The article “Acupuncture for Chronic Knee Pain” from the most recent issue of JAMA has brought acupuncture into the news lately, with its finding that needle and laser acupuncture did not perform significantly better than a sham laser treatment. Having seen acupuncture and Chinese medicine help with knee pain many times, I am puzzled! What keeps researchers from getting consistent measurable results?
This most recent study divided 282 adults fifty years of age and older into four conditions: no acupuncture, needle acupuncture, laser acupuncture, and sham laser acupuncture. Each received 8 to 12 treatments over the course of 12 weeks. Participants filled out questionnaires about their knee pain at the start of the study, at 12 weeks, and one year later.
Needle and laser acupuncture modestly improved pain at 12 weeks compared with the control group. Likewise, needle acupuncture improved function at 12 weeks compared to control. Both needle and laser acupuncture, however, did not perform significantly better than the sham laser treatment; and the improvements were not maintained one year later.
Why such meager results in this study, when practitioners and patients have such a different experience of the efficacy of Chinese medicine?
Chronic knee pain in older adults is sometimes hard to treat with acupuncture alone. Nearly 40% of subjects in the study had pain for over 10 years–such a long term problem will likely have structural changes in the joint itself and cause changes in gait and posture that interfere with recovery as well. Twelve weeks of acupuncture treatment alone for such a long term degenerative problem may simply not be enough–it may end up being more of a palliative measure than one that provides ground for enduring improvement (though a palliative measure that is much less harmful than relying on painkillers!).
What was most surprising and disappointing to me, however, was reading that the frequency and number of treatments was not standardized. The article says “twenty minute treatments were delivered once or twice weekly for 12 weeks, with 8 to 12 sessions in total permitted.” Perhaps some patients have 8 treatments sprinkled across the whole 12 weeks and others have 12 treatments like clockwork through the whole period. But others might have had one or two treatments a week for eight weeks and then treatment is stopped for a month before they are assessed for improvement.
Despite trying to standardize acupuncture treatment into a drug study model, the researchers neglect the importance of frequency of treatment. Imagine a drug study where subjects are taking the drug at hugely varied schedules—some space their dose out so much that they never get a therapeutic effect and others have enough to get a therapeutic effect, but have treatment stopped well before they are reassessed! A more accurate assessment would need to have all subjects receive the same number of treatments per week for a standard number of weeks. Ideally, too, there should be assessment during the course of treatment to assess palliative effects while patients are actively receiving treatment. It’s also instructive to consider studies carried out in China—a course of treatment usually includes at least three acupuncture treatments per week for several weeks!
Chinese Medicine is More than just Acupuncture
Finally, in the larger context of Chinese medicine, chronic cases often point to a Chinese medical diagnosis of some kind of deficiency that made the knee more vulnerable to injury or degeneration. Deficiencies can be treated with acupuncture, but especially in the elderly, practitioners would likely prescribe herbs, dietary changes, and use other modalities, such as electroacupuncture or warming the needle with moxibustion, to enhance the effect of the acupuncture. All these approaches can help to address overall health in a way that supports healing of the knee. When the acupuncture administered through the study focuses primarily on treating the knee itself, the broader perspective of Chinese medicine is lost. Taking acupuncture out of the context of Chinese medicine and its more holistic way of viewing the body likely dilutes its effect and makes the results of this study hard to generalize to the real world practice of Chinese medicine.