Adding Acupuncture to Physical Therapy and Anti-Inflammatory Drugs in the Treatment of Knee Osteoarthritis

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The summary below is from the full report titled "Acupuncture and Knee Osteoarthritis. A Three-Armed Randomized Trial." It is in the 4 July 2006 issue of Annals of Internal Medicine (volume 145, pages 12-20). The authors are H.-P. Scharf, U. Mansmann, K. Streitberger, S. Witte, J. Krämer, C. Maier, H.-J. Trampisch, and N. Victor.

What is the problem and what is known about it so far?

Knee osteoarthritis is a common condition in which changes in the knee joints lead to pain. Treatments include drugs to decrease pain and inflammation; weight loss, if needed; physical therapy; and exercise. Unfortunately, these treatments do not always help and some have side effects. Consequently, many people with knee osteoarthritis seek alternative treatments, such as acupuncture. Acupuncture is an ancient Chinese treatment that involves putting special needles into specific points on the body to treat medical conditions. Mainstream medicine is increasingly recognizing acupuncture as an effective treatment for some disorders. Past studies about acupuncture for osteoarthritis have had inconsistent results.

Why did the researchers do this particular study?

To find out whether acupuncture is an effective treatment for knee osteoarthritis.

Who was studied?

1007 patients with osteoarthritis knee pain for at least 6 months.

How was the study done?

The researchers assigned patients to receive either 10 sessions of traditional Chinese acupuncture (TCA), 10 sessions of sham acupuncture, or 10 doctor visits without acupuncture over 6 weeks. Traditional Chinese acupuncture was "real" acupuncture according to Chinese protocols that specify the location and depth of needle placement in the treatment of knee pain. Sham acupuncture was "fake" acupuncture in which the acupuncturist placed the needles at a shallow depth in places other than the TCA points. Patients in all 3 groups could receive 6 physical therapy treatments and could take anti-inflammatory medications as needed up to a certain amount. The researchers compared changes in patients' pain after 26 weeks.

What did the researchers find?

After 26 weeks, patients in the TCA and sham acupuncture groups had greater improvement in pain than those in the no acupuncture group. Surprisingly, the changes in pain were not different in the TCA and sham acupuncture groups. However, patients in the TCA group reported higher satisfaction with treatment than those in the sham acupuncture group, but both acupuncture groups reported higher satisfaction than the no acupuncture group. Of note, patients in both acupuncture groups had more contact with health care providers during the study than did those in the no acupuncture group.

What were the limitations of the study?

Patients knew whether they were getting acupuncture. The researchers did not monitor whether the acupuncturists were following the TCA and sham protocols exactly as the study plan specified.

What are the implications of the study?

Compared with patients with knee osteoarthritis treated with physical therapy and anti-inflammatory drugs alone, patients who also received TCA or sham acupuncture had improvements in pain at 26 weeks. Surprisingly, the researchers found no difference in pain reduction between real and fake acupuncture. Several potential explanations are possible. First, because of psychological effects, patients who know they are getting special types of treatment report feeling better regardless of whether the treatment really works. Second, patients who received acupuncture had more intense contact with health care providers, which could explain why they felt better. Third, sticking needles into the body may have a physical effect on pain, regardless of whether the needles are placed according to TCA principles.

Read all Rapid Responses

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Rejoinder

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Annals Online, 5 Sep 2006 [Full text]