needle did not work as they expected, the authors changed their research aims to test both needle and laser treatments in final report.

NIH Summary
Figure 2: A recent summary by National Center for Complementary and Integrative Health (NCCIH) of NIH states acupuncture may help to reduce pain and improve joint mobility for osteoarthritis. NCCIH analysis was based on data published prior to 2010. The quality of acupuncture trials is crucial, because flawed negative data may change this balance in the future.

Can Acupuncture Treat Knee Pain?

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Chinese Doctors Poke Holes in Australian Acupuncture Trial for Chronic Knee Pain by Rana Hinman-reported by AcupunctureToday

Chinese Doctors Poke Holes in Australian Acupuncture Trial for Chronic Knee Pain by Rana Hinman- By Bill Reddy, LAc, Dipl. Ac..

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Chinese Doctors Poke Holes in Australian Study- By Bill Reddy, LAc, Dipl. Ac.

Chinese Doctors Poke Holes in Australian Study

By Bill Reddy, LAc, Dipl. Ac.

http://www.acupuncturetoday.com/mpacms/at/article.php?id=33043

Editor’s Note: In addition to this interview, you can find several resources regarding this study atwww.acupuncturetoday.com, including a PDF of the Australian study published in JAMA, an article in response to the flaws seen in this study, the Letter to the Editor of JAMA referenced in this interview and a complaint letter from the Traditional Chinese Medicine American Alumni Association (TCMAAA).

For more information about the TCMAAA, contact: Selene Hausman, LAc at 480-510-2259 or via email at seleneph@gmail.com.

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A recent Australian clinical trial, published in theJournal of the American Medical Association (JAMA) in 2014 by Rana Hinman, et el., evaluating the effectiveness of both needle and laser acupuncture for chronic knee pain, caught the attention of Dr.’s Hongjian He, AP, MD, PhD; Lixing Lao, PhD, MB; Wing-Fai Yeung, BCM, PhD; and Yong Ming Li, MD, PhD. They were astonished to read that the conclusions of the study stated, “In patients older than 50 years with moderate or severe chronic knee pain, neither laser nor needle acupuncture conferred benefit over sham for pain or function. Our findings do not support acupuncture for these patients.” Obviously, that statement didn’t reflect their combined clinical experience. Upon further investigation, they felt there were serious design flaws in the study and wrote letters to the editor ofJAMA expressing their concerns that were published in February 2015 along with the Australian researchers’ responses.

more detail at: http://www.acupuncturetoday.com/mpacms/at/article.php?id=33043

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