Introduction
This is an article on a randomized controlled trial of acupuncture for osteoarthritis of the knee. Maria E. Suarez-Almazor, Carol Looney, Yanfang Liu, Vanessa Cox, Kenneth Pietz, and Richard L. have written it. The focus was on the effects of patient-provider communication in regards to the healing of the patient with Osteoarthritis. It is also done to determine the efficacy of two different acupuncture types. The research done was to prove that the effect either of an acupuncture done traditionally or in a modern day is highly dependent on the patient- provider interaction. At the introduction, the authors of the article can describe the background of acupuncture and the way it functions to reduce pain in an individual's body. The authors can explain the pattern of pain within the human body. It is essential for the understanding of the acupuncture technique. The abbreviations at the introduction point are defined in full to avoid confusion. The references that exist within the presentation indicate the number of sources that have been used to get the information. The references cited are adequate and give accurate information concerning acupuncture. The hypothesis of the research done was that patient- provider interactions result in increased benefits when the provider has an attitude exhuming confidence. The patient- provider interactions are to be independent of the type of acupuncture done. The hypothesis is focused regarding the intervention required when the provider- patient relationship is critical in the progress of a patient with osteoarthritis.
Evaluation of the Method Section
The Providers within the study were six Chinese males trained in Traditional Chinese Medicine who were recruited by the American College of Acupuncture and Oriental medicine. The six Chinese men had less than two years of clinical experience to ensure uniformity and equality. The patients were randomly selected and put into three groups according to the communication style of the providers. The communication styles were waiting list, high expectations, and neutral expectations. The study design used was a random stratified design.

The patients involved in the study were also randomly chosen. The sample size was 560. The sample size is adequate for the study thou the sample population from which the sample size is obtained is not mentioned. The formula used to calculate the sample size is not apparent. The inclusion criteria for the patients were, they should be 50 years and more and are to have a radiographic diagnosis of osteoarthritis. The patients taking part in the study were also to have a history of pain at the knee for more than 2 weeks, have pain rating at more than 3 on the visual analog scale, never have received acupuncture treatment must have stabilized with the used of Nonsteroidal anti-inflammatory drugs, should be receiving glucosamine for the past 2 months and must not have had any intraarticular injections. Any patient that did not meet all the characteristics within the criteria of inclusion was exempted from participating in the study.
The criteria for inclusion were adequate and would ensure specificity in determining the effect of Patient-provider interaction and the efficacy of the Traditional Chinese Acupuncture as compared to the Non-Traditional Acupuncture. The criteria of exclusion involved patients who were closely related to the health care providers, those below 50 years old, those who are under other analgesics apart from NSAIDs and those not receiving glucosamine. The essence of criteria of inclusion is to ensure that all the subjects present in a nearly similar way to avoid bias in the results. Criteria for inclusion also allow the researchers to sieve out individuals to bring the study to focus.
Randomization was done with a computer to rule out any bias in allocating different groups to the patients within the study. The randomized, stratified sampling method is most preferred for such studies to avoid bias. The study was also blinded so that the patients would not feign having less pain when the rest still have varying pain levels. The study was conducted in a two-stage process where in the first stage the six acupuncturists participated, and in the second phase, only four did participate. The acupuncturists with high expectation training would encourage the patients by giving them positive affirmations as compared to the neutral expectations. This was done to prove that patient- provider interaction is of importance in the management of pain in patients with osteoarthritis.
In the second phase, the providers decided to administer the different types of acupuncture. Some of the patients were given Traditional Chinese Acupuncture whereas others were given sham. Before the administration of the TCA and the sham, the researchers did a control on nine individuals. Seven received both TCA and Sham treatments, and the remaining two were made given separate TCA and Sham treatment. This was to establish whether differences exist. The consent was obtained from the patient. No ethical issues were surrounding the use of control.
The instrument that they used included the transcutaneous electrical nerve stimulation. The transcutaneous electrical nerve stimulation would ensure electro acupuncture, which is the commonly used method clinically. This made the instrument in use to be valid for the study. The validity of the TENS instrument would ensure the reliability of the results which will also be replicable. The tools used also involved the recording of patient responses concerning their views on treatment. This was important for it ensued as a primary source of the study. The existence of a significant source strengthens the findings of a researcher. The primary source also increases the validity of the research done. There were sites within the body that were identified for the placement of either the TCA or the Sham lines. These sites were near the knee. For some individuals, it was bilateral and another unilateral knee joint pain. The TCA lines were placed outside whereas the Sham lines were placed between the meridians. The depth at which the needle is placed is different in TCA and in Sham. Patient feedback would be recorded when the test is ongoing and would be given to the provider by the patient during follow up.
Evaluation of the results
The results of the tests would be recorded thrice: at four weeks six weeks than at 3months. At four weeks, the results would be according to the Joint- Specific Multi-Dimensional Assessment of pain that measures the frequency and intensity of pain, Western Ontario, and Mc Master Universities Osteoarthritis Index pain scale and the Satisfaction with Knee procedure. In the study, there was no use of the word placebo to avoid bias. At the 6th week, the results would be obtained through the WOMAC pain scale and in the 3rd month, they would be asked to guess whether they had received TCA or non-TCA treatment depending on the pain level.
There was the graphical analysis of the timing, the type of treatment administered, and the provider communication type. Statistical analysis done here was intended to allow for treatment of the patients. The unbalanced design was used to determine the number of patients who interacted with various providers. The numbers were as follows: 80 waiting lists, 160 TCA and 320 Sham. There was a power excess of 0.99 for the Analysis of variance within the pain scales. SAS version was used to analyze the data. The data analysis methods were complicated to interpret and display due to the calculation and formulae required to find a result. The study had 455 patients and 7 controls. Most of the patients received acupuncture on both legs.
The tables available within the research article illustrated that there were two groups of participants; those under high expectations provider and those under low expectation leader. Both of the groups are further divided into those receiving TCA and Sham respectively. Other patient information that was given within the table includes age, sex, ethnicity number, education number, duration of knee pain according to J-MAP scale, WOMAC scale, VAS pain score, SF-12 PCS score, SF-12 MCS score, TUG score and ROM score about flexion at the knee. The medications used are also documented in the table. Patients within table 1 showed improvement despite receiving either TCA or Sham. They also showed improvement irrespective of getting either a high or neutral expectation provider. This shows that the variants within this study did not affect patient recuperation.
The second table patients were on the different timelines with similar treatment under TCA and Sham. Patients under a high expectation provider were noted to improve faster than those with neutral expectation vendors. This concurs with the hypothesis that positive reinforcement ensures more rapid healing as opposed to a negative or no reinforcement. The assumptions made in the statistical analysis are that there are various constants in determining the pain scales, which are to illustrate a similar result. The statistics used are descriptive in that they use the quantitative data to represent the qualitative aspect of their research such as the quality of care given to the patient by the provider and the result of this. There is consistency in the distribution of the population, and the sample size is a perfect representation of the general population. The effect sizes for the TCA and Sham are 0.25 and 0.22 respectively. The effect size is described as being small in this study. The difference between TCA and Sham is considered quite dismal.
The study had a flow chart that indicated the study design of the research. The movement from the first half of the trial is illustrated showing the differentiation of the high expectation communication style and the neutral style. It then depicts on the second stage where the acupuncturist switches communication styles. A flow diagram is easier to interpret and understand. Therefore, it is effective in the studying of the plan required. The labeling of the flow diagram is done effectively. This is similar to the tables too.
Interpretation of the findings
The outcome of the study was that the Traditional Chinese Acupuncture is not superior to Sham. It also states that the communication styles of clinicians played a role in the healing of a patient. The patients who were given positive affirmation healed faster and reported to feel better more quickly than those to whom the providers showed uncertainty in their getting well. Acupuncture has been identified as a way of treating osteoarthritis. This has been the belief through ancient China where individuals were taught concerning acupuncture as a pain relief. There are various needles used for different types of acupuncture thou the result is the same. The study embraces this notion and strives to prove that whatever form of acupuncture done can lead to pain reduction for patients suffering from osteoarthritis. Pain reduction is the primary measure of patient wellness within this research.
The rating scale for pain may vary from one individual to another. There are different types of scales that rate pain. Different individuals also have different threshold for pain. Thus, the results may be subjective and not objective. Subjective results increase the bias within a study. The authors’ findings are therefore supported by the results of the research done. The clinical significance of the study is in ensuring that the health providers can identify that they are essential in the healing of patients. Failure to participate in the patient care decreases the level of care offered to a patient. The health care providers are also able to recommend patients with acupuncture treatment, which has proved to be quite handy in the treatment of osteoarthritis. The study done also expands on the knowledge within the medical fraternity of therapy of osteoarthritis and patient-provider relationship for it is the first of its own to compare these two aspects. The author has not generalized but has singly addressed all the parameters within the study, which is commendable.
Conclusion
The research done has a high internal validity for it can have a two-phase experiment, which can illustrate two different aspects individually. This ensures that the various variables can be analyzed at multiple times. Internal validity ensures that each variable is determined according to the objectives of the study. In this case, the variables were patient-provider interaction and the use of TCA and Sham. The confounding factors within the study are dismal. The strengths of the research are that it was the first of its kind to determine the relationship between two variables at different times. The study is also conducted in an orderly way allowing for the formulation of ways of getting the sample size, sample method, and formulae involved in statistical analysis. The weakness of the study is that some of the individuals left before the completion of the survey. They include 1 acupuncturist and 25 patients. The authors have not justified the time of 4 weeks six weeks and 3months throughout the article. The research done creates questions on determination of ways in which positive reinforcement results into better health to patient. This is because other individuals have not researched the relation between positive reinforcement and better patient health on. Hence, the TCA and Sham methods have similar effectiveness whereas provider interaction with the patient determines to some extent patient recuperation in such a way that each patient is given their own findings according to the duration taken to complete the research.

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Reference
Maria E. Suarez-Almazor, Carol Looney, Yanfang Liu, Vanessa Cox, Kenneth Pietz, Donald M.
Marcus and Richard L. 2010. A randomized controlled trial of acupuncture for
Osteoarthritis of the knee: Effects of patient- provider communication. Vol 62, issue 9.