Journal of Nursing Research Vol. 16, No.

2, 2008

The Effectiveness of Acupuncture on Pain and

Mobility in Patients With Osteoarthritis
of the Knee: A Pilot Study
Suh-Hwa Maa Mao-Feng Sun* Chi-Chuan Wu**

ABSTRACT: Acupuncture has been repeatedly reported to relieve pain associated with osteoarthritis of the knee. As
the vast majority of information on the effectiveness of acupuncture on this condition is based on data
collected in Western countries, little is known about patients with osteoarthritis of the knee in Asian
countries. In this pilot clinical study, acupuncture was incorporated into the standard care for adult
patients with osteoarthritis of the knee to determine its contribution to pain relief and improved mobility.
In a prospective, non-randomized controlled study, patients with osteoarthritis of the knee were
separated into two groups. The first (the experimental group; n = 12) was scheduled for up to 8 sessions
of acupuncture in addition to standard care, while the second (the control group; n = 12) received
standard care only. Measurements using the six-minute walking distance test, pain visual analogue scale,
and osteoarthritis of the knee outcome measurement were taken at baseline and after 4 weeks. Both study
and control groups showed significant improvement with respect to time effects in terms of six-minute
walking distance, pain visual analogue scale, pain domain and mobility domain scores determined by the
osteoarthritis of the knee outcome measurement (p < .01), after adjusting for covariables. However,
improvements measured in the study group did not differ significantly from those in the control group.
Patients with osteoarthritis of the knee seemed to experience clinical improvements in six-minute
walking distance, pain relief and mobility when their standard care was supplemented with acupuncture.
Key Words: acupuncture, osteoarthritis of the knee, osteoarthritis of the knee outcome measurement.

Introduction motivate patients to increase physical activity. In the hope

Previous evidence showed that acupuncture can help
alleviate pain associated with osteoarthritis (OA) of the
knee (Berman et al., 1995). Many research studies have
examined the effects of acupuncture on pain and joint
mobility in patients with OA of the knee (Berman et al.,
2004; Sangdee et al., 2002; Scharf et al., 2006; Tukmachi,
Jubb, Dempsey, & Jones, 2004; Witt et al., 2005; Witt et al.,
2006). A systematic review suggested that acupuncture
was an option worthy of consideration, particularly for
knee OA (Kwon, Pittler, & Ernst, 2006). This study hypo-
thesized that pain relief resulting from acupuncture might
of facilitating the integration of acupuncture into conven-
tional medicine, this study quantitatively evaluated the
effectiveness of acupuncture on pain and mobility in pa-
tients with osteoarthritis of the knee.
Osteoarthritis of the Knee
Osteoarthritis is a chronic medical condition that in-
volves the gradual destruction of one or more joints (Felson,
2006). Osteoarthritis has been identified as a leading cause
of impaired mobility in the elderly (Peat, McCarney, &
Croft, 2001). The joint most commonly affected by oste-
oarthritis is the knee (Felson & Zhang, 1998; Oliveria,

RN, DSN, Associate Professor, School of Nursing, Chang Gung University; *MD, Department of Acupuncture and Chinese Traumatology,
Center for Traditional Chinese Medicine, Chang Gung Memorial Hospital & Adjunct Associate Professor, Department of Nursing, Chang
Gung Institute of Technology; **MD, Director, Traumatological Division, Chang Gung Memorial Hospital & Professor, Department of
Orthopedics, Chang Gung University.
Received: November 19, 2007 Revised: March 4, 2008 Accepted: April 11, 2008
Address correspondence to: Suh-Hwa Maa, No. 259, Wen-Hwa 1st Rd., Kweishan Township, Taoyuan County 33302, Taiwan, ROC.
Tel: +886 (3) 211-8800 ext. 5481; Fax: +886 (3) 211-8199; E-mail: shmaa@mail.cgu.edu.tw

140
Patients With Osteoarthritis of the Knee
Felson, Reed, Cirillo, & Walker, 1995). Osteoarthritis of
the knee is a common medical problem in Taiwan as well.
Approximately 3,000 knee replacements are done on an
annual basis in Taiwan. These surgeries place a huge bur-
den on the health care system, requiring average hospital
stays of 10 days and annual costs of $66,025 to $79,230
(Taiwan dollars) per patient (Hsu, 1993).
Typical complaints of patients with osteoarthritis of
the knee are pain, stiffness, inflammation, swelling, tender-
ness, and grinding on affected knee joints, as well as de-
creased activity (Buckley, Vacek, & Cooper, 1990). There-
fore, main treatment priorities include pain relief and im-
proved mobility (Ausiello & Stafford, 2002; Banning,
2006; Felson, 2006; Wegman, van der Windt, van Tulder,
Stalman, & de Vries, 2004). However, the effects of non-
steroidal anti-inflammatory drugs are small and short-lived
(Bjordal, Ljunggren, Klovning, & Slrdal, 2004), and
these drugs have been associated with serious side effects,
including bleeding and perforated ulcers (Brien, Lewith, &
McGregor, 2006; Gutthann, Garcia Rodriguez, & Raiford,
1997). Consequently, many people with osteoarthritis of
the knee seek alternative treatments, such as acupuncture.
Acupuncture
The general theory of acupuncture is based on the
premise that there are patterns of energy flow (Qi) through
the body that are essential for health (Stux, 1987a). This Qi
can be traced through various body systems and along 12
main pathways known as meridians. Most illnesses and
disturbances are caused by either an excess or deficiency of
Qi in organ systems and meridians (Stux & Pomeranz,
1987). Acupuncture may correct imbalances of the Qi at
identifiable acupuncture points close to the skin along
meridians. The number and length of treatments and acu-
puncture points used may vary among individuals and dur-
ing treatment.
In traditional Chinese medicine, five Zang-fu net-
works refer to the gross anatomical entities of the internal
organs and physiological functions (Veith, 1972). The Heart
network propels the blood and is the seat of consciousness.
The lung network receives and disperses Qi. The spleen
network generates and distributes nourishment and fluid to
the heart and the lungs from where such are distributed to
nourish the whole body. The liver network stores the blood,
regulates the even movement of Qi, and regulates the
volume of blood circulating. The kidney network stores
the Qi, manufactures blood, and dominates fluid metabo-
J. Nursing Research Vol. 16, No. 2, 2008
lism. The underlying mechanism of osteoarthritis of the
knee is considered as slowdown of Qi, the consequence of
ineffective interaction between liver, spleen and kidney
networks. Osteoarthritis of the knee is characterized by
blood stasis and sputum accumulation. This study attempt-
ed to relieve pain by relaxing muscles and tendons using a
strategy targeted to strengthen liver, gall bladder, and
spleen networks. Treatment in this study focused mainly on
activating the blood to resolve stasis, promote smooth cir-
culation of blood and Qi to relax muscles and tendons, and
disperse blockages along the meridians to relieve pain.
Individualized acupoints were chosen from Zhenjiu
Dacheng (Compendium of Acupuncture and Moxibustion,
A.D. 1601) a work by Yangjizhou, a Ming Dynasty acu-
puncturist. All acupoints selected have been reported to
give maximum relief to patients with pain, and to enhance
immune system functions (Stux & Pomeranz, 1987). Three
acupuncture points that were universally applied to all
experimental group subjects included the Dubi (Stomach
35) (Berman et al., 2004; Sangdee et al., 2002; Witt et al.,
2005), Xiyan (Extra 32) (Berman et al., 2004; Sangdee et
al., 2002; Scharf et al., 2006; Tukmachi et al., 2004) and
Yanglingquan (GallBladder 34) (Berman et al., 2004;
Scharf et al., 2006; Tukmachi et al., 2004; Witt et al.,
2005). Treating Yanglingquan has been reported to have
beneficial effects on knee disorders, rheumatoid arthritis,
tendovaginitis, myodystrophies, myopathy, and mental
disorders (Stux, 1987b). Dubi and Xiyan are recom-
mended for use together as local acupuncture points for
treatment of knee joint disorders. Yanglingquan and Dubi
are located on the lateral side at the lower border of the
patella. Xiyan is located on the medial side of the li-
gamentum patella.
Additional acupuncture points for pain relief were
applied to address symptoms specific to each patient in
the experimental group. Complaints of pain on the inter-
nal side of the knee joint recommended the addition of
three points, including Yinlingquan (Spleen 9) (Berman
et al., 2004; Scharf et al., 2006; Tukmachi et al., 2004),
Xuehai (Spleen 10) (Scharf et al., 2006; Witt et al., 2005),
and Taixi (Kidney 3) (Berman et al., 2004; Vas et al.,
2004; Witt et al., 2005). Yinlinquan is recommended for
treating disorders of the edema, ascites and swelling in the
lower extremities. Xuehai is recommended for treating
skin disorders, allergies, infectious disorders, blood dis-
eases and urogenital disorders. Taixi is recommended for
treating urogenital disorders, enuresis, dysmenorrhea,
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J. Nursing Research Vol. 16, No. 2, 2008
impotence, cystitis and disorders of upper ankle joints
(Stux, 1987b). Yinlingquan is located on the medial side
of the leg, in the depression below the lower border of the
medial condyle at the level of the tuberositas tibiae. Xuehai
is located on the highest point of the muscle vastus
medialis, 6 cm proximal to the upper border of the patella.
Taixi is located midway between the most prominent
point of the malleolus medialis and the superior border of
the Achilles tendon.
Complaints of pain on the external side of the knee
joint recommended the additional application of acupunc-
ture therapy at the Liangqiu (Stomach 34) (Scharf et al.,
2006; Witt et al., 2005). Liangqiu, recommended for
treating disorders of the knee joint and acute gastrointesti-
nal disorders (Stux, 1987b), is located 6 cm above the
lateral and superficial border of the patella. Complaints of
pain on the top side of the knee joint recommended the
additional application of acupuncture therapy at the
Heding (Extra 31) (Witt et al., 2005). Heding is recom-
mended for knee joint pain relief and is located at the mid-
point of the upper border of the patella. Pain on the poste-
rior side of the knee recommended the addition of Wei-
zhong (Urinary Bladder 40) to the acupuncture therapy
program (Tukmachi et al., 2004). Weizhong, recom-
mended for relieving lumbago, sciatica, pelvic disorders,
impotence and enuresis (Stux, 1987b), is located at the
midpoint of the popliteal transverse crease. All acupoints
were used bilaterally.
Methods
This was a two-group prospective, quasi-experimen-
tal, pilot study conducted over a four week period (Parson,
1993). After data collection was completed in the experi-
mental group, researchers collected data from the control
group. Adjunctive to biomedical standard care compari-
sons assesses the efficacy of acupuncture plus standard
care relative to standard care alone (Hammerschlag, 1998).
The Institutional Ethical Committee approved our use of
this protocol.
Selecting and Assigning Patients
A non-probability purposive sample was drawn from
patients who visited the Department of Orthopedics as
outpatients. Patients were selected according to seven cri-
teria including: aged 55 years or older; diagnosis using
Western medical techniques or radiological evidence of
142
Suh-Hwa Maa et al.
Grade 1, 2, or 3 knee OA; at least moderate pain in one
knee for most of the past month; no evidence or history
suggesting (a) pregnancy, (b) systemic steroid therapy or
intra-articular steroid injections in the 3 months prior to the
study, (c) coexistent joint diseases (such as rheumatoid
arthritis, fibromyalgia, prior total knee replacement sur-
gery), (d) severe chronic or uncontrolled serious illness
(such as diabetes, stroke), or (e) history of bleeding dia-
thesis. After written informed consent and full medical his-
tories were obtained from each patient, experimental group
data was collected first. Control group data was then col-
lected. Of the 62 participants (37 in experimental group, 25
in control group) who initially agreed to participate in this
study, 38 withdrew during week four (25 in the experimen-
tal group, 13 in the control group). Withdrawals included,
but were not limited to, patients in the experimental group
who failed to complete a full course of treatment. Twenty-
four patients (n = 24) completed the full course of treat-
ment; the attrition rate was 37 %. The final group sizes
were: acupuncture, n = 12; and control, n = 12.
Standard Care
All patients were asked to maintain their current level
of oral medication (i.e., nonsteroidal anti-inflammatory
drugs, cyclooxygenase-2 inhibitors, and acetaminophen)
and physiotherapy (e.g., isotonic resistance exercise on
quadriceps and locally applied heat on affected knee)
throughout the experiment. The control group only re-
ceived such standard treatments. No subjects received any
steroids, but all took oral analgesics. All subjects received
instruction regarding proper use of all medication, de-
creased activity, and joint and muscle stretching exercises.
Acupuncture
Patients in the acupuncture group completed a total of
8 sessions of 30 minutes each, which were administered
two times weekly over a four week period. A total of 6-9
acupuncture points were addressed in each patient. Dr.
Sun, co-investigator of this study, assessed patient con-
ditions and performed acupuncture. Dr. Sun is the director
of the Department of Acupuncture and Chinese Trau-
matology and has practiced acupuncture independently for
more than 20 years, with expertise in the treatment of soft
tissue pain and allergy conditions. During acupuncture
treatment, each subject assumed a supine position to pro-
mote relaxation and prevent fainting. Disposable sterile
34-gauge stainless steel needles (0.22 mm diameter, 2.5 cm
Patients With Osteoarthritis of the Knee
length) were used and inserted to depths of 0.5-2 cm into
the acupoints. Once subjects verified the De Qi sensa-
tion, the physician would not stimulate the acupoints but
apply electricity to one of two-point groups (either Dubi
and Xiyan or Yanglingquan) and one of the other six points
(Yinlinquan, Xuehai, Taixi, Liangqiu, Heding or Wei-
zhong). Electricity was delivered at 2-5 V (amplitude of
pulse), 2 Hz (low-frequency), D-D wave for 15 min. In
addition, a tiny cone of moxa was placed on the top of the
needle on all points used except Weizhong and ignited for 3
minutes. Acupuncture needles then remained in place for
another 12 minutes without stimulation while subjects
rested.
The acupuncture points were identified using a flexi-
ble point selection formula. Such included local points
around the affected knee and the distal points at medial and
lateral aspects of the leg. Low-frequency (2 Hz) electro-
acupuncture was selected because it produces an analgesia
of long duration, which outlasts the 20-min stimulation
session by 30 mins to many hours. In addition, its effects
are cumulative after several sessions of treatment are given
on a daily or less frequent basis (2-3 times a week) (Sang-
dee et al., 2002). For these reasons, low-frequency electro-
acupuncture in this study was applied twice weekly for 4
weeks, as commonly recommended in electroacupuncture
practice.
Outcome Measures
Three measurements were performed at the begin-
ning and the end of the 4 week treatment period. These
included: the six-minute walking distance (6-MWD)
(Butland, Pang, Grossk, Woodcock, & Geddes, 1982),
the pain visual analogue scale and outcome measure-
ment the osteoarthritis of the knee. For 6-MWD, sub-
jects were asked to walk for 6 minutes at their own maxi-
mal pace along a 40-meter long hospital corridor, stop-
ping as necessary, at room temperature with researcher
accompaniment and encouragement. Distance actually
walked was measured in meters. Pain visual analogue
scale refers to a 100-mm horizontal line, with anchors
defined as no pain at the low end and extreme pain at
the high end.
The osteoarthritis of the knee outcome measure-
ment was developed in Taiwan. This instrument showed
acceptable construct validity, explaining 52.34% of total
variance in factor analysis and showing internal consis-
tency ranging from 0.79 to 0.90 for five subscales in a
J. Nursing Research Vol. 16, No. 2, 2008
previous study (Yang, Maa, Hsu, & Wu, 2001). The
questionnaire includes 37 items designed to reflect a
respondents degree of distress toward activities of daily
living in terms of pain, symptoms, mobility, emotional
reactions and social participation. Items are weighted
and each section yields a value between 0 and 100 on an
internal scale, with the worst state rated as 100 and the
best rated as 0.
Statistical Analysis
All data were analyzed using SAS/STAT version 9.1.
Participants who dropped out of the study were not statisti-
cally different from those who completed the study in
terms of age, gender, and pain visual analogue scale re-
sults. Therefore, only data for those participants who com-
pleted the study were analyzed. To account for dependence
within subjects due to repeated measurements of outcome
variables, generalized estimating equations (GEE) were
used throughout the analysis. Statistical tests were two-
sided and comparisons with a p-value < .05 were con-
sidered statistically significant.
Ethical Considerations
The Institutional Ethical Committee approved the
protocol. Patients signed a written consent form before par-
ticipating in this study.
Results
Participant Characteristics
Table 1 lists sample baseline demographic character-
istics. No significant differences were identified between
subjects in the experimental and control groups. Con-
sidered together, the mean age of all participants was
60.08 years, their mean body mass index was 26.55, and
their mean period of osteoarthritis of the knee history was
2.61 years. The sample contained more females (n = 20)
than males (n = 4).
Outcome Measures
Table 2 shows the mean values ( standard deviation)
of the outcome variables for all participants at the baseline
and after 4 weeks. The results of multiple linear regression
analysis for longitudinal data are reported in Table 3. Esti-
mates of linear regression coefficients and standard errors
(SE), obtained using the GEE method with working corre-
lation = AR (1) (1st-order autoregressive process), are pro-
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J. Nursing Research Vol. 16, No. 2, 2008 Suh-Hwa Maa et al.

Table 1.
Differences in Demographic and Clinical Characteristics Between Experimental and Control Groups*
Experimental (acupuncture Control (standard care)
plus standard care) Group Group All subjects
Characteristics n % n % n % p value
Total 12 100.000 12 100.000 24 100.000
Sex .59
Male 03 25.00 01 08.30 04 16.70
Female 09 75.00 11 91.70 20 83.30
Age .09
65 or older 07 58.30 02 16.70 09 37.50
55-64 05 41.70 10 83.30 15 62.50
Body Mass Index (BMI) .68
25 or higher 08 66.70 06 50.00 14 58.30
24 or lower 04 33.30 06 50.00 10 41.70
OA on Knee History (years) .22
3 or longer 08 66.70 04 33.30 12 50.00
2 or shorter 04 33.30 08 66.70 12 50.00
Estrogen Therapy .67
Yes 03 33.30 05 45.45 08 40.00
No 06 66.70 06 54.55 12 60.00
Other Alternative Therapy 1.000
Yes 08 66.70 04 33.30 12 50.00
No 04 33.30 08 66.70 12 50.00
Note. *Data are presented as No. (%) unless otherwise indicated. c2 and Fisher Exact test for between groups.

Table 2.
Outcome Measures for Experimental and Control Groups
Acupuncture plus standard care Standard care group
Possible scores group (n = 12) (n = 12)
Outcome measure worst-best M SD M SD
6 Minute Walking Distance (meter) better
Baseline 292.44 74.000 293.17 93.720
4-week 337.26 68.030 321.56 58.750
Pain VAS (mm) better
Baseline 04.11 01.95 05.59 02.26
4-week 02.49 01.96 04.83 01.71
Questionnaire
Pain 100-0
Baseline 26.04 14.23 37.15 15.12
4-week 16.67 10.21 27.78 12.09
Symptoms 100-0
Baseline 28.75 12.81 34.17 21.51
4-week 27.50 18.03 30.42 20.72
Mobility 100-0
Baseline 32.53 17.11 39.26 19.40
4-week 25.16 15.15 28.69 17.03
Emotional Reactions 100-0
Baseline 14.84 16.44 30.47 21.61
4-week 10.68 14.75 23.96 21.33
Social Participation 100-0
Baseline 18.75 21.23 30.42 24.63
4-week 19.58 21.37 33.75 27.15

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Patients With Osteoarthritis of the Knee J. Nursing Research Vol. 16, No. 2, 2008

Table 3.
Comparisons of Outcome Measurements Between Experimental and Control Groups After Adjusting for the
Effects of Age, Gender, BMI, and Osteoarthritis of the Knee History
Item Estimate Standard Error z value p-value
6 MWD
Group (intervention vs. standard) 14.73 27.850 -0.53 .60
4-week vs. baseline 32.44 8.75 -3.71 < .01 <
Pain VAS
Group (intervention vs. standard) -1.96 0.70 -2.78 .01
4-week vs. baseline -1.19 0.39 -3.04 < .01 <
Questionnaire
Pain
Group (intervention vs. standard) -12.57- 4.68 -2.68 .01
4-week vs. baseline -9.31 2.89 -3.22 < .01 <
Symptoms
Group (intervention vs. standard) -12.19- 7.79 -1.56 .12
4-week vs. baseline -2.50 3.42 -0.73 .47
Mobility
Group (intervention vs. standard) -14.13- 5.33 -2.65 .01
4-week vs. baseline -9.00 2.24 -4.01 < .01 <
Emotional Reactions
Group (intervention vs. standard) -13.86- 8.35 -1.66 .10
4-week vs. baseline 95.31 2.92 -1.82 .07
Social Participation
Group (intervention vs. standard) -18.36- 7.45 -2.47 .01
4-week vs. baseline -2.08 4.79 0-.44 .66
Note. 6MWD = 6 minute walking distance. The treatment time interaction was not significant and was deleted from the model.

vided. As shown in Table 3, after controlling for the effects
of age, gender, body mass index, and osteoarthritis of the
knee history (3 years or longer and 2 years or shorter as
separate variables), both acupuncture and control groups
showed significant improvement with respect to time
effects at 4 weeks in terms of six-minute walking distance,
pain visual analogue scale, pain domain and mobility
domain scores determined by the osteoarthritis of the knee
outcome measurement (p < .01).
Discussion
This study found that both the experimental and con-
trol group showed improvements in six-minute walking
distance, pain visual analogue scale, pain domain and
mobility domain scores as determined by the osteoarthritis
of the knee outcome measurement, after adjusting for co-
variables. However, the degree of improvement in the ex-
perimental group did not differ significantly from that in
the control group. The clinical implications of these find-
ings are consistent with the goals of osteoarthritis of the
knee treatment (Ausiello & Stafford, 2002; Wegman et al.,
2004).
Recruitment and Attrition
The high attrition rate in this experiment may be at-
tributable to the nature of acupuncture. Of the 38 subjects
in the acupuncture group who dropped out in week 4, five
refused to accept acupuncture treatment, six dropped out
because participation was too time-consuming, seven
withdrew due to fear of SARS (Severe Acute Respiratory
Syndrome) infection and twenty withdrew without giving
specific reasons. That most of the withdrawals were not for
medical reasons reflects the fact that some patients may not
have appreciated the value of acupuncture.
Acupuncture
Although the experimental group had negative scores
on demographic and clinical characteristics such as age,
BMI and osteoarthritis of the knee history (Table 1), this
group still had more positive scores on post-test outcome
measure (Table 2) compared to the control group. That

145
J. Nursing Research Vol. 16, No. 2, 2008
result implies that improvement in patients six-minute
walking distance, pain and mobility after acupuncture
treatment might be explained by the activation and st-
rengthening of the bodys natural defenses and repair sys-
tems with minimal side effects (NIH consensus confer-
ence, 1998). Apart from hematomas, no obvious adverse
effects due to acupuncture were detected, which supports
statements on the general safety of acupuncture (Melchart
et al., 2004). Our results confirmed the findings of 3 previ-
ous trials that used acupuncture with electrostimulation
(Berman et al., 2004; Sangdee et al., 2002; Vas et al.,
2004).
Overall results of this study may have been affected
by disappointment among control group patients in not
receiving adjunctive care. Limitation of this study included
a lack of randomizing participants into the two groups and
the possibility that the observed effectiveness of acupunc-
ture may be attributable to placebo effects. Also, due to the
nature of the intervention, it was not possible to blind
acupuncturists to treatment. Thus, results might be biased
due to a lack of adequate blinding. Other study limitations
include not obtaining information on how acupoints were
selected for each patient in the acupuncture group or on
other treatment modalities that might have affected out-
comes. Future studies should interview patients and their
families on several occasions to obtain information about
other treatment modalities practiced (e.g., meditation, exer-
cise and nutrition) as well as co-existing medical conditions.
Conclusion
Patients with osteoarthritis of the knee appear to expe-
rience clinically significant improvements measured in
terms of six-minute walking distance, pain relief and mo-
bility when standard care is supplemented with acupunc-
ture. In spite of issues of patient compliance and attrition,
our findings support the place of acupuncture in the mul-
timodal treatment of patients with osteoarthritis of the
knee. Similar studies must be undertaken with a larger
patient population using randomized allocation. A larger
population would permit a determination of the effect on
outcomes, if any, of compliance. Further investigation is
necessary to determine whether acupuncture provides
long-term improvement in pain and function and whether
the mechanism of the observed effect of acupuncture is
possibly due either to physiological effects or to the greater
intensity of physician contact experienced by those in the
experimental group.
146
Suh-Hwa Maa et al.
Acknowledgments
This study was supported by grant NSC 91-2320-
B-182A-008 from the National Science Council of the
Republic of China.
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* **

8 n = 12
n = 12

4


p < .01

*
**
96 11 19 97 3 4 97 4 11
33302 259

148