***Article 1

Osteoarthritis of the Knee
Acupuncture Shows Promise in Treating Osteoarthritis of the Knee

By Editorial Staff
Acupuncture Today
February, 2005, Vol. 06, Issue 02

In one of the largest trials of its kind published to date, researchers in Maryland have found that acupuncture applied to specific points on the leg can provide significant pain relief and improve function in patients who have osteoarthritis of the knee.

The results of the trial, published in the Dec. 21, 2004 issue of the Annals of Internal Medicine, suggest that acupuncture may be a safe, effective therapy that can be used in conjunction with other forms of care in the treatment of osteoarthritis, and that it has the potential to improve the quality of life for millions of people who suffer from the condition.

Osteoarthritis is the most common form of arthritis in the United States. It is associated with a breakdown of cartilage in the joints and can occur in almost any joint in the body. According to the American College of Rheumatology, approximately 21 million Americans are afflicted with some form of osteoarthritis. In addition to the knees, osteoarthritis commonly occurs in the fingers, hips and spine. To treat the condition, health care providers may recommend analgesics, nonsteroidal anti-inflammatory drugs, topical creams, or a combination of agents. However, these therapies are often ineffective, and may cause unwanted or potentially dangerous side-effects.

In the trial, investigators from the University of Maryland School of Medicine recruited 570 people, all at least age 50, who had already been diagnosed with knee osteoarthritis. None of the study participants had ever experienced acupuncture, had not had knee surgery in the previous six months, and had not used steroids or similar injections.

The patients were randomized into three groups. One group received 23 “true acupuncture” sessions over a 26-week period, using a tapered treatment schedule. Points were selected using traditional Chinese medicine meridian theory, and consisted of nine points – five local (GB 34, Sp 9, St 36, St 35, and extra point xiyan) and four distal (UB 60, GB 39, Sp 6, K 3) . The same points were treated for each affected leg. If both knees were affected, needles were inserted in each leg. All of the patients in the true acupuncture group achieved de qi, and electrical stimulation was applied to the xiyan point for 20 minutes.

The remaining groups received one of two control treatments. The first control group received sham acupuncture, using a combination of needles inserted into sham points on the abdomen, along with needle tubes tapped on the surface of the nine true acupuncture points. Patients in the second control group participated in six group education sessions on the self-management of arthritis and received printed materials on arthritis in the mail. Subjects in all three groups continued to receive medical care from their primary care physicians during the study, and were allowed to receive their usual medications.

To measure the effects of acupuncture on pain and stiffness in the knee, the scientists employed a device called the Western Ontario and McMaster Universities Osteoarthritis Index, or WOMAC. WOMAC scores were taken at baseline, and at four, eight, 14 and 26 weeks after the start of the trial. Patients in all three groups also completed a short form health survey (to measure improvements in physical functioning) and a walking test, and were asked to report any adverse events that could have been related to treatment.

Results: While pain scores decreased among participants in all three groups, the most significant reduction was seen in patients receiving true acupuncture approximately midway through the study period. According to the researchers, “by week 14, the mean WOMAC pain score had decreased by 3.6 units in the acupuncture group (a 40 percent decrease from baseline) compared with -2.7 in the sham group.” Pain scores continued to decrease in the acupuncture group; by the end of the study, average pain scores among acupuncture patients had decreased more than twice as much as patients in the education group.

Mean Change in WOMAC Pain Scores, Baseline-26 Weeks
Group Baseline 4 weeks 8 weeks 14 weeks 26 weeks
True acupuncture 8.92 – 2.22 – 3.15 – 3.63 – 3.79
Sham acupuncture 8.90 – 1.98 – 2.66 – 2.68 – 2.92
Education 9.01 – 0.84 – 1.25 – 1.54 – 1.69

Patients receiving acupuncture also showed dramatic improvements in knee function. Compared to baseline, average WOMAC function scores for acupuncture patients were 12.18 points lower at the 14 th week of the trial, and 12.42 points lower at the 26 th week of the trial. The investigators stated that “the true acupuncture group’s improvement in function from baseline was significantly greater than that of the sham control group at weeks 8, 14, and 26. A change of more than 12 units by 14 weeks is an almost 40 percent improvement from baseline.”

Mean Change in WOMAC Function Scores, Baseline-26 Weeks
Group Baseline 4 weeks 8 weeks 14 weeks 26 weeks
True acupuncture 31.31 – 7.56 – 10.77 – 12.18 – 12.42
Sham acupuncture 31.29 – 5.90 – 7.84 – 9.40 – 9.88
Education 32.48 – 4.65 – 5.30 – 5.62 – 7.17

Less significant results were seen when the scientists compared the short form health survey and the walking test among groups. Regarding the health survey, “changes in overall physical component score did not statistically significantly differ between the true versus sham acupuncture groups.” As for the walking test, the scientists “observed no statistically significant differences at any time point” during the trial.

A total of 26 adverse events were reported among the participants, more than half of which occurred in the true acupuncture group. However, the authors noted that “of the 14 adverse events observed in the true acupuncture group, none was interpreted as treatment-related, and the differences among groups did not reach statistical significance.”

Based on the differences in WOMAC scores between groups, the scientists stated that their results “demonstrate that true traditional Chinese acupuncture is safe and effective for reducing pain and improving physical function in patients with symptomatic knee osteoarthritis who have moderate or greater pain despite background therapy with analgesic or anti-inflammatory therapy.” They added that if future trials validate their research, “acupuncture may have an important role in adjunctive therapy as part of a multidisciplinary integrative approach to treating symptoms related to knee osteoarthritis.”

NCCAM, NIAMS Comment on Trial On Dec. 20, 2004, the day before the study was published, representatives from the National Center for Complementary and Alternative Medicine (NCCAM) and the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) held a press conference to announce the trial’s findings to the public. The NCCAM and NIAMS both helped to fund the trial.

“More than 20 million Americans have osteoarthritis,” said NIAMS Director Dr. Stephen Katz. “Thus, seeking an effective means of decreasing osteoarthritis pain and increasing function is of critical importance.”

“For the first time, a clinical trial with sufficient rigor, size, and duration has shown that acupuncture reduces the pain and functional impairment of osteoarthritis of the knee,” added NCCAM Director Dr. Stephen E. Straus. “These results also indicate that acupuncture can serve as an effective addition to a standard regiment of care and improve quality of life for knee osteoarthritis sufferers.”

The complete study, “Effectiveness of Acupuncture as Adjunctive Therapy in Osteoarthritis of the Knee: A Randomized, Controlled Trial,” can be ordered from the Annals of Internal Medicine Web site (www.annals.org).

References

1.Berman BM, Lao L, Langenberg P, et al. Effectiveness of acupuncture as adjunctive therapy in osteoarthritis of the knee: a randomized, controlled trial. Annals of Internal Medicine Dec. 21, 2004;141(12)901-910.
2.Acupuncture relieves pain and improves function in knee osteoarthritis. NCCAM press release, Dec. 20, 2004.

 

***Article 2

Knee Pain

Research:
Acupuncture Is Both Cost and Medically Effective
Two recent research reports find that acupuncture is an effective treatment for several types of chronic pain and has the added advantage of being less costly than standard medical care.
Acupuncture Today
November, 2012, Vol. 13, Issue 11

Acupuncture Found Valuable in Treatment of Knee Pain

A British study, which focussed specifically on acupuncture’s cost-effectiveness in treating chronic knee pain, concluded that one-third of patients with knee osteoarthritis and were candidates for total knee replacement surgery had achieved long-term symptom relief after two years. The study, published on Sept. 12, 2012, determined that the acupuncture treatments had saved at least 100,000 pounds (about $162,000) per year within the study group.

The report, “Group acupuncture for knee pain: evaluation of a cost-saving initiative in the health service,” was published in the journal, Acupuncture in Medicine.

About 80% of patients with knee osteoarthritis who attended MSK CATS (musculoskeletal clinical assessment and treatment services) in 2008 and were considered candidates for TKR surgery were willing to try acupuncture first. Ninety patients were screened for acupuncture in this NHS service offering treatment in groups. Of these 90 patients, we know that at least 31 had not had TKR within the following 2 years.”

Typical total knee replacement surgery in the UK costs about 5000 pounds (roughly $8100), the report stated.

It concluded: “Although TKR (Total Knee Replacement) is successful in the sense that revision rates are low, as many as 15% of patients experience severe knee pain 3–4 years later and 18% are dissatisfied with the results. Experts recommend that all conservative options should be offered before resorting to surgery.

“The evidence published on acupuncture in patients with knee osteoarthritis shows that it is safe and effective in reducing pain and improving function, thus qualifying it as an appropriate conservative treatment for this condition.”

 

***Article 3

Knee Pain & TCM
The Knee Bone’s Connected to the … Stomach?
What Do Knee Pain, Sinusitis and Acid Reflux Have in Common?
By Nancy Post, MAc, PhD

Acupuncture Today
June, 2007, Vol. 08, Issue 06
Most people would not think to ask this question because they would never believe an answer exists. Take my client Mark, a practical, solid fellow in his 40s.

He is a fourth-generation stone mason who runs his family’s construction business. He’s the kind of man who values a solid foundation, whether it’s made of family knowledge or fine stone. While he treasures traditional methods, Mark believes in giving the past a vote, not a veto. He’s working to grow a modern family business without sacrificing the family reputation for high-quality work.

This need for simultaneous stability and change presents challenges. The family was accustomed to doing standard jobs, like building stone walls or installing driveways. Mark’s leadership led to new challenges. For example, the company bid upon and won a contract to do land planning and all of the ceramic, stone and walkway installation at the city’s art museum. Mark has transformed a small family-owned masonry business into a full-service landscape and land-management group. Contracts are bigger and they have given Mark enormous satisfaction, as he has felt more and more capable of creating a stable base for the people he loves.

His wife, Carol, is an IT manager and has helped him to introduce technology into a family business whose best tools had always been manual. Project managers now use laptops as well as picks and axes. Despite jibes from elders, Mark has quietly updated office systems for billing, managing projects, managing inventory and payroll. He evaluated the company’s performance against competitors and created plans for growth in areas of the market in which more opportunity exists. For the first time in 80 years, someone in his family has made a business plan!

Confident that he could learn the necessary business skills to continue the transformation of the business, he enrolled in a local executive MBA program where I was teaching a course called “Change Management.” In this class, students identified all types of changes that were occurring in their organizations, including leadership, direction, staff, location, vision, mission, values, infrastructure and resources. We also talked about personal changes. “What has changed about you since you took this job?” I asked.

“My gut and my knee,” answered Mark. “And my face … no, my nose … no, probably my sinuses!” he said, struggling for accuracy. Of 32 people in the class, Mark, an intrinsically physical man, was the only one to notice a change in his body as a result of workplace change. Other people were aware that their work had been altered as a result of workplace changes, but no one else recognized that the change at work would likely mean changes in their energy. He was the only one at the time to calibrate the physical impact of these changes. Interestingly, two years later, when I attended the graduation ceremony, a number of the women in the class mentioned that the MBA program had changed them, adding pounds and dress sizes they hoped to shed now that they had completed the degree!

Mark was surprised by his own answer. “I went from using picks and hammers to sitting at a desk and driving a car! I shouldn’t be feeling more pain, I’m doing less! The guys shoveling gravel have the right to pain!”

Is pain only justified when it has a muscular origin? To a man like Mark, discomfort is something to endure and ignore until it becomes debilitating. Responding to pain demonstrates weakness and makes you feel vulnerable – effeminate even! Real men endure pain. Yet in front of 31 colleagues, including successful managers and leaders of area organizations, he admitted not one, but three signs of workplace stress: his knee, sinuses and stomach.

Formerly a high-school football player, an old injury to his lower leg has bothered Mark chronically since he broke his fibula in a tackle. He also suffers a long history of problems with his digestion, beginning as a child with food allergies and evolving into chronic and often painful flatulence (which was also an embarrassment when his work took him indoors). Though formerly seasonal, the phlegm in his sinuses is now a constant element in his life. Damp weather makes everything worse. These seemingly innocent problems escalated over time as his work responsibility grew.

“Are any of these symptoms better or worse at any time? I asked. And are they all better or worse at the same time, or do they come and go independently of one another?”

“Funny you ask!” Mark replied. “They seem to come and go together. When one is worse, the others are, too.”

“And when are they worse?” I asked.

“When I’m worrying about proposals for new work,” Mark responded. “I worry a lot. If I don’t succeed, the whole family comes down. I’m carrying a lot of people.”

So, what connects Mark’s knee pain to his sinuses and to his indigestion? His worry, one could answer. But there is also a line of energy that runs from his eyes, through his gut and down his leg, through his knees. It’s called the stomach meridian, of course. Like waterways crossing North America, connected pathways form a system of energy for the body. One of the longest channels is the stomach meridian, which distributes the energy of the stomach. What does the stomach do? It digests, holds and contains not only food but, metaphorically, also thoughts and feelings.
——————————————————————————–

“I receive, process and digest all nourishment coming from all sources in Heaven and Earth.”

– Suwen, Stang Interpretation, 1985.
——————————————————————————–

“What do you feel when you write proposals?” I asked Mark. “First I think, ‘what does the client need?'” he answered. “Then I cogitate about how we can meet their need, thinking up all the ways that we can break down the job into smaller parts. Then I think about our crew and whether they can do the job. I think about materials, timing and finally, cost. It’s a lot to think about, and the whole process takes hours. In the end, I worry whether or not our bid will win and if we’ll get the job.”

I think to myself, he breaks the work into “digestible” parts and while evaluating the work, he uses the energy from this pathway. It’s as if the reservoir in this line of energy in Mark’s body has a pipeline to his company – his energy fuels the business. But then, there isn’t quite enough left for him, and his symptoms get worse.

Having diagnosed the source of his periodic pain flare-ups, I was now able to work with Mark on addressing the problem from two directions: clinically and organizationally.

Clearly, he can never be sure his bids for work will be accepted, but he can make the process of developing the proposals less onerous and taxing on his energy. In a team with other class members and Carol, the IT manager, we built a set of proposal templates that identified all the different bid elements (staff, materials, timing, cost), which he could customize using the experience of past jobs tracked within his new financial and office systems, thereby adding a stable structure to the bid process.

And for him, personally, I suggested a short course of acupuncture treatment, which boosted and rebalanced his energy; as well as prescribing er chen wan, a Chinese herbal patent medicine whose origin descends back to Chen Shiwen, et al., in 1080 AD.1 The result: support for stability and change, simultaneously.

As Elisabeth Rochat de la Vallee wrote, “You can see that both stability and transformation are necessary for thinking, which is just a refinement of the fundamental notions linked with Earth.”2 In this case, classical Chinese notions of energy enhanced the life and business of an ambitious earth-mover.

References

1.Fratkin JP. Chinese Herbal Patent Medicines. Shya Publications, 2001, p.215.
2.Larre C, Rochat E. Spleen and Stomach. Monkey Press Publication, 1990; p. 52.

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