Acupuncture and Knee Osteoarthritis: Does Dose Matter?

Osteoarthritis (OA) is an extraordinarily prevalent and disabling disease (1).Current management options for pain and functional limitation are constrained by modest efficacy or a range of unwanted side effects.Our society is being impacted through underemployment and the opioid epidemic, and our health care systems are overstretched, as a consequence of the trajectory of increasing joint replacement requirements (2).In this context, development of new treatments or identification of the efficacy of existing therapies to address the huge unmet need of pain management are strongly desired.Acupuncture is a component of traditional East Asian medicine and has been used as a healing practice for many centuries (3).Acupuncture is generally thought to have arisen in China with documented clinical practice in the Huangdi Neijing "Yellow Emperor's Inner Classic" more than 2,000 years ago.However, ancient Chinese burial sites have uncovered acupuncture tools (Bian stones) that predate this period.Following its development in ancient China, acupuncture spread throughout Southeast Asia and Europe, and is becoming increasingly popular in North and South America.Acupuncture typically involves the insertion of thin (32-36-gauge) solid needles into specific points in the body (acupoints).Once needles are inserted, they may be stimulated mechanically, electrically, or thermally.Needles are then retained in the body for 20-30 minutes during a single session.When provided as a course of treatment, acupuncture is performed during multiple sessions spread over a number of weeks.The efficacy of acupuncture in the context of pain, and knee OA more specifically, is a subject of controversy.The initial literature struggled to consistently demonstrate efficacy of acupuncture over and above sham treatment.However, the Acupuncture Trialist Collaborative showed, in an individual participant meta-analysis (n = 20,827 patients; 39 trials), that acupuncture was superior to sham acupuncture for multiple pain conditions: OA had an effect