The effect of acupuncture on the symptoms of knee osteoarthritis--an open randomised controlled study

Acupuncture for peripheral joint osteoarthritis

BACKGROUND

Peripheral joint osteoarthritis is a major cause of pain and functional limitation. Few treatments are safe and effective.

OBJECTIVES

To assess the effects of acupuncture for treating peripheral joint osteoarthritis.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library 2008, Issue 1), MEDLINE, and EMBASE (both through December 2007), and scanned reference lists of articles.

SELECTION CRITERIA

Randomized controlled trials (RCTs) comparing needle acupuncture with a sham, another active treatment, or a waiting list control group in people with osteoarthritis of the knee, hip, or hand.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information. We calculated standardized mean differences using the differences in improvements between groups.

MAIN RESULTS

Sixteen trials involving 3498 people were included. Twelve of the RCTs included only people with OA of the knee, 3 only OA of the hip, and 1 a mix of people with OA of the hip and/or knee. In comparison with a sham control, acupuncture showed statistically significant, short-term improvements in osteoarthritis pain (standardized mean difference -0.28, 95% confidence interval -0.45 to -0.11; 0.9 point greater improvement than sham on 20 point scale; absolute percent change 4.59%; relative percent change 10.32%; 9 trials; 1835 participants) and function (-0.28, -0.46 to -0.09; 2.7 point greater improvement on 68 point scale; absolute percent change 3.97%; relative percent change 8.63%); however, these pooled short-term benefits did not meet our predefined thresholds for clinical relevance (i.e. 1.3 points for pain; 3.57 points for function) and there was substantial statistical heterogeneity. Additionally, restriction to sham-controlled trials using shams judged most likely to adequately blind participants to treatment assignment (which were also the same shams judged most likely to have physiological activity), reduced heterogeneity and resulted in pooled short-term benefits of acupuncture that were smaller and non-significant. In comparison with sham acupuncture at the six-month follow-up, acupuncture showed borderline statistically significant, clinically irrelevant improvements in osteoarthritis pain (-0.10, -0.21 to 0.01; 0.4 point greater improvement than sham on 20 point scale; absolute percent change 1.81%; relative percent change 4.06%; 4 trials;1399 participants) and function (-0.11, -0.22 to 0.00; 1.2 point greater improvement than sham on 68 point scale; absolute percent change 1.79%; relative percent change 3.89%). In a secondary analysis versus a waiting list control, acupuncture was associated with statistically significant, clinically relevant short-term improvements in osteoarthritis pain (-0.96, -1.19 to -0.72; 14.5 point greater improvement than sham on 100 point scale; absolute percent change 14.5%; relative percent change 29.14%; 4 trials; 884 participants) and function (-0.89, -1.18 to -0.60; 13.0 point greater improvement than sham on 100 point scale; absolute percent change 13.0%; relative percent change 25.21%). In the head-on comparisons of acupuncture with the 'supervised osteoarthritis education' and the 'physician consultation' control groups, acupuncture was associated with clinically relevant short- and long-term improvements in pain and function. In the head on comparisons of acupuncture with 'home exercises/advice leaflet' and 'supervised exercise', acupuncture was associated with similar treatment effects as the controls. Acupuncture as an adjuvant to an exercise based physiotherapy program did not result in any greater improvements than the exercise program alone. Information on safety was reported in only 8 trials and even in these trials there was limited reporting and heterogeneous methods.

AUTHORS' CONCLUSIONS

Sham-controlled trials show statistically significant benefits; however, these benefits are small, do not meet our pre-defined thresholds for clinical relevance, and are probably due at least partially to placebo effects from incomplete blinding. Waiting list-controlled trials of acupuncture for peripheral joint osteoarthritis suggest statistically significant and clinically relevant benefits, much of which may be due to expectation or placebo effects.

Clinical and endocrinological changes after electro-acupuncture treatment in patients with osteoarthritis of the knee

Neurobiological mechanisms invoking the release of endogenous opioids and depression of stress hormone release are believed to be the basis of acupuncture analgesia. This study compared plasma beta-endorphin and cortisol levels with self assessment scores of intensity of pain, before and after 10 days of electro-acupuncture treatment in patients suffering from chronic pain as a result of osteoarthritis knees. Forty patients of either sex over 40 years with primary osteoarthritis knee were recruited into a single-blinded, sham-controlled study. For electro-acupuncture group the points were selected according to the Traditional Chinese Medicine Meridian Theory. In the sham group needles were inserted at random points away from true acupoints and no current was passed. Both groups were treated for 10 days with one session every day lasting for 20-25min. Pre- and post-treatment Western Ontario and McMaster Universities (WOMAC) index of osteoarthritis knee and Visual Analogue Scale (VAS) for pain were recorded and blood samples were taken for the measurement of plasma cortisol and beta-endorphin levels. Following electro-acupuncture treatment there was a significant improvement in WOMAC index and VAS (p=0.001), a significant rise in plasma beta-endorphin (p=0.001), and a significant fall in plasma cortisol (p=0.016). In conclusion electro-acupuncture resulted in an improvement in pain, stiffness and disability. Of clinical importance is that an improvement in objective measures of pain and stress/pain associated biomarkers was shown above that of a sham treatment; hence demonstrating acupuncture associated physiological changes beyond that of the placebo effects.

The effectiveness of acupuncture on pain and mobility in patients with osteoarthritis of the knee: a pilot study

Acupuncture has been repeatedly reported to relieve pain associated with osteoarthritis of the knee. As the vast majority of information on the effectiveness of acupuncture on this condition is based on data collected in Western countries, little is known about patients with osteoarthritis of the knee in Asian countries. In this pilot clinical study, acupuncture was incorporated into the standard care for adult patients with osteoarthritis of the knee to determine its contribution to pain relief and improved mobility. In a prospective, non-randomized controlled study, patients with osteoarthritis of the knee were separated into two groups. The first (the experimental group; n = 12) was scheduled for up to 8 sessions of acupuncture in addition to standard care, while the second (the control group; n = 12) received standard care only. Measurements using the six-minute walking distance test, pain visual analogue scale, and osteoarthritis of the knee outcome measurement were taken at baseline and after 4 weeks. Both study and control groups showed significant improvement with respect to time effects in terms of six-minute walking distance, pain visual analogue scale, pain domain and mobility domain scores determined by the osteoarthritis of the knee outcome measurement (p < .01), after adjusting for covariables. However, improvements measured in the study group did not differ significantly from those in the control group. Patients with osteoarthritis of the knee seemed to experience clinical improvements in six-minute walking distance, pain relief and mobility when their standard care was supplemented with acupuncture.

Acupuncture and osteoarthritis of the knee: a review of randomized, controlled trials

Osteoarthritis of the knee is a major cause of disability among adults. Treatment is focused on symptom management, with nonpharmacologic therapies being the preferred first line of treatment. Acupuncture is considered a potentially useful treatment for osteoarthritis. The objective of this article is to review the English-language articles, indexed in MEDLINE or CINAHL, describing randomized, controlled trials of the effects of needle or electroacupuncture on knee osteoarthritis. Ten trials representing 1456 participants met the inclusion criteria and were analyzed. These studies provide evidence that acupuncture is an effective treatment for pain and physical dysfunction associated with osteoarthritis of the knee.

A pilot study on using acupuncture and transcutaneous electrical nerve stimulation (TENS) to treat knee osteoarthritis (OA)

BACKGROUND

The present study tests whether a combined treatment of acupuncture and transcutaneous electrical nerve stimulation (TENS) is more effective than acupuncture or TENS alone for treating knee osteoarthritis (OA).

METHODS

Thirty-two patients with knee OA were randomly allocated to four groups. The acupuncture group (ACP) received only acupuncture treatment at selected acupoints for knee pain; the TENS group (TENS) received only TENS treatment at pain areas; the acupuncture and TENS group (A&T) received both acupuncture and TENS treatments; the control group (CT) received topical poultice (only when necessary). Each group received specific weekly treatment five times during the study. Outcome measures were pain intensity in a visual analogue scale (VAS) and knee function in terms of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC).

RESULTS

The ACP, TENS and A&T groups reported lower VAS and WOMAC scores than the control group. Significant reduction in pain intensity (P = 0.039) and significant improvement in knee function (P = 0.008) were shown in the A&T group.

CONCLUSION

Combined acupuncture and TENS treatment was effective in pain relief and knee function improvement for the sampled patients suffering from knee OA.

Effect of combined laser acupuncture on knee osteoarthritis: a pilot study

Our objective was to assess the efficacy and safety of combined 10.6 microm and 650 nm laser irradiation on patients with knee osteoarthritis (OA). Forty patients with OA were randomly allocated to an active laser group or to a placebo laser group (20 per group). They either received active or sham laser treatment at acupoint Dubi (ST 35) in a total of 12 sessions. There was significant difference between the two groups in the Western Ontario and McMaster Universities (WOMAC) osteoarthritis index pain score change from baseline after 2 weeks of treatment (P = 0.047). The pain reduction of the active laser treatment group was 49%, whereas that of the placebo control group was only 13%. However, due to the high patient drop-out rate, the 4-week assessment could not be analyzed. Combined laser treatment seems beneficial to patients with knee OA. However, due to the small sample size and the high drop-out rate of patients in the placebo group, a large sample-size clinical trial is warranted to determine further the therapeutic efficacy of the device.

Evidence from Rcts on Optimal Acupuncture Treatment for Knee Osteoarthritis – An Exploratory Review

There are many differing opinions on what constitutes an optimal acupuncture dose for treating any particular patient with any particular condition, and only direct comparisons of different methods in a clinical trial will provide information on which reliable decisions can be made. This article reviews the recent research into acupuncture treatment for osteoarthritis of the knee, to explore whether any aspects of treatment seem more likely to be associated with good outcome of treatment. Among four recent, high quality RCTs, one showed a much greater treatment response than the other three, and the possible factors are discussed. A recent systematic review included 13 RCTs, and this article discusses the possible explanations for differences in their outcomes. It is speculated that optimal results from acupuncture treatment for osteoarthritis of the knee may involve: climatic factors, particularly high temperature; high expectations of patients; minimum of four needles; electroacupuncture rather than manual acupuncture, and particularly, strong electrical stimulation to needles placed in muscle; and a course of at least 10 treatments. These factors offer some support to criteria for adequate acupuncture used in the recent review. In addition, ethnic and cultural factors may influence patients’ reporting of their symptoms, and different versions of an outcome measure are likely to differ in their sensitivity – both factors which may lead to apparent rather than real differences between studies. The many variables in a study are likely to be more tightly controlled in a single centre study than in multicentre studies.

Electroacupuncture (EA) modulates the expression of NMDA receptors in primary sensory neurons in relation to hyperalgesia in rats

N-methyl-D-aspartate (NMDA) receptor on the central terminals of the dorsal root ganglion (DRG) appears to be playing an important role in the development of central sensitization related to persistent inflammatory pain. Acupuncture analgesia has been confirmed by numerous clinical observations and experimental studies to be a useful treatment to release different kinds of pains, including inflammatory pain and hyperalgesia. However, the underlying mechanisms of the analgesic effect of acupuncture are not fully understood. In the present study, using a rat model of inflammatory pain induced by complete Freund's adjuvant (CFA), we observed the effect of electroacupuncture (EA) on animal behavior with regard to pain and the expression of a subunit of NMDA receptor (NR1) and isolectin B4 (IB4) in the neurons of the lumbar DRG. Intraplantar injection of 50 microl CFA resulted in considerable changes in thermal hyperalgesia, edema of the hind paw and "foot-bend" score, beginning 5 h post-injection and persisting for a few days, after which a gradual recovery occurred. The changes were attenuated by EA treatment received on the ipsilateral "Huan Tiao" and "Yang Ling Quan" once a day from the first day post-injection of CFA. Using an immunofluorescence double staining, we found that the number of double-labeled cells to the total number of the IB4 and NR1-labeled neurons increased significantly on days 3 and 7 after CFA injection. The change was attenuated by EA treatment. These results suggest that EA affects the progress of experimental inflammatory pain by modulating the expression of NMDA receptors in primary sensory neurons, in particular, IB4-positive small neurons.

Effects of electrical acupuncture on acupoint BL15 evaluated in terms of heart rate variability, pulse rate variability and skin conductance response

In this research, heart rate variability (HRV), pulse rate variability (PRV) and human skin conductance (SC) of all acupoints on Heart Meridian were used to evaluate the effects of electrical acupuncture (EA) on acupoint BL15 (Bladder Meridian). Ten healthy volunteers (aged 23 +/- 6) were selected as the control group on the first day, and then used again as the experimental group on the second day. The control group received sham EA during the study, while subjects of the experimental group were stimulated by 2 Hz EA on acupoint BL15 for 10 minutes. Electrocardiogram (ECG), wrist blood pressure pulse meter and skin conductance response (SCR) device were used to measure and analyze HRV, PRV and SCR for the two groups before and after stimulation. From the spectrum analysis of ECG and pulse pressure graph, we found that the EA applied on BL15 could induce a significant increase in the normalized high frequency power (nHFP) component of HRV and PRV, as well as a significant decrease in the normalized low frequency power (nLFP) part (p < 0.05). Moreover, both the heart rate and pulse rate were reduced in the analysis of the time domain of ECG and PRV. Furthermore, most of the SCR values at acupoints were decreased after stimulation. These results also indicate that the stimulation of BL15 by EA could cause relaxation, calmness and reduce feeling of tension or distress.

Acupuncture for peripheral joint osteoarthritis

OBJECTIVE

To evaluate the evidence for the effectiveness of acupuncture in peripheral joint osteoarthritis (OA).

METHODS

Systematic searches were conducted on Medline, Embase, AMED, Cochrane Library, CINAHL, British Nursing Index, PsychINFO and CAMPAIN until July 2005. Hand-searches included conference proceedings and our own files. There were no restrictions regarding the language of publication. All randomized controlled trials (RCTs) of acupuncture for patients with peripheral joint OA were considered for inclusion. Trials assessing needle acupuncture with or without electrical stimulation were considered if sham- or placebo-controlled or controlled against a comparator intervention. Trials testing other forms of acupuncture were excluded. Methodological quality was assessed and, where possible, meta-analyses were performed.

RESULTS

Thirty-one possibly relevant studies were identified and 18 RCTs were included. Ten trials tested manual acupuncture and eight trials tested electro-acupuncture. Overall, ten studies demonstrated greater pain reduction in acupuncture groups compared with controls. The meta-analysis of homogeneous data showed a significant effect of manual acupuncture compared with sham acupuncture (standardized mean difference 0.24, 95% confidence interval 0.01-0.47, P = 0.04, n = 329), which is supported by data for knee OA. The extent of heterogeneity in trials of electro-acupuncture prevented a meaningful meta-analysis.

CONCLUSIONS

Sham-controlled RCTs suggest specific effects of acupuncture for pain control in patients with peripheral joint OA. Considering its favourable safety profile acupuncture seems an option worthy of consideration particularly for knee OA. Further studies are required particularly for manual or electro-acupuncture in hip OA.

Complementary or alternative therapies for osteoarthritis

Complementary or alternative therapies for osteoarthritis are commonly used and therefore it is important that health-care providers and patients are aware of the evidence for or against these approaches. In this article, the best available evidence is reviewed. The results suggest that, for several treatments, the risk-benefit profile is encouraging: acupuncture, several herbal medicines and capsaicin cream. For other therapies the evidence is weak or contradictory: homeopathy, magnet therapy, tai chi, leech therapy, music therapy, yoga, imagery and therapeutic touch. Many other treatments have not been scientifically tested. It is concluded that some complementary or alternative therapies have generated sufficiently promising results to warrant further investigation in large-scale, definitive, randomized clinical trials.

The Anti-Inflammatory Effects of Low- and High-Frequency Electroacupuncture Are Mediated by Peripheral Opioids in a Mouse Air Pouch Inflammation Model

BACKGROUND

Although acupuncture has been widely used for complementary therapeutic approaches to treat inflammatory diseases and inflammation-induced pain, the potential anti-inflammatory effects of acupuncture treatment remain controversial in clinical trials, and the underlying mechanisms are still unclear.

OBJECTIVE

The objective was to determine whether electroacupuncture (EA) is able to suppress the peripheral inflammatory response (e.g., zymosan-induced leukocyte migration into air pouch). As part of a mechanistic approach, it was further evaluated whether endogenous opioid systems are involved in the "EA-induced anti-inflammatory effect" (EA-AI).

METHODS

EA (1 or 120 Hz) was performed bilaterally in the Zusanli acupoint (ST36) or in a nonacupoint (gluteal muscle) for 30 min in ICR mice under anesthetic condition. The number of leukocytes that migrated into the air pouch was counted 4 hours after zymosan injection. EA was performed at 0, 0.5, 1, or 2 hours prior to zymosan injection, respectively. To evaluate opioid involvement in EA-AI, intrathecal naloxone (36 microg/mouse) and intraperitoneal naloxone methiodide (30 mg/kg) were administered 10 min before EA stimulation.

RESULTS

Both the 1 and 120 Hz frequencies of EA into Zusanli acupoint at the same time with zymosan injection significantly reduced leukocyte migration into the air pouch as compared with those of control groups (i.e., anesthetic control and needling control into Zusanli acupoint without electrical stimulation). The EA stimulation into nonacupoint did not produce any significant anti-inflammatory effect. EA treatment at 0.5 hours prior to zymosan injection also produced an anti-inflammatory effect but 1 and 2 hours prior to zymosan injection did not elicit any effect. Peripheral opioid blockage significantly reversed EA-AI, whereas spinal opioid blockage did not alter EA-AI.

CONCLUSION

EA can suppress peripheral inflammation through a peripheral opioid mechanism. To achieve the full effectiveness of EA, repeated application is recommended for the treatment of a variety of inflammatory diseases.

Is acupuncture a useful adjunct to physiotherapy for older adults with knee pain?: the "acupuncture, physiotherapy and exercise" (APEX) study [ISRCTN88597683]

BACKGROUND

Acupuncture is a popular non-pharmacological modality for treating musculoskeletal pain. Physiotherapists are one of the largest groups of acupuncture providers within the NHS, and they commonly use it alongside advice and exercise. Conclusive evidence of acupuncture's clinical effectiveness and its superiority over sham interventions is lacking. The Arthritis Research Campaign (arc) has funded this randomised sham-controlled trial which addresses three important questions. Firstly, we will determine the additional benefit of true acupuncture when used by physiotherapists alongside advice and exercise for older people presenting to primary care with knee pain. Secondly, we will evaluate sham acupuncture in the same way. Thirdly, we will investigate the treatment preferences and expectations of both the participants and physiotherapists participating in the study, and explore the effect of these on clinical outcome. We will thus investigate whether acupuncture is a useful adjunct to advice and exercise for treating knee pain and gain insight into whether this effect is due to specific needling properties.

METHODS/DESIGN

This randomised clinical trial will recruit 350 participants with knee pain to three intervention arms. It is based in 43 community physiotherapy departments in 21 NHS Trusts in the West Midlands and Cheshire regions in England. Patients aged 50 years and over with knee pain will be recruited. Outcome data will be collected by self-complete questionnaires before randomisation, and 6 weeks, 6 months and 12 months after randomisation and by telephone interview 2 weeks after treatment commences. The questionnaires collect demographic details as well as information on knee-related pain, movement and function, pain intensity and affect, main functional problem, illness perceptions, self-efficacy, treatment preference and expectations, general health and quality of life. Participants are randomised to receive a package of advice and exercise; or this package plus real acupuncture; or this package plus sham acupuncture. Treatment details are being collected on a standard proforma. Interventions are delivered by experienced physiotherapists who have all received training in acupuncture to recognised national standards. The primary analysis will investigate the main treatment effects of real or sham acupuncture as an adjunct to advice and exercise.

DISCUSSION

This paper presents detail on the rationale, design, methods, and operational aspects of the trial.