Adding Acupuncture to Advice, Exercise Does Not Benefit Knee Osteoarthritis

August 20, 2007 — The addition of acupuncture to a course of advice and exercise delivered by physiotherapists provides no additional improvement in pain scores in patients with osteoarthritis of the knee, according to the results of a prospective, randomized, controlled trial published in the August 15 Online First issue of BMJ.
"Systematic reviews conclude that acupuncture is more effective than placebo for osteoarthritis of the knee," write Nadine E. Foster, from Keele University in Stafford, United Kingdom, and colleagues. "However, questions about the benefit of adding acupuncture to mainstream, recommended treatments for this population remain unanswered. We have shown that exercise based physiotherapy is more effective than usual primary care for older adults with knee pain, but no high quality trial has investigated the additional benefit of integrating acupuncture with a recommended treatment such as exercise based physiotherapy for this population."
At 37 physiotherapy centers accepting primary care patients referred from general practitioners in the Midlands, United Kingdom, 352 adults aged 50 years or older with a clinical diagnosis of knee osteoarthritis were randomized to receive advice and exercise (n = 116), advice and exercise plus true acupuncture (n = 117), and advice and exercise plus nonpenetrating acupuncture (n = 119). Acupuncture was administered by experienced physiotherapists.
The main endpoint was change at 6 months in osteoarthritis index pain subscale scores on the Western Ontario and McMaster Universities scales, and secondary endpoints included 2-week, 6-week, 6-month, and 12-month ratings for function, pain intensity, and unpleasantness of pain.
Mean baseline pain score was 9.2 ± 3.8. At 6 months, follow-up rate was 94%. Mean decreases in pain score were 2.28 ± 3.8 for advice and exercise, 2.32 ± 3.6 for advice and exercise plus true acupuncture, and 2.53 ± 4.2 for advice and exercise plus nonpenetrating acupuncture.
Mean differences in change scores between advice and exercise alone and each acupuncture group were 0.08 (95% confidence interval [CI], -1.0 to 0.9) for advice and exercise plus true acupuncture and 0.25 (95% CI, -0.8 to 1.3) for advice and exercise plus nonpenetrating acupuncture. At subsequent follow-up points, similar nonsignificant differences were observed.
For true acupuncture vs advice and exercise alone, there were small, statistically significant improvements in pain intensity and unpleasantness at 2 and 6 weeks. Similar improvements in pain intensity and unpleasantness were seen for nonpenetrating acupuncture at all follow-up points.
"The addition of acupuncture to a course of advice and exercise for osteoarthritis of the knee delivered by physiotherapists provided no additional improvement in pain scores," the authors write. "Small benefits in pain intensity and unpleasantness were observed in both acupuncture groups, making it unlikely that this was due to acupuncture needling effects."
Study limitations include use of fewer treatment sessions than in previous studies of acupuncture practice.
"True acupuncture did not show any greater therapeutic benefit than a credible control procedure in patients with a clinical diagnosis of knee osteoarthritis," the authors conclude. "Further research is needed to investigate the possible mechanisms of acupuncture, particularly the role of expectancy effects."
The Arthritis Research Campaign, United Kingdom, and the North Staffordshire Primary Care Research Consortium for the National Health Service supported this study. The authors have disclosed no relevant financial relationships.
BMJ. Published online August 15, 2007.