Osteoarthritis

Papers describing individual trials, are summarised in Table 1. Over a 20 year period six distinct trials were carried out (some of the papers are different analyses of the same trial) involving a total of 191 patients. Gaw et al (1975), compared real and sham acupuncture for a range of osteoarthritic joints. Sham points are described as contiguous with traditional points and were needled without obtaining deqi. Although there was no statistically significant difference between the groups, both the experimental (real acupuncture) and the control (sham acupuncture) groups showed an improvement in tenderness, pain and mobility as assessed by two independent, blinded observers. Dickens & Lewith (1989), examined the effectiveness of acupuncture for osteoarthritis at the base of the thumb. In an attempt to side step the complications caused by sham acupuncture mock TNS was used for the control group. Again the difference between the experimental and the control groups was not statistically significant in this small sample, but acupuncture gave much better pain relief than the mock TENS. Lundeberg (1991), Thomas (1991) and Eriksson (1991), all write on trials of acupuncture in the treatment of osteoarthritis of the cervical vertebrae. In Lundeberg's article patients were allocated randomly to four treatment groups, receiving manual acupuncture (with deqi obtained), sham acupuncture and electroacupuncture at low and high frequencies. One treatment was given and effects measured by visual analogue scales shortly after. All experimental groups showed significant reductions in pain intensity and affect. Thomas reports on another four arm study comparing real and sham acupuncture and standard (diazapam) and placebo pain medications. Acupuncture produced the most significant reductions in pain scores in this short term evaluation. As acupuncture afforded the greatest relief it should be considered routinely for a non-drug treatment option, especially when wishing to avoid the sedative side effects of benzodiazepines. In the final article relating to this project Eriksson reports that pre-treatment with diazepam and naloxone (which blocks endorphins) diminishes the impact of acupuncture. Christensen (1992), reports a single blind trial of severe osteoarthritis of the knees with all 29 patients in the study awaiting surgery for their condition. It compares acupuncture to a control group receiving delayed treatment (nine weeks later). Six treatments were given with maintenance care available for a further 50 weeks.. Assessments included objective measures of distance walked and mobility as well as self assessed scales. In the treatment group improvement was recorded in pain levels, range of movement, mobility, and reduction in medication and a statistically significant difference was found between the treatment and control groups. The control group also recorded a decrease in pain when it was treated. This is an impressive result. Seven patients were also able to avoid surgery (at a total estimated saving of $60,000) and use of non-steroidal anti-inflammatory medications reduced significantly. The authors conclude mildly 'that acupuncture does work on knee osteoarthritis'. Bulow (1992), reports a further analysis of the Christensen (1992) trial. The data from the trial are examined in an attempt to identify the factors likely to predict a positive outcome from acupuncture treatment. It concludes that it is not possible to pinpoint in advance which patients might best benefit. It is noted however that less chronic conditions responded better to treatment, yet increasing age and severity of the condition did not appear to negatively influence the outcome of the treatment. Real and sham acupuncture for the treatment of pain in osteoarthritic knees were compared in a double blind trial of 40 patients by Takeda & Wessel (1994). Sham acupuncture was given by superficially needling points about one inch away from recognised acupuncture point sites. Outcome was assessed up to four weeks after termination of treatment using pain, stiffness and difficulty associated with various activites as measures. Both real and sham acupuncture decreased pain, stiffness and physical difficulty in this trial. The real acupuncture group showed a greater response but the difference between real and sham was not statistically significant. A number of interesting points come out of this study; men responded better than women; deqi was experienced by the majority of people in both groups and those who experienced deqi had a better response. Berman (1995), reports an uncontrolled outcome trial of 12 patients treated for moderate to severe osteoarthritis of the knee. Low frequency electrical stimulation was given to points St35 and Extra- Xiyan, otherwise manual stimulation was given. Treatment effect was assessed in terms of pain, function and physical performance. . It is the only study that used more than one distal point in addition to local points .Two thirds of patients registered a 50% or better alleviation of their condition and there were no significant adverse side effects.

Discussion

Without exception the papers reviewed report an improvement following acupuncture treatment. In addition the reduced reliance on medications and surgery mean both possible cost savings and reduced side effects. Where side effects from acupuncture are mentioned, (Gaw (1975) and Berman (1995)), they are described as negligible or insignificant. The most impressive study in terms of outcome was that by Christensen et al (1992) where no sham acupuncture was used. For practitioners, doctors and indeed for prospective patients, this type of study is the most useful in that it compares acupuncture with standard treatment Those studies which included a control group using sham acupuncture, Gaw (1975), Lundeberg (1991), Takeda (1994), were unable to find any statistically significant difference in outcome between the experimental and control groups. The use of sham acupuncture is much discussed in the literature (Birch 1997) and has particular disadvantages in trials where pain is concerned as even shallow needling at non traditional sites has been shown to activate qi and a healing response. From the point of view of traditional acupuncture these trials still fall short of reflecting practice. Thus in addition to the issue of sham needling treatment courses were short, sometimes one-off, and concentrated around the use of local points. The effect of achieving deqi may also be necessary to enhance success. No study presented a diagnosis in Chinese terms or gave the basis of point selection, and none appeared to include treatment of any underlying condition. Given these shortcomings the results are even more promising.

Conclusion

Overall acupuncture is shown to give relief from the symptoms of osteoarthritis with negligible side effects and acupuncture practitioners should treat with high expectations of a worthwhile outcome. Neither the chronicity and severity of the condition nor the age of the patient should be seen as factors preventing a useful outcome. Acupuncture may also be more effective than standard care options (Christensen 1992) but practitioners should ensure that acupuncture treatment is complemented by other useful procedures, for example exercise and weight reduction.

Rheumatoid Arthritis

A total of eight papers are reviewed in this section, three overview papers and five trial papers.

Review of Overview articles

Given that rheumatoid arthritis is a more complex disorder than osteoarthritis it can be expected that treatment and demonstration of effectiveness are more difficult. The three overview articles on rheumatoid arthritis (Table 2) confirm this. In 1985 Bhatt-Sanders concluded that, in view of the lack of high quality trials, acupuncture is not a treatment for rheumatoid arthritis, and this was probably the mainstream view in the UK for many years. However opinions may be changing. Kenyon (1995) suggests that acupuncture can help with pain relief. MacPherson and Blackwell (1994) include evidence from China (albeit with considerable caveats) that support acupuncture for both pain relief and control of inflammation. This paper is extremely helpful in that it gives a treatment strategy for rheumatoid arthritis based on Chinese experience.

Review of Trials

The trial papers reviewed are summarised in Table 3. Man and Baragar (1974), the single study undertaken in the West, gives impressive results, namely pain relief sustained over 2-3 months from one local treatment. They recorded no anti-inflammatory effect from the treatment. Surprisingly, in view of the results of the osteoarthritis studies, sham acupuncture gave only small and transient relief. This in spite of the fact that the sham acupuncture sites (above, in the middle of, and below the patella) would now be considered by some to be real acupuncture points. All four remaining uncontrolled outcome studies are from China and specifically address the question of immune response along with 'improvement'. Luo (1987) treated 65 patients with moxa and claims, along with an overall success rate of 86%, that ESR(see note) levels fell and negative rheumatoid factor (RF) increased. Wang (1993), reports on 650 patients given long term TCM treatment for rheumatoid arthritis and describes a range of positive symptomatic changes. He also reports significant reductions in ESR and RF levels. As with many such reports the methodology is unclear but he mentions that acupuncture is given in combination with (unspecified) drug administration. Obviously this makes accurate interpretation of results impossible. Liu (1993) attributes changes in immune function of his 34 patients to the acupuncture treatment. All patients improved and his findings reflect those of the earlier authors in relation to RF and ESR. Guan (1995) focused upon measuring immunoglobulin (Ig) antibody levels in his small study and describes a statistically significant change after a course of 15 acupuncture treatments. He also confirmed others’ findings of positive changes in ESR and RF. These are factors objectively recorded through serum tests and hence are significantly different from most results recorded in studies from China. However rheumatoid arthritis is a disease characterised by periodic flare-ups and without more explanation of how immune system parameters might be expected to vary in such patients, and in particular in the trial patients, these data must be considered as interesting and worthy of further research rather than categorical proof.

Discussion

It is common for Chinese research relating to the treatment of Western disease categories with acupuncture to claim success rates of well over 80% with little or no information being provided on outcome measures. However in this review the Chinese evidence includes changes in immunological function as well as pain alleviation and the numbers of patients involved in studies make them difficult to ignore, especially in disorders where conventional treatment is limited. Methodologically there are shortcomings from the point of view of what is scientifically acceptable, clearly, for example, one would need to have a far greater understanding of how the reported trials were carried out and assessed. However, they are more likely than many Western trials to use treatment protocols acceptable to practising acupuncturists, for example Man & Baragar (1974) gave one treatment at 3 points, whereas Liu (1993) gave 30 daily treatments on 22 points. If there is a mechanism whereby acupuncture can bring about an immune response it is hardly surprising that the Chinese treatments find the effect and the more limited Western studies do not.

Conclusion

Acupuncture has been shown to give some pain relief in rheumatoid arthritis and an anti- inflammatory response may also be present. Treatment early in the disease is preferable but age and duration of the disease should not be seen as barriers to treatment The research to date is limited and better trials, incorporating a diagnosis based on TCM differentiation along with pain scales and immune function measurements are advisable. Acknowledgements are due to Leon Saunders, Alison Gould and Hugh MacPherson for their work in preparing this briefing paper.

References

Arthritis Research Campaign Booklet - Osteoarthritis
Arthritis Research Campaign Booklet - Rheumatoid Arthritis
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Christensen BV, Iuhl IU, Vilbek H, Bulow HH, Dreijer NC, Rasmussen HF, 1992.
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Dickens W, Lewith GT, 1989. A Single-Blind Controlled and Randomised Clinical trial to
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Eriksson SV, Lundeberg T, Lundeberg S 1991. Interaction of Diazepam and Naloxone on
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Gaw AC, Chang LW, Shaw LC, 1975. Efficacy of Acupuncture on Osteoarthritic Pain, A
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Guan Z, Zhang J. 1995. Effects of Acupuncture on Immunoglobulins in Patients with Asthma
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ABBREVIATIONS USED

ESR Erythrocyte Sedimentation Rate; a form of blood test, ESR can be raised as a result of
inflammation , for example in autoimmune diseases
Ig Immunoglobulin; a type of protein or antibody produced by the immune system in
response to the presence of foreign proteins
RF Rheumatoid Factor; specific antibodies present in about 80% of rheumatoid arthritis
suffers, one of several tests for the disease
TENS Transcutaneous Electrical Nerve Stimulation

Table 1 - Osteoarthritis: summary of papers reviewed

Table 2 - Rheumatoid Arthritis: overview articles

Table 3 - Rheumatoid Arthritis: summary of papers reviewed