Journal article review of " Acupuncture for chronic patellar tendinopathy"

In today's article we will critically review the following research paper:

Acupuncture for chronic patellar tendinopathy

P. Jeffs

Journal of the Acupuncture Association of Chartered Physiotherapists, Autumn 2013, 79–86.

https://www.aacp.org.uk/journal/stream-file/12#page=79

So what type of evidence is this article?

The below image shows where this article ranks in the hierarchy of evidence:

So this article comes under the second from the base: Case reports, case series, practice guidelines etc.

What conclusion is made?

The author concluded that using acupuncture as an adjunct to usual treatment for Chronic Patella Tendinopathy was clinically significantly beneficial.

Are the conclusion’s justified by the data?

It would appear that the usual care with eccentric exercises was irritating to the injury and after acupuncture this enabled the patient to commence and progress this, which prior to the acupuncture wasn’t possible.

What is the article briefly saying?

Pain is significantly reduced in Chronic Patella Tendinopathy with acupuncture and worked well when used to reduce pain to enable the commencement and further progression of eccentric loading to improve functional capacity.

Is the purpose of the study clear and what is it?

Yes it is clear.  To establish if pain can be reduced via acupuncture and strengthening type exercise for Patella Tendinopathy, to clinically significant margins as to inform clinical practice to include this type of approach.

Were the search methods used to locate relevant studies comprehensive?

They picked studies to show the pathophysiology of the condition and the current traditional treatment but presented evidence to show limitations to this in high level athletes due to pain inhibiting high level progression. They show research on acupuncture’s effects on the condition with specific reference to pain and they show specific parameters used in these studies. They reference limitations to Cochrane reviews and meta-analysis due to sample sizes and selection criteria. They extrapolate to potential mechanisms relating to normal tendons, applying rationale of why treatment is effective to tendinopathy. They do make reference to this being a limitation. 

Is it clear what was measured, how & what the outcomes were?

They measured pain with the VAS, as this was limiting the ability of the patient to perform the progression of rehabilitation. They also looked at the effect on blood flow with a colour doppler scan to theorise the mechanism behind the acupuncture’s effects. They also used the Victorian Institute of Sport Assessment scale (VISA).
So, this is very clear and simple to understand.

Are the measurements valid, reliable & reproducible?

The Visual analogue scale (VAS) is considered valid, reproducible and a reliable measure for pain.
The Victorian Institute of Sport Assessment scale (VISA) is also considered valid, reproducible and a reliable for Patella tendinopathy.
The doppler was interesting but has some issues. Firstly, it is not something that you could easily do in clinical practice and there is no way of understanding if this effect is the reason behind the improvements. Also, the effect may be very transient and therefore not significant.

Is the data suitable for analysis?

Due to this being a case study there was no real data analysis, but the improvement effects were considered clinically significant, which is true as this enabled the progress functionally that was not possible previously. 

Are results presented clearly & in sufficient detail to enable readers to make their own judgement?

The results showed improvement in pain on the VAS, mentioned improvements in hyperaemia but how this was quantified wasn’t stated and therefore is hard to interpret. The VISA scores also improved, showing pain and functional progression.   

Are results discussed in relation to existing knowledge? 

It would appear that in this case, the acupuncture facilitated the reduction in pain to then perform the exercise and affected the hyperaemia at least in the short term. It is possible that this may have a long-term effect, but this could be from the exercise. That said the exercise was not possible before commencing the acupuncture. The reduction in pain is in keeping with current findings and the hyperaemia is something that was more of a surprising finding based on previous data..

Is the discussion biased?

In terms of bias, the journal for publication is the Journal of the Acupuncture Association of Chartered Physiotherapists and so they might be considered having some bias. In regards the author, the main author has extensive qualifications and experience in the field of sport. He hasn’t got any affiliation to the AACP but as he uses acupuncture in his practice then he has potential for bias.

Implications of the review for practice & research:

What it would seem, is that fundamentally, exercise and rehab is the key to progression back to sport but if pain is limiting this ability then acupuncture could be a adjunct modality to facilitate this to occur. It is possible that the acupuncture may also have a direct effect on the tendon based on the doppler results, but this is hard to be certain of.  Obviously more high-powered studies need to be done looking into this with comparisons to be able to draw firmer conclusions.

Conclusion:

In conclusion this case study shows that if pain limits rehab then it may be beneficial to use acupuncture to lower pain therefore enabling the rehab process to continue. Also, acupuncture may directly affect the tendon in a positive way to promote recovery.