KNEE PAIN RESEARCH (© JCM Ltd)

ACUPUNCTURE IMPROVES KNEE OSTEOARTHRITIS
Research from a team in Pakistan has shown that improvement in subjective measures of pain in knee osteoarthritis after electro-acupuncture (EA) was correlated with changes in biomarkers associated with stress and pain. Forty patients aged 40 years and over received ten daily 25 minute sessions of either EA (with points selected according to TCM theory) or sham acupuncture (with needles inserted at random non-acupuncture points and no electrostimulation). Following EA there was significant improvement in pain, stiffness and disability, accompanied by a significant rise in plasma beta-endorphin and a significant fall in plasma cortisol, compared with sham treatment. The authors conclude that acupuncture is associated with physiological changes beyond those of the placebo effect. (Clinical and endocrinological changes after electro-acupuncture treatment in patients with osteoarthritis of the knee. Pain. 2009 Dec 15;147(1-3):60-6).
Meanwhile, in a pilot study carried out to inform the design of a fully-powered pragmatic randomised controlled trial, UK researchers have shown a significant reduction in knee pain at three months for acupuncture compared with usual care. Thirty patients aged over 50 with pain and osteoarthritis of the knee were randomised to acupuncture plus usual care or usual care alone. Although this pilot study was not adequately powered to detect significant changes in outcome, pain scores showed a statistically significant reduction at three months in the acupuncture group compared with usual care. This was not sustained at 12 months. The authors calculated the sample size necessary for a fully powered two-arm trial to be 350. (Acupuncture for pain and osteoarthritis of the knee: a pilot study for an open parallel-arm randomised controlled trial. BMC Musculoskelet Disord. 2009 Oct 24;10:130).

ACUPUNCTURE DELAYED EFFECT IN KNEE OSTEOARTHRITIS
An RCT carried out in Israel has assessed the efficacy of acupuncture in providing improved function and pain relief when used as an adjunctive therapy to standard care in elderly patients with osteoarthritis (OA) of the knee. Fifty-five patients were randomly divided into an intervention group that received eight weeks of biweekly acupuncture treatment and a control group that received sham acupuncture; both groups additionally received standard therapy (painkillers and intra-articular hyaluronic acid and steroid injections). Primary outcome measures were changes in the Knee Society Score (KSS) knee score, function and pain ratings at therapy onset, at 8 weeks (closure of study) and at 12 weeks (one month after last treatment). Significant improvement was observed in all three scores in both groups after 8 and 12 weeks compared with baseline. Significant differences between the intervention and control groups in KSS were apparent only after 12 weeks. Patient satisfaction was found to be higher in the intervention group. (Delayed Effect of Acupuncture Treatment in OA of the Knee: A Blinded, Randomized, Controlled Trial. Evid Based Complement Alternat Med. 2009 Jan 5. [Epub ahead of print]).

ACUPUNCTURE IMPROVES CHRONIC KNEE PAIN
A meta-analysis has evaluated the effects of acupuncture on pain and function in patients with chronic knee pain. Combining data from five randomised controlled studies judged to have high validity (1334 patients), acupuncture was found to be superior to sham acupuncture for both pain and function. The differences were still significant at long-term follow-up. (Acupuncture treatment for chronic knee pain: a systematic review. Rheumatology. 2007 46(3):384-390)

ACUPUNCTURE IMPROVES SYMPTOMS OF KNEE OSTEOARTHRITIS
A blinded randomised trial of acupuncture has compared the effect of acupuncture with that of a non-penetrating sham in patients with osteoarthritic knee pain. Sixty-eight acupuncture naïve 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. Acupuncture points for pain and stiffness were selected according to TCM 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. Comparison between the two treatment groups found a significantly greater improvement with acupuncture than with sham. Within the acupuncture group there was a significant improvement in pain, which was not seen by those who had sham acupuncture. One month after treatment, the between-group pain difference had been lost, although the acupuncture group still experienced benefit compared with baseline. (A blinded randomised trial of acupuncture (manual and electroacupuncture) compared with a non-penetrating sham for the symptoms of osteoarthritis of the knee. Acupunct Med. 2008 Jun;26(2):69-78.)

ACUPUNCTURE EFFECTIVE FOR KNEE OSTEOARTHRITIS
A review, carried out by American researchers, of ten randomised, controlled trials (1456 participants) of acupuncture for osteoarthritis of the knee have concluded that it is an effective treatment for the pain and physical dysfunction caused by the condition. (Acupuncture and osteoarthritis of the knee: a review of randomized, controlled trials. Fam Community Health. 2008 Jul-Sep;31(3):247-54).

ACUPUNCTURE FOR OSTEOARTHRITIS OF THE KNEE
A meta-analysis by American researchers has evaluated the effects of acupuncture in the treatment of knee osteoarthritis (OA). Biomedical databases were searched for randomised controlled trials (RCTs), longer than six weeks in duration, which compared needle acupuncture with sham, usual care, or a waiting list control group. Eleven trials met the selection criteria and nine reported sufficient data for pooling. Compared with patients in waiting list control groups, patients who received acupuncture reported clinically relevant short-term improvements in pain and function. They also reported clinically relevant short- and long-term improvements in pain and function, when compared with patients in usual care control groups. Compared with sham control, acupuncture was found to provide clinically irrelevant short-term improvements in pain and function and clinically irrelevant long-term improvements in pain and function. The authors blame the variability of acupuncture and sham protocols, patient samples and settings for the heterogeneity displayed by the results of sham controlled trials. They also suggest that some of the clinically relevant benefits of acupuncture may be due to placebo or expectation effects. (Meta-analysis: acupuncture for osteoarthritis of the knee.  Ann Intern Med. 2007 Jun 19;146(12):868-77.)

OPTIMAL ACUPUNCTURE FOR KNEE OSTEOARTHRITIS
A review of recent research into acupuncture treatment for osteoarthritis (OA) of the knee explores whether any aspects of treatment are more likely to be associated with good outcomes. Based on their evaluation of four recent randomised controlled trials (RCTs) and a systematic review (which included 13 RCTs), the authors speculate that optimal results from acupuncture treatment for OA of the knee may involve: climatic factors (particularly high temperature); high patient expectation; use of a minimum of four needles; use of electroacupuncture (rather than manual acupuncture), in particular, use of strong electrical stimulation to needles placed in muscle; and a course of at least 10 treatments. (Evidence from RCTs on optimal acupuncture treatment for knee osteoarthritis-an exploratory review. Acupunct Med. 2007 Jun;25(1-2):29-35).

ACUPUNCTURE FOR HIP AND KNEE ARTHRITIS
A large German trial has found that acupuncture is of significant benefit in controlling the pain of osteoarthritis of the hip and knee. Of 3633 patients, 357 were randomised to receive acupuncture (15 treatments over three months), 355 were randomised to a non-acupuncture control group, and 2921 did not accept randomisation and opted for acupuncture treatment. All patients received usual medical care in addition to acupuncture. The randomised acupuncture group showed significant improvement over controls at both three and six months in osteoarthritis severity (WOMAC scale) and quality of life. Improvements were comparable to those in the non randomised acupuncture group. The authors report that  " P h y s i c i a n   c h a r a c t e r i s t i c s ,   s u c h   a s   t h e   l e v e l   o f   f o r m a l   a c u p u n c t u r e   t r a i n i n g   o r   c e r t i f i c a t i o n ,   d i d   n o t   i n f l u e n c e   t r e a t m e n t   o u t c o m e s " , although only 140 hours of certified training was a minimum requirement of participating physicians. Partly as a result of this trial, the German Ministry of Health is considering a recommendation from a federal committee of doctors and health insurers that acupuncture should be covered by medical insurance. (Acupuncture in patients with osteoarthritis of the knee or hip: A randomized, controlled trial with an additional nonrandomized arm. Arthritis & Rheumatism, 54; 11: 3485 – 3493).

ACUPUNCTURE & KNEE OSTEOARTHRITIS
Another German trial has shown a significant benefit for acupuncture treatment (in this case in the treatment of osteoarthritis of the knee), yet with no significant difference between true and sham acupuncture. In this large trial of 1007 patients (treated by 320 different practitioners in 315 primary care practices), who had had chronic pain from knee arthritis for over six months, a minimum 36% improvement was seen at 26 weeks (after ten acupuncture treatments) in 53.1% of true acupuncture patients, 51.0% of sham acupuncture patients and 29.1% for patients receiving conservative therapy (standard physician visits). This batch of German studies raises important questions for acupuncturists. While some attention has been focused on what might be the physiological effects of sham needling (usually very superficial insertion at non-points with no deqi), it is also necessary to examine the true acupuncture, and specifically how effectively practitioners succeeded in obtaining deqi, which was a necessary part of the true acupuncture protocol. (Acupuncture and Knee Osteoarthritis: A Three-Armed Randomized Trial, Annals of Internal Medicine, 4 July 2006).

ACUPUNCTURE EFFECTIVE FOR KNEE ARTHRITIS
In a study of the treatment of chronic arthritis of the knee, 150 patients were assigned to receive ‘true’ acupuncture, 76 to minimal acupuncture (superficial needling at non-acupuncture points) and 76 to a waiting list control. Both acupuncture groups received 12 treatment sessions over 8 weeks at 28 different outpatient centres. Patients completed standard questionnaires at 8, 26 and 52 weeks after onset of treatment. The study found that patients in both acupuncture groups improved compared to a waiting list group, but that those receiving true acupuncture  suffered significantly less pain and joint dysfunction at 8 weeks than the sham acupuncture group. The difference was no longer significant, however, at 52 weeks. (The Lancet 2005; 366:136-143).

ACUPUNCTURE & KNEE ARTHRITIS
The longest and largest randomised, controlled phase III clinical trial of acupuncture ever conducted has found that acupuncture can significantly improve the symptoms of arthritis of the knee. The study of 570 patients was carried out at the University of Maryland School of Medicine. The patients were randomly assigned to receive 23 treatments of either true or sham (no actual insertion of needles) acupuncture or a 12-week knee osteoarthritis education course. At the end of the study, the true acupuncture group had the greatest reduction (40%) in  knee pain and the greatest improvement (nearly 40%) in knee function. The study was funded by the National Center for Complementary and Alternative Medicine (NCCAM) and the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), both components of the US National Institutes of Health. "For the first time, a clinical trial with sufficient rigour, size, and duration has shown that acupuncture reduces the pain and functional impairment of osteoarthritis of the knee," said Stephen E. Straus, NCCAM Director. "These results also indicate that acupuncture can serve as an effective addition to a standard regimen of care and improve quality of life for knee osteoarthritis sufferers. (Ann Intern Med,  Dec 2004;  141:  901-910.)

ACUPUNCTURE & KNEE ARTHRITIS
In a separate Spanish study of the potential benefits of acupuncture in the treatment of knee osteoarthritis, 97 patients were randomly assigned to receive either acupuncture plus diclofenac, or placebo acupuncture plus diclofenac. The true acupuncture consisted of needling (followed by electroacupuncture at the local points) at Yanglingquan GB-34, Yinlingquan SP-9, Xiyan (MN-LE-16), Zusanli ST-36, Taixi KID-3, Sanyinjiao SP-6, Hegu L.I.-4 and Fenglong ST-40 (all with deqi). The placebo acupuncture was administered using retractable needles (with adhesive cylinders) at the same points, and sham electroacupuncture was also given. Both groups received twelve weekly treatments. At the end of the study, the true acupuncture group had a greater reduction in pain and stiffness, improved physical functioning, and an improved quality of life. (BMJ  2004;329:1216).ACUPUNCTURE FOR NECK PAIN
This very large German study compared the effects of fifteen acupuncture treatments over three months with no acupuncture in the treatment of chronic neck pain (longer than six months).  1753 patients were randomly allocated to receive acupuncture and 1698 to the non-acupuncture control group, and a further 10,395 patients rejected randomisation and elected to receive acupuncture. At the end of the three-month treatment period, chronic pain and disability scores and quality of life scores improved significantly in both acupuncture groups compared to controls, with no significant differences between the randomised and non-randomised acupuncture groups. (11th Annual Symposium on Complementary Health Care 2004).

ACUPUNCTURE FOR OSTEOARTHRITIS OF THE KNEE
30 patients with osteoarthritis of the knee were randomised to one of three groups: 1. acupuncture alone at Hegu L.I.-4, Xuehai SP-10, Xiyan (MN-LE-16), Yinlingquan SP-9, Yanglingquan GB-34, Zusanli ST-36, Taichong LIV-3, Weizhong BL-40 and Chengshan BL-57 (twice weekly treatment, obtaining of deqi, 10 treatments in total, using electro-acupuncture at most points); 2. identical acupuncture plus continuation of their symptomatic Western medication; 3. symptomatic medication alone for five weeks, followed by a course of acupuncture as above. Outcome measures (visual analogue pain scale/VAS and Western Ontario McMaster questionnaire/WOMAC) were administered by a blinded observer. Highly significant improvements in both measures were observed in the first two groups, and there was no change in the third group until they received acupuncture, when significant changes were observed. The benefits were maintained one month after the end of the course of acupuncture. (Acupuncture in Medicine 2004;22(1):14-22). In another study, 563 patients with arthritis of the knee (54% of 5-10 year duration; 23% more than 10 years) were treated with acupuncture for a maximum of 15 sessions, with treatment cessation if no improvement was noted after three treatments (these patients were included in the study results). Of the 85% of patients who completed treatment (standard points and additional points according to TCM pattern, with deqi, average 8.9 sessions per patient), 75% experienced a greater than 45% relief in pain scores. There was a significant difference in quantity of analgesics taken at completion of treatment (most of the 45% pain-relief responders ceased medication entirely). Cost analysis showed a reduction from a mean of .91 euros a day before treatment, to .18 euros a day after treatment, representing a daily saving of 349.50 euros a day for the 478 patients who stayed in the study. (Acupuncture in Medicine 2004;22(1):23-28).

ACUPUNCTURE & KNEE OSTEOARTHRITIS
60 patients on a waiting list for total knee replacement were randomly divided into two groups. 30 received “medical acupuncture” using one inch needles inserted “deeply” at Yinlingquan SP-9, Xuehai SP-10, Liangqiu ST 34, Zusanli ST-36 and Hegu L.I.-4. The needles were manipulated manually 4 times during a 15 minute retention and patients received a total of 6 weekly treatments. The 30 patients in the control group received no treatment. At a 2-month follow up, scores for the time to walk 50 metres and the time to climb 20 steps fell significantly in the acupuncture group compared to the control, as did pain scores, whilst HSS knee scores - which gives marks for pain, functional ability, range of motion, muscle strength, flexion deformity and knee stability - improved significantly in the acupuncture group. Scores for all measures deteriorated in the non-treatment group. 3 patients in the acupuncture group requested suspension from the waiting list due to the improvement in their symptoms. (Acupunct Med 2002; 20(1): 19-21).

ACUPUNCTURE & OSTEOARTHRITIS OF THE KNEE
44 patents with advanced osteoarthritis of the knee who were awaiting total knee joint replacements were given acupuncture either on the most affected knee only, or on both knees. Points needled were Yinlingquan SP-9, Xuehai SP-10, Liangqiu ST-34, Zusanli ST-36 and Hegu L.I.-4. Results showed a significant reduction in symptoms in both groups with no signficant dfference between the two groups, suggesting hat unilateral acupuncture is as effective as bilateral acupuncture for this condition. (Acupuncture in Medicine 2001;19(1):15-18).