Authors' objectives:

This review contains: a) A review of recent (1995 to present) systematic reviews on the use of acupuncture for osteoarthritis, updated with any RCTs published since the date of the last systematic review (2000 to present). b) Information available in the literature on training for persons performing this therapy and the number of physicians certified to perform this therapy.

Authors' recommendations: A key issue in studies of acupuncture is the effect of sham acupuncture. Most studies on acupuncture for osteoarthritis do not find a benefit for acupuncture compared to sham acupuncture. Researchers hypothesize that this may be because placement of a needle anywhere elicits a physiological response or because the sham sites chosen were actually true acupuncture sites. Most studies found a benefit for both acupuncture and sham acupuncture compared to baseline. All the reviewers agree that more research is necessary to understand the effects of sham acupuncture. The systematic reviews describe other methodological problems with some of the studies. Many studies are small and may be underpowered to measure statistically significant differences between the interventions. Other methodological issues include lack of blinding, lack of description of handling of dropouts and withdrawals, no formal test statistics, heterogeneous samples and groups not equal at entry in some of the studies. Two studies did find a benefit for acupuncture compared to sham: Petrou et al. and Molsberger et al. Ezzo et al. noted that in these studies the needles were placed superficially, at sites distal to true acupuncture sites. Ernst also reviewed the study by Petrou et al. and noted that there was a small sample size (31 patients), that it lacked blinding and that not all the variables showed improvement. The systematic reviews had somewhat different conclusions based on their interpretation of the evidence. Ernst qualitatively described methodological flaws in most of the studies, and concluded that acupuncture is not superior to sham. Ezzo et al. acknowledged the methodological problems in the studies, but concluded that acupuncture may play a role in the treatment of osteoarthritis; this conclusion was largely based on the two studies showing a positive effect of acupuncture compared to sham. Berman et al. also found no benefit for acupuncture compared to sham, but they suggest that sham acupuncture may have pain relieving effects and that this may explain the relative equivalence of acupuncture compared to sham acupuncture. They concluded that there is moderately strong evidence supporting adjunctive use of acupuncture. Overall, the NHS review concluded that the evidence was probably sufficient to justify the use of acupuncture as a second or third line treatment for a patient who is not responding to conventional management or not tolerating medication or experiencing recurrent pain, but also suggest that the evidence is not sufficient to justify acupuncture as first line treatment. Three clinical trials on the use of acupuncture in osteoarthritis are currently underway. These studies have randomized controlled designs and intend to enroll several hundred patients. Two of the studies are specifically designed to further investigate the effect of sham acupuncture. One of these studies uses a validated placebo needle that does not penetrate the skin. A study with this placebo needle suggested that patients who have never had acupuncture could not tell that the technique was a placebo. The needle is designed based on the hypothesis that the beneficial effect of sham acupuncture is due to penetration of the skin by the needle. This study is not testing acupuncture alone but acupuncture in combination with physical therapy. Another study is also designed to further understand the effect of sham acupuncture. In this study, patients are randomized to groups with different models for practitioner-patient interactions. Patients in each interaction group will be further randomized to receive either acupuncture or sham acupuncture. This study is designed to test the hypothesis that placebo effects of sham acupuncture can be enhanced by the practitioners communicative style, which can affect the patients expectations and beliefs. Most studies show a benefit for acupuncture compared to no treatment. It has been more difficult to determine whether the effect observed is a non-specific placebo effect because of the issues around the design of sham acupuncture procedures in randomized controlled trials. These problems arise from the lack of clear definition of what constitutes acupuncture and through what mechanisms it is purported to work. The currently available evidence is insufficient to determine whether acupuncture has a specific beneficial effect in osteoarthritis. New studies are underway which were designed with the aim of answering some questions about the effects associated with sham acupuncture. These studies should help to clarify the potential specific effect, if any, of acupuncture for osteoarthritis.

Authors' methods: Systematic review

Project Status: Completed

URL for project: http://www.cms.hhs.gov/ncdr/tadetails.aspid=84

Year Published: 2003

English language abstract: An English language summary is available

Publication Type: Not Assigned

Country: United States

Organisation Name: Agency for Healthcare Research and Quality

Contact Address: Center for Outcomes and Evidence Technology Assessment Program, 540 Gaither Road, Rockville, MD 20850, USA. Tel: +1 301 427 1610; Fax: +1 301 427 1639;

Contact Name: martin.erlichman@ahrq.hhs.gov

Contact Email: martin.erlichman@ahrq.hhs.gov

Copyright: Agency for Healthcare Research and Quality (AHRQ)