|Year : 2016 | Volume
| Issue : 1 | Page : 26-33
Comparison of the effects of acaupuncture and acupuncture like TENS on osteoarthritis of the knee among adult Nigerians
Ganiyu Sokunbi1, Usman Mohammad Bello2
1 Department of Physiotherapy, Faculty of Allied Health Sciences, Bayero University Kano, Kano, Nigeria
2 Department of Physiotherapy, Usmanu Danfodiyo University Teaching Hospital, Sokoto, Nigeria
|Date of Web Publication||2-Jul-2018|
Dr. Ganiyu Sokunbi
Department of Physiotherapy, Faculty of Allied Health Sciences, Bayero University Kano, Kano
Source of Support: None, Conflict of Interest: None
Osteoarthritis (OA) of the knee is a major cause of disability among adults with conservative therapies being among the preferred first line of treatment. Acupuncture and transcutaneous electrical nerve stimulation (TENS) are considered as potentially useful treatment for OA; however, there is dearth of information on the acceptability and efficacy of acupuncture in Nigeria. The study was designed to compare the effects of acupuncture and acupuncture-like TENS (ACUTENS) among adult Nigerian with OA of the knee joints. Thirty patients with knee OA were randomized into two intervention groups (i.e., acupuncture and ACUTENS) and a control (soft-tissue manipulation [STM]) group. Patients in the acupuncture and ACUTENS group were also treated with STM as the control group. Pain intensity, functional mobility, and knee active range of movement (AROM) were measured at preintervention, postintervention, and 3 months postintervention. Patients who received acupuncture showed statistically better improvement in the form higher mean changes ± standard error of means in pain intensity score of 4.20 ± 0.01 than the ACUTENS group who recorded changes in pain intensity scores of 30 ± 0.30. The mean changes in the functional mobility scores of 10.60 ± 3.35 and 4.30 ± 1.12 were recorded for the patients in the acupuncture and ACUTENS group, respectively. In addition, the mean changes in the knee AROM for the patients in the acupuncture group was 15.5 ± 5.18 while patients who received ACUTENS recorded mean changes of 5.50 ± 1.38. Acupuncture and ACUTENS treatment produced significant reduction in pain intensity level postintervention and at follow-up assessments (P < 0.05). Patients who received acupuncture treatment showed a significant improvement in functional mobility and knee active range of motion which was not present in the ACUTENS and control groups (P < 0.05). Acupuncture and ACUTENS treatment had significantly better pain-relieving effects when compared to STM in patients with OA of the knee. Acupuncture treatment produces better outcome than ACUTENS regarding pain reduction, knee range of movements, and functional mobility in patients with OA of the knee.
Keywords: Acupuncture, acupuncture-like transcutaneous electrical nerve stimulation, functional mobility, knee osteoarthritis, pain
|How to cite this article:|
Sokunbi G, Bello UM. Comparison of the effects of acaupuncture and acupuncture like TENS on osteoarthritis of the knee among adult Nigerians. Niger J Exp Clin Biosci 2016;4:26-33
|How to cite this URL:|
Sokunbi G, Bello UM. Comparison of the effects of acaupuncture and acupuncture like TENS on osteoarthritis of the knee among adult Nigerians. Niger J Exp Clin Biosci [serial online] 2016 [cited 2018 Nov 12];4:26-33. Available from: http://www.njecbonline.org/text.asp?2016/4/1/26/235806
| Introduction|| |
Osteoarthritis (OA) is the most common form of arthritis affecting 80% of those aged 65 years or older., The knee is the most vulnerable joint affected by OA. There is a high prevalence of OA among adult populations. It is estimated that approximately15.8 million Americans have OA of the knee. In a Nigerian study, it was found that 229 out of 1403 participants reported knee OA, giving a prevalence of 16.3%. OA of the knee is a common cause of severe, chronic, disabling, and intractable pain. The isometric peak torque of both the quadriceps and hamstrings of people with knee OA are weaker than those of individuals of the same age without knee OA. In addition, gait velocity is slower, cadence is reduced, and stride length is shorter among people with knee OA. After adjusting for age, sex, and comorbidity, knee OA is responsible for a higher percentage of disability than any other medical condition for the following activities: stair climbing, walking a mile, and housekeeping. In addition, as the prevalence of OA of the knee increases with age, it is possible that the already considerable impact of this disease will become even greater with the aging of the population.
No cure for OA currently exists. Thus, knee OA treatment focuses on managing the pain and dysfunction associated with the disease. Anti-inflammatory drugs usually, have various side-effects and patients with chronic knee OA pain increasingly seek alternative methods for pain relief. Guidelines for the medical management of knee OA by the American College of Rheumatology (ACR) in 1995 emphasize patient education, physiotherapy, occupational therapy, and exercise programs as the preferred first-line nonpharmacologic methods of management of symptoms of knee OA. The 2000 update of the ACR recommendations also mentioned acupuncture as a therapeutic approach under investigation. Traditional Chinese acupuncture is based on the theory that vital energy, called “qi,” flows through the body along pathways called meridians. There are specific points along these meridians called acupuncture points or acupoints at which the de qi may be accessed. Inserting needles into these points permits restoration of harmony to the system, rebalancing the flow of de qi, and to restore normalcy back to the body system. In the Western medical model, acupuncture is thought to relieve knee OA pain through the gate-control mechanism or through the release of neurochemicals. Acupuncture needle has been reported to activate sensory receptors in the inside the muscles, and this sends impulses to the spinal cord through Type II and III muscle afferent nerves. Type II afferents were reported to signal the numbness of “qi” needling sensation and Type III, the fullness, heaviness, and mild aching sensation. Stux and Pomeranz  described the possible neural mechanisms of acupuncture analgesia as follows; small diameter muscle afferents are stimulated, sending impulses to the spinal cord, which then activates three centers (spinal cord, midbrain, and pituitary) to release neurochemicals (endorphins and monoamines) that block pain messages. Although the evidence supporting the endorphin hypothesis is overpowering, midbrain monoamines (serotonin and norepinephrine) are also involved in acupuncture analgesia; however, the role of the pituitary is less clear. It appears that there is mixed evidence that acupuncture is an effective treatment of pain and physical dysfunction associated with OA of the knee. Sangdee et al. found that the reduction in pain was significantly greater for the acupuncture group versus the drug treatment (diclofenac) group in a group of patients with OA of the knee. Tukmachi et al. reported difference in pain levels between acupuncture group and drug treatment group but did not state whether or not the difference was significant and Sangdee et al. reported that there was no statistically significant difference between the groups over time. The practice of acupuncture has not gained so much popularity, availability, and acceptance in Nigeria unlike the use TENS.
TENS is one of the most widely used physical modalities for the management of OA of the knee. Similar to acupuncture, the effectiveness of TENS in the management of knee OA has been reported., It has the advantage of being inexpensive, simple, and essentially free of side effects. TENS may even be used at home by patients themselves due to its portability and simplicity. An essential feature of acupuncture-like TENS (ACUTENS) is the use of strong stimulation to produce strong sensation to send impulses to the spinal cord and activates central nervous system to cause analgesia. ACUTENS parameters are stimulated at low frequency and high intensity., In general, de qi occurs with current or voltage stimulation, which is 5–10 times the threshold value for muscle contraction. The intensity is kept below the level at which patient find it intolerable and hence that a pleasant mild aching sensation is felt. Although not completely understood the mechanism of action of acupuncture, it is safe and effective, recommended by the World Health Organization. It appears that acupuncture is not yet popularized in Nigeria, but in other countries, it is well-recognized and value for the control of pain and other treatments. Comparison of the efficacy of acupuncture and ACUTENS in the management of knee OA appeared not to have been widely investigated. Thus, the purpose of this study was to compare the effects of acupuncture and ACUTENS on pain, knee range of movement, and functional mobility of patient with knee OA.
| Materials and Methods|| |
This was a randomized controlled trial.
Approval to carry out this study was obtained from the Research and Ethics Committee of the University of Maiduguri Teaching Hospital (UMTH), Maiduguri. Detailed information on what the study was all about, potential benefits and possible side effects and what will be expected of the participants during the study was provided in patient information sheet which was made available to the patient before the intervention. Participants were required to sign the written informed consent, and they were given enough time to consult with their doctors to decide whether they will be suitable to take part in this trial.
The participants for this study were male and female aged 45 years and above who have radiologically features, i.e., radiological alterations in the knee joint of Grade 2 or more according to Kellgren–Lawrence criteria and clinically diagnosed with OA of the knee joint according to ACR. They are the patients who has been certified by their doctors to meet the above conditions and were referred by their doctors to the Physiotherapy Clinics of UMTH, Maiduguri, Nigeria, for physiotherapy treatment. Further, inclusion criteria include knee pain lasting for 3 months or longer with no previous surgery to the knee joint and/or other comorbid medical conditions such as benign or malignant tumors. Patients were also excluded if they had chondroprotective or intraarticular injection in the past 4 months, systemic corticoid treatment or local antiphlogistic treatment in the past 4 weeks, and acupuncture treatment during the past 12 months. Patients currently on analgesics at the time of the study were allowed to participate only if the medications had made no changes to their symptoms, and there had been no changes in the dosage for at least 1 month before the commencement of this study. Patients with skin conditions that might impair skin sensation or prevent the use of TENS on the knee joints were also excluded from the study.
Participant's flowchart is presented in [Figure 1].
Sample size estimation
Sample size estimation was based on the assumption that TENS could reduce pain intensity by at least 1.5 on numeric pain rating scale (NPRS) (this was based on the previous work which explored the effect of acupuncture and TENS in the treatment of knee OA). To yield a power of 80% with a significant level of 0.05, a sample size of at least eight subjects in each group was required (sample size estimation was determined by power analysis sample size software).
A computer-generated randomization schedule was created to assign the participants into one of the three Groups; acupuncture, ACUTENS, and control (soft-tissue manipulation [STM]) groups. Ten participants were assigned into each group. Randomization was carried out by a researcher who was not involved in any other aspects of the study. All participants were informed that they may be randomly allocated to any of the two intervention groups (Acupuncture + STM and ACUTENS + STM) or the control group (STM). This procedure was carried out to ensure that each eligible participants have equal probability of being assigned to one of the three groups.
Assessments of pain intensity, active range of knee flexion movement (active range of knee extension was not included as parts of the outcome measure as all the patients demonstrated full active range of knee extension at baseline assessment) and functional mobility were carried out before intervention, postintervention, and at 4 weeks postintervention follow-up assessments by a researcher who was blinded to patients' group allocations.
Pain intensity was measured with NPRS. NPRS is a verbally administered scale that measures pain intensity (0 = “no pain at all” to 10 = “worst possible pain”). Reliability and construct validity of NPRS with visual analog scale was reported by von Baeyer et al. Active range of knee flexion was measured with universal goniometer with the participants in supine lying position. Universal goniometer was reported to have a validity of; r = 0.73 and 0.77 when measuring angle of knee flexion. Functional mobility was assessed with timed-up-and-go test. Participants were seated in chair with knee and hip joints maintained at 90°, feet in contact with the floor and with the forearm resting on the armrest. The timed-up-and-go test was carried out as described by Nordin et al. The timed-up-and-go test has been validated and showed good intrarater and interrater reliability (r = 0.93 and 0.96, respectively).
Acupuncture intervention was provided by a physiotherapist who was trained and certified by the Association of Chartered Society of Physiotherapist, UK, and with 6 years of experience in acupuncture treatment of musculoskeletal conditions. Patients were informed about acupuncture and ACUTENS in the study as follows: “In this study, different types of treatment will be compared. One type is similar to the acupuncture treatment used in China. The other types do not follow these principles, but has also been associated with positive outcomes in clinical studies.” STM, acupuncture, and ACUTENS treatments were carried out for 30 min, twice weekly, and administered over 8 weeks period. For patients with bilateral knee OA, STM, acupuncture, and ACUTENS were administered to both knees. However, for patients with unilateral knee OA, treatment was administered on the affected knee. Patients currently on analgesics (nonsteroidal anti-inflammatory drugs [NSAIDs]) at the time of the study were allowed to participate, only if the medications had made no changes to their symptoms and there had been no changes in the dosage for at least 1 month before the commencement of this study. If necessary, patients were allowed to continue to treat their NSAIDs they had been taking before the commencement of the study. The use of other pain treatments, such as drugs acting through the central nervous system, or corticosteroids, was not allowed as it could potentially have an effect on acupuncture and ACUTENS-induced analgesia.
Patients in all the groups (i.e., acupuncture, ACUTENS and control) received STM to the thigh and the knee joint area was administered to the participants in all the groups in this study. Patients are positioned in half sitting or supine lying position with proper pillow support at the back of the head and the knee for comfort. Techniques of soft-tissue massage used were as described by Sokunbi and Usman. STM was carried out for 5 min, twice weekly for 8 weeks.
Patients assume half lying supine position with proper pillow support under the head and neck and behind the knee joints for comfort. In addition, they were informed of what to expect during and after the treatment regarding the possible effects and side effects.
Acupuncture treatment was carried out with the needles inserted at three selected points for the treatment of knee dysfunction according to the principles of traditional Chinese medicine, i.e., at the following acupoints; (I) Neixiyan or EX-LE 4, located at the depression medial to the patellar ligament when the knee is flexed, (II) Liangqiu on stomach meridian (Stomach 34), located at two finger breadth above the superior lateral border of the patella on the line connecting with the anterior superior iliac spine when the knee is fully flexed and (III) Yinlingquan on spleen meridian (Spleen 9), located on the lower border of the medial condyle of the tibia on level with the tuberosity of the tibia [Figure 2]. At each acupoint, the skin was wiped with alcohol, and the therapist's hands were clean with alcohol gel before the insertion of disposable stainless steel needles (0.2 mm × 40 mm, Seirin, China). After insertion, the acupoints were manually stimulated by lifting, thrusting, twirling, and rotating the needle, to elicit “de-qi.” The needle manipulation was stopped when participants felt de ('de qi': numbness, soreness, and or radiating sensation). The needle stimulation to elicit de qi was repeated at 5 min interval while the needles were left in position for 30 min. Treatments were carried out for 30 min duration twice weekly for 8 consecutive weeks.
Patient preparation was as described for acupuncture group.
Dual-channel TENS (Chinese, model 7000) was used to provide ACUTENS treatment. Electrodes were placed at similar locations as for acupoints to as described above. The following TENS variables were used: Lowest rate/frequency possible (2 Hz), the highest intensity that were tolerated by the subject for 30 min. Whenever the subject could tolerate the highest intensity stimulation, the duration of the pulse will be increased to the point of tolerance. Tolerance was defined as the level at which the patient asked the investigator to stop increasing the stimulation. Treatments were carried out for 30 min duration twice weekly for 8 consecutive weeks.
Statistical analyses were performed using Statistical Package for the Social Sciences, version 14.0 based on intention-to-treat principle. Demographic variables such as age, weight, height, and body mass index (BMI) and outcome variables such as pain, range of movements, and functional mobility were presented as mean and standard deviation) while gender and patterns of knee OA were presented as frequency and percentage. Chi-square analysis was used to test for any significant difference in the gender and pattern of knee OA among the groups. One-way analysis of variance (ANOVA) was used to compare age, weight, height, and BMI among the three groups. Within-group changes in the outcome variables over period taking into consideration; preintervention, postintervention, and 3 months follow-up were analyzed with multiple ANOVA. Effects of intervention were analyzed by comparing mean difference, i.e., ΔX, (postintervention mean score minus preintervention mean scores) of pain intensity, functional mobility, and knee range of motion between acupuncture and the ACUTENS groups. Statistical significance was set at 0.05.
| Results|| |
Thirty participants were enrolled into the study and completed the 8 weeks intervention between March 2014 and January 2015. Three patients, one in each group, were lost to follow-up (one moved to another town, one car accident, and one reason unclear) [Figure 1]. Thus, analysis of the data was carried out using intention-to-treat principle. Patients' age ranges from 49 to 68 years. Thirteen (43.3%) of the participants were male while 17 (56.7%) were female. Age BMI and duration of knee OA did not show significant difference among the groups (P > 0.05) [Table 1]. [Table 2] shows significant reduction in the preintervention pain intensity level of the patients who received acupuncture and ACUTENS at postintervention and follow up assessments (P < 0.05). Patients who received acupuncture treatment showed significant improvement in functional mobility and knee active range of motion which was not present in the ACUTENS and control groups (P < 0.05). Analysis of the changes in the mean scores of pain intensity, functional mobility, and active knee range of motion (mean postintervention minus mean preintervention scores) between the acupuncture and ACUTENS group is presented in [Table 3]. At 95% confidence interval, patients who received acupuncture showed statistically better improvement in the form higher reduction in pain intensity, functional mobility, and knee active range of movement than the ACUTENS group [Table 3].
|Table 2: Pain intensity, functional mobility, and active range of movement of patients in all the groups at preintervention, postintervention, and at follow up assessments|
Click here to view
|Table 3: Comparison of the mean difference in the pain intensity, functional mobility, and knee range of motion between patients in the acupuncture and acupuncture-like transcutaneous electrical nerve stimulation groups|
Click here to view
| Discussion|| |
This study was designed to compare the effects of acupuncture and ACUTENS on OA of the knee joints. Compared with the control group, patients that were treated with acupuncture and those who received ACUTENS experienced significantly better improvement in the form of pain relive after 8 weeks of treatment which was also maintained till 3 months after intervention. Comparison of the effect of intervention showed that patients who received acupuncture experienced better outcome in regarding of changes in pain reduction, functional mobility, and knee range of movement than patients who received ACUTENS. This results concur with the findings of three previous studies.,, Another study compared acupuncture and sham acupuncture (superficial needling at distant nonacupuncture points) and showed no difference between acupuncture and sham acupuncture. Lack of significance effect of acupuncture over sham intervention could be due to the fact that acupuncture treatment was administered over a short period (three times a week for 3 weeks) in this study. In contrast, in this present study, both acupuncture and ACUTENS were administered twice weekly for 8 weeks. This procedure could have produced more potent analgesic effects than the study involving acupuncture and sham intervention. Possible therapeutic effects of acupuncture could be linked to enhancing activation of A-δ and C afferent fibers in muscle during needle stimulation of acupuncture points thus, signals are transmitted to the spinal cord and through afferent pathways to the midbrain. The resulting flow and integration of this information among specific brain areas will leads to a change in the perception of pain through descending pain modulatory system. Acupuncture analgesia improved the noxious descending inhibitory controls and pain gate mechanism and therefore helped to reduce the patients' pain levels. The evidence for the mediation of acupuncture analgesia by endorphin is very strong, while that of the involvement of monoamines need more work to verify the possible synergism of serotonin and norepinephrine. The physiologic effects of acupuncture and ACUTENS could be link to both pain gate theory and descending pain inhibitory control at different level of the central nervous system.
Patients who received acupuncture treatment showed better improvement in the terms of pain reduction, in functional mobility, and knee range of motion after 8 weeks of intervention which was also maintained till 3 months after treatment, this was not the case with patients who received acupuncture-like TENS. These results might suggest that acupuncture treatment was significantly more effective than ACUTENS in the management of knee OA. Many of the previous studies involving acupuncture and ACUTENS on knee OA reported improvement with pain reduction; however, it appeared that there are not many which reported improvement in functional mobility. It could that in the acupuncture treatment groups, whereby needles are located at the exact acupoints along the meridians, more afferent input to activate the pain gate and descending inhibitory control from the central nervous system were provided than in the ACUTENS group. This perhaps likely explains why acupuncture group had better pain relieve than the ACUTENS group. It is also possible that the analgesic effects experienced by the participants in this study were not due to acupuncture and ACUTENS alone but might also be due to other peripheral and central mechanisms leading to analgesia associated with the use of NSAID's and/or perhaps other mechanisms not yet investigated.
The treatment of knee OA with either acupuncture or ACUTENS produced benefits to patients with knee OA regarding pain reduction, although greater reduction in pain intensity was experienced by the patients in the acupuncture group. However, the use of ACUTENS is not without some advantages when compared with acupuncture. Advantages include omission of certain risk of using needles such as infection. Many patients have a fear of needles and might prefer ACUTENS. Perhaps, the most compelling reason for ACUTENS will be the ease of use and the fact that not as much as precision is required in placement of pads over the acupuncture points as pushing the needles through the skin and muscle fibers to produce “de qi” sensations given the large areas covered by the pad. The ease of use would likely make ACUTENS more acceptable to patients and to therapist who are not certain about the points of needle placement, depth of penetration, and angle of the needle trajectory. Thus, it might be that while acupuncture treatment is recommendable for use in the clinic due to its better pain-relieving effects while ACUTENS could be recommended for home use by the patient in-between treatment appointments in the clinic. Currently, it appears that data are limited on public interest, patterns of use, effects, and side effects of acupuncture treatment in Nigeria. However, available reports from Western countries portrays acupuncture intervention as a cost effective and safe procedure with neither serious side effects nor life threatening effects. It could be that acupuncture treatment might serve a useful complementary treatment to physiotherapy management of knee OA and other noninvasive treatment approach in the management of numerous neuromusculoskeletal conditions if there are training opportunities to increase the local availability of acupuncture practitioners in this environment.
The small sample size might undermine the generalizability of the findings of this study to patients with OA of the knee. In addition, due to the nature of the intervention, it was not possible to blind the acupuncturists to treatment. However, assessment and analysis of data were carried out by independent researcher who was blinded to group allocations and the type of intervention administered to the patients. Using three acupuncture points stimulation could be another limitation of the study. Perhaps, most clinicians in acupuncture practice will use more than three points at local and distal points a time.
| Conclusion|| |
STM combined with acupuncture and ACUTENS treatment had significant and short-term pain-relieving effects when compared to STM only in patients with OA of the knee. Acupuncture treatment produces better outcome than ACUTENS regarding pain relief and functional mobility.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Adams JC, Hamblen DL. Outline of Orthopaedics. 11th
ed. Edingburg: Churchill Livingstone; 1990. p. 116-9.
Pomonis JD, Boulet JM, Gottshall SL, Phillips S, Sellers R, Bunton T, et al.
Development and pharmacological characterization of a rat model of osteoarthritis pain. Pain 2005;114:339-46.
Wen DY. Intra-articular hyaluronic acid injections for knee osteoarthritis. Am Fam Phys 2000;62:565-72.
Felson DT, Naimark A, Anderson J, Kazis L, Castelli W, Meenan RF, et al.
The prevalence of knee osteoarthritis in the elderly. The Framingham Osteoarthritis Study. Arthritis Rheum 1987;30:914-8.
Lawrence RC, Helmick CG, Arnett FC, Deyo RA, Felson DT, Giannini EH, et al.
Estimates of the prevalence of arthritis and selected musculoskeletal disorders in the United States. Arthritis Rheum 1998;41:778-99.
Akinpelu AO, Maduagwu SM, Odole AC, Alonge TO. Prevalence and pattern of knee osteoarthritis in a North Eastern Nigerian rural community. East Afr Orthop J 2011;5:48-554.
Dieppe PA. Clinical conundrum. Br J Rheumatol 1989;228:242.
Cheing GL, Hui-Chan CW. The motor dysfunction of patients with osteoarthritic knee in a Chinese population. Arthritis Care Res J 2001;45:62-8.
Guccione AA, Felson DT, Anderson JJ, Anthony JM, Zhang Y, Wilson PW, et al.
The effects of specific medical conditions on the functional limitations of elders in the Framingham study. Am J Public Health 1994;84:351-8.
Doherty M. Pain in osteoarthritis. In: Giamberardin O. An Updated Review: Refresher Course Syllabus. Seattle: International Association for the Study of Pain, Press; 2002. p. 51 7.
Tramèr MR, Moore RA, Reynolds DJ, McQuay HJ. Quantitative estimation of rare adverse events which follow a biological progression: A new model applied to chronic NSAID use. Pain 2000;85:169-82.
American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Recommendations for the medical management of osteoarthritis of the hip and knee: 2000 update. American College of Rheumatology Subcommittee on Osteoarthritis Guidelines. Arthritis Rheum 2000;43:1905-15.
Witt C, Brinkhaus B, Jena S, Linde K, Streng A, Wagenpfeil S, et al.
Acupuncture in patients with osteoarthritis of the knee: A randomised trial. Lancet 2005;366:136-43.
Tukmachi E, Jubb R, Dempsey E, Jones P. The effect of acupuncture on the symptoms of knee osteoarthritis – An open randomised controlled study. Acupunct Med 2004;22:14-22.
Stux G, Pomeranz B. Basics of Acupuncture. New York: Springer; 1998. p. 280-4.
Sangdee C, Teekachunhatean S, Sananpanich K, Sugandhavesa N, Chiewchantanakit S, Pojchamarnwiputh S, et al.
Electroacupuncture versus diclofenac in symptomatic treatment of osteoarthritis of the knee: A randomized controlled trial. BMC Complement Altern Med 2002;2:3.
Awotidebe OT, Adedoyin RA, Adegbesan OA, Babalola JF, Idowu O, Olukoju, et al
. Psychosocial correlates of physical activity. Int J Sports Sci 2014:205-11.
Sokunbi OG, Usman MB. Effects of conventional and acupuncture like transcutaneous electrical nerve stimulation [TENS] on osteoarthritis of the knee. Niger J Exp Clin Biosci 2014;2:69-74. [Full text]
Kessler S, Guenther KP, Puhl W. Scoring prevalence and severity in gonarthritis: The suitability of the kellgren and lawrence scale. Clin Rheumatol 1998;17:205-9.
Itoh K, Hirota S, Katsumi Y, Ochi H, Kitakoji H. A pilot study on using acupuncture and transcutaneous electrical nerve stimulation (TENS) to treat knee osteoarthritis (OA). Chin Med 2008;3:2.
von Baeyer CL, Spagrud LJ, McCormick JC, Choo E, Neville K, Connelly MA, et al.
Three new datasets supporting use of the numerical rating scale (NRS-11) for children's self-reports of pain intensity. Pain 2009;143:223-7.
Watkins MA, Riddle DL, Lamb RL, Personius WJ. Reliability of goniometric measurements and visual estimates of knee range of motion obtained in a clinical setting. Phys Ther 1991;71:90-6.
Nordin E, Rosendahl E, Lundin-Olsson L. Timed “Up & go” test: Reliability in older people dependent in activities of daily living – Focus on cognitive state. Phys Ther 2006;86:646-55.
Christensen BV, Iuhl IU, Vilbek H, Bülow HH, Dreijer NC, Rasmussen HF, et al.
Acupuncture treatment of severe knee osteoarthrosis. A long-term study. Acta Anaesthesiol Scand 1992;36:519-25.
Berman BM, Singh BB, Lao L, Langenberg P, Li H, Hadhazy V, et al.
A randomized trial of acupuncture as an adjunctive therapy in osteoarthritis of the knee. Rheumatology (Oxford) 1999;38:346-54.
Tillu A, Tillu S, Vowler S. Effect of acupuncture on knee function in advanced osteoarthritis of the knee: A prospective, non-randomised controlled study. Acupunct Med 2002;20:19-21.
Takeda W, Wessel J. Acupuncture for the treatment of pain of osteoarthritic knees. Arthritis Care Res 1994;7:118-22.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]