Acupuncture for knee osteoarthritis: A systematic review and meta-analysis

Knee osteoarthritis (KOA) is a degenerative disease in which articular cartilage and synovial fluid in the knee are lost, leading to lower limb disability, particularly in elderly individuals.1 While nonsteroidal anti-inflammatory drugs (NSAIDs) can improve the physical function of KOA patients, they pose a significant risk of gastrointestinal adverse events that hinder disease management.2 Acupuncture (AT) is one of the most common non-pharmacological therapies for the treatment of musculoskeletal disease-related symptoms.3 Although evidence supports the potential effectiveness of acupuncture in treating KOA-related symptoms, the findings are controversial.4 Therefore, we conducted a systematic review, quantitative analysis, and summary of existing evidence to investigate the safety and effectiveness of acupuncture for KOA.We compared the results to the minimal clinically important difference (MCID) framework to better inform health careproviders. This researchwas conducted as part of the acupuncture for knee osteoarthritis Rapid Recommendation Initiative. We conducted a comprehensive search across three Englishlanguage databases, four Chinese-language databases, and the registration platform. The eligible studies were categorized based on the following criteria: no treatment (including sham acupuncture, health education, and function rehabilitation) and usual care (including physiotherapy, NSAIDs, and glucosamine). We utilized the Cochrane Risk of Bias tool to assess the quality of studies, the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) to evaluate the certainty of results, and the Credibility of Effect Modification Analyses (ICEMAN)5 to appraise the credibility of subgroup inferences. Further details on the methodology used can be found in SupplementaryMaterial S1. Seventy-seven RCTswith a total of 9422 participants were included in the systematic review or qualitative synthesis, 33 articles were published in English, and 44 in Chinese. The risk of bias was overall unclear to high due to allocation concealment, blinding, and incomplete outcome data. Compared with no treatment, acupuncture showed a potentially positive effect on WOMAC total scores when measured at the end of treatment [MD −8.05, 95% CI (−10.14, −5.96), moderate certainty] and follow-up [MD −6.48, 95% CI (−10.11, −2.85), low certainty], which significantly exceeded the MCID (Table 1). At the end of treatment, the effect on decreasing WOMAC total score was statistically significantly greater in 4–8 weeks compared to less than 4 weeks or