Acupuncture treatment for chronic knee pain: a systematic review
A. White, N. E. Foster1, M. Cummings2and P. Barlas2
Objectives. To evaluate the effects of acupuncture on pain and function in patients with chronic knee pain.
Methods. Systematic review and meta-analysis of randomized controlled trials of adequate acupuncture. Computerized databases and
reference lists of articles were searched in June 2006. Studies were selected in which adults with chronic knee pain or osteoarthritis of the
knee were randomized to receive either acupuncture treatment or a control consisting of sham (placebo) acupuncture, other sham
treatments, no additional intervention (usual care), or an active intervention. The main outcome measures were short-term pain and function,
and study validity was assessed using a modification of a previously published instrument.
Results. Thirteen RCTs were included, of which eight used adequate acupuncture and provided WOMAC outcomes, so were combined in
meta-analyses. Six of these had validity scores of more than 50%. Combining five studies in 1334 patients, acupuncture was superior to sham
acupuncture for both pain (weighted mean difference in WOMAC pain subscale score¼2.0, 95% CI 0.57–3.40) and for WOMAC function
subscale (4.32, 0.60–8.05). The differences were still significant at long-term follow-up. Acupuncture was also significantly superior to no
additional intervention. There were insufficient studies to compare acupuncture with other sham or active interventions.
Conclusions. Acupuncture that meets criteria for adequate treatment is significantly superior to sham acupuncture and to no additional
intervention in improving pain and function in patients with chronic knee pain. Due to the heterogeneity in the results, however, further
research is required to confirm these findings and provide more information on long-term effects.
KEY WORDS: Acupuncture, Systematic review, Meta-analysis, Chronic knee pain, Osteoarthritis, WOMAC, Function.
Knee pain affects about a quarter of people older than 55yrs,
and is severe enough to restrict normal daily activities in about
half of these [1, 2]. After excluding specific conditions such as
inflammatory arthritis, much of this pain is given the label of
‘osteoarthritis’ (OA). The clinical problem of OA embraces a wide
group of older adults with knee pain, and will include a subgroup
of patients who have radiographic changes in the relevant joints as
well as a clinical syndrome of pain, stiffness and restricted
movement . There are divided opinions within the literature
about the use of radiology and the importance of separating the
disease process of OA from the syndrome of musculoskeletal pain
and disability [4, 5]. The main treatment priorities that have been
identified by both patients with arthritis and clinicians are pain
relief and improved mobility [6, 7].
Pharmacological therapies have limited appeal: the effects of
non-steroidal anti-inflammatory drugs are small and short-
lived , and their use is associated with serious side effects
including bleeding and perforated ulcer . Cyclooxygenase-2
inhibitors were introduced with the hope of reducing the
incidence of gastrointestinal side effects, but they may not be
successful at this, and seem to increase the risk of cardiovascular
Non-pharmacological therapies for knee arthritis are therefore
increasingly attractive and are included in current recommenda-
tions for treatment . Acupuncture, one of the most commonly
used of these [12, 13], may be considered a form of sensory
stimulation, and its use for relieving pain is supported by
evidence of biological mechanisms for its effects [14, 15].
However, until recently there has been insufficient evidence of
acupuncture within the health service .
A previous review of seven trials of acupuncture for knee pain
associated with OA reported that acupuncture might play a role in
treatment, but its conclusions were limited by the poor quality of
the majority of studies . Several more trials have recently been
published [18–21] and it is therefore timely to reconsider the
question of whether acupuncture reduces pain and improves
physical function in patients with chronic knee pain, compared
with placebo/sham treatment, no treatment and conventional
We undertook a systematic review and meta-analysis of the
evidence from randomized controlled trials on acupuncture’s
effect in reducing pain and increasing function in patients with
chronic knee pain.
We have conducted this review using a Western scientific
approach to acupuncture, viewing it as a form of sensory nerve
stimulation. According to this approach, acupuncture’s effect will
depend on the stimulation intensity, frequency and repetition,
and the neurological level at which it is given; the precise location
of needles may not be important . This approach provides a
basis for defining the adequacy of acupuncture and placebo
interventions. From clinical experience and empirical data [23, 24]
we defined acupuncture as ‘adequate’ if it consisted of at least six
treatments, at least one per week, with at least four points needled
for each painful knee for at least 20min, and either needle
sensation (de qi) achieved in manual acupuncture, or electrical
stimulation of sufficient intensity to produce more than minimal
sensation. We defined a control as a ‘true sham’ only when it
avoided stimulating nerves in the same neurological segments
as the knee joint; even superficial penetration with needles
is regarded as unacceptable because it has the potential to be
physiologically active .
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Peninsula Medical School, Universities of Exeter and Plymouth, N32 ITTC
Musculoskeletal Research Centre, Keele University, Keele, Staffordshire ST5
London Homeopathic Hospital, 60 Great Ormond Street, London WC1N 3HR, UK.
2British Medical Acupuncture Society, BMAS London Office, Royal
Submitted 4 July 2006; revised version accepted 7 November 2006.
Correspondence to: A. White, Peninsula Medical School, N32 ITTC Building,
Tamar Science Park, Plymouth PL6 8BX, UK. E-mail: email@example.com
Rheumatology 2007; 1 of 7doi:10.1093/rheumatology/kel413
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Rheumatology Advance Access published January 10, 2007
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29 van Tulder MW, Assendelft WJ, Koes BW, Bouter LM. Method guidelines for
systematic reviews in the Cochrane Collaboration Back Review Group for Spinal
Disorders. Spine 1997;22:2323–30.
30 Higgins JPT, Green S, eds. Cochrane handbook for systematic reviews of
interventions 4.2.5 [updated May 2005]. In: The Cochrane library, issue 3.
Chichester: John Wiley & Sons, Ltd, 2005.
31 DerSimonian R, Laird N. Meta-analysis in clinical trials. Controlled Clin Trials
32 Higgins JP, Thompson SG. Quantifying heterogeneity in a meta-analysis. Stat Med
33 Streitberger K, Witte S, Mansmann U et al. Efficacy and safety of acupuncture for
chronic pain caused by gonarthrosis: a study protocol of an ongoing multi-centre
randomised controlled clinical trial [ISRCTN27450856]. BMC Complement Altern
34 MilliganJL,Glennie-Smith K, Dowson
the knees. 15th International Congress of Rheumatology, Paris, 1981.
35 Berman BM, Singh BB, Lao L et al. A randomized trial of acupuncture
as an adjunctive therapy in osteoarthritis of the knee. Rheumatology 1999;
36 Christensen BV, Iuhl IU, Vilbek H et al. Acupuncture treatment of severe
knee osteoarthrosis: A long-term study. Acta Anaesthesiol Scand 1992;36:519–25.
37 Molsberger A, Bowing G, Jensen KU, Lorek M. Schmerztherapie mit Akupunktur
bei Gonarthrose. Der Schmerz 1994;8:37–42.
38 NgMM,LeungMC, Poon DM.The
transcutaneous electrical nerve stimulation on patients with painful osteoarthritic
knees: a randomized controlled trial with follow-up evaluation. J Altern Complement
effects ofelectro-acupuncture and
39 Petrou P, Winkler V, Genti G et al. Double-blind trial to evaluate the effect of
acupuncture treatment on knee osteoarthrosis. Scand J Acupunct Electrother
40 Sangdee C, Teekachunhatean S, Sananpanich K et al. Electroacupuncture versus
Diclofenac in symptomatic treatment of Osteoarthritis of the knee: a randomized
controlled trial. BMC Complement Altern Med 2002;2:3.
41 Takeda W, Wessel J. Acupuncture for the treatment of pain of osteoarthritic knees.
Arthritis Care Res 1994;7:118–22.
42 Tukmachi E, Jubb R, Dempsey E, Jones P. The effect of acupuncture on the
symptoms of knee osteoarthritis – an open randomised controlled study.
Acupunct Med 2004;22:14–22.
43 Yurtkuran M, Kocagil T. TENS, electroacupuncture and ice massage: comparison of
treatment for osteoarthritis of the knee. Am J Acupunct 1999;27:133–40.
44 Assendelft WJ,MortonSC,Yu EI,
manipulative therapy for low back pain. A meta-analysis of effectiveness relative to
other therapies. Ann Intern Med 2003;138:871–81.
45 House of Lords. Science and Technology – Sixth Report. 2000. http://www.
46 Vincent C. The safety of acupuncture. Br Med J 2001;323:467–8.
47 Cohen J. Statistical power analysis for behavioral sciences. New York: Academic
48 Lin J, Zhang W, Jones A, Doherty M. Efficacy of topical non-steroidal anti-
inflammatory drugs in the treatment of osteoarthritis: meta-analysis of randomised
controlled trials. Br Med J 2004;329:324–6.
49 Ezzo J, Vickers A, Richardson MA et al. Acupuncture-point stimulation for
chemotherapy-induced nausea and vomiting. J Clin Oncol 2005;23:7188–98.
50 Manheimer E, White A, Berman B, Forys K, Ernst E. Meta-analysis: acupuncture for
low back pain. Ann Intern Med 2005;142:651–63.
Suttorp MJ,Shekelle PG.Spinal
Systematic review of acupuncture for knee pain 7 of 7
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