Acupuncture

The Acupuncture recommendation has been downgraded two levels because of inconsistent evidence and a lack of internal consistency with recommendations of equal supporting evidence.

A meta-analysis was performed using pain data from five high quality studies (Chen 2013, Suarez-Almazor 2010, Mavrommatis 2012, Berman 2004, Hinman 2014) and two moderate quality studies (Vas 2007, Berman 1999). Acupuncture treatments were either traditional (Chen 2013, Hinman 2014) or electro-acupuncture. (Suarez-Almazor 2010, Mavrommatis 2012, Vas 2007, Berman 2004, Berman 1999) Control groups consisted of either no acupuncture, (Hinman 2014) sham acupuncture, (Mavrommatis 2012, Suarez-Almazor 2010, Vas 2007, Berman 2004) sham TENS (Chen 2013), or usual care. (Berman 1999) The meta-analysis also accounted for the degree of blinding effectiveness of the studies. The results of the meta-analysis can be seen in Figure 11 in the appendix. The overall findings were in favor of acupuncture for reducing pain in subjects with knee osteoarthritis. There appeared to be no effect in two studies where blinding was effective. In studies where there was no blinding or the effects of blinding were unclear, there were greater effects favoring acupuncture. This prompted our decision to apply a limited strength of recommendation in favor of acupuncture for pain control.

A similar meta-analysis was performed using the same studies for measures of function. The results of this meta-analysis can be seen in Figure 12 in appendix. The overall findings were in favor of acupuncture for improving measures of function in subjects with knee osteoarthritis. However, the effects of blinding effectiveness on the results were similar to that described above for pain. Again, this prompted our decision to apply a limited strength of recommendation in favor of acupuncture for improving function.

Some investigators examined variations in delivery of acupuncture treatment. Ju et al. examined high intensity vs low intensity electro-acupuncture and found no difference between these approaches for pain but possibly better improvements in function favoring the high intensity group. (Ju 2015) Others found no meaningful differences between using 2-point, 4-point, or 6-point acupuncture approaches. (Qi 2016, Taechaarpornkul 2009).

Benefits/Harms of Implementation

Many patients receive benefit such as reduced pain and improved function but not all patients respond favorably to treatment. The treatment should be administered by a certified acupuncture practitioner. Common side effects can include soreness and minor bleeding or bruising where needles are inserted. Risk of infection is low if proper procedures are followed. Patients who have a bleeding disorder, pacemaker, or could be pregnant may not be safe candidates for acupuncture and should consult with their physician before having the treatment.

Acceptability

The interventions are considered acceptable, but some individuals may not be enthusiastic about having needles inserted into their skin.

Feasibility

The intervention is feasible provided there is access to a trained practitioner. Not all clinics can provide such access.

Future Research

Continued research is encouraged, with more studies that improve blinding effectiveness in the methodology and studies that may identify patient characteristics that could discriminate between responders and non-responders of this treatment approach.