Research Review by Dr. Shawn Thistle©

Date:

Aug. 2006

Study Title:

Acupuncture and knee osteoarthritis: A three-armed randomized trial

Authors:

Sharf H et al.

Publication Information:

Annals of Internal Medicine 2006; 145(1): 12-20.

Summary:

Osteoarthritis (OA) of the knee is a common, disabling and costly condition. Most treatment guidelines published to date recommend a multimodal pharmacologic and nonpharmacologic approach until the condition progresses and warrants a total knee replacement.

Today's aging population wants to remain active and enjoy a multitude of sporting and leisure activities, and is seeking alternative treatments for conditions such as knee OA.

This study constitutes the largest study of this group, involving 1007 patients with chronic knee pain due to OA for at least 6 months. The experimental setup, although not exact when compared with the other studies, is similar in that it compares traditional acupuncture treatment with sham needling as the two primary groups. Relevant study design highlights include:
  • 315 primary care centres with 320 acupuncture providers having at least 2 years experience participated in this study (all clinics located in Germany)
  • to be included, patients had to be at least 40 years old, with chronic knee pain for at least six months due to OA (according to American College of Rheumatology criteria), and a WOMAC score of at least three, and a chronic pain score of at least one
  • the primary outcome measure was the WOMAC (a pen and paper outcome measure) score at 13 and 26 weeks after initiation of treatment - secondary outcomes included the SF-12 and global patient assessment
Patients were randomized to receive treatment in one of three groups:
  • conservative therapy group - received 10 visits to general practitioners and were prescribed Diclofenac or Rofecoxib for up to 23 weeks
  • Traditional Chinese Acupuncture (TCA) group - received 10 treatments administered over a 6 week period (those demonstrating partial success were allowed an additional 5 treatments)
  • sham acupuncture group - also received 10 treatments involving minimal depth needling at 10 points which were defined distances form traditional points
  • each of the three treatment groups had up to six physiotherapy sessions, but unfortunately these sessions were not described in detail

Pertinent Results:

  • the observed success rates were 53.1% for the TCA group, 51.0% for the sham acupuncture group, and 29.1% for the conservative therapy group
  • changes in the WOMAC score were much more distinct in the TCA and sham acupuncture group
  • global patient assessment ratings demonstrated a higher rate of satisfaction for the TCA (73%) and sham (62.5%) groups at 26 weeks than the conservative treatment group (47.1%)
  • ancillary data analysis was comprehensive for confounding events and patient scenarios - with major outcomes of the study remaining unchanged
  • interestingly, almost half of the acupuncture patients were blinded to whether they were receiving real or sham treatments, and 45% of the remaining patients who thought they knew their treatment group guessed incorrectly
  • incidence of adverse events was similar in all three treatment groups

Conclusions & Practical Application:

This is now the third large study published in a respected medical journal to demonstrate the effectiveness of acupuncture (traditional and to a lesser but real extent sham) in the treatment of osteoarthritis of the knee. It also joins a growing list of controlled clinical trials showing respectable improvements in pain and function when patients receive so called "sham" acupuncture.

As I have mentioned before, I feel strongly that this suggests a beneficial non-specific effect of acupuncture needling that needs to be further investigated. I am not saying that proper point selection guided by anatomical or traditional land-marking is not important, but even the authors concede that "Our observation raises the questions of whether there is a single optimal point selection and whether deep needling with stimulation and de qi sensation is superior to shallow needling." (pg. 19).

This study adds to the growing amount of evidence that acupuncture provides a real treatment alternative for those afflicted with knee osteoarthritis.