Acupuncture vs. physiotherapy for severe knee osteoarthritis
Posted on 15th February 2017 by Kristen Dufresne
This is a summary of a randomized control trial (RCT) comparing the effects of standardized western acupuncture and physiotherapy on pain and functional ability in patients with severe osteoarthritic knee pain awaiting knee arthroplasty (i.e. knee replacement).
Osteoarthritis (OA) is a degenerative disease of joint cartilage, and is a major cause of pain, disability and healthcare utilization. One of the treatments of late stage OA is a total joint arthroplasy, or joint replacement surgery. The authors looked at the impact of OA on knee pain and function as well as post-operative recovery.
The authors compared acupuncture and physiotherapy against each other (treatment groups), and against current standard management (control group). Both treatment groups attended a weekly 1 hour group session with 6-10 people for 6 weeks led by a senior physiotherapist.
The acupuncture group had needles inserted for 20 minutes at points most commonly used in previous reported research studies in the field, and up to three additional needles in trigger or traditional points at the physiotherapist’s discretion.
The physiotherapy group attended an exercise circuit devised and supervised by the same physiotherapist who provided the acupuncture. There were 10 exercises in the circuit which included balance training and lower extremity strengthening.
The control group received an exercise and advice leaflet, which had been designed by consensus between the physiotherapy, rheumatology and orthopaedic departments to reflect best current practice. At enrolment, patients were told that they were in the ‘home exercise group’.
The primary outcome measure was the Oxford Knee Score (OKS), a patient-completed questionnaire consisting of twelve questions on knee function and pain. Other outcomes were the Western Ontario MacMaster (WOMAC) Score, 10-cm pain visual analogue scale (VAS), Hospital Anxiety and Depression score (HAD). Fifty metre timed walk and weight were also measured at each visit.
Compared to patients in the control group, patients with severe knee OA achieved a short-term improvement in their Oxford Knee Score when treated with acupuncture. The difference between the control group and the physiotherapy group was not significant. Additionally, no other clinically or statistically significant effects were found between the groups.
Although the improvement in OKS in the acupuncture group was the only positive result out of a series of non-significant results, the study demonstrated that there may be some potential for improvements to knee pain and function, perhaps with longer or more intensive treatment courses. The effects observed in this study were smaller than those found in other knee OA studies, which all involved longer treatment courses in less disabled patients. Additionally, while not significant, the physiotherapy group had a shorter post-operative hospital stay (mean 6.5 days, S.D. 2.0) than the acupuncture group (mean 7.77, days S.D. 3.96). More research is needed to determine the impact of longer, more intensive, and combined treatments.
- This study had high dropout rates: A hundred and sixty-one (89%) patients were assessed at 7 weeks, 120 (66%) patients where assessed at 12 weeks and 69 (38%) patients were assessed at 3 months post-operatively.
- A 6-week course of treatment was used due to funding constraints, which was the minimum anticipated treatment time needed to document any meaningful acupuncture improvement, based on clinical experience and current practice. This may not have been long enough to build up the full effects of the physiotherapy.
- The treatment groups were limited to standardized programs, rather than individual treatment plans.
- The participants were not blinded as to which intervention they received, nor was sham acupuncture used.
- The research fellow carrying out all the assessments was blind to patient treatment allocation until the data analysis was completed.
- Analysis was performed using intention-to-treat analysis, with the baseline values used in place of any missing follow-up values..
- The study population was similar between groups at baseline, and the treatment groups were treated similarly (by the same practitioner in a group of 6-10, for 1 hour each week for 6 weeks) to minimize sources of variation.
- The study used reproducible therapies and primary outcome measures, which are directly relevant to current clinical practice.
Williamson, L., Wyatt, M.R., Yein, K., and Melton, J.T.K. (2007). Severe knee osteoarthritis: a randomized controlled trial of acupuncture, physiotherapy (supervised exercise) and standard management for patients awaiting knee replacement. Rheumatology 2007;46:1445–1449. https://academic.oup.com/rheumatology/article/46/9/1445/1788894/Severe-knee-osteoarthritis-a-randomized-controlled
See also: Manual therapy vs Exercise for Knee OA