A study suggests that compared to a placebo, acupuncture may not be helpful for treating knee osteoarthritis pain. 

“It might be disappointing, but data is data. And I think it’s better to know the truth,” says lead author Maria Suarez-Almazor, MD, PhD, chief of rheumatology at the MD Anderson Cancer Center in Houston. “My patients – I don’t tell them not to do it. If they ask me, what I’ll tell them is the studies don’t show there’s a lot of benefit. And if there is, it’s quite small. However we know that acupuncture is quite safe, so if you want to try it, by all means try it.”

Acupuncture is used by many people with osteoarthritis, or OA, and it involves using thin needles to stimulate specific points on the body in hopes of removing blockages to channels of energy known as meridians. 

Traditional Chinese medical experts believe this will allow energy to flow properly through the body, leading to a balanced state.

A recent study by the National Center for Complementary and Alternative Medicine estimated that 3.1 million adults in the U.S. are treated with acupuncture annually.

For the study, published in 2010 in Arthritis Care & Research, researchers used real and fake (or placebo) procedures developed by a Chinese acupuncturist on 455 knee OA patients over a period of six weeks.

The traditional Chinese method activated meridian points using deep needles and electric stimulation. The sham method used shallow needles, and while the electrical machine was turned on at the beginning of the procedure, it was turned off before needles were used and no electrical stimulation was given.

Researchers say when they tabulated pain scores, there were no differences between those who received traditional Chinese acupuncture and those who got the sham procedures. Both groups saw about a one-point reduction in pain.

A survey, taken after the study's conclusion, suggests that that sham procedure was convincing. About half of that group thought they had received the real acupuncture.

Dr. Suarez-Almazor says she’s not saying acupuncture never works. But she says her findings indicate traditional acupuncture is not effective at relieving the chronic pain that comes with knee OA.

“For this condition, and in general for chronic musculoskeletal pain, the results have been somewhat disappointing,” Dr. Suarez-Almazor says.

“Other studies have shown benefit, but when you compare the benefits of acupuncture to the control or sham group, the effect tends to be quite modest – very, very small and it could be questionable whether it has any clinical significance. Of course many patients improve, but that’s not necessarily related to the acupuncture because patients in control groups improve, too. The human brain is very powerful.”

That leads to the study’s other finding – that a clinician’s communication style affects a patient’s outcome.

Acupuncturists in this study were trained to deliver treatment with two communication styles: The high-expectation style involved practitioners telling patients they were optimistic acupuncture would help because they had previously had a high degree of success with the procedure, while the other group received a more neutral message that the treatment might or might not work for them.

After three months, 35.4 percent of patients who had been given high expectations reported 50 percent improvement, compared to 27.5 percent in the neutral category.

“It wasn’t necessarily being friendly. It was expressing confidence in the intervention – expressing confidence that acupuncture would be useful,” Dr. Suarez-Almazor says. “I think people can be influenced very much by their providers. So if a provider expresses hopefulness and confidence that something will work, it raises patients’ expectation of efficacy.”

Dr. Suarez-Almazor says she thinks this is the most important message of the study.

“It’s not only the intervention we deliver and the prescriptions we write. The way we interact with our patients is also very important in the outcome that a patient gets,” Dr. Suarez-Almazor says. “A provider-patient relationship is so important.”

Dr. Suarez-Almazor does caution that clinician style may be more important with some doctors than others.

“I think for a primary care physician that you are going to be seeing regularly, it’s important you have a good relationship with them,” Dr. Suarez-Almazor says, adding “there are providers you may encounter just once and while the interaction is important, it may not be as crucial as the interaction with the person who provides care over many years.”

Tong Gan, MD, a professor of anesthesiology at Duke University School of Medicine in Durham, N.C., says he has a number of concerns about the acupuncture part of this study, starting with how blind it really was since the electronic stimulation machine was turned on and then off in the sham group.

“In the past we kept stimulation going on in the sham group because we used non acupuncture points,” Dr. Gan says. “In a group when there is a stimulation and you can see the current and another where you can’t, that for most patients would raise questions if treatment was going on.”

He also takes issue with the choice of acupuncture points. He says there is a key point called large intestine 4, or Hegu in Chinese, that has an important bearing in terms of pain control and that was not used in this study. And he says a sham point they did use is very close to a real point called stomach 36, or Zu San Li in Chinese.

“It’s on the lateral aspect of the knee and in their description they use a sham point which is about half an inch from that particular point,” Dr. Gan explains. “That is a very important point for pain control. So it is possible that although it wasn’t exactly that point, half an inch is very close so I would have chosen a point farther away.”

He says according to traditional Chinese diagnosis, it’s also important to pay attention to the yin and yang or opposing forces causing pain and he says depending on the diagnosis, practitioners may chose different points in treatment. But in this study, they used the same points for every patient.

“One could argue it really is not based on traditional Chinese allocation of points,” Dr. Gan says. “You pick the points depending on what the underlying problems are. But for the study they picked the same points for the active and sham group. That may be a cleaner way to do it, but patients’ diagnoses may be different, so how can you use all the same points?”

Overall, he is not convinced by these findings about the effectiveness of acupuncture on knee OA.

“In the literature there have been a number of other studies, some in this population, others in other pain models, that showed positive results,” Dr. Gan says. “So it somewhat surprises me.”