Inspired by Liu et al 2024.[1]
EA – electroacupuncture
OA – osteoarthritis
OAK – OA of the knee
SR – systematic review
NICE – the National Institute for Health and Care Excellence
HVAC – high volume acupuncture clinic
RoB – risk of bias
NSAIDs – non-steroidal anti-inflammatory drugs
IPDM – individual patient data meta-analysis
GRADE – Grading of Recommendations, Assessment, Development and Evaluation
SMD – standardised mean difference
CI – confidence interval
MCID – minimum clinically important difference
NMA – network meta-analysis
MA – manual acupuncture– key to acronyms
This paper was published on 1st November 2024 in BMJ Evidence-Based Medicine (IF 9.8) – an open access journal from BMJ Group. Our journal used to be published from the same stable but was never invited to be part of the main herd like this one. Yes, I clearly still harbour some resentment over that.
This is the largest SR of acupuncture in OAK to date and includes 80 trials and almost 10k patients. The research team comes from Beijing, but with some help and guidance from South Korea in the guise of Myeong Soo Lee, whose research has featured here several times.
Early in my acupuncture career I noticed that EA appeared to be particularly good for the pain and stiffness of OAK and perhaps most telling was that all of my OAK patients wanted to continue with EA after starting on it. Soon I was using EA first line in every OAK patient. Remember, in the days before EA devices with fine digital control of intensity (current), it would not be recommended to use EA at the first session.
As the research improved, and in particular after the publications led by Jorge Vas in 2004,[2,3] I had the feeling that this might get picked up by NICE. I urged Adrian White to consider performing an SR on the topic, and I insisted on some consideration of acupuncture dose for the first time in an SR.[4] We also tried to impose a lack of dose in the sham acupuncture groups, but that resulted in us have very few trials to consider.
At the same time, I pushed to have a high volume or group clinic at the hospital where I worked in Central London focussed on providing EA for patients with OAK.[5,6]
Unfortunately, after the HVAC was set up, NICE specifically recommended against the use of EA in OA.[7–13] Despite this, what were subsequently called group clinics were very successful and continued to run for just over a decade until the fateful NG59 was published in draft form in early 2016.[14–17]
This paper sets a new milestone for acupuncture research in OAK. It is a huge undertaking to assess RoB in, and pool data from, 80 trials. Trials were included that compared acupuncture or EA with sham, NSAIDs, usual care (or waiting list), or ‘blank’. The latter threw me for a while… Blank refers to trials where acupuncture or EA was added to another intervention and compared with that intervention alone – so called A plus B versus B.
A large proportion of the trials, including all the trials directly comparing acupuncture or EA with NSAIDs, were from China, and ‘unequivocal allocation concealment’, the criteria used by Vickers et al in their IPDM,[18,19] was certainly not met for most of them. Indeed, there are only 26 green dots (out of 80) on the relevant row of the RoB table. Along with the usual blinding issues, and inevitable statistical heterogeneity, this means that GRADE assessment will not usually get above ‘low certainty’. In this case, for the main outcomes, the level of certainty was ‘very low’, which is as low as it goes! It was brought down by RoB, inconsistency (high heterogeneity), and possible publication bias.
It is probably not a great surprise, given what I have already expressed above, that acupuncture was superior to sham (SMD -0.74), usual care (SMD -1.01), and blank (SMD -1.65), but it was also superior to NSAIDs by a substantial margin (SMD -0.86). In all of these comparisons the smaller CI exceeded the MCID, which had been set at SMD 0.37.
An assessment of dose was also included in this SR, but dose only proved to have a significant effect in the comparison with NSAIDs. The factors used to determine dose were as follows: the number of points used; the de qi response; the frequency of treatment per week; and the total duration of treatment.[20]
An exploratory NMA including 19 trials was performed with nodes for MA, EA, and sham. This demonstrated superiority of EA over MA and sham, but did not confirm superiority of MA over sham. Whilst this is an exploratory analysis, it is the first time I have seen evidence that EA might be superior to MA in OAK, something I suspected from my clinical practice back in the 1990’s.
References
1 Liu C-Y, Duan Y-S, Zhou H, et al. Clinical effect and contributing factors of acupuncture for knee osteoarthritis: a systematic review and pairwise and exploratory network meta-analysis. BMJ Evid-Based Med. Published Online First: 1 November 2024. doi: 10.1136/bmjebm-2023-112626
2 Vas J, Perea-Milla E, Mendez C. Acupuncture and moxibustion as an adjunctive treatment for osteoarthritis of the knee – a large case series. Acupunct Med. 2004;22:23. doi: 10.1136/aim.22.1.23
3 Vas J, Méndez C, Perea-Milla E, et al. Acupuncture as a complementary therapy to the pharmacological treatment of osteoarthritis of the knee: randomised controlled trial. BMJ. 2004;329:1216. doi: 10.1136/bmj.38238.601447.3A
4 White A, Foster NE, Cummings M, et al. Acupuncture treatment for chronic knee pain: a systematic review. Rheumatology. 2007;46:384–90. doi: 10.1093/rheumatology/kel413
5 Berkovitz S, Cummings M, Perrin C, et al. High Volume Acupuncture Clinic (Hvac) for Chronic Knee Pain – Audit of a Possible Model for Delivery of Acupuncture in the National Health Service. Acupunct Med. 2008;26:46–50. doi: 10.1136/aim.26.1.46
6 Cummings M. The Development of Group Acupuncture for Chronic Knee Pain Was All about Providing Frequent Electroacupuncture. Acupunct Med. 2012;30:363–4. doi: 10.1136/acupmed-2012-010260
7 Osteoarthritis: the care and management of osteoarthritis in adults | Guidance | NICE | Published 27th February 2008. https://www.nice.org.uk/guidance/cg59 (accessed 14 December 2022)
8 Low back pain in adults: early management | Guidance | NICE | Published 27th May 2009. https://www.nice.org.uk/guidance/CG88 (accessed 14 December 2022)
9 Cummings M. Why recommend acupuncture for low back pain but not for osteoarthritis? A commentary on recent NICE guidelines. Acupunct Med. 2009;27:128–9. doi: 10.1136/aim.2009.001214
10 White A. NICE guideline on osteoarthritis: is it fair to acupuncture? No. Acupunct Med. 2009;27:70–2. doi: 10.1136/aim.2009.000810
11 Latimer N. NICE guideline on osteoarthritis: is it fair to acupuncture? Yes. Acupunct Med. 2009;27:72–5. doi: 10.1136/aim.2009.000802
12 Latimer NR, Bhanu AC, Whitehurst DGT. Inconsistencies in NICE guidance for acupuncture: reanalysis and discussion. Acupunct Med. 2012;30:182–6. doi: 10.1136/acupmed-2012-010152
13 Cummings M. NICE, electroacupuncture, and osteoarthritis. Int Musculoskelet Med. 2014;36:47–9. doi: 10.1179/1753614614Z.00000000068
14 Overview | Low back pain and sciatica in over 16s: assessment and management | Guidance | NICE | Published 30th November 2016. https://www.nice.org.uk/guidance/NG59 (accessed 14 December 2022)
15 Cummings M. NG59 used different levels of evidence for conventional interventions compared with those for acupuncture and may not have adequately addressed personal financial COIs of the GDG chair. BMJ – Rapid Responses. Published Online First: 2017. doi: https://www.bmj.com/content/356/bmj.i6748/rr-6
16 BMAS website. Acupuncture in Low Back Pain. https://www.medical-acupuncture.co.uk/Professionals/AcupunctureinLowBackPain.aspx (accessed 14 December 2022)
17 Cummings M. Integration of Acupuncture into UK Healthcare – A NICE Perspective: Why is Acupuncture Now Recommended for Chronic Pain but not for Back Pain or Osteoarthritis. Perspect Integr Med. 2023;2:3–7. doi: 10.56986/pim.2023.02.002
18 Vickers AJ, Cronin AM, Maschino AC, et al. Acupuncture for chronic pain: individual patient data meta-analysis. Arch Intern Med. 2012;172:1444–53. doi: 10.1001/archinternmed.2012.3654
19 Vickers AJ, Vertosick EA, Lewith G, et al. Acupuncture for Chronic Pain: Update of an Individual Patient Data Meta-Analysis. J Pain. 2018;19:455–74. doi: 10.1016/j.jpain.2017.11.005
20 Sun N, Tu JF, Lin LL, et al. Correlation between acupuncture dose and effectiveness in the treatment of knee osteoarthritis: a systematic review. Acupunct Med. 2019;37:261–7. doi: 10.1136/acupmed-2017-011608
The BMAS Blog 
You must be logged in to post a comment.