Acupuncture as a complementary therapy to the pharmacological treatment of osteoarthritis of the knee: randomised controlled trial

The results of the study by Vas et al are interesting but there are
potential problems with the blinding of the patients to their treatment
allocation. In addition they omit any evaluation of the costs involved.

Weekly visits to a specialist for acupucture are likely to be much more
expensive and more time consuming than additional oral anti-inflammatory
drugs which can be taken at home. If the effects of acupuncture are not
long-lasting this will further erode the cost effectiveness of this
intervention. From a practical point of view Dr Housley's suggestion of
the acupuncture control being placing the needle "in any old place" is a
reasonable one since such a procedure would require minimal training. If
this "sham acupuncture" was as effective as acupuncture from a trained
therapist, patients could apply it themselves at home as they do with
tablets.

Competing interests:
None declared

Knee problems – acupuncture and surgical treatment.

These articles in this week’s BMJ indicate that we GPs could do a lot
better for our patients by referring to other agencies than our overloaded
orthopaedic clinics. I have just done a survey of referrals in my practice
during the last 3 years and in spite of the number of NHS orthopaedic
referrals increasing only slowly (107 in 2002 and 112 in 2003) the waiting
times for our patients have been getting longer. The average wait for
those seen so far was 18 weeks but 13 of 33 patients with knee problems
were still waiting more than 6 months. I looked at those patients’ notes
and found that 5 of those they had not consulted us about that since
referral so possibly have got better. Another 5 had received physio or
had had injections done by us or had an MRI indicating no problem needing
attention. Unfortunately these patients still preferred to remain on the
waiting list as insurance in case it got worse! However 3 of the 13 were
still in a lot of pain and in two had we had asked for an appointment to
be expedited

I also found that only 6 out of the 20 patients who had been seen needed
any operative procedure – 3 arthroscopies and 3 other operations. Only 2
had been done. The others had been discharged (8)or followed up in clinic
Possibly if we referred for acupuncture or did more joint injections
ourselves we would improve patient care It is interesting that the Welsh
Assembly government is proposing to make more alternative therapies
available on the NHS providing there is an evidence base and here it seems
would be a good place to start. In addition we do have access to a limited
number of MRI slots in a private centre out of the area and this may also
help us to decide whether an orthopaedic referral is really justified.

The real increase in referral rates over the years has been in
private referrals; from 27 in 2002 to 45 in 2003. Of those 20 were for
knees in 2003 and all were seen promptly. Interestingly although the
number of private and NHS referrals actually seen was the same (20) 14 of
the private ones were recommended to have arthroscopy compared with 3 in
NHS Two had had open operations. Some of these patients were not insured
and were spending a lot of money. I am sure that if we could save on
referrals for patients who really could be treated in other ways then
speedy NHS treatment locally would be available to more patients.

Competing interests:
None declared

I was alerted to this article by a patient, who this morning
presented me a cutting from the Daily Mail, which featured said article!

I recently attended a BMAS foundation course, during which the
participants had to acquire and develop their needling skills.
Having thus had several chronic pains alleviated (eg from oa shoulder, oa
1st mcp and several dip joints, to say nothing of chronic back pain
following multiple episodes of PIVD at L5/S1) I can only confirm that
acupuncture appears to work!

Incidentally, the patient referred to above came back 1 week after
acupuncture for OA of knee, and was able to report 1) a dramatic
reduction in pain and 2) a dramatic increase in walking distance.

If only I had had the time to look into acupuncture at a far earlier
stage in my career............

Competing interests:
Course participant (at own expense) British Medical Acupuncture Society Foundation Course

Acupuncture studies generally fall short on methodological weakness
but, in this case, Vas et al have executed a well thought out study.

To answer some of their critics, I would like to point out that:

1. In using a single person to perform the treatments, they ruled out
inter-operator variability and error. For those who object to the use of
an acupuncturist for this task, may I ask who else would be able to locate
the acupuncture points accurately and make sure that stimulation is
adequate or make sure that there is no stimulation in the case of the
control?

2. It is not possible in any manual therapy to have a double-blind
trial because the therapist necessarily knows which treatment he is
giving! Therefore, in hands-on treatment, single-blind is the best you can
do.

3. As far as placebo is concerned, it is not sufficient to place an
acupuncture needle at a site other than classical acupuncture sites
because even this (sham acupuncture) has analgesic properties through
Diffuse Noxious Inhibitory Control (DNIC) and other neurophysiological
mechanisms. Therefore, the needle can be touching but must not puncture
the skin anywhere on the body in a control subject to get best results.

You can see from this that the investigators did pretty well in
overcoming a number of difficulties associated with acupuncture research
and should be commended on their thoroughness in study design.

It is disheartening to see colleagues being unduly cynical about a
treatment which brings relief to many with chronic pain that many medical
professionals themselves are sadly ill-equipped to understand or treat.

Competing interests:
Overseas Member of the British Medical Acupuncture Society