Acupuncture and Physical Therapy for Knee Osteoarthritis
Acupuncture and Physical Therapy for Knee Osteoarthritis
Background: Knee osteoarthritis is a chronic disease associated with significant morbidity and economic cost. The efficacy of acupuncture in addition to traditional physical therapy has received little study.
Objective: The objective of this study was to compare the efficacy and safety of integrating a standardized true acupuncture protocol versus nonpenetrating acupuncture into exercise-based physical therapy (EPT).
Methods: This was a randomized, double-blind, controlled trial at 3 physical therapy centers in Philadelphia, PA. We studied 214 patients (66% African Americans) with at least 6 months of chronic knee pain and x-ray–confirmed Kellgren scores of 2 or 3. Patients received 12 sessions of acupuncture directly following EPT over 6 to 12 weeks. Acupuncture was performed at the same 9 points dictated by the traditional Chinese "Bi" syndrome approach to knee pain, using either standard needles or Streitberger non–skin-puncturing needles. The primary outcome was the proportion of patients with at least a 36% improvement in Western Ontario and McMaster Universities Osteoarthritis Index score at 12 weeks.
Results: Both treatment groups showed improvement from combined therapy with no difference between true (31.6%) and nonpenetrating acupuncture (30.3%) in Western Ontario and McMaster Universities Osteoarthritis Index response rate (P = 0.5) or report of minor adverse events. A multivariable logistic regression prediction model identified an association between a positive expectation of relief from acupuncture and reported improvement. No differences were noted by race, sex, or age.
Conclusions: Puncturing acupuncture needles did not perform any better than nonpuncturing needles integrated with EPT. Whether EPT, acupuncture, or other factors accounted for any improvement noted in both groups could not be determined in this study. Expectation for relief was a predictor of reported benefit.
Acupuncture is a traditional Chinese medicine treatment modality that has gained popularity in the United States, especially for painful conditions. Its use among US adults increased from 2 million individuals in 2002 to 3.1 million per year in 2007. Recent high-quality clinical trials of acupuncture suggest that acupuncture may offer clinically relevant benefits when compared with standard medical care or wait-listed controls for acupuncture; however, studies that compare standard to nonstandard needling, either without puncturing the skin or in the wrong acupuncture points, have demonstrated smaller or negligible effects.4,6–11 A possible interpretation is that much of the acupuncture effects as compared with standard medical care are mediated through the entire process of acupuncture care (including patient-provider interaction and patient engagement) rather than the specific needling location or techniques. Factors that influence this type of nonspecific effect include the patient's expectation of benefit from the therapy. Following a review of the literature on acupuncture with physical therapy, we examined these issues using a 2-arm multicenter prospective randomized clinical trial designed to determine the specific efficacy and safety of acupuncture integrated with standard exercise-based physical therapy (EPT) for knee osteoarthritis (OA) in a population that included a large African American community.
Abstract and Introduction
Abstract
Background: Knee osteoarthritis is a chronic disease associated with significant morbidity and economic cost. The efficacy of acupuncture in addition to traditional physical therapy has received little study.
Objective: The objective of this study was to compare the efficacy and safety of integrating a standardized true acupuncture protocol versus nonpenetrating acupuncture into exercise-based physical therapy (EPT).
Methods: This was a randomized, double-blind, controlled trial at 3 physical therapy centers in Philadelphia, PA. We studied 214 patients (66% African Americans) with at least 6 months of chronic knee pain and x-ray–confirmed Kellgren scores of 2 or 3. Patients received 12 sessions of acupuncture directly following EPT over 6 to 12 weeks. Acupuncture was performed at the same 9 points dictated by the traditional Chinese "Bi" syndrome approach to knee pain, using either standard needles or Streitberger non–skin-puncturing needles. The primary outcome was the proportion of patients with at least a 36% improvement in Western Ontario and McMaster Universities Osteoarthritis Index score at 12 weeks.
Results: Both treatment groups showed improvement from combined therapy with no difference between true (31.6%) and nonpenetrating acupuncture (30.3%) in Western Ontario and McMaster Universities Osteoarthritis Index response rate (P = 0.5) or report of minor adverse events. A multivariable logistic regression prediction model identified an association between a positive expectation of relief from acupuncture and reported improvement. No differences were noted by race, sex, or age.
Conclusions: Puncturing acupuncture needles did not perform any better than nonpuncturing needles integrated with EPT. Whether EPT, acupuncture, or other factors accounted for any improvement noted in both groups could not be determined in this study. Expectation for relief was a predictor of reported benefit.
Introduction
Acupuncture is a traditional Chinese medicine treatment modality that has gained popularity in the United States, especially for painful conditions. Its use among US adults increased from 2 million individuals in 2002 to 3.1 million per year in 2007. Recent high-quality clinical trials of acupuncture suggest that acupuncture may offer clinically relevant benefits when compared with standard medical care or wait-listed controls for acupuncture; however, studies that compare standard to nonstandard needling, either without puncturing the skin or in the wrong acupuncture points, have demonstrated smaller or negligible effects.4,6–11 A possible interpretation is that much of the acupuncture effects as compared with standard medical care are mediated through the entire process of acupuncture care (including patient-provider interaction and patient engagement) rather than the specific needling location or techniques. Factors that influence this type of nonspecific effect include the patient's expectation of benefit from the therapy. Following a review of the literature on acupuncture with physical therapy, we examined these issues using a 2-arm multicenter prospective randomized clinical trial designed to determine the specific efficacy and safety of acupuncture integrated with standard exercise-based physical therapy (EPT) for knee osteoarthritis (OA) in a population that included a large African American community.
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