Intended for healthcare professionals


Acupuncture as an adjunct to exercise based physiotherapy for osteoarthritis of the knee: randomised controlled trial

BMJ 2007; 335 doi: (Published 30 August 2007) Cite this as: BMJ 2007;335:436

Physical exercise and Acupuncture in the treatment of knee osteoarthritis - Not both - but maybe either one of them?

It has been hypothesised that acupuncture and physical exercise
activates similar pain inhibitory mechanisms (Andersson, Lundeberg, 1995).
If so, it would not be expected that patients treated with both physical
training and acupuncture (or superficial needling) would report a better
effect. This suggestion is supported by the elegant study in the BMJ by
Foster and collaborators (2007).

The real issue though is whether acupuncture or physical training should
be recommended as both modalities have proven to be effective (White et
al., 2007; Devos-Comby et al., 2006). Furthermore, in the present study
the authors have used manual acupuncture despite the fact that
electrocupuncture is the modality that is likely to be most efficiaous in
knee osteoarthritis (OA) pain (Vas, White 2007). The statement that the
effects of acupuncture were short lived (like analgesics are in OA) is
likely relevant since the primary outcome was change in rated pain 6 month
after treatment based on 6 treatments.
In a clinical context both modalities may be recommended in patients with
osteoarthritis; i.e. patients that can exercise should exercise (active
treatment), whereas patients who cannot exercise may be treated with
acupuncture (passive treatment). Also, patients that are not candidates
for exercise may after some initial acupuncture treatments start with
physical exercise.

Before general treatment recommendations are stated they should be based
on results of comparative studies with the actual state of the clinical
condition and the optimal treatment modalities taken into account in order
to offer the best treatment for the patient. The number of acupuncture
treatments (commonly at least 8-10 are recommended possibly with
additional “top ups”) as well as the stimulus intensity used (all patients
did not experience de Qi, which is considered a prerequisite) is probably
suboptimal when aiming for an up-regulation of the function in the
endogenous pain inhibiting system with observational effects 6 months
after treatments. A further study comparing 10 sessions of
electroacupuncture (including induction of de Qi) with 10 sessions of
physical exercise would be of great interest.


1. Andersson S, Lundeberg T. Acupuncture-from empiricism to science:
functional background to acupuncture effects in pain and disease. Med
Hypotheses 1995;45(3):271-81.

2. 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. BMJ 2007;

3. Vas J, White A. Evidence from RCTs on optimal acupuncture
treatment for knee osteoarthritis--an exploratory review. Acupunct Med

4. White A, Foster NE, Cummings M, Barlas P. Acupuncture treatment
for chronic knee pain: a systematic review. Rheumatology (Oxford)

5. Devos-Comby L, Cronan T, Roesch SC. Do exercise and self-
management interventions benefit patients with osteoarthritis of the knee?
A metaanalytic review. J Rheumatol 2006;33(4):744-56.

Competing interests:
None declared

Competing interests: No competing interests

18 September 2007
Thomas CM Lundeberg
Thomas Lundeberga, Mike Cummingsb and Irene Lundc
Rehabilitationmedicine University Clinic Stockholm, Stockholm Danderyds Hospital AB, SE-182 88 Stock