Osteoarthritis involves damage to articular cartilage and other structures in and around joints, with variable levels of inflammation.(Hunter 2006) The most commonly affected joints are the knee and the hip.
It is a common condition; for example, about 10% of people aged over 55 years in the UK have painful knee osteoarthritis associated with mild to moderate disability.(Peat 2001) Many patients with osteoarthritis have significant pain and loss of function, often episodically, and will require treatment to control their symptoms. Around 25% of those with knee osteoarthritis are severely disabled.(Peat 2001) Every year, symptomatic knee osteoarthritis accounts for about 0.5% of all primary care consultations by those aged over 55 years, rising to 1% for those over 70 years.(Peat 2001) Disability due to osteoarthritis can limit quality of life and independent living, or the ability to care for a disabled spouse.(Arden 2006, Dawson 2005, Dawson 2004)
Treatment options for osteoarthritis involve a combination of non-drug and drug interventions.(National Collaborating Centre for Chronic Conditions 2008; Zhang 2008) The non-drug interventions include ongoing access to appropriate information; lifestyle measures (e.g. weight loss, exercise); walking aids; wedged insoles; local therapy involving heat or cold; physiotherapy; transcutaneous electrical nerve stimulation (TENS); cognitive behavioural therapy; and food supplements (e.g. glucosamine).(National Collaborating Centre for Chronic Conditions 2008; Porcheret 2007)
Drugs used include paracetamol, oral or topical NSAIDs, capsaicin, opioids and intra-articular corticosteroid injections.(National Collaborating Centre for Chronic Conditions 2008; Zhang 2008; Porcheret 2007) Joint replacement surgery is an option if pain relief and functional improvements are inadequate with other treatments, and there is a significant impact on quality of life.(National Collaborating Centre for Chronic Conditions 2008, Zhang 2008)
How acupuncture can help
Evidence from a systematic review suggests that moxibustion is more effective than conventional drug therapy for osteoarthritis of the knee, as well as in rheumatic conditions in general, and also that it improves benefits when added to conventional drugs (Choi 2011). Several systematic reviews of acupuncture for osteoarthritis of peripheral joints/knee and hip/knee alone have concluded that it is statistically superior to sham acupuncture and to usual physician care, and similar in benefit to some other active interventions such as exercise regimes (Kwon 2007; White 2007; Manheimer 2007, 2010). All of these, together with the expert consensus guidelines of the Osteoarthritis Research Society International (Zhang 2008, 2009), recognise that it has clinically relevant benefits and a favourable safety profile, and they recommend acupuncture as a treatment option for osteoarthritis. In addition, it has been found to be cost-effective (Reinhold 2008).
There have been many randomised controlled trials of acupuncture and/or moxibustion for osteoarthritis: only those too recent for the systematic reviews are discussed separately here. All seven studies (six for knee and one for hip) reported significantly better changes in the acupuncture than the control groups (Lev-Ari 2011, Sheng 2010, Zhu 2010, Wu 2010, Lu 2010, Ding 2009, Ahsin 2009 ); in two, this superiority was only manifest in the longer- rather than shorter-term. Most reported outcomes for pain and function, some for overall benefit, and one for gait patterns in particular. The acupuncture was more commonly electro- than manual, and moxibustion was added in two trials. The controls used were either sham acupuncture (four studies) or Western drugs (three). These recent trials thus strengthen the findings of the reviews.
In general, acupuncture is believed to stimulate the nervous system and cause the release of neurochemical messenger molecules. The resulting biochemical changes influence the body’s homeostatic mechanisms, thus promoting physical and emotional well-being. Stimulation of certain acupuncture points has been shown to affect areas of the brain that are known to reduce sensitivity to pain and stress (Hui 2010)
Acupuncture treatment may help to relieve pain and improve function in patients with osteoarthritis by:
- Stimulating nerves located in muscles and other tissues, which leads to release of endorphins and other neurohumoral factors, and changes the processing of pain in the brain and spinal cord (Pomeranz 1987; Han 2004; Zhao 2008; Cheng 2009; Ahsin 2009);
- Inhibiting pain through the modulatory effects of endogenous opioids (Uryu 2007; Ahsin 2009);
- Regulating metabolism-related genes and pathways (Tan 2010)
- Inhibiting the activity of cytokines that are mediators of inflammation, including interleukin (IL)-1, IL-6 and tumour necrosis factor (TNF)-alpha (Xu 2009; Wu 2010);
- Reducing inflammation, by promoting release of vascular and immunomodulatory factors (Zijlstra 2003; Kavoussi 2007);
- Increasing local microcirculation (Komori 2009), which aids dispersal of swelling.
- Arden N, Nevitt MC. Osteoarthritis: epidemiology. Best Pract Res Clin Rheumatol 2006; 20: 3-25.
- Dawson J et al. Epidemiology of hip and knee pain and its impact on overall health status in older adults. Rheumatology 2004; 43: 497-504.
- Dawson J et al. Impact of persistent hip or knee pain on overall health status in elderly people: a longitudinal population study. Arthritis Rheum 2005; 53:368-74.
- Hunter DJ, Felson DT. Osteoarthritis. BMJ 2006; 332: 639-42.
- National Collaborating Centre for Chronic Conditions, 2008. Osteoarthritis:national clinical guideline for care and management in adults [online].Available: http://www.nice.org.uk/nicemedia/pdf/CG059FullGuideline.pdf
- Peat G et al. Knee pain and osteoarthritis in older adults: a review of community burden and current use of primary health care. Ann Rheum Dis 2001;60: 91-7.
- Porcheret M et al. Treatment of knee pain in older adults in primary care:development of an evidence-based model of care. Rheumatology 2007; 46:638-48.