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Three Part Question

IN [adults with OA knee] WILL [acupuncture] IMPROVE [pain and increase function]

Clinical Scenario

A 65 year old patient presents with osteoarthritis of the knee in the outpatient department. After trying several more traditional treatments with little improvement in symptoms, you questioned whether it would be helpful to try acupuncture to improve his pain and function.

Search Strategy

MEDLINE 1966-07/07, CINAHL 1982 –07/07, AMED 1985-07/07, SPORTDiscus 1830-07/07, EMBASE 1996-07/07, via the OVID interface. In addition the Cochrane database and PEDro database were also searched
[(exp Osteoarthritis OR exp osteoarthritis, knee OR Arthropathy.mp OR Monoarthropathy.mp OR exp Arthritis OR Gonoarthritis.mp) AND (exp Knee Joint) AND (exp Acupuncture OR exp Acupuncture Therapy OR exp Electroacupuncture OR exp Acupressure)]
LIMIT to human AND English language.

Search Outcome

11 papers were retrieved of which 3 were considered relevant to the 3 part question.
1 was a systematic review of 13 RCT's . There was one other RCT (2006) which was not included in the systematic review as it was not considered relevant to the 3 part question.
Another paper retrieved was a explanatory review including all details within the systematic review.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
White et al 2006 UK	8 RCT N = 2362 Mean age = 56 Acupuncture: > 6 treatments , > 1 per week, > 20 mins > 4 needle points used. Short term = end of treatment to 6 months Long term = 6 months to 1 year	1a systematic review	Ac v sham Ac		Asian databases not searched. (Explanation given by authors) Search terms not described Not possible to describe exact points. Small number of studies available (n=8)
			WOMAC (short term pain)	1.54
			WOMAC (long term pain)	0.54
			WOMAC (short term function)	4.32
			WOMAC (long term function)	2.01
			Ac v usual care
			WOMAC (short term pain)	3.42
			WOMAC (long term function)	11.65
Manheimer et al 2006 USA	Randomised trial = 570 patients All patients had been diagnosed with OA knee. Patients had 23 sessions of acupuncture over 26 weeks. AP points used Local Points: GB34, SP9, ST36, ST35, Xiyan Distal Points: BL60, GB39, SP6, KI3	1b RCT	Ac v sham Ac	At 6/12 (n=283)	At 26 weeks 43% of participants in the education group and 25% in each of the true and sham acupuncture groups were not available for analysis.
			WOMAC pain scores	-0.87 (p=0.0003)
			WOMAC function scores	-2.5 (p=0.01)
			Patient global assessment	0.26 (p=0.02)
			4.6 minute walk test	NSS
			36-item Short-Form Health Survey	NSS

Comment(s)

The exploratory review (Vas and White 2007) cited all the RCT's in the systematic review, but was written to discuss the possible reasons for the differences in their outcomes. They advocated single rather than multi centre studies.

Clinical Bottom Line

Meta analysis provides strong evidence that acupuncture is more effective than placebo acupuncture in decreasing pain and increasing function in patients with OA knee.

References

1. White A, Foster N, Cummings M, Barlos P The effectiveness of acupuncture for osteoarthritis of the Knee- a systematic review Acupuncture in Medicine 2006;24(Suppl);S40-48
2. Manheimer E, Lim B, Lao L, Berman B Acupuncture for knee osteoarthritis Acupuncture in Medicine 2006;24 (suppl):S7-14
3. Jorge Vas, Adrian White Evidence from RCT's on optimal acupuncture treatment for knee OA Acupuncture in Medicine 25(1-2):29-35