Traditional Chinese acupuncture was not superior to sham acupuncture for knee osteoarthritis but delivering treatment with high expectations of improvement was superior to delivering treatment with neutral expectations.

QUESTION

What are the comparative effects of Traditional Chinese Acupuncture (TCA) and sham acupuncture for patients with knee osteoarthritis (OA) when controlling for the effect of the acupuncturists' communication styles.

DESIGN

A nested 2-stage randomised clinical trial, where patients were randomised to 1 of 3 style groups, waiting list, high expectations, or neutral expectations, and nested within style, TCA, or sham acupuncture.

SETTING

A hospital general internal medicine department in Texas, USA.

PARTICIPANTS

Men and women over 49 years with knee OA according to the American College of Rheumatology criteria. Additional inclusion criteria were pain in the knee in the preceding 2 weeks, > 3/10 on a visual analogue scale, no prior treatment with acupuncture, stable treatment with nonsteroidal anti-inflammatory drugs, analgesics, or glucosamine. Exclusion criterion was intraarticular injections in the knee in the previous 2 months. Randomisation of 560 participants allocated 238 to the high expectations group, 242 to the neutral expectations group, and 80 to the waiting list group.

INTERVENTIONS

Six acupuncturists licensed in traditional Chinese medicine carried out the intervention. For the communication style intervention, providers conveyed high expectations of improvement, by using positive utterances such as 'I think this will work for you', while neutral expectations were conveyed with uncertainty utterances such as 'It may or may not work for you'. For the acupuncture intervention the procedure and specific points were standardised by a panel consisting of the acupuncturists in each of the 2 arms: TCA points on the basis of clinical practice, and sham points outside the relevant meridians.

OUTCOME MEASURES

The primary outcomes were Joint-Specific Multidimensional Assessment of Pain (J-MAP), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain subscale, and Satisfaction with Knee Procedure (SKIP) measured at 4 weeks, 6 weeks (end of treatment), and 3 months.

RESULTS

527 (94%) participants completed the study. There were no significant differences between the TCA and sham groups in any of the outcome measures. Patients in the high expectations communication style group had statistically significant improvements in pain (J-MAP) and satisfaction (SKIP) compared with the neutral group. Mean differences (95% CI) at 3 months follow up were 0.4 (0.1 to 0.7) for J-MAP (1 to 7 scale), and 0.2 (0.03 to 0.3) for SKIP (1 to 5 scale).

CONCLUSION

In patients with knee OA, needling of meridian points was not more effective than the use of sham points, whereas acupuncturists' communication styles had a small but statistically significant effect on pain reduction and satisfaction.