Treatment of Knee Osteoarthritis With Acupuncture

Abstract

Osteoarthritis of the knee is one of 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 ochronosis as well as congenital deformity of a joint. Acupuncture, though surrounded by controversy, is gaining rapid popularity which has aroused interest from researchers. Acupuncture, which is one of the therapeutic approaches, has demonstrated effectiveness in relieving pain and as an anesthetic technique during minor surgeries.

This paper aims to conduct a review of selected published studies on the use of acupuncture in the treatment of knee osteoarthritis. All studies are analyzed in reference to the design they adopt which outlines the type of trials carried out by different authors. For this review, various relevant websites and online databases were accessed and only those containing sufficient details were chosen. This review concludes that the most appropriate standard used in the research on the treatment of knee osteoarthritis with acupuncture is the use of large randomized controlled trials (RCT). Large sample size and long trial durations increase the credibility of chance that the results obtained from the studies hence bringing out a meaningful interpretation. The review also recommends that more detailed studies and universally acceptable standardization should be done to create validity of the studies concerned.

Introduction

History and background

Osteoarthritis is one of the oldest diseases in human history. The name is derived from the Latin words ‘osteo,’ which means bone; ‘arthro’ means joint, and ‘itis’ which means inflammation; thus osteoarthritis(OA) refers to the inflammation of joint bones. This inflammation is a chronic condition resulting from continued wastage of cartilage that is located at the end 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, this may result in bone ends coming into contact with one another (Jeanette et al, 2001). This in turn causes pain and deformed anatomy of the bones and other joint structures. OA seems to affect mainly joints that carry most of the bodyweight such as the knee, hip and back. However, it also affects other body parts such as hand digits, ankle, elbow or shoulder joint that have been previously exposed to a form of trauma (Brewer & Angel, 2000).

The real cause of the condition is not known but it may be attributed to aging, repeated trauma to a joint, systemic disease such as obesity, diabetes, hemochromatosis and ochronosis and also from congenital deformity of a joint. The disease has a genetic component with studies showing multiple family members being susceptible to the condition. The risk of occurrence is related to the bone density and levels of estrogen 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 is due to shrinkage of the joint capsule. Newly formed bones are responsible for impaired movement. Knee osteoarthritis pain intensifies with increased movements, and in extreme cases; the pain may even be felt while resting. 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 there is a movement. This is due to the formation of irregular cartilage. This cartilage, when in collision with newly formed bones, causes a squeaking 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 the formation of hard nodules, especially within the joint, as a result of the newly developing bones. Owing to the lack of uniformed wear and tear of the cartilage, malposition occurs. This occurrence is accelerated by a collapse of the bone which makes the joint slide. Due to all the above-mentioned symptoms, the joint ultimately 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 granular cartilage in the early stages which are 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 the 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 the formation of structures called ‘joint mices’ (White, Foster, Cummings & Barlas, 2007).

The diagnosis is conclusively made by the use of an 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 its symptoms and treatment procedures, it can be classified as such. The most common treatment methods include 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, sometimes with total replacement of joints with artificial ones (Rayman, 2006).

Epidemiology of osteoarthritis

Osteoarthritis affects over ten percent 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 (Witt, et al, 2006).

Use of acupuncture

In alternative medical practices, a less common treatment method used is acupuncture. This method has been in use for the longest time in the world. The method is more popular among the Chinese; although, over the years, it has gained popularity in other 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, 2002). The widest techniques include 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 debate among medical practitioners. Proponents argue that the method is very effective in pain relief, a concept that has created an interest among scientific researchers. The National Centre for Complementary and Alternative Medicine (NCCAM) has been at the forefront in advancing research to enhance a scientific rather than mythical-based argument. Among the ongoing 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’ brains during the process. This demonstrates that it is not entirely about needles and acupoints (NCCAM, 2011). This paper will focus on the use of acupuncture in the treatment of knee osteoarthritis.

Literature Review

Aim of study

There are numerous medical procedures in use today to treat knee osteoarthritis. These 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. Acupuncture, a non-scientific therapeutic process originating from Traditional Chinese Medicine, has gained popularity in the treatment of knee OA. By reviewing relevant literature on acupuncture, the paper will attempt to outline the results of studies conducted to determine the effectiveness of acupuncture.

Method

A literature search was done from 26th Dec to 29th Dec 2011 with the aim to select the most relevant journal articles on the use of acupuncture in the treatment of knee osteoarthritis. Articles were retrieved from websites and online databases with relevant resources identified through thorough filtering of key studies. The databases accessed were Medline, CINAHL, Pub Med, Medline, Embase, British nursing index and AMED. Only journals written in English were considered. Some sites were inaccessible due to navigation problems or only provided brief abstracts. Personally authored websites were also considered. An inclusion-exclusion criterion was adopted. The articles were considered on the basis of age and the language used in writing them. In approving the validity and relevance of articles, a criteria tool developed by Birch, which specifically determines the validity of acupuncture controlled trials, was used.

Results

Results of the literature search generated sixteen studies, but some were not considered for this review owing to their irrelevance. Four of the studies were outdated and three were retrospective. Others were rejected on the basis of having non-linked titles or being shallow on acupuncture. The remaining studies are reviewed above and are grouped under the acupuncture-related trial studies. Some of the trials used acupuncture in combination with other therapeutic procedures and others focused only on acupuncture as a therapeutic process. The trials were all random-controlled trials (RCT). The outcomes of the studies done were all recorded as positive since they contained well-researched raw data.

Research studies

Several studies have shown reliable evidence of the success of acupuncture in the treatment of knee OA. In combination with other medical care procedures, patients have shown improved and quick recovery from knee osteoarthritis through acupuncture as opposed to only through the use of modern medical procedures (Nadine, et al, 2007). From another study carried out by Witt in 2005, it was found that following eight weeks of knee OA treatment using two approaches of modern treatment without acupuncture in comparison to 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 approach (Cooper, Kahn & Zucker, 2009). However, the efficacy of acupuncture neither decreased with time such that by the fifty-second week of the study, there was no marked difference between the two groups.

A comparative study carried out in 2006 by Scarf and his associates revealed that acupuncture use in the treatment of knee OA showed increased effectiveness in the healing process as compared to sham acupuncture. This involves the insertion of the acupuncture needles in anatomical sites not previously identified as acupoints. This went to further support the use of acupuncture as a treatment technique since sham acupuncture showed no healing power whereas 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 can be found in detail in the 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 by 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 patients who received acupuncture therapy performed better in pain scores as compared to those who did not go through the procedure. However, the two studies concluded that the long-term benefits of acupuncture treatment cannot be realistically demonstrated (Vadivelu, Urman & Hines, 2011).

Recently, three analyses were carried out involving highly controlled trials on the effectiveness of acupuncture in the treatment of osteoarthritis of the knee. From these studies carried out by Manheimer and his associates, it was revealed that acupuncture treatment surpasses sham acupuncture ineffectiveness by great margins. In one of the studies, effect sizes ranged from nine percent in short-term effects to ninety-five percent in the long-term for the acupuncture approach. The study provided statistical data comparing treatment protocols using conventional medical procedures and the combination of these procedures with acupuncture revealing a remarkable difference in the effectiveness of the two models (Manheimer, et al, 2010). The United Kingdom( UK) National Institute For Health And Clinical Excellence dismissed the evidence claiming that by now, there exists no concrete evidence on the effectiveness of acupuncture and thus the board cannot give any recommendation to support the use of acupuncture in the treatment of OA (Lansdown, Howard, Brealey & MacPherson, 2009).

The argument proposed against the use of acupuncture in the treatment of OA in the UK is that the statistical evidence given by numerous studies faces limitations. This includes the notion that the studies did not comprehensively address issues regarding the effectiveness of 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 being 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 headaches and low back pains have been evidenced; however, the benefits on the osteoarthritis of the knee in the long term have not been documented yet. Another limitation pointed out was that the evidence on the cost-effectiveness of the model is limited in the larger UK since the researchers only did comparative studies in Germany which may not necessarily reflect on the UK context. These limitations have contributed to the NHS’s decision to reject the 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 published in Advance Access Publication of August 2006 evaluating evidence for the effectiveness of acupuncture in peripheral joint osteoarthritis, pain reduction in acupuncture survey groups was noted (Kwon, Pittler & Ernst, 2006). 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; Embase; 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 the effectiveness between manual acupuncture and sham acupuncture. This remarkable piece of evidence shows that acupuncture may for sure be an effective pain-relieving 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 the results (Kwon, Pittler & Ernst, 2006).

The use of meta-analysis inhomogeneous data groups gives reliable evidence as compared to other survey models. This is because, despite a significant degree of subjectivity, all the data available from these groups indicates strong evidence (Kwon, Pittler & Ernst, 2006). With the use of the universally accepted Jadad scale, which uses score points to assess the 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 an understudy which would negatively affect the credibility of results.

To assess the effectiveness of acupuncture in relieving pain in knee and other peripheral joint osteoarthritis cases, comparisons were carried out with a wide array of controls to reduce the chances of inaccuracy and bias. The different controls also allow for different conclusions to be drawn and an overall comparison is 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 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 acupoints or using other methods of sensitizing the skin without necessarily using the acupuncture needles or puncturing the skin superficially in a non-stimulatory manner when 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 acupuncture treatment (Kwon, Pittler & Ernst, 2006).

As is common with any study or trial, limitations to the above-described approaches include the inability to locate all RCTs relevant for the study. Despite the efforts put to include all RCTs, it is universally agreed that it is not possible to do so. This could 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 percent 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 complementary medicine. The availability of complementary medical practices such as acupuncture has risen to about 40% of general practice health centers 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 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. Therefore, physiotherapy 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 the release of opioid neurotransmitters. The autonomic nervous system is also affected by acupuncture stimulation. Lack of scientific-based evidence has seen authorities become reluctant to embrace acupuncture in the treatment of knee osteoarthritis. Limitations in studies of acupuncture such as small sample sizes and inadequate control experiments mean that the results from these studies cannot be relied upon. 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).

According to the Chinese medical journal of 2010, acupuncture as a therapeutic approach has demonstrated effectiveness in relieving pain and as an anesthetic technique during minor surgeries. In traditional Chinese medicine, the acupuncture technique has been used to relieve pain and disability discomfort caused by OA leading to improved mobility and joint flexibility. Through its continued use in China, patients have confessed to rapid pain and discomfort relief after acupuncture at the knee joints following OA. Since this evidence is subjective, assessment of the efficacy cannot be evaluated through expert evidence, but can only be reported in the literature (National Cancer Institute, 2007).

Discussion

Knee disorders are a common problem affecting over twenty percent of the elderly population in the world. The most common disorder is osteoarthritis. Clinical manifestations of knee OA include 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 pain and stiffness since the condition is not curable (Vas, Perea-Milla & Méndez, 2004). Acupuncture is gaining popularity as a 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 in a deeper understanding of the efficacy and applicability of acupuncture (Vas, Perea-Milla & Méndez, 2004).

The application of acupuncture in medicine has gained momentum in Europe culminating in the establishment of the first-ever Pain Management Unit (PMU) in the Andalusian Public Health System which was mandated to study the effectiveness of non-conventional treatment techniques. To determine the 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, 2004). All patients were diagnosed with OA of the knee by the general practitioners in the area. The protocol involved the determination and selection of acupoints 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 the treatment of OA of the knee. The treatment involved the 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 and continued for over a fifteen-week period. However, this 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 analog scale (VAS), pain frequency, disability and comfort disturbance caused by the condition and analgesics consumed (Vas, Perea-Milla, & Méndez, 2004).

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 [that was carried out by the pain management unit (PMU) on the effectiveness of acupuncture in the 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 percent of the patients recorded a minimum of about forty-five percent improvement, a clear indication that acupuncture has a positive effect on the healing process of knee OA (Vas, Perea-Milla, & Méndez, 2004).

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 sector. This is mainly 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 researchers. The most popular hypothesis remains that was proposed by Zhang, a famous Chinese neurophysiologic, in 1970 (Tung-wu, et al, 2010). According to Zhang, acupuncture analgesia results from a complex network of integrated effects initiated by sensational waves in pain and motor receptors within 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. In 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 acupoints have different associated effects, and the specialist has to be extremely keen on the specific points to target so as to realize the necessary results. The actual acupoints have been realized following many years of trials and in-depth research. The generally targeted acupoints include body, auricular, and scalp points. To achieve therapeutic effects on the patient, the methods used include filiform needing, moxibustion, acupoint injection, electroacupuncture (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. Manual acupuncture involves inserting the needle into the acupoint, 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).

Electro acupuncture (EA) on the other hand involves applying electrical stimulation to the needle that is inserted in the acupoint. The pulse current creates stimulus through waveforms, pulse width, intensity and stimulation duration are increased resulting in rapid relief of pain. Fu’s subcutaneous needling (FSN) is a needling strategy specifically targeting the subcutaneous layer. Laser acupuncture involves using laser rays directed onto the acupoint. 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 acupoint injection that involves injecting drugs into the acupoint (Xia, 2010).

The clinical application of acupuncture in the treatment of knee osteoarthritis targets pain relief. The most commonly used acupuncture approaches in knee OA treatment are manual and electroacupuncture (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 on 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 knee OA, but advanced clinical research indicated that the unilateral is also as effective as the bilateral acupuncture when professionally manipulated to reduce pain from osteoarthritis of the knee and help in recovering its functioning (Xia, 2010).

To reduce the pain in the knee caused by osteoarthritis, the universally targeted acupoints 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 acupoint 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) acupoint is located in the depression on the lower border of the medial condyle of the tibia connected by the spleen meridian of Foot-Taiyin. The meridian is associated with abdominal pains and distension, diarrhea, oedema, jaundice, incontinence of urine accompanied by difficulty in urination and pain in the knee (Xia, 2010).

The Zusanli (ST-36) acupoint is located one finger-breadth from the anterior crest of the tibia and is linked with the stomach meridian of Foot-Yangming. According to traditional Chinese medicine, this meridian is associated with gastric pain, dysphagia, emaciation, vomiting and pain of the lower limbs. A point above this acupoint 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 acupoint 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 the external malleolus and the Achilles tendon and is connected by the bladder stomach meridian of Foot-Taiyang. This meridian’s clinical indications include headache, epistaxis, the pain of the lumbosacral segment and swelling and pain of the heel. Xuan Zhong (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) acupoint 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 acupoint located along the line joining the anterior and superior iliac spine and the lateral border of the patella, 2 cun above the later-superior border of the patella. The acupoint 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 traditional Chinese acupuncture shows potential in alternative and complementary medicine in the treatment of ailments such as knee OA (Harriet, Katie, Stephen & McPherson, 2009). The unproved and controlled surveys on acupuncture as a form of pain relief, especially for knee OA, have indicated that acupuncture has a powerful therapeutic effect (Vas, Perea-Milla & Méndez, 2004). Modifications and improvements are being incorporated in order to ascertain the quality and scientific mechanism of the technique in pain relief and treatment of knee OA, which has caused disability and other mobility defects in 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 the assessment of 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 for 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, 2004).

Berman et al (2004) published results indicating that acupuncture relieves knee OA symptoms, reduces swelling and increases range of motion. Further studies have shown that acupuncture is a beneficial therapy for 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 (2004) 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, the benefits for the patients were clearly manifested. Opponents of acupuncture have insisted that the therapy’s success depends on the personal attitude of the patients. However, in research carried out by Collier and his associates it was 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 & Peter, 2004).

Acupuncture for Osteoarthritis of the Knee has been comprehensively analyzed through numerous studies. One of the most successful studies which assessed the efficiency of this model was carried out by Ezzo and his associates 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 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. 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 of knee OA and the efficiency of acupuncture. The methodology of trials was structured so 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 cannot 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 cannot 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-acupoints. 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 will determine all dimensions of acupuncture therapy and its applicability in clinical procedures. Furthermore, the efficacy of acupuncture therapy techniques needs to be gauged alongside other medically approved therapeutic regimens (Kaptchuk, 2002).

Conclusion

From the above data, there seems to be significant evidence on the effectiveness of acupuncture in the treatment of knee osteoarthritis. However, the application of this technique requires further research before it is fully incorporated into mainstream primary and secondary health care. Furthermore, it is important that the health providers who are 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 the effectiveness of acupuncture in 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 traditional Chinese medicine. The variance in the 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 to acupuncture points. This would act 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 the application of acupuncture in the 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 have indicated the most satisfactory treatment records in the world. Individualized treatment is the most vital component of acupuncture healing therapy as practiced in China and psychologists argue that this could be the reason why 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, the supplemental efforts ought to be incorporated into the acupuncture treatment regimen. Most studies have indicated that acupuncture of knee OA has no adverse effects. This could have resulted from a 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. Future research has been proposed to give the side effects consideration in order to match the criteria used in other studies on the therapeutic efficacy of drugs and medical procedures.

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 acupuncture’s effectiveness on knee OA have argued that 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 the achievement of higher scores as has been demonstrated in numerous studies.

It is important that future researchers should strive to explain what constitutes an optimal acupuncture knee OA treatment. The researchers also need to address the sustainability of results in respondents in respect to the maintenance treatment. It would also be right if future researchers would 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 whether combining acupuncture with physical exercises has any additive or synergistic properties.

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 protocol since the majority of the patients are elderly. The age factor exposes them to a myriad of adverse side effects if treated using analgesic drugs and non-steroid anti-inflammatory medicine. Furthermore, at this age patients are leading independent lives and would not wish to be a bother to others. In order to adopt the most appropriate treatment or pain relief protocol to return these patients to a full quality life, there is a need for 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 the 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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