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EDITORIALS: Rob Herbert and Marlene Fransen Management of chronic knee pain BMJ 2007; 335: 786 [Full text]

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The data presented means your conclusions are unsafe

Mike Cummings   (21 October 2007)

The data presented means your conclusions are unsafe 21 October 2007
Mike Cummings, Medical Director British Medical Acupuncture Society Royal London Homeopathic Hospital Send response to journal: Re: The data presented means your conclusions are unsafe	This commissioned, not externally peer reviewed editorial was written by experts from the field of physiotherapy. The authors do not appear to have a background in acupuncture research or an understanding of the methodological difficulties of the latter. Furthermore they have been allowed to get away with supporting their conclusion by selective citation of two papers and pooling the results therein. I am surprised to such an example set in the BMJ. Foster et al compared six sessions of manual acupuncture with non- penetrating sham needling and with no needling.(1) Scharf et al, in a trial three times the size, compared 10 to 15 sessions of manual acupuncture with ‘off-point superficial needling’ and with no needling.(2) All groups in both trials received six sessions of physiotherapy; although it is not clear whether this was the same in both trials. Foster et al describe this as advice and exercise, and they detail the exercises, but it is simply described as physiotherapy in the methods section of Scharf et al. There are other differences. The acupuncture was performed by UK physiotherapists in one trial and by German physicians in the other. The group that received no needling in Scharf et al were actively prescribed diclofenac, up to 150 mg/d, or rofecoxib 25 mg/d. Foster et al reported the use of drugs, but did not allow a change in medication use. It is not appropriate the pool the results of these trials alone, but if we are to compare and interpret their results, the most interesting comparisons are not those of so called true acupuncture versus sham, but the more pragmatic comparisons of acupuncture and sham acupuncture versus forms of best standard care. In Scharf et al both acupuncture groups were significantly superior to standard care, and on the basis of this and possibly other data, the German health insurance companies now reimburse the cost of acupuncture for knee osteoarthrosis. If you must compare acupuncture with sham, which is a methodological minefield, it should be done in a systematic way, not through arbitrary selection of trials by commentators. Both of the recent systematic reviews have confirmed significant benefit of acupuncture over sham acupuncture in chronic knee pain,(3;4) although the interpretation has been debated. Williamson et al has recently suggested that acupuncture has some short term benefit in chronic knee pain of patients awaiting knee replacement surgery compared with a home exercise regime.(5) In the same study, physiotherapy exercise sessions did not show a reduction in pain, but a trend that suggested functional improvement. A discussion with the lead author, Lyn Williamson, at the British Medical Acupuncture Society Autumn Meeting yesterday, revealed that her current trial in the same population is combining group exercise sessions followed by group acupuncture, in an attempt to get the best of both interventions in a cost effective manner. Reference List 1. Foster NE, Thomas E, Barlas P, Hill JC, Young J, Mason E et al. Acupuncture as an adjunct to exercise based physiotherapy for osteoarthritis of the knee: randomised controlled trial. BMJ 2007. 2. 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. 3. Manheimer E, Linde K, Lao L, Bouter LM, Berman BM. Meta-analysis: acupuncture for osteoarthritis of the knee. Ann Intern Med 2007;146(12):868-77. 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. 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):1445-9. Competing interests: The author works for the British Medical Acupuncture Society, a non-profit organisation that encourages the appropriate use and scientific evaluation of acupuncture for the public benefit.