Does Needling Sensation (de qi) Affect Treatment Outcome in Pain? Analysis of Data from a Larger Single-blind, Randomised Controlled Trial A Blinded Randomised Trial of Acupuncture (Manual and Electroacupuncture) Compared with a Non-Penetrating Sham for the Symptoms of Osteoarthritis of the Knee A randomized trial of acupuncture as an adjunctive therapy in osteoarthritis of the knee. Interleukin-6 is a significant predictor of radiographic knee osteoarthritis: The Chingford study Acupuncture in patients with osteoarthritis of the knee: a randomised trial Effectiveness of Acupuncture as Adjunctive Therapy in Osteoarthritis of the Knee Effect of acupuncture ‘dose’ on modulation of the default mode network of the brain Acupuncture for chronic knee pain: a randomized clinical trial. The association between leptin, interleukin-6, and hip radiographic osteoarthritis in older people: a cross-sectional study Acupuncture for the treatment of pain of osteoarthritic knees. Central nervous pathway for acupuncture stimulation: localization of processing with functional MR imaging of the brain--preliminary experience. Circulating levels of IL-6 and TNF-α are associated with knee radiographic osteoarthritis and knee cartilage loss in older adults. Validation study of WOMAC: a health status instrument for measuring clinically important patient relevant outcomes to antirheumatic drug therapy in patients with osteoarthritis of the hip or knee. Acupuncture as an adjunctive therapy to pharmacological treatment in patients with chronic pain due to osteoarthritis of the knee: A 3-armed, randomized, placebo-controlled trial De-qi, not psychological factors, determines the therapeutic efficacy of acupuncture treatment for primary dysmenorrhea Acupuncture and knee osteoarthritis: a three-armed randomized trial. How traditional Chinese medicine acupuncturists would diagnose and treat chronic low back pain: results of a survey of licensed acupuncturists in Washington State.
Background Insertion of an acupuncture needle into an acupuncture point typically generates a range of sensations called ‘ de qi ’ . Most acupuncturists are taught that obtaining de qi is important when treating patients with pain but this can be quite uncomfortable for patients . Objective This study assesses the importance of the strength of de qi , on the clinical outcome in osteoarthritic pain . Method This study was part of a larger r and omised , single-blind , multifactorial trial involving three interventions : real acupuncture ( RA ) , Streitberger needle ( SN ) and mock electrical stimulation for the treatment of patients with osteoarthritis ( OA ) of the hip and knee . Patients were treated twice a week for 4 weeks . The two outcomes relevant to this study were pain reduction assessed by visual analogue scale and the Park needling sensation question naire , both measured at completion of the study . Two arms of the trial were analysed ( RA and SN ) . Reduction in pain was correlated against strength of de qi for both RA and SN . Those who felt de qi were compared with those who did not . Results 147 patients were recruited to the study ( 140 completed ) with a mean pain reduction  of 15.2 mm and mean de qi score of 6.2 . There was no significant correlation between the strength of de qi and improvement in pain ( p=0.49 ) . There was also no significant difference in pain relief ( p=0.52 ) between those who felt de qi and those who did not using the de qi subscale of the Park question naire . Conclusion These data suggest that the presence and intensity of de qi has no effect on the pain relief obtained for patients with OA . This result may have implication s for both acupuncture treatment and for future trial methodology Objectives To compare the effect of acupuncture ( manual and electroacupuncture ) with that of a non-penetrating sham ( ‘ placebo ’ needle ) in patients with osteoarthritic knee pain and disability who are blind to the treatment allocation . Methods Acupuncture naive patients with symptomatic and radiological evidence of osteoarthritis of the knee were r and omly allocated to a course of either acupuncture or non-penetrating sham acupuncture using a sheathed ‘ placebo ’ needle system . Acupuncture points for pain and stiffness were selected according to acupuncture theory for treating Bi syndrome . Both manual and electrical stimulation were used . Response was assessed using the WOMAC index for osteoarthritis of the knee , self reported pain scale , the EuroQol score and plasma β-endorphin . The effectiveness of blinding was assessed . Results There were 34 patients in each group . The primary end point was the change in WOMAC pain score after the course of treatment . Comparison between the two treatment groups found a significantly greater improvement with acupuncture ( mean difference 60 , 95 % CI 5 to 116 , P=0.035 ) than with sham . Within the acupuncture group there was a significant improvement in pain ( baseline 294 , mean change 95 , 95 % CI 60 to 130 , P<0.001 ) which was not seen by those who had sham acupuncture ( baseline 261 , mean change 35 , 95 % CI-10 to 80 , P=0.12 ) . Similar effects within group , but not between groups , were seen with the secondary end points of WOMAC stiffness , WOMAC function , and self reported pain . One month after treatment the between group pain difference had been lost ( mean difference 46 ; 95 % CI −9 to 100 , P=0.10 ) although the acupuncture group was still benefiting compared to baseline ( mean difference 59 ; 95 % CI 16 to 102 , P=0.009 ) . The EuroQol score , a generic measure of health related quality of life , was not altered by the treatments . A minority of patients correctly guessed their treatment group ( 41 % in the acupuncture group and 44 % in the control group ) . Plasma β-endorphin levels were not affected by either treatment . Conclusions Acupuncture gives symptomatic improvement for patients with osteoarthritis of the knee , and is significantly superior to non-penetrating sham acupuncture . The study did not confirm earlier reports of release of plasma β-endorphin during acupuncture OBJECTIVE The purpose of this study was to investigate the efficacy of acupuncture as an adjunctive therapy to st and ard care for the relief of pain and dysfunction in elderly patients with osteoarthritis ( OA ) of the knee . METHODS Seventy-three patients with symptomatic OA of the knee were r and omly assigned to treatment ( acupuncture ) or st and ard care ( control ) . Analysis was performed on last score carried forward to account for patients who dropped out before completion . Patients self-scored Western Ontario and McMaster Universities Osteoarthritis Index ( WOMAC ) and Lequesne indices at baseline and at 4 , 8 and 12 weeks . Patients in the control group were offered acupuncture treatment after 12 weeks . The data for these patients are pooled with those from the original acupuncture group for within-group analysis . RESULTS Patients r and omized to acupuncture improved on both WOMAC and Lequesne indices compared to those who received st and ard treatment alone . Significant differences on total WOMAC Scale were seen at 4 and 8 weeks . There appears to be a slight decline in effect at 4 weeks after cessation of treatment ( 12 weeks after first treatment ) . No adverse effects of acupuncture were reported . CONCLUSION These data suggest that acupuncture is an effective and safe adjunctive therapy to conventional care for patients with OA of the knee Objective There is a great need for identification of biomarkers that could improve the prediction of early osteoarthritis ( OA ) . We undertook this study to determine whether circulating levels of interleukin-6 ( IL-6 ) , tumor necrosis factor α ( TNFα ) , and C-reactive protein ( CRP ) can serve as useful markers of radiographic knee OA ( RKOA ) in a normal human population . Methods RKOA data were obtained from the cohort of the Chingford Study , a prospect i ve population -based study of healthy , middle-aged British women . The RKOA-affected status of the subjects was assessed using the  Kellgren/Lawrence ( K/L )  grade as determined on radiographs obtained at baseline ( n = 908 ) and at 10 years and 15 years thereafter . Serum levels of CRP , IL-6 , and TNFα  were assayed at 5 , 8 , and 15 years , using high-sensitivity commercial assays . A K/L grade of ≥2 in either knee was used as the outcome measure . Statistical analyses included analysis of variance for repeated measurements and logistic regression models , together with longitudinal modeling of dichotomous responses . Results During 15 years of followup , the prevalence of RKOA ( K/L grade ≥2 ) increased from 14.7 % to 48.7 % ( P < 0.00001 versus baseline ) . The body mass index ( BMI ) and circulating levels of CRP and IL-6 were consistently and significantly higher in subjects diagnosed as having RKOA . When multiple logistic regression was applied to the data , the variables of older age ( P = 3.93 × 10−5 ) , higher BMI at baseline ( P = 0.0003 ) , and increased levels of IL-6 at year 5 ( P = 0.0129 ) were determined to be independent predictors of the appearance of RKOA at year 10 . The results were fully confirmed using longitudinal modeling of repeated measurements of the data obtained at 3 visits . The odds ratio for RKOA in subjects whose IL-6 levels were in the fourth quartile of increasing levels ( versus the first quartile ) was 2.74 ( 95 % confidence interval 1.94–3.87 ) . Conclusion This followup study showed that individuals were more likely to be diagnosed as having RKOA if they had a higher BMI and increased circulating levels of IL-6 . These results should stimulate more work on IL-6 as a potential therapeutic target BACKGROUND Acupuncture is widely used by patients with chronic pain although there is little evidence of its effectiveness . We investigated the efficacy of acupuncture compared with minimal acupuncture and with no acupuncture in patients with osteoarthritis of the knee . METHODS Patients with chronic osteoarthritis of the knee ( Kellgren grade < or = 2 ) were r and omly assigned to acupuncture ( n=150 ) , minimal acupuncture ( superficial needling at non-acupuncture points ; n=76 ) , or a waiting list control ( n=74 ) . Specialised physicians , in 28 outpatient centres , administered acupuncture and minimal acupuncture in 12 sessions over 8 weeks . Patients completed st and ard question naires at baseline and after 8 weeks , 26 weeks , and 52 weeks . The primary outcome was the Western Ontario and McMaster Universities Osteoarthritis ( WOMAC ) index at the end of week 8 ( adjusted for baseline score ) . All main analyses were by intention to treat . RESULTS 294 patients were enrolled from March 6 , 2002 , to January 17 , 2003 ; eight patients were lost to follow-up after r and omisation , but were included in the final analysis . The mean baseline-adjusted WOMAC index at week 8 was 26.9 ( SE 1.4 ) in the acupuncture group , 35.8 ( 1.9 ) in the minimal acupuncture group , and 49.6 ( 2.0 ) in the waiting list group ( treatment difference acupuncture vs minimal acupuncture -8.8 , [ 95 % CI -13.5 to -4.2 ] , p=0.0002 ; acupuncture vs waiting list -22.7 [ -27.5 to -17.9 ] , p<0.0001 ) . After 52 weeks the difference between the acupuncture and minimal acupuncture groups was no longer significant ( p=0.08 ) . INTERPRETATION After 8 weeks of treatment , pain and joint function are improved more with acupuncture than with minimal acupuncture or no acupuncture in patients with osteoarthritis of the knee . However , this benefit decreases over time Context Previous studies of acupuncture for osteoarthritis have had conflicting results . This may have occurred because most studies have included small sample s , a limited number of treatment sessions , or other limitations . Contribution This r and omized , controlled trial compared 24 acupuncture sessions over 26 weeks with sham acupuncture or arthritis education in 570 patients with osteoarthritis of the knee .  Acupuncture led to greater improvements in function but not pain after 8 weeks and in both pain and function after 26 weeks . No adverse effects were associated with acupuncture . Caution s Many participants dropped out of the study , so readers should interpret the findings at 26 weeks with caution . The Editors Osteoarthritis is the most common form of arthritis and is a major cause of morbidity , limitation of activity , and health care utilization , especially in elderly patients ( 1 , 2 ) . Pain and functional limitation are the primary clinical manifestations of osteoarthritis of the knee . Current recommendations for managing osteoarthritis , including guidelines published by the American College of Rheumatology ( 3 ) and European League of Associations of Rheumatology ( 4 ) , focus on relieving pain and stiffness and maintaining or improving physical function as important goals of therapy . No curative therapies exist for osteoarthritis ; thus , both pharmacologic and nonpharmacologic management focus on controlling pain and reducing functional limitation ( 5 ) . Nonpharmacologic therapy , which includes patient education , social support , physical and occupational therapy , aerobic and resistive exercises , and weight loss , is the cornerstone of a multidisciplinary approach to osteoarthritis patient management ( 3 ) . Pharmacologic therapies include nonopioid analgesics ( such as acetaminophen ) , nonsteroidal anti-inflammatory drugs ( NSAIDs ) ( including cyclooxygenase-2 [ COX-2 ] enzyme selective inhibitors ) , topical analgesics ( capsaicin cream ) , opioid analgesics , and intra-articular steroid and hyaluronate injections . Often , these agents are used in combination for additive analgesic efficacy ( 6 ) . Pharmacologic management of osteoarthritis is often ineffective , and agents such as NSAIDs may cause unwanted and dangerous side effects ( 7 , 8) . Complementary and alternative medicine is another approach to treating osteoarthritis ( 9 - 12 ) , particularly in Asian societies ( 13 ) . Many U.S. patients with osteoarthritis also use complementary and alternative medical therapies ( 14 ) . A systematic review of acupuncture and knee osteoarthritis ( 15 ) identified 7 small r and omized , controlled trials published in English . Within the method ologic limitations of the studies , the evidence suggested that acupuncture seemed to alleviate knee pain and function compared with sham acupuncture controls , although 2 trials comparing acupuncture with an active , nonpharmacologic treatment ( physical therapy ) did not indicate such an effect ( 16 , 17 ) . Before conducting our large-scale trial , we completed both a pilot study ( 18 ) and a r and omized , single-blind trial ( 19 ) of the effect of acupuncture on osteoarthritis of the knee . Participants in the uncontrolled pilot study ( n= 12 ) showed statistically significant improvement in both self-reported pain and physical function , as well as performance measures of physical function after 8 weeks of acupuncture treatment and at 12-week follow-up as compared with their baseline ( 18 ) . In our larger r and omized , single-blind trial ( n= 73 ) , which examined the benefit of acupuncture added to st and ard management with NSAIDs , the acupuncture  treatment group experienced statistically significant improvements in self-reported pain and disability scores compared with a st and ard-care control group as late as 4 weeks after the end of treatment ( 19 ) . However , this effect diminished within 18 weeks ( 26 weeks after the beginning of the trial ) after the final acupuncture treatment . Together , however , the previously conducted trials ( both our preliminary studies [ 18 , 19 ] and those referenced in the systematic review [ 15 ] ) have 3 method ologic limitations : lack of credible controls for the placebo effect , inadequate assessment of long-term treatment benefits , and insufficient sample sizes . We tested the hypothesis that an 8-week intensive acupuncture treatment regimen , followed by an 18-week tapering regimen , reduces pain and improves function among patients with knee osteoarthritis as compared with both sham acupuncture and education control groups . Methods Patient Recruitment We recruited patients for this multisite , placebo-controlled trial from March 2000 through December 2003 , primarily through print and radio advertisements . The 3 sites were the Integrative Medicine Clinic of the University of Maryl and School of Medicine , Baltimore , Maryl and ; the Innovative Medical Research Center ( a private research firm ) , Towson , Maryl and ; and the Hospital for Special Surgery , New York City , New York . The institutional review boards of the 3 sites approved the study . We determined the sample size ( n= 570 ) by a power analysis based on our r and omized pilot study ( 19 ) , adjusted by the estimated decrease in effect size result ing from the inclusion of a sham acupuncture group design ed to control for placebo effects . Patients met the following inclusion criteria : age 50 years or older , a diagnosis of osteoarthritis of the knee , radiographic evidence of at least 1 osteophyte at the tibiofemoral joint ( KellgrenLawrence grade 2 ) , moderate or greater clinical ly significant knee pain on most days during the past month , and willingness to be r and omly assigned . Exclusion criteria were the presence of serious medical conditions that precluded participation in study , bleeding disorders that might contraindicate acupuncture , intra-articular corticosteroid or hyaluronate injections ( as well as any knee surgeries or concomitant use of topical capsaicin cream ) during the past 6 months , previous experience with acupuncture , or any planned events ( including total knee replacement ) that would interfere with participation in the study during the following 26 weeks . After a brief telephone screening , patients were scheduled to visit 1 of the 3 participating sites to sign an informed consent statement and undergo a brief rheumatologic examination ( including radiographic examination of affected knees ) by a physician or a nurse practitioner . Because the education course was a group activity , patients were recruited until a cohort of 12 to 21 patients was formed , at which point each cohort at each site was r and omly assigned to 1 of 3 groups by a computer-generated process using r and omly selected blocks of 3 , 6 , and 9 . We assured allocation concealment by using disguised letter codes that were generated and sent to the site coordinators by a central statistical core . We used this procedure to ensure that approximately equal numbers of participants were in each treatment group across the course of the study , to ensure that each cohort would have participants assigned to all 3 treatment groups , and to make the breaking of the group assignment process more difficult . The research assistants who collected assessment s from participants , the participants themselves ( in the true acupuncture and sham acupuncture groups ) , and the statistician were blinded to group assignment . Assessment s were conducted at baseline and 4 , 8 , 14 , and 26 weeks after r and omization . Study Interventions We developed and modified the acupuncture treatment and sham control protocol s from previously reported and vali date d procedures ( 18 - 21 ) . During the trial , 7 acupuncturists were used : 3 at the Integrative Medicine Clinic , 3 at the Innovative Medical Research Center , and 1 at the Hospital for Special Surgery . In general , acupuncturists were assigned to the same participants throughout the 26-week treatment schedule , except for vacation conflicts and staff turnover , and provided approximately the same proportions of true versus sham procedures . All acupuncturists were state-licensed and had at least 2 years of clinical experience . The study 's principal acupuncturist trained and supervised the acupuncturists in performing true or sham procedures and avoiding interactions that could inadvertently communicate group assignment . True Acupuncture The true acupuncture  ( experimental ) group underwent 26 weeks of gradually tapering treatment according to the following schedule : 8 weeks of 2 treatments per week followed by 2 weeks of 1 treatment per week , 4 weeks of 1 treatment every other week , and 12 weeks of 1 treatment per month . We based the acupuncture point selection s on Traditional Chinese Medicine meridian theory to treat knee joint pain , known as the Bi syndrome . These points consisted of 5 local points ( Yanglinquan [ gall bladder meridian point 34 ] , Yinlinquan [ spleen meridian point 9 ] , Zhusanli [ stomach meridian point 36 ] , Dubi [ stomach meridian point 35 ] , and extra point Xiyan ) and 4 distal points ( Kunlun [ urinarybladder , meridian point 60 ] , Xuanzhong [ gall bladder meridian point 39 ] , Sanyinjiao [ spleen meridian point 6 ] , and Taixi [ kidney meridian point 3 ] ) on meridians that traverse the area of pain ( 22 , 23 ) . The same points were treated for each affected leg . If both knees were affected , 9 needles were inserted in each leg . ( The outcome measures were not specifically targeted to whether the patient had osteoarthritis in 1 or both knees , and we observed no differential effects on the basis of the number of knees treated . ) The acupuncturists inserted 1.5-inch ( for local points ) and 1-inch ( for distal points ) 32-gauge ( 0.25-mm diameter ) acupuncture needles to a conventional depth of approximately 0.3 to 1.0 inch , depending on point location . All participants in the treatment group achieved the De-Qi sensation , a local sensation of heaviness , numbness , soreness , or paresthesia that accompanies the insertion and manipulation of needles during acupuncture , at these 9 points . Acupuncturists applied electrical Objective Recent functional MRI ( fMRI ) studies show that brain activity , including the default mode network ( DMN ) , can be modulated by acupuncture . Conventional means to enhance the neurophysiological ‘ dose ’ of acupuncture , including an increased number of needles and manual needle manipulation , are expected to enhance its physiological effects . The aim of this study was to compare the effects of both methods on brain activity . Methods 58 healthy volunteers were r and omly assigned into four groups that received single needle acupuncture ( SNA , n=15 ) or transcutaneous electrical nerve stimulation ( TENS , n=13 ) as active controls , or enhanced acupuncture by way of three needle acupuncture ( TNA , n=17 ) or SNA plus manual stimulation ( SNA+MS , n=13 ) . Treatment-associated sensations were evaluated using a visual analogue scale . Central responses were recorded before , during , and after treatment at LI4 on the left h and using resting state fMRI . Results TNA and SNA+MS induced DMN-insula activity and extensive DMN activity compared to SNA , despite comparable levels of de qi sensation . The TNA and SNA+MS groups exhibited a delayed and enhanced modulation of the DMN , which was not observed followed SNA and TENS . Furthermore , TNA increased precuneus activity and increased the DMN-related activity of the cuneus and left insula , while SNA+MS increased activity in the right insula . Conclusions The results showed that conventional methods to enhance the acupuncture dose induce different DMN modulatory effects . TNA induces the most extensive DMN modulation , compared with other methods . Conventional methods of enhancing the acupuncture dose could potentially be applied as a means of modulating brain activity IMPORTANCE There is debate about benefits of acupuncture for  knee pain . OBJECTIVE To determine the efficacy of laser and needle acupuncture for  chronic knee pain . DESIGN , SETTING , AND PARTICIPANTS Zelen- design clinical trial ( r and omization occurred before informed consent ) , in Victoria , Australia ( February 2010-December 2012 ) . Community volunteers ( 282 patients aged ≥50 years with chronic knee pain ) were treated by family physician acupuncturists . INTERVENTIONS No acupuncture ( control group , n = 71 ) and needle ( n = 70 ) , laser ( n = 71 ) , and sham laser ( n = 70 ) acupuncture . Treatments were delivered for 12 weeks . Participants and acupuncturists were blinded to laser and sham laser acupuncture . Control participants were unaware of the trial . MAIN OUTCOMES AND MEASURES Primary outcomes were average knee pain ( numeric rating scale , 0 [ no pain ] to 10 [ worst pain possible ] ; minimal clinical ly important difference [ MCID ] , 1.8 units ) and physical function ( Western Ontario and McMaster Universities Osteoarthritis Index , 0 [ no difficulty ] to 68 [ extreme difficulty ] ; MCID , 6 units ) at 12 weeks . Secondary outcomes included other pain and function measures , quality of life , global change , and 1-year follow-up . Analyses were by intention-to-treat using multiple imputation for missing outcome data . RESULTS At 12 weeks and 1 year , 26 ( 9 % ) and 50 ( 18 % ) participants were lost to follow-up , respectively . Analyses showed neither needle nor laser acupuncture  significantly improved pain ( mean difference ; -0.4 units ; 95 % CI , -1.2 to 0.4 , and -0.1 ; 95 % CI , -0.9 to 0.7 , respectively ) or function ( -1.7 ; 95 % CI , -6.1 to 2.6 , and 0.5 ; 95 % CI , -3.4 to 4.4 , respectively ) compared with sham at 12 weeks . Compared with control , needle and laser acupuncture result ed in modest improvements in pain ( -1.1 ; 95 % CI , -1.8 to -0.4 , and -0.8 ; 95 % CI , -1.5 to -0.1 , respectively ) at 12 weeks , but not at 1 year . Needle acupuncture result ed in modest improvement in function compared with control at 12 weeks ( -3.9 ; 95 % CI , -7.7 to -0.2 ) but was not significantly different from sham ( -1.7 ; 95 % CI , -6.1 to 2.6 ) and was not maintained at 1 year . There were no differences for most secondary outcomes and no serious adverse events . CONCLUSIONS AND RELEVANCE In patients older than 50 years with moderate or severe chronic knee pain , neither laser nor needle acupuncture conferred benefit over sham for pain or function . Our findings do not support acupuncture for these patients . TRIAL REGISTRATION anzctr.org.au Identifier : ACTRN12609001001280 Introduction The associations between leptin , interleukin (IL)-6 , and hip radiographic osteoarthritis  ( OA ) have not been reported , and their roles in obesity-related hip OA are unclear . The aim of this study was to describe the associations between leptin , IL-6 , and hip radiographic osteoarthritis ( ROA ) in older adults . Methods A cross-sectional sample of 193 r and omly selected subjects ( mean age , 63 years ; range , 52 to 78 years ; 48 % female subjects ) were studied .  Hip ROA , including joint-space narrowing ( JSN ) and osteophytes , was determined by anteroposterior radiograph .  Serum levels of leptin and interleukin (IL)-6  were measured with radioimmunoassay .  Fat mass was measured with dual-energy x-ray absorptiometry ( DXA ) . Body mass index ( BMI ) and waist-to-hip ratio ( WHR ) were calculated . Results In multivariable analysis , hip JSN was associated with serum levels of leptin in the whole sample ( β = 0.046 per μg/L , P = 0.024 for superior ; β = 0.068 per μg/L , P = 0.004 for axial compartment ) and IL-6 only in females ( β = 0.241 per pg/ml , P = 0.002 for superior ; β = 0.239 per pg/ml , P = 0.001 for axial compartment ) . The positive associations between body-composition measures ( BMI , WHR , percentage total fat mass , and percentage trunk fat mass ) and hip JSN in women became nonsignificant after adjustment for leptin but not for IL-6 . No significant associations were found between leptin , IL-6 , and the presence or severity of osteophytes . Conclusions This study suggests that metabolic and inflammatory mechanisms may play a role in the etiology of hip OA and that the associations between body composition and hip JSN are mediated by leptin , particularly in women OBJECTIVE The purpose of this study was to determine whether acupuncture was more effective than sham acupuncture in the reduction of pain in persons with osteoarthritis ( OA ) of the knee . METHODS Forty subjects ( 20 men , 20 women ) with radiographic evidence of OA of the knee were stratified by gender and r and omly assigned to either the experimental ( real acupuncture ) or control ( sham acupuncture ) groups . Subjects were treated three times per week for 3 weeks and evaluated at three test sessions . Outcome measures were : 1 ) the Pain Rating Index of the McGill Pain Question naire , 2 ) the Western Ontario and McMaster Universities ( WOMAC ) Osteoarthritis Index , and 3 ) pain threshold at four sites at the knee . RESULTS The analyses of variance showed that both real and sham acupuncture significantly reduced pain , stiffness , and physical disability in the OA knee , but that there were no significant differences between groups . CONCLUSIONS Acupuncture is not more effective than sham acupuncture in the treatment of OA pain PURPOSE To characterize the central nervous system ( CNS ) pathway for acupuncture stimulation in the human brain by using functional magnetic resonance ( MR ) imaging . MATERIAL S AND METHODS Functional MR imaging of the whole brain was performed in two groups of nine healthy subjects during four stimulation paradigms : real acupuncture at acupoints ST.36 ( on the leg ) and LI.4 ( on the h and ) and control stimulations ( minimal acupuncture and superficial pricking on the leg ) . Stimulations were performed in semir and omized , balanced order nested within two experiments . Psychophysical responses ( pain , De-Qi effect [ characteristic acupuncture effect of needle-manipulation sensation ] , anxiety , and unpleasantness ) and autonomic responses were assessed . Talairach coordinates-transformed imaging data were averaged for a group analysis . RESULTS Acupuncture at LI.4 and ST.36 result ed in significantly higher scores for De-Qi and in substantial bradycardia .  Acupuncture at both acupoints result ed in activation of the hypothalamus and nucleus accumbens and deactivation of the rostral part of the anterior cingulate cortex , amygdala formation , and hippocampal complex ; control stimulations did not result in such activations and deactivations . CONCLUSION Functional MR imaging can demonstrate the CNS pathway for acupuncture stimulation . Acupuncture at ST.36 and LI.4 activates structures of descending antinociceptive pathway and deactivates multiple limbic areas subserving pain association . These findings may shed light on the CNS mechanism of acupuncture analgesia and form a basis for future investigations of endogenous pain modulation circuits in the human brain OBJECTIVE The role of inflammation in osteoarthritis ( OA ) pathogenesis is unclear , and the associations between inflammatory cytokines and cartilage loss have not been reported . We determined the associations between serum levels of interleukin (IL)-6 and tumor necrosis factor-α ( TNF-α ) , knee radiographic OA ( ROA ) and cartilage loss over 2.9 years in older adults . METHODS A total of 172 r and omly selected subjects ( mean 63 years , range 52 - 78 , 47 % female ) were studied at baseline and approximately 3 ( range 2.6 - 3.3 ) years later . IL-6 and TNF-α were assessed by radioimmunoassay . T1-weighted fat-suppressed magnetic resonance imaging of the right knee was performed at baseline and follow-up to determine knee cartilage volume . Knee ROA of both knees was assessed at baseline . RESULTS At baseline , quartiles of IL-6 and TNF-α were associated with increased prevalence of medial tibiofemoral joint space narrowing ( OARSI grade ≥ 1 ) in multivariate analyses [ odds ratio ( OR ) : 1.42 and 1.47 per quartile , respectively , both P<0.05 ] . Longitudinally , baseline IL-6 predicted loss of both medial and lateral tibial cartilage volume ( β : -1.19 % and -1.35 % per annum per quartile , P<0.05 and P<0.01 , respectively ) , independently of TNF-α . Change in IL-6 was associated with increased loss of medial and lateral tibial cartilage volume ( β : -1.18 % and -1.06 % per annum per quartile , both P<0.05 ) and change in TNF-α was also negatively associated with change in medial cartilage volume ( β : -1.27 % per annum per quartile , P<0.05 ) . CONCLUSIONS Serum levels of IL-6 and TNF-α are associated with knee cartilage loss in older people suggesting low level inflammation plays a role in the pathogenesis of knee OA Within the context of a double blind r and omized controlled parallel trial of 2 nonsteroidal antiinflammatory drugs , we vali date d WOMAC , a new multidimensional , self-administered health status instrument for patients with osteoarthritis of the hip or knee . The pain , stiffness and physical function subscales fulfil conventional criteria for face , content and construct validity , reliability , responsiveness and relative efficiency . WOMAC is a disease-specific purpose built high performance instrument for evaluative research in osteoarthritis clinical trials Summary Acupuncture is a useful and safe adjunctive therapy to pharmacological treatment in the short term management of knee osteoarthritis . Abstract The efficacy of acupuncture as an adjunctive therapy to pharmacological treatment of chronic pain due to knee osteoarthritis was studied with a 3‐armed , single‐blind , r and omized , sham‐controlled trial ; it compared acupuncture combined with pharmacological treatment , sham acupuncture including pharmacological treatment , and pharmacological treatment alone . A total of 120 patients with knee osteoarthritis were r and omly allocated to 3 groups : group I was treated with acupuncture and etoricoxib , group II with sham acupuncture and etoricoxib , and group III with etoricoxib . The primary efficacy variable was the Western Ontario and McMaster Universities ( WOMAC ) index and its subscales at the end of treatment at week 8 . Secondary efficacy variables included the WOMAC index at the end of weeks 4 and 12 , a visual analogue scale ( VAS ) at the end of weeks 4 , 8 , and 12 , and the Short Form 36 version 2 ( SF‐36v2 ) health survey at the end of week 8 . An algometer was used to determine changes in a predetermined unique fixed trigger point for every patient at the end of weeks 4 , 8 , and 12 . Group I exhibited statistically significant improvements in primary and secondary outcome measures , except for Short Form mental component , compared with the other treatment groups . We conclude that acupuncture with etoricoxib is more effective than sham acupuncture with etoricoxib , or etoricoxib alone for the treatment of knee osteoarthritis Objective To study the impact of De-qi ( 得气 , obtaining qi ) and psychological factors on the efficacy of acupuncture treatment for primary dysmenorrhea , with an attempt to explore the relationship among De-qi , psychological factors , and clinical efficacy . Methods The patients with primary dysmenorrhea were r and omly assigned to a group of acupuncture with manual manipulation ( manipulation group , n=67 ) and an acupuncture group without manipulation ( non-manipulation group , n=64 ) . Pain intensity and pain duration were used as measures for evaluating the therapeutic efficacy of the acupuncture treatment . De-qi , the sensations a patient experienced during the acupuncture treatment , was scored on a 4-point scale by the subjects . In addition , the psychological factors , including belief in acupuncture , the level of nervousness , anxiety , and depression , were quantitatively assessed . The personality of the subject was assessed using the Eysenck personality question naire ( EPQ ) and 16 personality factor question naire ( 16PF ) . Results Complete data were obtained from 120 patients , 60 patients in each group . There were statistically significant differences in pain intensity ( W=2410.0 , P<0.01 ) and pain duration ( W=3181.0 , P<0.01 ) between the two groups . The number of De-qi acupoints ( W=1150.5 , P<0.01 ) and the average intensity of De-qi ( W=1141.0 , P<0.01 ) were significantly higher in the manipulation group as compared with their non-manipulation counterparts . The correlation coefficients between De-qi and therapeutic efficacy of acupuncture were greater than those between psychological factors and therapeutic efficacy . Conclusions Compared with the psychological factors , De-qi contributed more to the pain-relieving effect of acupuncture in subjects with primary dysmenorrhea . Moreover , manual manipulation is a prerequisite for eliciting and enhancing the De-qi sensations , and De-qi is critical for achieving therapeutic effects BACKGROUND Despite the popularity of acupuncture , evidence of its efficacy for reducing pain remains equivocal . OBJECTIVE To assess the efficacy and safety of traditional Chinese acupuncture ( TCA ) compared with sham acupuncture ( needling at defined nonacupuncture points ) and conservative therapy in patients with chronic pain due to osteoarthritis of the knee . DESIGN R and omized , controlled trial . SETTING 315 primary care practice s staffed by 320 practitioners with at least 2 years ' experience in acupuncture . PATIENTS 1007 patients who had had chronic pain for at least 6 months due to osteoarthritis of the knee ( American College of Rheumatology [ ACR ] criteria and Kellgren-Lawrence score of 2 or 3 ) . INTERVENTIONS Up to 6 physiotherapy sessions and as-needed anti-inflammatory drugs plus 10 sessions of TCA , 10 sessions of sham acupuncture , or 10 physician visits within 6 weeks . Patients could request up to 5 additional sessions or visits if the initial treatment was viewed as being partially successful . MEASUREMENTS Success rate , as defined by at least 36 % improvement in Western Ontario and McMaster Universities Osteoarthritis Index ( WOMAC ) score at 26 weeks . Additional end points were WOMAC score and global patient assessment . RESULTS Success rates were 53.1 % for TCA , 51.0 % for sham acupuncture , and 29.1 % for conservative therapy . Acupuncture groups had higher success rates than conservative therapy groups ( relative risk for TCA compared with conservative therapy , 1.75 [ 95 % CI , 1.43 to 2.13 ] ; relative risk for sham acupuncture compared with conservative therapy , 1.73 [ CI , 1.42 to 2.11 ] ) . There was no difference between TCA and sham acupuncture ( relative risk , 1.01 [ CI , 0.87 to 1.17 ] ) . LIMITATIONS There was no blinding between acupuncture and traditional therapy and no monitoring of acupuncture compliance with study protocol . In general , practitioner-patient contacts were less intense in the conservative therapy group than in the TCA and sham acupuncture groups . CONCLUSIONS Compared with physiotherapy and as-needed anti-inflammatory drugs , addition of either TCA or sham acupuncture led to greater improvement in WOMAC score at 26 weeks . No statistically significant difference was observed between TCA and sham acupuncture , suggesting that the observed differences could be due to placebo effects , differences in intensity of provider contact , or a physiologic effect of needling regardless of whether it is done according to TCA principles OBJECTIVES This survey was undertaken to learn how Traditional Chinese Medicine acupuncturists ' diagnose and treat patients with chronic low back pain in order to develop a st and ardized treatment for a clinical trial of that condition . DESIGN We surveyed a r and omly selected group of 56 acupuncturists in Washington State , USA about styles of  acupuncture they used for treating chronic low back pain , diagnoses made , and key features of treatment for this condition . RESULTS While substantial variability existed among practitioners , there was agreement on several broad features of treatment including : the use of local and distal acupuncture points  ( 86 % of practitioners ) , the use of acupuncture points on the meridians traversing the back ( especially the UB meridian , 90 % ) the use of acupoints determined by palpation ( 82 % ) , the importance of eliciting de qi ( 60 % ) , and of providing up to eight treatments for achieving therapeutic results ( 79 % ) . CONCLUSION The use of practitioner surveys can enhance the systematic development of acupuncture treatment protocol s and should be part of this process in future clinical trials of common conditions
Background : Acupuncture is a widely used treatment for  knee osteoarthritis  , but evidence of its effectiveness from r and omised controlled trials ( RCTs ) is contradictory .
Objective : To systematic ally review RCTs to determine whether the effect of acupuncture is dose dependent for symptom management in knee osteoarthritis .