Sommaire

1. Systematic Reviews and Meta-Analysis
2. Overviews of Systematic Reviews
3. Cost-effectiveness Analysis
4. Clinical Practice Guidelines
5. Overviews of Clinical Practice Guidelines
- 5.1. Gibbs 2023
6. Randomized Controlled Trials
- 6.1. Sources
- 6.2. List

Knee Pain, Knee Osteoarthritis

Genou douloureux, Gonarthrose

articles connexes : - arthrose - traitements de référence - conduites thérapeutiques - taiji-qigong -

1. Systematic Reviews and Meta-Analysis

☆☆☆	Evidence for effectiveness and a specific effect of acupuncture.
☆☆	Evidence for effectiveness of acupuncture.
☆	Evidence for effectiveness of acupuncture mais limitées qualitativement et/ou quantitativement.
Ø	No evidence or insufficient evidence.

1.1. Generic Acupuncture

1.1.1. Chen 2024

Chen H, Shi H, Gao S, Fang J, Yi J, Wu W, Liu X, Liu Z. Durable Effects of Acupuncture for Knee Osteoarthritis: A Systematic Review and Meta-analysis. Curr Pain Headache Rep. 2024 Jul;28(7):709-722. https://doi.org/10.1007/s11916-024-01242-6

Purpose of review	Knee osteoarthritis (KOA) is a degenerative joint disease which can result in chronic pain and disability. The current interventions available for KOA often fail to provide long-lasting effects, highlighting the need for new treatment options that can offer durable benefits. Previous studies have suggested the efficacy of acupuncture for knee osteoarthritis (KOA) with its durability remaining uncertain. In this review, we aimed to investigate the durability of the efficacy after completion of treatment.
Recent findings	We performed thorough searches of PubMed, EMBASE, Web of Science, and Cochrane Central Register of Controlled Trials from inception to November 4, 2023. The outcomes were assessed at all available time points after completion of treatment. Primary outcomes were changes from baseline in pain and function measured using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function subscales. Secondary outcomes included response rate, overall pain, the WOMAC stiffness subscale, total WOMAC index, and physical and mental health components of 12/36-item Short-Form Health Survey. A total of 10 randomized controlled trials (RCTs) involving 3221 participants were included. Pooled estimates suggested that acupuncture may offer potential improvements in function and overall pain for 4.5 months post-treatment versus sham acupuncture (SA). Acupuncture may provide durable clinically important pain relief and functional improvement up to 5 months post-treatment versus usual care, and up to 6 months post-treatment versus diclofenac. For acupuncture versus no treatment, one trial with large sample size indicated that improvements in pain and function persisted for 3 months post-treatment, while the other trial reported that significant pain reduction and functional improvement were only observed at the end of the treatment, not at 9 months post-treatment. However, acupuncture as adjunct to exercise-based physical therapy (EPT) showed no superiority to SA as an adjunct to EPT or EPT alone up to 11.25 months after completion of treatment. Acupuncture may provide pain alleviation and functional improvements in KOA patients for 3 to 6 months after completion of treatment with a good safety profile.

Purpose of review

Knee osteoarthritis (KOA) is a degenerative joint disease which can result in chronic pain and disability. The current interventions available for KOA often fail to provide long-lasting effects, highlighting the need for new treatment options that can offer durable benefits. Previous studies have suggested the efficacy of acupuncture for knee osteoarthritis (KOA) with its durability remaining uncertain. In this review, we aimed to investigate the durability of the efficacy after completion of treatment.

Recent findings

We performed thorough searches of PubMed, EMBASE, Web of Science, and Cochrane Central Register of Controlled Trials from inception to November 4, 2023. The outcomes were assessed at all available time points after completion of treatment. Primary outcomes were changes from baseline in pain and function measured using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain and function subscales. Secondary outcomes included response rate, overall pain, the WOMAC stiffness subscale, total WOMAC index, and physical and mental health components of 12/36-item Short-Form Health Survey. A total of 10 randomized controlled trials (RCTs) involving 3221 participants were included. Pooled estimates suggested that acupuncture may offer potential improvements in function and overall pain for 4.5 months post-treatment versus sham acupuncture (SA). Acupuncture may provide durable clinically important pain relief and functional improvement up to 5 months post-treatment versus usual care, and up to 6 months post-treatment versus diclofenac. For acupuncture versus no treatment, one trial with large sample size indicated that improvements in pain and function persisted for 3 months post-treatment, while the other trial reported that significant pain reduction and functional improvement were only observed at the end of the treatment, not at 9 months post-treatment. However, acupuncture as adjunct to exercise-based physical therapy (EPT) showed no superiority to SA as an adjunct to EPT or EPT alone up to 11.25 months after completion of treatment. Acupuncture may provide pain alleviation and functional improvements in KOA patients for 3 to 6 months after completion of treatment with a good safety profile.

1.1.2. Kwak 2023 ☆☆

Kwak SG, Kwon JB, Seo YW, Choi WK. The effectiveness of acupuncture as an adjunctive therapy to oral pharmacological medication in patient with knee osteoarthritis: A systematic review and meta-analysis. Medicine (Baltimore). 2023 Mar 17;102(11):e33262. https://doi.org/10.1097/MD.0000000000033262.

Background	We aimed to find out whether the combined treatment of acupuncture and oral medication is more effective than sole oral medication in reducing pain and improving knee function at the end of treatment and after short-term period (4-6 weeks after treatment). Second, if it is effective, we investigated whether the effect surpasses the minimal clinically important difference.
Methods	Articles published between January 1, 1992, and August 31, 2022, were searched in PubMed, Cochrane, and Embase. The PICO (population, intervention, comparison, and outcome) of this study are as follows: Population: knee osteoarthritis patients; Intervention: acupuncture (non-sham acupuncture) + oral medication (analgesic or non-steroidal anti-inflammatory drugs); Comparison: oral medication (analgesic or non-steroidal anti-inflammatory drugs); Outcome: visual analog scale (VAS) or Western Ontario and McMaster University (WOMAC) osteoarthritis index.
Results	The combined treatment of oral medication and adjuvant acupuncture showed statistically significant improvement in VAS and WOMAC scores at the end of acupuncture treatment and short-term follow-up time (between 4 and 6 weeks after acupuncture). In addition, the degree of improvement of VAS and WOMAC index showed effects beyond minimal clinically important differences compared to pretreatment at both the end of acupuncture treatment and the short-term follow-up of acupuncture treatment.
Conclusion	The existing evidence suggests that adjuvant acupuncture may play a role in the treatment of knee osteoarthritis. However, physicians should be aware of adverse effects such as hematoma in adjuvant acupuncture treatment.

1.1.3. Lee 2023 ☆☆☆

Lee B, Kim TH, Birch S, Alraek T, Lee HW, Nielsen A, Wieland LS, Lee MS. Comparative effectiveness of acupuncture in sham-controlled trials for knee osteoarthritis: A systematic review and network meta-analysis. Front Med (Lausanne). 2023 Jan 9;9:1061878. https://doi.org/10.3389/fmed.2022.1061878.

Objectives	Although many trials have assessed the effect of acupuncture on knee osteoarthritis (KOA), its efficacy remains controversial. Sham acupuncture techniques are regarded as representative control interventions in acupuncture trials and sometimes incorporate the use of sham devices (base units) to support a non-penetrating needle. To achieve successful blinding, these trials also use acupuncture base units in the verum acupuncture group. Base units are not used in real-world clinical settings. We aimed to assess the effect sizes of verum and sham acupuncture for KOA in sham-controlled trials with or without base units.
Methods	A total of 10 electronic databases for randomized controlled trials (RCTs) comparing the efficacy of verum manual acupuncture and sham acupuncture for the treatment of KOA were searched for articles published before April 12, 2022. The primary outcome was pain intensity, and the secondary outcomes included physical function. The first assessment after the end of treatment was chosen for analysis. Effect sizes are reported as standardized mean differences (SMDs) with 95% confidence intervals (95% CIs). The risk of bias was assessed using the Cochrane risk of bias tool, and publication bias was evaluated using a funnel plot and Egger's test. The quality of evidence for estimates was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach.
Results	Fifteen RCTs were included. There was generally a low risk of bias except for the difficulty in blinding acupuncture therapists (performance bias). Compared to verum acupuncture in sham-controlled trials using base units, verum acupuncture in sham-controlled trials without base units was more effective for improving pain (SMD -0.56, 95% CI -1.09 to -0.03) and function (SMD -0.73, 95% CI -1.36 to -0.10) in KOA. The quality of evidence for network estimates was moderate to low due to the risk of bias and imprecision.
Conclusion	These findings suggest that verum acupuncture in different types of sham-controlled trials has different effect sizes for KOA. Because base units are not used in clinical settings, the results of verum acupuncture in sham-controlled trials with base units need to be interpreted carefully.

1.1.4. Tian 2022 RETRACTED

RETRACTED. Tian H, Huang L, Sun M, Xu G, He J, Zhou Z, Huang F, Liu Y, Liang F. Acupuncture for Knee Osteoarthritis: A Systematic Review of Randomized Clinical Trials with Meta-Analyses and Trial Sequential Analyses. Biomed Res Int. 2022 Apr 21;2022:6561633. https://doi.org/10.1155/2022/6561633

Background	Knee osteoarthritis (KOA) can cause chronic pain and seriously affect the quality of patient lives. The continued emergence of high-quality RCTS requires us to update the quality of evidence. This study aims to evaluate the efficacy of acupuncture for KOA patients and calculate the required information size (RIS) to determine whether further clinical studies are required.
Methods	We searched PubMed, Embase, WOS, CBM, CNKI, VIP, WHO ICTRP, ChiCTR, and Grey literature to collect randomized controlled trials (RCTs) of acupuncture for KOA from inception to December 2021. A meta-analysis was performed according to the Cochrane systematic review method by using Review Manager 5.4 and TSA 0.9.5.10 beta, and GRADE was used to evaluate the quality of the evidence. Trial sequential analysis was used to control random errors and calculate the required information size.
Results	Eleven RCTs with 2484 patients were included in our meta-analysis, meeting the inclusion criteria for the meta-analysis. The meta-analysis indicated that acupuncture had beneficial effect on knee osteoarthritis in reducing pain [n = 2387; SMD = -0.12, 95% CI (-0.20, -0.04); I 2 = 0%] and improved patients function activities [n = 2408; MD = -1.25, 95% CI (-1.97, -0.53); I 2 = 0%], but true acupuncture showed no significant effect in relieve patient's stiffness [n = 1337; MD = -0.07, 95% CI (-0.30, 0.15); I 2 = 0%]. We pooled the studies which found no significant difference in improving the quality life of mental [n = 1462; SMD = 0.02, 95% CI (-0.23, 0.27); I 2 = 78%] and patients physical health (SF-36 or SF-12) [n = 1745; SMD = 1.01, 95% CI (-0.08, 2.11); I 2 = 0%] compared with sham acupuncture. The pain and function TSA graphs indicated that cumulative Z-curves intersected with the traditional level of statistical favoring acupuncture, and more RCTs will required in the future studies.
Conclusion	Acupuncture has beneficial effect on pain relief and improves function activities, and this treatment can be recommended as a beneficial alternative therapy in patients with KOA, particularly for chronic patients and those currently undergoing long-term pain and help them increasing quality of life. But it should be further verified through more RCTs in function. Available studies suggested that acupuncture was superior to sham acupuncture in reduce pain and function as verified by TSA.

1.1.5. Fan 2020 ☆☆

Fan Mengmeng. [Meta-analysis for the Efficacy and Safety of Acupuncture and Moxibustion in the Treatment of Knee Osteoarthritis]. Rheumatism and Arthritis. 2020. [212927].

Objective	To systematically evaluate the clinical efficacy and safety of acupuncture and moxibustion in the treatment of knee osteoarthritis.
Methods	Literature on randomized controlled trials of treating knee osteoarthritis with acupuncture and moxibustion was retrieved from databases such as CNKI, Wanfang, VIP, PubMed and Cochrane Library. The retrieval time was from January 1, 2017 to October 29, 2019. A meta-analysis was made for the literature by software Review Manager 5. 3.
Results	A total of 1844 patients (928 in the experiment group and 916 in the control group) were included in 23 articles. Meta-analysis showed that the experiment group was better than the control group in improving the total effective rate (OR=3. 48, 95%CI=[2. 55, 4. 76], P < 0. 000 01), VAS score (MD=-2. 27, 95%CI=[-2. 87, -1. 67], P < 0. 000 01), WOMAC score (MD=-14. 55, 95%CI=[-18. 67, -10. 43], P < 0. 000 01).
Conclusion	Acupuncture and moxibustion have distinct advantages in the treatment of knee osteoarthritis.

1.1.6. Sun 2020 ☆

Sun ning. [Systematic Evaluation on Acupuncture and Moxibustion for Treatment of Knee Osteoarthritis]. Chinese Journal of Information on TCM. 2020. [212932].

Objective	To assess the clinical efficacy of acupuncture and moxibustion in the treatment of knee osteoarthritis.
Methods	Randomized controlled trials (RCT) involving experiment group (acupuncture and moxibustion) and control group (routine Western medicine) for the treatment of knee osteoarthritis were retrieved from CNKI, VIP, Wanfang, CBM, Pubmed, and Embase. Two reviewers independently extracted and cross-checked the included literature. The Cochrane Review Handbook 5. 1 bias risk tool was used to evaluate the quality of the included literature, and RevMan5. 3 was used for meta-analysis.
Results	Totally 19 RCTs were included, involving 1550 patients. Meta-analysis showed that the total effective rate (RR=1. 17, 95%CI [1. 12, 1. 23]), WOMAC score (treatment course <4 weeks, SMD=-0. 25, 95%CI [-0. 66, 0. 17]; treatment course = 4 weeks, SMD=1. 16, 95%CI [0. 87, 1. 45]; treatment course >4 weeks, SMD=0. 15, 95%CI [-0. 10, 0. 41]), VAS score (SMD=2. 43, 95%CI [2. 09, 2. 78]), Lequesne index (SMD=0. 63, 95%CI [0. 15, 1. 11]) and joint pain score (SMD=1. 30, 95%CI [0. 93, 1. 67]) of experiment group were better than those of the control group.
Conclusion	Compared with routine Western medicine treatment, acupuncture and moxibustion treatment of knee osteoarthritis can significantly improve patients' knee symptoms, improve quality of life, and have fewer adverse reactions. However, due to the low quality of the included literature, high-quality research is still needed to verify.

1.1.7. Wang 2020 ☆☆☆

Wang T, Liu Y, Ning Z et al. Efficacy and safety of acupuncture for the treatment of knee osteoarthritis: a systematic review and meta-analysis. Journal of Acupuncture and Tuina Science. 2020;18(3):180-190. [210392]. doi

Objective	To evaluate the efficacy and safety of acupuncture for the treatment of knee osteoarthritis and to provide evidence for its use in clinical practice.
Methods	Eight databases were extensively searched up to March 2018. Randomized controlled trials (RCTs) comparing the efficacy of acupuncture with sham acupuncture or no acupuncture for knee osteoarthritis were included. Study selection, data extraction and quality assessment were independently conducted by two reviewers. The Cochrane Collaboration’s tool was used for assessing the risk of bias.
Results	A total of 18 RCTs were included, involving a total of 3 522 participants. The results showed that acupuncture was superior to sham acupuncture in relieving pain (SMD=−0.34, 95%CI: −0.57 to −0.11, l2=85%, P=0.003) and improving physical function (SMD=−0.34, 95%CI: −0.57 to −0.11, l2=85%, P=0.003). In comparison to the no-acupuncture group, the acupuncture group also showed significant advantages in relieving pain (SMD=−0.79, 95%CI: −1.15 to −0.43, l2=87%, P<0.0001) and improving physical function (SMD=−0.75, 95%CI: −1.19 to −0.31, l2=91%, P=0.0008). Sensitivity analyses suggested that the results were robust, and Egger’s test found no potential publication bias.
Conclusion	In the treatment of knee osteoarthritis, the acupuncture group had significant advantages over sham acupuncture or no-acupuncture groups in relieving pain and improving physical function.

1.1.8. Ferreira 2019

Ferreira RM, Torres RT, Duarte JA, Gonçalves RS. Non-Pharmacological and Non-Surgical Interventions for Knee Osteoarthritis: A Systematic Review and Meta-Analysis. Acta Reumatol Port. 2019;44(3):173-217. [212789]. doi

Objective	The aim of the present systematic review and meta-analysis is to know, based on the available randomized controlled trials, if the non-surgical and non-pharmacological interventions commonly used for knee osteoarthritis (OA) patients are effective and which are the most effective ones.
Material and methods	RCTs were identified through electronic databases respecting the following terms to guide the search strategy: PICO (Patients - Humans with knee OA; Intervention - Non-surgical and non-pharmacological interventions; Comparison - Pharmacological, surgical, placebo, no intervention, or other non-pharmacological/non-surgical interventions; Outcomes - Pain, physical function and patient global assessment). The methodological quality of the selected publications was evaluated using the PEDro and GRADE scales. Additionally, a meta-analysis was performed using the RevMan. Only studies with similar control group, population characteristics, outcomes, instruments and follow-up, were compared in each analysis.
Results	Initially, 52 RCTs emerge however, after methodological analysis, only 39 had sufficient quality to be included. From those, only 5 studies meet the meta-analysis criteria. Exercise (especially resistance training) had the best positive effects on knee OA patients. Pulsed Electromagnetic Fields and Moxibustion showed to be the most promising interventions from the others. Balance Training, Diet, Diathermy, Hydrotherapy, High Level Laser Therapy, Interferential Current, Mudpack, Neuromuscular Electrical Stimulation, Musculoskeletal Manipulations, Shock Wave Therapy, Focal Muscle Vibration, stood out, however more studies are needed to fully recommend their use. Other interventions did not show to be effective or the results obtained were heterogeneous.
Conclusions	Exercise is the best intervention for knee OA patients. Pulsed Electromagnetic Fields and Moxibustion showed to be the most promising interventions from the others options available.

1.1.9. Vickers 2018 ☆☆☆

Vickers AJ, Vertosick EA, Lewith G et al, Acupuncture Trialists' Collaboration. Acupuncture for Chronic Pain: Update of an Individual Patient Data Meta-Analysis. J Pain. 2018 May;19(5):455-474. [168043]

Purpose	Our objective was to update an individual patient data meta-analysis to determine the effect size of acupuncture for 4 chronic pain conditionss.
Methods	We searched MEDLINE and the Cochrane Central Registry of Controlled Trials randomized trials published up until December 31, 2015. We included randomized trials of acupuncture needling versus either sham acupuncture or no acupuncture control for nonspecific musculoskeletal pain, osteoarthritis, chronic headache, or shoulder pain. Trials were only included if allocation concealment was unambiguously determined to be adequate. Raw data were obtained from study authors and entered into an individual patient data meta-analysis.
Results	The main outcome measures were pain and function. An additional 13 trials were identified, with data received for a total of 20,827 patients from 39 trials. Acupuncture was superior to sham as well as no acupuncture control for each pain condition (all P < .001) with differences between groups close to .5 SDs compared with no acupuncture control and close to .2 SDs compared with sham. We also found clear evidence that the effects of acupuncture persist over time with only a small decrease, approximately 15%, in treatment effect at 1 year. In secondary analyses, we found no obvious association between trial outcome and characteristics of acupuncture treatment, but effect sizes of acupuncture were associated with the type of control group, with smaller effects sizes for sham controlled trials that used a penetrating needle for sham, and for trials that had high intensity of intervention in the control arm. We conclude that acupuncture is effective for the treatment of chronic pain, with treatment effects persisting over time. Although factors in addition to the specific effects of needling at correct acupuncture point locations are important contributors to the treatment effect, decreases in pain after acupuncture cannot be explained solely in terms of placebo effects. Variations in the effect size of acupuncture in different trials are driven predominantly by differences in treatments received by the control group rather than by differences in the characteristics of acupuncture treatment.
Perspective	Acupuncture is effective for the treatment of chronic musculoskeletal, headache, and osteoarthritis pain. Treatment effects of acupuncture persist over time and cannot be explained solely in terms of placebo effects. Referral for a course of acupuncture treatment is a reasonable option for a patient with chronic pain..
	Les 10 ECR relatifs à l'arthrose concernent la gonarthrose

1.1.10. Zhang 2017 ☆

Zhang Q, Yue J, Golianu B, Sun Z, Lu Y. Updated systematic review and meta-analysis of acupuncture for chronic knee pain. Acupunct Med. 2017;35(6):392-403. [99888].

Objective	To assess the effectiveness and safety of acupuncture for the treatment of chronic knee pain (CKP).
Methods	We searched the MEDLINE, EMBASE, Cochrane CENTERAL, CINAHL and four Chinese medical databases from their inception to June 2017. We included randomised controlled trials of acupuncture as the sole treatment or as an adjunctive treatment for CKP. The primary outcome was pain intensity measured by visual analogue scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain subscale and 11-point numeric rating scale. Secondary outcome measurements included the 36-Item Short Form Health Survey and adverse events. The quality of all included studies was evaluated using the Cochrane risk-of-bias criteria and the STRICTA (Standards for Reporting Interventions in Controlled Trials of Acupuncture) checklist.
Result	Nineteen trials were included in this systematic review. Of these, data from 17 studies were available for analysis. Regarding the effectiveness of acupuncture alone or combined with other treatment, the results of the meta-analysis showed that acupuncture was associated with significantly reduced CKP at 12 weeks on WOMAC pain subscale (mean difference (MD) -1.12, 95% confidence interval (CI) -1.98 to -0.26, I2=62%, 3 trials, 608 participants) and VAS (MD -10.56, 95% CI -17.69 to -3.44, I2=0%, 2 trials, 145 patients). As for safety, no difference was found between the acupuncture and control groups (risk ratio 1.08, 95% CI 0.54 to 2.17, I2=29%).
Conclusion	From this systematic review, we conclude that acupuncture may be effective at relieving CKP 12 weeks after acupuncture administration, based on the current evidence and our protocol. However, given the heterogeneity and methodological limitations of the included trials, we are currently unable to draw any strong conclusions regarding the effectiveness of acupuncture for chronic knee pain. In addition, we found that acupuncture appears to have a satisfactory safety profile, although further studies with larger numbers of participants are needed to confirm the safety of this technique.

1.1.11. Lin 2016 ★★

Lin X, Huang K, Zhu G, Huang Z, Qin A, Fan S. The Effects of Acupuncture on Chronic Knee Pain Due to Osteoarthritis: A Meta-Analysis. J Bone Joint Surg Am. 2016;98(18):1578-85. [188513].

Background	Acupuncture reportedly relieves chronic knee pain and improves physical function in patients diagnosed with osteoarthritis, but the duration of these effects is controversial. The aim of this study was to evaluate the temporal effects of acupuncture on chronic knee pain due to knee osteoarthritis by means of a meta-analysis.
Methods	The PubMed, Embase, and Cochrane Central Register of Controlled Trials databases were searched for studies published through March 2015. Ten randomized controlled trials of acupuncture compared with sham acupuncture, usual care, or no intervention for chronic knee pain in patients with clinically diagnosed or radiographically confirmed knee osteoarthritis were included. All of the studies were available in English. Weighted mean differences (WMDs), 95% confidence intervals (Cis), publication bias, and heterogeneity were calculated.
Results	The acupuncture groups showed superior pain improvement (p < 0.001; WMD = -1.24 [95% CI, -1.92 to -0.56]; I(2) > 50%) and physical function (p < 0.001; WMD = 4.61 [95% CI, 2.24 to 6.97]; I(2) > 50%) in the short term (up to 13 weeks). The acupuncture groups showed superior physical function (p = 0.016; WMD = 2.73 [95% CI, 0.51 to 4.94]; I(2) > 50%) but not superior pain improvement (p = 0.199; WMD = -0.55 [95% CI, -1.39 to 0.29]; I(2) > 50%) in the long term (up to 26 weeks). Subgroup analysis revealed that the acupuncture groups tended to have better outcomes compared with the controls. Significant publication bias was not detected (p > 0.05), but the heterogeneity of the studies was substantial.
Conclusions	This meta-analysis demonstrates that acupuncture can improve short and long-term physical function, but it appears to provide only short-term pain relief in patients with chronic knee pain due to osteoarthritis.
Level of Evidence	Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

1.1.12. Ai 2016 (network meta-analysis) ★★

Ai Jin-Wei, Li De-Sheng, Liu Yu, Lin Hong-Ming, Wang Qian, Pei Bin. [Effectiveness of traditional chinese medicine therapy for knee osteoarthritis: a network meta-analysis]. Chinese Journal of EBM. 2016;16(5): 532-42. [166128].

Objective	To systematically review the efficacy and safety of traditional Chinese medicine (TCM) therapies versus non-steroidal anti-inflammatory drugs (NSAIDs) for knee osteoarthritis (KOA).
Methods	We electronically searched databases including PubMed, The Cochrane Library (Issue 5, 2015), Embase, CNKI, CBM, VIP and WanFang Data from inception to 14 June 2015, to collect randomized controlled trials (RCTs) about TCM therapies for KOA. Two reviewers independently screened literature, extracted data and assessed the methodological quality of included studies. Then network meta-analysis was performed using Stata 12.0 and WinBUGS 1.4.3 softwares.
Results	A total of 56 RCTs involving 7 256 patients were included, in which 19 different treatment strategies were investigated. All were short-term efficacy studies. Our work yielded 33 direct and 138 indirect comparisons, among which 76 were demonstrated statistically significant. The result of meta-analysis showed that, the TCM-based therapy group had lower complication rates, compared with the NSAIDs group. TCM internal application + acupuncture + fumigation, internal application + fumigation + moxibustion, acupuncture + massage, TCM extra-apply + massage, massage + fumigation + moxibustion, and massage + fumigation were the top six in terms of treatment effect. NSAIDs ranked 18th.
Conclusion	The safety and effectiveness of TCM therapies are generally better than NSAIDs except moxibustion, particularly more remarkable for the top six TCM therapies. TCM comprehensive therapies are superior over monomodality therapies. Due to the limitation of the present studies, the long-term efficacy of TCM therapies needs further investigation, and our findings also need to be verified by large-scale and well-designed RCTs.

1.1.13. Hu 2016 ☆

Hu Hanzuo. [ Meta-analysis of Acupuncture and moxibustion in treatment of knee Osteoarthritis]. Today Nurse. 2016;9: 115-116,117. [190146].

目的：评价针灸治疗膝骨性关节炎的有效性和安全性，为临床上优化膝骨性关节炎的治疗方案提供证据。方法检索针灸治疗膝骨性关节炎的临床RCT文献，评价纳入研究文献的质量，并进行meta分析。结果经筛选，最终纳入文献8篇，涉及945例患者，但其方法学质量均较低；与对照组(西医常规治疗)比较，治疗组（针灸治疗）治疗膝骨性关节炎在总有效率、降低WOMAC总积分方面，差异有统计学意义（P＜0.05），纳入文献均无不良反应报道。结论针灸治疗膝骨性关节炎有一定的疗效，但还需要设计良好的随机对照实验及多中心临床实验做进一步证实。
Objective	To evaluate the efficacy and safety of acupuncture in the treatment of knee osteoarthritis and to provide evidence for the clinical treatment of knee osteoarthritis.
Methods	The clinical RCT literature of acupuncture and moxibustion for knee osteoarthritis was searched, the quality of the included literature was evaluated, and meta-analysis was performed.
Results	The results were screened and finally included in the literature, involving 945 patients, but the methodological quality was low. Compared with the control group (the traditional Chinese medicine treatment), the treatment group (acupuncture treatment) in the treatment of knee osteoarthritis in total effective rate The difference in the total score of WOMAC was statistically significant (P<0.05), and no adverse reactions were reported in the literature.
Conclusion	Acupuncture has certain curative effect on knee osteoarthritis, but it also needs well-designed randomized controlled trials and multi-center clinical trials to further confirm.

1.1.14. Hou PW 2015 ★★

Hou PW, Fu PK, Hsu HC, Hsieh CL. Traditional Chinese medicine in patients with osteoarthritis of the knee. J Tradit Complement Med. 2015;5(4):182-196. [184928]

Objectifs	To evaluate whether the use of traditional Chinese medicine (TCM; zhōng yī) influences symptoms or functional outcomes in patients with osteoarthritis (OA) of the knee ( xī guān jié yán).
Méthodes	A systematic review of randomized control trials was conducted. Searches for studies in PubMed that were performed between 1965 and August 2013, and retrieved studies were subjected to reference screening. The types of studies included in our review were 1) placebo-based or comparative studies; 2) open label, single-blinded or double-blinded studies; 3) studies evaluating the efficacy of TCM for treating OA of the knee; and 4) studies evaluating only TCM or combination preparations. Trials were conducted with participants over 18 years of age with knee pain and at least three of the following characteristics: 1) an age greater than 50 years; 2) morning stiffness lasting for fewer than 30 min; 3) a crackling or grating sensation; 4) bony tenderness of the knee; 5) bony enlargement of the knee; or 6) no detectable warmth of the joint to the touch. Studies were rated for risk of bias and graded for quality.
Results	After screening, 104 studies that satisfied the eligibility requirements were identified, and only 18 randomized control trials were included in the quantitative and qualitative synthesis. Upon review, we found “moderate-quality” evidence of effects from acupuncture ( zhēn jiǔ) on pain, which was measured using a visual analogue scale, and physical function, which was measured using qigong ( qì gōng) with motion. “Low-quality” evidence was found regarding the effects of acupuncture on physical function, and no evidence was found regarding the effects of herbal medicine on pain or physical function. Herbal patches ( yào bù) appeared to affect pain and physical and function, but these effects were not found to be significant.
Conclusion	The initial findings included in this review suggest that acupuncture is a promising intervention according to the primary outcome measure, pain, and qigong with motion is an effective method for treating physical function. However, according to the Grades of Recommendation, Assessment, Development, and Evaluation criteria, only moderate-quality evidence was found in these studies.

1.1.15. Corbett 2013 (network meta-analysis) ★★

Corbett MS, Rice SJ, Madurasinghe V, Slack R, Fayter DA, Harden M, Sutton AJ, Macpherson H, Woolacott NF. Acupuncture and other physical treatments for the relief of pain due to osteoarthritis of the knee: network meta-analysis. Osteoarthritis Cartilage. 2013;21(9):1290-8. [170417]
Corbett MS, Rice SJ, Slack R, Harden M, Madurasinghe V, Sutton AJ, Macpherson H, Conaghan P, Woolacott NF. Acupuncture and other physical treatments for the relief of chronic pain due to osteoarthritis of the knee: a systematic review and network meta-analysis. Centre for Reviews and Dissemination (cCRD), University of York. 2012;206P. 158086

Objectifs	To compare the effectiveness of acupuncture with other relevant physical treatments for alleviating pain due to knee osteoarthritis.
Méthodes	Systematic review with network meta-analysis, to allow comparison of treatments within a coherent framework. Comprehensive searches were undertaken up to January 2013 to identify randomised controlled trials in patients with osteoarthritis of the knee, which reported pain.
Results	Results: Of 156 eligible studies, 114 trials (covering 22 treatments and 9,709 patients) provided data suitable for analysis. Most trials studied short-term effects and many were classed as being of poor quality with high risk of bias, commonly associated with lack of blinding (which was sometimes impossible to achieve). End of treatment results showed that eight interventions: interferential therapy, acupuncture, TENS, pulsed electrical stimulation, balneotherapy, aerobic exercise, sham acupuncture, and muscle-strengthening exercise produced a statistically significant reduction in pain when compared with standard care. In a sensitivity analysis of satisfactory and good quality studies, most studies were of acupuncture (11 trials) or muscle-strengthening exercise (9 trials); both interventions were statistically significantly better than standard care, with acupuncture being statistically significantly better than muscle-strengthening exercise (standardised mean difference: 0.49, 95% credible interval 0.00-0.98).).
Conclusion	As a summary of the current available research, the network meta-analysis results indicate that acupuncture can be considered as one of the more effective physical treatments for alleviating osteoarthritis knee pain in the short-term. However, much of the evidence in this area of research is of poor quality, meaning there is uncertainty about the efficacy of many physical treatments.

1.1.16. Cao 2012 ★★★

Cao L, Zhang XL, Gao YS, Jiang Y. Needle acupuncture for osteoarthritis of the knee. A systematic review and updated meta-analysis. Saudi Med J. 2012;33(5):526-32.[160091].

Purpose	To evaluate the efficacy of treatment with acupuncture for knee osteoarthritis.
Methods	We searched PUBMED, EMBASE, and the Cochrane Central Register of Controlled Trials databases from July to October 2011 for randomized controlled trials that compared needle acupuncture with sham acupuncture, standard care, or waiting list control groups in patients with knee osteoarthritis. Of the 490 potentially relevant articles, 14 RCTs involving 3,835 patients were included in the metaanalysis. Two authors independently extracted outcome data on short-term and long-term pain and functional measures.
Results	Standardized mean differences and 95% confidence intervals were calculated using the mean differences in improvements from baseline and the associated standard deviations in patients assigned to acupuncture and those assigned to control groups according to measurement time points. Compared with sham acupuncture control treatment, acupuncture was signiﬁcantly better at relieving pain (p=0.002) and restoring function (p=0.01) in the short-term period, and relieving pain (p=0.06) and restoring function (p=0.06) in the long-term. Compared with the standard care and waiting list control treatments, acupuncture was significantly better at relieving pain and restoring function.
Conclusion	Acupuncture provided signiﬁcantly better relief from knee osteoarthritis pain and a larger improvement in function than sham acupuncture, standard care treatment, or waiting for further treatment.

1.1.17. Lu 2012

Lu M, Tan XY, Huang L. [Meta-analysis of acupuncture and moxibustion in treatment of knee osteoarthritis], Guiding J Trad Chin Med Pharm. 2012;18:81-3. [199114].

Cité dans Li J , Li YX , Luo LJ , Ye J , Zhong DL , Xiao QW , Zheng H , Geng CM , Jin RJ , Liang FR. The effectiveness and safety of acupuncture for knee osteoarthritis: An overview of systematic reviews. Medicine (Baltimore). 2019;98(28). [200308]

1.1.18. Vickers 2012 ★★★

Vickers AJ, Cronin AM, Maschino AC, et al; Acupuncture Trialists’Collaboration. Acupuncture for chronic pain: individual patient data meta-analysis. Arch Intern Med 2012;172:1444-53. [157530].

Purpose	We aimed to determine the effect size of acupuncture for 4 chronic pain conditions: back and neck pain, osteoarthritis, chronic headache, and shoulder pain.
Methods	We conducted a systematic review to identify randomized controlled trials (RCTs) of acupuncture for chronic pain in which allocation concealment was determined unambiguously to be adequate. Individual patient data meta-analyses were conducted using data from 9 RCTs, with a total of 2713 patients analyzed.
Results	In the primary analysis, including all eligible RCTs, acupuncture was superior to both sham and noacupuncture control for each pain condition (P< 0,001 for all comparisons). After exclusion of an outlying set of RCTs that strongly favored acupuncture, the effect sizes were similar across pain conditions. Patients receiving acupuncture had less pain, with score for knee osteoarthritis that were 0.16 (95% CI, 0.07-0.25) SDs lower than sham controls for osteoarthritis; the effect sizes in comparison to noacupuncture controls were 0.57(95% CI, 0.50-0.64) SDs.These results were robust to a variety of sensitivity analyses, including those related to publication bias.
Conclusion	Acupuncture is effective for the treatment of chronic pain and is therefore a reasonable referral option. Significant differences between true and sham acupuncture indicate that acupuncture is more than a placebo [Conclusions sur la douleur chronique en général].

1.1.19. Manheimer 2010 ★★★

Manheimer E, Cheng K, Linde K, Lao L, Yoo J, Wieland S, van der Windt DAWM, Berman BM, Bouter LM. Acupuncture for peripheral joint osteoarthritis. Cochrane Database of Systematic Reviews 2010, CD001977. [154597].

Purpose	To assess the effects of acupuncture for treating peripheral joint osteoarthritis.
Methods	We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library 2008, Issue 1), MEDLINE, and EMBASE (both through December 2007), and scanned reference lists of articles. Randomized controlled trials (RCTs) comparing needle acupuncture with a sham, another active treatment, or a waiting list control group in people with osteoarthritis of the knee, hip, or hand.
Results	Sixteen trials involving 3498 people were included. Twelve of the RCTs included only people with OA of the knee, 3 only OA of the hip, and 1 a mix of people with OA of the hip and/or knee. In comparison with a sham control, acupuncture showed statistically significant, short-term improvements in osteoarthritis pain (standardized mean difference -0.28, 95% confidence interval -0.45 to -0.11; 0.9 point greater improvement than sham on 20 point scale; absolute percent change 4.59%; relative percent change 10.32%; 9 trials; 1835 participants) and function (-0.28, -0.46 to -0.09; 2.7 point greater improvement on 68 point scale; absolute percent change 3.97%; relative percent change 8.63%); however, these pooled short-term benefits did not meet our predefined thresholds for clinical relevance (i.e. 1.3 points for pain; 3.57 points for function) and there was substantial statistical heterogeneity. In comparison with sham acupuncture at the six-month followup, acupuncture showed borderline statistically significant, clinically irrelevant improvements in osteoarthritis pain (-0.10,-0.21 to 0.01; 0.4 point greater improvement than sham on 20 point scale; absolute percent change 1.81%; relative percent change 4.06%;4 trials;1399 participants) and function (-0.11, -0.22 to 0.00; 1.2 point greater improvement than sham on 68 point scale; absolute percent change 1.79%; relative percent change 3.89%). In a secondary analysis versus a waiting list control, acupuncture was associated with statistically significant, clinically relevant short-term improvements in osteoarthritis pain (-0.96, -1.19 to -0.72; 14.5 point greater improvement than sham on 100 point scale; absolute percent change 14.5%; relative percent change 29.14%; 4 trials; 884 participants) and function (-0.89, -1.18 to -0.60; 13.0 point greater improvement than sham on 100 point scale; absolute percent change 13.0%;relative percent change 25.21%).
Conclusion	Sham-controlled trials show statistically significant benefits; however, these benefits are small, do not meet our pre-defined thresholds for clinical relevance, and are probably due at least partially to placebo effects from incomplete blinding. Waiting list-controlled trials of acupuncture for peripheral joint osteoarthritis suggest statistically significant and clinically relevant benefits, much of which may be due to expectation or placebo effects.

1.1.20. Chai 2009 ★

Chai Hua, Li Bo, Du Yuan-Hao. [Meta-analysis for acupuncture and moxibustion treatment of knee osteoarthritis]. Liaoning Journal of Traditional Chinese Medicine. 2009;7:1197-120. [187039].

Objective	To assess the therapeutic effect of acupuncture on knee osteoarthritis.
Methods	A Meta-analysis of all relevant randomized controlled trials (RCT)about acupuncture and moxibustion treatment of knee osteoarthritis was carried out. The data were statistically analyzed with a special software RevMan 4. 2. 8.
Results	Six papers of RCT including 500 patients met the enrolled criteria. Meta-analysis indicated that relative risk was 2. 26, 95% confidence interval (1. 71, 2. 99), P<0. 00001; weighted mean difference was 9. 83, 95% confidence interval (6. 21, 13. 45), P<0. 00001, as acupuncture group compared with drug group.
Conclusion	The therapeutic effect of acupuncture and moxibustion on knee osteoarthritis is superior to that of drug group with safety and less adverse reactions. However, because of lower methodological quality of the trials, this conclusion needs further be confirmed.

1.1.21. Selfe 2008 ★★

Selfe Tk, Taylor Ag. Acupuncture and osteoarthritis of the knee: a review of randomized, controlled trials. Fam Community Health. 2008;31(3):247-54.149266.

Osteoarthritis of the knee is a major cause of disability among adults. Treatment is focused on symptom management, with nonpharmacologic therapies being the preferred first line of treatment. Acupuncture is considered a potentially useful treatment for osteoarthritis. The objective of this article is to review the English-language articles, indexed in MEDLINE or CINAHL, describing randomized, controlled trials of the effects of needle or electroacupuncture on knee osteoarthritis. Ten trials representing 1456 participants met the inclusion criteria and were analyzed. These studies provide evidence that acupuncture is an effective treatment for pain and physical dysfunction associated with osteoarthritis of the knee.

1.1.22. Manheimer 2007 ★

Manheimer E, Linde K, Lao L, Bouter Lm, Berman Bm. Meta-Analysis: acupuncture for osteoarthritis of the knee. Ann Intern Med. 2007;146(12):868-77.[146350].

Purpose	To evaluate the effects of acupuncture for treating knee osteoarthritis.
Methods	Data Sources: Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE databases to January 2007. No language restrictions were applied. Study Selection: randomized trials longer than 6 weeks in duration that compared needle acupuncture with a sham, usual care, or waiting list control group for patients with knee osteoarthritis. Data Extraction: two authors independently agreed on eligibility, assessed methodological quality and acupuncture adequacy, and extracted outcome data on pain and function measures.
Results	Eleven trials met the selection criteria, and 9 reported sufficient data for pooling. Standardized mean différences were calculated by using differences in improvements from Baseline between patients assigned to acupuncture and those assigned to control groups. Compared with patients in waiting list control groups, patients who received acupuncture reported clinically relevant short-term improvements in pain (standardized mean difference —0.96 [95% CI, —1.21 to —0.701) and function (standardized mean difference, —0.93 [CI, —1.16 to —0.69]). Patients who received acupuncture also reported clinically relevant short- and long-term improvements in pain and function compared with patients in usual care control groups. Compared with a sham control, acupuncture provided clinically irrelevant short-term improvements in pain (standardized mean difference, —0.35 [CI, —0.55 to -0.151) and function (standardized mean difference, —0.35 [CI,—Q.56 to —0.14]) and clinically irrelevant long-term improvements in pain (standardized mean difference, —0.13 [CI, —0.24 to —0.01]) and function (standardized mean difference, —0.14 [CI, —0.26 to —0.03]). Limitation: sham-controlled trials had heterogeneous results that were probably due to the variability of acupuncture and sham protocols, patient samples, and settings.
Conclusion	Sham-controlled trials show clinically irrelevant short term benefits of acupuncture for treating knee osteoarthritis. Waiting list controlled trials suggest clinically relevant benefits, some of which may be due to placebo or expectation effects.

1.1.23. White 2007 ★★★

White A, Forster NE, Cummings M, Barlas P. Acupuncture treatment for chronic knee pain: a systematic review. Rheumatology. 2007;46(3):384-90. [143258].

Purpose	To evaluate the effects of acupuncture on pain and function in patients with chronic knee pain.
Methods	Systematic review and meta-analysis of randomized controlled trials of adequate acupuncture. Computerized databases and reference lists of articles were searched in June 2006. Studies were selected in which adults with chronic knee pain or osteoarthritis of the knee were randomized to receive either acupuncture treatment or a control consisting of sham (placebo) acupuncture, other sham treatments, no additional intervention (usual care), or an active intervention. The main outcome measures were short-term pain and function,and study validity was assessed using a modification of a previously published instrument.
Results	Thirteen RCT were included, of which eight used adequate acupuncture and provided WOMAC outcomes, so were combined in meta-analyses. Six of these had validity scores of more than 50%. Combining five studies in 1334 patients, acupuncture was superior to sham acupuncture for both pain (weighted mean difference in WOMAC pain subscale score =2.0, 95% CI 0.57-3.40) and for WOMAC function subscale (4.32, 0.60-8.05). The differences were still significant at long-term follow-up. Acupuncture was also significantly superior to no additional intervention. There were insufficient studies to compare acupuncture with other sham or active interventions.
Conclusion	Acupuncture that meets criteria for adequate treatment is significantly superior to sham acupuncture and to no additional intervention in improving pain and function in patients with chronic knee pain.

1.1.24. Bjordal 2007 ★★

Bjordal JM, Johnson MI, Lopes-Martins RA, Bogen B,Chow R, Ljunggren AF. Short-term efficacy of physical intervention in osteoarthritis knee pain. A systematic review and meta-analysis of randomised placebo-controlled trials. BMC Musculoskelet Disord. 2007;8(1):51.[146448].

Purpose	Treatment efficacy of physical agents in osteoarthritis of the knee (OAK) pain has been largely unknown, and this systematic review was aimed at assessing their short-term efficacies for pain relief.
Methods	Systematic review with meta-analysis of efficacy within 1-4 weeks and at follow up at 1-12 weeks after the end of treament.
Results	36 randomised placebo-controlled trials (RCTs) were identified with 2434 patients where 1391 patients received active treatment. 33 trials satisfied three or more out of five methodological criteria (Jadad scale). The patient sample had a mean age of 65.1 years and mean baseline pain of 62.9 mm on a 100 mm visual analogue scale (VAS). Within 4 weeks of the commencement of treatment manual acupuncture, static magnets and ultrasound thérapies did not offer statistically significant short-term pain relief over placebo. Pulsed electromagnetic fields offered a small reduction in pain of 6.9 mm [95% CI: 2.2 to 11.6](n=487). Transcutaneous electrical nerve stimulation (TENS, including interferential currents), electro-acupuncture (EA) and low level laser therapy (LLLT) offered clinically relevant pain relieving effects of 18.8 mm [95% CI: 9.6 to 28.1] (n=414), 21.9 mm [95% CI:17.3 to 26.5] (n=73) and 17.7 mm[95% CI: 8.1 to 27.3] (n=343) on VAS respectively versus placebo control. In a subgroup analysis of trials with assumed optimal doses, short-term efficacy increased to 22.2 mm [95% CI: 18.1 to 26.3] for TENS, and 24.2 mm [95% CI: 17.3 to 31.3] for LLLT on VAS. Follow-up data up to 12 weeks were sparse, but positive effects seemed to persist for at least 4 weeks after the course of LLLT, EA and TENS treatment was stopped.
Conclusion	TENS, EA and LLLT administered with optimal doses in an intensive 2-4 week treatment regimen, seem to offer clinically relevant short-term pain relief for OAK.

1.1.25. Kwon 2006 ★★★

Kwon YD, Pittler MH, Ernst E. Acupuncture for peropheral joint osteoarthritis : a systematic review and meta-analysis. Rheumatology (Oxford).2006;45(11):1331-7. [141385].

Purpose	To evaluate the evidence for the effectiveness of acupuncture in 1 eripheral joint osteoarthritis (OA).
Methods	Systematic searches were conducted on Medline, Embase, AMED, Cochrane Library, CINAHL, British Nursing Index, PsychiNFO and CAMPAIN until July 2005. Hand-searches included conference proceedings and our own files. There were no restrictions regarding the language of publication. All randomized controlled trials (RCTs) of acupuncture for patients with peripheral joint OA were considered for inclusion. Trials assessing needle acupuncture with or without electrical stimulation were considered if sham- or placebo-controlled or controlled against a comparator intervention. Trials testing other forms of acupuncture were excluded. Methodological quality was assessed and, where possible, meta-analyses were performed.
Results	Thirty-one possibly relevant studies were identified and 18 RCTs were included (14 RCTs in knee OA, 1735 patients). Ten trials tested manual acupuncture and eight trials tested electro-acupuncture. Overall, ten studies demonstrated greater pain reduction in acupuncture groups compared with controls. The meta-analysis of homogeneous data showed a significant effect of manual acupuncture compared with sham acupuncture (standardized mean difference 0.24, 95% confidence interval 0.01-0.47, P = 0.04, n=329), which is supported by data for knee OA. The extent of heterogeneity in trials of electro-acupuncture prevented a meaningful meta-analysis.
Conclusion	Sham-controlled RCTs suggest specific effects of acupuncture for pain control in patients with peripheral joint OA. Considering its favourable safety profile acupuncture seems an option worthy of consideration particularly for knee OA.

1.1.26. Markow 2003 ★★

Markow Mj, Secor Er. ACupuncture for the pain management of osteoarthritis of the knee. Techniques in Orthopaedics. 2003;18:33-36.[140970].

Objective	The objective of this study is to review research on acupuncture in the treatment of osteoarthritis of the knee, to document adverse effects, and to identify patient parameters associated with outcomes.
Methods	A literature search was completed using Alt Med., CINAHL, MEDLINE, and the Cochrane database, since 1977, using the key words acupuncture, knee, osteoarthritis, and pain. Studies were excluded that involved electrical stimulation of acupuncture needles, injection therapies, and other knee pathologies including patellar femoral pain, rheumatoid arthritis, and gonarthritic pain.
Results	Five trials representing 205 patients with osteoarthritis of the knee were identified. There are rare but mild side effects from acupuncture that include bruising and nausea. The evidence suggests that acupuncture reduces pain in osteoarthritis of the knee. The best results for reducing pain in osteoarthritis of the knee with acupuncture treatments occurs in patients who report the highest pain levels. Preliminary results suggest that long-term continuous treatment with acupuncture sustains the effectiveness in pain reduction. Also, there is sustained pain reduction 4 months after an initial 6-week treatment regimen was discontinued

1.1.27. Ferrández Infante 2002 ∅

Ferrández Infante A, García Olmos L, González Gamarra A, Meis Meis MJ, Sánchez Rodríguez BM. Effectiveness of acupuncture in the treatment of pain from osteoarthritis of the knee. Aten Primaria. 2002;30(10):602-610.[181780].

Purpose	To determine the effectiveness of acupuncture in controlling pain from arthritis of the knee.
Methods	Data sources. MedLine, the Cochrane Library. Study selection. Of the 9 studies located, only 4 met the inclusion criteria. All were controlled, randomized clinical trials that studied the effect of acupuncture only in the knee joint. Data extraction. Primary outcome variables were intensity of pain, overall measure (general improvement, proportion of patients who recovered, subjective improvement in symptoms) and functional status. As secondary outcome measures we used objective physiological measures (range of knee movement, muscle strength, time needed to walk a certain distance, time needed to climb a certain number of stairs), general health status, and other information such as medication needed and side effects.
Results	There was moderately strong evidence that acupuncture was more effective in treating knee joint pain than no treatment. The difference can be explained by its marked placebo effect.
Conclusion	There is currently insufficient evidence to recommend acupuncture as a treatment for pain from osteoarthritis of the knee.

1.1.28. Ezzo 2001 ★★

Ezzo J et al. Acupuncture for osteoarthritis of the knee: a systematic review. Arthritis & Rheumatism. 2001;44(4):819-25.[94842].

Purpose	To evaluate trials of acupuncture for osteoarthritis (OA) of the knee, to assess the methodologic quality of the trials and determine whether low-quality trials are associated with positive outcomes, to document adverse effects, to identify patient or treatment characteristics associated with positive response,and to identify areas of future research.
Methods	Eight databases and 62 conference abstract series were searched. Randomized or quasirandomized trials of all languages were included and evaluated for methodologic quality using the Jadad scale. Outcomes were pain, function, global improvement, and imaging. Data could not be pooled; therefore, a best-evidence synthesis was performed to determine the strength of evidence by control group. The adequacy of the acupuncture procedure was assessed by 2 acupuncturists trained in treating OA and blinded to study results inconclusive evidence that real acupuncture is more effective than sham acupuncture. There was insufficient evidence to determine whether the efficacy of acupuncture is similar to that of other treatments.
Results	Seven trials representing 393 patients with knee OA were identified. For pain and function, there was limited evidence that acupuncture is more effective than being on a waiting list for treatment or having treatment as usual. For pain, there was strong evidence that real acupuncture is more effective than sham acupuncture; however, for function, there was.
Conclusion	The existing evidence suggests that acupuncture may play a role in the treatment of !wee OA.

1.2. Special Acupuncture Techniques

1.2.1. Comparison of acupuncture techniques

1.2.1.1. Lee 2023 (acupotomy vs acupuncture)

Lee CJ, Luo WT, Tam KW, Huang TW. Comparison of the effects of acupotomy and acupuncture on knee osteoarthritis: A systematic review and meta-analysis. Complement Ther Clin Pract. 2023 Feb;50:101712. https://doi.org/10.1016/j.ctcp.2022.101712|

Background and purpose	Acupotomy and acupuncture are both treatments for knee osteoarthritis symptoms. However, acupotomy also has the additional anatomical effect of dissecting inflamed tissue. The problem this study aims to address is whether acupotomy is a better treatment than acupuncture in treating knee osteoarthritis.
Methods	We searched the PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure, Airiti Library, and Wanfang Data databases from inception to March 2022 for randomized controlled clinical trials (RCTs) comparing the effects of acupotomy and acupuncture in patients with knee osteoarthritis.
Results	In total, we identified 43 RCTs in this meta-analysis. Compared to the acupuncture group, acupotomy had a higher cure rate (odds ratio (OR) 2.94, 95% confidence interval (CI) 2.36 to 3.65), indicating a better improvement in daily activity function. Acupotomy was also more effective in pain relief and knee score improvement. However, some RCTs indicated that adverse events in the acupotomy group were greater than in the acupuncture group (OR 1.23, 95% CI 0.42 to 3.60).
Conclusion	Our findings indicated that acupotomy was a more effective treatment for knee osteoarthritis than acupuncture. However, most of the included RCTs had moderate risk of bias, meaning that more high-quality RCTs were needed.

1.2.1.2. Ma 2023 (Network meta-analysis)

Ma W, Zhang CY, Huang X, Cheng W. Network meta-analysis of 7 acupuncture therapies for knee osteoarthritis. Medicine (Baltimore). 2023 Oct 27;102(43):e35670. https://doi.org/10.1097/MD.0000000000035670.

Objective	With the progression of society aging demographic, the prevalence of knee osteoarthritis (KOA) continues to rise steadily, exerting a significant impact on individuals' quality of life. Acupuncture therapy has garnered extensive utilization in the management of osteoarthritis; however, a comprehensive systematic review integrating acupuncture with traditional Chinese medicine remains absent. This study compared the clinical efficacy of 7 acupuncture methods (electroacupuncture, conventional acupuncture, warm needle, floating needle, fire needle , needle knife, and silver needle) for the treatment of KOA through a network meta-analysis.
Methods	This study examined the databases-PubMed, EMbase, The Cochrane Library, the China Biology Medicine, Chinese Journal Full-text Database, Wanfang Database, and VIP Database-for randomized controlled trials of the 7 methods for KOA treatment. The search time spanned from the database establishment to March 5, 2022. The primary outcome indicator was the total effective rate, and the secondary outcome indicator was the visual analog scale. After the layer-by-layer screening, the quality of the literature was assessed using the Cochrane systematic reviewer manual 5.1.0 bias risk assessment tool for randomized controlled trials. After data extraction, the R4.0.1 software was used for network meta-analysis.
Results	Based on the network meta-analysis, the ranking of interventions based on the surface under the cumulative ranking curve for the total effective rate is as follows: silver needle (0.99) > floating needle (0.97) > needle knife (0.66) > fire needle (0.56) > warm needle (0.44) > conventional acupuncture (0.35) > electroacupuncture (0.13). Regarding the improvement in visual analog scale scores, the surface under the cumulative ranking curve ranking is as follows: silver needle (0.97) > conventional acupuncture (0.67) > needle knife (0.64) > floating needle (0.51) > warm needle (0.44) > fire needle (0.14) > electroacupuncture (0.09).
Conclusion	Based on the network meta-analysis, silver needle therapy emerged as the most efficacious and analgesic intervention for KOA. Nevertheless, given the notable variations in the quality and quantity of studies encompassing diverse treatment modalities, the findings of this research necessitate further substantiation through forthcoming high-quality multicenter, large-sample, randomized double-blind trials.

1.2.1.3. Wang 2023

Wang Z, Xu H, Wang Z, Zhou H, Diao J, Zhang L, Wang Y, Li M, Zhou Y. Effects of externally-applied, non-pharmacological Interventions on short- and long-term symptoms and inflammatory cytokine levels in patients with knee osteoarthritis: a systematic review and network meta-analysis. Front Immunol. 2023 Dec 14;14:1309751. https://doi.org/10.3389/fimmu.2023.1309751

Backgound	With the continuous development of clinical medicine, an increasing number of non-pharmacological interventions have been applied for the treatment of knee osteoarthritis (KOA), with the results of several recent randomized controlled trials (RCTs) showing that a variety of externally-applied, non-pharmacological interventions (EANPI) can improve symptoms and inflammation in patients with KOA. However, the relative benefits and disadvantages of non-drug therapies remain uncertain, and an optimal treatment strategy has not yet been determined.
Objective	This study applied network meta-analysis (NMA) to compare and rank the effectiveness of EANPI on the short- and long-term clinical symptoms and inflammatory cytokine levels in patients with KOA.
Methods	Two independent researchers searched online databases and performed manual retrieval of related citations to identify RCTs that met the selection criteria for the network meta-analysis. These researchers retrieved studies indexed from database inception to August 2023 and performed data extraction and assessment of the risk of bias.
Results	The analysis included 80 RCTs involving 8440 participants and nine externally-applied, non-pharmacological therapies, namely extracorporeal shock wave, radiofrequency, acupotomy, laser therapy, Tuina therapy, kinesio taping, electroacupuncture, platelet-rich plasma injection, and ozone therapy. The treatment courses ranged from 1 to 12 weeks, with follow-up periods ranging from 4 to 24 weeks. The results of the NMA indicated that each non-drug therapy was superior to sham intervention in improving all outcome indicators. Except for the visual analog scale (VAS) and Western Ontario MacMaster (WOMAC) pain outcomes, all non-drug therapies had better efficacy than pharmacological treatments. For short-term VAS and tumor necrosis factor-alpha (TNF-α), extracorporeal shock wave performed better than other therapies (90.2% and 85.2% respectively). Radiofrequency therapy may be the most promising method to reduce long-term VAS, short- and long-term WOMAC pain, and interleukin (IL)-1β level (84.8%, 97.8%, 90.1%, 94.8% respectively). Tuina therapy may be a significant choice for short- and long-term outcomes of WOMAC function and range of motion (ROM).
Conclusions	The results of the comprehensive comparison of the outcome indicators in 9 different EANPI indicated that radiofrequency and Tuina therapy were more effective and consistently ranked high in improving clinical symptoms in the short and long term. Radiofrequency is effective at relieving pain, and Tuina therapy can be given priority for treatment when hypofunction is the main symptom. EANPI to improve pain symptoms may be related to the regulation of inflammatory cytokine levels, which may be a potential mechanism of action.

1.2.1.4. Ye 2022 RETRACTED

Retracted: The Effectiveness Comparison of Different Acupuncture-Related Therapies on Knee Osteoarthritis: A Meta-Analysis. Evid Based Complement Alternat Med. 2023 Jul 19;2023:9892726. https://doi.org/10.1155/2023/9892726
Ye C, Zhou J, Wang M, Xiao S, Lv A, Wang D. The Effectiveness Comparison of Different Acupuncture-Related Therapies on Knee Osteoarthritis: A Meta-Analysis. Evid Based Complement Alternat Med. 2022 Jun 30;2022:2831332. https://doi.org/10.1155/2022/2831332

Objective	This meta-analysis aims to assess the efficacy of acupuncture-related therapy on knee osteoarthritis (KOA) patients.
Method	We searched PubMed, Embase, and CNKI databases to screen eligible trials between 2017 and 2022. All trials that used acupuncture/moxibustion of KOA patients were included. Study selection and data extraction were performed by 2 researchers independently. The statistics was performed by using R 4.1.1.
Results	A total of 17 trials were included in our meta-analysis. Meta-analysis results showed the evidence of the relation of several common acupunture/moxibustion treatments by network meta-analysis. In the fixed effect model, acupuncture/moxibustion has superior therapy efficacy than sham treatment (mean difference = -0.34, 95% confidence interval = (-0.52,-0.16), P=0.95). In fixed effect model, specific acupuncture/moxibustion has superior therapy efficacy than usual acupuncture/moxibustion (mean difference = -0.45, 95% confidence interval = (-0.62, -0.29), P < 0.01).
Conclusion	Acupuncture/moxibustion has superior therapy efficacy than sham treatment. Specific acupuncture/moxibustion has superior therapy efficacy than usual acupuncture/moxibustion.

1.2.1.5. Liu 2021 (Network Meta-Analysis)

Liu W, Fan Y, Wu Y, Hou X, Xue B, Li P, Zhang S, Yue Q. Efficacy of Acupuncture-Related Therapy in the Treatment of Knee Osteoarthritis: A Network Meta-Analysis of Randomized Controlled Trials. J Pain Res. 2021:2209-2228. [220530]. https://doi.org/10.2147/jpr.s315956

Objective	Knee osteoarthritis (KOA) is prevalent in middle-aged and elderly people. This condition negatively affects the quality of life of patients. Although non-steroidal anti-inflammatory drugs (NSAIDs) are often used to relieve symptoms associated with KOA, it is associated with many side effects. Acupuncture and moxibustion therapies have been applied in the treatment of KOA. However, the efficacy of various acupuncture and moxibustion treatments has not been compared.
Methods	Randomized controlled trials (RCTs) on the application of acupuncture and moxibustion in the treatment of KOA were searched in English databases and Chinese databases. Data were retrieved from establishment of the database to September 2020. Data analysis was performed using Stata14.0 and GeMTC 0.14.3 softwares.
Results	A total of 40 RCTs involving 3215 patients with KOA were retrieved. Network meta-analysis revealed that the fire needle was superior to western medicine, electro-acupuncture, conventional acupuncture, warm needle and sham acupuncture; warm needle was better than conventional acupuncture and western medicine whereas electro-acupuncture was better than conventional acupuncture in improving pain scores in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Moreover, we found that fire needle and warm needle more effectively improved WOMAC stiffness scores than western medicine and sham moxibustion, whereas electro-acupuncture was superior to western medicine and sham moxibustion in improving WOMAC stiffness scores. Further analysis revealed that fire needle , warm needle and electro-acupuncture were more effective in improving WOMAC joint function scores than conventional acupuncture and western medicine. The fire needle was superior to conventional acupuncture and sham acupuncture, whereas electro-acupuncture was better than western medicine, conventional acupuncture and sham acupuncture in improving visual analogue scale scores.
Conclusion	This study shows that fire needle is superior to warm needle and electro-acupuncture, whereas warm needle and electro-acupuncture are better than conventional acupuncture, western medicine, sham moxibustion and sham acupuncture.

1.2.1.6. Li 2018 (Network Meta-Analysis)

Li S, Xie P, Liang Z, Huang W, Huang Z, Ou J, Lin Z, Chai S. Efficacy Comparison of Five Different Acupuncture Methods on Pain, Stiffness, and Function in Osteoarthritis of the Knee: A Network Meta-Analysis. Evid Based Complement Alternat Med. 2018. https://www.hindawi.com/journals/ecam/2018/1638904/ [189184].

Objective	The principal objective of this present study was to compare the effects of different acupuncture methods on pain, stiffness, and physical function for osteoarthritis of the knee by the pairwise and network meta-analysis (NMA).
Methods	A network meta-analysis of randomized controlled trials (RCTs) was searched from three English databases and one Chinese database until January 2018. A pairwise meta-analysis was performed with a random effects model. Then we carried out the NMA within a Bayesian framework. Mean difference (MD) and its 95% confidence interval (CI) were calculated by R 3.4.1, Stata 14.0, and RevMan 5.3 software to assess the relief of pain, the effectiveness for stiffness, and physical function recovery. Node-splitting method was used to calculate the inconsistency. Rank probabilities were assessed and clustered by the surface under the cumulative ranking curve (SUCRA).
Results	16 trials mostly researched short-term effectiveness and showed that fire needle and electro-acupuncture were statistically significant to decrease WOMAC pain and physical function scores when compared with other treatments, but there was no significant difference in stiffness calculations.
Conclusions	Our NMA demonstrated that acupuncture with heat pain or electrical stimulation might be suggested as the better choices in all acupuncture methods to osteoarthritis of the knee.

1.2.1.7. Xin 2023 (acupuncture vs moxibustion)

Xin S, Liu J, Yang Z, Li C. Comparative effectiveness of moxibustion and acupuncture for the management of osteoarthritis knee: A systematic review and meta-analysis. Heliyon. 2023 Jul 4;9(7):e17805. https://doi.org/10.1016/j.heliyon.2023.e17805

Background	Moxibustion, a traditional Chinese medicine approach, stimulates blood circulation by burning wormwood at acupuncture points and is frequently used in conjunction with acupuncture for managing knee osteoarthritis. This review aims to compare the effectiveness of moxibustion and acupuncture in the management of knee osteoarthritis.
Methods	Our team conducted a comprehensive search across several databases: PubMed Central, EMBASE, MEDLINE, the Chinese Biomedical Literature Database (CBM), China National Knowledge Infrastructure (CNKI), and the Cochrane Library, covering the timeframe from January 1964 up until April 2022. We implemented a meta-analysis, utilizing a random-effects model, and we've presented the pooled standardized mean difference (SMD) and risk ratio (RR) inclusive of the 95% confidence intervals (CIs), in accordance with the nature of the outcome.
Results	21 studies were included, of which, half were identified as having high risk of bias. The pooled SMD for the pain score was found to be -0.53 (95% CI: -0.91 to -0.15). In-depth analysis focusing on the kind of moxibustion indicated that fire needle moxibustion was more effective in pain reduction (SMD = -0.56; 95% CI: -1.10 to -0.01) compared to alternative moxibustion methods (SMD = -0.47; 95% CI: -0.80 to -0.13). The pooled RR for the success rate in treatment was 1.39 (95% CI: 1.19 to 1.62). Subgroup analysis demonstrated that fire needle moxibustion reported a superior success rate (RR = 1.43; 95% CI: 1.19 to 1.72) in comparison to other types of moxibustion (RR = 1.33; 95% CI: 1.02 to 1.74).
Conclusion	Moxibustion, specifically fire needle moxibustion, demonstrated superior effectiveness in managing knee osteoarthritis compared to acupuncture.

1.2.2. Combined with Chinese herbal medicine

1.2.2.1. Yang 2021

Yang F, Chen Y, Lu Z, Xie W, Yan S, Yang J, Li Y. Treatment of knee osteoarthritis with acupuncture combined with Chinese herbal medicine: a systematic review and meta-analysis. Ann Palliat Med. 2021 Nov;10(11):11430-11444. https://doi.org/10.21037/apm-21-2565

Background	Many studies have demonstrated that acupuncture combined with Chinese herbal medicine (CHM) effectively treats knee osteoarthritis (KOA), with few side effects. However, few systematic reviews have offered evidence-based support. Here we conducted a meta-analysis on the combination of acupuncture with CHM in treating KOA.
Methods	Databases including CNKI, Wanfang, VIP, PubMed, EMBASE, and Cochrane library were systematically searched for articles on the treatment of KOA by acupuncture combined with CHM from the establishment of the database to May 2021. Three researchers independently searched, screened, extracted, and included articles that met the inclusion standards. The primary outcome measure was overall response rate (ORR), and the secondary outcome measures included Visual Analogue Scale (VAS) score, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, and Lysholm score. ORR was a binary variable, while other indicators were continuous variables. The quality of literature was assessed with a modified Jadad scale. The RevMan 5.3 software provided by the Cochrane Collaboration was used for statistical analysis.
Results	Thirty-three randomized controlled trials involving 3,954 patients were included. Meta-analysis showed that ORR [odds ratio (OR) =5.41; 95% confidence interval (CI): (4.38, 6.68); P<0.00001], VAS score [mean difference (MD) =-1.86; 95% CI: (-2.44, -1.29); P<0.00001], WOMAC score [MD =-13.05; 95% CI: (-21.70, -4.41); P=0.003], and Lysholm score [MD =10.47; 95% CI: (5.21, 15.72); P<0.0001] in the combination group were significantly superior to those in the control group.
Discussion	Compared with acupuncture alone or CHM/Western drug alone, acupuncture combined with CHM can effectively alleviate knee pain, improve knee function, and increase the quality of life. Thus, this combination can be used as a conservative treatment for KOA. However, due to the small number of high-quality articles and possible biases in our analysis, our conclusions need to be further verified in more and higher-quality studies.

1.2.3. Combined with massage

1.2.3.1. Wang 2022

Wang Z, Wang Y, Wang C, Li X, Zhou Z, Zhang L, Li M, Pan Y, Jiao T, Shi X, Liu Q. Systematic Review and Network Meta-analysis of Acupuncture Combined with Massage in Treating Knee Osteoarthritis. Biomed Res Int. 2022 Aug 13;2022:4048550. https://doi.org/10.1155/2022/4048550

Background	Knee osteoarthritis is a common clinical disease with frequent occurrence. More and more studies have shown that external therapies such as acupuncture and massage are beneficial to the treatment of knee osteoarthritis.
Objective	The purpose of this systematic review and meta-analysis of randomized controlled trials (RCTS) was to evaluate the efficacy and safety of acupuncture and massage combined with treatment of KOA and to provide some reference for clinical treatment of KOA.
Methods	Network meta-analysis was used to evaluate the efficacy of acupuncture combined with massage in the treatment of knee osteoarthritis. PubMed, Cochrane Library, Web of Science, Embase, Chinese Knowledge Infrastructure (CNKI), Chinese Biomedical Literature Database (CBM), VIP, and Wanfang were searched by computer for randomized controlled trials on acupuncture combined with massage in the treatment of knee osteoarthritis. All researchers independently screened the literature, extracted data, and evaluated quality, and studies that met the quality criteria were analyzed using Stata16.0 software.
Results	A total of 3076 articles were retrieved, and finally, 49 studies involving 10 acupuncture combined with massage methods were included. The total sample size was 4458, including 2182 in the experimental group and 2276 in the control group. The results of network meta-analysis showed the following: in terms of effective rate, the optimal first three interventions were floating needle+massage, needle knife+massage, and silver needle+massage; in terms of reducing VAS score, the optimal first three interventions were common acupuncture+massage, needle knife+massage, and warm needle+massage; in terms of improving total Lysholm index score, the optimal first three interventions were silver needle+massage, electroacupuncture+massage, and needle knife+massage; in terms of reducing total WOMAC score, the optimal first three interventions were silver needle+massage, electrothermal needle+massage, and common acupuncture+massage; in terms of reducing WOMAC stiffness score, the optimal first three interventions were warm needle+massage, silver needle+massage, and common acupuncture+massage; and in terms of reducing WOMAC joint function score, the optimal first three interventions were silver needle+massage, warm needle+massage, and common acupuncture+massage.
Conclusion	The results showed that acupuncture combined with massage could improve the clinical therapeutic effect of patients with knee osteoarthritis. Limited by the quality of the included studies, the conclusions obtained still need to be further validated.

1.2.4. Combined with intra-articular injection of sodium hyaluronate

1.2.4.1. Zheng 2020

Zheng Y, Duan X, Qi S, Hu H, Wang M, Ren C, Xu H, Quan R. Acupuncture Therapy plus Hyaluronic Acid Injection for Knee Osteoarthritis: A Meta-Analysis of Randomized Controlled Trials. Evid Based Complement Alternat Med. 2020. [204788]. DOI

Objective	This meta-analysis aimed to investigate the effectiveness of acupuncture therapy plus hyaluronic acid injection versus hyaluronic acid injection alone for patients with knee osteoarthritis.
Methods	Relevant randomized controlled trials that compared the combined effect of acupuncture therapy and hyaluronic acid injection with hyaluronic acid injection alone for knee osteoarthritis patients were included. 10 studies were included in this meta-analysis, and the relative risk (RR) and weight mean difference (MD) with 95% CI for the Lysholm knee score (LKSS), visual analogue scale (VAS), and effective rate (ER) were evaluated by using RevMan 5.3 software. Besides, the bias assessment of the included studies was evaluated using the Cochrane risk of bias tool, and the GRADE (Grading of Recommendations, Assessment Development, and Evaluation) system was applied to assess the overall quality of the evidence.
Results	A total of 10 studies involving 998 participants were included in this study. Compared to hyaluronic acid injection alone, the combined therapy significantly reduced pain on the visual analogue scale (VAS) and improved the ER and knee function on the Lysholm knee score (LKSS). Of these, the pooled LKSS (MD = 8.09, 95% CI = [7.02, 9.16], p < 0.00001, 7 studies) and ER (RR = 1.23, 95% CI 1.15 to 1.31, p < 0.00001, 7 studies) and ER (RR = 1.23, 95% CI 1.15 to 1.31, p < 0.00001, 7 studies) and ER (RR = 1.23, 95% CI 1.15 to 1.31.
Conclusion	Current evidence suggests that acupuncture therapy combined with hyaluronic acid injection is more effective in alleviating pain, improving the ER and knee function compared with hyaluronic acid injection alone. However, considering the low quality, small size, and high risk of the studies identified in this meta-analysis, more higher methodological quality, rigorously designed randomized controlled trials with large sample sizes are needed to confirm the results.

1.2.4.2. Cao 2019

Cao Jia, Zhou Qi, Qian Qirong. [Clinical curative effect of combination therapy of acupuncture and intra-articular injection of sodium hyaluronate versus monotherapy of intra-articular injection of sodium hyaluronate for treatment of knee osteoarthritis: a systematic review]. The Journal of Traditional Chinese Orthopedics and Traumatology Year. 2019;Issue 3:33-37. [201718].

目的:系统评价针灸联合玻璃酸钠关节腔注射与单纯玻璃酸钠关节腔注射治疗膝骨关节炎的临床疗效.方法:通过计算机检索中国知网、万方医学网、重庆维普、美国医学文摘和Cochrane临床对照试验中心注册库(2018年第1期)等数据库从建库至2018年3月15日,关于针灸联合玻璃酸钠关节腔注射与单纯玻璃酸钠关节腔注射治疗膝骨关节炎临床疗效比较的文献,进行Meta分析.结果:初检共检出相关文献231篇,依据文献纳入和排除标准筛选后,最终纳入9篇文献进行分析,均为中文文献.纳入的9篇文献均为单中心随机对照临床试验;8篇文献描述了随机分组方法,1篇文献仅描述随机分组,未提及随机分组方法;1篇文献描述了在分组时采用了单盲的方法,均未提及患者盲法;9篇文献均未提及结果评估者盲法;9篇文献均有明确的诊断标准及疗效评价标准.9篇文献均计算了两种疗法的近期临床治疗有效率,并进行了比较,各项研究间异质性较小(I2=0％),采用固定效应模型分析,针灸联合玻璃酸钠关节腔注射治疗膝骨关节炎近期临床治疗有效率高于单纯玻璃酸钠关节腔注射[RR=1.16,95％ CI(1.10,1.22)].9篇文献的发表偏倚较小.结论:针灸联合玻璃酸钠关节腔注射治疗膝骨关节炎的近期临床疗效优于单纯玻璃酸钠关节腔注射.

[Automatic translation].
Objective	To systematically evaluate the clinical efficacy of acupuncture combined with intra-articular injection of sodium hyaluronate and intra-articular injection of sodium hyaluronate in the treatment of knee osteoarthritis.
Methods	Computer search for Chinese Knowledge Network, Wanfang Medical Network, Chongqing Weipu, American Medical Abstracts and Cochrane Clinical Controlled Trial Center Registry (No. 1 in 2018) and other databases from the establishment of the database to March 15, 2018, on the clinical application of acupuncture combined with intra-sodium hyaluronate injection and intra-articular injection of sodium hyaluronate in the treatment of knee osteoarthritis The literature comparing the efficacy was analyzed by Meta.
Results	A total of 231 related literatures were detected in the initial examination. After screening according to the literature inclusion and exclusion criteria, 9 literatures were finally included for analysis. All of them were Chinese literature. Single-center randomized controlled clinical trials; 8 papers describe random grouping methods, 1 document only describes random grouping, no random grouping method is mentioned; 1 document describes a single-blind method used in grouping, none of which is mentioned The patient blinded; 9 articles did not mention the blind method of the result evaluator; 9 articles have clear diagnostic criteria and efficacy evaluation criteria. Nine articles have calculated the recent approach of the two therapies. The treatment efficiency was compared and compared. The heterogeneity between the studies was small (I2=0%). The fixed effect model was used to analyze the clinical treatment of knee osteoarthritis with acupuncture combined with intra-sodium hyaluronate injection. In the intra-articular injection of Sodium Hyaluronate [RR=1.16, 95% CI(1.10,1.22)]. The publication bias of 9 articles was small.
Conclusion	The recent clinical practice of acupuncture combined with intravitreal injection of sodium hyaluronate for knee osteoarthritis. The curative effect is better than the simple intraocular injection of sodium hyaluronate.

1.2.4.3. Zhan 2018 ☆

Zhan Lingyan, Lin Zhuoyin, Yin Lunhui, Chen Zhen. [System Review and Meta-analysis on the Combination of Acupuncture with Medicine in the Treatment of Knee Osteoarthritis]. Guangming Journal of Chinese Medicine. 2018;20:3047-3050. [182153].

Objective	To assess the efficacy and safety of the combination of acupuncture with medicine in the treatment of knee osteoarthritis.
Methods	Database in both English and Chinese such as Pubmed, Embase, the Cochrane library, CNKI, VIP, CBM were searched for combination of acupuncture with medicine randomized controlled trials for the treatment of knee osteoarthritis. And the quality evaluation of the literature of into standard, extraction of available data was made using Rev Man 5. 3 Meta-analysis software.
Results	10 papers were included in the related study, a total of 1052 patients. Correlation analysis showed that combination of acupuncture with medicine treatment of knee osteoarthritis was efficient in difference is statistically significant. And after six months, 1 year and 2 years of following-up, the recurrence rate had statistical differences.
Conclusion	Combination of acupuncture with medicine in the treatment of knee osteoarthritis has high efficient, low recurrence rate and good security, while needs to be verify by high quality randomized controlled trials.

1.2.5. Combined with sodium vitrate injection

1.2.5.1. Jiang 2023

Jiang R, Zhang T, Zhen M. Traditional Chinese medicine external treatment combined with sodium vitrate injection for the treatment of knee osteoarthritis: A meta-analysis. Medicine (Baltimore). 2023 Dec 15;102(50):e36632. https://doi.org/10.1097/MD.0000000000036632

Background	Osteoarthritis of the knee is a clinically common degenerative joint disease that has a high prevalence and, if left untreated, can seriously affect a patient's quality of life. The objective of this article is to systematically evaluate the efficacy and safety of the combination of traditional Chinese medicine external treatment with sodium vitrate injection in the treatment of osteoarthritis of the knee.
Methods	By searching China National Knowledge Infrastructure (CNKI), China Science and Technology Journal Database (VIP), Wanfang Database (WF), Chinese Biomedical Literature Database (CBM), Embase, Pubmed, Cochrane Library. The search time was set from 2010 to March 2023. Revman 5.4 software was used for data analysis. The protocol was registered in the PROSPERO database (ref. CRD42023426707).
Results	A total of 3239 patients from 31 RCTs were finally included. Meta-analysis showed significant differences in the Total clinical Efficiency (mean difference (MD) = 4.62, 95% Confidence Interval (CI) = 3.52-6.08, P < .01), WOMAC score (MD = 6.57, 95% CI = 5.78-7.36, P < .01), VAS score (MD = 0.26, 95% CI = 0.14-0.37, P < .0001), Lysholm scores (MD = 5.21, 95% CI = 4.51-5.90, P < .0001), and Lequesne index (MD = 5.21, 95% CI = 4.51-5.90, P < .0001) between the Traditional Chinese Medicine External Treatment combined with sodium vitrate injection group and control group.
Conclusion	The efficacy of traditional Chinese external treatment combined with sodium vitrate injection for osteoarthritis of the knee was superior to that of sodium vitrate injection only in all cases. Due to the limitations of the quantity and quality of the included literature, more high-quality literature is needed to validate this conclusion at a later stage.

1.2.6. Combined with active exercise training

1.2.6.1. Chen 2023

Chen J, Guo H, Pan J, Li H, Wang Y, Liu Z, Xie Y, Jin S. Efficacy of acupuncture combined with active exercise training in improving pain and function of knee osteoarthritis individuals: a systematic review and meta-analysis. J Orthop Surg Res. 2023 Dec 2;18(1):921. https://doi.org/10.1186/s13018-023-04403-2

Objective	To conduct a systematic review and meta-analysis to investigate the clinical efficacy of acupuncture combined with active exercise training in improving pain and function of knee osteoarthritis (KOA) individuals.
Methods	Data sources. PubMed, EMBASE, The Cochrane Library, Web of Science, China National Knowledge Infrastructure, Wan Fang Data, Technology Periodical Database and China Biology Medicine were searched from their inceptions to April 5, 2023. Review methods: We analyzed trials of acupuncture combined with active exercise training for KOA. The included studies were of high quality (Jadad ≥ 4) and RCTs. Study selection, data extraction, risk of bias and quality assessment were independently performed by two reviewers. We performed systematic analyses based on different outcome measures, including total efficiency rate, visual analogue scale (VAS), the Western Ontario and Mcmaster Universities Osteoarthritis Index (WOMAC), the Lysholm Knee Scale (LKS) and range of motion (ROM). We used Review Manager 5.3 and Stata/MP 14.0 to analyze the data. And it was verified by trial sequence analysis (TSA). If I2 > 50% and p < 0.05, we performed sensitivity analysis and subgroup analysis to find the source of heterogeneity. Publication bias was studied by funnel plot and Egger’s test was used to verify it.
Results	Full 11 high-quality studies (Jadad ≥ 4) including 774 KOA individuals were included in this review for meta-analysis. The results showed that acupuncture combined with active exercise training (combined group) was superior to the acupuncture group in improving the total effective rate [RR = 1.13, 95%CI (1.05, 1.22), I2 = 0%, P = 0.70], reducing the pain level (VAS) [MD = − 0.74, 95%CI (− 1.04, − 0.43), I2 = 68%, P < 0.05], improving knee joint function (WOMAC) [MD = − 6.97, 95%CI (− 10.74, − 3.19), I2 = 76%, P < 0.05] and improving joint range of motion (ROM) [MD = 6.25, 95%CI (2.37, 10.04), I2 = 0%, P = 0.71]. Similarly, the combined group showed significant improvements in the total effective rate [RR = 1.31, 95% CI (1.18, 1.47), I2 = 48%, P = 0.10], pain (VAS) [MD = 1.42, 95% CI (− 1.85, − 1.00), I2 = 65%, P = 0.02] and knee function (WOMAC) [MD = 7.05, 95% CI (− 11.43, − 2.66), I2 = 86%, P < 0.05] compared with the non-acupuncture group.
Conclusion	The combined effect of all studies showed significant benefits of acupuncture combined with active exercise training in improving the total effective rate, reducing pain, promoting recovery of knee function and expanding range of motion. However, some evaluation indicators are highly subjective and need to be further confirmed by more objective and evidence-based high-quality RCTs in future.

1.2.7. Combined with manipulation

1.2.7.1. Wang 2015 ★

Wang Liwei, Xie Bing, Zhou Honghai, Liu Yuan. [Acupuncture combined with manipulation in treating knee osteoarthritis: a meta-analysis]. Journal of Emergency in Traditional Chinese Medicine. 2015;7:1153-115. [186995].

Objective	to systematically review the effectiveness of acupuncture combined with manipulation in the treatment of knee osteoarthritis (KOA).
Methods	Systematic searches were conducted in CNKI, VIP, WANFANG DATA, Pub Med and the Cochrane Liabrary to collect all the randomized controlled trails (RCTs) on acupuncture combined with manipulation in the treatment of KOA from inception to December 2014. Studies that met the inclusion criteria were selected and received the quality evaluation strictly. Then the meta-analysis was performed by using Rev Man5. 2.
Results	Five hundred and sixty-five literatures in total were retrieved. After selection, finally, 8 literatures including 710 patients met the inclusion criteria, which were all Chinese literatures. Then the meta-analysis for these 8 literatures showed that there was statistical difference (OR =4. 35, 95% CI [2. 53, 7. 49], P < 0. 01) between Acupuncture Combined with Manipulation and Simple Acupuncture in the treatment of KOA. The graphic was not inverted funnel-shaped which existed small part of sloping. Due to the low quality researches, it indicated that there existed some publication bias.
Conclusion	Acupuncture combined with manipulation in the treatment of knee osteoarthritis has good clinical curative effects on KOA and has certain advantages compared with the treatment of simple acupuncture and moxibustion. But restricted by the quality and quantity of the researches, these results need more evidence of clinical research with high quality to enrich.

1.2.8. Fu′s Subcutaneous Needling

1.2.8.1. Chen 2020

Chen Jin. [Meta-analysis of Effectiveness of Fu′s Subcutaneous Needling in Treatment of Knee Osteoarthritis]. World Chinese Medicine. 2020. [212942].

Objective	To systematically evaluate the therapeutic effects of Fu′s subcutaneous needling in treatment of knee osteoarthritis.
Methods	By searching Chinese databases such as CNKI, VIP, Wanfang database etc. and 3 major English databases PubMed, Embase, Cochrane, randomized controlled trials of Fu′s subcutaneous needling and conventional acupuncture for knee osteoarthritis were included. After the Cochrane systematic review method was used to evaluate the quality and data extraction of the included literatures, the Meta-analysis was performed by using Review Manager 5. 2 software, and the funnel chart was used to analyze the publication bias.
Results	A total of 7 literature were included with 595 cases. Meta-analysis results were shown as follows: Compared with conventional acupuncture, the effectiveness of Fu′s subcutaneous needling or combined with other methods for treating knee osteoarthritis (OR=6. 18, 95% CI: [3. 20, 1. 92]), the degree of improvement in pain visual analogue score VAS[WMD=-1. 22, 95% CI (-1. 86, -0. 58)]. The differences were statistically significant (P<0. 05). The results of the subgroup analysis confirmed the above conclusions.
Conclusion	The Fu′s subcutaneous needling can effectively treat knee osteoarthritis. However, due to the limited number and quality of the included studies, the above conclusions are still to be verified by more high-quality large-sample long-term follow-up studies.

1.2.9. Acupotomy

1.2.9.1. Lin 2023 (ultrasound-guided acupotomy)

Lin S, Lai C, Wang J, Lin Y, Tu Y, Yang Y, Zhang R. Efficacy of ultrasound-guided acupotomy for knee osteoarthritis: A systematic review and meta-analysis of randomized controlled trials. Medicine (Baltimore). 2023 Jan 13;102(2):e32663. https://doi.org/10.1097/MD.0000000000032663.

Background	This systematic review aimed to evaluate the effectiveness and safety of ultrasound-guided acupotomy (UGAT) therapy in the treatment of patients with knee osteoarthritis (KOA).
Methods	We conducted online researches in the databases including PubMed, the Cochrane Library, EMBASE, China national knowledge infrastructure, China biomedical literature database, and Wan Fang data. All data were collected until January 1, 2022. Relevant randomized controlled trials on the effectiveness of UGAT for the treatment of KOA were included. Meta-analyses were carried out by RevMan 5.3 software. Evidence quality was evaluated by the grading of recommendations, assessment development, and evaluation.
Results	Eight studies including 543 participants were analyzed in this study. The pooled analysis indicated that UGAT was significantly more efficient than the control group in decreasing the visual analogue scale score (mean difference = -0.81, 95% confidence interval (CI) = [-1.15, -0.47], P < .00001, 8 studies), improving knee function on the Lysholm knee score (mean difference = 8.26, 95% CI = [1.56, 14.97], P = .02, 2 studies), and increasing clinical effective rate (relative risk = 1.14, 95% CI = [1.06, 1.23], P = .0005, 6 studies). For adverse events, UGAT was also associated with lower incidence of adverse event (odds ratio = 0.27, 95% CI = [0.12, 0.63], P = .002, 4 studies) compared to traditional acupotomy.
Conclusion	Current evidence suggested that UGAT therapy was effective and safe in the clinical treatments of KOA, thus could be suggested in the clinical managements of KOA. However, considering the unsatisfactory quality of the available trials, more large-scale, and better quality randomized controlled trials were recommend in future.

1.2.9.2. Wu 2023 (combined with sodium hyaluronate)

Wu Q, Wu Z, Lu Z. Efficacy of acupotomy combined with sodium hyaluronate versus sodium hyaluronate alone in the treatment of knee osteoarthritis: A meta-analysis. Medicine (Baltimore). 2023 Sep 15;102(37):e34930. https://doi.org/10.1097/MD.0000000000034930.

Background	The efficacy of acupotomy combined with hyaluronic sodium acid in the treatment of knee osteoarthritis (KOA) is unclear. Therefore, this meta-analysis aims to evaluate the efficacy of acupotomy combined with hyaluronic sodium acid compared with hyaluronic sodium acid alone in the treatment of KOA.
Methods	Studies from 8 Online databases were searched on KOA treatment using acupotomy combined with sodium hyaluronate until May 2022. The primary outcome indicator was clinical effectiveness, and the secondary outcome indicators included the visual analogue scale scores and Lysholm scores. We calculated the weighted mean difference (WMD) or relative risk for all relevant outcomes.
Results	Nine studies were identified, involving 644 cases. The results showed that acupotomy combined with intra-articular sodium hyaluronate injection for KOA was superior to sodium hyaluronate injection alone in terms of clinical effectiveness (relative risk = 1.17, 95% confidence interval [CI]: 1.09-1.25, P < .001) and visual analogue scale (WMD = -2.1, 95% CI: -2.25 to 1.95, P < .001), Lysholm score (WMD = 13.83, 95% CI: 3.47-24.19, P = .009).
Conclusion	Acupotomy combined with intra-articular sodium hyaluronate injection for KOA is superior to sodium hyaluronate injection alone. Limited by the number and quality of included studies, this conclusion still needs to be verified by more high-quality Research.

1.2.9.3. Yin 2022

Yin X, Liu Y, Liu W, Liang W, Liang Q. Blade needle therapy versus conventional acupuncture for knee osteoarthritis: A meta-analysis. Medicine (Baltimore). 2022 Jul 29;101(30):e29647. https://doi.org/10.1097/MD.0000000000029647

Background	This study investigated the hypothesis that the efficacy of blade needle therapy for the treatment of knee osteoarthritis (KOA) is superior to that of conventional acupuncture. In addition, the efficacy of blade needle therapy versus conventional acupuncture for the treatment of KOA was analyzed in a meta-analysis.
Methods	Randomized controlled trials (RCTs) of blade needle therapy and conventional acupuncture for treating KOA were retrieved from the electronic databases CNKL, Wanfang, VIP, PubMed, EMBASE and the Cochrane Library from the commencement of each database to July of 2021. Data were extracted and evaluated by 2 reviewers independently. RevMan 5.3 software was used to conduct the meta-analysis after the studies were evaluated.
Results	A total of 11 RCTs were included, all from China, involving 1142 patients. The meta-analysis results showed that the effective rate of the blade needle group was better than that of the conventional acupuncture group (OR = 3.61, 95% CI [2.56-5.10], P < .00001).
Conclusion	The efficacy of blade needle treatment for KOA is superior to that of conventional acupuncture, but more high-quality studies are needed for future validation due to the low proportion of high-quality studies included and the possible bias factor.

1.2.9.4. Lee 2021

Seung Min Lee, Cham Kyul Lee, Kyung Ho Kim, Eun Jung Kim, Chan Yung Jung, Byung-Kwan Seo, Bon Hyuk Goo, Yong Hyeon Baek, Eun Yong Lee. Acupotomy for Osteoarthritis of the Knee; A Systematic Review and Meta-Analysis. J Acupunct Res. 2021;38(2):96-109. [219985]. doi

Purpose	The purpose of this study was to evaluate the effectiveness and safety of acupotomy for the treatment of patients with knee osteoarthritis.
Methods	There were 9 databases searched to retrieve randomized controlled trials until August 3, 2019 regarding acupotomy versus conventional Western medicine, conventional Western medicine treatment with and without acupotomy, and Korean medicine treatment with and without acupotomy, and meta-analysis was performed.
Results	Of 303 potentially relevant studies retrieved, 43 were systematically reviewed. All studies were conducted in China. Effective rate, visual analogue scale, and Western Ontario and McMaster Universities Osteoarthritis index were used as the evaluation scales. The ashi point was selected most frequently. In all studies, the intervention group was more effective than the control group. Meta-analysis revealed that acupotomy showed statistically significant beneficial results.
Conclusion	Although acupotomy had a beneficial effect on knee osteoarthritis, the risk of bias of the included studies was not low. The majority of the results from the evaluation scales used were highly heterogeneous (> 50%) which reduced confidence in the estimation of effect, or had a small sample size. Further clinical research and development is required in the future.

1.2.9.5. Qu 2021

Qu B, Wu X, Liu H, Cai W, Wang G, Song H, Wang F. Meta-analysis and systematic review of acupotomy combined with puncture and moxibustion in the treatment of knee osteoarthritis. Ann Palliat Med. 2021;10(6):6637-6649. [220191]. doi

Background	This study aimed to systematically evaluate the therapeutic effects of acupotomy combined with acupuncture and moxibustion on knee osteoarthritis (KOA), which was expected to provide a reference for clinical treatment of KOA using traditional Chinese medicine (TCM).
Methods	The databases PubMed, Embase, Medline, Ovid, and Springer were searched to retrieve randomized controlled trials (RCTs) on KOA treatment by acupotomy combined with acupuncture and moxibustion. The search time was set as from the date the database was established to 31 December 2020. The Cochrane Handbook for Systematic Reviews of Intervention 5.0.2 was used to conduct bias risk assessment on the included literature, and Review Manager 5.3 software was used for meta-analysis.
Results	A total of 10 RCTs were included in this study, including 1,073 participants. Meta-analysis results showed that compared with the control group, the clinical treatment efficiency of the experimental group was higher [mean difference (MD) =5.72; 95% confidence interval (CI): 3.39 to 9.64; Z=6.54; P<0.00001], and the postoperative visual analogue scale (VAS) scores were reduced (MD =-1.72; 95% CI: -2.41 to -1.03; Z=4.86; P<0.00001).
Discussion	Acupotomy combined with acupuncture and moxibustion treatment for KOA can increase clinical treatment efficiency, and relieve postoperative pain, suggesting that the combination of acupotomy, acupuncture, and moxibustion has better therapeutic effects on KOA and can be promoted clinically.

1.2.9.6. Fang 2020

Fang T, Li Q, Zhou F, Liu F, Liu Z, Zhao M, Chen M, You J, Jin Y, Xie J. Effect and safety of acupotomy in treatment of knee osteoarthritis: a systematic review and Meta-analysis. Journal of TCM. 2020;40(3):355-364. [221075]. https://doi.org/10.19852/j.cnki.jtcm.2020.03.002

Objective	To evaluate the clinical efficacy and safety of acupotomy in treatment of knee osteoarthritis (OA).
Methods	Extensive literature searches were carried out in PubMed, EMBASE, Cochrane Library (Issue 5, 2017), Chinese Biomedical Literature Database, China National Knowledge Infrastructure Database, China Science and Technology Journal Database and Wanfang Database. All databases were retrieved from their inception until May 31, 2017. Randomized controlled trials incorporating acupotomy versus intra-articular sodium hyaluronate for knee osteoarthritis were included. According to Cochrane Reviews' Handbook (5.2), two reviewers screened each article and extracted data independently and were blinded to the findings of each reviewer. Meta-analysis was performed by the Cochrane Collaboration's RevMan 5.3 software.
Results	We identified 12 studies involving 1150 patients aged between 40 and 78 years old. The pooled analysis indicated that acupotomy showed a significant improvement for short-term effect [cure rate: odds ratio (OR) = 2.04, 95% confidence interval (CI) (1.46, 2.85), P < 0.01; total effective rate: OR = 2.25, 95% CI (1.55, 3.28), P < 0.01; pain score: standard mean difference (SMD) = －1.02; 95% CI (－1.72, －0.31); P = 0.005; Western Ontario and McMaster Universities Questionnaire (WOMAC) score: SMD = －0.74; 95% CI (－1.11, －0.37); P < 0.01]; and also for long-term effect [total effective rate: OR = 2.99, 95%CI (1.88, 4.76), Z = 4.64, P < 0.01; pain score: SMD = －1.68; 95% CI (－2.14, －1.22); P < 0.001; WOMAC score: SMD = －0.91; 95% CI (－1.40, －0.41); P < 0.001]. In addition, there was no obvious difference between acupotomy group and control group in adverse events [OR = 2.13, 95%CI (0.14, 32.28), P = 0.58].
Conclusion	Acupotomy is a safe and effective treatment for KOA. However, due to the methodological deficiency of the included studies, well-designed randomized controlled trials are required to further confirm the findings.

1.2.9.7. Sun 2020

Sun J, Zhao Y, Zhu R, Chen Q, Song M, Xue Z, Wang R, Chen W. Acupotomy Therapy for Knee Osteoarthritis Pain: Systematic Review and Meta-Analysis. Evid Based Complement Alternat Med. 2020. [213667]. doi

Background and Purpose	Knee osteoarthritis (OA) is a major public health problem, and currently, few effective medical treatments exist. Chinese acupotomy therapy has been widely used for the treatment of knee OA in China. We conducted this systematic review and meta-analysis to evaluate the efficacy of Chinese acupotomy in treating knee OA to inform clinical practice.
Methods	We performed a comprehensive search on PubMed, the Cochrane Library, EMBASE, and four Chinese databases for articles published prior to June 2020. We included only randomized controlled trials (RCTs) that used acupotomy therapy as the major intervention in adults with knee OA, were published in either Chinese and English, included more than 20 subjects in each group, and included pain and function in the outcome measures. Knee OA was defined by the American College of Rheumatology or Chinese Orthopedic Association criteria in all studies. We extracted the visual analogue scale (VAS) pain score, the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain score, the total effectiveness rate, the modified Japanese Orthopedic Association (JOA) activities of daily living score, and Lysholm's score. We calculated the mean difference (MD) or risk ratio (RR) for all relevant outcomes. Meta-analyses were conducted using random-effects models when appropriate.
Results	We identified 1317 potentially relevant studies, thirty-two of which met the eligibility criteria and were conducted in China between 2007 and 2020. A total of 3021 knee OA patients (62.96% female, median age: 57 years, and median disease duration: 33 months) were included. The treatment duration ranged from 1 week to 5 weeks (median: 3 weeks). The typical acupotomy treatment involved releasing soft tissue adhesions and was performed once a week for 1-5 weeks until the pain was relieved. The control group treatments included acupuncture (8 studies), electroacupuncture (10 studies), sodium hyaluronate (8 studies), radiofrequency electrotherapy (1 study), and nonsteroidal anti-inflammatory drugs (NSAIDs, 5 studies). The results from the meta-analysis showed that acupotomy led to superior improvements in the VAS pain score (MD = -1.11; 95% confidence interval (CI), -1.51 to -0.71; p < 0.00001) and WOMAC pain score (MD = -2.32; 95% CI, -2.94 to -1.69; p < 0.00001), a higher total effectiveness rate (RR = 1.15; 95% CI, 1.09-1.21; p < 0.00001), and superior improvements in the JOA score (MD = 6.39; 95% CI, 4.11-9.76; p < 0.00001) and Lysholm's score (MD = 12.75; 95% CI, 2.61-22.89; p = 0.01) for overall pain and function. No serious adverse events were reported.
Conclusion	Chinese acupotomy therapy may relieve pain and improve function in patients with knee OA. Furthermore, rigorously designed and well-controlled RCTs are warranted.

1.2.9.8. Zhang 2019

Zhang Lei, Wei Mubin, Liu Aifeng. [Meta-analysis of acupotomy versus acupuncture for knee osteoarthrits]. Tianjin Journal of Traditional Chinese Medicine. 2019;3:253-7. [195740].

Objective	To evaluate the efficacy of acupotomy for knee osteoarthritis (KOA) by Meta-analysis.
Methods	Randomized controlled trials about acupotomy treating KOA were indexed from CNKI, Wanfang Date, VIP and PubMed from the begining to October2017. The literature was screened and evaluated and Review Manager 5.3 software was used for analysis.
Results	The 9 RCT were included and there were 655 patients in total. Meta-analysis result showed that the effective rate of acupotomy therapy for KOA was higher than acupuncture.
Conclusion	The efficacy of acupotomy in the treatment of KOA was positive. However, because the number of literature included in the study was small, the quality was uneven and the sample size was limited, more perfect experiments need to be designed.

1.2.9.9. Liu 2012 ★

Liu Fu-shui, Jin De-zhong. [Acupotomy versus acupuncture for knee osteoarthritis: A meta-analysis of randomized controlled trials]. Journal of Clinical Rehabilitative Tissue Engineering Research. 2012;44:8235-823. [186992].

Background	Acupotomy and acupuncture are widely used in the clinical treatment of knee osteoarthritis in recent years. However, there remains no systematic review to assess the clinical effect.
Objective	To professionally assess the different effects of acupotomy versus acupuncture for knee osteoarthritis.
Methods	A computer-based search was conducted on the CNKI database, VIP database, Wanfang database, PubMed database and Cochrane Central Register of Controlled Trials (Issue 3, 2011). The time limitation ran from the commencement of each database to September 15, 2011. Randomized controlled trials of acupotomy in the treatment group and acupuncture in the control group were included. Data were extracted and evaluated by two reviewers independently. RevMan5. 1 software was used for Meta-analysis after the literatures were evaluated.
Results and conclusion	A total of 8 trials involving 654 patients were included. The Meta-analysis showed that both curative rate and total effective rate of acupotomy for the treatment of knee osteoarthritis are higher than those of acupuncture in short term. It showed effects as follows respectively: OR=4. 27, 95%CI (2. 32-7. 85); OR=3. 01, 95% I (1. 77-5. 14). Acupotomy is more effective than acupuncture in the treatment of knee osteoarthritis in short term. However, due to low quality of included studies and there are no reports on the adverse events, further well-designed randomized controlled trials with high quality are still needed to evaluate the beneficial effects of acupotomy.

1.2.10. Warm Needles

1.2.10.1. Jin 2022

Jin S, Guan X. A systematic review and meta-analysis of the comparative curative effects of warm acupuncture and other traditional Chinese medicines in the treatment of knee osteoarthritis. Ann Palliat Med. 2022 Feb;11(2):708-716. https://doi.org/10.21037/apm-21-3972

Background	Knee osteoarthritis (KOA) is more common in middle-aged and elderly people, and seriously affects the quality of life of those affected. Traditional Chinese medicine (TCM) treatment of KOA has been widely recognized. In recent years, warm needling acupuncture (WNA) has been used to treat KOA and has achieved good results. However, there is a lack of comparison of the efficacy of WNA and other TCM treatments for KOA.
Methods	We conducted a search for reports of WNA and/or TCM treatment of KOA in English- and Chinese-language databases. The data was retrieved from inception of the database until October 2021. The Cochrane risk of bias tool was used to evaluate the quality of the included studies, and the network meta-analysis was performed using the software RevMan 5.20.
Results	A total of 8 articles met the inclusion criteria, including 399 patients treated with WNA (WNA group), and 396 patients treated with other TCM (TCM group). The results of meta-analysis showed that compared with patients in the TCM group, the effective rate [relative risk (RR)] was 1.18, 95% confidence interval (CI): 1.06 to 1.33, the last follow-up osteoarthritis index [mean difference (MD)] was -6.93, 95% CI: -12.14 to -1.72, and the last follow-up knee pain visual analogue scale (VAS) MD was -1.06, 95% CI: -1.61 to -0.51, which were all statistically significant. However, the difference in daily activities (MD: -4.31, 95% CI: -10.90 to 2.28) was not statistically significant.
Discussion	Compared with other TCM treatments for KOA, WNA has better overall patient efficacy. However, further randomized controlled studies are needed to compare WNA and other TCM treatments individually to confirm the efficacy of WNA.

1.2.10.2. Li 2022

Li J, Yang H, Hu T. Comparison of Warming Needle Moxibustion and Drug Therapy for Treating Knee Osteoarthritis: A Systematic Review and Meta-analysis. Comput Math Methods Med. 2022 Jul 27;2022:3056109. https://doi.org/10.1155/2022/3056109

Objective	To compare the efficacy of warming needle moxibustion (WNM) with that of drug therapy for treating knee osteoarthritis (KOA), so as to provide evidence-based reference for the treatment of knee osteoarthritis.
Methods	PubMed, Embase, Cochrane Library, VIP, WanFang, and CNKI were searched from inception to March 23, 2022. Literature selection was processed in strict accordance with inclusion and exclusion criteria. Cochrane Risk of Bias Assessment tool was applied for quality assessment of included studies. Data analysis and publication bias assessment were performed using Stata 15.0.
Results	There were 30 RCTs included, with 1324 participants in the WNM group and 1293 in the control group. Meta-analysis showed that the WNM group yielded more excellent effect than the control group (RR = 1.22, 95% CI (1.17, 1.27), p = 0), improvement in WOMAC scores was greater in the WNM group than in the control group (WMD = -8.48, 95% CI (-13.13, -3.83), p = 0.002), activity of daily living (ADL) score was higher in the WNM group than in the control group (WMD = -7.66, 95% CI (-10.22, -5.09), p = 0.01), improvement in joint stiffness scores was greater in the WNM group than in the control group (WMD = -1.72, 95% CI (-2.50, -0.93), p = 0.005), and improvement in pain scores was greater in the WNM group than in the control group (SMD = -1.09, 95% CI (-1.38, -0.79), p = 0.001).
Conclusions	WNM would be more effective in improving quality of life, decreasing WOMAC score, promoting knee function recovery, and alleviating the joint pain and stiffness, compared with orally taken drug therapies. Therefore, WNM could be given prior consideration for the treatment of KOA.

1.2.10.3. Hui 2019 (+ Sodium Hyaluronate)

Jiang Huijing, Zhang Shudan. [Meta-analysis of warm acupuncture combined with Sodium Hyaluronate therapy in treatment of knee osteoarthritis]. China Medical Herald. 2019;6:154-158. [201726].

目的系统评价温针灸联用玻璃酸钠治疗膝骨性关节炎的效果和安全性.方法检索PubMed、Embase、Cochrane Library、CBM、WF、CNKI和VIP数据库建库至2018年7月21日关于温针灸联用玻璃酸钠治疗膝骨性关节炎的随机对照试验(RCT)和临床对照试验(CCT),并对全部纳入研究的参考文献进行追溯,由2个评价员根据纳入排除标准独立对纳入研究进行筛选和评价,然后进行数据提取.运用RevMan 5.3软件进行统计分析.结果共纳入20篇文献,共1719例患者,联合治疗组859例,玻璃酸钠组860例,经Meta分析表明:联合组对膝骨性关节炎疗效优于玻璃酸钠组(OR=4.45,95％CI:3.12～6.35,P＜0.05).各组均未发生不良反应.结论温针灸联用玻璃酸钠治疗膝骨性关节炎疗效显著,安全性较好.

[Automatic translation].
Objective	To systematically evaluate the efficacy and safety of warm acupuncture combined with sodium hyaluronate in the treatment of knee osteoarthritis.
Methods	Search the PubMed, Embase, Cochrane Library, CBM, WF, CNKI and VIP databases to build the database until July 21, 2018. Acupuncture combined with sodium hyaluronate for the treatment of knee osteoarthritis in randomized controlled trials (RCT)and clinical controlled trials (CCT), and traced all references included in the study, independently by two reviewers based on inclusion exclusion criteria The study was screened and evaluated, and then data was extracted. Statistical analysis was performed using RevMan 5.3 software.
Results	The results included 20 articles, a total of 1719 patients, 859 patients in the combined treatment group, and 860 patients in the sodium hyaluronate group. The effect of knee group on knee osteoarthritis was better than that of sodium hyaluronate group (OR=4.45, 95% CI: 3.12~6.35, P<0.05). No adverse reactions occurred in each group.
Conclusion	Warm acupuncture combined with sodium hyaluronate for knee treatment Osteoarthritis has significant efficacy and safety.

1.2.10.4. Zhang 2019 (+ Sodium Hyaluronate)

Zhang Jierong, Wang Zigeng, Yin Xiaolong. [Meta Analysis of Warming Acupuncture Combined with Intra-articular Injection of Sodium Hyaluronate in Treatment of Knee Osteoarthritis]. Journal of Shandong University of Traditional Chinese Medicine. 2019;3:250-6. [192930].

Objective	To evaluate the efficacy of warming acupuncture combined with sodium hyaluronate in the treatment of knee osteoarthritis.
Methods	The randomized controlled trial(RCTs) about warming acupuncture combined with sodium hyaluronate for the treatment of knee bone was retrieved from PubMed, Wed of Science CBM,The Cochrane Library, EMBase, CNKI, Wanfang Data, VIP from the date of database construction to July 2018. After literature screening,data extraction and quality evaluation were carried out by two researchers, Meta analysis was carried out with revman 5.3 software.
Results	Total 1247 patients with knee osteoarthritis(628 patients in the experimental group,619 patients in the control group) were included in this study from 15 RCTs articles. Experimental group was treated by warming acupuncture combined with sodium hyaluronate. Control group was treated by sodium hyaluronate or warming acupuncture or other treatment. The total effective rate of the experimental group was 15%,20% and 24% higher than that of the sodium hyaluronate group, the warming acupuncture group and the other treatment group, respectively, and the difference was statistically significant(RR= 1.15,95%CI:1.10～1.21,P< 0.00001; RR= 1.20,95%CI:1.05～1.36,P=0.005; RR=1.36,95%CI:1.11～1.66,P=0.003). The VAS score of knee osteoarthritis in the experimental group was better than that in the sodium hyaluronate group, warming acupuncture group and other treatment group, and the difference was statistically significant(MD=-1.46,95%CI:-1.84～-1.08,P= 0.009;MD=-4.73,95%CI:-6.46 ～-3.01,P< 0.00001;MD=-1.83,95%CI:-2.39 ～-1.28,P< 0.00001). The WOMAC score of the experimental group in the treatment of knee osteoarthritis was better than that in the warming acupuncture group, and the difference was statistically significant(MD=-37.11,95%CI:-49.36～-24.85,P< 0.00001). The LKSS score of the experimental group in the treatment of knee osteoarthritis was better than that in the sodium hyaluronate group and the warming acupuncture group, and the difference was statistically significant(MD= 39.14,95%CI:20.87～57.42,P< 0.0001;MD= 41.05,95%CI:27.77～54.33,P< 0.00001).
Conclusions	The therapeutic effect of warming acupuncture combined with sodium hyaluronate in the treatment of knee osteoarthritis is better than that in other groups. However, the quality and quantity of the literature included in this study are limited, so more long follow-up and high quality RCTs test are needed to verify results.

1.2.10.5. Zhang 2018

Zhang Jiwei, Deng Qiang, Yang Zhenyuan, Zhang Yanjun, Wang Peng, Guo Tiefeng. [Meta Analysis of Randomized Controlled Trials of Warming Needle Moxibustion for Knee Osteoarthritis]. Clinical Journal of Traditional Chinese Medicine. 2018;11:2049-2054. [197921].

Objective	To systematically evaluate the effectiveness of warming needle moxibustion and simple acupuncture or electroacupuncture in treating knee osteoarthritis.
Methods	Retrieve the CNKI, Wanfang database, VIP, PubMed, Embase, and obtain the RCT literature about warm acupuncture and simple acupuncture or electroacupuncture in the treatment of KOA from the database to June 2018.According to the requirements of Cochrane evaluation manual 5.0.2, the experiment was screened and the data were extracted, and the methodological quality was evaluated according to the modified Jadad score. Total effective rate, VAS score, WOMAC score, remission time(pain, stiffness and average cure), and ISOA were selected as the indicators for meta-analysis State 12.0 software was used for metaanalysis, heterogeneity was tested, and the corresponding effect model was selected for analysis. Begg’s rank correlation test and Egger’s linear regression were used to test the literature publication bias. The counting and measurement data were expressed by RR, SMD and 95% CI respectively.
Results	Twelve RCT papers were included, of which 6 were about the efficacy of warming acupuncture and simple acupuncture in the treatment of KOA, 6 were about the efficacy of warming acupuncture and electroacupuncture in the treatment of KOA, all of which were from China and included1176 subjects. Meta-analysis showed that there was no significant difference in the total effective rate of KOA between the two groups, RR = 1.04(95% CI: 1.00-1.08), Begg’s test P = 0.086, Egger’s test P = 0.296. After treatment, VAS scores were subgroup analyzed according to intervention measures. The results showed that there were significant differences in VAS scores between the two groups after treatment, SMD =-1.57(95% CI:-1.83 ～-1.80), and SMD = 0.32(95% CI:-0.11 ～0.76)as compared with electroacupuncture. There was no significant difference in total WOMAC score between warm acupuncture group and electroacupuncture group after treatment, SMD = 0.08(95% CI:-0.15 ～ 0.32).In terms of remission time, there were significant differences in pain and stiffness between warm acupuncture group and electroacupuncture group, SMD and 95% CI were 0.69(95% CI: 0.46-0.92)and-0.60(95% CI:-0.82-0.37), respectively, and there was no significant difference in mean cure time between the two groups, SMD =-0.04(95% CI:-0.27-0.18). The difference of ISOA index between warm acupuncture group and simple acupuncture group was statistically significant, SMD =-1.68(95% CI:-2.03 ～-1.32).
Conclusion	Compared with acupuncture alone in the treatment of KOA, warm acupuncture can better relieve subjective pain and reduce the severity index of KOA in Lequesne, but the total effective rate is the same. Compared with electroacupuncture in treating KOA, warm acupuncture can alleviate knee stiffness more quickly, but there is no significant difference in total effective rate, subjective pain relief, WOMAC score reduction and average healing time, and in pain relief time, warm acupuncture is inferior to electroacupuncture. In view of the low quality of the included literature and the statistical heterogeneity between studies, high quality RCT is needed to verify the above conclusions

1.2.10.6. Lu 2015

Lu W. [Needle warming moxibustion versus oral western medicine for knee osteoarthritis: a systematic review and meta-analysis]. J Trauma Emerg. 2015;2:30-4. [176313].

Objective
Method	Randomized controlled trials(RCTs) of needle warming moxibustion versus oral western medicine in the treatment of knee osteoarthritis were searched from CNKI, VIP, WFSD, CBM and Pub Med. The time limitation ran from the commencement of each database to December 2013. The Cochrane Collaboration's Rev Man5.0 software was used for meta-analysis.
Result	A total of 6 trials involving 509 patients were included. The meta-analysis showed that the curative rate, adverse effects rate and total effective rate of needle warming moxibustion were better than oral western medicine.
Conclusion	Needle warming moxibustion is more effective than oral western medicine in the treatment of knee osteoarthritis (KOA). However, further well-designed RCTs with high quality are still needed to evaluate the beneficial effects of needle warming moxibustion due to low quality and less sample size of included studies.

1.2.11. Fire Needle

1.2.11.1. Ko 2019

Ko H, Yoo J, Shin J. A Systematic Review and Meta-Analysis of Fire Needling Treatment for Knee Osteoarthritis: Focused on Comparative Studies with Manual Acupuncture Treatment during Recent Five Years. Korean Journal of Acupuncture. 2019;36(2):104-114. [207910]. doi

Objectives	The purpose of this study is to review the effectiveness of fire needling treatment for knee osteoarthritis in comparison with manual acupuncture treatment.
Methods	Through four foreign online databases (PubMed, Cochrane library, EMBASE, and CNKI) and five domestic online databases (NDSL, RISS, KISS, OASIS, and KTKP), we searched for clinical studies that performed fire needling treatment for knee osteoarthritis until May 10, 2019. Only randomized controlled trials were selected and we assessed the risk of bias according to the Cochrane RoB criteria. This review examined the selected studies into first author, publication year, sample size, outcome measurements, results, acupoints, treatment time & period and so on.
Results	A total of 7 RCTs were selected in this review and all were conducted in China. Treatment period of more than 4 weeks and treatment visits of 10 to 20 times were the most common. EX-LE4 and ST35 (=EX-LE5) acupoints were most frequently selected in treatment. Among the evaluation indexes, a total efficacy rate was used the most. Most of fire needling groups showed more significant results compared with the manual acupuncture groups statistically.
Conclusions	All studies showed that fire needling treatments for knee osteoarthritis were more effective than manual acupuncture treatments statistically. Therefore, the results of this study could be utilized as a preliminary data for another clinical research on fire needling treatment for knee osteoarthritis. However, further well-designed randomized controlled trials will be needed to develop sufficient evidence about the effectiveness and safety of fire needling treatment for knee osteoarthritis in the future.

1.2.11.2. Wang 2016 ☆

Wang Y, Xie X, Zhu X, Chu M, Lu Y, Tian T, Zhuang X, Jiang L. Fire-Needle Moxibustion for the Treatment of Knee Osteoarthritis: A Meta-Analysis. Evid Based Complement Alternat Med. 2016; : 1392627.[191807]

Objectives	The aim of this study was to evaluate the effectiveness of fire-needle moxibustion as an intervention in the treatment of knee osteoarthritis (KOA).
Methods	An updated meta-analysis of randomized controlled trials (RCTs) on fire-needle moxibustion in treating KOA was conducted by searching PubMed, Embase, the Cochrane Library, Web of Science, Wanfang database, and the Chinese Medical Database (CNKI) since their inception through March 2016. The meta-analysis was performed using RevMan 5.3.
Results	Thirteen RCTs were identified in the systematic study which consisted of 1179 participants. Fire-needle moxibustion treatment group had a statistical significance on recovery rate as well as recovery and marked-improvement rate compared with control group. Subgroup analysis indicated that there was significant difference between fire-needle moxibustion group and control group. However, GRADE analysis indicated that the quality of evidence for all outcomes was relatively low. Only two of 13 studies reported adverse reactions (difficulty in movement and intolerance of cold).
Conclusions	This meta-analysis suggests that fire-needle moxibustion is more effective than control group in symptom management of KOA. Further high quality trials should be conducted to evaluate the effectiveness of fire-needle moxibustion on KOA.

1.2.12. Electro-acupuncture

1.2.12.1. Shi 2021

Shi X, Yu W, Zhang W, Wang T, Battulga O, Wang L, Guo C. A comparison of the effects of electroacupuncture versus transcutaneous electrical nerve stimulation for pain control in knee osteoarthritis: a Bayesian network meta-analysis of randomized controlled trials. Acupuncture in Medicine. 2021;39(3):163-174. [221950]. https://doi.org/10.1177/0964528420921193

Background	To compare the effectiveness of electroacupuncture (EA) and transcutaneous electrical nerve stimulation (TENS) for pain control in knee osteoarthritis (KOA).
Methods	Four English (MEDLINE, EMBASE, Cochrane Library and Web of Science) and three Chinese (China Science Journal Citation Report (VIP), Wanfang and China National Knowledge Infrastructure (CNKI)) language databases were searched for eligible randomized controlled trials (RCTs), comparing four approaches: EA, TENS, medication and sham/placebo controls. The primary outcome was pain intensity, measured by visual analogue scale (VAS), numeric-rating scale (NRS) or Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scale. Classic pairwise and Bayesian network meta-analyses were conducted to integrate the treatment efficacy/effectiveness through direct and indirect evidence.
Results	Thirteen studies were included. In the direct meta-analyses, there was no statistically significant overall effect of EA (mean difference (MD) -4.77, 95% confidence interval (CI) -12.51 to 2.96), while the overall effects of high-frequency transcutaneous electrical nerve stimulation (H-TENS) (MD -16.63, 95% CI -24.57 to -8.69) and medication (MD -7.12, 95% CI -12.07 to -2.17) were statistically significant. In the network meta-analyses, the relative effect of the EA and H-TENS groups (MD 5.07, 95% CI -11.33 to 21.93) on pain control did not differ. Meanwhile, H-TENS demonstrated the highest probability of being the first best treatment, and EA had the second highest probability.
Conclusion	The present analysis indicated that both EA and TENS exert significant pain relieving effects in KOA. Among the four treatments, H-TENS was found to be the optimal treatment choice for the management of KOA pain in the short-term, and EA the second best treatment option. Given that the application of TENS is recommended by various international guidelines for the treatment of KOA, EA may also represent a potentially effective non-pharmacologic therapy.

1.2.12.2. Chen 2020 ☆

Chen Rilan. [Effect of electro-acupuncture on pain relief and joint function in patients with knee osteoarthritis: a meta-analysis]. Chinese Journal of Tissue Engineering Research. 2020. [212946].

Background	Numerous clinical data have shown that electro-acupuncture in the treatment of knee osteoarthritis has the advantages of fast onset, good therapeutic effect and less side effects, but there is a lack of multicenter large-sample clinical research regarding the treatment of knee osteoarthritis.
Objective	To systematically evaluate the effect of electro-acupuncture on pain relief and joint function in patients with knee osteoarthritis by meta-analysis.
Methods	The literatures related to clinical randomized controlled trials of electro-acupuncture treatment of knee osteoarthritis were retrieved in CNKI, Wanfang, VIP, PubMed, Embase and Cochrane Library database from the inception to June 2019. After literature screening, a meta-analysis of included studies was carried out using Review Manager 5. 3.
Results and Conclusion	Finally, 11 articles were included in the study, with 721 cases of knee osteoarthritis. There were 366 cases in the electro-acupuncture group and 361 in the control group with routine acupuncture or drug treatment. Compared with the control group, the total effective rate, cure rate, visual analogue scale score, WOMAC score and ISOA score in the electro-acupuncture group were significantly higher than those in the control group [odds ratio (OR)=3. 22, 95% confidence interval (CI) (2. 13, 4. 87), Z=5. 53, P < 0. 000 01; OR=2. 73, 95%CI (1. 80, 4. 15), Z=4. 72, P < 0. 000 01; mean difference (MD)=-1. 00, 95%CI (-1. 71, -0. 30), Z=2. 80, P=0. 005; MD=-7. 69, 95%CI (-10. 31, -5. 07), Z=5. 75, P < 0. 000 01; MD=-2. 22, 95%CI (-3. 74, -0. 70), Z=2. 86, P=0. 004]. Based on the evidence of meta-analysis, the short-term effect of electro-acupuncture on knee osteoarthritis is definite, and electro-acupuncture can play a positive effect on pain symptoms and joint function of knee osteoarthritis patients with few adverse reactions. Considering small sample size, low-quality literatures and possible presence of bias factors, further investigations on more high-quality randomized controlled trials are warranted.

1.2.12.3. Chen 2017 ★★

Chen N, Wang J, Mucelli A, Zhang X, Wang C. Electro-Acupuncture is Beneficial for Knee Osteoarthritis: The Evidence from Meta-Analysis of Randomized Controlled Trials. American Journal of Chinese Medicine. 2017;45(5):965-985. [182181].

Objectives	Knee osteoarthritis (KOA) is a common chronic degenerative disease of the elderly. Electro-acupuncture (EA) is considered as a beneficial treatment for KOA, but the conclusion is controversial. This systematic review compiled the evidence from 11 randomized controlled trials to objectively assess the effectiveness and safety of EA for KOA.
Methods	Eight databases including PubMed, Cochrane Library, Clinic trials, Foreign Medical Literature Retrial Service (FMRS), Science Direct, China National Knowledge Infrastructure (CNKI), Chinese Scientific Journal Database (VIP), and Wanfang Data were extensively searched up to 5 July 2016. The outcomes included the evaluation of effectiveness, pain and physical function. Risk of bias was evaluated according to the Cochrane risk of bias tool.
Results	Eleven RCTs with 695 participants were included. Meta-analysis indicated that EA was more effective than pharmacological treatment (RR [Formula: see text] 1.14; 95% CI [Formula: see text] 1.01,1.28; [Formula: see text]) and manual acupuncture (RR [Formula: see text] 1.12; 95% CI [Formula: see text] 1.02,1.22; [Formula: see text]). Also, EA had a more significant effect in reducing the pain intensity (SMD [Formula: see text]; 95% CI [Formula: see text]; [Formula: see text]) and improving the physical function in the perspective of WOMAC (MD [Formula: see text]; 95% CI [Formula: see text], 5.56; [Formula: see text]) and LKSS (pharmacological treatment: MD [Formula: see text]; 95% CI [Formula: see text], 6.64; [Formula: see text]). Furthermore, these studies implied that EA should be performed for at least 4 weeks.
Conclusions	Conclusively, the results indicate that EA is a great opportunity to remarkably alleviate the pain and improve the physical function of KOA patients with a low risk of adverse reaction. Therefore, more high quality RCTs with rigorous methods of design, measurement and evaluation are needed to confirm the long-term effects of EA for KOA.

1.2.12.4. Lin 2016

Lin J, Fu CL, Li L, et al. [Effect of electroacupuncture on knee osteoarthritis: a systematic review], Rehabil Med. 2016;26:52-8. [199135]. Cité dans Li J , Li YX , Luo LJ , Ye J , Zhong DL , Xiao QW , Zheng H , Geng CM , Jin RJ , Liang FR. The effectiveness and safety of acupuncture for knee osteoarthritis: An overview of systematic reviews. Medicine (Baltimore). 2019;98(28). [200308].

1.2.12.5. Shim 2016

Shim JW, Jung JY, Kim SS. Effects of Electroacupuncture for Knee Osteoarthritis: A Systematic Review and Meta-Analysis. Evid Based Complement Alternat Med. 2016:3485875. [199890].

Purpose	This study aims to verify the effects of electroacupuncture treatment on osteoarthritis of the knee.
Methods	MEDLINE/PubMed, EMBASE, CENTRAL, AMED, CNKI, and five Korean databases were searched by predefined search strategies to screen eligible randomized controlled studies meeting established criteria. Any risk of bias in the included studies was assessed with the Cochrane Collaboration's tool. Meta-analysis was conducted using RevMan version 5.3 software.
Results	Thirty-one randomized controlled studies of 3,187 participants were included in this systematic review. Meta-analysis was conducted with eight studies including a total of 1,220 participants. The electroacupuncture treatment group showed more significant improvement in pain due to knee osteoarthritis than the control group (SMD -1.86, 95% CI -2.33 to -1.39, I2 75%) and in total WOMAC score than the control group (SMD -1.34, CI 95% -1.85 to -0.83, I2 73%). Compared to the control group, the electroacupuncture treatment group showed more significant improvement on the quality of life scale.
Conclusion	Electroacupuncture treatment can relieve the pain of osteoarthritis of the knees and improve comprehensive aspects of knee osteoarthritis and the quality of life of patients with knee osteoarthritis.

1.2.13. Laser Acupuncture

1.2.13.1. Chen 2019

Chen Z, Ma C, Xu L, Wu Z, He Y, Xu K, Moqbel SAA, Wu L. Laser Acupuncture for Patients with Knee Osteoarthritis: A Systematic Review and Meta-Analysis of Randomized Placebo-Controlled Trials. Evid Based Complement Alternat Med. 2019. [203299].

Objectives	To provide updated evidence from randomized controlled trials (RCTs) on the effectiveness of laser acupuncture for patients with knee osteoarthritis (KOA).
Methods	A literature search in 9 databases was conducted from their inception through February 2019. Randomized controlled trials (RCTs) written in English that compared active laser acupuncture with placebo in KOA patients were included. Two authors independently extracted data from these trials. Meta-analysis software was used to analyze the data. Included studies were assessed in terms of the follow-up period, the methodological quality, and appropriateness of their technical features.
Results	Of 357 studies, seven RCTs (totaling 395 patients) met the inclusion criteria. The short-term outcomes showed that laser acupuncture offered significant pain relief over placebo when assessed by the 100 mm visual analog scale (VAS) pain score (p = 0.02), while there was no significant difference between laser acupuncture and placebo based on Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain score (p = 0.25). For subgroup analysis, laser acupuncture had superiority over placebo in terms of both VAS and WOMAC pain scores in the appropriate technical features subgroup and the excellent methodological quality subgroup. But the effect of laser acupuncture on pain relief was not maintained in terms of either VAS (p = 0.19) or WOMAC pain score (p = 0.60). The pooled effect showed no significant difference between laser acupuncture and placebo at either time point according to WOMAC function scale, WOMAC stiffness scale, and quality of life outcome.
Conclusions	Our findings indicate that laser acupuncture can effectively reduce knee pain for patients with KOA at short term when appropriate technical features are applied, but the effect likely fades away during the subsequent follow-up period.

1.2.14. Moxibustion

1.2.14.1. Deng 2020

Deng Kafeng, Zhu Ying, Wei Xingcheng, Yan Jiaxing, Gao Qianqian, Ma Yinglu, Chen Rilan. [Meta - Analysis on Clinical Efficacy and Safety of Thunder - Fire Moxibustion in Treating KOA]. Journal of Clinical Acupuncture and Moxibustion. 2020;36(3):44. [210488]. doi

Objective	To evaluate the clinical efficacy and safety of thunder - fire moxibustion in treating knee osteoarthritis ( KOA) by Meta - analysis.
Methods	RCTs of KOA treated by thunder - fire moxibustion were searched from the databases of CNKI, WF, VIP and Pubmed, and the original literature was screened out according to the inclusion and the exclusion criteria. Review Manager 5. 3 software was used for Meta - analysis of the literature included in the study.
Results	A total of 987 patients were included in 10 articles, including 508 patients in the treatment group and 479 patients in the control group. Two pieces of the literature were with high qua1ity and eight pieces were with Low quality. There was no significant difference in WOMAC score between the thunder - fire moxibustion group and the control group( P =0. 14). In terms of overall effective rate, cure rate and improvement of VAS score, the therapeutic effect of thunder - fire moxibustion was better [ OR = 3. 19, 95%CI(2.07,4.90),P<O.00001],[OR=2.63,95%CI(1.68,4.11),P<O.0001],[MD=-1.66, 95%CI ( 一 2. 16, - 1. 16) ,P <0. 000 01].
Conclusion	Thunder - fire moxibustion has certain curative effects on KOA treatment. Compared to medication, it has more advantages in overall effective rate, cure rate, VAS score, Lequesne score and adverse reactions. It still needs to be observed in improving WOMAC score. However, due to the limited sample size, the general low quality of literature and the possible bias, it needs more standardized RCTs with high qualities, which are of more centers and large samples, to verify the research results.

1.2.14.2. Park 2020

Jang Mi Park, Cham Kyul Lee, Kyung Ho Kim, Eun Jung Kim, Chan Yung Jung, Byung-Kwan Seo, Bon Hyuk Goo, Yong Hyeon Baek, Eun Yong Lee. A Systematic Review and Meta-Analysis of Moxibustion Treatment for Knee Osteoarthritis. J Acupunct Res. 2020;37(3):137-150. [219951]. doi

Purpose	The purpose of this study was to evaluate the evidence supporting the effectiveness of moxibustion treatment for osteoarthritis.
Methods	There were 9 databases used to retrieve randomized controlled trials (RCTs) that used moxibustion as treatment for osteoarthritis. The quality of methodology for the RCTs was assessed using the Cochrane Risk of Bias tool [Review Manager (RevMan) Version 5.3 Windows, The Nordic Cochrane Centre, Copenhagen, Denmark].
Results and conclusions	The inclusion criteria for this review was met by 27 RCTs. All studies were conducted in China. A 4-week moxibustion treatment period was the most common. EX-LE4 and SP10 and GB34 acupoints were most frequently selected in the treatment of osteoarthritis. The most commonly used evaluation index was the visual analog scale (VAS). All studies, including a meta-analysis showed that moxibustion treatments were statistically significantly effective at treating knee osteoarthritis. However, well-designed randomized RCTs without a high risk of bias should be designed in the future.

1.2.14.3. Yuan 2019

Yuan T, Xiong J, Wang X, Yang J, Jiang Y, Zhou X, Liao K, Xu L. The Effectiveness and Safety of Moxibustion for Treating Knee Osteoarthritis: A PRISMA Compliant Systematic Review and Meta-Analysis of Randomized Controlled Trials. Pain Res Manag. 2019. [204219]. doi

Background	Knee osteoarthritis (KOA) seriously affects people's life. Therefore, it has already become a worldwide health concern. Moxibustion has a significant clinical effect on KOA. This systematic review and meta-analysis is performed to renew previous studies and strictly evaluate the quality of RCT and thus test the effect and safety of moxibustion for KOA.
Objective	To evaluate the effectiveness and safety of moxibustion treatment for alleviating pain and improving lower limb function for patients with KOA. Materials and Methods: CNKI (1979∼2019), CBM (1979∼2019), VIP (1989∼2019), WF (1998∼2019), PubMed (1966∼2019), Embase (1980∼2019), Cochrane Library, and Web of Science (1900∼2019) were all retrieved by a computer from their inception to June 02, 2019, replenished by manual retrieval of relevant bibliographies. Randomized controlled trials (RCTs) were included if moxibustion was compared to western medicine or negative control (placebo moxibustion or no treatment or UC) for treating KOA. The primary outcomes were the total effect and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC scale). The secondary outcomes include VAS, Symptom score, Lysholm score, and Lequesne score. RCTs were collected, and the quality of evidence was evaluated by using the Jadad scale and Cochrane risk assessment tools. We used RevMan5.3.0 software for meta-analysis.
Results	A total of 39 RCTs were included, including 3293 patients. In the assessment of the quality, the evidence differs from low to high based on the Cochrane Bias Evaluation Tools and Jadad scale. Fourteen trials were of high quality, ten were of moderate quality, and 15 were of low quality. Therefore, the quality of the included studies was moderate. In this study, there were 66.67% of the literature, and only 17.95% of the literature correctly reported randomized grouping and allocation of hidden information, respectively. In adverse reactions, only 13 trials included were reported in the study. The main adverse reactions of moxibustion are burns and blisters, whereas the western medicine group was in epigastric discomfort. As for the total effective rate, the meta-analysis of 27 RCTs showed a significant effect of moxibustion VS western medicine (RR = 1.20, 95% CI = 1.16 to 1.25, I 2 = 45%, P=0.007); as for the WOMAC scale, the subgroup meta-analysis of 13 trials showed that there was a statistically significant effect of moxibustion VS western medicine (MD = -11.08, 95% CI = -11.72 to -10.44, I 2 = 98%, P < 0.00001) and 2 trials on moxibustion VS negative control (MD = -8.38, 95% CI = -12.69 to -4.06, I 2 = 0%, P=0.77); as for the VAS score, the meta-analysis of 6 trials showed that there was a significant effect of moxibustion VS western medicine (MD = -2.12, 95% CI = -2.30 to -1.93, I 2 = 98%, P < 0.00001); as for the symptom score, the meta-analysis of 7 trials showed that there was a significant effect of moxibustion VS western medicine (MD = -0.81, 95% CI = -1.24 to -0.37, I 2 = 50%, P=0.06); as for the Lysholm score, the meta-analysis of 5 trials showed that there was a significant effect of moxibustion VS western medicine (MD = 7.61, 95% CI = 6.04 to 9.17, I 2 = 95%, P < 0.00001); and as for the Lequesne score, the meta-analysis of 3 trials showed that there was a significant effect of moxibustion VS western medicine (MD = 3.29, 95% CI = 2.93 to 3.65, I 2 = 99%, P < 0.00001).
Conclusion	Moxibustion treatment for KOA is more effective than the positive control (western medicine) or negative control (placebo moxibustion or no treatment or UC), and there were fewer adverse reactions to moxibustion. Due to the universally low quality of the eligible trials, it still needs further large-scale and high-quality randomized controlled trials to verify the effectiveness and safety of moxibustion in the treatment of KOA.

1.2.14.4. Tao 2017 ★★

Tao Si-Yuan, Zheng Jing-Huan, Liang Fan-Rong, Pu Chen, Peng Jie-Ru, Zhang Gui-Ting, Yang Chun-Xia. [Heat-sensitive moxibustion for the treatment of knee osteoarthritis: a systematic review and meta-analysis]. Modern Preventive Medicine. 2017;21:. [52180].

Objective	To compare the effectiveness of heat-sensitive moxibustion (HSM) and traditional moxibustion in the treatment of knee osteoarthritis (KOA), and to provide the basis for the promotion of heat-sensitive moxibustion therapy and the choice of treatment of KOA.
Methods	CNKI, CBM, WF, VIP, PubMed, Medline, Cochrane library Central and Embase were searched for randomized controlled trials (RCTs) which compare heat-sensitive moxibustion therapy with traditional moxibustion. The data were analyzed by using Review Manager 5. 3.
Results	7 RCTs were enrolled. Current clinical researchers showed that, after receiving HSM treatment, patients got lower VAS grade and had apparently improved in joint swelling and stiffness, as well as knee joint function and walking ability (all P < 0. 05), compared with conventional moxibustion. The heat-sensitive moxibustion led to higher effective rate (P < 0. 05) and greater improvement in all outcomes (P > 0. 05).
Conclusion	Heat-sensitive moxibustion therapy is a method which can effectively relieve the symptoms of KOA and improve the knee function of patients. And more high-quality RCTs are needed to confirm the conclusions.

1.2.14.5. Liu 2017 ★

Liu Yue, Xu Jian-Yun, Lin Min. [Moxibustion for the treatment of patients with keen osteoarthritis. A systematic review and Meta-analysis]. Journal of Clinical and Experimental Medicine. 2017;08:. [52057].

Objective	To explore effects of moxibustion intervention for the treatment of patients with osteoarthritis by systematic review.
Methods	Electronic databases, including PubMed, Embase, Cochrane Central Register of Controlled Trials, CINAHL, CNKI and WanFang, were used to search. Randomized controlled trials (RCTs) which met the inclusion criteria were collected. After quality of the RCTs was appraised and the data was extracted, meta-analysis was used in Numerical Rating Scale, SF-36 QoL scale, Western Ontario and Mc Master Universities Questionnaire, WOMAC. All data were analyzed with Revman5. 3. 5.
Results	Seven RCTs were included, the quality of RCTs were moderate. Meta-analysis showed that compared with the control group, moxibustion intervention group had significant improvements in NRS, SF-36 QoL (P <0. 01). While no significant difference was found in terms of WOMAC.
Conclusion	Moxibustion intervention has a positive role in improving patients’ osteoarthritis. But in the future research, it still has to overcome the corresponding methodological defects.

1.2.14.6. Song 2016 ★★★

Song GM, Tian X, Jin YH, Deng YH, Zhang H, Pang XL, Zhou JG. Moxibustion is an Alternative in Treating Knee Osteoarthritis: The Evidence From Systematic Review and Meta-Analysis. Medicine (Baltimore). 2016;95(6):e2790.[186318]

Background	Knee osteoarthritis (KOA) is a common disorder in elderly. There is no known cure for KOA, and thus therapeutic strategies of alleviating symptoms are increasingly emphasized. Moxibustion has been widely used to treat KOA; however, results are inconclusive.
Aim	The aim of our study is to critically reassess the effects of moxibustion on KOA.
Methods	We searched PubMed, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), and Chinese Biomedical Literature database (CBM) through 25 November 2015. Two independent reviewers selected studies and abstracted information, as well as assessed the risk of bias using Cochrane risk of bias tool. The random-effects meta-analyses were performed based on abstracted data. We initially captured 163 citations and added 4 records through checking review.
Results	After critical appraisal, 13 RCTs were included. Meta-analyses indicated that moxibustion is not statistically different from oral drug in improving the response rate (MD = 1.09; 95% CI = 1.00, 1.20; P = 0.05), alleviating pain and improving physical function. Our meta-analysis also found that moxibustion is superior to usual care and sham moxibustion in reducing WOMAC score (MD = 7.56; 95% CI = 4.11, 11.00; P = 0.00), pain and function, as well as increasing QoL. Moreover, most Aes caused by moxibustion can heal without medical care.
Conclusions	We concluded that moxibustion treatment is equal to the oral drugs and intra-articular injections and may be an alternative in treating patients with KOA.

1.2.14.7. Li 2016 ★★

Li A, Wei ZJ, Liu Y, Li B, Guo X, Feng SQ. Moxibustion Treatment for Knee Osteoarthritis: A Systematic Review and Meta-Analysis. Medicine (Baltimore). 2016;95(14):e3244. [186546]..

Objectives	To determine whether the administration of moxibustion is an effective treatment for knee osteoarthritis (KOA).
Methods	We conducted a search of relevant articles using Medline, EMBASE, the Web of Science, and the Cochrane Library published before October 2015. The Western Ontario and McMaster Universities' Osteoarthritis Index (WOMAC scale) and the short form 36 questionnaire (SF-36 scale) were assessed. Evidence grading was evaluated according to the Grading of Recommendations, Assessment, Development and Evaluation system.
Results	Four studies containing 746 participants fulfilled the inclusion criteria in the final analysis. In terms of quality of life (QOL), the meta-analysis of 2 randomized clinical trials (RCTs) showed significantly effects of moxibustion only in bodily pain (BP) compared with those in the control group (n = 348; weighted mean difference [WMD], 4.36; 95% confidence intervals [Cis], 2.27-6.44; P < 0.0001; heterogeneity: χ = 1.53, P = 0.22, I = 34%) in all of the subcategories of the SF-36 scale, with moderate quality. The meta-analysis of the 2 included trials showed that there was not a statistically significant difference in the pain or function subscale for the WOMAC scale when the 2 groups were compared (n = 322; WMD, 17.63; 95% CI, -23.15-58.41; P = 0.40; heterogeneity: χ = 19.42, P < 0.0001, I = 95%), with low or moderate quality separately.
Conclusions	The administration of moxibustion can to some extent alleviate the symptoms of KOA. More rigorous, randomized controlled trials are required in the future.

1.2.14.8. Yu 2015 (heat-sensitive moxibustion)★★

Yu Jun, Xiong Jun. [Systematic evaluation and meta-analysis of clinical effectiveness of heat-sensitive moxibustion for knee osteoarthritis]. Journal of Guangzhou University of Traditional Chinese Medicine. 2015;1:60-66.[187002].

Objective	To evaluate the clinical effectiveness of heat-sensitive moxibustion for knee osteoarthritis (KOA) by systematic evaluation and Meta-analysis methods.
Methods	Electronic information retrieval combined manual retrieval methods were used for collecting clinical randomized control trial of heat-sensitive moxibustion for KOA. The systematic evaluation was conducted by two individual researcher following the principles of Cochrane Review Handbook 5. 1, and RevMan5. 0 software was applied for the statistical analysis.
Results	Fifteen randomized controlled trials (RCT) were enrolled into the analysis, which involved 1228 cases. The results of systematic evaluation showed that the quality of most of the enrolled RCT were not so high. The results of Meta-analysis were as follows: (1) Between heat-sensitive moxibustion and traditional moxibustion, the weighted mean difference (WMD) and 95%confidence index (CI) were-1. 76, [-2. 33, -1. 18] for visual analog scale (VAS) scores (P<0. 001) , were -2. 36, [-3. 42, -1. 30] for the scores of guiding principle of clinical research on new drugs (GPCRND) for KOA (GPCRND-KOA) (P<0. 001) , and were 13. 61, [7. 60, -19. 61]for Lysholm knee joint function scores (P<0. 001), respectively; (2) Between heat-sensitive moxibustion and acupuncture, WMD and 95%CI were 6. 19, [ 0. 01, 11. 37] for Lysholm scores (P<0. 05); (3) Between heat-sensitive moxibustion and warm-needling acupuncture, WMD and 95%CI were -10. 14, [-17. 47, -2. 81] for the Western Ontario and McMaster Universities (WOMAC) osteoarthritis index scores (P<0. 05).
Conclusion	It is indicated that heat-sensitive moxibustion shows certain therapeutic effect for knee osteoarthritis, better than traditional moxibustion.

1.2.15. Combined with Acupoints Bloodletting

1.2.15.1. Fan 2019

Fan Si-Qi, Zeng Ping, Liu Xiong, Chen Jin-Long, Nong Jiao. [A Meta-analysis of Pricking Blood Therapy combined with Acupuncture in the Treatment of Knee Osteoarthritis]. Guiding Journal of Traditional Chinese Medicine and Pharmacy. 2019;2:119-123. [201737].

Objective	To systematic review of the efficacy of pricking blood therapy combined with acupuncture in the treatment of knee osteoarthritis(KAO).
Methods	The literatures on clinical randomized controlled trials of pricking blood therapy for KAO in CNKI, Wanfang database, VIP database, Pubmed database and CBM were searched by computer. The original literatures were screened according to the proposed inclusion and exclusion criteria, and the quality of the literatures was evaluated and Meta-analyzed. Review Manager 5.3 software was used to test the heterogeneity and calculate the OR value and 95% confidence interval of each index.
Results	10 articles were included in the study, 3 of them were high quality research and 7 were low quality research. The cure rate and the total effective rate of OR and 95% CI were: the total effective rate was[OR=4.38, 95%CI(2.63,7.28), P<0.00001], the cure rate was [OR=2.40, 95%CI(1.54, 3.74), P=0.0001]. Among them, there were 577 samples with VAS score as pain index, and the combined effect of mean deviation(MD)of VAS difference before and after treatment was [MD =-1.81, 95% CI(-2.33,-1.28), P <0.000,01], which indicated that pricking blood therapy combined with acupuncture treatment of KOA is better than conventional acupuncture or simple western medicine treatment.
Conclusion	Pricking blood therapy combined with acupuncture has more advantages in the treatment of KOA than conventional acupuncture or western medicine alone. Due to the low quality, small sample size and possible bias of the included studies, more randomized controlled studies with high quality and standardized methodology are needed.

1.2.16. Bee Acupuncture

1.2.16.1. Li 2018

Li Shaowei, Huang Weihan, Pan Yuanle, Ou Jinming, Huang Zhanhui, Liu Haifeng, Huang Mengfen. [A Meta-analysis of Bee-sting Acupuncture in the Treatment of Knee Osteoarthritis]. Journal of Traditional Chinese Medicine. 2018;5:693-696. [201793].

Objective	To systematically evaluate the effect of bee acupuncture on patients with knee osteoarthritis (KOA).
Methods	Computerized comprehensive search of randomized controlled trials (RCTs) published in domestic and international journals on bee acupuncture for treatment of KOA patients. RevMan5.3 Meta-analysis of the software was carried out using the Cochrane Handbook 5.0 standard.
Results	The results were finally included in 7 literatures totaling 481 patients. The results of the meta-analysis showed that bee-needle therapy is more effective than conventional western medicine, ordinary acupuncture, and intermediate frequency electrotherapy. (P<0.05); there was no significant difference in the efficiency of bee acupuncture plus oral Chinese medicine and oral Chinese medicine (P>0.05); the overall efficacy of bee acupuncture was better than other therapies (OR=3.68, 95% CI[2.26, 5.98]).
Conclusion	The treatment of knee osteoarthritis (KOA) with bee acupuncture is effective in improving the symptoms, but higher quality clinical research is needed to support its clinical efficacy.

1.2.17. TENS

1.2.17.1. Rutjes 2009 ∅

Rutjes AW, Nüesch E, Sterchi R, Kalichman L, Hendriks E, Osiri M, Brosseau L, Reichenbach S, Jüni P. Transcutaneous electrostimulation for osteoarthritis of the knee. Cochrane Database Syst Rev. 2009:CD002823.

Background	Osteoarthritis is the most common form of joint disease and the leading cause of pain and physical disability in the elderly. Transcutaneous electrical nerve stimulation (TENS), interferential current stimulation and pulsed electrostimulation are used widely to control both acute and chronic pain arising from several conditions, but some policy makers regard efficacy evidence as insufficient..
Objectives	To compare transcutaneous electrostimulation with sham or no specific intervention in terms of effects on pain and withdrawals due to adverse events in patients with knee osteoarthritis.
Search strategy	We updated the search in CENTRAL, MEDLINE, EMBASE, CINAHL and PEDro up to 5 August 2008, checked conference proceedings and reference lists, and contacted authors..
Selection criteria	Randomised or quasi-randomised controlled trials that compared transcutaneously applied electrostimulation with a sham intervention or no intervention in patients with osteoarthritis of the knee.
Data collection and analysis	We extracted data using standardised forms and contacted investigators to obtain missing outcome information. Main outcomes were pain and withdrawals or dropouts due to adverse events. We calculated standardised mean differences (SMDs) for pain and relative risks for safety outcomes and used inverse-variance random-effects meta-analysis. The analysis of pain was based on predicted estimates from meta-regression using the standard error as explanatory variable.
Main Results	In this update we identified 14 additional trials resulting in the inclusion of 18 small trials in 813 patients. Eleven trials used TENS, four interferential current stimulation, one both TENS and interferential current stimulation, and two pulsed electrostimulation. The methodological quality and the quality of reporting was poor and a high degree of heterogeneity among the trials (I(2) = 80%) was revealed. The funnel plot for pain was asymmetrical (P < 0.001). The predicted SMD of pain intensity in trials as large as the largest trial was -0.07 (95% CI -0.46 to 0.32), corresponding to a difference in pain scores between electrostimulation and control of 0.2 cm on a 10 cm visual analogue scale. There was little evidence that SMDs differed on the type of electrostimulation (P = 0.94). The relative risk of being withdrawn or dropping out due to adverse events was 0.97 (95% CI 0.2 to 6.0).
Reviewer's conclusions	In this update, we could not confirm that transcutaneous electrostimulation is effective for pain relief. The current systematic review is inconclusive, hampered by the inclusion of only small trials of questionable quality. Appropriately designed trials of adequate power are warranted.

1.2.17.2. Osiri 2000 ★★

Osiri M1, Welch V, Brosseau L, Shea B, McGowan J, Tugwell P, Wells G. Transcutaneous electrical nerve stimulation for knee osteoarthritis. Cochrane Database Syst Rev. 2000;(4):CD002823. • Transcutaneous electrostimulation for osteoarthritis of the knee. [Cochrane Database Syst Rev. 2009]

Background	Osteoarthritis (OA) is a disease that affects synovial joints, which mainly causes degeneration and destruction of hyaline cartilage. To date, no curative treatment for OA exists. The primary goals for OA therapy are to relieve pain, maintain or improve functional status, and minimize deformity. Transcutaneous electrical nerve stimulation (TENS) is a noninvasive modality in physiotherapy that is commonly used to control both acute and chronic pain arising from several conditions. A number of trials evaluating the efficacy of TENS in OA have been published.
Objectives	To assess the effectiveness of TENS in the treatment of knee OA. The primary outcomes of interest were those described by the Outcome Measures in Rheumatology Clinical Trials (OMERACT) 3, which included pain relief, functional status, patient global assessment, and change in joint imaging for studies of one year or longer. The secondary objective was to determine the most effective mode of TENS application in pain control.
Search strategy	We searched MEDLINE, EMBASE, CINAHL, HEALTHSTAR, PEDro, Current Contents and the Cochrane Controlled Trial Register using the Cochrane Musculoskeletal Group search strategy for trials up to and including December 1999. We also hand-searched reference lists and consulted content experts.
Selection criteria	Two independent reviewers selected the trials that met predetermined inclusion criteria.
Data collection and analysis	Two independent reviewers extracted the data using standardized forms and assessed the quality of randomization, blinding and dropouts. A third reviewer was consulted to resolve any differences. For dichotomous outcomes, relative risks (RR) were calculated. For continuous data, weighted mean differences (WMD) or standardized mean difference (SMD) of the change from baseline were calculated. A fixed effects model was used unless heterogeneity of the populations existed. In this case, a random effects model was used.
Main Results	Seven trials were eligible to be included in this review. Six used TENS as the active treatment while one study used acupuncture-like TENS (AL-TENS). A number of 148 and 146 patients were involved in the active TENS treatment and placebo, respectively. Three studies were cross-over studies and the others were parallel group, randomized controlled trials (RCTs). Median methodological quality of these studies was two. Pain relief from active TENS and AL-TENS treatment was significantly better than placebo treatment. Knee stiffness also improved significantly in active treatment group compared to placebo. Different modes of TENS setting (High Rate and Strong Burst Mode TENS) demonstrated a significant benefit in pain relief of the knee OA over placebo. Subgroup analyses showed a heterogeneity in the studies with methodological quality of three or more and those with repeated TENS applications.
Reviewer's conclusions	TENS and AL-TENS are shown to be effective in pain control over placebo in this review. Heterogeneity of the included studies was observed, which might be due to the different study designs and outcomes used. More well designed studies with a standardized protocol and adequate number of participants are needed to conclude the effectiveness of TENS in the treatment of OA of the knee.

1.2.18. Dry Needling

1.2.18.1. Lin 2022

Lin X, Li F, Lu H, Zhu M, Peng TZ. Acupuncturing of myofascial pain trigger points for the treatment of knee osteoarthritis: A systematic review and meta-analysis. Medicine (Baltimore). 2022 Feb 25;101(8):e28838. https://doi.org/10.1097/MD.0000000000028838

Background	Osteoarthritis of the knee is one of the major disorders leading to social dysfunction, economic loss and social development. This study was conducted to systematically evaluate the efficacy and safety effectiveness of acupuncture inactivation of myofascial pain trigger points in the treatment of osteoarthritis of the knee.
Methods	Randomized Controlled Trials (RCTs) on the treatment of knee pain were searched by computer from PubMed, The Cochrane Library, China journal full-text database (CNKI), Chinese biomedical literature database (CBM), China academic journal database (Wanfang Data) databases from the date of creation to December 2021, and the data were analyzed by Reman 5.3 software for data analysis.
Results	A total of 724 patients from 9 RCTs were finally included, and the results of meta-analysis showed that the acupuncture myofascial pain trigger point group was better than the control group in terms of total effective rate, cure rate, VAS score, Lysholm score, and WOMAC score.
Conclusion	The efficacy and safety of acupuncturing myofascial pain trigger points in the treatment of knee osteoarthritis is positive, but due to the limited number of literature included in this study and the low quality of the included literature, there is still a need for high-quality and large sample size RCTs for the analysis of this treatment option.

1.2.19. Oriental Medicine

1.2.19.1. Park 2023

Park YC, Park KJ, Goo BH, Kim JH, Seo BK, Baek YH. Oriental medicine as collaborating treatments with conventional treatments for knee osteoarthritis: A PRISMA-compliant systematic review and meta-analysis. Medicine (Baltimore). 2023 Jul 21;102(29):e34212. https://doi.org/10.1097/MD.0000000000034212

Background	We aimed to evaluate the effectiveness and safety of oriental medicine (OM) treatments as monotherapy and add-on therapy compared to conventional treatments for knee osteoarthritis and assess the quality of evidence for these results. OM treatment included acupuncture, herbal medicine, pharmacoacupuncture, and moxibustion.
Methods	PubMed, Embase, Cochrane, Google Scholar, 4 Korean medical databases (KoreaMed, Korean Studies Information Service System, Research Information Service System, and Oriental Medicine Advanced Searching Integrated System), and one Chinese database (China National Knowledge Infrastructure) were searched for articles published between January 1, 2000, and January 1, 2021. Randomized controlled trials (RCTs) investigating the effect of OM interventions, single or combined with conventional treatments, on knee osteoarthritis were searched. The risk of bias and quality of evidence of the included studies were evaluated using the Cochrane Collaboration's risk of bias tool and Grading of Recommendations, Assessment, Development, and Evaluation methods, respectively.
Results	A total of 3911 relevant studies were retrieved and only 23 studies were included for systematic review. Most of the studies showed a significant effect on knee osteoarthritis. 21 studies comparing single OM treatment with conventional treatment were included in the meta-analysis. The effect size of standardized mean difference (SMD) was analyzed as a “small effect” with 0.48 (95% CI -0.80 to -0.16, Z = 2.98, P = .003). In addition, a meta-analysis of 4 studies comparing integrative treatment with conventional treatment showed a “very large effect” with 1.52 (95% CI -2.09 to -0.95, Z = 5.19, P < .001).
Conclusion	Our results suggest that single OM treatment and integrative treatment significantly reduce pain in patients with knee osteoarthritis. However, there is a limited number of RCTs considering integrative treatment which implies more related RCTs should be conducted in the future.

1.3. Special Clinical Forms

1.3.1. Patellofemoral Pain Syndrome

See corresponding item

1.3.2. Postoperative Pain in Knee Surgery

See corresponding item

1.3.3. Gonarthromeningitis

1.3.3.1. Guo 2020

Guo Wei. [Effect of Acupuncture on gonarthromeningitis: A systematic review]. World Journal of Integrated Traditional and Western Medicine. 2020. [212956].

Objective	To systematically review the curative effect of acupuncture on gonarthromeningitis.
Methods	Databases of CNKI, VIP, Wanfang Data, Pub Med, The Cochrane Library, Embase were searched from the inception to July 15 th, 2018. All the Randomized Controlled Trials ( RCTs) on gonarthromeningitis treated by western medicine with electroacupuncture were collected. These RCTs were selected independently by two reviewers according to the pre-designed inclusion and exclusion criteria. The effect was evaluated by using quantitative or descriptive analysis.
Results	The total effective rate was reported in 7 studies, which showed that the total effective rate of acupuncture for gonarthromeningitis is significantly higher than that of western medicine. 3 studies reported pain and function score, indicating that acupuncture could relieve pain and improve the function compared to the control group. 2 studies reported improvement in synovial index, suggesting that acupuncture was superior to the control group in reducing synovial swelling and promoting synovial fluid absorption, but it is equivalent to western medicine in promoting the absorption of inflammatory cytokines. 2 studies reported adverse events, and acupuncture had fewer adverse effects.
Conclusion	Limited evidence suggests that acupuncture has better effect and less adverse reactions compared with western medicine in treating gonarthromeningitis. However, due to the poor quality and large heterogeneity of the included studies, it is recommended that more high-quality and well-designed RCTs be conducted in the future, also studies with better homogeneity should be included to further validate the efficacy of acupuncture in the treatment of gonarthromeningitis.

1.4. Special outcome

1.4.1. Contextual effect

1.4.1.1. Chen 2021

Chen AT, Shrestha S, Collins JE, Sullivan JK, Losina E, Katz JN. Estimating contextual effect in nonpharmacological therapies for pain in knee osteoarthritis: a systematic analytic review. Osteoarthritis Cartilage. 2020;28(9):1154-1169. [220695]. https://doi.org/10.1016/j.joca.2020.05.007

Objective	Conduct a systematic review and use meta-analytic techniques to estimate the proportion of total treatment effect that can be attributable to contextual effects (PCE) in adults receiving nonpharmacological, nonsurgical (NPNS) treatments for knee osteoarthritis (OA).
Design	We reviewed the published literature to identify five frequently studied NPNS treatments for knee OA: exercise, acupuncture, ultrasound, laser, and transcutaneous electrical nerve stimulation (TENS). We searched for randomized controlled trials (RCTs) of these treatments and abstracted pre- and post-intervention pain scores for groups receiving placebo and active treatments. For each study we calculated the PCE by dividing the change in pain in the placebo group by the change in pain in the active treatment group. We log transformed the PCE measure and pooled across studies using a random effects model.
Results	We identified 25 studies for analysis and clustered the RCTs into two groups: acupuncture and topical energy modalities (TEM). 13 acupuncture studies included 1,653 subjects and 12 TEM studies included 572 subjects. The combined PCE was 0.61 (95% CI 0.46-0.80) for acupuncture and 0.69 (95% CI 0.54-0.88) for TEM.
Conclusion	Our findings suggest that about 61% and 69% of the total treatment effect experienced by subjects receiving acupuncture and TEM treatments, respectively, for knee OA pain may be explained by contextual effects. Contextual effects may include the placebo effect, changes attributable to natural history, and effects of co-therapies. These data highlight the important role of contextual effects in the response to NPNS OA treatments.

2. Overviews of Systematic Reviews

2.1. Araya-Quintanilla 2022

Araya-Quintanilla F, Cuyúl-Vásquez I, Gutiérrez-Espinoza H. Does acupuncture provide pain relief in patients with osteoarthritis knee? An overview of systematic reviews. J Bodyw Mov Ther. 2022 Jan;29:117-126. https://doi.org/10.1016/j.jbmt.2021.10.012

Background	Knee osteoarthritis (OA) is the most common condition that causes pain and disability in adults over 50 years old. The application of acupuncture, as a method of complementary intervention, could be beneficial for pain relief and knee function in patients with knee OA.
Objective	Analyze the effectiveness of acupuncture versus control interventions in patients with knee OA.
Methods	An electronic search was performed in the MEDLINE (via PubMed), EMBASE, PEDro, Cochrane CENTRAL, CINAHL, Web of Science and LILACS databases. The eligibility criteria for selecting systematic reviews included clinical trials that compared acupuncture versus control interventions for pain intensity in patients with knee OA.
Results	A total of 15 systematic reviews met the eligibility criteria for the quantitative synthesis. In the short term, the mean difference (MD) for pain intensity was -0.32 cm (95% CI = -0.57 to -0.08, p = 0.01). There was a very low quality of evidence according to the GRADE rating. In the short term, the mean difference (MD) for knee function was -8.74 points (95% CI = -13.36 to -4.12, p ≤ 0.001). There was low quality of evidence according to the GRADE rating. All differences were in favor of acupuncture.
Conclusion	At short-term, there was low to very low evidence and there were statistically significant differences in pain intensity and knee function in favor of acupuncture versus control interventions in patients with knee OA. However, these differences were not clinically important. For the acupuncture versus sham, in the short-term, no differences clinical neither statistically significant to favor of acupuncture in pain intensity and knee function.

2.2. Yin 2022 (moxibustion)

Yin S, Zhu F, Li Z, Che D, Li L, Feng J, Zhang L, Huo Z. An Overview of Systematic Reviews of Moxibustion for Knee Osteoarthritis. Front Physiol. 2022 Feb 3;13:822953. https://doi.org/10.3389/fphys.2022.822953

Background	Currently, many systematic reviews (SRs) of moxibustion as a treatment of KOA have been published. However, the evidence of different SRs of moxibustion to treat KOA has not been comprehensively evaluated.
Aim	This overview aimed to evaluate the existing results and provide scientific evidence of the effectiveness and safety of moxibustion in the treatment of KOA.
Methods	We conducted a comprehensive search of Embase, PubMed, Web of Science, Cochrane Library, SinoMed, CNKI, Wanfang, VIP, and other databases until October 31, 2021. A Measurement Tool to Assess Systematic Reviews 2 (AMSTAR-2) was used to assess the methodological quality of SRs. Preferred Reporting Item for Systematic Reviews and Meta-Analyses was used to evaluate the reporting quality, and the risk of bias in SRs was evaluated by ROBIS Tool. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool to determine the strength of evidence and conducted a meta-analysis of the total effectiveness rate.
Results	Finally, 10 qualified SRs were included, including 57 randomized controlled trials and 5,149 participants. All SRs evaluated by AMASTAR-2 had more than one critical deficiency, so all SRs were rated as critically low. In the PRISMA checklist, the manuscript structures of the included SRs were relatively complete. Including four SRs with a low risk of bias and six with a high risk of bias using the ROBIS tool. In GRADE, two items (6.25%) were rated as high quality, three (9.37%) as medium quality, 17 (53.12%) as low quality and 10 (31.25%) as very low quality. A re-meta-analysis showed that moxibustion and moxibustion combined treatment improved the total effectiveness rate in knee osteoarthritis (risk ratio = 1.17, 95% confidence interval 1.13-1.21, P < 0.001 and risk ratio = 1.13, 95% CI: 1.04-1.23, P < 0.001), with low heterogeneity (I 2 = 36.3%, P = 0.020, and I 2 = 0.0%, P = 0.956). A total of eight SRs reported adverse events, and no serious adverse events occurred in the moxibustion group and control group.
Conclusion	Moxibustion seems to be effective in treating KOA. Four SRs reported 10 common discomfort symptoms caused by moxibustion, and these adverse events can spontaneously subside, even can be avoided, therefore, moxibustion for KOA appears to be safe. However, the reliability of the results is reduced by the high risk of bias of the original studies and the low methodological quality of SRs. Therefore, future studies should pay more attention to the quality of the original study and the evidence quality of the SRs to provide more powerful and scientific evidence of the effectiveness and safety of moxibustion treatment of KOA.

2.3. Chen 2021

Chen J, Liu A, Zhou Q, Yu W, Guo T, Jia Y, Yang K, Niu P, Feng H. Acupuncture for the Treatment of Knee Osteoarthritis: An Overview of Systematic Reviews. Int J Gen Med. 2021 Nov 19;14:8481-8494. https://doi.org/10.2147/IJGM.S342435

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

2.4. Li 2019 ☆☆

Li J , Li YX , Luo LJ , Ye J , Zhong DL , Xiao QW , Zheng H , Geng CM , Jin RJ , Liang FR. The effectiveness and safety of acupuncture for knee osteoarthritis: An overview of systematic reviews. Medicine (Baltimore). 2019;98(28). [200308].

Background	Knee osteoarthritis (KOA), known as severe degenerative arthritis, commonly occurs in middle-aged and elderly people all over the world. Acupuncture as traditional oriental intervention is getting widely used and several systematic reviews (SRs) have reported the effectiveness of acupuncture on pain relief and functional recovery in patients with KOA.
Objective	Conducting an overview of SRs to provide more reliable evidence-based medical references for clinical practitioners and researchers of the effectiveness and safety of acupuncture for KOA.
Methods	DATA SOURCES: EMBASE, Medline, Web of science, the Cochrane library, China National Knowledge Infrastructure, the Chinese Science and Technology Periodical Database, China Biology Medicine, Wan Fang Digital Journals, and PROSPERO databases from inception to December 2018, magazines, websites, and unpublished sources. SELECTION CRITERIA: Potential SRs were independently selected by 2 reviewers following a predetermined protocol. DATA EXTRACTION: Data information of included SRs were independently extracted by 2 reviewers following a predetermined standardized data extraction form. REVIEW APPRAISAL: The risk of bias and reporting quality of included SRs were evaluated by the Risk of Bias in Systematic reviews (ROBIS) tool and the Preferred Reporting Item for Systematic Review and Meta-analysis (PRISMA) statement. The quality of evidence of outcomes was evaluated by the Grading of Recommendations Assessment, Development and Evaluation (GRADE).
Results	A total of 12 SRs were included. All the SRs were published in recent 12 years, ranging from 2006 to 2017. According to ROBIS, 4 SRs were in low risk in domain 1 and 7 in domain 3 of phase 2, and 2 SRs were low risk in phase 3. Among 27 items of PRISMA, 19 items were reported over 70% of compliance. Using GRADE assessment, of 34 outcomes, high quality of evidence was found in 5 outcomes, 17 outcomes were rated moderate quality, and 11 outcomes were low quality. According to high-quality outcomes, acupuncture had more total effective rate, short-term effective rate, and less adverse reactions than western medicine in treating KOA. In terms of Lequesne index and Lysholm knee score scale score, the effectiveness of electroacupuncture was better than that of western medicine.
Limitations	There might be missing information. There may be duplicated clinical trials included by each SR that might have impact on the synthetic findings.
Conclusions	According to the high-quality evidence, we concluded that acupuncture may have some advantages in treating KOA. However, there are some risk of bias and reporting deficiencies still needed to be improved.

2.5. Ferreira 2018 ☆☆

Ferreira RM, Duarte JA, Gonçalves RS. Non-pharmacological and non-surgical interventions to manage patients with knee osteoarthritis: An umbrella review. Acta Reumatol Port. 2018;43(3):182-200. [189056].

Objective	Update the last known umbrella review and summarize the available high-quality evidence from systematic reviews on the effectiveness of non-pharmacological and non-surgical interventions for patients with knee OA.
Methods	The systematic reviews were identified thought electronic databases such as, MEDLINE, Embase, Physiotherapy Evidence Database (PEDro), The Cochrane Library, SciELo, Science Direct, Google Scholar, Research Gate and B-ON. The studies selection respected the following terms to guide the search strategy using the P (humans with knee osteoarthritis) I (non-pharmacological and non-surgical treatments) C (pharmacological, surgical, placebo, no intervention, or other non-pharmacological/ non-surgical conservative treatments) O (pain, functional status, stiffness, inflammation, quality of life and patient global assessment) model.
Results	Following the PRISMA statement, 41 systematic reviews were found on the electronic databases that could be included in the umbrella review. After methodical analysis (R-AMSTAR), only 35 had sufficient quality to be included. There is gold evidence that Standard Exercise programs can reduce pain and improve physical function in patients with knee OA. Additionally, there is silver evidence for Acupuncture, Aquatic Exercise, Electroacupuncture, Interferential Current, Kinesio Taping, Manual Therapy, Moxibustion, Pulsed Electromagnetic Fields, Tai Chi, Ultrasound, Yoga, and Whole-Body Vibration. For other interventions, the quality of evidence is low or did not show sufficient efficacy from the systematic reviews to support their use.
Conclusion	Comparing to last known umbrella review, similar results were achieved on Acupuncture and Exercise interventions to improve the patients' pain, stiffness, function and quality of life, but it was found different results regarding the utilization of Transcutaneous Electrical Nerve Stimulation and Low-Level Laser Therapy as they do not improved the patients' pain and physical function.

2.6. Yang 2017

Yang M, Jiang L, Wang Q, Chen H, Xu G. Traditional Chinese medicine for knee osteoarthritis: An overview of systematic review. PLoS One. 2017;12(12):e0189884. [195757].

Background	Traditional Chinese medicine (TCM) has been accepted as a complementary therapy for knee osteoarthritis. However, the efficacy and safety of the intervention were still conflicting and uncertain. Meanwhile, the quality of methodology and evidence in the field was unknown.
Objective	To summarize the characteristics and critically evaluate the quality of methodology, as well as the evidence of systematic reviews (SRs) on TCM for knee osteoarthritis.
Methods	Five electronic databases were searched from inception to April 2016. The methodological quality of the included studies was assessed by AMSTAR and ROBIS. The quality of the evidence was determined using the GRADE approach.
Results	Ten SRs were included. The conclusions suggest that TCM provides potential benefits for patients with knee osteoarthritis. These benefits include pain relief, functional improvement, and presence of few adverse events. Limitations of the methodological quality mainly included the lack of a-priori protocol or protocol registration and incomprehensive literature search. A list of excluded studies was also not provided. The overall quality of evidence in the SRs was poor, ranging from “very low” to “low,” mainly because of the serious risk of bias of original trials, inconsistencies, and imprecision in the outcomes.
Conclusions	TCM generally appears to be effective for knee osteoarthritis treatment. However, the evidence is not robust enough because of the methodological flaws in SRs. Hence, these conclusions on available SRs should be treated with caution for clinical practice.

3. Cost-effectiveness Analysis

See l'corresponding item

4. Clinical Practice Guidelines

⊕ positive recommendation (regardless of the level of evidence reported)
Ø negative recommendation (or lack of evidence)

4.1. Osteoarthrosis Committee of Chinese Aging Well Association (China) 2024 ⊕

Osteoarthrosis Committee of Chinese Aging Well Association. [Guideline for diagnosis and non-surgical treatment of early-stage knee osteoarthritis (2024 edition)]. Zhonghua Yi Xue Za Zhi. 2024 Aug 13;104(31):2895-2909. https://doi.org/10.3760/cma.j.cn112137-20240503-01035

Recommendation 12: The recommended traditional Chinese medicine techniques for early-stage knee osteoarthritis (EKOA) include acupuncture, needle-knife therapy, auricular acupressure, and massage techniques. (Recommendation Strength: 2, Evidence Level: B)

4.2. China Association for Chinese Medicine (China) 2023 ⊕

Zeng L, Zhou G, Yang W, Liu J. Guidelines for the diagnosis and treatment of knee osteoarthritis with integrative medicine based on traditional Chinese medicine. Front Med (Lausanne). 2023 Oct 17;10:1260943. https://doi.org/10.3389/fmed.2023.1260943

Acupuncture: (Evidence level: Level I, highly recommended). Acupotomy:Evidence level: Level II, highly recommended).

4.3. Hong Kong Physiotherapy Association (HKPA, Hong Kong, China) 2023 ⊕

Al Zoubi FM, Wong AYL, Cheing GLY, Cheung JPY, Fu SN, Tsang HHL, Law RKY, So BCL, Tsang R, Tsang S, Wen C, Wong M, Yau YC, Bussières AE. Adapting a Clinical Practice Guideline for Management of Patients with Knee and Hip Osteoarthritis by Hong Kong Physiotherapists. Healthcare (Basel). 2023 Nov 15;11(22):2964. https://doi.org/10.3390/healthcare11222964

Acupuncture : conditionnaly recommanded

4.4. American Academy of Orthopaedic Surgeons (AAOS, USA) 2021 ⊕

. Management of Osteoarthritis of the Knee (Non-Arthroplasty) (3rd Edition) The American Academy of Orthopaedic Surgeons (AAOS, USA). 2021;:126P. [219883]. URL

Acupuncture. Acupuncture may improve pain and function in patients with knee osteoarthritis. Strength of Recommendation: Limited (downgrade) Evidence from two or more “Moderate” quality studies with consistent findings, or evidence from a single “High” quality study for recommending for or against the intervention. Also requires no or only minor concerns addressed in the EtD framework.

Brophy RH, Fillingham YA. AAOS Clinical Practice Guideline Summary: Management of Osteoarthritis of the Knee (Nonarthroplasty), Third Edition. J Am Acad Orthop Surg. 2022 Apr 5. https://doi.org/10.5435/JAAOS-D-21-01233

Acupuncture. Acupuncture may improve pain and function in patients with knee osteoarthritis. Strength of recommendation: Limited ★★☆☆. (downgrade) Implication: Practitioners should feel little constraint in following a recommendation labeled Limited, exercise clinical judgment, and be alert for emerging evidence that clarifies or helps to determine the balance between benefits and potential harm. Patient preference should have a substantial influencing role

4.5. Société Française de Médecine Physique et de Réadaptation, Société Française de Rhumatologie (SOFMER, SFR, France) 2021 ⊕

Recommandations de la Société Française de Médecine Physique et de Réadaptation et de la Société Française de Rhumatologie. Traitements non-pharmacologiques dans la gonarthrose. 2021. https://seralpar.aphp.fr/sites/default/files/recommandations_non-pharmacologiques_gonarthrose_nguyen_rannou.pdf

Recommandation 8. L’acupuncture pourrait être proposée à visée antalgique non spécifique. Grade 1A-A (niveau de preuve 1A, force de recommandation A)

4.6. Agency for Healthcare Research and Quality (ARQ, USA) 2020 Ø

Skelly AC, Chou R, Dettori JR, Turner JA, Friedly JL, Rundell SD, Fu R, Brodt ED, Wasson N, Kantner S, Ferguson AJR. Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review Update [Internet]. . 2020;:607p. [208656]. doi

Acupuncture: No differences were seen between acupuncture and control interventions (sham acupuncture, waitlist, or usual care) for function in the short term (4 trials) or the intermediate term (4 trials) (SOE: low for short term; moderate for intermediate term). Stratified analysis showed no differences between acupuncture and sham treatments (4 trials) but moderate improvement in function compared with usual care (2 trials) short term. For pain, there were no differences between acupuncture versus control interventions in the short term (6 trials) or clinically meaningful differences in the intermediate term (4 trials) (SOE: low for short term; moderate for intermediate term). Short-term differences in pain were significant for acupuncture versus usual care but not for acupuncture versus sham acupuncture.

4.7. American College of Rheumatology (ACR, USA) 2020 ⊕

Kolasinski SL, Neogi T, Hochberg MC, Oatis C, Guyatt G, Block J, Callahan L, et al. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee. Arthritis Rheumatol. 2020;Jan 6:. [175069]. CrossRef.

Acupuncture is conditionally recommended for patients with knee, hip, and/or hand OA.

4.8. Department of Veterans Affairs Department of Defense (VA/DOD, USA) 2020 Ø

VA/DOD clinical practice guideline for the non-surgical management of hip & knee osteoarthritis. Department of Veterans Affairs Department of Defense. 2020;:127P. [219381]. URL

Recommendation 18. There is insufficient evidence to recommend for or against the use of complementary and integrative health interventions for the treatment of osteoarthritis of the hip or knee, including: Acupuncture Massage Light touch Meditation Tai chi Yoga (Neither for nor against. Reviewed, New-replaced).

4.9. Aetna (insurance provider, USA) 2018 ⊕

Acupuncture. Aetna (insurance provider, USA). 2018. 73P. [188029].

Aetna considers needle acupuncture (manual or electroacupuncture) medically necessary for any of the following indications:Pain from osteoarthritis of the knee or hip (adjunctive therapy)

4.10. Finnish Medical Association and the Finnish Orthopedic Association (Finland) 2018 ⊕

[Osteoarthritis of the knee and hip]. by the Duodecim of the Finnish Medical Association and the Finnish Orthopedic Association. 2018;:20p. [219462]. URL

Acupuncture apparently reduces pain B and improves function B, at least for a short time in osteoarthritis.

4.11. The Royal Australian College of General Practitioners (RACGP, Australia) 2018 Ø

Guideline for the management of knee and hip osteoarthritis. The Royal Australian College of General Practitioners. 2018:82P. [196824]. Technical Document [197845]. URL

Acupuncture – Knee and/or hip We suggest not offering acupuncture (ie traditional, laser, electro) for people with knee and/or hip osteoarthritis (OA). Strength of recommendation: Conditional against recommendation. Quality of evidence : Low (knee) Very low (hip).

GERA comments: Most recent publication included: 2010. Inclusion only of RCTs vs sham. Separate analysis of Acupuncture (4RCTs), Electro Acupuncture (2RCTs) and Laser Acupuncture (3RCTs).

4.12. Canadian Medical Association (CMA, Canada) 2017 ⊕

Lignes directrices canadiennes relatives à l’utilisation des opioïdes pour le traitement de la douleur chronique non cancéreuse, Canadian Medical Association. 2017:110P. [196698].

Recommandation 1: Lorsqu’on envisage le traitement d'un patient atteint de douleur chronique non cancéreuse nous recommandons l’optimisation de la pharmacothérapie non opioïde et du traitement non pharmacologique plutôt qu’un essai d’opioïdes (Recommandation Forte).
Le tableau 2 énumère certains des traitements spécifiques disponibles pour la prise en charge de la douleur chronique non cancéreuse ainsi que les données probantes appuyant chacun de ces traitements .
Douleurs dorsales, ostéo-arthrite du genou, douleurs cervicales, fibromyalgie, céphalées graves ou migraines. Qualité des données probantes : Faible ou très faible. Thérapies dont l’efficacité est appuyée par certaines données probantes : acupuncture, yoga, massothérapie, manipulation rachidienne, manipulation ostéopathique, tai-chi et approches de relaxation peuvent aider certains patients à gérer leur douleur.

4.13. American College of Occupational and Environmental Medicine (ACOEM, USA) 2016 ⊕

Knee disorders. American College of Occupational and Environmental Medicine. 2016. 613P. [189901].

1. Recommendation: Acupuncture for Chronic Osteoarthrosis of the Knee. Acupuncture is moderately recommended for select use for treatment of chronic osteoarthrosis of the knee as an adjunct to more efficacious treatments. Indications - Moderate to severe chronic osteoarthrosis of the knee. Prior treatments should include NSAIDs, weight loss, and exercise, including a graded walking program and strengthening exercises. Should be considered as an adjunct to a conditioning program that has resulted in insufficient clinical response. Frequency/Duration - A limited course of 6 appointments(1187) with clear objective and functional goals to be achieved. Additional appointments would require documented functional benefits, lack of plateau in measures and probability of obtaining further benefits. There is quality evidence suggesting traditional acupuncture needle placement may be unnecessary(1188) and that superficial needling is as successful as deep needling.(1189, 1190) There is evidence suggesting it is not necessary to perform bilateral needling, (1191) although that result has not been replicated. Indications for Discontinuation - Resolution, intolerance, and non-compliance, including noncompliance with aerobic and strengthening exercises. Strength of Evidence - Moderately Recommended, Evidence (B).
2. Recommendation: Acupuncture for Acute or Subacute Knee Pain. There is no recommendation for or against the use of acupuncture for the treatment of acute or subacute knee pain. Strength of Evidence - No Recommendation, Insufficient Evidence (I)

4.14. Osteoarthritis Research Society International (OARSI) 2014 Ø

Mcalindon TE, Bannuru RR, Sullivan MC, Arden NK, Berenbaum F, Bierma-Zeinstra SM, Hawker GA, Henrotin Y, Hunter DJ, Kawaguchi H, Kwoh K, Lohmander S, Rannou F, Roos EM, Underwood M. OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthritis Cartilage. 2014. 22(3):363-88. [171113].

Acupuncture : recommendation uncertain.

4.15. National Institute for Health and Care Excellence (NICE, UK) 2014 Ø

National Clinical Guideline Centre (UK). Osteoarthritis: Care and Management in Adults. London: National Institute for Health and Care Excellence (UK); 2014 Feb. NICE-1 NICE-2

Do not offer acupuncture for the management of osteoarthritis.

4.16. Department of Veterans Affairs, Department of Defense (VA/DoD, USA) 2014 Ø

Non-Surgical Management of Hip and Knee Osteoarthritis Working Group. VA/DoD clinical practice guideline for the non-surgical management of hip and knee osteoarthritis. Washington (DC): Department of Veterans Affairs, Department of Defense. 2014; : 126P. [165832].

In adults with hip and/or knee osteoarthritis, there is insufficient evidence to recommend for or against referral for short term trial needle acupuncture or chiropractic therapy for relief of pain and improved function.

4.17. American Academy of Orthopaedic Surgeons (AAOS, USA) 2013 Ø

Jevsevar DS, Brown GA, Jones DL, Matzkin EG, Manner PA, Mooar P, Schousboe JT, Stovitz S, Sanders JO, Bozic KJ, Goldberg MJ, Martin WR 3rd, Cummins DS, Donnelly P, Woznica A, Gross L; American Academy of Orthopaedic Surgeons.The American Academy of Orthopaedic Surgeons evidence-based guideline on: treatment of osteoarthritis of the knee, 2nd edition.J Bone Joint Surg Am. 2013 Oct 16;95(20):1885-6.AAOS
Hauk L.Treatment of knee osteoarthritis: a clinical practice guideline from the AAOS. Am Fam Physician. 2014 Jun 1;89(11):918-20.

We cannot recommend using acupuncture in patients with symptomatic osteoarthritis of the knee. Strength of Recommendation: Strong

4.18. American College of Rheumatology (ACR, USA) 2012 ⊕

Hochberg MC, Altman RD, April KT, Benkhalti M, Guyatt G, McGowan J, Towheed T, Welch V, Wells G, Tugwell P; American College of Rheumatology. 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 (Hoboken). 2012 Apr;64(4):465-74. [165333]

We conditionally recommend that patients with knee OA should do the following: Be treated with traditional Chinese acupuncture (*).

(*) These modalities are conditionally recommended only when the patient with knee osteoarthritis (OA) has chronic moderate to severe pain and is a candidate for total knee arthroplasty but either is unwilling to undergo the procedure, has comorbid medical conditions, or is taking concomitant medications that lead to a relative or absolute contraindication to surgery or a decision by the surgeon not to recommend the procedure.

4.19. American College of Occupational and Environmental Medicine (ACOEM,USA) 2011 ⊕

American College of Occupational and Environmental Medicine (ACOEM). Knee disorders. Elk Grove Village (IL): American College of Occupational and Environmental Medicine (ACOEM). 2011; :503P. [166091].

Acute, Subacute, or Chronic Knee Pain. Recommended: Acupuncture for select use for chronic osteoarthrosis of the knee as an adjunct to more efficacious treatments (B). No recommendation: Acupuncture for acute or subacute knee pain (I)
Knee Sprains. No recommendation: Acupuncture (I)
Anterior and Posterior Cruciate Ligament Tears. No recommendation: Acupuncture (I)
Meniscal Tears. No recommendation: Acupuncture (I)
Patellar Tendinosis, Patellar Tendinopathy (“Jumpers Knee”), and Anterior Knee Pain. No recommendation: Acupuncture for acute or subacute knee pain (I)
Knee Osteoarthrosis. Recommended: Acupuncture for select use for chronic osteoarthrosis of the knee as an adjunct to more efficacious treatments (B)

4.20. Accident Compensation Corporation 2011 (ACC, New-Zealand) Ø

Hardaker N, Ayson M. Pragmatic Evidence Based Review. The efficacy of acupuncture in the management of musculoskeletal pain. Accident Compensation Corporation (ACC, New-Zealand). 2011. [182414].

There is no evidence to recommend the use of acupuncture for injury-related knee pain.

4.21. National Health and Medical Research Council (NHMRC, Australia) 2009 ⊕

Guideline for the non-surgical management of hip and knee osteoarthritis. National Health and Medical Research Council (NHMRC, Australia). 2009. 70P. [188083].

Recommendation 13 – Acupuncture (Grade C). There is some evidence to support GPs recommending acupuncture for treatment of OA of the knee.

4.22. Osteoarthritis Research Society International (OARSI) 2009 ⊕

Zhang W, Nuki G, Moskowitz Rw, Abramson S, Altman Rd, Arden Nk, Bierma-Zeinstra S, Brandt Kd, Croft P, Doherty M, Dougados M, Hochberg M, Hunter Dj, Kwoh K, Lohmander Ls, Tugwell P. OARSI Recommendations for the management of hip and knee osteoarthritis part iii: changes in evidence following systematic cumulative update of research published through january 2009. Osteoarthritis Cartilage. 2010;18(4):476-99.[155227]

Nine SRs of the use of acupuncture for the treatment of OA published between 2006 and 2009 have confirmed that this non-pharmacological modality of treatment does have some efficacy for relief of pain. Level of Evidence : Ia : méta-analysis of RCTs.

4.23. Royal Australian College of General Practitioners (Australie) 2009 ⊕

Royal Australian College of General Practitioners. Guideline for the non-surgical management of hip and knee osteoarthritis. South Melbourne: the Royal Australian College of General Practitioners. 2009. [168102].

There is some evidence to support GPs recommending acupuncture for treatment of OA of the knee (grade C).

4.24. American Academy of Orthopaedic Surgeons (AAOS, USA) 2009 Ø

Richmond J, Hunter D, Irrgang J, Jones MH, Levy B, Marx R, Snyder-Mackler L, Watters WC 3rd, Haralson RH 3rd, Turkelson CM, Wies JL, Boyer KM, Anderson S, St Andre J, Sluka P, McGowan R; American Academy of Orthopaedic Surgeons.Treatment of osteoarthritis of the knee (nonarthroplasty). J Am Acad Orthop Surg. 2009 Sep;17(9):591-600. [159501]

The work group was unable either to recommend or not recommend the use of acupuncture

4.25. Massachusetts Department of Industrial Accidents (DIA, USA) 2009 ⊕

Knee Injury Conservative Treatment Guideline. Massachusetts Department of Industrial Accidents (DIA). 2009. 4P . [180845].

Acupuncture is commonly used when pain medication is reduced or not tolerated. It may be used as an adjunct to physical rehabilitation and/or surgical intervention for pain relief when there is delayed recovery. 1. Requirements: a. Acupuncture may be authorized when it is ordered by a licensed MD, DC, DO, DO, PA, NP, or PT. The ordering practitioner cannot also be the provider of the service. b. Acupuncture must be performed by an acupuncturist licensed by the Board of Registration in the state where the service will be provided. c. Time to produce effect: six (6) visits in first eight (8) weeks d. After six (6) visits the ordering practitioner may request additional visits if functional clinical progress is documented. Maximum visits are not to exceed sixteen (16) visits in twelve (12) weeks.

4.26. Osteoarthritis Research Society International (OARSI (OARSI PART III)) 2009 ⊕

Henrotin Y, Marty M , Appelboom T , Avouac B , Berenbaum F , Briole V , Djian P et al. Traduction française des recommandations de L’osteoarthritis Research Society International (OARSi) sur la prise en charge de la gonarthrose et de la coxarthrose. Revue du Rhumatisme. 2009;76:279-88. (fra). [165799].

L’acupuncture peut apporter un bénéfice symptomatique aux patients atteints d’arthrose du genou (niveau de preuve Ia).

4.27. Osteoarthritis Research Society International (OARSI PART II) 2008 ⊕

Zhang W, Moskowitz Rw, Nuki G, Abramson S, Altman Rd, Arden N, Bierma-Zeinstra S, Brandt Kd, Croft P, Doherty M, Dougados M, Hochberg M, Hunter Dj, Kwoh K, Lohmander Ls, Tugwell P. OaRSI Recommendations for the management of hip and knee osteoarthritis, part II: oarsi evidence-based, expert consensus guidelines. Osteoarthritis Cartilage. 2008;16(2):137-62. [148159]

Acupuncture may be of symptomatic benefit in patients with knee OA. Level of Evidence : Ia : meta-analysis of RCTs.

4.28. The European League Against Rheumatism (EULAR) 2003 ⊕

Jordan KM, Arden NK, Doherty M, Bannwarth B, Bijlsma JW, Dieppe P et al. EULAR Recommendations 2003: an evidence based approach to the management of knee osteoarthritis. Ann Rheum Dis. 2003;62(12):1145-55. [166418].

Recommendation: acupuncture (level of evidence 1b, Strength of recommendation B)

4.29. National Health and Medical Research Council (Australie) 2003 Ø

Australian Acute Musculoskeletal Pain Guidelines Group. Evidence-based management of acute musculoskeletal pain. Brisbane: Australian Academic Press Pty Ltd. 2003. 259P. [166495].

Anterior Knee Pain. There are no randomised controlled studies evaluating the effect of acupuncture for relief of patellofemoral pain (No Level I or II evidence)

5. Overviews of Clinical Practice Guidelines

5.1. Gibbs 2023

Gibbs AJ, Gray B, Wallis JA, Taylor NF, Kemp JL, Hunter DJ, Barton CJ. Recommendations for the management of hip and knee osteoarthritis: A systematic review of clinical practice guidelines. Osteoarthritis Cartilage. 2023 Oct;31(10):1280-1292. https://doi.org/10.1016/j.joca.2023.05.015

Objectives	Guideline adherence for hip and knee osteoarthritis management is often poor, possibly related to the quality and/or inconsistent recommendations. This systematic review of hip and knee osteoarthritis guidelines aimed to appraise the quality and consistency in recommendations across higher-quality guidelines.
Methods	Eight databases, guideline repositories, and professional associations websites were searched on 27/10/2022. Guideline quality was appraised using the Appraisal of Guidelines for Research and Evaluation II (AGREE II tool) (six domains). Higher quality was defined as scoring ≥60% for domains 3 (rigour of development), 6 (editorial independence), plus one other. Consistency in recommendations across higher-quality guidelines was reported descriptively. This review was registered prospectively (CRD42021216154).
Results	Seven higher-quality and 18 lesser-quality guidelines were included. AGREE II domain scores for higher-quality guidelines were > 60% except for applicability (average 46%). Higher-quality guidelines consistently recommended in favour of education, exercise, and weight management and non-steroidal anti-inflammatory drugs (hip and knee), and intra-articular corticosteroid injections (knee). Higher quality guidelines consistently recommended against hyaluronic acid (hip) and stem cell (hip and knee) injections. Other pharmacological recommendations in higher-quality guidelines (e.g., paracetamol, intra-articular corticosteroid (hip), hyaluronic acid (knee)) and adjunctive treatments (e.g., acupuncture) were less consistent. Arthroscopy was consistently recommended against in higher-quality guidelines. No higher-quality guidelines considered arthroplasty.
Conclusion	Higher-quality guidelines for hip and knee osteoarthritis consistently recommend clinicians implement exercise, education, and weight management, alongside consideration of Non-Steroidal Anti-Inflammatory Drugs and intra-articular corticosteroid injections (knee). Lack of consensus on some pharmacological options and adjunctive treatments creates challenges for guideline adherence. Future guidelines must prioritise providing implementation guidance, considering consistently low applicability scores.

6. Randomized Controlled Trials

6.1. Sources

Acudoc2: RCT included in the GERA Database and not cited in other sources.
ARQ 2020: Skelly AC, Chou R, Dettori JR, Turner JA, Friedly JL, Rundell SD, Fu R, Brodt ED, Wasson N, Kantner S, Ferguson AJR. Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review Update [Internet]. . 2020;:607p. [208656]. doi
ACR 2019: Kolasinski SL, Neogi T, Hochberg MC, Oatis C, Guyatt G, Block J, Callahan L, et al. 2019 American College of Rheumatology/Arthritis Foundation Guideline for the Management of Osteoarthritis of the Hand, Hip, and Knee. Arthritis Rheumatol. 2020;Jan 6:. [175069]. CrossRef.
Vickers 2018: Vickers AJ, Vertosick EA, Lewith G et al, Acupuncture Trialists' Collaboration. Acupuncture for Chronic Pain: Update of an Individual Patient Data Meta-Analysis. J Pain. 2018 May;19(5):455-474. [168043]
Zhang 2017: Zhang Q, Yue J, Golianu B, Sun Z, Lu Y. Updated systematic review and meta-analysis of acupuncture for chronic knee pain. Acupunct Med. 2017;35(6):392-403. [99888].
Lin 2016: Lin X, Huang K, Zhu G, Huang Z, Qin A, Fan S. The Effects of Acupuncture on Chronic Knee Pain Due to Osteoarthritis: A Meta-Analysis. J Bone Joint Surg Am. 2016;98(18):1578-85. [188513].
Hou 2015: Hou PW, Fu PK, Hsu HC, Hsieh CL. Traditional Chinese medicine in patients with osteoarthritis of the knee. J Tradit Complement Med. 2015;5(4):182-196. [184928].
NICE 2014: National Clinical Guideline Centre. Osteoarthritis: care and management; London (UK): National Institute for Health and Clinical Excellence (NICE). 2014. 505P. [188816].
AAOS 2013: Jevsevar DS, Brown GA, Jones DL, Matzkin EG, Manner PA, Mooar P, Schousboe JT, Stovitz S, Sanders JO, Bozic KJ, Goldberg MJ, Martin WR 3rd, Cummins DS, Donnelly P, Woznica A, Gross L; American Academy of Orthopaedic Surgeons.The American Academy of Orthopaedic Surgeons evidence-based guideline on: treatment of osteoarthritis of the knee, 2nd edition.J Bone Joint Surg Am. 2013;95(20):1885-6. [170215].
Corbett 2013: Corbett MS, Rice SJ, Madurasinghe V, Slack R, Fayter DA, Harden M, Sutton AJ, Macpherson H, Woolacott NF. Acupuncture and other physical treatments for the relief of pain due to osteoarthritis of the knee: network meta-analysis. Osteoarthritis Cartilage. 2013;21(9):1290-8. [170471]
Cao 2012: Cao L, Zhang XL, Gao YS, Jiang Y. Needle acupuncture for osteoarthritis of the knee. A systematic review and updated meta-analysis. Saudi Med J. 2012;33(5):526-32.[160091].
Vickers 2012: Vickers AJ, Cronin AM, Maschino AC, et al; Acupuncture Trialists’Collaboration. Acupuncture for chronic pain: individual patient data meta-analysis. Arch Intern Med 2012;172:1444-53. [157530].
Manheimer 2010: Manheimer E, Cheng K, Linde K, Lao L, Yoo J, Wieland S, van der Windt DAWM, Berman BM, Bouter LM. Acupuncture for peripheral joint osteoarthritis. Cochrane Database of Systematic Reviews 2010, CD001977. [154597].

6.2. List

	RCT	Sources
2020	Krusche-Mandl I, Kaider A, Starlinger J, Preschitz M, Schuster R, Kefurt R, Marhofer P, Kasparek M, Hajdu S, Sator-Katzenschlager S. Implementation of Electrical Auricular Acupuncture and Low Frequency Modulated Electric Current Therapy in Pain Management of Patients with Knee Osteoarthritis: A Randomized Pilot Trial. J Clin Med. 2019;8(8). [201047].	Acudoc2
2019	Liu SR, Qiu JQ, Zhang LY, Lin QL, Ye GP, Zhu DY. [Warming acupuncture combined with moxibustion at Yongquan (KI 1) for knee osteoarthritis with kidney-marrow deficiency: a randomized controlled trial]. Chinese Acupuncture and Moxibustion. 2019;39(8):799-803. [200375].	Acudoc2
	Luo X, Hou XS, Tian ZY, Meng X, Li SM, Bai P. [Randomized controlled clinical trial of acupuncture treatment for knee osteoarthritis in the early stage]. Acupuncture Research. 2019;44(3):211-5. [196640].	Acudoc2
	Qiu JQ, Liu SR, Lin QL, Li MJ, Zhuang JX, Wu GW. [Acupuncture combined with cinesiotherapy cupping for knee osteoarthritis with qi stagnation and blood stasis syndrome: a randomized controlled trial]. Chinese Acupuncture and Moxibustion. 2019;39(5):462-6. [197862].	Acudoc2
2018	Li LW, Harris RE, Tsodikov A, Struble L, Murphy SL. Self-Acupressure for Older Adults With Symptomatic Knee Osteoarthritis: A Randomized Controlled Trial. Arthritis Care Res (Hoboken). 2018;70(2):221-229. [190104].	Acudoc2
	Li Zhe, Bai Yu,Yan dong, Gao Yu, Fu Ai-ling. [Effect of Knee Tri -acupucture and Moxibustion Combined with upper-laser Irradiation in the Treatment of Knee Osteoarthritis: Changes Of Biomechanics Parameters of Lower limbs]. Journal of Clinical Acupuncture and Moxibustion. 2018;34(1):33. [187275].	Acudoc2
	Lin LL, Li YT, Tu JF, Yang JW, Sun N, Zhang S, Wang TQ, Shi GX, Du Y, Zhao JJ, Xiong DC, Hou HK, Liu CZ. Effectiveness and feasibility of acupuncture for knee osteoarthritis: a pilot randomized controlled trial. Clin Rehabil. 2018;32(12):1666-1675. [196388].	Acudoc2
	Lü JJ, Yang XC, Ji TT, Xue MX. [Randomized Controlled Clinical Trials of Treatment of Knee Osteoarthritis of Yang-deficiency Pattern by Acupuncture Plus Moxibustion]. Acupuncture Research. 2018;43(10):661-5. [181352].	Acudoc2
	Yuan Yong-Jin, Zhao Yao-Dong, Zhang Guo-Xiao, Zhao Cheng-Zhen. Ma Xue-Jiao, Xue-Yan. [Randomized Controlled trial for The Treatment of Knee Osteoarthritis by The Muscle Meridian Acupuncture]. Chinese Journal of Basic Medicine in TCM. 2018;24(5):662. [180968].	Acudoc2
	Zheng Zhao, Jia-Hong Se, Guang Shi and Ning Li. A randomized controlled trail on the treatment of knee osteoarthritis with acupotomy therapy based on the meridian sinew theory. World Journal of Acupuncture-Moxibustion. 2018;28(4):246. [196834].	Acudoc2
2017	Cao Wen-Ji, Wu Qun, Qu Qun-Wei, Shen Yu-Jie. [A Randomized Controlled Trial of Ozone Injection plus Electrothermal Acupuncture for Treatment of Knee Osteoarthritis] Shanghai Journal of Acupuncture and Moxibustion. 2017;36(6):739-743. [173487].	Acudoc2
	Wang Xiang-Bin, Hou Mei-Jin, Chen- Jian, Li Xiang, Wang Xiao-Ling. [Effect of Electro-acupuncture on Functional Status and Temporospatial Variations during Stair Climbing in Knee Osteoarthritis: A Clinical Randomized Controlled Trial]. Chinese Journal of Basic Medicine in TCM. 2017;23(8):1139. [113434].	Acudoc2
2016	Ding Y, Wang Y, Shi X, Luo Y, Gao Y, Pan J. Effect of ultrasound-guided acupotomy vs electro-acupuncture on knee osteoarthritis: a randomized controlled study. Journal of TCM. 2016;36(4):450-5. [195739].	Acudoc2
	Gang J, Mi Y, Wang H. [Clinical efficacy comparison between electroacupuncture and meloxicam in the treatment of knee osteoarthritis at the early and middle stage: a randomized controlled trial]. Chinese Acupuncture and Moxibustion. 2016;36(5):467-70. [188002].	Acudoc2
	Helianthi DR, Simadibrata C, Srilestari A, Wahyudi ER, Hidayat R. Pain Reduction After Laser Acupuncture Treatment in Geriatric Patients with Knee Osteoarthritis: a Randomized Controlled Trial. Acta Med Indones. 2016;48(2):114-21. [187901].	Acudoc2
	Li Hong-Yu, Zhu Lu-Wen, Wu Xiao-Jun, Ye Tao, Jiang Yun-Fei, Tang Qiang. [Randomized Controlled Trail of Acupuncture plus Keritherapy for Knee Osteoarthritis]. Shanghai Journal of Acupuncture and Moxibustion. 2016;35(8):1001-100. [191499].	Acudoc2
	Tu Xue-Song, Liu Xiao-An, Hu Li-Xia. [Clinically Randomized Controlled Study of Warm Acupuncture in the Treatment of Knee Osteoarthritis]. Journal of Clinical Acupuncture and Moxibustion. 2016;32(6):38-40. [186487].	Acudoc2
	White A, Tough L, Eyre V, Vickery J, Asprey A, Quinn C, Warren F, Pritchard C, Foster NE, Taylor RS, Underwood M, Dieppe P. Western medical acupuncture in a group setting for knee osteoarthritis: results of a pilot randomised controlled trial. Pilot Feasibility Stud. 2016. [190447].	Acudoc2
	Yang Yong-Ju, Zhang Jiang, Lv Shi-Wei, Luo Jia, Guan Xue-Feng. [Randomized Controlled Trial of Point-through-point Electric Acupuncture for Treating Knee Osteoarthritis]. Journal of Clinical Acupuncture and Moxibustion. 2016;32(10):1-4. [188231].	Acudoc2
	Zhao Y, Han D, Liu Q, Zhao Z, Yuan Y, Xue Y. [“Warming-promotion acupuncture” on knee osteoarthritis: a randomized controlled trial]. Chinese Acupuncture and Moxibustion. 2016;36(9):919-922. [192255]	Acudoc2
2015	Liu Min, Lu Peng, Hu You -Pin. [A Clinical Randomized Controlled Trial on Acupuncture with Muscle Meridan Focus for the Treatment of Knee Osteoarthritis] Journal of Clinical Acupuncture and Moxibustion. 2015;31(10):23. [187680].	Acudoc2
	Yan Hai -Lan,Liu Na,Zhao Jin, et al. [A Randomized Controlled Study on the Effect of Acupoint Massage Combined with Moxibustion on Knee Joint Function in Elderly Patients] Journal of Clinical Acupuncture and Moxibustion. 2015;31(11):30. [187710].	Acudoc2
2014	Al Rashoud As, Abboud Rj, Wang W, Wigderowitz C. Efficacy of low-level laser therapy applied at acupuncture points in knee osteoarthritis: a randomised double-blind comparative trial. Physiotherapy. 2014;100(3):242-8. [179468].	Acudoc2
	Ashraf A, Zarei F, Hadianfard Mj, Kazemi B, Mohammadi S, Naseri M, Nasseri A, Khodadadi M, Sayadi M. Comparison the effect of lateral wedge insole and acupuncture in medial compartment knee osteoarthritis: a randomized controlled trial. Knee. 2014;21(2):439-44. [170122].	Acudoc2
	Hinman RS, McCrory P, Pirotta M, Relf I, Forbes A, Crossley KM, et al. Acupuncture for chronic knee pain: a randomized clinical trial. JAMA. 2014;312(13):1313-1322. [142921].	ARQ 2020, ACR 2019, Zhang 2017, Lin 2016
	Li Wei-Dong. [Randomized controlled observation of acupuncture treatment for knee osteoarthritis]. Shanghai Journal of Acupuncture and Moxibustion. 2014;33(10):937. [184830].	Acudoc2
	Plaster R, Vieira Wb, Alencar Fa, Nakano Ey, Liebano Re. Immediate effects of electroacupuncture and manual acupuncture on pain, mobility and muscle strength in patients with knee osteoarthritis: a randomised controlled trial. Acupuncture in Medicine. 2014. [171706]	Acudoc2
2013	Bao F, Zhang Y, Wu ZH, Wang Y, Sheng M, Hu N, Feng F, Wang DH, Zhang YX, LI T, Sun H. [Efficacy observation on knee osteoarthritis treated with electroacupuncture and its influence on articular cartilage with t2 mapping]. Chinese Acupuncture and Moxibustion. 2013;33(3):193-7. [162625].	Acudoc2
	Chen LX, Mao JJ, Fernandes S, Galantino ML, Guo W, Lariccia P, Teal VL, Bowman MA, Schumacher HR, Farrar JT. Integrating acupuncture with exercise-based physical therapy for knee osteoarthritis: A randomized controlled trial. J Clin Rheumatol 19:308-316, 2013. [172631].	ACR 2019, Vickers 2018, Lin 2016
	Cheng Y, Wu K, Cheng Z, Zhu Y, Yang Zg, Ma H, Wang Sw, Jiang Zl. [Randomized controlled study on the treatment of knee osteoarthritis with different acupuncture methods at different stages]. Chinese Acupuncture and Moxibustion. 2013;33(6):508-12. [162521].	Acudoc2
	DQ F, JE L. [Efficacy observation of electroacupuncture and embedding needle on treatment of knee osteoarthritis in the elderly]. Chinese Acupuncture and Moxibustion 2013;33:20–3.	Zhang 2017
	Gao YL, Yao JH, Guo JX. [Clinical observation on fire needles at bones combined with cupping and tuina for knee osteoarthritis]. Chinese Acupuncture and Moxibustion. 2013;33(8):697-9. [162464].	Acudoc2
	Liu K, Tian LF. [Knee osteoarthritis treated with acupuncture at neiguan (PC 6) and taichong (LR 3)]. Chinese Acupuncture and Moxibustion. 2013;33(2):105-8. [162653].	Acudoc2
	Qiu L, Kan JW, Zheng X, Zhang M, Zhang J. [Observation on the long-term efficacy of knee osteoarthritis treated with warm needling and rehabilitation training]. Chinese Acupuncture and Moxibustion. 2013;33(3):199-202. [162623].	Acudoc2
	Saleki M, Ahadi T, Razi M, et al. Comparison of the effects of acupuncture and isometric exercises on symptom of knee osteoarthritis. Int J Prev Med. 2013;4(Suppl 1):S73–7. [170842].	Hou 2015
	Xu L, Jing L, He K, Wang Jl, Wang Y. [treatment of knee osteoarthritis with acupuncture and moxibustion: a randomized controlled trial]. Chinese Acupuncture and Moxibustion. 2013;33(10):871-6. [162412].	Acudoc2
2012	Fu Mu-Yong, Zhang Zhi-Long. Knee osteoarthritis treated with acupuncture based on syndrome differentiation: a randomized controlled trial. World Journal of Acupuncture-Moxibustion. 2012;22(3):11. [167099].	Acudoc2
	Mavrommatis CI, Argyra E, Vadalouka A, Vasilakos DG. Acupuncture as an adjunctive therapy to pharmacological treatment in patients with chronic pain due to osteoarthritis of the knee: A 3-armed, randomized, placebo-controlled trial. Pain 153:1720- 1726. [166557].	ACR 2019, Vickers 2018, Zhang 2017, Hou 2015, Corbett 2013
	Park J, Ty Hopkins J. Immediate effects of acupuncture and cryotherapy on quadriceps motoneuron pool excitability: randomised trial using anterior knee infusion model. Acupuncture in Medicine. 2012;30(3):195-202. [167373].	Acudoc2
	Soni A, Joshi A, Mudge N, Wyatt M, Williamson L. Supervised exercise plus acupuncture for moderate to severe knee osteoarthritis: a small randomised controlled trial. Acupunct Med: journal of the British Medical Acupuncture Society. Sep 2012;30:176e181	Hou 2015
	White P, Bishop FL, Prescott P, Scott C, Little P, Lewith G: Practice, practitioner, or placebo? A multifactorial, mixed methods randomized controlled trial of acupuncture. Pain 2012; 153:455-462.	ACR 2019, Vickers 2018
2011	Dong BQ, Han Y, Cr L, et al. Clinical study on treatment of knee osteoarthritis with long-round needle acupuncture release: a blind, multicenter randomized control study. China J of Trad Chin Med and Pharm 2011;26:1883–5. [203893].	Zhang 2017
	Fu MY, Zhang ZL. Knee osteoarthritis treated with acupuncture at the points selected according to syndrome differentiation: a randomized controlled trial. Chinese Acupuncture and Moxibustion. 2011;31:1062–6. [161646]	Zhang 2017
	Miller E, Maimon Y, Rosenblatt Y, Mendler A, Hasner A, Barad A, et al. Delayed effect of acupuncture treatment in OA of the knee: a blinded, randomized, controlled trial. Evid Based Complement Alternat Med 2011;2011. [792975].	NICE 2014, Corbett 2013
	Zhang Ys, Wang Zx. [Randomized controlled clinical trails for treatment of knee osteoarthritis by warm acupuncture combined with intra-articular injection of sodium hyaluronate]. Acupuncture Research. 2011;36(5):373-6. [159598]
2010	Fan Yuan-Zhi, Gong Li, Yan Juan-Tao. Effects of acupuncture and chinese massage on the functions of knee flexors and extensors in the patients with knee osteoarthritis: randomized controlled trial. World Journal of Acupuncture-Moxibustion. 2010;20(4):29. [165138].	Acudoc2
	Lu TW, Wei IP, Liu YH, et al. Immediate effects of acupuncture on gait patterns in patients with knee osteoarthritis. Chin Med J. Jan 20 2010;123:165e172.	Hou 2015, Corbett 2013
	Suarez-Almazor ME, Looney C, Liu Y, Cox V, Pietz K, Marcus DM, Street RL Jr: A randomized controlled trial of acupuncture for osteoarthritis of the knee: Effects of patient-provider communication. Arthritis Care Res 2010; 62:1229-1236. [155527]. Suarez Almazor M ET AL. A randomised controlled trial of acupuncture for osteoarthritis of the knee : effects of provider communication style. Arthritis Rheum. 2007;56 (supp:s315:739. [149169].	ARQ 2020, ACR 2019, Vickers 2018, NICE 2014, AAOS 2013, Corbett 2013, Cao 2012
	Wang Jinrong, Wang Yongzhi. [Random control study of acupoint injection method for treatment of osteoarthritis of the knee ]. Beijing Journal of TCM. 2010;29(11): 854-856. [186453].	Acudoc2
	Wang SH, Xu MZ, CUI SY, Guo YQ. [Randomised controlled trials on treatment of knee osteoarthritis with acupuncture combined with blood-letting therapy]. Acupuncture Research. 2010;35(2):129-33. [183799].	Acudoc2
2009	Lansdown H, Howard K, Brealey S, MacPherson H. Acupuncture for pain and osteoarthritis of the knee: a pilot study for an open parallel-arm randomised controlled trial. BMC Musculoskelet Disord. 2009;10:130. [203686].	ARQ 2020, ACR 2019, Zhang 2017, NICE 2014, Corbett 2013, Cao 2012
	Miller E, Maimon Y, Rosenblatt Y, Mendler A, Hasner A, Barad A, et al. Delayed effect of acupuncture treatment in OA of the knee: a blinded, randomized, controlled trial. Evid Based Complement Alternat Med 2009. [153188].	Corbett 2013
	Taechaarpornkul W, Suvapan D, Theppanom C, Chanthipwaree C, Chirawatkul A. Comparison of the effectiveness of six and two acupuncture point regimens in osteoarthritis of the knee: a randomised trial. Acupuncture in Medicine. 2009;27(1):3-8. [159578].	AAOS 2013,
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