terça-feira, 12 de maio de 2015


YOGA


Yoga is one of the commonest forms of complementary and alternative medicine therapies, which is increasingly being practiced worldwide. It is an ancient Indian practice with its roots in Hindu religion based on the principles of mind-body medicine. The word “yoga” comes from the Sanskrit “yuj,” meaning “yoke” or “union.”
The three essential elements of yoga are: asanas (postures), pranayama (breathing exercises), and dhyana (meditation) [1]. These three components are practiced through multiple steps comprising of yama (moral codes, self-control), niyama (self-purification and process for maintaining morality), asana (posture), pranayama, (breath control), pratyahara (governing sense), dharana (concentration), dhyana (meditation), and samadhi (supreme contemplation and meditation) [2].
Yoga has been used to treat a variety of body ailments including neurological and psychiatric disorders. Multiple studies have documented the beneficial effects of yoga suggesting numerous mechanisms of its action [3]. The asanas are the aerobic component and may stimulate the central nervous system release of endorphins, monoamines, and brain-derivedneurotrophic factor (BDNF) in the hippocampus. The pranayama and dhyana components may regulate the emotional responses by reducing the sympathetic and increasing the parasympathetic tone and improve the cognitive functioning by increasing the EEG synchrony and coherence. An increase in melatonin and decrease in cortisol have been associated with the meditative component of yoga. A rise in melatonin promotes sleep, stimulates immune system and reduces blood pressure. Numerous studies have found a positive correlation between levels of cortisol, negative effects, and depression.
Different forms of yoga have shown effectiveness in treatment of many chronic diseases such as cancer, asthma, diabetes,arthritis, fibromyalgia, cardiac problems etc., where stress is considered to play an important role [3]. Though the studies are limited by their sample sizes and methodology discrepancies, yoga has shown benefit for an array of neuropsychiatric disorders.
Three non-randomized and two randomized controlled trials (RCTs) have assessed the effects of yoga in patients with epilepsy. The studies report an improvement on various parameters such as seizure frequency, seizure index, EEG alterations (increase in alpha and beta frequencies), autonomic functioning and quality of life [4].
Three RCTs have demonstrated effectiveness of yoga in curbing headache frequency, intensity and duration in migraineurs [5- 7]. Another RCT has shown improvement in vascular endothelial functioning in migraine subjects receiving yoga compared to controls [8]. OneRCT have shown no significant effect of yoga in migraine for the primary outcome variablesas compared to conventional care [9].
Multiple sclerosis (MS) is a debilitating and demyelinating disease that damages the myelin sheath surrounding the spinal cord. The first reported RCT of yoga in MS demonstrated that yoga improved fatigue to a comparable traditional aerobic exercise regime but either was not able to have any improvement in cognitive functioning [10]. A later RCT reported yoga to be beneficial in improving attention but not in fatigue (which also was improved in the sport climbing group), mood, spasticity or other executive functioning [11]. A RCT found yoga therapy to be more effective in improving balance, walking endurance, fatigue, depression and anxiety in MS as compared to controls but did not differed from treadmill training [12]. The study by Hogan et al. reported yoga to be beneficial only for improving balance but not for other parameters of fatigue, physical and psychological impact of MS or walking endurance [13]. Pranayama, hatha and raja yoga was shown in a RCT to improve physical pain and quality of life of women with MS [14]. An exploratory study reported improvement in functional strength, balance, and peak expiratory flow in patients with MS receiving Anand yoga [15]. The study also showed a trend towards improving quality of life in such patients. A prospective case series reported integrated yoga to improve neurogenic bladder dysfunction in MS [13].
The only systemic review of yoga therapy in strokepatients found 5RCTs,4 single case studies and one qualitative research studyreporting positive results, including improvements in cognition, mood, and balance and reductions in stress concluding that yoga and mindfulness could be clinically valuable self-administered intervention options for stroke rehabilitation [16,17]. A recent RCT reported that yoga intervention improved the quality of life in stroke patients but not the objective motor function measures such as task-orientated function, balance or mobility [18].
A single RCT exhibited that yoga was more effective than wrist splinting in improving grip strength, pain reduction and mending Phalen's sign in patients with carpel tunnel syndrome [19].
Multiple studies have been conducted for evaluating the effect of yoga on depression.A systemic review included 12 RCTs with 619 participants and concluded that despite methodological drawbacks, the pooled analyses suggest positive evidence for effects [20]. Studies also suggest that yoga interventions improve depression severity in patients with a co-morbid disorder like cancer or fibromyalgia [21].
A systematic review and meta-analysis of yoga therapy for schizophrenia included 5 RCTs with a total of 337 patients and found only moderate evidence for short-term effects on quality of life and no effect on positive or negative symptoms and social functioning [22].
There have been 3 RCTs assessing the role of yoga in post-traumatic stress disorder (PTSD).Yoga breath intervention was observed to be more beneficial compared to wait-listed controls in reducing post traumatic symptoms [23]. Another RCT reported decrease in sadness but no change in heart rate variability by yoga therapy in comparison to waitlist control group of PTSD [24]. Trauma-informed yoga intervention was demonstrated as superior to supportive women's health education in an RCT comprising of 64 women with PTSD [25].
Studies have also demonstrated symptom improvement in other psychiatric disorders such as by ustilizing Sudarshan Kriya Yoga (SKY) course in generalized anxiety disorder [26].
Although yoga is suggested to be relatively safe and well tolerated, there are risks of overstretching, strains, fractures and dehydration [3]. It can worsen glaucoma as the inverted asanas increase the intraocular pressure by raising episcleral venous pressure and choroidal volume due to vascular enlargement.Inverted postures pose the risk of a sudden drop in blood pressure, which can induce a stroke or heart attack particularly in susceptible individuals.Yoga also lowers blood glucose levels posing a danger for diabetic patients. Bikram yoga, which is practiced in very hot temperatures, is likely risky for patients with multiple sclerosis [27]. The majority of RCTs have not reported any safety data on yoga.
The available researchis limited by small sample size, few randomized studies, inadequate control, diversely modified yoga practices, limited assessments and lack of safety data.This precludes any firm conclusions on efficacy of yoga on the various psychiatric and neurological disorders and advocate requirement of more research to decisively assess the validity of applying yoga as a mainstream therapeutic treatment for neuro-psychiatric disorders.
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Aggressive Massage Techniques can Accelerate Safe Return after Hamstrings Strain: A Case Study of a Professional Soccer Player
Konstantinos Fousekis1, 2,*, Konstantinos Mylonas1,2 and Venetia Charalampopoulou3
1Biomechanics and Sports Injuries Laboratory, Department of Physiotherapy, Technological Educational Institute of Western Greece, Branch Department of Aigion, Greece
2Physiotherapy Team of Panaigialeios, Football Club- Greek Football league, Greece
3PALLADION Rehabilitation Centre, Tripoli Arcadia, Greece

Keywords
Hamstrings strain; Aggressive physiotherapy; Stripping massage; Cryostretching; Soccer
Introduction
Lower extremity injuries are very common among professional soccer players with reported incidence rate varying from 7.4-47.5 injuries per 1000 hrs of play. The vast majority of these injuries refer to the lower extremity (68–88%) [1,2], approximately 25% of which are non-contact hamstring muscle strains [3,4].These injuries are mainly caused by an excessive stretch of an eccentrically contracted muscle [5,6]and etiology is attributed to both extrinsic and intrinsic factors [7,8]. The main extrinsic factor, recorded in 44–74% of the injuries [9,10], is the physical contact between opponent players (contact injury). Contrariwise, asymmetries in muscle strength, flexibility, proprioception, anatomical and anthropometric characteristics [9- 16]and previous injury [5,6] constitute the main intrinsic etiological factors for hamstrings’ strains.
Hamstrings’ strains are classified into three grades (grades I, II, III) with regard to the severity of symptoms. Grade I refers to a mild strain where few muscle fibres are torn while grade II strain is a moderate injury associated with a greater number of injured fibers. Symptoms of both Grades I and II muscle strains include pain and tenderness upon pressure, local swelling, muscle spasm and a decrease in the range of motion. Pain becomes stronger during passive stretching or contraction of the muscle. Grade III strain is a complete tear of the muscle causing absolute loss of muscle function, as well as considerable pain, swelling, tenderness and ecchymosis [17].
Physiotherapy techniques applied to treatment at the acute and sub-acute stages of muscle healing are primarily aiming at reducing inflammation, pain and swelling and secondary at early muscle loading and strengthening. The reduction of swelling and intramuscular hematomas is of critical importance since it relates directly to the speed of the healing process [18].
For this purpose, different types of sports’ massage, electrotherapy and cryotherapy are being used by physiotherapists. The massage performed in most cases includes pain-free superficial and deep effleurages (strokings) in an effort to mechanically enhance the venous blood return and decrease muscle spasm and pain [19]. Nevertheless, techniques of aggressive massage (cupping massage, stripping massage and massage with the use of instruments-Instrument Assisted Soft Tissue Massage-IASTM ) which have been developed in the last years are being carried out with particular intensity and pressure causing considerable pain (VAS=4-5) [20,21].
These aggressive procedures have not yet been tested in the treatment of muscle strain. This represents a challenge worthy of investigation, given their obvious contribution to accelerating reduction of swelling and hematoma after a strain. In that direction, this case study presents the application and effect of an aggressive rehabilitation programme which included a combination of aggressive massage with cupping therapy–IASTM, cryostretching-cryokinetics and progressive core and lower extremities strengthening on a professional soccer player of the Greek Second National Division diagnosed with a Grade I hamstring muscle strain.
Case Report
In April 2013, a 30 year old soccer player suffered a right hamstrings’ injury during soccer speed drills. The evaluation of the injury from the team of orthopedic physicians identified the presence of a grade I biceps femoris muscle strain near the musculotendinous junction. MRI examination showed a 3-4 mm lesion and confirmed diagnosis (Figure 1). Physical examination revealed a 10º deficit in hip flexion with extended knee, compared with the healthy limb, due to pain and increased muscle spasm. The compression of the area caused moderate pain (3-4 Vas scale) and the athlete reported a feeling of tightness in the hamstrings region during daily living activities (walking, ascending and descending stairs etc.)
Aggressive rehabilitation program
Physiotherapy: The rehabilitation process began immediately after the injury and its contents are presented in table 1 below. The first two days after the strain, during the acute phase, the main objectives of rehabilitation were (i) decreasing swelling and hematoma, (ii) preventing re-injury, (iii) decreasing pain, and (iv) accelerating the healing process. In this regard, R.I.C.E. (Rest-Immobilisation-Cryotherapy-Elevation) and therapeutic non-warm ultrasound were applied daily. To prevent further swelling a soft wrapped bandage and therapeutic non-thermal ultra sound were used [22].
First (A) sub-acute phase treatment took place from the 3rd until the 7th day with the main objectives of (i) reducing/removing the hematoma and swelling, (ii) initialising alignment and reattachment of muscle fibers and minimising the risk of developing scar tissue. The treatment started with 10 min of thermotherapy (short-wave diathermy) followed by cupping, stripping and IASTM stripping massage techniques.
The application of negative pressure massage (suction cups) started with static applications over the injury site for 5 min and progressed to dynamic application and movement of the cups towards the heart (Figure 2) [23,24].
Stripping massage with or without instruments was performed with high pressure intensity (pain perception VAS6-7)in two phases: initially to the region centrally to the injury for “draining” of the thigh great vessels and then directly upon the site of the injury for the mobilisationdecrease of muscle hematoma-swelling (Figures 2 and 3) [23].
In addition, cryotherapy, pain-free cryokinetic isometric and cryostretching exercises were used to achieve the aforementioned objectives [25,26]. These cryostretching exercises were performed with an ice bag attached to the injury site, passively by the physiotherapist.
The program concluded with therapeutic ultrasound, TENS and gentle passive stretching. Core stabilisation was enhanced through plank exercises in all directions [27]. In order to prevent a subsequent injury, kinesiotaping was applied on the hamstrings at the end of each treatment session.
On the 4th and 5th day, after the injury began to emerge signs of surface displacement of intramuscular hematomas, the patient reported significantly less pain during massage and passive hip flexion improved by 5ο. Τhe skin ecchymosis was progressively removed until 10th-2th day (Figure 4).
On the 7th day, treatment had successfully progressed and the athlete was able to meet the criteria which would allow treatment to progress to the next stage, namely (i) reduction of swelling and pain, (ii) full range of hip flexion with knee extended and (iii) minimum pain (VAS =1-2) during compression (Table 1). It must be noted that during the A subacute phase, the athlete reported daily improvement, either in terms of pain or of his functional ability (flexibility, strength etc.).
Second (b) sub-acute phase treatment aimed at (i) ensuring elasticity of the scar tissue and (ii) regaining functional muscle ability, strength, endurance and coordination. From the 8th until the 15th day, the athlete was subjected to roughly the same techniques as in the previous phase with minimum qualitative adjustments such as the application of stripping massage combined with eccentric exercise [20] and incorporating hamstrings isotonic exercises with elastic resistance (Table 1).
IASTM stripping massage and cupping therapy were not used at this stage since swelling and hematoma had already retreated. Balance exercises were also added to the program in order to prepare the athlete to rejoin regular training. Isokinetic strengthening began on the 14th day after the injury while kinesiotaping application continued to be used in order to prevent further injury. Criteria set to determine completion of this phase and the ability of the athlete to rejoin regular training were met on the 15th day including (i) isokinetic strength symmetry, (ii) full range of motion in hamstrings’ movement, (iii) the ability to perform soccer burst exercises without experiencing discomfort, and (iv) positive psychology and confidence (Table 1).
Home-based rehabilitation program
During all phases the athlete was given instructions to follow a daily home-based physiotherapy program. During the acute phase, the athlete was expected to rest with repeated intermittent cryotherapy application on the injured muscle. Sub-acute phase homework included hamstrings’ stretching up to the limit of pain, and isometric exercises. Sub-acute phase B home-based rehabilitation comprised of hamstrings’ stretching, muscle strengthening exercises with elastic bands in standing position and foam roller myofascial release exercises (table 1).
Progressive Sports Rehabilitation program
Following the acute phase, the athlete also followed a progressive sports rehabilitation protocol which was executed in the field. During sub-acute phase A, strength building exercises for the trunk and upper extremities were performed under the guidance of the team physiotherapist. After day 4, organised gaiting was added to the program in forward and backward motion. During sub-acute phase B, a progressive rehabilitation program was designed to be executed from the 8th until the 15th day in order to prepare the athlete for safe reintegration to normal training schedule. Cardiovascular conditioning was achieved through an aerobic running regime of gradually elevated duration and intensity. The athlete also performed several skipping routines and dynamic (ballistic) stretching exercises. Special attention was paid to the trunk and pelvis stabilisation exercises throughout this stage. The program gradually progressed from isokinetic strengthening and dynamic stretching to dynamic stabilisation and proprioception exercises of lower limbs. Soccer mimic exercises and plyometric training were initiated on the 14th day (table 1).
After 15 days, full strength and range of motion were achieved, the palpation of the area was pain-free and the athlete was released to return to full competition.
The athlete was monitored for six months following completion of rehabilitation in which nore-injury episode occurred. This period represents an extended timeframe within which the injury at the same site can be characterised as a recurrence injury. More specifically, although the site of the injury is active and sensitive for the following several months, [28] no recurrences of muscle strains have been reported in sports literature after a period of 5-6 months from the initial injury [29].
Conclusions
The implementation of an aggressive rehabilitation protocol in the treatment of a grade I muscle strain of a soccer player decrease recovery time by 50% approximately compared with traditional muscle strain rehabilitation protocols [17,28] proposing absence from sports and physiotherapy for 20-30 days. In this case study the athlete was able to return to full training within 15 days from injury and did not experience re-injury in the following6 months.
The proposed treatment protocol was based on aggressive techniques which were performed under considerable pain. This method has not been reported in international literature since techniques that cause pain are avoided in classical physiotherapy [17,30] because of the belief that these cause re-injures and increase the recovery period. In the present case study, massage techniques performed with great intensity directly on the injury site provoked significant temporary pain. However, they also significantly accelerated the mobilisation of hematoma and edema without causing any other problems to the athlete besides temporary pain. The pain exacerbated by the execution of these massage techniques is attributed to temporary increase in pressure on pain receptors from mechanical stress and not from deterioration of the injury [31]. This theoretical assumption is reinforced by the fact that the athlete reported significant improvement in his symptoms and functional capacity after each treatment.
The intense pressure and cephalic direction of massage strokes mobilise the swelling-hematomas in the superficial layers of the muscle, through myofascial pathways. This “draining” adaptation creates favourable conditions for the re-union of the injured muscle fibers and preliminarily explains the significant reduction in recovery time from grade I hamstrings strain observed in our case study.
In relation to the positive results of massage, it has been observed that cryostretching also contributed to a faster recovery of the passive range of hip flexion. These techniques have limited research support but are generally considered safe when performed with care and to the limits of pain [26]. Furthermore, integrating core exercises also helped the dynamic stabilisation of the trunk-pelvis of the athlete and probably reduced his risk of re-injury, confirming previous research findings [27]. The findings of the present case study are very encouraging. Further research with large randomised controls studies is deemed necessary in order for the effects of aggressive physiotherapy techniques to be clarified.
On the basis of the aforementioned results, the preliminary conclusion may be drawn that aggressive massage techniques have a positive effect on reducing edema-hematoma after hamstrings strain. In addition, they significantly reduce the recovery time in comparison to the standard approach.
Th ese techniques need to be tested also in treatment of more severe muscle strains (grade II). However, based on the promising findings of this case study, it can be assumed that such techniques are likely to have an equally important impact on reducing the time of absence after more severe muscle strains. This is being amplified by the fact that reduction of post-traumatic edema-hematoma constitutes the predominant problem in these cases. Future studies should also compare traditional and aggressive physiotherapy in restoration of other important parameters such as elasticity, strength and proprioception.
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Pain management with acupuncture in osteoarthritis: a systematic review and meta-analysis

Taru Manyanga12*, Maria Froese2, Ryan Zarychanski34, Ahmed Abou-Setta4, Carol Friesen5, Michael Tennenhouse5 and Barbara L Shay6




Abstract

Background

The utility of acupuncture in managing osteoarthritis symptoms is uncertain. Trial results are conflicting and previous systematic reviews may have overestimated the benefits of acupuncture.

Methods

Two reviewers independently identified randomized controlled trials (up to May 2014) from multiple electronic sources (including PubMed/Medline, EMBASE, and CENTRAL) and reference lists of relevant articles, extracted data and assessed risk of bias (Cochrane’s Risk of Bias tool). Pooled data are expressed as mean differences (MD), with 95% confidence intervals (CI) (random-effects model).

Results

We included 12 trials (1763 participants) comparing acupuncture to sham acupuncture, no treatment or usual care. We adjudicated most trials to be unclear (64%) or high (9%) risk of bias. Acupuncture use was associated with significant reductions in pain intensity (MD -0.29, 95% CI -0.55 to -0.02, I2 0%, 10 trials, 1699 participants), functional mobility (standardized MD -0.34, 95% CI -0.55 to -0.14, I2 70%, 9 trials, 1543 participants), health-related quality of life (standardized MD -0.36, 95% CI -0.58 to -0.14, I2 50%, 3 trials, 958 participants). Subgroup analysis of pain intensity by intervention duration suggested greater pain intensity reduction with intervention periods greater than 4 weeks (MD -0.38, 95% CI -0.69 to -0.06, I2 0%, 6 trials, 1239 participants).

Conclusions

The use of acupuncture is associated with significant reductions in pain intensity, improvement in functional mobility and quality of life. While the differences are not as great as shown by other reviews, current evidence supports the use of acupuncture as an alternative for traditional analgesics in patients with osteoarthritis.

Systematic review registration


Keywords: 
Acupuncture; Osteoarthritis; Pain; Functional mobility; Health-related quality of life; Systematic review; Meta-analysis



Background

Osteoarthritis, the most common form of arthritis, is a progressive degenerative disease characterised by gradual loss of joint cartilage [1,2], resulting in loss of movement and pain [3,4]. It is the leading cause of disability among non-institutionalized adults [2], and is associated with major impacts on physical function and mobility [5]. Diagnosis is based on radiological changes, and clinical presentation of joint pain; including tenderness, limitation of movement, crepitus, joint effusion, and variable degrees of localized inflammation [5]. The prevalence, disability, and associated costs of treating osteoarthritis are expected to steadily increase over the next decades because of an aging population [6-8]. It is estimated that approximately 10% of men and 18% of women aged 60 years or older have symptomatic osteoarthritis worldwide [9,10]. In the USA, job-related osteoarthritis costs up to $13 billion per year [9].
With no known cure [1], treatment of osteoarthritis is focused on symptom management. Pharmacological agents commonly prescribed include non-steroidal anti-inflammatory drugs (NSAIDs), acetaminophen, and in severe cases, narcotics [3,5]. NSAIDs and acetaminophen are only marginally effective for short-term relief of osteoarthritic pain [2,5,11] and NSAIDs are associated with common adverse effects (e.g. upset stomach) [1,5]. Analgesics are frequently prescribed in combination with other non-pharmacological therapies to decrease the dependency on analgesics [1,2,5]. These therapies include exercise [8,12], weight reduction [2,5,8] and other complimentary/alternative therapies [2,5,13].
Acupuncture is reported to be effective in treating many conditions including, but not limited to, fibromyalgia [14] and chronic low back pain [15]; as well as chronic pain caused by osteoarthritis[16]. Due to its analgesic effects, acupuncture is widely used [2], cost effective [17,18] and a relatively safe non-pharmacological treatment of musculoskeletal pain [1,2,19]. The ability of acupuncture to successfully manage osteoarthritic symptoms, either as monotherapy, or as an adjunct to usual medical care, remains uncertain [1,20]. Inferences from previous systematic reviews that evaluated the effects of acupuncture on osteoarthritis have been speculative due to important limitations [2]. For example several previous reviews included trials in which electrical needle stimulation was performed [1,2,5] while another included data from non-randomized trials and quasi experiments [21].
The objective of the present systematic review was to identify, and synthesize data from prospective randomized controlled trials comparing acupuncture to sham acupuncture, usual care, or no treatment, in adults diagnosed with osteoarthritis.

Methods

We conducted all aspects of this systematic review according to an a priori published protocol [22], and adhered to the Cochrane Handbook for Systematic Reviewers’ methodological guidelines. Our findings are reported in accordance to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses [23]. The review question was formulated in consultation with an expert panel of clinicians and researchers with extensive knowledge synthesis experience, acupuncture and other therapeutic modalities.

Populations, interventions, comparators, outcome measures and study designs (PICOS)

We posed the question, “What is the comparative efficacy and safety of acupuncture compared to sham acupuncture, usual care, or no treatment to reduce pain intensity in adults diagnosed with osteoarthritis?” (Additional file 1: Table S1). To address this question, we included randomized controlled trials of adults diagnosed with osteoarthritis (Additional file 1: Table S2). Our primary outcome measure was the reduction in pain intensity using a validated measurement tool. As secondary outcomes we compared functional mobility, health-related quality of life and procedural safety.
Additional file 1. Table S1. Research question using PICOS structure. Table S2. Study eligibility criteria. Table S3. PubMed/MEDLINE search strategy. Table S4. Needle location for each trial. Figure S1. Funnel plot for pain intensity. Figure S2. Subgroup analysis (clinical considerations). Figure S3. Subgroup analysis (methodological considerations). Figure S4.Adverse Events.
Format: DOCX Size: 520KB Download fileOpen Data

Search strategy for identification of trials

We searched PubMed/MEDLINE (National Library of Medicine), EMBASE (Ovid), CENTRAL (the Cochrane Library), CINAHL (EbscoHost) and Natural Standard from inception to May 2014. We present the PubMed/MEDLINE strategy in Additional file 1: Table S3. To identify additional relevant citations, we conducted forward searches in Scopus and Web of Science. Our grey literature search included Osteoarthritis Research Society International (OARSI) conference proceedings (http://www.oarsi.org webcite) from 2008 to 2014. To identify ongoing or planned trials, we searched the World Health Organization’s International Clinical Trials Registry Platform (ICTRP) and ClinicalTrials.gov. Finally, we hand-searched reference lists of narrative and systematic reviews and of the included trials for potentially relevant citation. We performed reference management in EndNote X6 (Thompson Reuters).

Study selection

We used a two-step process for trial screening and selection. Two reviewers (TM and MF) independently screened the titles and abstracts to determine if a citation met the general inclusion criteria. We included randomized controlled trials (RCTs) of acupuncture administration to adults diagnosed with osteoarthritis. We excluded non-RCTs, trials involving animals and trials in which electro-needle stimulation was performed. Full details of inclusion and exclusion criteria are found in Additional file 1: Table S2. The full text of citations classified as include or unclear were reviewed independently with reference to the predetermined inclusion and exclusion criteria. Non-English full text citations were first translated and then reviewed independently. Disagreements between the two reviewers were resolved through consensus and by third-party adjudication, as needed.

Data extraction and management

Two reviewers (TM and MF) independently extracted data from the included trial reports using standardized and piloted data extraction forms. Disagreements between the two reviewers were resolved by consensus or with adjudication of the content expert (BLS), as needed. The following data were extracted from each trial: patient demographics, interventions and comparators, trial outcomes, total acupuncture sessions, relevant co-interventions, length of each trial and duration of follow up.

Assessment of methodological quality

We evaluated the internal validity of included trials using the Cochrane Risk of Bias tool [24]. This tool consists of six domains (sequence generation, allocation concealment, blinding, incomplete outcome data, selective outcome reporting, and ‘other’ sources of bias). Each separate domain was rated having a ‘low’, ‘unclear’ or ‘high’ risk of bias. If one or more individual domains were assessed as having a high risk of bias, the overall assessment was rated as having a high risk of bias. The overall risk of bias was considered low only if all components were rated as having a low risk of bias. The risk of bias for all other studies was rated as unclear.

Adequacy of acupuncture

Due to significant variability and lack of standardization, we decided, a priori, to consider acupuncture therapy regardless of frequency of administration, duration of each session, number, depth of penetration and location of needles, as well as the designation of the acupuncturist. In most trials, acupuncturists ensured de chi was achieved and performed manual needle stimulation at least once during each session. The most commonly used acupuncture points were ST34, ST36, Xiyan, GB34 and SP9 (Additional file 1: Table S5).

Measures of treatment effect

We analyzed all outcomes using Review Manager (RevMan, version 5.2) (24). Pooled continuous data were expressed as mean difference (MD) with 95% confidence intervals (CI). We calculated standardized mean differences (SMD) when multiple scales were used to measure the same outcome in different trials. Pooled dichotomous data are presented as odds ratios (OR). We used the random effects model for all analyses and quantified statistical heterogeneity using the I2statistic. If significant heterogeneity was detected (I2 > 50%), sensitivity analyses were conducted to identify the source (s) of the heterogeneity. We assessed publication bias by viewing the overlap of confidence intervals and using funnel plot techniques [25].

Measurement tools

Pain intensity was measured using the visual Analogue scale. Two variations of this scale (0–10 cm or 0–100 mm) [26] were used in the included trials. To assess functional mobility, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scale was used [27]. This scale rates activities according to degree of difficulty (0 = none and 4 = extreme difficult). Other trials used the Knee injury and Osteoarthritis Outcome Score (KOOS) with five categories (0 = none and 5 = extreme) difficulty) [28].

Subgroup/sensitivity analysis

For the primary outcome of pain intensity, we performed the following a priori subgroup analyses: Clinical considerations: We hypothesized greater reduction in pain intensity when 1) acupuncture was compared to sham acupuncture, usual care or no treatment or; 2) trials had ten or more acupuncture sessions or 3) had intervention periods longer than 4 weeks of intervention. Methodological considerations: We hypothesised greater effect sizes among 4) trials with unclear or high risk of bias; or 5) single centre trials.

Results

Of the 14449 citations identified through electronic and hand searches, we included 12 unique trials enrolling a total of 1763 participants [16,29-39] (Figure 1). Trials were published between 1989 and 2013; 75% were single-centre trials. Nine trials [13,29-34,36,39] were conducted in physiotherapy outpatients departments while three [35,37,38] occurred in primary care centres. All trials were published in English language journals. Nine trials were conducted in Europe [13,30-32,35-39], two in Iran [29,34] and one in Israel [33]. Manual needle stimulation was performed in most (75%) of the trials. Only three trials [30,36,39] did not perform manual needle stimulation.
thumbnailFigure 1. Study Flow diagram.
Duration of interventions ranged from two to twelve weeks, with total follow-up durations ranging from four to 52 weeks. The age of participants ranged from 39 to 72 years; 65% of trial participants were female (Table 1). Eight trials (67%) were adjudicated to be unclear risk of bias[13,29,30,33-35,37,38], three (25%) were considered low risk [31,36,39] and one trial (8%) was classified as high risk of bias [32] (Figure 2). Four trials compared true acupuncture to a sham acupuncture [31,33,37,38] six trials used ‘usual care’ as the control [29,32,34-36,39], one [13] used a waiting list control (i.e. no treatment), and one trial [30] used mock transcutaneous electrical nerve stimulation in the control group. From a practical perspective, we considered conservative therapy, pharmacological treatments, and exercises as ‘usual care’.
Table 1. Characteristics of Included studies
thumbnailFigure 2. Summary risk of bias assessment.

Primary outcome: pain intensity

Ten trials [13,29,31,33-39] involving 1699 participants contributed pain intensity data for meta-analysis (Figure 3). Overall, the use of acupuncture in adults with osteoarthritis was associated with significantly reduced osteoarthritic pain on the visual analogue scale (MD -0.29, 95% CI -0.55 to -0.02, I2 0%). Publication bias could not be excluded (Additional file 1: Figure S1) due to the modest number of included trials [40]. We evaluated the efficacy of acupuncture for osteoarthritic pain according to predefined subgroups. Compared to intervention durations of ≤ 4 weeks, longer intervention periods were associated with significant difference reductions in pain intensity (MD -0.38, 95% CI -0.69 to -0.06, I2 0%, 6 trials, 1239 participants) (Additional file 1: Figure S2).
thumbnailFigure 3. Pain intensity (Visual Analog Scale).
We observed no significant differences in pain intensity according to type of comparator (sham acupuncture vs. other treatments) and use of co-interventions (NSAIDs vs. none). In a subgroup analysis of trials at low risk of bias, the pooled mean difference for pain intensity associated with acupuncture was -0.59 (95% CI -1.18 to -0.00, I2 0%, 3 trials, 410 participants) (Additional file 1: Figure S3). Pain intensity was not significantly different in the subgroups of single centre or multicentre trials, nor did it differ between trials with adequate vs. unclear blinding of participants and assessors.

Secondary outcomes: functional mobility and HRQoL

Nine trials [13,29,31-33,35-37,39] involving 1543 participants contributed functional mobility data (Figure 4). Functional mobility assessed at the end of trials was significantly improved in the acupuncture groups compared to control groups (SMD -0.34, 95% CI -0.55 to -0.14), but there was moderate statistical heterogeneity (I2 65%) between the results of the included trials. We explored this heterogeneity by excluding the trial with the longest study intervention (12 weeks) as it had demonstrated the greatest benefit [37]. The results of this outlying trial were statistically different from the other trials (I2 93%). With this trial excluded, statistical heterogeneity was reduced (I215%), and acupuncture remained associated with improvements in functional mobility. Three trials[13,35,37] involving 958 participants reported HRQoL. Acupuncture was associated with significant improvements in HRQoL at the end of intervention period (SMD -0.36, 95% CI -0.58 to -0.14, I250%) (Figure 5).
thumbnailFigure 4. Functional mobility (multiple scales).
thumbnailFigure 5. Health-related quality of life (multiple scales).

Adverse events

pt?>Two [13,35] of 11 trials involving 861 participants systematically reported adverse events (Additional file 1: Figure S4). The odds ratio for any adverse event associated with acupuncture compared with the controls was 1.44, (95% CI 0.77 to 2.71, I2 39%). With regard to the remaining trials, one trial reported five adverse events in the acupuncture group (pain, sleepiness, fainting, nausea, and localized swelling) but omitted to report adverse events the control group [31]. A second trial reported bruising associated with acupuncture sites, while a third trial [38] presented a table of side effects without incidence rates in either group [37].

Discussion

In this systematic review, we found acupuncture administered to adults with osteoarthritis to be associated with a statistically significant reduction in pain intensity, improved functional mobility and improved health-related quality of life. Reductions in pain were greater in trials with longer intervention periods. Though under-reported and inconsistently described, major adverse events with acupuncture were not reported. Subgroup analyses suggest that acupuncture is most effective for reducing osteoarthritic pain when administered for more than four weeks. Outcome assessment for the majority of trials occurred immediately following the intervention period and thus the durability of treatment effects are unknown.
Given the chronic nature of osteoarthritic pain, the presence of inflammation and well-established nociceptive pathways may necessitate a threshold dose or duration of treatment prior to clinical effect [41,42]. As such, guidelines recommend on average, 10 acupuncture treatment sessions for chronic conditions [41,43]. This recommendation is supported by pathophysiologic and anatomic studies showing how sustained nociceptive input caused by osteoarthritis can have profound effects on the central nervous system causing pathologic neuroplastic changes [41]. The controlled stimulation of peripheral nociceptors with acupuncture may reverse such pathologic neuroplasticity in the central nervous system; especially when administered over a prolonged period [41]. Optimal dose density, (i.e. sessions per week and duration of each session), remains to be established.
Although our review demonstrated statistically significant reductions in pain intensity and improvements in both functional ability and quality of life, the clinical relevance of these findings is of great importance. Pooled treatment effects observed in our review did not meet previously established thresholds (effect size of 0.39 and 0.37 for pain and function respectively) for the minimal clinically important difference (MCID) in patients with osteoarthritis [44]. Determination of what constitutes MCID in osteoarthritic patients is however subject to considerable debate due in part to the use of ‘intuitive sense’ [44,45]. Lack of consensus, as evidenced by three different recommendations [5,44-46], makes it difficult to conclude that our findings are clinically irrelevant and not merely an issue of “judgement”. Further investigations are needed to establish a relevant definition of MCID for therapeutic interventions of osteoarthritis.
Results from previous reviews [1,2,5,47] of acupuncture conducted in participants with osteoarthritis are inconsistent. Two reviews [2,5] found only short term reductions in pain and improvement of function, while another [47] found both short and long term benefits for acupuncture. One previous review [1] concluded reduced pain but no change in function. Some of these reviews included a subset of the trials included in this review and/or analyzed data from trials with substantial variability in the definition and application of acupuncture. Inconsistent findings may also relate to the inclusion of trials comparing traditional acupuncture to minimal/superficial acupuncture as well as trials studying electro-acupuncture. Electrical needle stimulation can enhance the effects of acupuncture [19,45], and thus equating electro-acupuncture to traditional acupuncture is not an accurate representation of the efficacy of acupuncture. Previous inclusion of non-randomized trials or quasi-experiments may have also exaggerated effect estimate [21]. In our systematic review we excluded non randomized trials, trials in which superficially penetrating needles were used as sham acupuncture, and trials where electrical needle stimulation was performed in the treatment arm.

Strengths

The strengths of our review included completeness of our search strategy, including searching multiple bibliographic databases, trial registries and conference proceedings for randomized controlled trials comparing traditional acupuncture to a ‘true control’ (e.g. sham/placebo acupuncture, exercise, or waiting list). Furthermore, we focused on patient-centered outcomes, and evaluated the efficacy of acupuncture in the context of its safety profile. Finally, we used an a priori published protocol, and followed established methodological guidelines for synthesizing the evidence.

Weaknesses

Our review may be limited by methodological challenges inherent in the included trials. From the included trials, 75% were adjudicated to be of unclear or high risk of bias. We decided, a priori, to consider acupuncture therapy regardless of frequency of administration, duration of each session, number and location of needles, as well as the designation of the acupuncturist. While these variables may affect the adequacy of acupuncture administered, we’ve also acknowledged a lack of consensus on what defines ‘usual care’ in acupuncture. It is unknown if this a priorimethodological decision represents a source of systemic error or natural variability representative of current practice. Most trials included in our review provided inadequate descriptions of blinding procedures or methods to ensure allocation concealment. Failure to maintain allocation concealment or blinding in trials has been associated with inflated effect estimates [2,5,15,46,47].

Conclusions

The use of acupuncture is associated with significant reductions in pain intensity, improvement in functional mobility and quality of life. While the differences are not as great as shown by other reviews, current evidence supports the use of acupuncture as an alternative for traditional analgesics in patients with osteoarthritis.

Ethical approval

No ethics approval was sought since this study involved a synthesis and analysis of data from previously published research.

Data access

TM had full access to all of the data in this review and takes responsibility for the integrity of the data and the accuracy of its analysis.

Abbreviations

MD: Mean Difference; SMD: Standardized Mean Difference; CI: Confidence Interval; SE: Standard Error; NSAIDs: Non-steroidal anti-inflammatory drugs; PICOs: Populations, Interventions, Comparators, Outcomes, Study designs; OARSI: Osteoarthritis Research Society International; OR: Odds Ratio; HRQoL: Health Related Quality of Life; MCID: Minimal Clinically Important Difference; RCT: Randomized Controlled Trials; DF: Degrees of Freedom; IV: Inverse Variance; Chi2: Chi-squared; I2: I-squared; M-H: Mantel-Haenszel; Tau2: Tau-squared; VAS: Visual Analogue Scale; WOMAC: Western Ontario and McMaster Universities Osteoarthritis Index; KOOS: Knee injury and Osteoarthritis Outcome Score.

Competing interests

The authors declare no competing interests.

Authors’ contribution

The systematic review was conceived and designed by TM, RZ and AMAS with input from BLS. CF and MT provided guidance on developing and updating the search strategy. TM and MF screened and reviewed trials, extracted data and assessed the included trials for methodological quality. TM analysed the data and drafted this manuscript. All authors contributed in the interpretation of the results, were involved in revising the manuscript and gave final approval of the version to be published.

Acknowledgements

No specific funding was obtained for this review. TM is a Western Regional Training Centre studentship and the Manitoba Health Research Council Masters Student award recipient. RZ is a recipient of a RCT-mentorship award from the Canadian Institute of Health Research. These entities had no role in the design or conduct of the study, including but not limited to, study identification, collection, management, analysis, and interpretation of the data, or preparation, review, or approval of the final report.











References

  1. Ezzo J, Hadhazy V, Birch S, Lao L, Kaplan G, Hochberg M, Berman B: Acupuncture for osteoarthritis of the knee: a systematic review.
    Arthritis Rheum 2001, 44(4):819-825. PubMed Abstract | Publisher Full Text OpenURL
  2. Manheimer E, Cheng K, Linde K, Lao L, Yoo J, Wieland S, van der Windt DA, Berman BM, Bouter LM: Acupuncture for peripheral joint osteoarthritis.
    Cochrane Database Syst Rev 2010, 1:CD001977. PubMed Abstract | Publisher Full Text |PubMed Central Full Text OpenURL
  3. Balanescu AR, Feist E, Wolfram G, Davignon I, Smith MD, Brown MT, West CR: Efficacy and safety of tanezumab added on to diclofenac sustained release in patients with knee or hip osteoarthritis: a double-blind, placebo-controlled, parallel-group, multicentre phase III randomised clinical trial.
    Ann Rheum Dis 2013, 73(9):1665-1672. PubMed Abstract | Publisher Full Text OpenURL
  4. Sovani S, Grogan SP: Osteoarthritis: detection, pathophysiology, and current/future treatment strategies.
    Orthop Nurs 2013, 32(1):25-36.
    quiz 37–28
    PubMed Abstract | Publisher Full Text OpenURL
  5. Manheimer E, Linde K, Lao L, Bouter LM, Berman BM: Meta-analysis: acupuncture for osteoarthritis of the knee.
    Ann Intern Med 2007, 146(12):868-877. PubMed Abstract | Publisher Full Text OpenURL
  6. Bhatia D, Bejarano T, Novo M: Current interventions in the management of knee osteoarthritis.
    J Pharm Bioallied Sci 2013, 5(1):30-38. PubMed Abstract | Publisher Full Text |PubMed Central Full Text OpenURL
  7. Prieto-Alhambra D, Judge A, Javaid MK, Cooper C, Diez-Perez A, Arden NK: Incidence and risk factors for clinically diagnosed knee, hip and hand osteoarthritis: influences of age, gender and osteoarthritis affecting other joints.
    Ann Rheum Dis 2013, 73(9):1659-1664. PubMed Abstract | Publisher Full Text OpenURL
  8. Wang SY, Olson-Kellogg B, Shamliyan TA, Choi JY, Ramakrishnan R, Kane RL: Physical therapy interventions for knee pain secondary to osteoarthritis: a systematic review.
    Ann Intern Med 2012, 157(9):632-644. PubMed Abstract | Publisher Full Text OpenURL
  9. Leigh JP, Seavey W, Leistikow B: Estimating the costs of job related arthritis.
    J Rheumatol 2001, 28(7):1647-1654. PubMed Abstract | Publisher Full Text OpenURL
  10. Woolf AD, Pfleger B: Burden of major musculoskeletal conditions.
    Bull World Health Organ 2003, 81(9):646-656. PubMed Abstract | Publisher Full Text |PubMed Central Full Text OpenURL
  11. Karner M, Brazkiewicz F, Remppis A, Fischer J, Gerlach O, Stremmel W, Subramanian SV, Greten HJ: Objectifying specific and nonspecific effects of acupuncture: a double-blinded randomised trial in osteoarthritis of the knee.
    Evid Based Complement Alternat Med 2013, 2013:427265. PubMed Abstract |Publisher Full Text | PubMed Central Full Text OpenURL
  12. Roos EM, Juhl CB: Osteoarthritis 2012 year in review: rehabilitation and outcomes.
    Osteoarthritis Cartilage 2012, 20(12):1477-1483. PubMed Abstract | Publisher Full Text OpenURL
  13. Witt CM, Jena S, Brinkhaus B, Liecker B, Wegscheider K, Willich SN: Acupuncture in patients with osteoarthritis of the knee or hip: a randomized, controlled trial with an additional nonrandomized arm.
    Arthritis Rheum 2006, 54:3485-3493. PubMed Abstract | Publisher Full Text OpenURL
  14. Iannuccelli C, Mannocci F, Guzzo MP, Olivieri M, Gerardi MC, Atzeni F, Sarzi-Puttini P, Valesini G, Di Franco M: Complementary treatment in fibromyalgia: combination of somatic and abdominal acupuncture.
    Clin Exp Rheumatol 2012, 30(6 Suppl 74):112-116. PubMed Abstract | Publisher Full Text OpenURL
  15. Lee JH, Choi TY, Lee MS, Lee H, Shin BC, Lee H: Acupuncture for acute low back pain: a systematic review.
    Clin J Pain 2013, 29(2):172-185. PubMed Abstract | Publisher Full Text OpenURL
  16. Witt C, Brinkhaus B, Jena S, Linde K, Streng A, Wagenpfeil S, Hummelsberger J, Walther HU, Melchart D, Willich SN: Acupuncture in patients with osteoarthritis of the knee: a randomised trial.
    Lancet 2005, 366:136-143. PubMed Abstract | Publisher Full Text OpenURL
  17. Kim SY, Lee H, Chae Y, Park HJ, Lee H: A systematic review of cost-effectiveness analyses alongside randomised controlled trials of acupuncture.
    Acupunct Med 2012, 30(4):273-285. PubMed Abstract | Publisher Full Text OpenURL
  18. Reinhold T, Witt CM, Jena S, Brinkhaus B, Willich SN: Quality of life and cost-effectiveness of acupuncture treatment in patients with osteoarthritis pain.
    Eur J Health Econ 2008, 9(3):209-219. PubMed Abstract | Publisher Full Text OpenURL
  19. Deare JC, Zheng Z, Xue CC, Liu JP, Shang J, Scott SW, Littlejohn G: Acupuncture for treating fibromyalgia.
    Cochrane Database Syst Rev 2013, 5:CD007070. PubMed Abstract | Publisher Full Text |PubMed Central Full Text OpenURL
  20. Kim EJ, Lim CY, Lee EY, Lee SD, Kim KS: Comparing the effects of individualized, standard, sham and no acupuncture in the treatment of knee osteoarthritis: a multicenter randomized controlled trial.
  21. Green S, Buchbinder R, Hetrick S: Acupuncture for shoulder pain.
    Cochrane Database Syst Rev 2005., 2
    CD005319
    OpenURL
  22. Manyanga T, Froese M, Zarychanski R, Abou-Setta A, Friesen C, Tennehouse M, Shay BL:
    Pain management with acupuncture in osteoarthritis: a systematic review and meta-analysis PROSPERO International prospective register of systematic reviews. 2013. OpenURL
  23. Moher D: Corrigendum to: preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
    Int J Surg 2010, 8:336-341. PubMed Abstract | Publisher Full Text OpenURL
  24. Higgins JP, Altman DG, Gotzsche PC, Juni P, Moher D, Oxman AD, Savovic J, Schulz KF, Weeks L, Sterne JA, Cochrane Bias Methods Group; Cochrane Statistical Methods Group:The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials.
  25. Ioannidis JP, Trikalinos TA: The appropriateness of asymmetry tests for publication bias in meta-analyses: a large survey.
    CMAJ 2007, 176(8):1091-1096. PubMed Abstract | Publisher Full Text |PubMed Central Full Text OpenURL
  26. Hawker GAMS, Mian S, Kendzerska T, French M: Measures of Adult Pain: Visual Analog Scale for Pain (VAS Pain), Numeric Rating Scale for Pain (NRS Pain), McGill Pain Questionnaire (MPQ), Short-Form McGill Pain Questionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form-36 Bodily Pain Scale (SF-36 BPS), and Measure of Intermittent and Constant Osteoarthritis Pain (ICOAP).
    Arthritis Res 2011, 63(11):S240-S252. OpenURL
  27. Theiler R, Sangha O, Schaeren S, Michel BA, Tyndall A, Dick W, Stucki G: Superior responsiveness of the pain and function sections of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) as compared to the Lequesne-Algofunctional Index in patients with osteoarthritis of the lower extremities.
    Osteoarthritis Cartilage 1999, 7(6):515-519. PubMed Abstract | Publisher Full Text OpenURL
  28. Roos EM, Roos HP, Lomander LS, Ekdahl C, Beynnon BD: Knee injury and Osteoarthritis Outcome Score (KOOS): development of a self-administered outcome measure.
    J Orthop Sports Phys Ther 1998, 28(2):88-96. PubMed Abstract | Publisher Full Text OpenURL
  29. Ashraf A, Zarei F, Hadianfard MJ, Kazemi B, Mohammadi S, Naseri M, Nasseri A, Khodadadi M, Sayadi M: Comparison the effect of lateral wedge insole and acupuncture in medial compartment knee osteoarthritis: a randomized controlled trial.
    Knee 2014, 21(2):439-444. PubMed Abstract | Publisher Full Text OpenURL
  30. Dickens W, Lewith GT: A single-blind controlled and randomised clinical trial to evaluate the effect of acupuncture in the treatment of trapezio-metacarpal osteoarthritis.
    Complement Med Res 1989, 3:5-8. OpenURL
  31. Foster NE, Thomas E, Barlas P, Hill JC, Young J, Mason E, Hay EM: Acupuncture as an adjunct to exercise based physiotherapy for osteoarthritis of the knee: randomised controlled trial.
  32. Haslam R: A comparison of acupuncture with advice and exercises on the symptomatic treatment of osteoarthritis of the hip–a randomised controlled trial.
    Acupunct Med 2001, 19(1):19-26. PubMed Abstract | Publisher Full Text OpenURL
  33. Lev-Ari S, Miller E, Maimon Y, Rosenblatt Y, Mendler A, Hasner A, Barad A, Amir H, Dekel S:Delayed effect of acupuncture treatment in OA of the knee: a blinded, randomized, controlled trial.
    Evid Based Complement Alternat Med 2011, 2011(792975):1-5. OpenURL
  34. Saleki M, Ahadi T, Razi M, Raeisi GR, Forough B: Comparison of the effects of acupuncture and physical modality on symptoms of knee osteoarthritis.
    J Isfahan Med Sch 2012, 30(194):S73-S77. OpenURL
  35. Scharf HP, Mansmann U, Streitberger K, Witte S, Krämer J, Maier C, Trampisch HJ, Victor N:Acupuncture and knee osteoarthritis: a three-armed randomized trial.
    Ann Intern Med 2006, 145:12-20. PubMed Abstract | Publisher Full Text OpenURL
  36. Soni A, Joshi A, Mudge N, Wyatt M, Williamson L: Supervised exercise plus acupuncture for moderate to severe knee osteoarthritis: a small randomised controlled trial.
    Acupunct Med 2012, 30(3):176-181. PubMed Abstract | Publisher Full Text OpenURL
  37. Vas J, Mendez C, Perea-Milla E, Vega E, Panadero MD, Leon JM, Borge MA, Gaspar O, Sanchez-Rodriguez F, Aguilar I, Jurado R: Acupuncture as a complementary therapy to the pharmacological treatment of osteoarthritis of the knee: randomised controlled trial.
  38. White P, Bishop FL, Prescott P, Scott C, Little P, Lewith G: Practice, practitioner, or placebo? A multifactorial, mixed-methods randomized controlled trial of acupuncture.
    Pain 2012, 153(2):455-462. PubMed Abstract | Publisher Full Text OpenURL
  39. Williamson L, Wyatt MR, Yein K, Melton JT: Severe knee osteoarthritis: a randomized controlled trial of acupuncture, physiotherapy (supervised exercise) and standard management for patients awaiting knee replacement.
    Rheumatology (Oxford) 2007, 46(9):1445-1449. PubMed Abstract | Publisher Full Text OpenURL
  40. Lau J, Ioannidis JP, Terrin N, Schmid CH, Olkin I: The case of the misleading funnel plot.
    BMJ 2006, 333(7568):597-600. PubMed Abstract | Publisher Full Text |PubMed Central Full Text OpenURL
  41. Audette JF, Ryan AH: The role of acupuncture in pain management.
    Phys Med Rehabil Clin N Am 2004, 15(4):749-772.
    v
    PubMed Abstract | Publisher Full Text OpenURL
  42. Stux G: Basics of acupuncture. 3rd edition. Berlin, New York: Springer; 1995. OpenURL
  43. Kubiena GAS: B: Practice Handbook of Acupuncture. 3rd edition. Edinburgh, New York: Churchill Livingstone Elsevier; 2010. OpenURL
  44. Angst F, Aeschlimann A, Stucki G: Smallest detectable and minimal clinically important differences of rehabilitation intervention with their implications for required sample sizes using WOMAC and SF-36 quality of life measurement instruments in patients with osteoarthritis of the lower extremities.
    Arthritis Rheum 2001, 45(4):384-391. PubMed Abstract | Publisher Full Text OpenURL
  45. Jaeschke R, Singer J, Guyatt GH: Measurement of health status. Ascertaining the minimal clinically important difference.
    Control Clin Trials 1989, 10(4):407-415. PubMed Abstract | Publisher Full Text OpenURL
  46. Tubach F, Ravaud P, Baron G, Falissard B, Logeart I, Bellamy N, Bombardier C, Felson D, Hochberg M, van der Heijde D, Dougados M: Evaluation of clinically relevant changes in patient reported outcomes in knee and hip osteoarthritis: the minimal clinically important improvement.
    Ann Rheum Dis 2005, 64(1):29-33. PubMed Abstract | Publisher Full Text |PubMed Central Full Text OpenURL
  47. White A, Tough E, Cummings M: A review of acupuncture clinical trials indexed during 2005.
    Acupunct Med 2006, 24(1):39-49. PubMed Abstract | Publisher Full Text OpenURL
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