Acupuncture Plus Routine Care Relieves Osteoarthritis Pain

BERLIN, Oct. 30 -- Acupuncture needles appear to help knit osteoarthritis pain

in the bud, particularly when combined with routine care.

Action Points

• Explain to interested patients that this randomized controlled study suggests that acupuncture, when combined with standard care, can provide significant relief from pain associated with osteoarthritis of the knee or hip.
  
• Understand that both patients and physicians knew the therapy they were receiving, and the results may be biased.

In a large randomized trial, patients with knee or hip joint pain who had acupuncture had significant improvement in severity and quality-of-life index scores, compared with those who had routine care alone, reported Claudia M. Witt, M.D., of the Charité University Medical Center here, and colleagues, in the November issue of Arthritis & Rheumatism.

"Given that the biologic mechanism of acupuncture is still unclear, the study by Witt et al furthers our understanding of acupuncture and adds to the accumulated evidence supporting its efficacy," wrote Tao Liu, M.D., and Chen Liu, M.D., of the 2nd Teaching Hospital of Jilin University in Changchun, Jilin, China, in an accompanying editorial. "Such evidence warrants extensive use of acupuncture in various chronic pain conditions."

Although other investigators have looked at the effects of acupuncture on joint pain compared with sham acupuncture procedures in randomized trials, there are few data on the efficacy of the therapy in real-life situations -- that is, when it's combined with routine care, Dr. Witt and colleagues noted.

They conducted a trial in which patients with chronic pain from osteoarthritis of the knee or hip were randomly assigned to undergo up to 15 sessions of acupuncture over a three-month period, or to a control group receiving no acupuncture. Patients who did not consent to randomization but underwent acupuncture treatment were also studied for comparison purposes.

All patients in the study were allowed to receive usual medical care in addition to the study treatment.

The investigators assessed clinical severity with the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index with pain and function scales, and with a health-related quality-of-life questionnaire (Short Form 36), at both three and six months from baseline.

A total of 3,633 patients (61% female) with a mean age of 61.8 + 10.8 years were enrolled. In all, 357 patients were randomized to the acupuncture group, and 355 to the control group. An additional 2,921 patients were included in the non-randomized acupuncture group.

The authors found that among patients randomized to acupuncture, the mean (with standard error of the mean) WOMAC score improved (that is, decreased) by 17.6 + 1.0 points at three months compared with 0.9 + 1.0 in the control group. The three-month WOMAC scores were 30.5 + 1.0 for patients randomized to acupuncture, versus 47.3 + 1.0 for controls. The absolute difference in improvement was 16.7 + 1.4; P<0.001.

The improvements at three months in the patients who underwent acupuncture but were not part of the randomized group were similar to those who were randomized to the treatment, the authors noted. In both randomized and non-randomized acupuncture-treated groups, the proportion of responders (35.7% and 34.5%, respectively) was also similar.

Quality-of-life improvements were also significantly higher among the randomized acupuncture group members compared with controls (P<0.001).

Three months after completion of acupuncture treatment (six months from study outset), the differences from baseline in the WOMAC and Short Form-36 scores of patients in the randomized and non-randomized acupuncture groups were only slightly lower than they had been at three months, with 31.7% of patients randomized to acupuncture having a response, compared with 32.8% of non-randomized patients (P=0.674).

The authors acknowledged that while the study was randomized and controlled, it was unblinded to both patients and providers, and could be subject to biases.

In their editorial Dr. Tao Liu and Dr. Chen Liu pointed out that part of the treatment effect of acupuncture comes from patient-practitioner interaction.

"In real-world primary care, few patients with osteoarthritis seek acupuncture as the sole treatment, and due to the inconclusive information regarding its efficacy, acupuncture is very likely an undervalued treatment option as an element of a multidisciplinary integrative approach to treating this disorder," they wrote.

"As a pragmatic clinical trial comparing acupuncture in addition to routine care with routine care alone in patients with pain due to OA of the knee or hip, this study reflects as closely as possible the conditions of daily medical practice, and, as the authors point out, maximizes external validity and clinical relevance," the editorialists added.

Primary source: Arthritis & Rheumatism
Source reference:
Witt CM et al. "Acupuncture in Patients With Osteoarthritis of the Knee or Hip: A Randomized, Controlled Trial With an Additional Nonrandomized Arm." Arthritis & Rheumatism. 54;11: 3485-93.

Additional source: Arthritis & Rheumatism
Source reference:
Liu T and Liu C. "Acupuncture for Treating Osteoarthritis of the Knee and the Hip." Arthritis & Rheumatism. 54;11: 3375-77.

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