Tuesday 9th August 2022

Acupuncture for the treatment of knee osteoarthritis | IJGM


Jixin Chen,1,2,* Aifeng Liu,1,2,* Qinxin Zhou,1,2 Weijie Yu,1,2 Tianci Guo,1,2 Yizhen Jia,1,2 Kun Yang,1,2 Puyu Niu,1,2 Huichuan Feng1,2

1Department of Orthopaedic Surgery, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, Tianjin, 300381, People’s Republic of China; 2National Clinical Research Center for Chinese Medicine Acupuncture and Moxibustion, Tianjin, 300381, People’s Republic of China

Correspondence: Aifeng Liu
Department of Orthopaedic Surgery, First Teaching Hospital of Tianjin University of Traditional Chinese Medicine, No. 88 Changling Road, Xiqing District, Tianjin, 300381, People’s Republic of China
Tel +86-13803091533
Email [email protected]

Background: Acupuncture has been widely used in the clinical management of osteoarthritis of the knee (KOA). Many systematic reviews (SRs) and meta-analyses (MAs) have reported its effectiveness in relieving pain. This overview aimed to summarize SRs and MAs on the effectiveness and safety of acupuncture for KOA and evaluate their methodological and evidence quality of the included SRs and MAs.
Methods: We conducted a comprehensive literature search for SRs and MAs in four Chinese and four international databases from their inception until August 2021. Two researchers independently searched the reviews, extracted the data, and cross-checked the data. The Assessing the Methodological Quality of Systematic Reviews 2 (AMSTAR 2) tool was used to evaluate the methodological quality of the included SRs and MAs. The Grades of Recommendations, Assessment, Development, and Evaluation (GRADE) system was used to assess the quality of evidence for the outcomes of the included SRs and MAs.
Results: A total of 14 SRs and MAs were included. The evaluation results of the AMSTAR 2 tool showed that the methodological quality of all the 14 SRs and MAs was critically low. The principal causes are the lack of a pre-registration proposal and a list of excluded studies and justify the exclusions, the report on the sources of funding, and the reasons for the study designs for inclusion. The results of the GRADE evaluation showed 25 of 46 outcomes were very low-level evidence. Seventeen were of low level, four were of moderate level and none were of high level. Most outcomes were downgraded in quality of evidence mainly because of publication bias and imprecision.
Conclusion: The existing evidence suggests that acupuncture seems to be an effective and safe therapy for KOA. However, the deficiencies in the methodological quality and quality of evidence of the included SRs/MAs have limited the reliability of the conclusions. Therefore, further rigorous and comprehensive studies are warranted to verify the effectiveness and safety of acupuncture in KOA.

Keywords: acupuncture, knee osteoarthritis, overview, AMSTAR 2, GRADE, systematic review


Knee osteoarthritis (KOA) is a degenerative disorder with the main clinical manifestations of pain, joint swelling, functional limitation, and even disability.1 The incidence of KOA shows an increasing trend in recent years, and the disease has become one of the major causes of physical disability worldwide.2–4 Patients with pain and limited mobility are prone to negative emotions such as anxiety, which greatly affects their quality of life. To date, there is no radical cure for KOA, and the treatment mainly aims to relieve pain and restore joint function, with a commitment to reducing the disability rate. In the latest guidelines of the management of KOA released by the American College of Rheumatology, exercise, self-management, strength training, weight loss, use of canes and knee pads, topical NSAIDs, and intra-articular injections of glucocorticoids are strongly recommended for all patients with KOA.5 Analgesics alone for pain control, although effective, can cause not only liver and kidney damage in the long term, but also lead to overuse of the joints and increase joint damage and degeneration.6 There is still reservation about the long-term safety and efficacy of NSAIDs and opioids, which will cause significant gastrointestinal reactions, cardiovascular reactions and hepatic and renal toxicities.7–9 According to the guidelines, oral glucocorticoids are not considered, and chondroprotective agents such as glucosamine and chondroitin sulphate are not effective on KOA patients.10,11 The long-term efficacy of oral antioxidants or vitamin D remains controversial, while intra-articular hormone injections can also accelerate articular cartilage degeneration, although they can relieve pain and improve joint function.12 Besides, intra-articular injections such as sodium vitreous acid are ineffective on patients with severe KOA.13,14 Total knee arthroplasty (TKA) is mainly indicated for the treatment of severe KOA, with a high incidence of complications.15 Neither biological nor tissue-engineered restorative treatments are applied in clinic at present.11,12,16

Acupuncture is an important component of traditional Chinese medicine (TCM) and an effective alternative therapy for relieving pains.17,18 It is associated with fewer adverse effects than conventional approaches.19,20 As many people with KOA have difficulties in exercise and weight loss, acupuncture is conditionally recommended for KOA. Several studies have suggested the potential benefits of acupuncture to generally improve symptoms such as joint pain, swelling and stiffness in KOA.21–23 The theoretical biochemical basis of acupuncture includes the release of various endogenous substances to relieve pain.24–26 In recent years, numerous RCTs, SRs and MAs on the acupuncture treatment of KOA have been published to compare the effectiveness and safety of acupuncture treatment with control group. However, the results of SRs and MAs are conflicting, and the conclusions are comprised by the sample size and included study quality.27,28 However, no consensus has been reached and their quality has not been evaluated yet, which is an indispensable step before treatment recommendations can confidently be made. A systemic review is a new approach designed to synthesize the results from multiple SRs and MAs.29 To overcome the limitations of an individual SR and to provide comprehensive evidence, a systemic review on SRs and MAs is required.

Several recent SRs27,28,30 have evaluated acupuncture interventions since the publication of the first systemic review in 2019.31 Hence, to fully appraise the available data, we updated the prior analyses and included studies published during the last 3 years. To draw the most reliable conclusion possible, the PubMed database search was also conducted, and only SRs/MAs including randomized controlled trials (RCTs) were considered. This review aimed to comprehensively evaluate the methodological quality of these SRs and MAs using the Assessing the Methodological Quality of Systematic Reviews 232 (AMSTAR 2) tool, access the quality of the latest evidence of important outcomes from the included MAs using the Grades of Recommendations, Assessment, Development, and Evaluation33 (GRADE) system, and summarize the conclusions of these SRs and MAs to further clarify the safety and effectiveness.

Materials and Methods

The protocol of this overview was registered on the International Prospective Register of Systematic Reviews (PROSPERO; http://www.crd.york.ac.uk/PROSPERO/; registration number, CRD42021277210). This overview of SRs/MAs was performed in accordance with guidelines introduced by the Cochrane Collaboration Search Strategy and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.

Search Strategy

Electronic literature searches were conducted by 2 independent researchers in four international electronic databases (PubMed, EMBASE, Cochrane Library, and Web of Science) and four Chinese electronic databases (China National Knowledge Infrastructure Database, Wanfang database, Chinese Biomedical Literature Database and Chongqing VIP) from inception to July 31, 2021. No restrictions were made on publication time and language. The search terms were as follows: (“osteoarthritis of the knee” OR “knee osteoarthritis” OR “koa” OR “gonarthritis” OR “knee pain” AND (“acupuncture” OR “acupuncture therapy” OR “manual acupuncture” OR “electroacupuncture” OR “auricular acupuncture” OR “warm acupuncture” OR “acupoints” OR “filiform needle” OR “fire needle”) AND (“systematic…


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