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Date Last Updated: 20/10/04

Acupuncture for osteoarthritis

Overview

Osteoarthritis is a chronic disease of the joints. Acupuncture (which usually involves the insertion of fine needles into specific points in the body) has been widely used for treating the pain caused by osteoarthritis. This evidence summary identified three health technology assessments, three systematic reviews, and 21 clinical trials (758 patients) on acupuncture for the management of osteoarthritis. Results from the trials are difficult to compare due to differences in study design and the acupuncture techniques used. Results from one of the health technology assessments found that acupuncture can temporarily decrease pain levels in osteoarthritis sufferers compared to no treatment at all. This review also reported that both acupuncture and sham/placebo treatments showed similar benefits. Results from the other reviews in this area are broadly consistent with these findings. Side effects for acupuncture (such as fainting, bleeding and bruising around the needle site, and nausea) tend to be mild, uncommon and reversible. Serious side effects (such as punctured organs, infection, or death) can occur but are extremely rare.


Background

Osteoarthritis
Osteoarthritis is a chronic disease of the joints caused by wear and tear (degeneration) of the protective layer of the cartilage (the softer part of the bones) which cushions the bone connections within the joint1. This process of wear and tear, and the resulting inflammation, may also be associated with changes in the bone underneath the cartilage forming an abnormal boney growth1, 2. Degeneration of the joints is part of the aging process1. Consequently, the occurrence of osteoarthritis increases with age2. Severe joint injury may also lead to osteoarthritis2. Osteoarthritis is also referred to as degenerative joint disease or degenerative arthrosis, and is considered the most common type of arthritis, especially among older people3. People with osteoarthritis usually have joint pain and limited joint movement. Unlike some other forms of arthritis, osteoarthritis only affects the joints and not the internal organs. Acupuncture has been widely used for treating the pain caused by osteoarthritis.

Acupuncture
Acupuncture is one of the oldest and most commonly used medical procedures in the world. Acupuncture usually involves the insertion of fine needles into specific acupuncture points. Small metal beads, lasers, diodes, heat from the herb ‘moxa’ (moxabustion), suction cups and finger pressure may be used instead of needles. Acupuncture is widely used in many countries for the relief or prevention of pain, and for the treatment of health conditions such as headaches, stress, ‘low energy’, ear, nose and throat conditions, addictions, and allergies4. Acupuncture is a complex treatment that can produce very different results among patients with similar complaints, particularly given that the number, length of treatment, and the specific points used may vary among individuals and during the course of treatment4. During treatment sessions between five and 15 needles are usually used5, 6. The acupuncture points used tend to differ during the course of the treatment5, 6. Sessions are usually held weekly3, although for chronic conditions such as osteoarthritis, more frequent visits may be required. Acupuncture is a relatively safe procedure when performed by properly trained individuals in a clinical environment, using sterile, disposable needles7.

There is a wide variation in the way different cultures use acupuncture. For instance, Japanese-style acupuncture involves the insertion of needles under the skin without stimulation, whereas the Chinese-style of acupuncture is based on insertion of the needles into the muscle, as well as manual stimulation8. According to traditional Chinese medicine there are more than 2,000 acupuncture points on the human body6, and these connect with 12 main and eight secondary pathways called meridians (channels)9. In practice, however, a typical acupuncturist may only use 150 points6. Traditionally each acupuncture point has defined healing (therapeutic) actions6. Traditional Chinese medicine practices (including acupuncture, herbs, diet, massage, and meditative physical exercise) are all intended to improve and balance the flow of energy or qi (pronounced ‘chee’), in order to maintain and restore health to the body and mind. Western acupuncture uses the same needling technique but is based on affecting nerve impulses and the central nervous system.

The practice of acupuncture is not currently regulated in New Zealand. Many acupuncture therapists are affiliated with a self-regulating professional body (such as the New Zealand Charter of Health Practitioners, the New Zealand Register of Acupuncturists, the Medical Acupuncturists Society of New Zealand, or the Physiotherapy Acupuncture Association of New Zealand).


Evidence reviewed in this summary

Efficacy information
  • Health Technology Assessments: Three health technology assessments on acupuncture for the treatment of osteoarthritis were identified for this evidence summary5, 7, 10. The first assessment was an update of one conducted in 199711, and looked at acupuncture for chronic osteoarthritic pain, headache and low back pain7. The assessment included one systematic review and two trials of acupuncture for osteoarthritis in the knee. The second assessment included two systematic reviews on osteoarthritis10. The third assessment summarised the findings from an earlier health technology assessment10, one systematic review, and four clinical trials5.
  • Systematic reviews: The above health technology assessments identified three systematic reviews12-14. One review identified 12 trials on osteoarthritis at different sites, representing 370 patients12. The second review identified eight studies on the use of acupuncture for the treatment of osteoarthritis13, of which four (136 patients) were randomised clinical trials. The third review included seven trials involving 393 patients with osteoarthritis in the knee14.
  • Clinical trials: The above health technology assessments and systematic reviews identified 19 controlled clinical trials15-33. The trials involved between 12-97 people, representing a total of 638 patients. An additional two clinical trials, involving 60 people each, have recently been published34, 35. At least three clinical trials (involving between 300-760 people) of acupuncture and osteoarthritis are currently underway (see http://www.controlled-trials.com/).
  • Case-control studies/Cohort studies/Case studies: Given the extensive coverage of the above systematic reviews, no case-control, cohort or case studies were assessed for this evidence summary.
Safety information
  • Health Technology Assessments: The three health technology assessments5, 7, 10 identified for the efficacy section of this summary reported information on side effects associated with the use of acupuncture for the treatment of osteoarthritis. An additional health technology assessment was identified that included information on complications of acupuncture in general36.
  • Systematic reviews: The three systematic reviews12-14 identified for the efficacy section of this summary reported information on side effects associated with the use of acupuncture for the treatment of osteoarthritis. The additional health technology assessment above identified two systematic reviews8, 37 that reported on the side-effects of acupuncture in general. One of these reviews8 identified ten articles representing nine prospective surveys of 17,925 patients from Europe and the Far East. The second review37 identified 56 articles published between 1965-1996 that reported serious and/or life-threatening adverse reactions following acupuncture. A further systematic review38 that was not included in the above health technology assessment was also identified for this summary. This review reported on 89 Japanese articles on case reports for adverse events related to acupuncture (representing 124 events).
  • Other studies: The additional health technology assessment above also identified a literature review39 and three surveys40-42 that reported on the side-effects of acupuncture in general. The literature review summarised 78 case reports of adverse events identified between 1981-199439, representing 193 treatments. A further narrative review43 on side effects of acupuncture was identified for this summary, as well as one case report44. Given the comprehensive information provided by the above studies, no further information on side effects was sought.


Evidence on efficacy

Evidence on acupuncture for the management of osteoarthritis is available from three health technology assessments5, 7, 10, three systematic reviews12-14, and 21 clinical trials (758 patients)15-35. Many of the trials conducted in this area are of poor scientific quality, in that they did not clearly define the outcome of interest, involved less than 100 participants, involved different sites of osteoarthritis, and did not select an appropriate control group. In addition, many trials tested different acupuncture techniques, had different needle designs, stimulated different acupuncture points and were undertaken for different periods of time. For these reasons it is difficult to compare the results from all of the trials. A recent health technology assessment concluded that:
  • Acupuncture can decrease pain levels in osteoarthritis sufferers compared to no treatment at all7. However, this decrease in pain may only be temporary (that is, for four weeks after the end of treatment)21.
  • Both acupuncture and sham/placebo treatment showed similar benefits7.
Results from the other two health technology assessment5,10, the three systematic reviews12-14 and the two recently published trials34, 35 are broadly consistent with these findings.


Evidence on safety

Findings from the four health technology assessments5, 7, 10,36, the six systematic reviews8,12-14,8, 37,38, the one literature review39, the three surveys40-42, the one narrative review43 and the one case report44 on safety reviewed for this summary, indicate that side effects with acupuncture tend to be uncommon, mild and reversible, and may include sleepiness, fainting, nausea, vomiting, aggravation of symptoms, and bleeding, bruising and/or pain at the needle site8, 37, 38, 40, 41. Other side effects may include infection and dermatitis43. Estimates of the risk of developing any side effects due to acupuncture are given below:
  • Minor side effects (total)41: 67 in every 1,000 acupuncture visits
    • Eg. Bleeding: 31 in every 1,000 acupuncture visits
    • Eg. Needling pain: 11 in every 1,000 acupuncture visits
    • Eg. Aggravation of symptoms: 10 in every 1,000 acupuncture visits
  • Severe nausea and vomiting40: 1 in every 1,000 acupuncture visits
Although extremely rare, evidence of serious, potentially life threatening complications associated with acupuncture have been reported, and include punctured organs38, serious infection (e.g. hepatitis38, 43and streptococcal38), spinal cord injury38, and shortness of breath43. For this summary we found that over a period of 33 years (1966-1999) information on six deaths associated with acupuncture had been published. Two deaths were from infections (streptococcal toxic shock-like syndrome and pyohemothorax)38, one was due to compression of the heart by blood (cardiac tamponade)44, one was from a collapsed lung (pneumothorax)39, one was from inflammation of the lining of the heart (endocarditis)39, and one was from a severe asthma attack39.


Cited references

To find out more about any of the references listed below go to the "About page" of this website and read the section titled "How can referenced articles be obtained."

  1. Cochrane Musculoskeletal Injuries Group. Summary of evidence from Cochrane Reviews on osteoarthritis. Available from: http://healthsci.otago.ac.nz/dsm/cmsig/pdf/Osteoarthritis.pdf: Cochrane Collaboration Musculoskeletal Injuries Collaborative Review Group; Undated.
  2. Felson DT, Lawrence RC, Dieppe PA, Hirsch R, Helmick CG, Jordan JM, et al. Osteoarthritis: new insights. Part 1: the disease and its risk factors. Annals of Internal Medicine. 2000;133(8):635-646.
  3. Ernst E, Pilter M, Stevinson C, White A. The desktop guide to Complementary and Alternative Medicine: an evidence-based approach. London: Mosby; 2001.
  4. Acupuncture: National Institutes of Health Consensus Development Conference Statement... this statement was originally published as Acupuncture. NIH Consensus Statement. (1997, November 3-5), 15(5). Dermatology Nursing 2000;12(2):126-133.
  5. Agency for Healthcare Research & Quality. Acupuncture for osteoarthritis. Available from: http://cms.hhs.gov/coverage/download/id84.pdf. Rockville, MD: Agency for Healthcare Research & Quality; 2003.
  6. Kaptchuk TJ. Acupuncture: theory, efficacy, and practice.[see comment]. Annals of Internal Medicine. 2002;136(5):374-383.
  7. Smith JC, Greer NL. Acupuncture for chronic osteoarthritis pain, headache, and low back pain. Available from: http://www.icsi.org/index.asp. Bloomington, MN.: Institute for Clinical Systems Improvement; 2000.
  8. Ernst E, White AR. Prospective studies of the safety of acupuncture: a systematic review. American Journal of Medicine. 2001;110(6):481-485.
  9. National Center for Complementary and Alternative Medicine (NCCAM). Acupuncture. NCCAM publication No. D003. Available from: http://nccam.nci.nih.gov/health/acupuncture/#theory Accessed on 10.03.04 2002.
  10. NHS Centre for Reviews and Dissemination. Acupuncture. Effective Health Care 2001;7(2):1-12. Available from: http://www.york.ac.uk/inst/crd/ehc72.htm.
  11. Smith JC, Greer NL. Acupuncture for chronic osteoarthritis pain, headache, and low back pain. Available from: http://www.icsi.org/index.asp. Bloomington, MN: Institute for Clinical Systems Improvement; 1997.
  12. Ernst E. Acupuncture as a symptomatic treatment of osteoarthritis: A systematic review. Scandinavian Journal of Rheumatology 1997;26(6):444-447.
  13. Berman BM, Swyers JP, Ezzo J. The evidence for acupuncture as a treatment for rheumatologic conditions. Rheumatic Disease Clinics of North America 2000;26(1):103-115.
  14. Ezzo J, Hadhazy V, Birch S, Lao L, Kaplan G, Hochberg M, et al. Acupuncture for osteoarthritis of the knee: A systematic review. Arthritis & Rheumatism 2001;44(4):819-825.
  15. Fink MG, Wipperman B, Gehrke A. Non-specific effects of traditional Chinese acupuncture in osteoarthritis of the hip. Complementary Therapies in Medicine. 2001;9(2):82-89.
  16. Haslam R. A comparison of acupuncture with advice and exercises on the symptomatic treatment of osteoarthritis of the hip - A randomised controlled trial. Acupuncture in Medicine 2001;19(1):19-26.
  17. Singh BB, Berman BM, Hadhazy V, Bareta J, Lao L, Zarow FM, et al. Clinical decisions in the use of acupuncture as an adjunctive therapy for osteoarthritis of the knee. Alternative Therapies in Health & Medicine 2001;7(4):58-65.
  18. Tillu A, Roberts C, Tillu S. Unilateral versus bilateral acupuncture on knee function in advanced osteoarthritis of the knee - A prospective randomised trial. Acupuncture in Medicine 2001;19(1):15-18.
  19. Takeda W, Wessel J. Acupuncture for the treatment of pain of osteoarthritic knees. Arthritis Care & Research 1994;7(3):118-122.
  20. Christensen BV, Iuhl IU, Vilbek H, Bulow HH, Dreijer NC, Rasmussen HF. Acupuncture treatment of severe knee osteoarthrosis. A long-term study. Acta Anaesthesiologica Scandinavica. 1992;36(6):519-525.
  21. Berman BM, Singh BB, Lao L, Langenberg P, Li H, Hadhazy V, et al. A randomized trial of acupuncture as an adjunctive therapy in osteoarthritis of the knee. Rheumatology 1999;38(4):346-354.
  22. Junnila SY. Acupuncture superior to piroxicam in the treatment of osteoarthrosis. American Journal of Acupuncture 1982;10(4):341-346.
  23. Petrou P, Winkler V, Genti G, Balint G. Double blind trial to evaluate the effect of acupuncture treatment on knee osteoarthrosis. Scandinavian Journal Of Acupuncture And Electrotherapy 1988;3:112-115.
  24. Molsberger A, Bowing G, Jensen KU, Lorek M. Acupuncture treatment for the relief of gonoarthrosis pain - a controlled clinical trial. Schmerz 1994;8:37-42.
  25. Gaw AC, Chang LW, Shaw LC. Efficacy of acupuncture on osteoarthritic pain. A controlled, double-blind study. New England Journal of Medicine. 1975;293(8):375-378.
  26. Coan RM, Wong G, Coan PL. The acupuncture treatment of neck pain: a randomized controlled study. American Journal of Chinese Medicine 1982;9(4):326-332.
  27. Milligan JL, Glennie-Smith K, Dowson DI, Harris J. Comparison of acupuncture with physiotherapy in the treatment of osteoarthritis of the knees. [Abstract] Paper presented at 15th International Conference of Rheumatology, Paris. 1981.
  28. Loy TT. Treatment of cervical spondylosis. Electroacupuncture versus physiotherapy. Medical Journal of Australia 1983;2(1):32-34.
  29. Petrie JP, Langley GB. Acupuncture in the treatment of chronic cervical pain. A pilot study. Clinical & Experimental Rheumatology 1983;1(4):333-336.
  30. Petrie JP, Hazleman BL. A controlled study of acupuncture in neck pain. British Journal of Rheumatology 1986;25(3):271-275.
  31. Ammer K, Petschnig R. [Comparison of the effectiveness of acupuncture and physical therapy in ambulatory patients with gonarthrosis]. Wiener Medizinische Wochenschrift. 1988;138(22):566-569.
  32. Dickens W, Lewith GT. A single-blind, controlled an randomised clinical trial to evaluate the effect of acupuncture in the treatment of trapezio-metacarpal osteoarthritis. Complementary Medical Research 1989;3(2):5-8.
  33. Thomas M, Eriksson SV, Lundeberg T. A comparative study of diazepam and acupuncture in patients with osteoarthritis pain: a placebo controlled study. American Journal of Chinese Medicine. 1991;19(2):95-100.
  34. Tillu A, Tillu S, Vowler S. Effect of acupuncture on knee function in advanced osteoarthritis of the knee: A prospective, non-randomised controlled study. Acupuncture in Medicine 2002;20(1):19-21.
  35. Kwon YB, Lee JD, Lee HJ, Han HJ, Mar WC, Kang SK, et al. Bee venom injection into an acupuncture point reduces arthritis associated edema and nociceptive responses. Pain 2001;90(3):271-280.
  36. Tait PL, Brooks L, Harstall C. Acupuncture: evidence from systematic reviews and meta-analyses. HTA 27. Edmonton: Alberta Heritage Foundation for Medical Research. Available from: http://www.ahfmr.ab.ca/publications.html; 2002.
  37. Ernst E, White A. Life-threatening adverse reactions after acupuncture? A systematic review.[see comment]. Pain. 1997;71(2):123-126.
  38. Yamashita H, Tsukayama H, White AR, Tanno Y, Sugishita C, Ernst E. Systematic review of adverse events following acupuncture: the Japanese literature. Complementary Therapies in Medicine 2001;9(2):98-104.
  39. Norheim AJ. Adverse effects of acupuncture: a study of the literature for the years 1981-1994. Journal of Alternative and Complementary Medicine 1996;2(2):291-297.
  40. MacPherson H, Thomas K, Walters S, Fitter M. The York acupuncture safety study: prospective survey of 34 000 treatments by traditional acupuncturists. BMJ 2001;323(7311):486-487.
  41. White A, Hayhoe S, Hart A, Ernst E. Adverse events following acupuncture: prospective survey of 32 000 consultations with doctors and physiotherapists.[comment]. BMJ 2001;323(7311):485-486.
  42. Yamashita H, Tsukayama H, Tanno Y, Nighijo K. Adverse events in acupuncture and moxibustion treatment: a six year survey at a National Clinic in Japan. Journal of Alternative and Complementary Medicine 1999;5(3):229-236.
  43. Singh BB, Zarow FM, Mishra LC, Dagenais S. Acupuncture as a treatment for osteoarthritis of the knee: clinical relevance. Topics in Clinical Chiropractic 2000;7(2):39-42.
  44. Halvorsen TB, Anda SS, Naess AB, Levang OW. Fatal cardiac tamponade after acupuncture through congenital sternal foramen.[comment]. Lancet. 1995;345(8958):1175.


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