Songning Zhang

Biomechanics/Sports Medicine Laboratory,Department of Kinesiology,Recreation and Sport Studies,University of Tennessee,Knoxville,TN 37996,USA

Research highlight

Recent changes in evidence-based,non-pharmacological treatment recommendations for acupuncture and Tai Chi for knee osteoarthritis

Songning Zhang

Biomechanics/Sports Medicine Laboratory,Department of Kinesiology,Recreation and Sport Studies,University of Tennessee,Knoxville,TN 37996,USA

Osteoarthritis(OA)is the most common form of arthritis. The knee and hip joints are the most common sites for OA, and knee OA is more prevalent than hip OA.1Knee OA patients often suffer pain,functional disability,articular cartilage wear and related joint space narrowing.Among U.S.adults, 46.4 million have physician-diagnosed arthritis representing 21.6%of the U.S.population,and 8.3%(17.4 million)had activity limitations attributable to arthritis.2It is estimated that by 2030,the number of physician-diagnosed arthritis cases will reach 67 million,and 25 million will have arthritisattributable activity limitations.2Although 7.9%of U.S.adults aged 18—44 years have arthritis,this percentage increases to 29.3%and 50.0%for adults between 45 and 64 years and older than 65 years,respectively.Currently,there is no cure for this degenerative disease.3The economic and functional impacts of this disease have become an increased burden for society and individuals.The treatment strategies for knee OA often are aimed at reducing pain,improving physical function, decreasing disability,and limiting OA progression.1,4,5

Over the two decades,several national and international medical organizations including the American College of Rheumatology(ACR),European League Against Rheumatology(EULAR),Osteoarthritis Research Society International(OARSI),and National Institute of Health(NIH)have published evidence-based guidelines for the management of knee OA.3—8These guidelines are mostly evidence-based with expert consensus.1,3,4The treatment recommendations from these guidelines include non-pharmacological and pharmacologicaltherapies,intraarticularinjections,andsurgicalprocedures including arthroscopy,osteotomy and total/unicompartmental knee replacement.4—7,9A combination of pharmacological and non-pharmacological treatments is commonly recommended in clinical practice and is universally recommended in existing guidelines for the management of knee OA.4,5The non-pharmacologicaltherapies commonlyinclude patienteducation,selfmanagement programs,personalized social support through telephone contact,weight loss(if overweight),aerobic exercise programs,physical therapy,range-of-motion exercises,muscle strengthening,transcutaneous electricalnerve stimulation (TENS),electromagnetic field therapy(EFT),acupuncture,ultrasound,laser,spa,assistive devices for ambulation,patellar taping,theappropriatefootwear,lateral-wedgedinsoles(forgenu varum),bracing,occupational therapy,joint protection and energy conservation,and assistive devices for activities of daily living.3—5In earlier guidelines,6acupuncture,TENS,EFT,ultrasound,laser,bracing/taping,and footwear and orthotics were not usually recommended as non-pharmacological treatments. Among the non-pharmacological recommendations,patient education,muscle strengthening,aerobic and range of motion exercises and walking aids received the highest support.5

Chinese acupuncture as a knee OA treatment alternative first appeared in the knee OA guidelines in 20007and since then,has beenincludedinmorerecentrecommendations.4,5,8,9Inanearlier systematic review of OA,it was found that seven of the studies included reported positive results for acupuncture treatment,and six reported non-significant results.10The NIH OA working group made the evidence-based conclusion that“the research to date on the efficacy of acupuncture in osteoarthritis is inconclusivebutpromising”.7Inarecentmeta-analysisofacupuncturefor knee OA,patients receiving acupuncture showed short-term improvements in pain(effect size(ES)=-0.96)and function (ES=-0.93)as compared to patients in a waitlist control group.11However,when compared to a sham control group, acupuncture showed diminished short-term effects on pain (ES=-0.35)and function(ES=-0.35).TheES for pain relief was furtherreduced at6 months after treatment.In a morerecent review of 16 qualified randomized control trials(RCT)for knee OA,it was shown that the external validity was inadequate in thetrial setting,treatment providers and statistical reporting.12The most commonly-used acupoints were ST34,ST35,ST36,SP6, SP9,SP10,GB34,Xiyan,andAhShi.Theacupuncturetreatment usually involved 20 min per treatment session,two sessions per week,and 10—15 sessions in total.In its most recent evidencebasedguideline,theACRconditionallyrecommendedtraditional Chinese acupuncture for knee OA patients.9

Tai Chi(or Tai Ji)was not included as a non-pharmacological treatment in the majority of the recent guidelines for knee OA treatment from the ACR,NIH,EULAR,and OARSI.3—8However,the most recent guideline from the ACR for knee OA included Tai Chi as a recommended non-pharmacological treatment.9The guideline was developed based on systematic literature reviews(uptoDecember2010)anda technicalexpertpanel. It conditionally recommended Tai Chi as one of the non-pharmacological treatments among others such as medial wedge insoles for valgus knee OA,subtalar strapped lateral insoles for varuskneeOA,mediallydirectedpatellartaping,manualtherapy, walking aids,thermal agents,self-management programs,and psychosocial interventions.This recommendation was mainly based on a recent systematic review13and a Tai Chi RCT.14Among the 10 studies included in the review,the ES for pain reduction after Tai Chi intervention ranged between 0.28 and 1.67.13AnRCTperformedbyWangetal.14had20patientsinthe TaiChigroupand20controls,andshowedthatthepatientsinthe Tai Chi group had an ES of 1.17(95%confidence interval: 0.50—1.84).It was also found that the Sun style was most commonlyused(in4outof10studies)forkneeOAinterventions, whereas the Yang style(used in 3 out 10)achieved the best results.13The Sunstyle usesslow and gentlemotionswith a higher body posture than other Tai Chi styles,and was therefore considered to be better for OA patients.However,the Yang style is the most popular Tai Chi form practiced worldwide.

1.Zhang W,Moskowitz RW,Nuki G,Abramson S,Altman RD,Arden N, et al.OARSI recommendations for the management of hip and knee osteoarthritis,part I:critical appraisal of existing treatment guidelines and systematic review of current research evidence.Osteoarthr Cartil2007;15:981—1000.

2.Hootman JM,Helmick CG.Projections of US prevalence of arthritis and associated activity limitations.Arthritis Rheum2006;54:226—9.

3.American College of Rheumatology Subcommittee on Osteoarthritis Guidelines.Recommendations for the medical management of osteoarthritis of the hip and knee:2000 update.Arthritis Rheum2000;43:1905—15.

4.Jordan KM,Arden NK,Doherty M,Bannwarth B,Bijlsma JW,Dieppe P, et al.EULAR recommendations 2003:an evidence based approach to the management of knee osteoarthritis:report of a task force of the standing committee for international clinical studies including therapeutic trials (ESCISIT).Ann Rheum Dis2003;62:1145—55.

5.Zhang W,Moskowitz RW,Nuki G,Abramson S,Altman RD,Arden N, et al.OARSI recommendations for the management of hip and knee osteoarthritis,part II:OARSI evidence-based,expert consensus guidelines.Osteoarthr Cartil2008;16:137—62.

6.Hochberg MC,Altman RD,Brandt KD,Clark BM,Dieppe PA, Griffin MR,et al.Guidelines for the medical management of osteoarthritis.Part II.Osteoarthritis of the knee.American College of Rheumatology.Arthritis Rheum1995;38:1541—6.

7.Felson DT,Lawrence RC,Hochberg MC,McAlindon T,Dieppe PA, Minor MA,et al.Osteoarthritis:new insights.Part 2:treatment approaches.Ann Intern Med2000;133:726—37.

8.Zhang W,Nuki G,Moskowitz RW,Abramson S,Altman RD,Arden NK, et al.OARSI recommendations for the management of hip and knee osteoarthritis:part III:changes in evidence following systematic cumulative update of research published through January 2009.Osteoarthr Cartil2010;18:476—99.

9.Hochberg MC,Altman RD,April KT,Benkhalti M,Guyatt G, McGowan J,et al.American College of Rheumatology 2012 recommendations for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the hand,hip,and knee.Arthritis Care Res(Hoboken)2012;64:465—74.

10.Ernst E.Acupuncture as a symptomatic treatment of osteoarthritis.A systematic review.Scand J Rheumatol1997;26:444—7.

11.Manheimer E,Linde K,Lao L,Bouter LM,Berman BM.Meta-analysis: acupuncture for osteoarthritis of the knee.AnnInternMed2007;146:868—77.

12.Purepong N,JitvimonratA,SitthipornvorakulE,Eksakulkla S, Janwantanakul P.External validity in randomised controlled trials of acupuncture for osteoarthritis knee pain.Acupunct Med2012;30:187—94.

13.Escalante Y,Saavedra JM,Garc?′a-Hermoso A,Silva AJ,Barbosa TM. Physical exercise and reduction of pain in adults with lower limb osteoarthritis: a systematic review.JBackMusculoskeletRehabil2010;23:175—86.

14.Wang C,Schmid CH,Hibberd PL,Kalish R,Roubenoff R,Rones R,et al. Tai Chi is effective in treating knee osteoarthritis:a randomized controlled trial.Arthritis Rheum2009;61:1545—53.

27 June 2013;accepted 30 June 2013

E-mail address:szhang@utk.edu.

Peer review under responsibility of Shanghai University of Sport

2095-2546/$-see front matter Copyright?2013,Shanghai University of Sport.Production and hosting by Elsevier B.V.All rights reserved. http://dx.doi.org/10.1016/j.jshs.2013.06.002