Inspired by Tu et al 2020.[1]
EA – electroacupuncture
key to acronyms
MA – manual acupuncture
OA – osteoarthritis
OAK – OA knee
RR – responder rate
NRS – numerical rating scale
WOMAC – Western Ontario and McMaster Universities osteoarthritis index
MCII – minimum clinically important improvement
GERAC – German acupuncture (trial)
ARC – acupuncture in routine care (trial)
This paper is directly related to one I highlighted on this blog in June: Frequency of Rx in OAK.[2] Tu et al is much bigger, having randomised 480 patients with OAK. Lin et al randomised 60 patients. Both trials recruited over the same time period, and from the same hospital in Beijing. Lin et al was described as an exploratory trial and compared treatment frequency of once per week with three times per week. Treatment was a combination of EA and MA. Tu et al randomised patients to three groups EA, MA and sham, and adopted the three times per week schedule, so presumably this group had already seen the preliminary results of Lin et al before finalising the protocol for the larger trial.
The trial was properly blinded in that all three groups had needles placed and an EA device connected. The current was increased until the needles began to vibrate slightly in the EA group, and in the other groups the power light of the device was switched on, but no current was applied. The sham group used superficial (2-3mm) off-point needling without de qi. Treatment sessions were for 30 minutes three times a week for 8 weeks, with a total of 24 sessions.
The primary outcome was the same in both trials – RR at 8 weeks. RR was determined by a minimum reduction in pain score of 2 on an 11-point NRS, and 6 on the 68-point WOMAC function subscale. Both represent the minimum clinically important improvement (MCII) on each respective scale.
At week 8 after 26 treatment sessions the RRs were 60.3%, 58.6% and 47.3% in the EA, MA and sham groups respectively.
Responder rates in OAK after 26 sessions:
Tu et al [1]
EA – 60.3%
MA – 58.6%
Sham – 47.3%
The biggest sham controlled trial of acupuncture on OAK to date is Scharf et al from 2006,[3] one of the GERAC trials in the Modellvorhaben Akupunktur.[4] This trial randomised 1007 patients to either MA, sham or conventional treatment (physiotherapy and NSAIDs). The RR was measured by a 36% improvement in the total WOMAC score, and the RRs were 53.1%, 51.0% and 29.1% respectively.
Responder rates in OAK after 10-15 sessions:
Scharf et al [3]
MA – 53.1%
Sham – 51.0%
Conventional Rx – 29.1%
It is interesting to note that the sham group was very similar in both Tu et al and Scharf et al. Both used superficial off-point needling in the region of the knee, and the RR percentage was broadly similar, with obvious caveats.
ARC – 18 points improvement on WOMAC from MA
Witt et al [5]
The only other trial of acupuncture in OAK of comparable size is the ARC trial on OA from the Modellvorhaben Akupunktur.[5] This has MA compared with usual care with over 300 in each arm and a non-randomised cohort receiving MA of over 2500. It includes both OA knee and OA hip, but the vast majority are OA knee. At the end of the randomised treatment course of 3 months the MA group had improved by 18 points on the total WOMAC scale compared with the usual care group, and this was almost identical to the change in the non-randomised group receiving MA.
All in all, this is robust data supporting both efficacy and effectiveness of EA and MA in OA. Only time will tell whether or not it is robust enough for the NICE OA peeps.
Reference list
1 Tu J-F, Yang J-W, Shi G-X, et al. Efficacy of intensive acupuncture versus sham acupuncture in knee osteoarthritis: A randomized controlled trial. Arthritis Rheumatol 2020;:art.41584. doi:10.1002/art.41584
2 Lin L-L, Tu J-F, Wang L-Q, et al. Acupuncture of different treatment frequency in knee osteoarthritis: a pilot randomised controlled trial. Pain Published Online First: 29 May 2020. doi:10.1097/j.pain.0000000000001940
3 Scharf H-P, Mansmann U, Streitberger K, et al. Acupuncture and knee osteoarthritis: a three-armed randomized trial. Ann Intern Med 2006;145:12–20. doi:10.7326/0003-4819-145-1-200607040-00005
4 Cummings M. Modellvorhaben Akupunktur–a summary of the ART, ARC and GERAC trials. Acupunct Med 2009;27:26–30. doi:10.1136/aim.2008.000281
5 Witt CM, Jena S, Brinkhaus B, et al. Acupuncture in patients with osteoarthritis of the knee or hip: A randomized, controlled trial with an additional nonrandomized arm. Arthritis Rheum 2006;54:3485–93. doi:10.1002/art.22154
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