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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Acupunture vs prescribed medication
- Dr Tanveer Afzal Afzal (17 August 2007)
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Do the poor results of this study reflect inadequate or incorrect use of TCM acupuncture methodology?
- Wainwright Churchill (29 August 2007)
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Exercise trumps acupuncture: but needles should not be dismissed
- Adrian R White (31 August 2007)
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Re: Exercise trumps acupuncture: but needles should not be dismissed
- John P Heptonstall (1 September 2007)
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Was the control procedure really a placebo?
- Anthony Campbell (1 September 2007)
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Re: Was the control procedure really a placebo?
- John P Heptonstall (10 September 2007)
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Physical exercise and Acupuncture in the treatment of knee osteoarthritis - Not both - but maybe either one of them?
- Thomas CM Lundeberg, Thomas Lundeberga, Mike Cummingsb and Irene Lundc (18 September 2007)
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Re: Physical exercise and Acupuncture in the treatment of knee osteoarthritis - Not both - but maybe either one of them?
- John P Heptonstall (19 September 2007)
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Clearly suboptimal acupuncture
- Andrew Hoe (1 October 2007)
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Is only patient masking acceptable for acupuncture studies?
- Nobuari Takakura, Hiroyoshi Yajima (22 October 2007)
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Dr Tanveer Afzal Afzal, Doctor Manchester
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As a medical student you dedicate your life to studying and eventually prescribing drugs to deal with pain. However, as a doctor in working overseas I have seen firsthand the vast amounts of people preferring acupuncture as an alternative to prescribed medication. From, my experience this is due to the fact they have long standing problems such as osteoarthritis cannot be permanent relief from their drugs instead they become reliant. As well as the side effects they are wary of taking pain killers for a long period therefore the viable alternative is acupuncture. However, my own experience leads me to believe that acupuncture gives very little temporary relief but this is not an answer or a cure as patients who stop their acupuncture treatment usually face the same problems as before they begun their treatment. In my opinion exercise, physiotherapy combined with medications such as glucosamine usually help the patient,. More importantly, patients do not need to become dependent on painkillers. So, I agree with the findings of this research that acupunture doesnt give any substantial benefits to the patients compared with patients taking only exercise and supportive measures. Competing interests: None declared |
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Wainwright Churchill, TCM Acupuncturist and Herbalist London, UK
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I am writing to comment on the following passage in this study: “Advice and exercise plus true acupuncture
As a TCM acupuncturist with over 20 years of clinical experience, I wish to point out that the acupuncture protocols used in this study are very different from standard Traditional Chinese medicine (TCM) acupuncture practice, even though a person not knowledgeable about TCM might believe that they conform to standard TCM practice. In TCM practice, knee pain, including that related to osteoarthritis, is always diagnosed further, and the resulting diagnosis is used as a basis for acupuncture treatment. This diagnosis does not appear to have been done in this research. Acupuncture point selection is careful and balanced, and it would be extremely artificial to restrict the choice to only the 16 points listed. On the other hand, selecting 10 of those points might well be considered to be excessive in many and perhaps most cases. De qi – needle sensation – is used in TCM practice in a very precise manner, coupled with needle manipulation techniques. Different ways of manipulating needles have very different purposes and results. The uniform method employed in this study would seem to correspond to what is called a strong dispersing technique, and the decision to use strong dispersing on every acupuncture point is very surprising, and almost certainly contrary to standard TCM acupuncture practice, in which one would almost certainly treat different points using de qi and needle manipulation differently. It could be anticipated that treating points such as ST 36, SP 6 and KI 3 with strong dispersing manipulation might be counterproductive to treatment, and even harm the patient from a Chinese diagnostic perspective. Furthermore, additional refinements of acupuncture treatment, such as using moxibustion, could be considered very important, if not essential, in TCM acupuncture. Systematically eliminating these refinements of therapeutic practice appears to be arbitrary, and in fact wrong. In brief, the protocols that were used in this study only bear a superficial resemblance to standard TCM acupuncture. In fact, from a TCM point of view, the treatment protocol adopted might not be only poor, it might even be actively bad. I wonder whether the protocols adopted in this study account for the poor results obtained, which stand in contrast to systematic reviews which have concluded that acupuncture is more effective than placebo for osteoarthritis of the knee. I would also point out that TCM acupuncture is not a trivial discipline that can be practised correctly without a great deal of training. There is a tendency for people working in the areas of conventional medicine to trivialize it. Inadequate training and expertise in TCM acupuncture is often apparent in Western clinical studies that purport to be based on TCM acupuncture, and it is extremely likely that the results of such studies reflect substandard practice. Such concerns have been raised, for example, with regard to recent acupuncture trials in Germany – see Birch, 2007 [1]. Reference [1] S. Birch (2007). Reflections on the German Acupuncture Studies. Journal of Chinese Medicine, No. 83, February 2007, p12-17. Available at http://www.jcm.co.uk/media/cms/File/Birch.pdf Competing interests: None declared |
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Adrian R White, Clinical Research Fellow Peninsula Medical School, N32 ITTC Building, Tamar Science Park, Plymouth PL6 8BX
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Foster et al are to be congratulated for their rigorous study on acupuncture, sham acupuncture and exercise for osteoarthritis of the knee.1 They showed how useful well supervised, intensive and sustained exercise can be, when used as a first line treatment for these patients. They also showed that acupuncture is not appropriate for first line management (at least, not when it is applied in the form they used, with only 6 sessions and no electroacupuncture - acceptable but probably suboptimal). This is in line with current thinking, namely that acupuncture is best kept in reserve for patients who cannot, or will not, do their exercises, or have done them but found no benefit, or are in special circumstances.2 Acupuncture certainly seems to offer considerable advantage over non-steroidal drugs in this situation, both for efficacy and safety.3 Foster et al found no difference between the effectiveness of real and of sham acupuncture, so they comment that it is ‘… difficult to sustain the argument that the observed effects of acupuncture are explained by specific physiological mechanisms of needling and eliciting de qi sensations’. They should consider another possible interpretation: that the intensive exercise had the maximum possible effect in these patients, and so trumped any possible effect of acupuncture. After all, it has been proposed that exercise and acupuncture operate by very similar mechanisms;4 another recent study5 also showed that acupuncture had little effect in addition to exercises, in contrast to other studies where acupuncture was given alone and was superior to sham;6;7 and the combined evidence shows a clear statistical benefit for acupuncture compared with sham controls.8;9 They are careful not to generalise about the mechanisms of acupuncture in their Abstract, but I wanted to draw your readers’ attention to this comment in the Discussion section so that it is not misinterpreted. Reference List (1) Foster NE, Thomas E, Barlas P, Hill JC, Young J, Mason E et al. Acupunctue as an adjunct to exercise based physiotherapy for osteoarthritis of the knee: randomised controlled trial. BMJ 2007;335:436 (2) Williamson L, Wyatt MR, Yein K, Melton JT. Severe knee osteoarthritis: a randomized controlled trial of acupuncture, physiotherapy (supervised exercise) and standard management for patients awaiting knee replacement. Rheumatology (Oxford) 2007; 46(9):1445-1449. (3) White A, Kawakita K. The evidence on acupuncture for knee osteoarthritis - editorial summary on the implications for health policy. Acupunct Med 2006; 24 Suppl:S71-S76. (4) Andersson S, Lundeberg T. Acupuncture - from empiricism to science: functional background to acupuncture effects in pain and disease. Med Hypotheses 1995; 45(3):271-281. (5) Scharf HP, Mansmann U, Streitberger K, Witte S, Kramer J, Maier C et al. Acupuncture and knee osteoarthritis - a three-armed randomized trial. Ann Intern Med 2006; 145(1):12-20. (6) Berman BM, Lao L, Langenberg P, Lee WL, Gilpin AM, Hochberg MC. Effectiveness of acupuncture as adjunctive therapy in osteoarthritis of the knee: a randomized, controlled trial. Ann Intern Med 2004; 141(12):901 -910. (7) Witt C, Brinkhaus B, Jena S, Linde K, Streng A, Wagenpfeil S et al. Acupuncture in patients with osteoarthritis of the knee: a randomised trial. Lancet 2005; 366(9480):136-143. (8) White A, Foster NE, Cummings M, Barlas P. Acupuncture treatment for chronic knee pain: a systematic review. Rheumatology (Oxford) 2007; 46(3):384-390. (9) Manheimer E, Linde K, Lao L, Bouter LM, Berman BM. Meta- analysis: acupuncture for osteoarthritis of the knee. Ann Intern Med 2007; 146(12):868-877. Competing interests: The author is paid as Editor of the journal Acupuncture in Medicine |
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John P Heptonstall, Director of the Morley Acupuncture Clinic Leeds LS27 8EG
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I am surprised that Adrian White omits to mention perhaps the most glaring and important points, alluded to by Wainwright Churchill above, that invalidate this study. Osteoarthritis (as opposed to rheumatoid arthritis), in TCM and western medical (WM) terms, by it's nature tends to develop over many years and therefore afflicts the elderly more than young. It involves alternating periods of inflammation ('hot' periods in TCM) that is improved with rest and inti-inflammatory treatment, and periods of 'cold' (to TCM but unrecognised in WM) for which the frequency increases with respect to 'hot' periods as the condition becomes more chronic. As Western medicine does not recognise 'cold' periods for osteoarthritis its practitioners maintain anti-inflammatory (make the condition cold) treatments throughout both hot and cold periods, thereby most probably adding to the chronic deterioration where patients suffer predominently cold symptoms. TCM provides 'cold' treatments for inflammatory (hot) periods through the use of acupuncture; a technique that can be enhanced with the application of electrical stimulation (electroacupuncture). TCM provides 'hot' treatments for cold periods through the application of moxibustion (eg. burning the herb artemesia vulgaris either directly over skin or via the acupuncture needles). A patient whose osteoarthritis is in a hot/inflammatory period (hot to touch, red, swollen, worse with increasing movement, better for rest) should receive acupuncture or electroacupuncture. If one applies that regime to a patient whose osteoarthritic state is 'cold', it will cause the condition to deteriorate over time. A patient whose osteoarthritis is in a cold state (cold to touch, better for warmth, better for movement, worse for rest, worse in cold damp environment) requires heat treatment - in TCM that would be moxibustion - without which the condition cannot improve. Anti-inflammatories (eg NSAIDS) will worsen the condition. Clearly the authors/researchers of the quoted study had little clue about TCM as, unless they excluded patients with 'cold' osteoarthritis before using only needling, they would guarantee all those in a 'cold' state of disease deterioration of their osteoarthritis. The patients who would benefit over time from acupuncture would have to be suffering 'hot' stage osteoarthritis during the trial. I can find no evidence that patients were excluded with 'cold' stage osteoarthritis therefore the study is invalidated by the stringent TCM standards. Of course, as exercise improved the patients' conditions (better for movement) they must be have been suffering predominently 'cold' osteoarthritis and, as explained above, acupuncture would be contraindicated unless accompanied by moxibustion ('hot') applications. The application of acupuncture without moxibustion to such sufferers is an abuse of TCM principles and patients. Competing interests: A TCM Specialist |
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Anthony Campbell, retired retired
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The placebo control used in this trial was a blunt-tipped needle that retracted into the handle. Curiously, this appeared to give greater and more prolonged relief than did "true" acupuncture. A possible reason for this is that gentle tactile stimulation of C tactile fibres in the hairy skin appears to activate limbic system areas responsible for feelings of well-being(1). It is therefore questionable whether even gentle skin stimulation can be considered a genuine placebo. I also have a question about the best acupuncture treatment to use for joint pain. including knee pain. I have generally found that periosteal stimulation, first described in detail by Mann(2), is the most effective form. It consists in brief (3-5 second) "pecking" or tapping with the needle over the medial subcondylar area of the tibia. This, in ny experience, is surprisingly effective although not necessarily long- lasting; patients often require repeated treatment at intervals of perhaps 8 to 12 weeks. As the treatment is quick, however, it is not a big drain on resources. I would however agree that exercise should be an integral part of the treatment and, at least when the problem is not too severe, this may render repeated acupuncture unnecessary. References: 1.Campbell A, Role of C tactile fibres in touch and emotion - clincal and research relevance to acupuncture. Acupuncture in medicine 2006;24(4):169-171. 2.Mann, F. Reinventing Acupuncture (2nd edition):Butterworth- Heinemann, Oxford, 2000. Competing interests: None declared |
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John P Heptonstall, Director of the Morley Acupuncture Clinic Leeds LS27 8EG
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As I said above, acupuncture in cases of 'cold' disease will tend to deteriorate the condition over time; ipso facto not giving acupuncture, or giving an intervention that is not of a 'cold' form, will be better than acupuncture. A 'placebo' such as doing nothing at all would be better than acupuncture where the latter is contraindicated. Perhaps Anthony Campbell can explain what is meant in TCM by 'cold' disease and, if so, what fibres or other aspects of neurological systems could be effected that might improve said 'cold' conditions? Competing interests: TCM Specialist |
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Thomas CM Lundeberg, MD PhD Rehabilitationmedicine University Clinic Stockholm, Stockholm Danderyds Hospital AB, SE-182 88 Stock, Thomas Lundeberga, Mike Cummingsb and Irene Lundc
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It has been hypothesised that acupuncture and physical exercise activates similar pain inhibitory mechanisms (Andersson, Lundeberg, 1995). If so, it would not be expected that patients treated with both physical training and acupuncture (or superficial needling) would report a better effect. This suggestion is supported by the elegant study in the BMJ by Foster and collaborators (2007). The real issue though is whether acupuncture or physical training should be recommended as both modalities have proven to be effective (White et al., 2007; Devos-Comby et al., 2006). Furthermore, in the present study the authors have used manual acupuncture despite the fact that electrocupuncture is the modality that is likely to be most efficiaous in knee osteoarthritis (OA) pain (Vas, White 2007). The statement that the effects of acupuncture were short lived (like analgesics are in OA) is likely relevant since the primary outcome was change in rated pain 6 month after treatment based on 6 treatments. In a clinical context both modalities may be recommended in patients with osteoarthritis; i.e. patients that can exercise should exercise (active treatment), whereas patients who cannot exercise may be treated with acupuncture (passive treatment). Also, patients that are not candidates for exercise may after some initial acupuncture treatments start with physical exercise. Before general treatment recommendations are stated they should be based on results of comparative studies with the actual state of the clinical condition and the optimal treatment modalities taken into account in order to offer the best treatment for the patient. The number of acupuncture treatments (commonly at least 8-10 are recommended possibly with additional “top ups”) as well as the stimulus intensity used (all patients did not experience de Qi, which is considered a prerequisite) is probably suboptimal when aiming for an up-regulation of the function in the endogenous pain inhibiting system with observational effects 6 months after treatments. A further study comparing 10 sessions of electroacupuncture (including induction of de Qi) with 10 sessions of physical exercise would be of great interest. References 1. Andersson S, Lundeberg T. Acupuncture-from empiricism to science: functional background to acupuncture effects in pain and disease. Med Hypotheses 1995;45(3):271-81. 2. Foster NE, Thomas E, Barlas P, Hill JC, Young J, Mason E, Hay EM. Acupuncture as an adjunct to exercise based physiotherapy for osteoarthritis of the knee: randomised controlled trial. BMJ 2007; 335(7617):436. 3. Vas J, White A. Evidence from RCTs on optimal acupuncture treatment for knee osteoarthritis--an exploratory review. Acupunct Med 2007;25(1-2):29-35. 4. White A, Foster NE, Cummings M, Barlas P. Acupuncture treatment for chronic knee pain: a systematic review. Rheumatology (Oxford) 2007;46(3):384-90. 5. Devos-Comby L, Cronan T, Roesch SC. Do exercise and self- management interventions benefit patients with osteoarthritis of the knee? A metaanalytic review. J Rheumatol 2006;33(4):744-56. Competing interests: None declared |
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John P Heptonstall, Director of the Morley Acupuncture Clinic Leeds LS27 8EG
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Dr Lundeberg is correct in asserting that the experience of de Qi can enhance prospects for improvement, though it is certainly not essential – particularly with stimulation enhanced through ectroacupuncture (EA) which, despite positioning of needles not quite optimally, the constant electrostimulation will usually ‘seek’ out the nearby meridian pathway. However, as I already stated, according to TCM principles one requires the application of moxibustion to cure or greatly improve the cold chronic type osteoarthritic conditions. It is relatively easy to provide limited pain relief for arthritic knees, be they cold or hot, using acupuncture or EA but for long-term reversal of chronically cold osteoarthritic knees and therefore the most effective long term pain relief one requires to incorporate moxibustion into the intervention. I am surprised that physicians who feel able to comment on the use of acupuncture for arthritic states under TCM principles do not appear to have an opinion on moxibustion – which is an essential consideration if one purports to use a TCM basis for the intervention. A few references for the effects of moxibustion are:- http://www.ncbi.nlm.nih.gov/sites/entrez? Db=PubMed&Cmd=ShowDetailView&TermToSearch=17432646&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=PubMed&list_uids=15077934&dopt=Citation http://www.ncbi.nlm.nih.gov/sites/entrez?cmd=Retrieve&db=PubMed&list_uids=16312925&dopt=AbstractPlus Zhongguo Zhen Jiu. 2007 Jul ;27 (7):513-5 17722832 at http://lib.bioinfo.pl/auth:Zhang,HF Competing interests: TCM Specialist |
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Andrew Hoe, Physiotherapist Oxfordshire Primary care Trust
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We already have other evidence to support the use of acupuncture in the treatment of osteoarthritis of the knee in the form of systematic review, meta-analysis, safety-profiling and cost-benefit analysis (Acupuncture in Medicine 2006, Vo. 24, Supplement).
However, other controlled trials that have shown positive effects for acupuncture on chronic knee conditions have used considerably longer courses of treatment than that used by Foster et al. (2007) who used “up to six treatments” (Foster et al. 2007, p.5). This is illustrated below: Authors [Number of treatments used] Berman et al. (2004) [23] Scharf et al. (2006) [10 or 15] Witt et al. (2006) [up to 15] Vas et al. (2004) [12] Sangdee et al. (2002) [12] Witt et al. (2005) [12] Tukmachi et al. (2004) [10] In their review, White et al. (2007) included a meta-analysis which also demonstrated positive effects for acupuncture in this condition, however, in six out of the eight studies which were of a good-enough quality and similarity to be included electro-acupuncture was used. Among scientific acupuncturists this is commonly believed to be a stronger form of acupuncture treatment. Therefore Foster et al. (2007) have used the weaker form of acupuncture (manual acupuncture) and they have chosen to use only about 50% of the amount that other research teams have deemed it necessary to use, despite their claims that this meets minimum standards of “adequacy”. In short, there is a very real possibility that the negative findings in this trial are due to the suboptimal use of acupuncture in terms of number of treatments and type of acupuncture applied. References Berman B.M., Lao L., Langenberg P., Lee W.L., Gilpin A.M., Hochberg M.C. (2004) Effectiveness of acupuncture as adjunctive therapy in osteoarthritis of the knee: a randomized controlled trial. Annals of Internal Medicine 141 (12) 901-10 Foster N.E., Thomas E., Barlas P., Hill J.C., Young J, Mason E., Hay E.M. (2007) Acupuncture as an adjunct to exercise based physiotherapy for osteoarthritis of the knee (15 August 2007). www.bmj.com Sangdee C., TeeKachunhatean S., Sanapanich K, Sugandhavesa N., Chiewchantanakit S., Pojchamarnwiputh S., Jayasvasti S. (2002) Electroacupuncture versus Diclofenac in symptomatic treatment of osteoarthritis of the knee: a randomized controlled trial. Complementary and Alternative Medicine 2 Scharf H-P, Mansmann U., Steitberger K., Witte S., Kramer J., Maier C., Trampisch H-J., Victor N. (2006) Acupuncture and knee osteoarthritis. Annals of Internal Medicine 145 12-20 Tukmachi E., Jubb R., Dempsey E., Jones P. (2004) The effect of acupuncture on the symptoms of knee osteoarthritis – an open randomised controlled study. Acupuncture in Medicine 22 (1) 14-22 Vas J., Mendez C., Perea-Milla E. (2004) Acupuncture as a complementary therapy to the pharmacological treatment of osteoarthritis of the knee: randomised controlled trial. British Medical Journal 329 (7476) 1216-1219 White A., Foster N., Cummings M., Barlas P. (2007) Acupuncture treatment for chronic knee pain: a systematic review. Rheumatology 54 Witt C., Brinkhaus B., Jena S., Linde K., Streng A., Hummelsberger J., Walther H.U., Melchart D., Willich S.N. (2005) Acupuncture in patients with osteoarthritis of the knee: a randomised trial. The Lancet 366 (Jul 9-Jul 15) Witt C.M., Jena S., Brinkhaus B., Wegscheider K., Willich S.N. (2006) Acupuncture in patients with osteoarthritis of the knee or hip: A randomized controlled trial with an additional nonrandomized arm. Arthritis and Rheumatism 54 (11) 3485-3493. Competing interests: Practicing physiotherapist using acupuncture. |
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Nobuari Takakura, Lecturer Hanada College 150-0031, Hiroyoshi Yajima
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In a recent single-blind study on acupuncture for knee osteoarthritis, Foster et al. concluded that true acupuncture did not show any greater therapeutic benefit than a credible control procedure (1). The conclusions deduced from a single-blind acupuncture study, possibly of the highest design level, remain controversial because of the unfeasibility of practitioner masking (2, 3). This is because patients may have been strongly biased towards the unmasked practitioner (3), thereby compromising the efficacy of acupuncture based on the practitioner/researcher's approach towards acupuncture. However, the report and related rapid responses skirted the issue that the practitioners were not blinded to the type of needle that was being administered. Considering the significant amount of patient-provider interaction in acupuncture therapy, a double-blind (practitioner-patient masking) procedure is an essential tool for minimizing biases especially in this field. However, the single-blind assessment has apparently been accepted as the only plausible method in acupuncture research, although it fails to meet the methodological standards for study blinding in current medical practice (2, 3). Recently, we solved the methodological conundrum of practitioner masking by designing a double-blind placebo needle for acupuncture research (4). Given the recent increase in interest in the field of acupuncture research and practice, we should pave the way for double-blind experiments and scientifically assess the genuine effect of acupuncture. Nobuari Takakura, Hiroyoshi Yajima
1 Foster NE, Thomas E, Barlas P, Hill JC, Young J, Mason E, Hay EM. Acupuncture as an adjunct to exercise based physiotherapy for osteoarthritis of the knee: randomized controlled trial. BMJ 2007;335:436- 40 2 Kaptchuk TJ, Frank E, Shen J, Wenger N, Glaspy J, Hays RD, Albert PS, Choi C, Shekelle PG. Methodological issues in trials of acupuncture. JAMA 2001;285:1015-16 3 Kaptchuk TJ. Placebo needle for acupuncture. The Lancet 1998;352:992 4 Takakura N, Yajima H. A double-blind placebo needle for acupuncture research. BMC Complement Altern Med 2007;7:31 Competing interests: None declared |
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