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BMJ. 2007 October 20; 335(7624): 786.
Published online 2007 September 20. doi:  10.1136/bmj.39343.501863.80
PMCID: PMC2034747

Management of chronic knee pain

Rob Herbert, associate professor1 and Marlene Fransen, senior research fellow2

Acupuncture has no additional benefit in people taking a course of exercise

Two papers have recently been published on bmj.com on the treatment of osteoarthritis of the knee.1 2 The first is a randomised trial of adding acupuncture to a course of advice and exercise delivered by physiotherapists1; the second, which is also published in this week's BMJ, is a systematic review of the effectiveness of physiotherapy after elective total knee arthroplasty in people with osteoarthritis.2

Clinical trials conducted over the past decade have helped to define the role of acupuncture in various clinical conditions. A particular focus of these trials has been the use of acupuncture for chronic knee pain or osteoarthritis of the knee.3

The findings of randomised trials of acupuncture have caused much debate. Positive trials have been criticised because of inadequate blinding. Negative trials have been criticised because the intervention was not administered by properly trained practitioners or because control interventions may have had analgesic effects. However, a systematic review of high quality randomised controlled trials suggests that acupuncture can reduce pain and disability in people with chronic pain.3

Despite this evidence the role of acupuncture in the management of chronic knee pain is still unclear. Foster and colleagues argue that acupuncture is useful only if it adds to the benefits of the first line treatments of exercise and advice.1 They investigated whether acupuncture is useful for people receiving exercise and advice by randomising 352 adults with osteoarthritis of the knee to advice and exercise, advice and exercise plus acupuncture, and advice plus sham acupuncture.

The trial found that acupuncture did not significantly reduce pain (measured on the Western Ontario and McMaster Universities osteoarthritis index (WOMAC) subscale) at six months compared with sham acupuncture when combined with advice and exercise. This finding agrees with another large well designed trial that compared acupuncture with sham acupuncture given in addition to exercise in people with knee osteoarthritis.4 A pooled estimate from these two studies shows that acupuncture does not significantly reduce pain compared with sham acupuncture (reduction in pain score on the 10 point WOMAC subscale 0.1 points, 95% confidence interval 0 to 0.2).

A systematic review by Minns Lowe and colleagues,2 published in this week's BMJ, assesses the effects of physiotherapy exercise programmes given after total knee replacement surgery in people with osteoarthritis. The review found a small to moderate effect of functional exercise on joint motion and quality of life at three to four months after surgery, but the effect was not sustained at one year.

The findings should be considered provisional at best. In four of the six included trials, all study participants received an exercise or physiotherapy programme after discharge from the acute hospital5 6 7 8; these trials cannot tell us about the effectiveness of such programmes because the control groups also received an exercise intervention. The two remaining trials9 10 focused on the effects of outpatient programmes on the range of knee flexion and found little or no effect on this outcome. Most of the trials evaluated low intensity exercise programmes provided soon after surgery. More lengthy and intensive physiotherapy exercise programmes may be needed to overcome the considerable deficits in muscle strength and endurance that are evident in these patients.

What conclusions can be drawn from these studies? The findings of the trial by Foster and colleagues suggest there is little point in recommending acupuncture to people with chronic knee pain who are already undertaking a course of exercise.1 Acupuncture might be recommended to people who do not exercise.3 It is difficult to make clinical recommendations on the basis of Minns Lowe and colleagues' review, although it does highlight the lack of research into the effectiveness of physiotherapy exercise programmes after total knee replacement.2

Notes

This article was posted on bmj.com on 20 September 2007: 10.1136/bmj.39343.501863.80

Notes

Competing interests: None declared.

Provenance and peer review: Commissioned; not externally peer reviewed.

References

1. Foster NE, Thomas E, Barlas P, Hill JC, Young J, Mason E, et al. Acupuncture as an adjunct to exercise based physiotherapy for osteoarthritis of the knee: randomised controlled trial. BMJ 2007;335:436-40. [PMC free article] [PubMed]
2. Minns Lowe CJ, Barker KL, Dewey M, Sackley CM. Effectiveness of physiotherapy exercise after knee arthroplasty for osteoarthritis: systematic review and meta-analysis of randomised controlled trials. BMJ 2007 doi: 10.1136/bmj.39311.460093.BE
3. White A, Foster NE, Cummings M, Barlas P. Acupuncture treatment for chronic knee pain: a systematic review. Rheumatology (Oxford) 2007;46:384-90. [PubMed]
4. Scharf HP, Mansmann U, Streitberger K, Witte S, Krämer J, Maier C, et al. Acupuncture and knee osteoarthritis. Ann Intern Med 2006;145:12-20. [PubMed]
5. Frost H, Lamb SE, Robertson S. A randomized controlled trial of exercise to improve mobility and function after elective knee arthroplasty. Feasibility, results and methodological difficulties. Clin Rehabil 2002;16:200-9. [PubMed]
6. Kramer JF, Speechley M, Bourne R, Rorabeck C, Vaz M. Comparison of clinic- and home-based rehabilitation programs after total knee arthroplasty. Clin Orthop 2003;410:225-34. [PubMed]
7. Codine P, Dellemme Y, Denis-Laroque F, Herisoon C. The use of low velocity submaximal eccentric contractions of the hamstring for recovery of full extension after total knee replacement: a randomized controlled study. Isokinet Exerc Sci 2004;12:215-8.
8. Moffet H, Collet J-P, Shapiro SH, Paradis G, Marquis F, Roy L. Effectiveness of intensive rehabilitation on functional ability and quality of life after first total knee arthroplasty. A single-blind randomized controlled trial. Arch Phys Med Rehabil 2004;85:546-56. [PubMed]
9. Mockford BJ, Beverland DE. Does an outpatient physiotherapy regime improve the range of knee motion after total knee arthroplasty: a prospective study. J Bone Joint Surg 2003;86B(suppl III):128.
10. Rajan RA, Pack Y, Jackson H, Gillies C, Asirvatham R. No need for outpatient physiotherapy following total knee arthroplasty. Acta Orthop Scand 2004;75:71-3. [PubMed]

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