Acupuncture for osteoarthritis in the UK: A turning point for NICE?

A comparison of the effects of electroacupuncture vs transcutaneous electrical nerve stimulation for pain control in knee osteoarthritis: A protocol for network meta-analysis of randomized controlled trials

BACKGROUND

Knee osteoarthritis (KOA), the most common type of osteoarthritis, is a chronic degenerative joint disease accompanied by pain and functional limitation for the elderly. The 2 nonpharmacologic approaches, electroacupuncture (EA) and transcutaneous electrical nerve stimulation (TENS), are considered beneficial in relieving KOA pain, however, the current conclusions are controversial. Furthermore, no direct or indirect meta-analyses between EA and TENS have been reported for the pain relief of KOA patients.

METHODS

PubMed, EMBASE, Cochrane library, Web of Science, CNKI, VIP, Wan Fang will be systematically searched their inception to May 2018. Randomized controlled trials that compared the effect of EA and TENS on pain control in knee osteoarthritis will be included. The primary outcome was the knee pain levels, and secondary outcome was the comprehensive indicators. Risk of bias assessment of the included studies will be performed according to the Cochrane risk of bias tool. The pairwise and network meta-analysis will be performed by STATA 14.0 software.

RESULTS

This study is ongoing and will be submitted to a peer-reviewed journal for publication.

CONCLUSION

This study will provide comprehensive evidence on the effects of EA and TENS for pain control in knee osteoarthritis.

PROSPERO REGISTRATION NUMBER

CRD42018091826.

Use of acupuncture in the management of pain

Nurses practising in almost any area of healthcare may encounter individuals who are considering acupuncture, particularly those caring for people who are experiencing chronic pain. Acupuncture is a complex intervention and in traditional practice is not simply the insertion of needles, as some people believe. This article provides a historical understanding of acupuncture, outlining some of the differences between styles of practice that may be relevant when selecting an acupuncturist. It also examines the issues that should be considered when assessing the evidence base for acupuncture.

Physiotherapy management of lower limb osteoarthritis

BACKGROUND

Osteoarthritis (OA) of the lower limb affects millions of people worldwide, and results in pain and reduced function. We reviewed guidelines and Cochrane reviews for physical therapy interventions to manage the condition.

SOURCES OF DATA

Evidence from meta-analyses and systematic reviews was included. We also identified the recommendations from guidelines relevant to practice in the UK.

AREAS OF AGREEMENT

There is strongest evidence to support the use of exercise to improve pain, function and quality of life.

AREAS OF CONTROVERSY

There is limited evidence to support the use of some commonly utilized physiotherapy interventions. National Institute for Health and Clinical Excellence do not recommend the use of acupuncture.

GROWING POINTS

Programmes that include single exercise type may be more beneficial than combined strengthening and aerobic interventions.

AREAS TIMELY FOR DEVELOPING RESEARCH

Further research is required to determine how to facilitate long-term engagement with exercise to sustain the beneficial effects on pain, function and quality of life. Studies that investigate packages of care, combining interventions require further investigation.

The U.K. NICE 2014 Guidelines for Osteoarthritis of the Knee: Lessons Learned in a Narrative Review Addressing Inadvertent Limitations and Bias

Several systematic reviews suggest that acupuncture is effective for knee osteoarthritis (OA), and furthermore a safe and cost-effective treatment for this condition. A recent clinical practice guideline (CPG) from the National Institute for Health and Care Excellence (NICE), in the United Kingdom, recommended against the use of acupuncture on the grounds that the effect size (ES) in comparison with sham acupuncture is too small. Safety data were not considered in the review, in addition the levels of evidence for acupuncture against other recommended therapies were not compared. Consequently, it is argued that this NICE guideline has limitations that lead to several potential biases in its evaluation of acupuncture, which were not addressed correctly: (1) NICE's prior scoping process limited its review. (2) NICE introduced the method of developing recommendations based on the consideration of which interventions make "minimal important differences" of an ES of 0.5 or greater, rather than the statistical significance of the effect of an intervention when compared with an appropriate comparison. (3) Evidence that sham acupuncture is not physiologically inert and has some level of beneficial effect, hence artificially reducing the magnitude of the ES in comparison with sham. (4) The low adverse effects profile of acupuncture. (5) Evidence from trials comparing acupuncture with usual or standard care was not considered, nor was cost-effectiveness data. (6) Lack of the usual CPG "head-to-head" comparisons between interventions. If the same criteria and methods that have been applied to acupuncture were applied to other NICE-recommended therapies for knee OA, including patient centeredness, patient education, self-management and weight loss, nonsteroidal anti-inflammatory drug (NSAIDs), and cyclooxygenase-2 inhibitor (COX-2 inhibitors), these too would no longer be recommended and opiates would become the first line of drug prescription. Given the problems with sham acupuncture, perhaps now is the time to embrace pragmatic studies and employ comparative effectiveness studies instead.