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com

Letters
had postulatedalthough the estimated ES is the same size as the
MCIDbut it more than meets the
MCID chosen by patients themselves (ES 0.39) and that selected by
NICE (ES 0.5). In interpreting this
result, the secondary outcomes
should also have been brought into
thoughtful consideration: there
were significant differences in
favour of acupuncture for six out of
eight secondary outcomes (see
eTable 5 in their paper) and the
response rate, which is the most
patient-orientated
measure
of
success,7 was 76% in the acupuncture group compared with 32% in
the no acupuncture control group.
It should also be noted that
Hinman et al did not apply optimal
acupuncture. Use of electroacupuncture was shown to be superior
to manual stimulation alone for
knee pain in 2010.8
So, the correct message from the
study by Hinman et al is that even
suboptimal acupuncture gives clinically relevant benefits for patients
with knee OA who have few options
other than surgery. Their results
give a powerful and positive result
that is clearly consistent with the
best data from other studies. Instead
of concluding that their findings do
not support acupuncture for these
patients, they should have concluded that patients with knee OA
should consider acupuncture as an
option. Indeed, acupuncture is
more likely to give relief than any
other option: a network analysis
comparing physical interventions
for knee pain shows acupuncture to
be best with an ES of 0.89; the
nearest is warm baths (ES 0.65) followed by exercise (ES 0.55).11 The
global evidence clearly shows that
acupuncture offers real and meaningful benefits for these patients
with real pain and disability.
(This letter is a modified version
of a letter submitted for publication
to JAMA but rejected).
Adrian White,1 Mike Cummings2
1
Plymouth University Peninsula School of Medicine
and Dentistry, Plymouth, Devon, UK
2
British Medical Acupuncture Society, London, UK

86

Correspondence to Dr Adrian White, Plymouth

University Peninsula School of Medicine and
Dentistry, Plymouth, Devon PL6 8BX, UK;
Adrian.white@plymouth.ac.uk

Competing interests AW and MC are

employed by the British Medical
Acupuncture Society (BMAS) as journal
editor and medical director respectively
and have received travel expenses.

Provenance and peer review Not

commissioned; internally peer reviewed.
10

To cite White A, Cummings M. Acupunct Med

2015;33:8486.
Received 21 November 2014
Accepted 29 November 2014
Published Online First 23 December 2014

11

what really matters to patients. JAMA

2014;312:13423.
Manheimer E, Cheng K, Linde K, et al.
Acupuncture for peripheral joint
osteoarthritis. Cochrane Database Syst
Rev 2010;(1):CD001977.
Vickers AJ, Cronin AM, Maschino AC,
et al. Acupuncture for chronic pain:
individual patient data meta-analysis.
Arch Intern Med 2012;172:144453.
Linde K, Niemann K, Schneider A,
et al. How large are the nonspecific
effects of acupuncture? A meta-analysis
of randomized controlled trials. BMC
Med 2010;8:75.
Corbett MS, Rice SJC, Madurasinghe V,
et al. Acupuncture and other physical
treatments for the relief of pain due to
osteoarthritis of the knee: network
meta-analysis. Osteoarthritis Cartilage
2013;21:12908.

http://dx.doi.org/10.1136/acupmed-2014-010727
Acupunct Med 2015;33:8486.
doi:10.1136/acupmed-2014-010719

REFERENCES
1 Hinman RS, McCrory P, Pirotta M,
et al. Acupuncture for chronic knee
pain. JAMA 2014;312:1313.
2 Conaghan PG, Peloso PM, Everett SV,
et al. Inadequate pain relief and large
functional loss among patients with
knee osteoarthritis: evidence from a
prospective multinational longitudinal
study of osteoarthritis real-world
therapies. Rheumatology (Oxford).
Published Online First: 23 August
2014. http://dx.doi.org/10.1093/
rheumatology/keu332
3 Minerva. BMJ 2014;349:g5449. http://
dx.doi.org/10.1136/bmj.g5449
4 Bellamy N, Carette S, Ford PM, et al.
Osteoarthritis antirheumatic drug trials.
III. Setting the delta for clinical trials:
results of a consensus development
(Delphi) exercise. J Rheumatol 1992;
19:4517. http://www.ncbi.nlm.nih.gov/
pubmed/1578462 (accessed 12 Nov
2014).
5 Angst F, Aeschlimann A, Michel BA,
et al. Minimal clinically important
rehabilitation effects in patients with
osteoarthritis of the lower extremities.
J Rheumatol 2002;29:1318.
6 National Institute for Health and Care
Excellence (NICE). Osteoarthritis: care
and management in adults. 2014. http://
www.nice.org.uk/guidance/cg177
7 McGlothlin AE, Lewis RJ. Minimal
clinically important difference: defining

Acupuncture for chronic

knee pain: a randomised
clinical trial. Authors reply
Drs White and Cummings state1
that we negatively reported findings
of our positive studynamely,
our trial evaluating acupuncture for
chronic knee osteoarthritis (OA).2
Our study was not a positive
study as they suggest. Rather, our
study showed no benefit of needle
or laser acupuncture compared
with sham laser acupuncture on
either of our two primary outcomes ( pain and function), and
small clinically irrelevant benefits
compared with no acupuncture for
both laser and needle acupuncture.
In accordance with best practice in
the conduct and interpretation of
clinical trials, we (1) a priori specified our primary outcome measures,
including the minimum clinically
important difference (MCID) on the
scale of measurement for each
outcome measure; (2) determined
and recruited the sample size needed
to show meaningful between-group
differences in primary outcomes
based on our chosen MCIDs and
estimated SDs with adequate power;
and (3) interpreted our findings
based on both of these primary outcomes, their MCIDs and considering

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Letters
both control conditions included in
our study design (ie, sham laser acupuncture and no acupuncture).
Accordingly, the conclusion stating
that our findings do not support acupuncture for these patients is appropriate and is the only conclusion that
can (and should) be drawn from our
study.
We powered our study to detect
the absolute MCID between groups
in pain (1.8 units) and function (6
units), which have been recommended specifically for our chosen
primary outcome measurement tools
(numerical rating scale and Western
Ontario and McMaster Universities
OA Index, respectively). Estimated
between-group differences did not
reach these thresholds, nor were
active acupuncture groups statistically different from sham laser.
Drs White and Cummings do not
like our choice of MCIDs for our
primary outcomes. Their comments
focus solely on MCIDs expressed as
a dimensionless quantity (or, equivalently, in SD units). However, this
approach confounds the absolute
size of effect on the scale of the
outcome measure with the variability
(SD) of the outcome measure
between patients. By their definition,
two trials with exactly the same difference in mean outcome between
treatments would result in a different
MCID solely because of differing
diversity of patient populations. Our
approach of specifying an absolute
MCID separates the definition of a
clinically meaningful change from
decisions regarding the patient population of interest, which clarifies the
clinical interpretation of the trial
results.
Drs White and Cummings imply
that our presentation of secondary
results was unthoughtful because
we did not quote the results from
the supplemental content. The
results in the main tables (tables 3
and 4) are based on analyses using
multiple imputation of the nonnegligible amount of missing
outcome data. The results in the
supplemental content are based on
complete case analyses, which
require stricter assumptions about

Acupunct Med February 2015 Vol 33 No 1

the missing outcome data than the

main tables and, as such, are likely
to be more prone to bias than the
main analyses. We therefore concentrated interpretation on the
most statistically sound analyses.
Drs White and Cummings suggest
our comparison of needle acupuncture with sham laser acupuncture is
clinically irrelevant because sham
laser is not an available therapy. We
are rather surprised by this statement. Of course sham laser is not an
available therapy: sham treatments,
by their very definitions, are fake
treatments used for one reason only
in clinical researchto isolate the
active physiological effects of a
given treatment from placebo contextual effects. If this assertion by
the authors was true, then most
pharmacological research needs to
be discarded given that a sham treatment ( placebo pill) is the gold standard control condition for drug
clinical trials. An individual patient
meta-analysis3 has shown that effect
sizes for needle acupuncture compared with sham needle acupuncture
are very small (0.16, 95% CI 0.07 to
0.25) and unlikely to be of any clinical relevance. It is unclear why Drs
White and Cummings think we
should have used a sample size large
enough to detect such small and clinically
meaningless
differences
between needle and sham laser acupuncture. They highlight that the
National Institute for Health and
Clinical Excellence (NICE) chose a
threshold of 0.5 (standardised mean
difference) to interpret findings of
their meta-analysis when devising
clinical practice guidelines for OA.4
However, Drs White and Cummings
failed to state that NICE considered
the comparison of acupuncture with
sham acupuncture to be the most
appropriate clinical comparison to
assess the benefits and harms of acupuncture, which is why acupuncture
is not recommended for OA by
NICE in the 2014 guidelines.
Drs White and Cummings state
that our manual needle acupuncture was not optimal because we
did not use electrical stimulation.
However, the most up-to-date

evidence
from
a
2013
meta-regression study that pooled
data from 29 trials of acupuncture
for chronic pain (including OA)
showed that electrical stimulation
did not significantly influence the
effects of needle acupuncture on
pain.5
Drs White and Cummings state
that we should have concluded that
patients with OA knee should consider acupuncture as an option. We
agree with this statement when it is
with reference to no treatment at
all, as long as it is qualified with
the appropriate evidence from the
trialthat is, patients with OA
knee should consider needle, laser
or sham laser acupuncture as an
optionbecause all were shown to
be equally efficacious in comparison with no treatment. To omit the
fact that the needle and laser acupuncture demonstrated nil benefit
over sham laser acupuncture is misrepresenting the results of the trial.
We agree patients with knee OA
need a considered answer to their
question: Should I try acupuncture?
So too do clinicians, policymakers
and funders of healthcare services
asking: Should my patient have acupuncture? or Should tax-payers
money support the provision of acupuncture for knee OA? Interpreting
the acupuncture evidence base
remains challenging, given differences in opinion regarding the most
appropriate comparator for determining acupuncture efficacy as well
as lack of consensus about what constitutes a MCID in OA. Our trial
adds to the substantial body of literature and will no doubt fuel the acupuncture debate further. Based on
our trial findings, it is likely that an
individual patient with OA will
experience some pain relief from
adding acupuncture to their usual
care; however, the benefit will be
due to placebo effects (rather than
physiological effects of acupuncture)
and of no clinical importance
according to our a priori definitions
of the MCID. Policymakers and
funders of healthcare services will
decide whether they should invest in
treatments that offer no benefit over
87

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Letters
and above sham treatments. OA is a
long-term condition with no cure
that requires a chronic disease management approach. This should
focus on active self-management by
patients, not passive treatments provided by clinicians. Given the effectiveness of exercise and weight loss
for knee OA (core recommended
treatments in OA clinical practice
guidelines6 7) and the underutilisation of these strategies in primary
care,810 should we really be recommending acupuncture for patients
with knee OA?
Rana S Hinman,1 Andrew Forbes,2
Elizabeth Williamson,3,4 Kim L Bennell1
1

Faculty of Medicine Dentistry & Health Sciences,

Department of Physiotherapy, Centre for Health,
Exercise and Sports Medicine, School of Health
Sciences, The University of Melbourne, Melbourne,
Victoria, Australia
2
School of Public Health and Preventative Medicine,
Monash University, Melbourne, Victoria, Australia
3
Farr Institute of Health Informatics Research,
London, UK
4
Department of Medical Statistics, London School of
Hygiene & Tropical Medicine, London, UK
Correspondence to Associate Professor Rana
Hinman, Centre for Health Exercise & Sports
Medicine, Department of Physiotherapy, School of
Health Sciences, The University of Melbourne, VIC
3010, Australia; ranash@unimelb.edu.au

Competing interests None.

Provenance and peer review
Commissioned; internally peer reviewed.

88

To cite Hinman RS, Forbes A, Williamson E, et al.

Acupunct Med 2015;33:8688.
Received 15 December 2014
Accepted 16 December 2014
Published Online First 16 January 2015

http://dx.doi.org/10.1136/acupmed-2014-010719
7
Acupunct Med 2015;33:8688.
doi:10.1136/acupmed-2014-010727

REFERENCES
1 White A, Cummings M. Acupuncture
for knee osteoarthritis: study by
Hinman et al represents missed
opportunities. Acupunct Med 2015;33:
846.
2 Hinman RS, McCrory P, Pirotta M,
et al. Acupuncture for chronic knee
pain: a randomized clinical trial. JAMA
2014;312:131322.
3 Vickers AJ, Cronin AM, Maschino AC,
et al. Acupuncture for chronic pain:
individual patient data meta-analysis.
Arch Intern Med 2012;172:144453.
4 National Institute for Health and Care
Excellence. Osteoarthritis. Care and
management in adults. Clinical
guideline CG177. Methods, evidence
and recommendations. London:

10

National Institute for Health and Care

Excellence, 2014.
MacPherson H, Maschino AC, Lewith
G, et al. Characteristics of acupuncture
treatment associated with outcome: an
individual patient meta-analysis of
17,922 patients with chronic pain in
randomised controlled trials. PLoS
ONE 2013;8:e77438.
McAlindon TE, Bannuru RR, Sullivan
MC, et al. OARSI guidelines for the
non-surgical management of knee
osteoarthritis. Osteoarthritis Cartilage
2014;22:36388.
Hochberg MC, Altman RD, Toupin AK,
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 2012;64:
46574.
Li LC, Sayre EC, Kopec JA, et al.
Quality of nonpharmacological care in
the community for people with knee
and hip osteoarthritis. J Rheumatol
2011;38:22307.
Gronhaug G, Osteras N, Hagen K. Quality
of hip and knee osteoarthritis management
in primary health care in a Norwegian
county: a cross-sectional survey. BMC
Health Serv Res 2014;14:598.
Runciman WB, Hunt TD, Hannaford
NA, et al. CareTrack: assessing the
appropriateness of health care delivery
in Australia. Med J Aust 2012;197:
1005.

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Acupuncture for chronic knee pain: a

randomised clinical trial. Authors' reply
Rana S Hinman, Andrew Forbes, Elizabeth Williamson and Kim L Bennell
Acupunct Med 2015 33: 86-88 originally published online January 16,
2015

doi: 10.1136/acupmed-2014-010727
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