Acupuncture for peripheral joint osteoarthritis

Abstract

Background: Peripheral joint osteoarthritis is a major cause of pain and functional limitation. Few treatments are safe and effective.

Objectives: To assess the effects of acupuncture for treating peripheral joint osteoarthritis.

Search strategy: We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library 2008, Issue 1), MEDLINE, and EMBASE (both through December 2007), and scanned reference lists of articles.

Selection criteria: Randomized controlled trials (RCTs) comparing needle acupuncture with a sham, another active treatment, or a waiting list control group in people with osteoarthritis of the knee, hip, or hand.

Data collection and analysis: Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information. We calculated standardized mean differences using the differences in improvements between groups.

Main results: Sixteen trials involving 3498 people were included. Twelve of the RCTs included only people with OA of the knee, 3 only OA of the hip, and 1 a mix of people with OA of the hip and/or knee. In comparison with a sham control, acupuncture showed statistically significant, short-term improvements in osteoarthritis pain (standardized mean difference -0.28, 95% confidence interval -0.45 to -0.11; 0.9 point greater improvement than sham on 20 point scale; absolute percent change 4.59%; relative percent change 10.32%; 9 trials; 1835 participants) and function (-0.28, -0.46 to -0.09; 2.7 point greater improvement on 68 point scale; absolute percent change 3.97%; relative percent change 8.63%); however, these pooled short-term benefits did not meet our predefined thresholds for clinical relevance (i.e. 1.3 points for pain; 3.57 points for function) and there was substantial statistical heterogeneity. Additionally, restriction to sham-controlled trials using shams judged most likely to adequately blind participants to treatment assignment (which were also the same shams judged most likely to have physiological activity), reduced heterogeneity and resulted in pooled short-term benefits of acupuncture that were smaller and non-significant. In comparison with sham acupuncture at the six-month follow-up, acupuncture showed borderline statistically significant, clinically irrelevant improvements in osteoarthritis pain (-0.10, -0.21 to 0.01; 0.4 point greater improvement than sham on 20 point scale; absolute percent change 1.81%; relative percent change 4.06%; 4 trials;1399 participants) and function (-0.11, -0.22 to 0.00; 1.2 point greater improvement than sham on 68 point scale; absolute percent change 1.79%; relative percent change 3.89%). In a secondary analysis versus a waiting list control, acupuncture was associated with statistically significant, clinically relevant short-term improvements in osteoarthritis pain (-0.96, -1.19 to -0.72; 14.5 point greater improvement than sham on 100 point scale; absolute percent change 14.5%; relative percent change 29.14%; 4 trials; 884 participants) and function (-0.89, -1.18 to -0.60; 13.0 point greater improvement than sham on 100 point scale; absolute percent change 13.0%; relative percent change 25.21%). In the head-on comparisons of acupuncture with the 'supervised osteoarthritis education' and the 'physician consultation' control groups, acupuncture was associated with clinically relevant short- and long-term improvements in pain and function. In the head on comparisons of acupuncture with 'home exercises/advice leaflet' and 'supervised exercise', acupuncture was associated with similar treatment effects as the controls. Acupuncture as an adjuvant to an exercise based physiotherapy program did not result in any greater improvements than the exercise program alone. Information on safety was reported in only 8 trials and even in these trials there was limited reporting and heterogeneous methods.

Authors' conclusions: Sham-controlled trials show statistically significant benefits; however, these benefits are small, do not meet our pre-defined thresholds for clinical relevance, and are probably due at least partially to placebo effects from incomplete blinding. Waiting list-controlled trials of acupuncture for peripheral joint osteoarthritis suggest statistically significant and clinically relevant benefits, much of which may be due to expectation or placebo effects.

Conflict of interest statement

Declarations of Interest: This review includes trials in which some of the reviewers were involved: Berman 1999 and Berman 2004: Brian Berman and Lixing Lao; Witt 2005: Klaus Linde. These trials were reviewed by at least two other members of the review team. Eric Manheimer was one of the two reviewers for all included trials, including the two Berman trials. Mr. Manheimer works at the same research center at which the two Berman trials were conducted, but he was not involved in the conduct of either of these two trials. Lixing Lao uses acupuncture in his clinical work. Klaus Linde has received travel reimbursement and in two cases fees for speaking on research at meetings of acupuncture societies (British, German and Spanish Medical Acupuncture Society, Society of Acupuncture Research). Brian Berman, Lixing Lao, and Eric Manheimer received honoraria for preparing and delivering presentations on acupuncture at the 2007 meeting of the Society for Acupuncture Research.

Figures

Figure 1. Effects of acupuncture versus a sham control group on the pain outcome at the short-term measurement point*Comparison of electroacupuncture with sham acupuncture using a diclofenac co-intervention. **Comparison of electroacupuncture with sham acupuncture using a placebo diclofenac co-intervention

Figure 2. Effects of acupuncture versus a sham acupuncture control group on the pain outcome at the long-term measurement point

Figure 3. Effects of acupuncture compared with a waiting list or other active treatment control group at the short-term measurement point

Figure 4. Funnel plot of acupuncture vs. sham short term change for peripheral OA pain

Figure 5. Funnel plot of acupuncture vs. sham short term change for peripheral OA function

Comparison 1. Acupuncture vs. sham acupuncture for knee OA change from baseline analysis

Comparison 2. Acupuncture vs. sham acupuncture for knee OA post-treatment scores analysis

Comparison 3. Acupuncture vs. sham acupuncture for hip OA change from baseline analysis

Comparison 4. Acupuncture vs. sham acupuncture for hip OA post-treatment scores post-analysis

Comparison 5. Acupuncture vs. sham acupuncture for peripheral joint OA change from baseline analysis

Comparison 5. Acupuncture vs. sham acupuncture for peripheral joint OA change from baseline analysis

Comparison 6. Acupuncture vs. sham acupuncture for peripheral joint OA post-treatment scores analysis

Comparison 7. Acupuncture vs. waiting list or other active treatment controls for knee OA change from baseline analysis

Comparison 7. Acupuncture vs. waiting list or other active treatment controls for knee OA change from baseline analysis

Comparison 7. Acupuncture vs. waiting list or other active treatment controls for knee OA change from baseline analysis

Comparison 7. Acupuncture vs. waiting list or other active treatment controls for knee OA change from baseline analysis

Comparison 8. Acupuncture vs. waiting list or other active treatment controls for knee OA post-treatment scores analysis

Comparison 8. Acupuncture vs. waiting list or other active treatment controls for knee OA post-treatment scores analysis

Comparison 8. Acupuncture vs. waiting list or other active treatment controls for knee OA post-treatment scores analysis

Comparison 9. Acupuncture vs. waiting list or other active treatment controls for hip OA post-treatment scores analysis

Comparison 9. Acupuncture vs. waiting list or other active treatment controls for hip OA post-treatment scores analysis

Comparison 10. Acupuncture vs. waiting list or other active treatment controls for peripheral joint OA change from baseline analysis

Comparison 10. Acupuncture vs. waiting list or other active treatment controls for peripheral joint OA change from baseline analysis

Comparison 10. Acupuncture vs. waiting list or other active treatment controls for peripheral joint OA change from baseline analysis

Comparison 11. Acupuncture vs. waiting list or other active treatment controls for peripheral joint OA post-treatment scores analysis

Comparison 11. Acupuncture vs. waiting list or other active treatment controls for peripheral joint OA post-treatment scores analysis

Comparison 11. Acupuncture vs. waiting list or other active treatment controls for peripheral joint OA post-treatment scores analysis

Analysis 1.1. Comparison 1 Acupuncture vs. sham acupuncture for knee OA change from baseline analysis, Outcome 1 Pain (Time point equal to or less than three months and closest to eight weeks post-randomization)

Analysis 1.2. Comparison 1 Acupuncture vs. sham acupuncture for knee OA change from baseline analysis, Outcome 2 Function (Time point equal to or less than three months and closest to eight weeks post-randomization)

Analysis 1.3. Comparison 1 Acupuncture vs. sham acupuncture for knee OA change from baseline analysis, Outcome 3 Total score (Time point equal to or less than three months and closest to eight weeks post-randomization)

Analysis 1.4. Comparison 1 Acupuncture vs. sham acupuncture for knee OA change from baseline analysis, Outcome 4 Pain (26 weeks after baseline)

Analysis 1.5. Comparison 1 Acupuncture vs. sham acupuncture for knee OA change from baseline analysis, Outcome 5 Function (26 weeks after baseline)

Analysis 1.6. Comparison 1 Acupuncture vs. sham acupuncture for knee OA change from baseline analysis, Outcome 6 Total score (26 weeks after baseline)

Analysis 2.1. Comparison 2 Acupuncture vs. sham acupuncture for knee OA post-treatment scores analysis, Outcome 1 Pain (Time point equal to or less than three months and closest to eight weeks post-randomization)

Analysis 2.2. Comparison 2 Acupuncture vs. sham acupuncture for knee OA post-treatment scores analysis, Outcome 2 Function (Time point equal to or less than three months and closest to eight weeks post-randomization)

Analysis 2.3. Comparison 2 Acupuncture vs. sham acupuncture for knee OA post-treatment scores analysis, Outcome 3 Total score (Time point equal to or less than three months and closest to eight weeks post-randomization)

Analysis 2.4. Comparison 2 Acupuncture vs. sham acupuncture for knee OA post-treatment scores analysis, Outcome 4 Pain (26 weeks after baseline)

Analysis 2.5. Comparison 2 Acupuncture vs. sham acupuncture for knee OA post-treatment scores analysis, Outcome 5 Function (26 weeks after baseline)

Analysis 2.6. Comparison 2 Acupuncture vs. sham acupuncture for knee OA post-treatment scores analysis, Outcome 6 Total score (26 weeks after baseline)

Analysis 3.1. Comparison 3 Acupuncture vs. sham acupuncture for hip OA change from baseline analysis, Outcome 1 Pain (Time point equal to or less than three months and closest to eight weeks post-randomization)

Analysis 3.2. Comparison 3 Acupuncture vs. sham acupuncture for hip OA change from baseline analysis, Outcome 2 Function (Time point equal to or less than three months and closest to eight weeks post-randomization)

Analysis 4.1. Comparison 4 Acupuncture vs. sham acupuncture for hip OA post-treatment scores post-analysis, Outcome 1 Pain (Time point equal to or less than three months and closest to eight weeks post-randomization)

Analysis 4.2. Comparison 4 Acupuncture vs. sham acupuncture for hip OA post-treatment scores post-analysis, Outcome 2 Function (Time point equal to or less than three months and closest to eight weeks post-randomization)

Analysis 5.1. Comparison 5 Acupuncture vs. sham acupuncture for peripheral joint OA change from baseline analysis, Outcome 1 Pain (Time point equal to or less than three months and closest to eight weeks post-randomization)

Analysis 5.1. Comparison 5 Acupuncture vs. sham acupuncture for peripheral joint OA change from baseline analysis, Outcome 1 Pain (Time point equal to or less than three months and closest to eight weeks post-randomization)

Analysis 5.2. Comparison 5 Acupuncture vs. sham acupuncture for peripheral joint OA change from baseline analysis, Outcome 2 Function (Time point equal to or less than three months and closest to eight weeks post-randomization)

Analysis 5.3. Comparison 5 Acupuncture vs. sham acupuncture for peripheral joint OA change from baseline analysis, Outcome 3 Total score (Time point equal to or less than three months and closest to eight weeks post-randomization)

Analysis 5.4. Comparison 5 Acupuncture vs. sham acupuncture for peripheral joint OA change from baseline analysis, Outcome 4 Pain (26 weeks after baseline)

Analysis 5.5. Comparison 5 Acupuncture vs. sham acupuncture for peripheral joint OA change from baseline analysis, Outcome 5 Function (26 weeks after baseline)

Analysis 5.6. Comparison 5 Acupuncture vs. sham acupuncture for peripheral joint OA change from baseline analysis, Outcome 6 Total score (26 weeks after baseline)

Analysis 6.1. Comparison 6 Acupuncture vs. sham acupuncture for peripheral joint OA post-treatment scores analysis, Outcome 1 Pain (Time point equal to or less than three months and closest to eight weeks post-randomization)

Analysis 6.2. Comparison 6 Acupuncture vs. sham acupuncture for peripheral joint OA post-treatment scores analysis, Outcome 2 Function (Time point equal to or less than three months and closest to eight weeks post-randomization)

Analysis 6.3. Comparison 6 Acupuncture vs. sham acupuncture for peripheral joint OA post-treatment scores analysis, Outcome 3 Total score (Time point equal to or less than three months and closest to eight weeks post-randomization)

Analysis 6.4. Comparison 6 Acupuncture vs. sham acupuncture for peripheral joint OA post-treatment scores analysis, Outcome 4 Pain (26 weeks after baseline)

Analysis 6.5. Comparison 6 Acupuncture vs. sham acupuncture for peripheral joint OA post-treatment scores analysis, Outcome 5 Function (26 weeks after baseline)

Analysis 6.6. Comparison 6 Acupuncture vs. sham acupuncture for peripheral joint OA post-treatment scores analysis, Outcome 6 Total score (26 weeks after baseline)

Analysis 7.1. Comparison 7 Acupuncture vs. waiting list or other active treatment controls for knee OA change from baseline analysis, Outcome 1 Pain (Time point equal to or less than three months and closest to eight weeks post-randomization)

Analysis 7.1. Comparison 7 Acupuncture vs. waiting list or other active treatment controls for knee OA change from baseline analysis, Outcome 1 Pain (Time point equal to or less than three months and closest to eight weeks post-randomization)

Analysis 7.2. Comparison 7 Acupuncture vs. waiting list or other active treatment controls for knee OA change from baseline analysis, Outcome 2 Function (Time point equal to or less than three months and closest to eight weeks post-randomization)

Analysis 7.2. Comparison 7 Acupuncture vs. waiting list or other active treatment controls for knee OA change from baseline analysis, Outcome 2 Function (Time point equal to or less than three months and closest to eight weeks post-randomization)

Analysis 7.3. Comparison 7 Acupuncture vs. waiting list or other active treatment controls for knee OA change from baseline analysis, Outcome 3 Total score (Time point equal to or less than three months and closest to eight weeks post-randomization)

Analysis 7.4. Comparison 7 Acupuncture vs. waiting list or other active treatment controls for knee OA change from baseline analysis, Outcome 4 Pain (26 weeks after baseline)

Analysis 7.5. Comparison 7 Acupuncture vs. waiting list or other active treatment controls for knee OA change from baseline analysis, Outcome 5 Function (26 weeks after baseline)

Analysis 7.6. Comparison 7 Acupuncture vs. waiting list or other active treatment controls for knee OA change from baseline analysis, Outcome 6 Total score (26 weeks after baseline)

Analysis 8.1. Comparison 8 Acupuncture vs. waiting list or other active treatment controls for knee OA post-treatment scores analysis, Outcome 1 Pain (Time point equal to or less than three months and closest to eight weeks post-randomization)

Analysis 8.1. Comparison 8 Acupuncture vs. waiting list or other active treatment controls for knee OA post-treatment scores analysis, Outcome 1 Pain (Time point equal to or less than three months and closest to eight weeks post-randomization)

Analysis 8.2. Comparison 8 Acupuncture vs. waiting list or other active treatment controls for knee OA post-treatment scores analysis, Outcome 2 Function (Time point equal to or less than three months and closest to eight weeks post-randomization)

Analysis 8.2. Comparison 8 Acupuncture vs. waiting list or other active treatment controls for knee OA post-treatment scores analysis, Outcome 2 Function (Time point equal to or less than three months and closest to eight weeks post-randomization)

Analysis 8.3. Comparison 8 Acupuncture vs. waiting list or other active treatment controls for knee OA post-treatment scores analysis, Outcome 3 Total score (Time point equal to or less than three months and closest to eight weeks post-randomization)

Analysis 8.3. Comparison 8 Acupuncture vs. waiting list or other active treatment controls for knee OA post-treatment scores analysis, Outcome 3 Total score (Time point equal to or less than three months and closest to eight weeks post-randomization)

Analysis 8.4. Comparison 8 Acupuncture vs. waiting list or other active treatment controls for knee OA post-treatment scores analysis, Outcome 4 Pain (26 weeks after baseline)

Analysis 8.5. Comparison 8 Acupuncture vs. waiting list or other active treatment controls for knee OA post-treatment scores analysis, Outcome 5 Function (26 weeks after baseline)

Analysis 8.6. Comparison 8 Acupuncture vs. waiting list or other active treatment controls for knee OA post-treatment scores analysis, Outcome 6 Total score (26 weeks after baseline)

Analysis 9.1. Comparison 9 Acupuncture vs. waiting list or other active treatment controls for hip OA post-treatment scores analysis, Outcome 1 Pain (Time point equal to or less than three months and closest to eight weeks post-randomization)

Analysis 9.2. Comparison 9 Acupuncture vs. waiting list or other active treatment controls for hip OA post-treatment scores analysis, Outcome 2 Function (Time point equal to or less than three months and closest to eight weeks post-randomization)

Analysis 9.3. Comparison 9 Acupuncture vs. waiting list or other active treatment controls for hip OA post-treatment scores analysis, Outcome 3 Total score (Time point equal to or less than three months and closest to eight weeks post-randomization)

Analysis 10.1. Comparison 10 Acupuncture vs. waiting list or other active treatment controls for peripheral joint OA change from baseline analysis, Outcome 1 Pain (Time point equal to or less than three months and closest to eight weeks post-randomization)

Analysis 10.1. Comparison 10 Acupuncture vs. waiting list or other active treatment controls for peripheral joint OA change from baseline analysis, Outcome 1 Pain (Time point equal to or less than three months and closest to eight weeks post-randomization)

Analysis 10.2. Comparison 10 Acupuncture vs. waiting list or other active treatment controls for peripheral joint OA change from baseline analysis, Outcome 2 Function (Time point equal to or less than three months and closest to eight weeks post-randomization)

Analysis 10.2. Comparison 10 Acupuncture vs. waiting list or other active treatment controls for peripheral joint OA change from baseline analysis, Outcome 2 Function (Time point equal to or less than three months and closest to eight weeks post-randomization)

Analysis 10.3. Comparison 10 Acupuncture vs. waiting list or other active treatment controls for peripheral joint OA change from baseline analysis, Outcome 3 Total score (Time point equal to or less than three months and closest to eight weeks post-randomization)

Analysis 10.4. Comparison 10 Acupuncture vs. waiting list or other active treatment controls for peripheral joint OA change from baseline analysis, Outcome 4 Pain (26 weeks after baseline)

Analysis 10.5. Comparison 10 Acupuncture vs. waiting list or other active treatment controls for peripheral joint OA change from baseline analysis, Outcome 5 Function (26 weeks after baseline)

Analysis 10.6. Comparison 10 Acupuncture vs. waiting list or other active treatment controls for peripheral joint OA change from baseline analysis, Outcome 6 Total score (26 weeks after baseline)

Analysis 11.1. Comparison 11 Acupuncture vs. waiting list or other active treatment controls for peripheral joint OA post-treatment scores analysis, Outcome 1 Pain (Time point equal to or less than three months and closest to eight weeks post-randomization)

Analysis 11.1. Comparison 11 Acupuncture vs. waiting list or other active treatment controls for peripheral joint OA post-treatment scores analysis, Outcome 1 Pain (Time point equal to or less than three months and closest to eight weeks post-randomization)

Analysis 11.2. Comparison 11 Acupuncture vs. waiting list or other active treatment controls for peripheral joint OA post-treatment scores analysis, Outcome 2 Function (Time point equal to or less than three months and closest to eight weeks post-randomization)

Analysis 11.2. Comparison 11 Acupuncture vs. waiting list or other active treatment controls for peripheral joint OA post-treatment scores analysis, Outcome 2 Function (Time point equal to or less than three months and closest to eight weeks post-randomization)

Analysis 11.3. Comparison 11 Acupuncture vs. waiting list or other active treatment controls for peripheral joint OA post-treatment scores analysis, Outcome 3 Total score (Time point equal to or less than three months and closest to eight weeks post-randomization)

Analysis 11.3. Comparison 11 Acupuncture vs. waiting list or other active treatment controls for peripheral joint OA post-treatment scores analysis, Outcome 3 Total score (Time point equal to or less than three months and closest to eight weeks post-randomization)