iii) Literature review
Osteoarthritis of the knee is among the most common forms of arthritis leading to inhibited movement, excruciating pain and joint arthroplasty. The condition affects mainly the elderly and it accounts for at least 20% of the world’s elderly population. The condition has no specific known cause but has been attributed to aging, repeated trauma to a joint, systemic disease such as obesity, diabetes, hemochromatosis and onchronosis and also from congenital deformity of a joint. The disease may also be inherited as multiple studies have shown multiple family members being more susceptible to the condition. To treat knee osteoarthritis is complex and the most commonly used methods involve management of the condition through lifestyle changes in consultation with physiotherapists. Other procedures that are used but are costly include medical treatment for reducing pain, hormone therapy and the popular use of glucosamine to reduce cartilage destruction. Surgical treatment is also employed in cases of intense pain and related functional impairment.
A less costly therapeutic procedure that has also been in use is acupuncture. Though surrounded by controversy, the method is gaining rapid popularity and arousing interest among researchers. Acupuncture as a therapeutic approach has demonstrated effectiveness in relieving of pain and as an anaesthetic technique during minor surgeries. In the traditional Chinese medicine, the acupuncture technique has been used to relief pain and disability discomfort caused by osteoarthritis leading to improved mobility and joint flexibility. Through continued use in China over the years, patients have confessed to rapid pain and discomfort relief following acupuncture at the knee joints following osteoarthritis.
The treatment of knee Osteoarthritis with Acupuncture (Literature Review)
Osteoarthritis is one of the oldest diseases in human history. The name is derived from a Latin word ‘osteo’ which means bone, ’arthro’ means joint and ‘itis’ means inflammation, thus osteoarthritis(OA) is inflammation of joint bones. This inflammation is a chronic condition resulting from continued wastage of the cartilage located at the ends of bones. The condition majorly affects the synovial joints. The cartilage loss leads to a decrease in space within the joint and in extreme cases, may result in bone ends coming into contact with one another (Jeanette et al, 2001). This in turn results in pain and a deformed anatomy of the bones and other joint structures. OA seems to affect mainly joints that carry most of the body weight such as the knee, hip and back. However it also affects other body parts such as hand digits, ankle, elbow or shoulder joint that has been previously exposed to a form of trauma (Brewer & Angel, 2000).
The real cause of the condition is not known but may be due to aging, repeated trauma to a joint, systemic disease such as obesity, diabetes, hemochromatosis and onchronosis and also from congenital deformity of a joint. The disease also has a genetic component with studies showing multiple family members susceptible to the condition. The risk of occurrence is related to the bone density and levels of oestrogen in the body. The condition is manifested by sharp pains, joint stiffness and crepitus. OA patients face movement challenges and may require walking aids. This results from shrinkage of the joint capsule. Newly formed bones are responsible for the impaired movement. Knee osteoarthritis pain intensifies with increased movements and in extreme cases; the pain may even be felt while at rest. Weather changes may also affect pain patterns and in some cases the nervous system may be affected with radiating pains crossing from one organ to another. For instance, hip arthrosis may cause pain from the knee (Reid & Miller, 2008).
Other symptoms include creaking sounds especially when a movement is made. This is due to formation of irregular cartilage. This cartilage when in collision with new formed bones causes a squiking sound upon movement of joints. Swelling of joints is also a common phenomenon associated with OA. This results from irritation of the joint capsule. This then leads to formation of hard nodules especially within the joint as a result of the newly developing bones. Owing to ununiformed wear and tear of the cartilage, malposition occurs. This occurrence is accelerated by a collapse of the bone which makes the joint to slide. Due to all the above mentioned symptoms, the joint eventually becomes unstable eventually losing its anatomical function (Barnes, Powell-Griner, McFann, Nahin, 2002). This is characterized by slackening of surrounding muscles and the eventual loss of the anatomical and functional properties of the joint (Brewer & Angel, 2000).
In medical terms, the condition is diagnosed by a granular cartilage in the early stages which is softer than usual. With time, the cartilage is eaten away and increased contact of the bones leads to a phenomenon called ’bone eburnation’. Other features include development of subchondral cysts and outgrowths at the articular surface margins. Eventually, small fractures develop through the bones and the cartilage wreckages destroy the joint completely resulting in formation of structures called ‘joint mices’ (White, Foster, Cummings & Barlas, 2007).
The diagnosis is conclusively made by use of x-ray. To reduce susceptibility, one needs to lose weight in cases of obesity and do frequent workouts such as swimming, jogging and cycling. OA is not a disease but owing to the elements of symptoms and treatment procedures it can be classified thus. The most common treatment methods are the conventional lifestyle changes in consultation with physiotherapists, medical treatment for reducing pain, hormone therapy and the popular use of glucosamine to reduce cartilage destruction. Surgical treatment is also employed in cases of intense pain and related functional impairment, some times with total replacement of joints with artificial ones (Rayman, 2006).
In alternative medical practices, a less common treatment method used is Acupuncture. This method has been in use in the world for the longest time. The method is more popular among the Chinese although over the years it has gained popularity in almost all parts of the world. Acupuncture is a conglomeration of procedures aimed at stimulating different anatomical parts of the body using a variety of performances (Barnes Powell-Griner, McFann, Nahin, 2004). The most widely used of these techniques is the treatment of patients using insertion and manipulation of thin needles in the body by use of hands and or electrical stimulation (Ernst, 2006). Its use is based on the concept that all functions of the body are under the control of an energy component. The acupuncture treatment method aims to correct imbalances in these energy components by stimulating acupuncture points (specific anatomical locations on and under the skin) that are said to be connected by imaginary networks called meridians (Eisenberg et al, 2002).
The therapeutic effectiveness of acupuncture has elicited a debate among medical practitioners. Proponents argue that the method is very effective in pain relief creating an interest among scientific researchers. The National Centre for Complimentary and Alternative Medicine (NCCAM) has been at the forefront in advancing the research to enhance a scientific rather than mythical based argument. Among the on going research studies have focused on the effectiveness of acupuncture on conditions such as chronic back pain and osteoarthritis of the knee (Lundeberg, Eriksson, Lundeberg, Thomas, 1991).
Through the use of advanced technology in areas of neuroimaging and genomics, scientists have made remarkable progress in drafting graphic images of relations between acupuncture methods and neuron receptors. Through genomics the scientists are following on aspects of gene expression and their related molecular transformations in the immune and nervous systems (Ernst, 2006). Numerous studies have recorded significant levels of efficacy of the acupuncture technique in pain relief in body parts such as the back, neck, post operation discomfort and OA. The acupuncture technique has several components involving other body parts such as the brain and the central nervous system as has been demonstrated by non-invasive studies of patients’ brain during the process. This demonstrates that it is not entirely about needles and accupoints (NCCAM, 2011). This paper will focus on the use of acupuncture in the treatment of knee osteoarthritis.
Osteoarthritis affects over ten per cent of persons over sixty five years of age. Medical statistics indicate that OA is the leading cause of disability among the aged. The most common forms of OA affect the hip, back and knee. It is estimated that more than twenty million Americans suffer from OA of the knee. Several studies have shown reliable evidence of success of acupuncture in treatment of knee OA. In combination with other medical care procedures, patients have shown improved and quick recovery from knee osteoarthritis as opposed to only the use of modern medical procedures without the use of acupuncture (Nadine et al, 2007). From another study carried out by Witt in 2005,it was found that following eight weeks of OA of knee treatment using two approaches of modern treatment without acupuncture in comparison with a second approach which involved acupuncture , the patients in the second approach showed an improved recovery and registered less pain as compared to the former (Cooper, Kahn, & Zucker, 2009).The efficacy of acupuncture however decreased with time such that by the fifty second week of the study there was nor marked difference between the two groups.
A comparative study carried out in 2006 by Scarf et al revealed that acupuncture use in treatment of knee OA showed increased effectiveness in the healing process as compared to sham acupuncture. This involves insertion of the acupuncture needles in anatomical sites not previously identified as accupoints. This went to further the support of acupuncture as a treatment technique since the sham acupuncture showed no healing power but expertly done acupuncture had a positive influence on the healing process. Despite this supposed evidence, further research on the same is still necessary. The results of this study are found in details in annals of internal medicine of 2006 (Cooper, Kahn & Zucker, 2009).
Following widespread cases of knee OA in the United States, a study was carried out in the University of North Carolina which showed that approximately 50% of adults in the United States and about two thirds of adults with obesity may develop OA of the knee b y the time they hit eighty five years of age. The condition is said to be among the top ten most expensive medical conditions. The use of acupuncture was investigated as a therapy to knee OA through a study at McMaster University. It involved a random sample of five hundred and seventy patients and spanned six months. By the end of the research duration, it was concluded that the patients who received acupuncture therapy performed better in pain scores as compared to those who did not go through the procedure. The two studies however concluded that long term benefits of acupuncture treatment can not be realistically demonstrated (Vadivelu, Urman & Hines, 2011).
According to the Chinese medical journal of 2010, acupuncture as a therapeutic approach has demonstrated effectiveness in relieving of pain and as an anaesthetic technique during minor surgeries. In the traditional Chinese medicine, the acupuncture technique has been used to relief pain and disability discomfort caused by OA leading to improved mobility and joint flexibility. Through continued use in China over the years, patients have confessed to rapid pain and discomfort relief following acupuncture at the knee joints following OA. Since this evidence is subjective, assessment of the efficacy can not be evaluated through expert evidence but can only be reported in literature (National Cancer Institute, 2007).
Assessment of OA is usually carried out using radiography. Studies have indicated that up to 40% of all patients with degenerative OA do not show any clinical symptoms and only radiography can show the level of degeneration of the knee cartilage. The use of acupuncture on patients may therefore not be effective in treating such patients since they may not be experiencing the pain which acupuncture is said to relief. A more precise tool should be used in assessment of the healing process, since acupuncture lacks the scientific basics of treatment procedures. The psychological status of the patient contributes immensely to response to treatment while using the acupuncture method unlike in other treatment procedures. Knee OA is a progressive and incurable condition that can only be dealt with through a managerial approach as opposed to curative approaches. The continued interest in the use of acupuncture as a management practice has aroused worldwide interest among researchers and this can be evidenced by many studies being carried out in many parts of the world. Recently, three analyses were carried out involving highly controlled trials on the effectiveness of acupuncture in treatment of osteoarthritis of the knee. From these studies carried out by Manheimer et al, it was revealed that acupuncture treatment surpasses sham acupuncture in effectiveness by great margins. In one of the studies, effect sizes ranged from nine per cent in short-term effects to ninety five per cent in long-term effects of this approach. The study provided statistical data comparing treatment protocols using conventional medical procedures and the combination of these procedures with acupuncture revealing remarkable difference in effectiveness of the two models. The United Kingdom( UK) National Institute For Health And Clinical Excellence dismissed the evidence by claiming that by now there exist no concrete evidence on the effectiveness of acupuncture and thus the board can not give any recommendation to support the use of acupuncture in treatment of OA ( Lansdown, Howard, Brealey & MacPherson, 2009).
The arguments proposed against the use of acupuncture in treatment of OA in the UK is that the statistical evidence given by numerous studies faces limitations such as the studies did not comprehensively address issues regarding the effectiveness of the acupuncture treatment technique as an adjunctive treatment to the conventional primary health care commonly used in the UK. The institute also pointed to the duration of study follow-ups as unreliable (Vas, Emilio, Camila, 2011). Most trials had only short-term follow ups not exceeding six months and others as low as one month. Long-term effects of acupuncture for head ache and low back pains have been evidenced but the benefits on the osteoarthritis of the knee in the long-term has not been documented yet. Another limitation proposed was that the evidence on the cost-effectiveness of the model is limited in the larger UK since the researchers only did comparative studies with Germany which may not necessarily fit in the UK context. These limitations have contributed to the NHS decision to reject inclusion of acupuncture into the primary health care program since benefits and costs are major considerations in NHS approvals (Lansdown, Howard, Brealey & MacPherson, 2009).
In a study carried out by Kwon, Pittler and Ernst and published in Advance Access Publication, of August, 2006, to evaluate the evidence for the effectiveness of acupuncture in peripheral joint osteoarthritis, pain reduction in acupuncture survey groups was noted as compared to the lack of it. This study was very comprehensive in that it incorporated randomized controlled trials of acupuncture in patients with knee and other peripheral joint OA, hand searches from conferences, systematic searches from Medline, Embasse, British nursing index and AMED among many others. Out of eighteen studies, ten of the trials tested manual acupuncture and eight focused on electro-acupuncture. Compared to controls, the trials demonstrated increased pain reduction with meta-analysis indicating a marked difference in effectiveness between manual acupuncture and sham acupuncture. This remarkable piece of evidence shows that acupuncture may for sure be an effective pain relief treatment of knee osteoarthritis. This survey incorporated many sources and models to eliminate an element of bias in the study. Other independent surveys after this have shown similarity in their results (Kwon, Pittler & Ernst, 2006).
The use of meta-analysis in homogeneous data groups’ gives reliable evidence as compared to other survey models, since though with a significant degree of subjectivity, all the data available from these groups indicates strong evidence (Kwon, Pittler & Ernst, 2006). The use of the universally accepted Jadad scale which uses score points to assess quality of data, the eighteen data sets had five of the groups under patient blinded and assessor blinded format, four of the groups had neither subject nor assessor blinding. This approach is aimed at eliminating the likelihood of patients giving biased information on the effects of acupuncture as under study which would negatively affect credibility of results.
To assess the effectiveness of acupuncture in relieving pain in knee and other peripheral joint osteoarthritis cases, comparisons were carried with a wide array of controls to reduce chances of inaccuracy and bias. The different controls also allow for different conclusions to be drawn and an overall comparison done making recommendations more conclusive. This trial used a waiting-list control which brings out the effectiveness of the item under study, in this case acupuncture treatment technique, without the need for placebo effects (Kwon, Pittler & Ernst, 2006). The other model used sham acupuncture as the control in comparison to manual acupuncture. These formats provide comprehensive data that can be used to make an inference. From the data collected in this particular study, beneficial effects of acupuncture were noted with intergroup differences all in the positive to indicate that the acupuncture is an effective method in relieving pain in knee OA patients. It was concluded that the placebo effect of acupuncture in pain relief can be beneficial. This has been confirmed by more advanced studies that involve trials of puncturing the skin away from accupoints or using other methods of sensitizing the skin without necessarily using the acupuncture needles or puncturing the skin superficially in a non-stimulatory manner if using the electro-acupuncture method. This is done by using electro-acupuncture without cables. Reliable results from these studies all point to the beneficial role of the acupuncture treatment (Kwon, Pittler & Ernst, 2006).
As is common with any study or trial, limitations to the above described approaches could include the inability to locate all RCTs relevant for the study. Despite the efforts put to include all RCTs it is universally agreeable that it is not possible to do so. This could therefore affect the final results. The use of primary data sources could have also affected the results since it is difficult to design placebo or blinding features for acupuncture studies. The use of acupuncture has been shown to have some negative effects in approximately seven per cent of the patients (Kwon, Pittler & Ernst, 2006).
Due to expenses and ineffectiveness of conventional treatment methods on OA and other musculoskeletal pains, many patients in the US and the UK have been looking for alternative and complimentary medicine. The availability of complimentary medical practices such as acupuncture has risen to about 40% of general practice health centres and has reached 84% in the UK’s chronic pain clinics. Over four thousand physiotherapists and general practitioners have received training on acupuncture (Hay et al, 2004). The NHS nevertheless insists that further research needs to be carried out before acupuncture can be incorporated in the treatment of knee OA among the majority elderly. Since its effectiveness has not yet been established, most physiotherapists under the NHS combine it with exercise and advice as part of primary and secondary care. Physiotherapy therefore provides the best platform to assess the effectiveness of acupuncture so as to decide whether to integrate it into mainstream treatment procedures or not (Hay et al, 2004).
Acupuncture offers remarkable benefits to patients with knee OA but only when in combination with other management techniques. Most laboratory investigations have revealed the physiological properties of acupuncture. The tests have shown that acupuncture stimulates the central nervous system in particular the pain control mechanisms leading to release of opioid neurotransmitters. The autonomic nervous system is also affected by acupuncture stimulation. The lack of scientific based evidence has seen authorities become reluctant to embrace its use in treatment of knee osteoarthritis. Limitations in studies of acupuncture such as small sample sizes and inadequate control experiments means results from the studies can not be relied on. Recent trials in Germany have proven that the use of acupuncture has a remarkable healing effect on knee and back pains but not migraines (Hay et al, 2004).
Knee disorders are a common problem affecting over twenty per cent of the elderly in the world. The most common disorder is osteoarthritis. Clinical manifestations of the knee OA are joint pain, stiffness in the morning and after rest, pain at night limited joint motion and deformity. Management of knee OA is the most effective way of reducing the pain and stiffness since the condition is not curable (Vas, Perea-Milla, Méndez, 2011). Acupuncture is gaining popularity as the management method of choice for OA in the western world after highly publicized success stories from Asia. Furthermore, other medical approaches aimed at relieving pain such as drugs for instance analgesics, and non-steroidal anti inflammatory drugs (NSAIDs) are associated with adverse side effects such as high blood pressure, kidney disorders, gastrointestinal bleeding and cardiac disorders (Witt et al, 2006). The cost of these drugs is inhibitory and cheaper alternatives have been proposed for use. Among the new approaches targeted for use include acupuncture, with experts from Europe reaching a common census on the need to indulge into deeper understanding of the efficacy and applicability of acupuncture (Vas, Perea-Milla, Méndez, 2011).
The application of acupuncture in medicine has gained momentum in Europe culminating in establishment of the first ever Pain Management Unit(PMU) in the Andalusian Public Health System which was mandated to study effectiveness of non-conventional treatment techniques. To determine effectiveness of the acupuncture technique, the pain management unit carried out a survey on five hundred and sixty three patients over a period of three years ( Vas, Perea-Milla, Méndez, 2011). All the patients were diagnosed with OA of the knee by the general practitioners in the area. The protocol involved determination and selection of accupoints in the patients as described in literature from earlier studies and practices in other parts of the world particularly Asia that were believed to be effective in treatment of OA of the knee. The treatment involved insertion of acupuncture needles on the focal points of the knee. The 30 gauge, 45mm long needles were focused on ST36, GB34, SP9 and Neixiyan ( eye of the knee). The needles were either manipulated manually using Artemisia cones or others stimulated electrically. Following the laid down protocol by the pain management unit, the therapy began , continued over a fifteen week period and was terminated in some cases if the patients did not respond by the third weekly session. Data was collected on pain intensity on a visual analogue scale (VAS), pain frequency, disability and comfort disturbance caused by the condition and analgesics consumed ( Vas, Perea-Milla, Méndez, 2011).
Following this and other studies, significant levels of evidence were collected on the efficacy of acupuncture in combination with other methods of pain control in relieving the amount of pain experienced by patients suffering from knee OA. This study carried out by the pain management unit(PMU) on effectiveness of acupuncture in treatment of knee OA, was a pilot trial on a random population. The use of acupuncture was accompanied by a decreased use of non-steroid anti-inflammatory drugs to assess its actual effectiveness. By the end of the trial period, up to seventy five per cent of the patients recorded a minimum of about forty five per cent improvement, a clear indication that acupuncture has a positive effect on the healing process of knee OA ( Vas, Perea-Milla, Méndez, 2011).
To come up with a comprehensive conclusion on the efficacy of acupuncture, it is vital that more rigorous trials involving larger population sizes that are more randomly distributed should be used. The technique faces difficulties of analysis since an individualized treatment protocol is required to realize more comprehensive results (Selfe, Taylor, Faan , 2008). Despite the inconclusive studies done so far, the acupuncture method is still increasingly gaining popularity and approval among practitioners in the health field. This is mainly as a result of the response from patients and the low cost involved. The side effects associated with the model are minimal in comparison to analgesics and other conventional medical procedures (Lundeberg, Eriksson , Lundeberg , Thomas, 1991).
There are many types of acupuncture methods as developed by neurobiological researches. The most popular hypothesis remains that proposed by Zhang, a famous Chinese neurophysiologist in 1970 (Tung-wu Lu, et al, 2010). According to Zhang, the acupuncture analgesia results from a complex network of integrated effects initiated by sensational waves in pain and motor receptors in the central nervous system. The motor neurons link different components of the central nervous system such as the spinal cord, the medulla oblongata or brain stem and the thalamencephalon. The process of acupuncture , the pain receptors in the central nervous system are activated triggering an upsurge and release of a variety of endogenous bioactive substances. The elements contain pain relief ability. They include opioids and other elementary neurotransmitters including neuropeptides, 5-hydroxytryptamine and acetylcholine (Xia, 2010).
To treat knee OA, the acupuncturist can use different forms of acupuncture depending on the extent of the osteoarthritis damage to the knee joint. Different accupoints have different associated effects and the specialist has to be extremely keen on the specific points to target to realize the necessary result. The actual accupoints have been realized following many years of trials and in-depth research. The generally targeted accupoints include body, auricular, and scalp points. To achieve therapeutic effects on the patient, the methods used include filiform needing, moxibustion, accupoint injection, electro acupuncture (EA), Fu’s subcutaneous needling ( FSN), trigger-point acupuncture and laser acupuncture (Xia, 2010).
The acupuncturist may also combine the different forms of acupuncture to achieve the desired effect. These forms are used through different manipulations. The manual acupuncture involves inserting the needle into the accupoint, lifting and thrusting it so as to induce the “De-Qi”. It is the most commonly used especially in traditional Chinese medicine. In knee OA treatment, the sensation caused by this manipulation is registered as soreness, distension or numbness. This feeling means that the right spot has been punctured. The manipulation of the needle after touching this spot triggers inter-meridian communication in turn initiating a therapeutic effect (Xia, 2010).
The electro acupuncture (EA) on the other hand involves applying electrical stimulation to the needle that is inserted in the accupoint. The pulse current creates stimulus through wave forms, pulse width, intensity and stimulation duration is increased resulting in a rapid relief of pain. The Fu’s subcutaneous needling (FSN) is a needling strategy specifically targeting the subcutaneous layer. The laser acupuncture involves using of laser rays directed onto the accupoint. Trigger-point acupuncture is a technique that involves targeting the needle into the trigger point. The other method which is not very popular among acupuncturists is the accupoint injection that involves injecting drugs into the accupoint (Xia, 2010).
The clinical application of acupuncture in treatment of knee osteoarthritis targets pain relief. The most commonly used acupuncture approaches in knee OA treatment are the manual and the electro acupuncture (Usichenko, et al, 2007). The perfect selection of the acupuncture points in clinical practice relies on the traditional Chinese medicine meridian theory that is focused in treating joint pains popularly known as ‘Bi’ syndrome involving the distal and local points. Unilateral and bilateral acupuncture techniques are the most effective forms of both manual and electro acupuncture. The bilateral form has been the one mostly used in treating the knee OA but advanced clinical researches indicated that the unilateral is also as effective as the bilateral acupuncture when professionally manipulated to reduce pain from osteoarthritis of the knee and helping in recovering its functioning (Xia, 2010).
To reduce the pain in the knee caused by osteoarthritis, the universally targeted accupoints include; Yanglingquan (GB-34) which is located in the depression anterior and inferior to the small head of the fibula. According to the TCM meridian theory this accupoint is associated with the gallbladder meridian of Foot-Shaoyang and is manifested through pain in the hypochondriac region, vomiting, muscular atrophy, infantile convulsion, jaundice and pain of the lower limbs. The Yinglingquan (SP-9) accupoint is located in the depression on the lower border of the medical condyle of the tibia connected by spleen meridian of Foot-Taiyin. The meridian is associated with abdominal pains and distension, diarrhoea, oedema, jaundice, incontinence of urine accompanied by difficulty in urination and pain in the knee (Xia, 2010).
The Zusanli (ST-36) accupoint is located one finger-breadth from the anterior crest of the tibia and is linked with the stomach meridian of Foot-Yangming. According to the c traditional Chinese medicine, this meridian is associated with gastric pain, dysphagia, emaciation, vomiting and pain of the lower limbs. A point above this accupoint is the Dubi (ST-35) which is the point located in the depression between the patella and the lateral ligament when the knee is flexed. It is associated with the stomach meridian of Foot-angming. This is the accupoint associated with pain, numbness and motor impairment of the knee (Xia, 2010).
The Kunlun (BL-60)is located in the depression between the tip of external malleolus and the Achilles tendon and is connected by bladder stomach meridian of Foot-Taiyang. This meridian’s clinical indications include headache, epistaxis, pain of the lumbosacral segment and swelling and pain of the heel. Xuanzhong (GB-39) is located 3 cun above the tip of the medial malleolus, on the posterior border of the fibula. This in TCM is connected to the gallbladder meridian of Foot-Shaoyang and is manifested clinically through pain in the hypochondriac region, muscular atrophy and pain of the lower limbs. The Sanyinjiao (SP-6) is found 3 cun directly above the tip of the medial malleolus, on the posterior border of the medial aspect of the tibia. It is connected to the spleen meridian of Foot-Taiyin. The meridian is associated with clinical symptoms such as muscular atrophy, enuresis, leukorrhagia, insomnia and pain of the lower limbs (Xia, 2010).
The Taixi (KI-3) accupoint is located in the depression between the tip of the medial malleolus and the Achilles tendon and is associated with the kidney meridian of Foot-Shaoyin. This is associated with nocturnal emission, lumbar pain, frequent urination and insomnia. The Liangqiu (ST-34) is an accupoint located along the line joining the anterior and superior iliac spine and the lateral border of the patella, 2 cun above the latero-superior border of patella. The accupoint is connected to the stomach meridian of Foot-Yangming. It is associated with swelling and pain of the knees, paralysis of the lower limbs and haematuria (Xia, 2010).
The continued research into the efficacy of the traditional Chinese acupuncture shows the potential in alternative and complimentary medicine in treatment of ailments such as knee OA (Harriet, Katie, Stephen & McPherson, 2009). The unproved and controlled surveys on the acupuncture as a form of pain relief especially for knee OA have indicated that acupuncture has a powerful therapeutic effect ( Vas, Perea-Milla, Méndez, 2011). Modifications and improvements are being incorporated in order to ascertain the quality and the scientific mechanism of working of the technique in pain relief and treatment of knee OA which has caused disability and other mobility defects on a majority of the elderly in the world (Tillu, Roberts, Tillu, 2011).
Today’s research involves the use of cross-over designs, single and double blinding, randomization and sham controls. The trials using all these methods will enable assess the similarity in the results which could give direction on the suitability of the method. Treatment of osteoarthritis has universal guidelines of control and management but acupuncture is not yet classified as one of the OA treatment methods anywhere in the world except its widespread application in traditional Chinese medicine (TCM) in china and other Asian countries (Yuelong, 2011). Research on acupuncture follows guidelines set by earlier researchers such as Western Ontario and McMaster Universities Osteoarthritis Index pain scores (WOMAC) which set scores on which to gauge the success of such research studies. For instance, if patients with knee OA are under study over a given period, the response to acupuncture therapy follows these scores to determine its success ( Vas, Perea-Milla, Méndez, 2011).
Berman et al (1999) published results indicating that acupuncture relieves knee OA symptoms, reduces swelling and increases range of motion. Further studies have shown that acupuncture is also a beneficial therapy to patients awaiting knee surgery. Using the WOMAC scores, the patients who underwent acupuncture therapy showed improvements as compared to those who did not. Berman et al also found that acupuncture therapy is a safe technique since out of the twelve patients in their pilot study, none of them showed any adverse side effects from the therapy. Though the follow-up time was minimal but nevertheless the benefits on the patients were clearly manifested. Opponents of acupuncture have insisted that the therapy’s success depends on the personal attitude of the patients but in a research carried out by Collier et al revealed that the response to acupuncture therapy does not in any way depend on the patient’s attitude or knowledge. The use of real acupuncture in advanced knee OA therapy has proved to be more successful than sham acupuncture (Tukmachi, Jubb, Dempsey & Jones, 2011).
Acupuncture for Osteoarthritis of the Knee has been comprehensively analysed through numerous studies. One of the most successful studies which assessed the efficiency of this model was carried out by Ezzo et al. using a large sample of three hundred and ninety three patients with knee OA, and covering seven different trials, the experts found out that acupuncture is far more effective than the conventional methods that are associated with adverse side effects and are more demanding in terms of patient input and cost. The results of this study which focused on pain and function elements indicated that real acupuncture relieves pain more effectively than sham acupuncture does. However; in terms of the functioning of the knee after therapy, it was not possible to conclusively state whether sham acupuncture is less effective than real acupuncture (Ezzo et al, 2001).
This study covered all possible components on knee OA and the efficiency of acupuncture. The methodology of trials was structured as to identify possible areas of future research. The research incorporated eight databases and more than sixty abstract series. Also included were random and non randomized trials from different states and the quality of the trials scaled on the Jadad scale. The results of the study suggested that acupuncture related analgesic effects can not be described in relation to placebo effects as is the case with waiting lists (Ezzo et al, 2001). The study concluded that the current evidence can not be used to determine whether acupuncture is more or less effective than other therapies on knee OA. In the trials, real acupuncture outperformed sham acupuncture since the sham targeted only superficial distal non-accupoints. The authors claim it is difficult to compare acupuncture with other therapy techniques since large sample sizes are required to come up with a comprehensive comparison due to the element of statistical power ( Vas,Emilio, Camila, 2011). According to Ezzo et al (2001) more research on acupuncture needs to be done. This they argue will determine all dimensions of acupuncture therapy and its applicability in clinical procedures. Furthermore, the efficacy of the acupuncture therapy technique needs to be gauged alongside other medically approved therapeutic regimens (Kaptchuk, 2002).
From all the above data, there seems to be significant evidence on the effectiveness of acupuncture in treatment of knee osteoarthritis. The application of this technique however requires further research before it is fully incorporated into the mainstream primary and secondary health care. Furthermore, it is important that health providers interested in using acupuncture on patients with knee OA first understand the efficacy, applicability and confines of use. So far, all trials, surveys and studies carried out on effectiveness of acupuncture on healing knee OA and other musculoskeletal defects have only focused on evaluating standardized treatment procedures. This means any other forms of acupuncture apart from the use of insertion needles have not received the necessary attention yet they also constitute acupuncture as described in the traditional Chinese medicine The difference in description of acupuncture in different regions has complicated the process of realizing universal standards and guidelines on acupuncture as a therapeutic technique for primary and/or secondary health care. Even the almost universal acupuncture technique of needling exists in more than one form. For instance the Japanese and the Chinese have different references of the acupuncture points. This would only to complicate not only the training of experts in the field but also increase doubt on the authenticity of the technique in the first place.
Further challenges in application of acupuncture in treatment of knee and other OA arise from the way research is carried out. In comparison to the original approach as used in china, the purported initiators of the technique, modern researchers do not include the use of Chinese herbs or the traditional Chinese medicine diagnostic formats which are said to result in the most satisfactory treatment records in the world. Individualized treatment is the most vital component of the acupuncture healing therapy as practiced in China and psychologists argue that this could be the reason the technique has achieved so much success in the country. The effects of these supplemental efforts need to be investigated and if found beneficial as claimed , ought to be incorporated into the acupuncture treatment regimen. Most studies have indicated that acupuncture of the knee OA has no adverse effects. This could have resulted from lack of keen focus on the same. It could also be due to the absence of measuring criteria as the acupuncture method itself does not have all the elements of a conventional therapeutic process. The authors propose future researches to also give the side effects consideration in order to match the criteria used in other studies on therapeutic efficacy of drugs and medical procedures. From the analysis carried out by Ezzo et al, numerous reviews are available on the effect of acupuncture on knee OA but they give inconclusive results. The trials carried out by Ezzo and colleagues had studied these weaknesses and research gaps and their research was more accurate and conclusive. By using seven different trial set ups on groups of patients with knee OA, these authors gave more conclusive results which apparently are in support of acupuncture as an effective therapeutic approach to treating knee osteoarthritis. A major strength in this research was the exclusive focus attached to the knee OA among all the patients and the systematic analysis of each acupuncture session undertaken.
To determine the efficacy of any medical procedure trials, the psychological element of the patient does not require manipulation. Most acupuncture trials on patients with knee OA, use the Jadad scale which does not advocate for double blinding. Most researchers doing trials on the acupuncture effectiveness on knee OA, have argued it is impossible to blind their patients. The Jadad scale allows to some extent the application of single-blind techniques into the trials. This method indirectly leads to achievement of higher scores as has been demonstrated in numerous studies. This should therefore be considered when comparing results with control groups. The Jadad scale can however not be said to be overly inapplicable. This was proved by the reports given by knee OA patients who were blinded. All these patients claimed to have had knee pain drop and therefore it would not be right to suggest that unblinded patients give reports only in favour of the acupuncture therapy.
It is important future researchers explain what constitutes an optimal acupuncture knee OA treatment. The researchers also need to address sustainability of results in respondents pertaining the maintenance treatment. It would also be right if the future researchers clearly outline the actual effects of combining acupuncture and other knee OA treatments. This would answer questions on whether the combination maximizes effectiveness or reduces adverse side effects or achieves both as unconfirmed theories have consistently claimed. Further exploration would also be necessary to determine if combining acupuncture with physical exercises has any additive or synergistic property
Patients suffering from knee osteoarthritis experience excruciating pain and mobility impediments and in extreme cases may require knee replacement. Managing this pain using acupuncture, is the most convenient management protocols since majority of the patients are elderly. This age factor exposes them to a myriad of adverse side effects if treated using analgesic drugs and the non-steroid anti-inflammatory medicine. Furthermore, at this age the patients are leading independent lives and would not wish to be a bother to others. To adopt the most appropriate treatment or pain relief protocol to return these patients to full quality life requires thorough analysis. Many studies have revealed that patients who experience a lot of pain and discomfort prior to surgery of the knee due to conditions such as osteoarthritis have worse repercussions within one or two years after the operation. This means that an appropriate management therapy is vital before the operation to avoid post-operation pains
Acupuncture has been identified as a most effective treatment procedure when combined with exercise therapy in treating the osteoarthritic pain of the knee. There is a growing trend of recommendations by medical practitioners to embrace the use of non-drug methods in reducing knee OA pain. There still exists controversy about this technique on whether it should be classified as a medical or a physiotherapy procedure.
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