Opioids & Scattergun Shots for Knee Pain Relief in Modern Medicine
On Sept 8, 2022, the American Society of Pain and Neuroscience published in the Journal of Pain Research a Consensus Guidelines (2022 ASPN Guidelines) on how to treat knee pain. The guideline was authored by 25 experienced MD or PT researchers from the US nationwide (16 institutes in 12 states) based on an extensive literature search (Corey W Hunder et al, 2022).
One of the principal goals of this 2022 ASPN guideline is, as clarified by the authors, to illustrate just how many evidence-based treatment options that are available for knee pain that go beyond the opioid medication.
The background is that in the US, from 2004 to 2014, 16% of the patients presenting with knee pain and osteoarthritis were prescribed opioid medications for treatment (DeMik DE et al, 2017). The opioid overdose deaths in 2018 amounted to 46,802 as reported by the Centers for Disease Control (CDC) in the US (Drugabuse.gov, 2021).
Opioids Crisis & Pain Experts' Lament
According to the Lancet Editorial 2022, the year 2020 marked the deadliest year yet in the North American opioid epidemic: more than 100 000 drug overdoses were recorded in the USA, nearly 76 000 of them attributed to opioids, an increase of approximately 30% over 2019; in Canada, deaths rose by 67% in a single year, to more than 6200 (The Lancet Editorial, 2022).
Confronted with such an opioids crisis, the 25 American pain science experts lamented:
Opioids: Fatal Risks Aside, A Fanciest Placebo
While there are no data supporting the effectiveness of opioids for either pain or functional improvement in patients with osteoarthritis (Ivers N et al, 2012), from 2007 to 2014, 17.0% of patients with any joint osteoarthritis, 13.4% of patients with hip osteoarthritis, and 15.9% with knee osteoarthritis were prescribed an opioid for their condition (DeMik EE, et al, 2017).
In 2014, a systematic review on 22 trials with 8275 participants demonstrated that compared to placebo, the efficacy of opioids in pain relief is clinically irrelevant: the difference of pain reduction between opioids and placebo is less than 9% on a 10-cm VAS (de Costa BR et al, 2014).
So, by all means, opioids are just a fanciest placebo with fatal risks.
Knee Pain Relief beyond Use of Opioids
Knee pain, mostly osteoarthritis (OA) related, is a major cause of pain and disability, estimated to affect at least 654 million people worldwide (Cui A et al, 2020), with the lifetime risk estimated to be 44.7% in the USA (Murphy et al, 2008).
So the fatal opioids aside, how many modalities are there in mainstream medicine currently used to treat knee pain? Which is the best-evidence based? Are there some that are superior to others?
Scattergun Shot for Knee Pain Relief
There are a plethora of modalities which have been tried for knee pain relief. However, there is no consensus on whether one modality is superior than the other and which treatments should be offered over others and in what order (Corey Huter et al, 2022).
The 2022 ASPN guidelines (Corey Huter et al, 2022) and other recent systematic reviews provided us a most up-to-date picture as shown below.
There is only limited efficacy and such low efficacy is accompanied by a lot of side effects.
A 2019 Cochrane review concluded that paracetamol, a widely used first-line pain medication, provides only minimal clinical benefit (Leopoldino AO et al, 2019). With limited efficacy, all NSAIDs are associated with increased risk of digestive disorders, kidney injury, easy bruising or bleeding and others.
There is little evidence supporting their efficacy.
There is insufficient evidence to make any recommendations
Very low evidence supporting its efficacy.
A most recent 2022 Cochrane review & meta-analysis (Sasaki R et al, 2022) involving 20 trials with 2,350 patients on physiotherapy (exercise combined with education) treating hip/knee osteoarthritis demonstrated that there is very low evidence that the exercise plus education improve the physical activity level at the endpoint. Low evidence was observed for combination therapy reducing pain (SMD -0.15, 95% CI -0.29 to -0.02, P = 0.03).
There is no evidence to support MPT's efficacy for CRPS. Injury-induced knee pain is known as Complex Regional Pain Syndrome of Knee (CRPS).
Its efficacy for CRPS is unclear.
Its efficacy for CRPS is absent.
Regarding the above 3 physiotherapeutic modalities, a 2016 Cochrane review (Smart KM et al, 2016) found no evidence supporting their efficacy for CRPS knee pain. The review involving 18 RCTs with 739 participants concluded: Evidence of the effectiveness of multimodal physiotherapy, electrotherapy and manual lymphatic drainage for treating people with CRPS is generally absent or unclear.
There is no high-quality evidence supporting the use of PT to manage soft tissue injuries of knee.
There was only anecdotal evidence that facility-based PT programs can potentially benefit patients with PFPS. But the authors of the ASPN gideline suggested that further high-quality research on this topic is needed.
No data available indicating an effective intervention. The 2022 ASPN suggested this decision should be deferred to the surgeon who performed the procedure.
There was only low quality of evidence supporting its efficacy due to lack of good comparison to drug standards.
Braces are cumbersome and uncomfortable, shoe inserts require bigger bulkier and less stylish shoes. Up to 87% of the orthopedic surgeons prescribed functional knee bracing post ACL repair. However, these braces, which may lead to thigh muscle atrophy and decrease strength, do not significantly impact the laxity in the knee joint nor have a significant impact on pain reduction or an effect on joint laxity or satisfaction. It can add support but not replace rehabilitative therapies (Baron R et al, 2014).
These braces are most commonly used in American football leagues; however, both the American Academy of Orthopedic Surgeons and the American Academy of Pediatrics claim there is insufficient evidence to support their use.
No significant difference between the bracing and non-bracing group.
A systematic review (Yang XG et al, 2019) involving 7 studies with 440 participants concluded that knee bracing does not improve the clinical outcomes on the function and stability for ACL-reconstructed knees. There was no significant difference between the bracing and not bracing group.
The optimal choice for an orthosis modality remains unclear, and long‐term implications are still to be determined.
May provide short-term weak to moderate pain relief but is associated with an increase in cartilage volume loss.
Evidence is conflicting for the treatment of OA knee.
There was moderate evidence showing PRP as effective as hyaluronic acid for knee pain secondary to osteoarthritis. But further research is needed for development of standardized treatment protocols.
领英推荐
There is moderate evidence supporting the use of MSCs for treatment of knee osteoarthritis in improvements of pain and function. However, given the inherent heterogeneity of MSCs as well as the lack of RCTs, there is insufficient evidence for ideal treatment paradigms and generalizability at this time.
Moderate evidence for knee pain secondary to OA.
There is no high-level evidence to support its use for knee pain
There are limited data to support its use currently (Ilfeld BM et al. 2017).
A Scattergun Shot in The Dark
With such a wide variety of modalities for knee pain management, the expert authors of 2022 ASPN guide lines pointed out:
In other words, there is no permanent cure available for knee pain. The final destination of a knee pain patient is expected to be nothing but to have their “flesh and bones” knee joint replaced with metal or plastic screws.
In summary, as a musculoskeletal health practitioner of this modern times, in order to help our patients get rid of bothersome knee pain, we tried this, we tried that, we further tried another this, another that, we continue to try more and more ... but have never been able to find any strong or high quality evidence to support a single thing we tried. All we can do is essentially blindly firing shots in the dark with a scattergun.
A Failure of Today's Mainstream Medicine
In 2018, the British Journal of Sports Medicine published an editorial titled:
"Is it time to reframe how we care for people with non-traumatic musculoskeletal pain?" The editorial loudly voiced:
The leading author of the editorial is Jeremy Lewis, Professor of Musculoskeletal Research at the Universities of Hertfordshire, UK, and also a consultant physiotherapist working in the UK-NHS.
A Magic Sharpshooter Medicine in Ancient China
While a simple pain at the knee joint defeated the entire modern medicine world, few healthcare practitioners today are aware that there was a healing art 2000 years ago in China which could instantly knock out or greatly relieve any pain on the body including knee pain. This marvelous healing art is called acupuncture.
The efficacy of the acupuncture in ancient China as described in Chinese medicine classic Huangdi Neijing was indeed marvelous: the symptom relief happens the instant the needle is in and the permanent cure will eventually follow with high-level of certainty. Such instant efficacy was highly consistent, reliable and reproducible.
By at latest 100 BC, acupuncture in China had already developed into such a point that it was widely practiced as mainstream medicine. It was so popular and successful that the authors of Huandi Neijing strongly proposed that the herbs, most of them are poisonous, should be replaced by needles (LS 1 of Huangdi Neijing). I call this ancient acupuncture in China “Neijing Acupuncture” (NA).
When you read Neijing, you can always feel intensely the strong confidence of the Chinese physicians in that era with the efficacy of their needling: If the symptom relief is not instant, you just have not done the job correctly. The Lingshu 1 says:
“The therapeutic effect should happen like the wind blows away cloud (效之信，若风之吹云); …
"Those who are skilled in using needles will cure an illness easily like plucking out a thorn from the skin, brushing away a dirt, untying a knot, or unclogging a blocked drain. However chronic a disease may be, there is a way to treat. Those who say 'incurable' simply lacked the skills” (夫善用针者，取其疾也，犹拔刺也，犹雪污也，犹解结也，犹决闭也。疾虽久，犹可毕也。言不可治者，未得其术也) (Lingshu 1).
Knock out Knee Pain in A Breeze
If you understand the “hidden” principles of Neijing acupuncture, knee pain relief is just a breeze (not just knee pain but pain anywhere on the body including internal organs). The “secret” of the magic Neijing acupuncture is very simple and straightforward: where to insert needles for a maximum effectiveness cure is exclusively determined by the specific location of an illness or the pathogen.
For the details of how to knock out a specifically localized knee pain (such as anterior, posterior, medial or lateral …) in a breeze, read my earlier posts about knee pain (Relieve Knee Pain Instantly upon Needle Insertion; Anterior Knee Pain; The Best Therapy Available Today for Knee Pain Relief).
Epilogue
Critical Thinking Propel Science to Move Forward
The writing of this Newsletter - Truth of Acupuncture Science - would not have been possible without inspiration from many scientificaly-minded critics or skeptics such as British Professor Jeremy Lewis, a scientist in Musculoskeletal Research & Physiotherapy. Science will not advance without criticism and critical thinking. Critical attitude and thinking, or constantly questioning over the status quo have been, and are, and will be one of the important forces propelling science to constantly move forward.
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