The Best Treatment for Knee Pain: No Clinician Fails, Theory Irrelevant & Experience Unnecessary
Knee pain due to osteoarthritis (OA) is one of the most commonly seen joint disorders in adults aged 45 years or more. The prevalence of disabling OA knee in people over 55 years is 10% (Peat G et al, 2001). Until the late 2010s, very few national or international guidelines contained recommendations for the treatment of OA knee pain. This is not surprising, as although there had been various attempts to treat knee pain, no scientific evidences from randomized studies had yet shown that any particular form of treatment for knee pain is superior to others.
German Acupuncture Trials (GERAC)
Among a broad variety of modalities for knee pain treatment, acupuncture has been a popular one since 1980s. However, it was not until the middle 2010s that the efficacy of acupuncture became reliably substantiated by scientific data, which were obtained in Germany from the “German Acupuncture Trials" (GERAC) conducted in 2001 to 2006.
In 2001, the Joint Federal Committee in Germany initiated a nationwide large-scale project putting acupuncture to the test (GERAC). The result of the trial on the efficacy of acupuncture for knee pain was reported by Germany researchers Heinz G. Endres et al in 2007. A total of 1007 patients with knee pain and 320 primary care practitioners across the country participated in this randomized trial. Three groups of patients separately received 10 to 15 sessions of verum TCM acupuncture, sham acupuncture (non-meridian non-stimulation) or conventional care (physiotherapy plus as-needed drugs) during a period of 6 - 10 weeks. Assessments were conducted at 3 months and 6 months after the beginning of the treatments.
Verum vs Sham: Which Is Superior?
For verum TCM Acupuncture, the primary acupoints were all located close to the knee joint: ST34, ST36, Xiyan, SP9, SP10 and GB34. Optional points included 1–4 Ahshi points and 1–2 of 16 defined distant points. The acupuncture treatment was performed by physicians. 56% of participating physicians had a type A diploma in acupuncture (obtained after an average of 216 hours of postgraduate study), and 44% had a type B diploma (obtained after an average of 374 hours of postgraduate study).
In sham acupuncture (minimum Acupuncture), the stimulation is kept at the minimum at the location without known acupoints. The needles were only superficially inserted (< 3 mm) and not twisted or thrust (no de qi). They were inserted at points not recognized as meridian points or disease-specific "ah shi" points, so that no point-specific (so-believed) effects could be induced.
The key findings of this GERAC trial on OA knee pain can be summarized as below:
1. Compared to physio-drugs, acupuncture, both verum or sham (minimal acupuncture), worked 3 times better in terms of patient-responder rate, and twice better in terms of pain reduction.
The patient response rate (a reduction of WOMAC score by 36% or more) assessed at 6 months were 34.7%, 37.3%, and 10.1% for verum TCM acupunture, minimum acupuncture and physio-drugs. The pain reduction at 3 months were 30.2%, 28.4% and 14.7% respectively.
2. Verum and sham worked equally good
Interestingly, no meaningful differences between verum and sham acupuncture for any measured criteria were found in any of the major assessment points of the studies (baseline, 3 months and 6 months. See the example figure showing the change of pain intensity), indicating that needling alone, even in nontraditional insertion sites and without any stimulation produced the same effect no less than the verum TCM acupuncture.
The Effect of Physicians' Experience
3. Physicians' experience was irrelevant
The study also found that practitioners' experience with acupuncture did not make any difference in the efficacy of intervention.
4. No difference between randomized trial and daily routine care
Surprisingly, the study further demonstrated that the efficacy of acupuncture in routine care of daily practice across Germany was nearly identical to the efficacy of verum TCM acupuncture in the randomized trial. In routine care, the TCM theory or diagnosis principles may not be as strictly followed by all individual physicians as in the randomized trials, and in addition the intervention in daily routine care is often administered in conjunction with other treatments. No difference between daily routine care and randomized trial indicated that whether or not acupuncture is performed by strictly following TCM theory does not make any difference in the efficacy of acupuncture.
Acupuncture Specifically Tested in Daily Routine Care
The primary purpose of GERAC trial was to investigate the efficacy of verum acupuncture as compared with sham (placebo) acupuncture. In parallel with the GERAC study, another large-scale knee pain study called ARC (Acupuncture in Routine Care) was also conducted at the same time in Germany (Witt C.M. et al, 2006). The objective of this study was to investigate the efficacy of acupuncture in combination with routine care (physio + drugs) compared with routine care alone.
This study was by far one of the largest randomized trials of acupuncture to date. A total of 3,553 patients (322 in the randomized acupuncture group, 310 in the control group, 2,921 in the non-randomized acupuncture group) were included. Nationwide, as many as 5% of physicians specializing in acupuncture in Germany participated in this trial, representing a full 1% of all primary care physicians across the country.
This study made essentially the identical findings as GERAC did:
TCM Theories Questioned
Based on the above results, the Germany researchers (Heinz G. et al, 2007) concluded:
“The lack of superiority of verum over sham acupuncture puts the major assumptions of traditional Chinese medicine in question, in particular with regard to the choice of acupuncture points, the depth of puncture (sham acupuncture was no more than 3 mm deep), and the stimulation of the needles to obtain a feeling of de qi, which was not performed in the sham acupuncture group.
“The effectiveness of both types of acupuncture can only be explained by a combination of a specific physiological effect of repeated, superficial puncture of specific bodily regions – as in Japanese acupuncture – with non-specific psychological factors.”
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Needle Insertion Alone Matters, No Modifiers Exist
Thus, no matter what the variables may be, the “needling insertion” (as performed in routine care today in Germany nationwide and in the randomized trials) works persistently at the same level of efficacy. No modifiers whatsoever could be identified which can improve or diminish the efficacy of acupuncture.
Now we are facing a fact that the efficacy of today's acupuncture for OA knee pain remains persistently at a success rate (patient-responder rate) of about 35% and a pain reduction of about 30% after 10-15 sessions of treatment in 2 to 3 months. That is, for each 100 knee pain patients, there are constantly 65 for whom acupuncture is useless. Nothing could change this scenario. Is't interesting? And why?
Same Conclusion Reached in American Study
In 2010, American researchers (Maria E. Suarez-Almazor et al, 2010) published the results of their study on acupuncture's efficacy in treating knee pain. A total of 455 patients who received treatment of verum TCM acupuncture, minimum acupuncture (sham) and waiting control were included. The study reached the same conclusion as Germany researchers did: Meridian point insertion plus de qi (TCM acupuncture) was not superior to superficial insertion without stimulation at the location without known acupoints (Sham acupuncture), although both types of the needle insertion produced significant reductions in pain compared to the waiting group.
Same Conclusion Reached in Meta-analyses Reviews
In 2007, six researchers from America, Germany and Netherlands jointly published their meta-analyses review (Eric Manheimer et al, 2007) on the efficacy of acupuncture versus sham acupuncture in treating OA knee pain.
The review included 9 sham-controlled trials conducted worldwide in the US, Canada, Germany, the UK, Spain, Denmark and Thailand. The results showed that although acupuncture obviously produced benefits as compared to no treatment, no clinically meaningful benefits were identified when compared to sham acupuncture.
Note that these 6 researchers from different countries considered the benefits from sham acupuncture, if any, to be clinically meaningless placebo effect. This is a prevailing misled conception within the scientific research community worldwide. The reason causing the misleading is that no one is aware that TCM acupuncture is a “stab in the dark” and “one size fit all” therapeutic modality but not the true acupuncture traditionally practiced 2000 years ago in ancient China. In the true millennia old traditional Chinese acupuncture (Huandi Neijing acupuncture), any where on the body can be a potential point which once pricked could produce a cure effect more or less for a specific disease (the fixed point needling was only used in less than 0.1% of cases in daily practice in Ancient China at latest prior to 100-200 BC).
If No-Frill Similarly Good, Why Bother with Those Fancy Additions?
The TCM theories is esoterically or beautifully complicated. But no matter how fancy it is, the acupuncture based on such a beautiful theory works no better than superficially inserting needles randomly at any location of the body with no stimulation whatever needed.
Yes, indeed, I can guarantee all of you who are reading this post that for every 100 knee pain patients you treated using needles, on average 35 would get at least about 30% pain reduction after 10 – 15 sessions of treatment no matter where you put the needles, 100% for sure.
Best Way Available Today for Treating OA Knee Pain
In 2012, British researchers (Mark Corbett et al, 2012) published the results of their systematic meta-analysis review, which compared the effectiveness of acupuncture with other physical treatments for relieving chronic OA knee pain. The review analyzed 134 original trials which involved 18 interventions for OA knee pain including acupuncture:
Based on the results from 32 higher-quality trials, the most reliable and consistent therapeutic benefit for OA knee pain was demonstrated only for acupuncture and exercise, with the former being significantly superior to the latter.
So the best therapy available today for OA knee pain is any type of ACUPUNCTURE, which could produce a pain reduction of at least 30% with at least 35% success rate with 10 – 15 sessions of treatment in 1.5 to 2 months.
But you can do it even far more better than the "best"! In my oncoming posts, I will talk about how to relieve knee pain by at least 50% within 5 seconds after needle insertion with 95% success rate, not only for OA knee pain but for almost any type of knee pain with pathology largely regardless. Forget the stab in the dark and one size fit all acupuncture! Stay connected.
References
Claudia M. Witt et al, Acupuncture in Patients With Osteoarthritis of the Knee or Hip. A Randomized, Controlled Trial With an Additional Nonrandomized Arm, ARTHRITIS & RHEUMATISM Vol. 54, No. 11, November 2006, pp 3485–3493
Eric Manheimer et al, Meta-analysis: Acupuncture for Osteoarthritis of the Knee. Ann Intern Med. 2007;146:868-877
Heinz G. Endres et al, Acupuncture for the Treatment of Chronic Knee and Back Pain, Dtsch Arztebl 2007; 104(3): A 123–30
Maria E. Suarez-Almazor et al, A Randomized Controlled Trial of Acupuncture for Osteoarthritis of the Knee: Effects of Patient-Provider Communication, Arthritis Care Res (Hoboken). 2010 Sep; 62(9): 1229–1236.
Mark Corbett et al, Acupuncture and other physical treatments for the relief of chronic pain due to osteoarthritis of the knee: a systematic review and network meta-analysis, NIHR Report 40, 2012 Centre for Reviews and Dissemination, University of York
Scharf H-P, Mansmann U, Streitberger K et al.: Acupuncture and Knee Osteoarthritis: A Three-Armed Randomized Trial. Ann Intern Med 2006; 145: 12–20.
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