Acupuncture and Osteoarthritis
Research is mixed when it comes to needle sticks relieving OA pain. But does the research tell the whole story?
People with osteoarthritis (OA) who seek symptom relief outside of mainstream medicine have many options, from exotic herbal preparations to hands-on treatments such as massage and chiropractic. However, just 1 or 2 percent of OA patients choose to try acupuncture, despite the popularity of this ancient therapy for treating other conditions. That’s unfortunate, say physicians who practice acupuncture or refer patients to specialists for treatments. While poking someone with a pin to cure pain may seem counterintuitive, they insist that acupuncture often provides modest symptom improvement and serves as a useful add-on therapy for people struggling with aching joints.
One barrier to greater acceptance may be that many studies have found acupuncture to offer minimal benefits for OA, at best. Yet researchers point out that designing clinical trials to test acupuncture – and interpreting their results – is tricky business, which may misrepresent the true value of pinprick therapy.
How Does Acupuncture Work – and How Well?
Acupuncture has been practiced for thousands of years and plays an important role in traditional Chinese medicine (TCM). Acupuncturists treat medical conditions by inserting slender metal needles into the skin at specific points on the body. According to principles of TCM, health is governed by the flow of energy (known as qi) throughout the body along pathways called meridians. Illness occurs when this energy flow is disrupted or becomes unbalanced, the theory goes. Precise insertion of acupuncture needles is said to restore the flow of this essential energy and improve health.
Western medicine doesn’t recognize the concepts of qi and meridians. However, a solid body of scientific evidence suggests alternate explanations for why acupuncture might provide pain relief.
“There’s a lot of research that says when we put an acupuncture needle into the body, a number of physiological mechanisms occur,” says Brian Berman, MD, a professor of family and community medicine and director of the University of Maryland Center for Integrative Medicine.
A well-placed needle insertion sets off a cascade of events, Dr. Berman explains, producing a signal that travels along the spinal cord to the brain, triggering a release of neurotransmitters called endorphins and enkephalins, which scientists believe reduce the sensation of pain. Research also shows that the inserting an acupuncture needle induces production of cortisol, a hormone that helps to control inflammation. Acupuncture may stimulate activity of other pain-relieving chemicals in the body, as well.
But do all these biochemical changes relieve sore, stiff joints? In the largest study of its kind ever conducted, Dr. Berman and his colleagues recruited 570 men and women over 50 who had osteoarthritis of the knee. Some of the study subjects were placed in a group that received 23 acupuncture treatments over the course of a half year or so. For comparison, the researchers gave a control group of study participants a placebo, or phony treatment designed to simulate acupuncture; the investigators used specially designed fake needles that produced the sensation of pinpricks, but didn’t pierce the skin.
The 2004 trial, which was published in the Annals of Internal Medicine, found that after 26 weeks, patients receiving real acupuncture felt significantly less pain and functioned better (as measured by how far they could walk in six minutes) than their counterparts who received fake acupuncture.
The Trouble with Fake Acupuncture
Yet, many other studies comparing real acupuncture to fake or “sham” acupuncture for OA have found needle therapy to be much less effective, points out researcher Eric Manheimer, the lead author of a major 2010 review of the scientific literature on acupuncture and OA and a colleague of Dr. Berman’s at the University of Maryland. However, there are several reasons why trials using sham acupuncture as a placebo may produce disappointing – and misleading – results, Manheimer explains.
Placebos used in clinical trials are supposed to be inert and have no medicinal value. Yet the fake needles used as placebos in some trials may have stimulated acupuncture points even if they didn’t penetrate the skin. In other trials, investigators have performed sham acupuncture by using real needles, but inserting them randomly – that is, they avoided traditional acupuncture points.
However, some scientists believe that any piercing of the skin could stimulate the neurochemical changes associated with acupuncture. In these scenarios, says Manheimer, unintended pain relief brought on by sham acupuncture may have distorted the study results, since in some cases the fake treatments behaved too much like real acupuncture.
Meanwhile, much greater benefits for OA have been found in research trials where sham acupuncture isn’t used as a placebo. In these studies, patients undergoing acupuncture have been compared to other patients who received only standard care such as pain relievers and physical therapy. Unlike placebo-controlled studies, in these trials patients in the treatment group knew they were receiving real acupuncture.
Some critics argue that these studies aren’t reliable, since patients who know they’re getting an active treatment may be biased, making them more inclined to report feeling less pain and disability. But Dr. Berman feels that these types of studies reflect how medicine works in the real world. “We’re people, and we have our expectations and beliefs. That can be a big part of the overall effect” of acupuncture or any therapy, he says.
Not For Everyone
Acupuncture doesn’t seem to work for everyone, but slightly more than half of patients with moderate OA will experience some benefit, says pain specialist James N. Dillard, MD, former medical director of Columbia University’s Rosenthal Center for Complementary and Alternative Medicine.
Dr. Dillard believes that acupuncture is superior to corticosteroid injections, a common treatment for OA, and just as effective as frequently prescribed drugs such as duloxetine and tramadol. “And it’s incredibly safe,” he adds.
Side effects, such as bleeding and bruising, are uncommon. By contrast, notes Dr. Dillard, many patients can’t tolerate non-steroidal anti-inflammatory drugs (NSAIDs) and other OA medications. “The adverse side effects a patient may have with those drugs are way, way worse,” he says.
If you decide to try acupuncture, ask your doctor for a referral or check with an organization such as the American Academy of Medical Acupuncture (www.medicalacupuncture.org). Find out if a practitioner is licensed and ask what type of acupuncture he or she practices.
There are several forms of the therapy, including electroacupuncture, in which needles are connected to wires that deliver a mild electrical current. (Electroacupuncture generates a greater release of pain-blunting neurochemicals, according to some practitioners.) Some health insurance plans cover the cost of acupuncture. If it isn't covered under your plan, expect to pay anywhere from $60 to $150 per session.
Certain forms of OA may respond better than others to acupuncture. Patients with OA of the knee and spine appear to have the most success, says rheumatologist Scott Zashin, MD, a clinical assistant professor of internal medicine at the University of Texas Southwestern Medical School at Dallas.
Dr. Zashin, who practices electroacupuncture on occasion, says it can take three or more sessions before symptoms begin to improve and that benefits usually last a month or so, after which follow-up treatment is necessary. He believes that acupuncture can provide important pain relief as part of an overall plan for managing OA.
Adds Dr. Zashin: “I think we should be using it more often.”