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Editors should be allowed to beat a drum from time to time, and in this one we bang on about the use of acupuncture for knee osteoarthritis (OA) pain. The harmony is provided by an editorial and four papers. The melody was first heard when Freedman and Richardson set up a group acupuncture clinic, (shown in the figure 1). The lyric was ‘Integration of acupuncture in the health service’. Acupuncture is known to be cost effective—meaning that additional benefits to patients are worth extra money. But there is no extra money. When group treatment, given by nurses, in place of knee joint surgery, were added to the score, it became music to the commissioners' ears.
I was privileged to collaborate with Freedman and Richardson in evaluating their clinic's effects on symptoms, and with Asprey and Paterson in looking at what benefits or problems the group itself might bring, and making some recommendations for anyone else setting up such a service. The outcomes of the first year's referrals to the clinic show a high rate of acceptability among patients, and estimated savings to the commissioning group of £100 000 per annum. The editorial by Glass and Underwood calls this study ‘tantalising’ and rightly reminds readers that it was not a controlled trial.
Group acupuncture for knee pain is offered in secondary care too. In the controlled trial reported by Soni and colleagues, changes in pain are difficult to interpret because of small size and baseline differences; but patients in the acupuncture group cancelled surgery more often than those in the control group.
The cost effectiveness of pharmaceuticals is estimated by comparison with placebo. National Institute for Health and Clinical Excellence (NICE), in its OA guidelines, compared acupuncture with placebo (well, sham) and concluded it was not cost effective. But in its low back pain guidelines, NICE decided to compare acupuncture with usual care: it was cost effective. Latimer and colleagues demonstrate the dramatic effect of this decision: it is the equivalent to Pass or Fail an examination.
The ‘knee pain’ theme turns up again when Purepong and colleagues explore a crucial question about the relevance of clinical trials: Are their patients and treatments different from those in ‘real’ practice? Looking at the literature on acupuncture for knee OA pain, they found there was reasonable correlation—and interestingly a majority clinical opinion in favour of treatment more frequently than once a week.
Knee pain inhibits the activation of the surrounding muscles, as measured by the H-reflex. In a neat and novel exploratory study, Park and colleagues found that a single session of acupuncture did not reverse this effect in experimental pain.
Patients with knee OA are recommended to lose weight—even though the evidence that dieting works is itself decidedly slim. The evidence on acupuncture as part of a weight reduction programme gains a little weight in this issue. Leptin, isolated about 20 years ago, is known to suppress appetite and fall with increasing obesity. Darbandi and colleagues found both weight and leptin are reduced in the short term by auricular acupressure; Bahar and colleagues found the same with body acupuncture. Still on obesity, a letter from Huang and colleagues reports studies on the effectiveness of the Chinese method of embedding catgut over the abdominal wall.
Advances in research methodology need to be shared with the research community, so we are pleased to include Yu and colleagues’ validation study of the Chinese version of the scale used to evaluate de qi. In our laboratory slot, Kim and colleagues suggest that electroacupuncture may increase neurotrophic factor in recovery from brain injury, which might be relevant to stroke rehabilitation.
Although a final discordant note is struck by our case reports of adverse events of cupping and of a broken needle, overall this issue offers readers a tuneful symphony on the theme of integration.
Competing interests None.
Provenance and peer review Commissioned; internally peer reviewed.
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