Evidence from RCTs on optimal acupuncture treatment for knee osteoarthritis - An exploratory review

Pain Treatment Unit, Dos Hermanas, Sevilla, Spain.
Acupuncture in Medicine (Impact Factor: 1.5). 07/2007; 25(1-2):29-35. DOI: 10.1136/aim.25.1-2.29
Source: PubMed


There are many differing opinions on what constitutes an optimal acupuncture dose for treating any particular patient with any particular condition, and only direct comparisons of different methods in a clinical trial will provide information on which reliable decisions can be made. This article reviews the recent research into acupuncture treatment for osteoarthritis of the knee, to explore whether any aspects of treatment seem more likely to be associated with good outcome of treatment. Among four recent, high quality RCTs, one showed a much greater treatment response than the other three, and the possible factors are discussed. A recent systematic review included 13 RCTs, and this article discusses the possible explanations for differences in their outcomes. It is speculated that optimal results from acupuncture treatment for osteoarthritis of the knee may involve: climatic factors, particularly high temperature; high expectations of patients; minimum of four needles; electroacupuncture rather than manual acupuncture, and particularly, strong electrical stimulation to needles placed in muscle; and a course of at least 10 treatments. These factors offer some support to criteria for adequate acupuncture used in the recent review. In addition, ethnic and cultural factors may influence patients' reporting of their symptoms, and different versions of an outcome measure are likely to differ in their sensitivity - both factors which may lead to apparent rather than real differences between studies. The many variables in a study are likely to be more tightly controlled in a single centre study than in multicentre studies.

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    • "Although the optimum dosage50,51,83,85,124 (frequency of treatment sessions per week or month), duration (length of time the needles should remain in situ), and intensity (the number of needles used and degree of manual manipulation or electrical stimulation) has yet to be determined23,24,50,51,83,85,114,135,174 for many neuromusculoskeletal conditions, the vast majority of ‘dry’ needling randomized controlled trials attempt to elicit a deqi response.175,176 Deqi has been defined as a dull ache, heaviness, distension, numbness, tingling, cramping, pressure, fullness, spreading, warmth, or coolness.175,176 "
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    ABSTRACT: Background: Wet needling uses hollow-bore needles to deliver corticosteroids, anesthetics, sclerosants, botulinum toxins, or other agents. In contrast, dry needling requires the insertion of thin monofilament needles, as used in the practice of acupuncture, without the use of injectate into muscles, ligaments, tendons, subcutaneous fascia, and scar tissue. Dry needles may also be inserted in the vicinity of peripheral nerves and/or neurovascular bundles in order to manage a variety of neuromusculoskeletal pain syndromes. Nevertheless, some position statements by several US State Boards of Physical Therapy have narrowly defined dry needling as an ‘intramuscular’ procedure involving the isolated treatment of ‘myofascial trigger points’ (MTrPs). Objectives: To operationalize an appropriate definition for dry needling based on the existing literature and to further investigate the optimal frequency, duration, and intensity of dry needling for both spinal and extremity neuromusculoskeletal conditions. Major findings: According to recent findings in the literature, the needle tip touches, taps, or pricks tiny nerve endings or neural tissue (i.e. ‘sensitive loci’ or ‘nociceptors’) when it is inserted into a MTrP. To date, there is a paucity of high-quality evidence to underpin the use of direct dry needling into MTrPs for the purpose of short and long-term pain and disability reduction in patients with musculoskeletal pain syndromes. Furthermore, there is a lack of robust evidence validating the clinical diagnostic criteria for trigger point identification or diagnosis. High-quality studies have also demonstrated that manual examination for the identification and localization of a trigger point is neither valid nor reliable between-examiners. Conclusions: Several studies have demonstrated immediate or short-term improvements in pain and/or disability by targeting trigger points (TrPs) using in-and-out techniques such as ‘pistoning’ or ‘sparrow pecking’; however, to date, no high-quality, long-term trials supporting in-and-out needling techniques at exclusively muscular TrPs exist, and the practice should therefore be questioned. The insertion of dry needles into asymptomatic body areas proximal and/or distal to the primary source of pain is supported by the myofascial pain syndrome literature. Physical therapists should not ignore the findings of the Western or biomedical ‘acupuncture’ literature that have used the very same ‘dry needles’ to treat patients with a variety of neuromusculoskeletal conditions in numerous, large scale randomized controlled trials. Although the optimal frequency, duration, and intensity of dry needling has yet to be determined for many neuromusculoskeletal conditions, the vast majority of dry needling randomized controlled trials have manually stimulated the needles and left them in situ for between 10 and 30 minute durations. Position statements and clinical practice guidelines for dry needling should be based on the best available literature, not a single paradigm or school of thought; therefore, physical therapy associations and state boards of physical therapy should consider broadening the definition of dry needling to encompass the stimulation of neural, muscular, and connective tissues, not just ‘TrPs’.
    Full-text · Article · Aug 2014 · Physical Therapy Reviews
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    • "By the end of 2009, all but six states had passed legislation authorizing acupuncture practice and regulation. Regarding treatment, there is an ample body of research on acupuncture efficacy with certain disease conditions (Cheng 2009; Ezzo et al., 2006; Linde et al., 2009; Vas & White, 2007); mechanisms of action (Cabioglu & Surucu, 2009; Crisostomo, Li, Tjen-A-Looi, & Longhurst, 2005; Han, 1998; Kaptchuk, 2002; Zhou, Fu, Tjen-A-Looi, Li, & Longhurst, 2005), along with well-documented studies describing why patients seek out acupuncture services (Bonefede et al., 2008; Burke, Upchurch, Dye, & Chyu, 2006; Gray et al., 2002; ). Despite the establishment of a literature on acupuncture research and utilization, the Bureau of Labor and Statistics (BLS) does not list acupuncturist as a profession and, therefore, does not track occupational data. "
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    ABSTRACT: Factors that determine practice success have not been thoroughly examined in the acupuncture profession. Five surveys representing three important communities within acupuncture provide a window into some of the factors that these groups believe influence economic success. Acupuncture communities have historically aligned on preferences for theoretical foundations, spiritual beliefs, and needling techniques. Recently, communities within the profession have conducted surveys to learn how other acupuncturists are doing in terms of income, number of work hours, typical fees, how much student loan debt acupuncturists retain post graduation, and how this student loan debt may be paid by these LAc loanholders. Knowledge about the relationships of income levels, years in practice, and hours worked can empower current and emerging practitioners to gauge the likelihood of their ability to practice successfully and pay off their student loan debt. Generally speaking, the respondents to these independent surveys charge fees between $20 and $65 per patient visit; work approximately 30 or fewer hours per week; and generate median gross incomes between $20,000 and $50,000. Mean figures are generally higher. These surveys are not representative of the profession as a whole because the groups that completed them are a few among the myriad groups found within the profession. The surveys were constructed in such a way that data required transformations for the sake of making comparisons. Despite data limitations in a profession where workforce survey data are rare, it is important to examine any findings that shed light on the acupuncture workforce.
    Full-text · Article · Jan 2012
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    • "Some clinical trials that compared acupuncture with no treatment or other treatment modalities have been reported [1-6]. However, variability in the study results [7,8] makes the interpretation difficult [9-11]. Some positive results were mistakenly attributed to placebo [12]. "
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    ABSTRACT: Variable results of pain alleviation in response to acupuncture have been reported, complicating its interpretation. Sources of variability are probably multi-factorial, including the contribution of gender related effects. Gender related variation in perceived pain has been discussed frequently, but documented effects of acupuncture referring to gender are sparse. Furthermore, factors such as operationalisation of the outcome variable and the statistical method for evaluation could also be sources of variability. When pain is regarded as subjective, the produced data should be treated as ordinal. The rank-based method by Svensson, taking the non-metric qualities of the ordinal data into account as well as the variability at the group and the individual level, is therefore an alternative. The present commentary aims to (1) evaluate changes in electrical sensory thresholds and electrical pain thresholds after low frequency electro-acupuncture separately in healthy women and men; (2) introduce and exemplify the method by Svensson in a user-friendly approach. To analyze the systematic patterns of change in thresholds, indicating evidence of treatment on a group level, the relative position (RP) and relative concentration (RC), were measured. The variation related to the individual, the relative rank variation (RV) was also measured. The results were divergent between women (n = 23) and men (n = 22), i.e. unchanged sensory threshold after acupuncture at the group level in women while changed in men. The assessed pain threshold after acupuncture on the other hand was changed towards higher levels in women and unchanged in men. The individual variation was apparent in both women and men but larger in women. For statistical analysis of the variability for both group and individual related effects, the rank-based method by Svensson could be used. The present study indicates that evaluation of sensory and pain threshold response should be analysed separately in women and men.
    Full-text · Article · Sep 2010 · Chinese Medicine
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