Acupuncture treatment of severe knee osteoarthrosis. A long-term study

Periosteal Dry Needling for Carpometacarpal Osteoarthritis: A Prospective Case Series

BACKGROUND

Carpometacarpal (CMC) osteoarthritis (OA) of the thumb is a painful condition that affects over 15% of individuals above the age of 30 and up to 30% of post-menopausal women. Dry needling (DN) has been found to reduce pain and disability in a variety of neuromusculoskeletal conditions; however, DN in the management of CMC OA has not been well studied.

METHODS

Consecutive patients with clinical and radiographic evidence of CMC OA were treated with DN. The primary outcome measure was pain using the Numerical Pain Rating Scale (NPRS) at 12 weeks. Secondary outcome measures were the Upper Extremity Functional Index (UEFI-20) and the Global Rating of Change (GROC) scale. Outcome measures were collected at baseline, 4 weeks, 8 weeks, and 12 weeks.

RESULTS

Nine patients were treated for six sessions of periosteal DN over 3 weeks. Compared to baseline, statistically significant and clinically meaningful improvements were observed in thumb pain (NPRS mean difference: 2.6; p = 0.029) and function (UEFI-20 mean difference: 21.3; p = 0.012) at 12 weeks.

CONCLUSION

Statistically significant and clinically meaningful within-group improvements in thumb pain and function were observed at 12 weeks following six sessions of periosteal DN treatment. DN may be a useful intervention in the management of patients with CMC OA of the thumb.

Economic Evaluation of Acupuncture

Economic evaluation of treatments is essential to make the best use of limited resources. The methodology for this is established and there are four basic analyses: cost-minimisation compares different methods of achieving an overall result, cost-effectiveness measures the outcome of treatment in a natural endpoint, cost-utility attempts to measure the treatment's effect on the overall quality of life, and cost-benefit examines the benefits of treatment in monetary terms. Economic evaluation should ideally be performed alongside randomised controlled trials, preferably placebo-controlled. Other less rigorous designs may be easier to arrange but will generate less conclusive results. In such trials, costs must be measured accurately and as fully as possible. Some examples of economic analysis of acupuncture are discussed.

The Effectiveness of Acupuncture for Osteoarthritis of the Knee – a Systematic Review

Objective

To determine the effectiveness of acupuncture treatment for pain and function of patients with osteoarthritis of the knee.

Methods

A systematic review of randomised controlled trials was performed, including a meta-analysis which combined the results of trials that used adequate acupuncture treatment and used WOMAC scores to measure the effect. The internal validity (quality) and heterogeneity of studies were taken into account.

Results

Thirteen studies were available, of which eight, involving 2362 patients, could be combined. For both reduction of pain and improvement of function, acupuncture was significantly superior to sham acupuncture (P<0.05 for all comparisons) in both the short term and the long term. Compared with no additional intervention (usual care), acupuncture was again significantly superior for pain and function. The treatment effects were maintained after taking account of quality and heterogeneity in sensitivity analyses.

Conclusion

Acupuncture is an effective treatment for osteoarthritis of the knee. Its overall effect size is 0.8, and it can be considered instead of non-steroidal anti-inflammatory drugs for patients whose symptoms are not controlled by education, exercise, weight loss if appropriate and simple analgesics. Further research is necessary into the most efficient way of delivering acupuncture, and its longer term benefits.

A Blinded Randomised Trial of Acupuncture (Manual and Electroacupuncture) Compared with a Non-Penetrating Sham for the Symptoms of Osteoarthritis of the Knee

Objectives

To compare the effect of acupuncture (manual and electroacupuncture) with that of a non-penetrating sham (‘placebo’ needle) in patients with osteoarthritic knee pain and disability who are blind to the treatment allocation.

Methods

Acupuncture naive patients with symptomatic and radiological evidence of osteoarthritis of the knee were randomly allocated to a course of either acupuncture or non-penetrating sham acupuncture using a sheathed ‘placebo’ needle system. Acupuncture points for pain and stiffness were selected according to acupuncture theory for treating Bi syndrome. Both manual and electrical stimulation were used. Response was assessed using the WOMAC index for osteoarthritis of the knee, self reported pain scale, the EuroQol score and plasma β-endorphin. The effectiveness of blinding was assessed.

Results

There were 34 patients in each group. The primary end point was the change in WOMAC pain score after the course of treatment. Comparison between the two treatment groups found a significantly greater improvement with acupuncture (mean difference 60, 95% CI 5 to 116, P=0.035) than with sham. Within the acupuncture group there was a significant improvement in pain (baseline 294, mean change 95, 95% CI 60 to 130, P<0.001) which was not seen by those who had sham acupuncture (baseline 261, mean change 35, 95% CI-10 to 80, P=0.12). Similar effects within group, but not between groups, were seen with the secondary end points of WOMAC stiffness, WOMAC function, and self reported pain. One month after treatment the between group pain difference had been lost (mean difference 46; 95% CI −9 to 100, P=0.10) although the acupuncture group was still benefiting compared to baseline (mean difference 59; 95% CI 16 to 102, P=0.009). The EuroQol score, a generic measure of health related quality of life, was not altered by the treatments. A minority of patients correctly guessed their treatment group (41% in the acupuncture group and 44% in the control group). Plasma β-endorphin levels were not affected by either treatment.

Conclusions

Acupuncture gives symptomatic improvement for patients with osteoarthritis of the knee, and is significantly superior to non-penetrating sham acupuncture. The study did not confirm earlier reports of release of plasma β-endorphin during acupuncture.

Comparison of the Effectiveness of Six and Two Acupuncture Point Regimens in Osteoarthritis of the Knee: A Randomised Trial

Background

Although substantial data have supported the effectiveness of acupuncture for treating knee osteoarthritis (OA), the number of points used has varied. The objective of this study was to compare the effectiveness of six and two acupuncture points in the treatment of knee OA.

Methods

A randomised trial of knee OA patients was conducted. Patients were randomly allocated into two groups of 35. The “six point group” received treatment at six acupuncture points, ST35, EX-LE4 ( Neixiyan), ST36, SP9, SP10 and ST34, while the “two point group” received treatment at just the first pair of points, ST35 and EX-LE4. Both groups received twice weekly electroacupuncture on 10 occasions. Electrical stimulation was carried out at low-frequency of 3 Hz to all points, with the intensity as high as tolerable. Both groups were allowed to take a 200 mg celecoxib capsule per day for intolerable pain. Patients were assessed at baseline, week 5, week 9 and week 13, using a Thai language version of the Western Ontario and McMaster Osteoarthritis Index (WOMAC). Global assessment of change after 10 treatments was also recorded.

Results

Acupuncture at both six and two acupuncture points was associated with significant improvement. Mean total WOMAC score at weeks 5 and 13 of patients in both groups showed no significant difference statistically (p = 0.75 and p = 0.51). Moreover, the number of celecoxib capsules taken, global assessment of global change and body weight change of both groups also showed no statistical difference.

Conclusion

This evidence suggests that electroacupuncture to two local points may be sufficient to treat knee OA, but in view of some limitations to this study further research is necessary before this can be stated conclusively.

A Comparison of Acupuncture with Intra-Articular Steroid Injection as Analgesia for Osteoarthritis of the Hip

This controlled trial used a prospective, randomised open design to compare the effectiveness of acupuncture and intra-articular injections in reducing chronic pain associated with osteoarthritis of the hip. Thirty two patients awaiting hip arthroplasty with chronic pain of more than twelve months duration were included. Group A received acupuncture using a standardised technique of periosteal needling to the greater trochanter of the femur with three acupuncture needles. The treatment was repeated on three occasions at weekly intervals. Group B received an intra-articular/peri-articular hip injection of 20ml of 1% lignocaine + 80mg Depo-Medrone. Patients were assessed for pain intensity, mobility and pattern of analgesia usage pre-treatment and at one, two and four week intervals thereafter.

Both groups experienced a decrease in pain intensity and analgesic usage following treatment. This decrease was greater in the acupuncture group. However, mobility remained unchanged in both groups. From the results of this study, periosteal acupuncture appears to be as effective as an intra-articular injection in relieving the pain associated with osteoarthritis of the hip. However, due to the small numbers involved, statistical significance was not achieved.

Safety of Acupuncture for Osteoarthritis of the Knee – a Review of Randomised Controlled Trials, Focusing on Specific Reactions to Acupuncture

In order to assess how many reported adverse reactions to acupuncture are truly associated with the physiological mechanisms of acupuncture, we performed a literature review of published RCTs of acupuncture for osteoarthritis of the knee. We searched for reports of RCTs using two data sources: PubMed and Japana Centra Revuo Medicina (Igaku Chuo Zasshi). Of the twelve RCTs located, seven included information on adverse events. No serious adverse events were reported. Joint swelling, local inflammation, haematoma and back pain occurred more frequently in the dummy electroacupuncture or minimal acupuncture group. We confirmed the possibility that many adverse reactions to acupuncture treatment reported in RCTs, at least for the knee OA, are non-specific, and that not all reported events should be attributed to the mechanism of action of acupuncture. It is likely this is also true for RCTs of acupuncture in other conditions, and for prospective surveys on adverse events of acupuncture.

Is Acupuncture for Pain Relief in General Practice Cost-Effective?

Sixty-five selected patients with pain, mainly of musculo-skeletal origin, were offered treatment by a qualified medical acupuncturist in his general practice surgery as an alternative to hospital outpatient referral. The patients assessed their own outcomes on a digital scale: there were 46 successful treatments and 14 failures, with 5 being lost to follow up. The cost of acupuncture treatment was compared to that of the referral that would have been made if acupuncture had not been offered. The acupuncture was found to have cost £10,943 against a minimum likely cost for hospital referrals of £26,783. A minimum total saving for all 60 patients of £13,916 was determined, giving an average saving per patient of £232. Additional hidden savings through avoiding further hospital procedures and expenditure on medication were not taken into account. It is concluded that acupuncture in selected patients and when used by an appropriately qualified practitioner appears to be a cost-effective therapy for use in general practice, reducing the need for more expensive hospital referrals.

Effect of Acupuncture Treatment on Heel Pain Due to Plantar Fasciitis

Eighteen patients attending an orthopaedic outpatient clinic with a year or more's history of heel pain due to plantar fasciitis were studied. All had had conservative treatment of physiotherapy and shoe-support without significant pain relief before acupuncture was offered, and thus acted as their own controls for the purposes of the study. The following traditional points were needled: Taixi (KI.3), Kunlun (BL.60) and Sanyinjiao (SP.6). Pain was assessed by a 100mm visual analogue scale (VAS) before treatment was started and after four, weekly sessions of acupuncture treatment. If complete pain relief was not obtained by the initial four-week treatment, a further two, weekly sessions of the above mentioned acupoints, with the addition of trigger point acupuncture in the gastro-soleus and plantar fascia, was carried out and pain assessed.

Patients were also assessed with a verbal rating score to indicate the percentage improvement after acupuncture compared to before treatment. The mean duration of heel pain was 25.11 months (SD 10.68). The VAS data obtained at 4 and 6 weeks of acupuncture treatment showed a statistically highly significant improvement compared to the VAS before acupuncture (p < 0.0009 and p < 0.0001 respectively). Using the Mann-Whitney test, there was a statistically significant difference in VAS obtained at 6 weeks, after trigger point acupuncture had been added for poor responders, compared to that obtained after the first 4 weeks of acupuncture treatment (p < 0.047). Our study demonstrates that acupuncture is effective in treating patients with chronic heel pain due to plantar fasciitis and that the addition of trigger point acupuncture in poor or non-responders may be useful.

Acupuncture's Place within Mainstream Medicine

This is a discussion paper reviewing the evidence for acupuncture in the fields of its current Western medical use. It is proven by controlled trials to be effective in pain relief, for dysmenorrhoea, and in nausea and vomiting. It has been found clinically useful in a wide variety of other areas including allergy bladder dysfunction, drug dependency and stroke.

There is an increasing body of evidence that acupuncture is a cost-effective treatment option, and its use has become widespread in pain clinics, hospital rheumatology and physiotherapy departments, and in general practice. Medical acupuncture is now based firmly on modern physiological principles, and an understanding of the opioid and other neurotransmitters involved in needle stimulation has made clinically useful acupuncture practice readily accessible to medical practitioners.

Acupuncture for hip osteoarthritis

BACKGROUND

Hip osteoarthritis (OA) is a major cause of pain and functional limitation. Few hip OA treatments have been evaluated for safety and effectiveness. Acupuncture is a traditional Chinese medical therapy which aims to treat disease by inserting very thin needles at specific points on the body.

OBJECTIVES

To assess the benefits and harms of acupuncture in patients with hip OA.

SEARCH METHODS

We searched Cochrane CENTRAL, MEDLINE, and Embase all through March 2018.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) that compared acupuncture with sham acupuncture, another active treatment, or no specific treatment; and RCTs that evaluated acupuncture as an addition to another treatment. Major outcomes were pain and function at the short term (i.e. < 3 months after randomization) and adverse events.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

Six RCTs with 413 participants were included. Four RCTs included only people with OA of the hip, and two included a mix of people with OA of the hip and knee. All RCTs included primarily older participants, with a mean age range from 61 to 67 years, and a mean duration of hip OA pain from two to eight years. Approximately two-thirds of participants were women. Two RCTs compared acupuncture versus sham acupuncture; the other four RCTs were not blinded. All results were evaluated at short term (i.e. four to nine weeks after randomization).In the two RCTs that compared acupuncture to sham acupuncture, the sham acupuncture control interventions were judged believable, but each sham acupuncture intervention was also judged to have a risk of weak acupuncture-specific effects, due to placement of non-penetrating needles at the correct acupuncture points in one RCT, and the use of penetrating needles not inserted at the correct points in the other RCT. For these two sham-controlled RCTs, the risk of bias was low for all outcomes.The combined analysis of two sham-controlled RCTs gave moderate quality evidence of little or no effect in reduction in pain for acupuncture relative to sham acupuncture. Due to the small sample sizes in the studies, the confidence interval includes both the possibility of moderate benefit and the possibility of no effect of acupuncture (120 participants; Standardized Mean Difference (SMD) -0.13, (95% Confidence Interval (CI) -0.49 to 0.22); 2.1 points greater improvement with acupuncture compared to sham acupuncture on 100 point scale (i.e., absolute percent change -2.1% (95% CI -7.9% to 3.6%)); relative percent change -4.1% (95% CI -15.6% to 7.0%)). Estimates of effect were similar for function (120 participants; SMD -0.15, (95% CI -0.51 to 0.21)). No pooled estimate, representative of the two sham-controlled RCTs, could be calculated or reported for the quality of life outcome.The four other RCTs were unblinded comparative effectiveness RCTs, which compared (additional) acupuncture to four different active control treatments.There was low quality evidence that addition of acupuncture to the routine primary care that RCT participants were receiving from their physicians was associated with statistically significant and clinically relevant benefits, compared to the routine primary physician care alone, in pain (1 RCT; 137 participants; mean percent difference -22.9% (95% CI -29.2% to -16.6%); relative percent difference -46.5% (95% CI -59.3% to -33.7%)) and function (mean percent difference -19.0% (95% CI -24.41 to -13.59); relative percent difference -38.6% (95% CI -49.6% to -27.6%)). There was no statistically significant difference for mental quality of life and acupuncture showed a small, significant benefit for physical quality of life.The effects of acupuncture compared with either advice plus exercise or NSAIDs are uncertain.We are also uncertain whether acupuncture plus patient education improves pain, function, and quality of life, when compared to patient education alone.In general, the overall quality of the evidence for the four comparative effectiveness RCTs was low to very low, mainly due to the potential for biased reporting of patient-assessed outcomes due to lack of blinding and sparse data.Information on safety was reported in four RCTs. Two RCTs reported minor side effects of acupuncture, which were primarily minor bruising, bleeding, or pain at needle insertion sites. Four RCTs reported on adverse events, and none reported any serious adverse events attributed to acupuncture.

AUTHORS' CONCLUSIONS

Acupuncture probably has little or no effect in reducing pain or improving function relative to sham acupuncture in people with hip osteoarthritis. Due to the small sample size in the studies, the confidence intervals include both the possibility of moderate benefits and the possibility of no effect of acupuncture. One unblinded trial found that acupuncture as an addition to routine primary physician care was associated with benefits on pain and function. However, these reported benefits are likely due at least partially to RCT participants' greater expectations of benefit from acupuncture. Possible side effects associated with acupuncture treatment were minor.

Updated systematic review and meta-analysis of acupuncture for chronic knee pain

OBJECTIVE

To assess the effectiveness and safety of acupuncture for the treatment of chronic knee pain (CKP).

METHODS

We searched the MEDLINE, EMBASE, Cochrane CENTERAL, CINAHL and four Chinese medical databases from their inception to June 2017. We included randomised controlled trials of acupuncture as the sole treatment or as an adjunctive treatment for CKP. The primary outcome was pain intensity measured by visual analogue scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain subscale and 11-point numeric rating scale. Secondary outcome measurements included the 36-Item Short Form Health Survey and adverse events. The quality of all included studies was evaluated using the Cochrane risk-of-bias criteria and the STRICTA (Standards for Reporting Interventions in Controlled Trials of Acupuncture) checklist.

RESULTS

Nineteen trials were included in this systematic review. Of these, data from 17 studies were available for analysis. Regarding the effectiveness of acupuncture alone or combined with other treatment, the results of the meta-analysis showed that acupuncture was associated with significantly reduced CKP at 12 weeks on WOMAC pain subscale (mean difference (MD) -1.12, 95% confidence interval (CI) -1.98 to -0.26, I²=62%, 3 trials, 608 participants) and VAS (MD -10.56, 95% CI -17.69 to -3.44, I²=0%, 2 trials, 145 patients). As for safety, no difference was found between the acupuncture and control groups (risk ratio 1.08, 95% CI 0.54 to 2.17, I²=29%).

CONCLUSION

From this systematic review, we conclude that acupuncture may be effective at relieving CKP 12 weeks after acupuncture administration, based on the current evidence and our protocol. However, given the heterogeneity and methodological limitations of the included trials, we are currently unable to draw any strong conclusions regarding the effectiveness of acupuncture for chronic knee pain. In addition, we found that acupuncture appears to have a satisfactory safety profile, although further studies with larger numbers of participants are needed to confirm the safety of this technique.

STRENGTHS

Systematic review without language restrictions.

LIMITATIONS

Only a few high-quality and consistent trials could be included in this review.

Effects of Electroacupuncture for Knee Osteoarthritis: A Systematic Review and Meta-Analysis

Purpose. This study aims to verify the effects of electroacupuncture treatment on osteoarthritis of the knee. Methods. MEDLINE/PubMed, EMBASE, CENTRAL, AMED, CNKI, and five Korean databases were searched by predefined search strategies to screen eligible randomized controlled studies meeting established criteria. Any risk of bias in the included studies was assessed with the Cochrane Collaboration's tool. Meta-analysis was conducted using RevMan version 5.3 software. Results. Thirty-one randomized controlled studies of 3,187 participants were included in this systematic review. Meta-analysis was conducted with eight studies including a total of 1,220 participants. The electroacupuncture treatment group showed more significant improvement in pain due to knee osteoarthritis than the control group (SMD −1.86, 95% CI −2.33 to −1.39, I² 75%) and in total WOMAC score than the control group (SMD −1.34, CI 95% −1.85 to −0.83, I² 73%). Compared to the control group, the electroacupuncture treatment group showed more significant improvement on the quality of life scale. Conclusion. Electroacupuncture treatment can relieve the pain of osteoarthritis of the knees and improve comprehensive aspects of knee osteoarthritis and the quality of life of patients with knee osteoarthritis.

Effects of acupuncture and sham acupuncture in addition to physiotherapy in patients undergoing bilateral total knee arthroplasty — a randomized controlled trial

Objective: To compare the acute effects of acupuncture with sham acupuncture on knee pain, range of motion and ambulation in patients with knee osteoarthritis undergoing bilateral total knee arthroplasty, when added to a standard postoperative physiotherapy programme.

Design: Prospective patient- and assessor-blinded randomized controlled trial.

Setting: Acute inpatient physiotherapy department.

Patients: Thirty patients (24 women and 6 men) undergoing bilateral total knee arthroplasty were included for final analysis in the study.

Interventions: Both groups received a standard postoperative physiotherapy programme. Each patient was also given either 10 sessions of acupuncture or sham acupuncture within two weeks.

Main outcome measures: The primary outcome measures were the levels of pain at rest and at maximum after exercise measured by the numeric pain rating scale. Other outcome measures included active and passive ranges of knee motion measured by standard goniometer, and ambulation measured by the timed up-and-go test.

Results: Thirty-six patients were recruited at the start of the study with 18 patients allocated to the acupuncture group and another 18 patients to the sham acupuncture group. On postoperative day 15, there were 30 patients with complete data; three patients in each group dropped out from the study. The mean differences (95% confidence interval (CI)) in overall averages of postoperative mean pain levels were 0.4 (—0.6 to 1.3) and —0.8 (—2.0 to 0.4) at rest and at maximum respectively. There were no significant differences in the active and passive ranges of knee motion and the time for the timed up-and-go test between the two groups.

Conclusion: There is no difference between the acute effects of acupuncture and sham acupuncture in addition to standard postoperative physiotherapy programme in patients with knee osteoarthritis undergoing bilateral total knee arthroplasty.

Efficacy of acupuncture during post-acute phase of rehabilitation after total knee arthroplasty

OBJECTIVE

The purpose of this study was to determine whether acupuncture is effective in reducing pain and swelling around the knee and improving range of motion (ROM) during the post-acute phase of rehabilitation after total knee arthroplasty (TKA).

METHODS

Following TKA, 80 knees in 80 patients were randomly assigned to either an acupuncture treatment group (Group A) or a control group (Group C). In Group A, the complementary treatment of acupuncture was performed three times/week from postoperative day 7 until postoperative day 21. Outcome measures were: i) pain as assessed by a visual analog scale; ii) reduction of swelling around the knee as indicated by its circumference at the center of the patella; and iii) ROM of the affected knee.

RESULTS

Group A patients had significantly reduced pain and swelling around the knees and earlier recovery of ROM than did those in Group C.

CONCLUSION

Acupuncture provides effective treatment during the post-acute phase of rehabilitation after TKA with respect to pain relief, reduction of swelling around the knee, and early recovery of ROM.

Acupuncture for chronic pain: individual patient data meta-analysis

BACKGROUND

Although acupuncture is widely used for chronic pain, there remains considerable controversy as to its value. We aimed to determine the effect size of acupuncture for 4 chronic pain conditions: back and neck pain, osteoarthritis, chronic headache, and shoulder pain.

METHODS

We conducted a systematic review to identify randomized controlled trials (RCTs) of acupuncture for chronic pain in which allocation concealment was determined unambiguously to be adequate. Individual patient data meta-analyses were conducted using data from 29 of 31 eligible RCTs, with a total of 17 922 patients analyzed.

RESULTS

In the primary analysis, including all eligible RCTs, acupuncture was superior to both sham and no-acupuncture control for each pain condition (P < .001 for all comparisons). After exclusion of an outlying set of RCTs that strongly favored acupuncture, the effect sizes were similar across pain conditions. Patients receiving acupuncture had less pain, with scores that were 0.23 (95% CI, 0.13-0.33), 0.16 (95% CI, 0.07-0.25), and 0.15 (95% CI, 0.07-0.24) SDs lower than sham controls for back and neck pain, osteoarthritis, and chronic headache, respectively; the effect sizes in comparison to no-acupuncture controls were 0.55 (95% CI, 0.51-0.58), 0.57 (95% CI, 0.50-0.64), and 0.42 (95% CI, 0.37-0.46) SDs. These results were robust to a variety of sensitivity analyses, including those related to publication bias.

CONCLUSIONS

Acupuncture is effective for the treatment of chronic pain and is therefore a reasonable referral option. Significant differences between true and sham acupuncture indicate that acupuncture is more than a placebo. However, these differences are relatively modest, suggesting that factors in addition to the specific effects of needling are important contributors to the therapeutic effects of acupuncture.

Evaluation of the effect of laser acupuncture and cupping with ryodoraku and visual analog scale on low back pain

The purpose of this study was to evaluate the effect of laser acupuncture (LA) and soft cupping on low back pain. In this study, the subjects were randomly assigned to two groups: active group (real LA and soft cupping) and placebo group (sham laser and soft cupping). Visual analog scale (VAS) and Ryodoraku were used to evaluate the effect of treatment on low back pain in this trial. Laser, 40 mW, wavelength 808 nm, pulse rate 20 Hz, was used to irradiate Weizhong (BL40) and Ashi acupoints for 10 minutes. And the Ryodoraku values were measured 2 times, that is, before and 15 minutes after treatment. The results show that there were significant difference between the first day baseline and the fifth day treatment in VAS in the two groups. Therefore, LA combined with soft cupping or only soft cupping was effective on low back pain. However, the Ryodoraku values of Bladder Meridian of the placebo group have been decreased apparently, and didn't come back to their original values. It means that "cupping" plays the role of "leak or purge" in traditional Chinese medicine (TCM). On the other hand, the Ryodoraku values of Bladder Meridian of the active group have been turned back to almost their original values; "mend or reinforcing" effect is attributed to the laser radiation.

Etiology, assessment, and management of aromatase inhibitor-related musculoskeletal symptoms

Aromatase inhibitors (AIs) are recommended as adjuvant endocrine therapy for postmenopausal women with hormone-responsive breast cancer. With the widespread use of AI adjuvant endocrine therapy, a significant profile of musculoskeletal symptoms has emerged. Moderate to severe musculoskeletal symptoms have led some women to discontinue therapy, compromising the survival benefit. The etiology of AI-related musculoskeletal symptoms is poorly understood, which challenges development of effective management strategies. The purpose of this article is to describe AI-related musculoskeletal symptoms, review possible causes, provide assessment guidelines, and recommend management strategies based on the best available evidence. Little evidence exists for effective management strategies of AI-related musculoskeletal symptoms, and randomized clinical trials are needed to establish effective interventions. A thorough musculoskeletal assessment can help guide clinical decision making for the best individual management approach. Providers need to manage symptoms with the best available evidence to minimize symptom distress and maximize adherence to AI therapy.

Effect of low-level laser stimulation on EEG

Conventional laser stimulation at the acupoint can induce significant brain activation, and the activation is theoretically conveyed by the sensory afferents. Whether the insensible low-level Laser stimulation outside the acupoint could also evoke electroencephalographic (EEG) changes is not known. We designed a low-level laser array stimulator (6 pcs laser diode, wavelength 830 nm, output power 7 mW, and operation frequency 10 Hz) to deliver insensible laser stimulations to the palm. EEG activities before, during, and after the laser stimulation were collected. The amplitude powers of each EEG frequency band were analyzed. We found that the low-level laser stimulation was able to increase the power of alpha rhythms and theta waves, mainly in the posterior head regions. These effects lasted at least 15 minutes after cessation of the laser stimulation. The amplitude power of beta activities in the anterior head regions decreased after laser stimulation. We thought these EEG changes comparable to those in meditation.

Group acupuncture for knee pain: evaluation of a cost-saving initiative in the health service

BACKGROUND

Acupuncture has been provided in nurse-led group clinics in St Albans since 2008. It is funded by a commissioning group within the National Health Service, on a trial basis, for patients with knee osteoarthritis who would otherwise be referred to an orthopaedic surgeon.

AIM

To evaluate the patients seen in the service's first year of operation and their outcome up to the end of 2010.

METHODS

Service evaluation was made of patient data from the referral centre and the acupuncture clinics, including baseline characteristics, attendance data and Measure Yourself Medical Outcome Profile (MYMOP) symptom, function and well-being scores over at least 2 years.

RESULTS

114 patients were offered acupuncture, of whom 90 patients were assessed in the acupuncture clinics. 41 of these were still attending after 1 year and 31 (34%) after 2 years. MYMOP scores showed clinically significant improvements at 1 month for pain (4.2 (SD 1.2) to 2.9 (SD 1.4)), stiffness (4.1 (SD 1.3) to 2.9 (SD 1.3)) and function (4.5 (SD 1.1) to 3.3 (SD 1.2)) which continued up to 2 years. Well-being scores did not change.

CONCLUSIONS

This is the first evaluation of nurse-led group (multibed) acupuncture clinics for patients with knee osteoarthritis to include a 2 year follow-up. It shows the practicability of offering a low-cost acupuncture service as an alternative to knee surgery and the service's success in providing long-term symptom relief in about a third of patients. Using realistic assumptions, the cost consequences for the local commissioning group are an estimated saving of £100 000 a year. Sensitivity analyses are presented using different assumptions.

Supervised Exercise plus Acupuncture for Moderate to Severe Knee Osteoarthritis: A Small Randomised Controlled Trial

Objectives

Although total knee replacement (TKR) is cost effective and successful in most cases, patient-reported outcome measures demonstrate 20% of people remain unsatisfied at 1 year after a technically successful procedure. Our group has previously shown that patients with severe knee osteoarthritis (OA) awaiting surgery can achieve a short-term reduction in symptom severity when treated with acupuncture, and that a trend towards improved walking distance, as a measure of function, is achieved with preoperative supervised exercise. The aim of this study was to evaluate the effect of combined acupuncture and physiotherapy on preoperative and postoperative pain and function.

Methods

A total of 56 patients awaiting TKR surgery were randomised to receive either combined physiotherapy and acupuncture or a standardised exercise and advice leaflet. Pain and function were measured primarily using the Oxford Knee Score (OKS), with assessments at baseline prior to intervention, 6 and 12 weeks after intervention and at 3 months postoperatively.

Results

Due to the introduction of the 18-week waiting times target during this study, the required sample size was not achieved. There were no significant differences demonstrated between the control and treatment groups for OKS. Seven patients withdrew from surgery because of symptomatic improvement in their knees: six from the treatment group and one from the control group (OR 7.64, 95% CI 0.86 to 68.20).

Conclusions

This study demonstrated that the use of combined acupuncture and physiotherapy in the treatment of patients with moderate to severe knee OA preoperatively did not improve patient outcome postoperatively. As the study was underpowered, a larger trial is required to examine this result further.

External validity in randomised controlled trials of acupuncture for osteoarthritis knee pain

OBJECTIVES

To assess two aspects of the external validity of acupuncture research for osteoarthritis knee pain and determine the common acupoints and treatment parameters used.

METHODS

The external validity of 16 randomised controlled trials (RCTs) was investigated using a scale consisting of two aspects: reporting and performance. The reporting aspect included acupuncturist's background, study location, treatment detailed, patient characteristics, positive trial results, adverse effects and between-group statistical differences, whereas treatment appropriateness, appropriate controls and outcomes were classified as the performance aspect. Acupuncture treatment in RCTs was compared with common practice according to the literature sources and survey of acupuncturists working in different parts of Thailand.

RESULTS

The levels of external validity for the reporting and performance aspects were in the range of 31.3% to 100%. Statistic values such as mean difference and confidence interval were reported by the minority of trials (43.8%). Patient satisfaction and quality of life were seldom used (31.3%). There were minor differences between research and practice in terms of the points used (25.0%), number of treatment sessions (6.3%) and frequency (12.5%). The most frequently used points were ST34, ST35, ST36, SP6, SP9, SP10, GB34, Xiyan and ah shi points, and the commonly used treatment parameters were 20 minutes, 10-15 sessions and two treatments weekly.

CONCLUSIONS

Reporting of the external validity of acupuncture RCTs for knee pain was notably inadequate in terms of trial setting, treatment provider and statistical reporting. The majority of studies involved appropriate controls and outcomes and applied acupuncture treatments in line with practice.

Complementary therapies for osteoarthritis: are they effective?

Increasing interest has focused on complementary management modalities, including tai chi, acupuncture, yoga, and massage therapy, as treatments for osteoarthritis (OA). This review article synthesizes evidence from randomized controlled trials (RCTs) and systematic reviews (SRs) that examined one or more of the above as treatments for OA. Medline, Pubmed, and Cinahl databases were searched to identify English-language articles using an RCT design or that conducted a SR of published studies and presented data on symptom or functional outcomes. Two authors independently abstracted relevant information (e.g., study sample, intervention characteristics, treatment effects, safety data). Retained articles (n = 29) included those that evaluated tai chi (8 RCTs, 2 SRs), acupuncture (11 RCTs, 4 SRs), yoga (2 RCTs), and massage therapy (2 RCTs). Available evidence indicates that tai chi, acupuncture, yoga, and massage therapy are safe for use by individuals with OA. Positive short-term (≤6 months) effects in the form of reduced pain and improved self-reported physical functioning were found for all 4 treatments. Limited information exists regarding the relative effectiveness of the therapies (e.g., yoga vs. tai chi vs. acupuncture), as well as treatment effects in persons with joint involvement besides the knee and in distinct patient subgroups (e.g., older vs. younger adults, persons with mild vs. moderate vs. advanced disease). Complementary therapies can reduce pain and improve function in adults with OA. Research is needed to evaluate long-term benefits of the treatments, as well as their relative effects among diverse patient subgroups.

Pre-operative interventions (non-surgical and non-pharmacological) for patients with hip or knee osteoarthritis awaiting joint replacement surgery--a systematic review and meta-analysis

OBJECTIVE

To determine if pre-operative interventions for hip and knee osteoarthritis provide benefit before and after joint replacement.

METHOD

Systematic review with meta-analysis of randomised controlled trials (RCTs) of pre-operative interventions for people with hip or knee osteoarthritis awaiting joint replacement surgery. Standardised mean differences (SMD) were calculated for pain, musculoskeletal impairment, activity limitation, quality of life, and health service utilisation (length of stay and discharge destination). The GRADE approach was used to determine the quality of the evidence.

RESULTS

Twenty-three RCTs involving 1461 participants awaiting hip or knee replacement surgery were identified. Meta-analysis provided moderate quality evidence that pre-operative exercise interventions for knee osteoarthritis reduced pain prior to knee replacement surgery (SMD (95% CI)=0.43 [0.13, 0.73]). None of the other meta-analyses investigating pre-operative interventions for knee osteoarthritis demonstrated any effect. Meta-analyses provided low to moderate quality evidence that exercise interventions for hip osteoarthritis reduced pain (SMD (95% CI)=0.52 [0.04, 1.01]) and improved activity (SMD (95% CI)=0.47 [0.11, 0.83]) prior to hip replacement surgery. Meta-analyses provided low quality evidence that exercise with education programs improved activity after hip replacement with reduced time to reach functional milestones during hospital stay (e.g., SMD (95% CI)=0.50 [0.10, 0.90] for first day walking).

CONCLUSION

Low to moderate evidence from mostly small RCTs demonstrated that pre-operative interventions, particularly exercise, reduce pain for patients with hip and knee osteoarthritis prior to joint replacement, and exercise with education programs may improve activity after hip replacement.

Randomized, Blinded, Sham-Controlled Trial of Acupuncture for the Management of Aromatase Inhibitor–Associated Joint Symptoms in Women With Early-Stage Breast Cancer

Purpose

Women with breast cancer (BC) treated with aromatase inhibitors (AIs) may experience joint symptoms that can lead to discontinuation of effective therapy. We examined whether acupuncture improves AI-induced arthralgias in women with early-stage BC.

Methods

We conducted a randomized, controlled, blinded study comparing true acupuncture (TA) versus sham acupuncture (SA) twice weekly for 6 weeks in postmenopuasal women with BC who had self-reported musculoskeletal pain related to AIs. TA included full body/auricular acupuncture and joint-specific point prescriptions, whereas SA involved superficial needle insertion at nonacupoint locations. Outcome measures included the Brief Pain Inventory–Short Form (BPI-SF), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Modified Score for the Assessment of Chronic Rheumatoid Affections of the Hands (M-SACRAH) obtained at baseline and at 3 and 6 weeks.

Results

Of 51 women enrolled, 43 women were randomly assigned and 38 were evaluable. Baseline characteristics were comparable between the two groups. Our primary end point was the difference in mean BPI-SF worst pain scores at 6 weeks, which was lower for TA compared with SA (3.0 v 5.5; P < .001). We also found differences between TA and SA in pain severity (2.6 v 4.5; P = .003) and pain-related interference (2.5 v 4.5; P = .002) at 6 weeks. Similar findings were seen for the WOMAC and M-SACRAH scores. The acupuncture intervention was well-tolerated.

Conclusion

Women with AI-induced arthralgias treated with TA had significant improvement of joint pain and stiffness, which was not seen with SA. Acupuncture is an effective and well-tolerated strategy for managing this common treatment-related side effect.

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.

Remote influences of acupuncture on the pain intensity and the amplitude changes of endplate noise in the myofascial trigger point of the upper trapezius muscle

OBJECTIVE

To investigate the remote effect of acupuncture on the pain intensity and the endplate noise (EPN) recorded from a myofascial trigger point (MTrP) of the upper trapezius muscle.

DESIGN

Randomized controlled trial.

SETTING

University hospital.

PARTICIPANTS

Patients (N=20) with active MTrPs in upper trapezius muscles and no experience in acupuncture therapy.

INTERVENTIONS

Patients were divided into 2 groups. Those in the control group received sham acupuncture, and those in the acupuncture group received modified acupuncture therapy with needle insertion into multiple loci to elicit local twitch responses. The acupuncture points of Wai-guan and Qu-chi were treated.

MAIN OUTCOME MEASURES

Subjective pain intensity (numerical pain rating scale) and mean EPN amplitude in the MTrP of the upper trapezius muscle.

RESULTS

The pain intensity in the MTrP was significantly reduced after remote acupuncture (from 7.4+/-0.8 to 3.3+/-1.1; P<.001), but not after sham acupuncture (from 7.4+/-0.8 to 7.1+/-0.9; P>.05). The mean EPN amplitude was significantly lower than the pretreatment level after acupuncture treatment (from 21.3+/-9.5 microV to 9.5+/-3.5 microV; P<.01), but not after sham acupuncture treatment (from 19.6+/-7.6 microV to 19.3+/-7.8 microV; P>.05). The change in the pain intensity was significantly correlated with the change of EPN amplitude (r=0.685).

CONCLUSIONS

Both subjective changes in the pain intensity and objective changes of the EPN amplitude in the MTrP region of the upper trapezius muscle were found during and after acupuncture treatment at the remote ipsilateral acupuncture points. This study may further clarify the physiological basis of the remote effectiveness of acupuncture therapy for pain control.

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.

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.

Acupuncture in patients with osteoarthritis of the knee or hip: a randomized, controlled trial with an additional nonrandomized arm

OBJECTIVE

To investigate the effectiveness of acupuncture in addition to routine care, compared with routine care alone, in the treatment of patients with chronic pain due to osteoarthritis (OA) of the knee or hip.

METHODS

In a randomized, controlled trial, patients with chronic pain due to OA of the knee or hip were randomly allocated to undergo up to 15 sessions of acupuncture in a 3-month period or to a control group receiving no acupuncture. Another group of patients who did not consent to randomization underwent acupuncture treatment. All patients were allowed to receive usual medical care in addition to the study treatment. Clinical OA severity (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]) and health-related quality of life (Short Form 36) were assessed at baseline and after 3 months and 6 months.

RESULTS

Of 3,633 patients (mean +/- SD age 61.8 +/- 10.8 years; 61% female), 357 were randomized to the acupuncture group and 355 to the control group, and 2,921 were included in the nonrandomized acupuncture group. At 3 months, the WOMAC had improved by a mean +/- SEM of 17.6 +/- 1.0 in the acupuncture group and 0.9 +/- 1.0 in the control group (3-month scores 30.5 +/- 1.0 and 47.3 +/- 1.0, respectively [difference in improvement 16.7 +/- 1.4; P < 0.001]). Similarly, quality of life improvements were more pronounced in the acupuncture group versus the control group (P < 0.001). Treatment success was maintained through 6 months. The changes in outcome in nonrandomized patients were comparable with those in randomized patients who received acupuncture.

CONCLUSION

These results indicate that acupuncture plus routine care is associated with marked clinical improvement in patients with chronic OA-associated pain of the knee or hip.

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.

Akupunktur

In Germany, acupuncture is one of the most frequently used complementary and alternative therapies. In the year 2000, we initiated three large projects in co-operation with statutory health insurance companies to assess the effectiveness, safety and costs of acupuncture in patients with chronic headache, low back pain and pain due to osteoarthritis. Our findings showed that acupuncture was more effective than conventional standard treatment, treatment without acupuncture or a waiting list control. A significant difference between acupuncture and sham acupuncture was only seen for arthritis of the knee; for the other diagnoses, both forms of acupuncture showed similar effects. Whether the effects of acupuncture are due primarily to specific or unspecific mechanisms appears to depend on the diagnosis and should be investigated in further studies.

Acupuncture in patients with osteoarthritis of the knee: a randomised trial

BACKGROUND

Acupuncture is widely used by patients with chronic pain although there is little evidence of its effectiveness. We investigated the efficacy of acupuncture compared with minimal acupuncture and with no acupuncture in patients with osteoarthritis of the knee.

METHODS

Patients with chronic osteoarthritis of the knee (Kellgren grade < or =2) were randomly assigned to acupuncture (n=150), minimal acupuncture (superficial needling at non-acupuncture points; n=76), or a waiting list control (n=74). Specialised physicians, in 28 outpatient centres, administered acupuncture and minimal acupuncture in 12 sessions over 8 weeks. Patients completed standard questionnaires at baseline and after 8 weeks, 26 weeks, and 52 weeks. The primary outcome was the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index at the end of week 8 (adjusted for baseline score). All main analyses were by intention to treat.

RESULTS

294 patients were enrolled from March 6, 2002, to January 17, 2003; eight patients were lost to follow-up after randomisation, but were included in the final analysis. The mean baseline-adjusted WOMAC index at week 8 was 26.9 (SE 1.4) in the acupuncture group, 35.8 (1.9) in the minimal acupuncture group, and 49.6 (2.0) in the waiting list group (treatment difference acupuncture vs minimal acupuncture -8.8, [95% CI -13.5 to -4.2], p=0.0002; acupuncture vs waiting list -22.7 [-27.5 to -17.9], p<0.0001). After 52 weeks the difference between the acupuncture and minimal acupuncture groups was no longer significant (p=0.08).

INTERPRETATION

After 8 weeks of treatment, pain and joint function are improved more with acupuncture than with minimal acupuncture or no acupuncture in patients with osteoarthritis of the knee. However, this benefit decreases over time.

Acupuncture as a complementary therapy to the pharmacological treatment of osteoarthritis of the knee: randomised controlled trial

OBJECTIVES

To analyse the efficacy of acupuncture as a complementary therapy to the pharmacological treatment of osteoarthritis of the knee, with respect to pain relief, reduction of stiffness, and increased physical function during treatment; modifications in the consumption of diclofenac during treatment; and changes in the patient's quality of life.

DESIGN

Randomised, controlled, single blind trial, with blinded evaluation and statistical analysis of results.

SETTING

Pain management unit in a public primary care centre in southern Spain, over a period of two years.

PARTICIPANTS

97 outpatients presenting with osteoarthritis of the knee.

INTERVENTIONS

Patients were randomly separated into two groups, one receiving acupuncture plus diclofenac (n = 48) and the other placebo acupuncture plus diclofenac (n = 49).

MAIN OUTCOME MEASURES

The clinical variables examined included intensity of pain as measured by a visual analogue scale; pain, stiffness, and physical function subscales of the Western Ontario and McMaster Universities (WOMAC) osteoarthritis index; dosage of diclofenac taken during treatment; and the profile of quality of life in the chronically ill (PQLC) instrument, evaluated before and after the treatment programme.

RESULTS

88 patients completed the trial. In the intention to treat analysis, the WOMAC index presented a greater reduction in the intervention group than in the control group (mean difference 23.9, 95% confidence interval 15.0 to 32.8) The reduction was greater in the subscale of functional activity. The same result was observed in the pain visual analogue scale, with a reduction of 26.6 (18.5 to 34.8). The PQLC results indicate that acupuncture treatment produces significant changes in physical capability (P = 0.021) and psychological functioning (P = 0.046). Three patients reported bruising after the acupuncture sessions.

CONCLUSIONS

Acupuncture plus diclofenac is more effective than placebo acupuncture plus diclofenac for the symptomatic treatment of osteoarthritis of the knee.

The role of acupuncture in pain management

This article reviews the theories and applications of acupuncture to musculoskeletal pain management. First, Chinese theories of acupuncture are discussed briefly. Next, current understanding of nociception and central pain modulation is discussed in detail,followed by discussion of the physiologic effect of acupuncture analgesia. Other theories of acupuncture analgesia are presented based on neuromodulation of the central nervous system. Finally,the efficacy of acupuncture for many musculoskeletal pain syndromes,including spine-related pain, soft tissue pain, neuropathic pain, arthritis of the knee, and upper extremity tendinitis, is reviewed. The article concludes with a discussion of methodologic issues related to conducting randomized, placebo-controlled trials of acupuncture and goals for future research in this area of pain management.

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.

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

BACKGROUND

Using an open randomised controlled study, we examined the effectiveness of manual and electroacupuncture on symptom relief for patients with osteoarthritis of the knee.

METHODS

Patients with symptomatic osteoarthritis of the knee were randomised to one of three treatment groups. Group A had acupuncture alone, group B had acupuncture but continued on their symptomatic medication, and group C used their symptomatic medication for the first five weeks and then had a course of acupuncture added. Patients receiving acupuncture were treated twice weekly over five weeks. Needles were inserted (with manual and electrical stimulation) in acupuncture points for pain and stiffness, selected according to traditional acupuncture theory for treating Bi syndrome. Patients were assessed by a blinded observer before treatment, after five weeks' treatment and at one month follow up, using a visual analogue pain scale (VAS) and the Western Ontario McMaster (WOMAC) questionnaire for osteoarthritis of the knee.

RESULTS

The 30 patients in our study were well matched for age, body mass index, disease duration, baseline VAS pain score and baseline WOMAC scores. Repeated measure analyses gave a highly significant improvement in pain (VAS) after the courses of acupuncture in groups A (P = 0.012) and B (P=0.001); there was no change in group C until after the course of acupuncture, when the improvement was significant (P = 0.001). Similarly significant changes were seen with the WOMAC pain and stiffness scores. These benefits were maintained during the one month after the course of acupuncture. Patients' rating of global assessment was higher than that of the acupuncturist.

CONCLUSION

We conclude that manual and electroacupuncture causes a significant improvement in the symptoms of osteoarthritis of the knee, either on its own or as an adjunct therapy, with no loss of benefit after one month.

Comparison Between Electro-Acupuncture and Hydrotherapy, Both in Combination With Patient Education and Patient Education Alone, on the Symptomatic Treatment of Osteoarthritis of the Hip

OBJECTIVES

The aim of the study was to evaluate the therapeutic effect of electro-acupuncture (EA) and hydrotherapy, both in combination with patient education or with patient education alone, in the treatment of osteoarthritis in the hip.

METHODS

Forty-five patients, aged 42-86 years, with radiographic changes consistent with osteoarthritis in the hip, pain related to motion, pain on load, and ache were chosen. They were randomly allocated to EA, hydrotherapy, both in combination with patient education, or patient education alone. Outcome measures were the disability rating index (DRI), global self-rating index (GSI), and visual analogue scale (VAS). Assessments were done before the intervention and immediately after the last treatment and 1, 3, and 6 months after the last treatment.

RESULTS

Pain related to motion and pain on load was reduced up to 3 months after last the treatment in the hydrotherapy group and up to 6 months in the EA group. Ache during the day was significantly improved in both the EA and hydrotherapy group up to 3 months after the last treatment. Ache during the night was reduced in the hydrotherapy group up to 3 months after the last treatment and in the EA group up to 6 months after. Disability in functional activities was improved in EA and hydrotherapy groups up to 6 months after the last treatment. Quality of life was also improved in EA and hydrotherapy groups up to 3 months after the last treatment. There were no changes in the education group alone.

DISCUSSION

In conclusion, EA and hydrotherapy, both in combination with patient education, induce long-lasting effects, shown by reduced pain and ache and by increased functional activity and quality of life, as demonstrated by differences in the pre- and post-treatment assessments.

Efficacy and safety of acupuncture for chronic pain caused by gonarthrosis: a study protocol of an ongoing multi-centre randomised controlled clinical trial [ISRCTN27450856]

Background

Controlled clinical trials produced contradictory results with respect to a specific analgesic effect of acupuncture. There is a lack of large multi-centre acupuncture trials. The German Acupuncture Trial represents the largest multi-centre study of acupuncture in the treatment of chronic pain caused by gonarthrosis up to now.

Methods

900 patients will be randomised to three treatment arms. One group receives verum acupuncture, the second sham acupuncture, and the third conservative standard therapy. The trial protocol is described with eligibility criteria, detailed information on the treatment definition, blinding, endpoints, safety evaluation, statistical methods, sample size determination, monitoring, legal aspects, and the current status of the trial.

Discussion

A critical discussion is given regarding the considerations about standardisation of the acupuncture treatment, the choice of the control group, and the blinding of patients and observers.

The effects of electro-acupuncture and transcutaneous electrical nerve stimulation on patients with painful osteoarthritic knees: a randomized controlled trial with follow-up evaluation

OBJECTIVES

To examine the relative effectiveness of electro-acupuncture (EA) and transcutaneous electrical nerve stimulation (TENS) in alleviating osteoarthritic (OA)-induced knee pain.

DESIGN

Single-blinded, randomized controlled study.

SUBJECTS

Twenty-four (24) subjects (23 women and 1 man), mean age 85, were recruited from eight subsidized Care & Attention Homes for the elderly.

INTERVENTIONS

Subjects were randomly assigned to the EA, TENS, or control groups. Subjects in the EA group (n = 8) received low-frequency EA (2 Hz) on two acupuncture points (ST-35, Dubi and EX-LE-4, Neixiyan) of the painful knee for 20 minutes. Subjects in the TENS group (n = 8) received low-frequency TENS of 2 Hz and pulse width of 200 micros on the same acupuncture points for 20 minutes. In both treatment groups, electrical treatment was carried out for a total of eight sessions in 2 weeks. Eight subjects received osteoarthritic knee care and education only in a control group. All subjects were evaluated before the first treatment, after the last treatment, and at 2-week follow-up periods.

RESULTS

After eight sessions of treatment, there was significant reduction of knee pain in both EA group and TENS group, as measured by the Numeric Rating Scale (NRS) of pain (p < 0.01). Prolonged analgesic effect was maintained in the EA and the TENS groups at a 2-week follow-up evaluation. The Timed Up-and-Go Test (TUGT) score of the EA group was significantly lower than that of the control group (p < 0.05), but such change was not observed in the TENS group.

CONCLUSIONS

Both EA and TENS treatments were effective in reducing OA-induced knee pain. EA had the additional advantage of enhancing the TUGT results as opposed to TENS treatment or no treatment, which did not produce such corollary effect.

Acupuncture used in the management of pain due to arthropathy in a patient with haemophilia

A case report is presented of a haemophilia patient, with pains due to arthropathy, being successfully treated with acupuncture. Acupuncture may have something to offer this type of patient in terms of pain management and reduction of strong analgesics. Treatment should be performed only by practitioners with special training in acupuncture, and close co-operation with a haemophilia clinic is necessary.