Factors Associated with the Magnitude Of acUpuncture treatment effectS (FAMOUS): a meta-epidemiological study of acupuncture randomised controlled trials

Clinical effect and contributing factors of acupuncture for knee osteoarthritis: a systematic review and pairwise and exploratory network meta-analysis

OBJECTIVES

This study aims to evaluate (1) the effect and safety of acupuncture in patients with knee osteoarthritis (KOA) and explore (2) whether the effect of acupuncture differed according to acupuncture type, acupuncture dose and follow-up time.

DESIGN

Systematic review and pairwise and exploratory network meta-analysis.

SETTING

PubMed, Embase, Cochrane Central Register of Controlled Trials, Web of Science, China National Knowledge Infrastructure, Chinese Biomedical Literature Database, VIP Database for Chinese Technical Periodicals and Wanfang from inception to 13 November 2023.

PARTICIPANTS

Randomised controlled trials comparing acupuncture with sham acupuncture, non-steroidal anti-inflammatory drugs (NSAIDs), usual care or waiting list groups, intra-articular (IA) injection and blank groups in patients with KOA.

INTERVENTIONS

Eligible interventions included manual acupuncture (MA) and electroacupuncture (EA).

MAIN OUTCOMES MEASURES

The primary outcome was pain intensity at the end of treatment.

RESULTS

80 trials (9933 participants) were included. Very low certainty evidence suggested that acupuncture may reduce pain intensity compared with sham acupuncture (standardised mean difference, SMD -0.74, 95% CI -1.08 to -0.39, corresponded to a difference in Visual Analogue Scale of -18.50 mm, -27.00 to -9.75), NSAIDs (SMD -0.86 -1.26 to -0.46, corresponded to -21.50 mm, -31.50 to -11.50), usual care or waiting list groups (SMD -1.01, -1.47 to -0.54, corresponded to -25.25 mm, -36.75 to -13.50) and blank groups (SMD -1.65, -1.99 to -1.32, corresponded to -41.25 mm, -49.75 to -33.00), but not IA injection. Similar results were also found in other outcomes. For most of the subgroup analyses, acupuncture type, acupuncture dose and follow-up time did not show a significant relative effect. Only when compared with NSAIDs, a higher dose of acupuncture may provide greater pain relief (interaction p<0.001). The network meta-analysis revealed that electroacupuncture (SMD -0.75, 95% CI -1.34 to -0.17) had a greater effect on pain relief in patients with KOA compared with manual acupuncture.

CONCLUSIONS

The findings suggest that acupuncture may provide clinically important effects in reducing pain and improving physical function in patients with KOA, but the certainty of evidence was very low. Electroacupuncture and higher dose of acupuncture probably are two potential contributing factors.

PROSPERO REGISTRATION NUMBER

CRD42021232177.

Factors and Their Impact on Treatment Effect of Acupuncture in Different Outcomes: A Meta-Regression of Acupuncture Randomized Controlled Trials

BACKGROUND

The effects of acupuncture have varied in different randomized controlled trials (RCTs), and there are many factors that influence treatment effect of acupuncture in different outcomes, with conflicting results.

OBJECTIVE

To identify factors and their impact on the treatment effect of acupuncture in different outcomes.

METHODS

Acupuncture RCTs were searched from 7 databases including Medline (PubMed), Embase, Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure, Wanfang Database, VIP Database, and China Biology Medicine disc between January 1st, 2015 and December 31st, 2019. Eligible studies must compare acupuncture to no acupuncture, sham acupuncture, or waiting lists, and report at least 1 patient-important outcome. A multi-level meta-regression was conducted using a 3-level robust mixed model and univariate analyses were performed for all independent variables, even those excluded from the multivariable model due to collinearities. We used thresholds of 0.2 and 0.4 for the difference of standardized mean differences (SMDs), categorising them as small (<0.2), moderate (0.2-0.4), or large (>0.4) effects.

RESULTS

The pain construct analysis involved 211 effect estimates from 153 studies and 14 independent variables. High-frequency acupuncture treatment sessions produced larger effects compared to low-frequency sessions [large magnitude, the difference of adjusted SMDs 0.46, 95% confidence interval (CI) 0.07 to 0.84; P=0.02]. The non-pain symptoms construct analysis comprised 323 effect estimates from 231 studies and 15 independent variables. Penetrating acupuncture showed moderately larger effects when compared to non-penetrating acupuncture (0.30, 95% CI 0.06 to 0.53; P=0.01). The function construct analysis included 495 effect estimates from 274 studies and 14 independent variables. Penetrating acupuncture and the flexible acupuncture regimen showed moderately larger effects, compared to non-penetrating acupuncture and fixed regimen, respectively (0.40, 95% CI 0 to 0.80; P=0.05; 0.29, 95% CI 0.06 to 0.53; P=0.01).

CONCLUSIONS

High-frequency acupuncture sessions appear to be a more effective approach to managing painful symptoms. Penetrating acupuncture demonstrated greater effect in relieving non-painful symptoms. Both penetrating acupuncture type and flexible acupuncture regimen were linked to significant treatment effects in function outcomes. Future studies should consider the factors that are significantly associated with the effects of acupuncture in patient-important outcomes.

Real-world data analysis on effectiveness of integrative therapies: A practical guide to study design and data analysis using healthcare databases

Real world data (RWD) is increasingly used to investigate health outcomes and treatment efficacy in the field of integrative medicine. Due to the fact that the majority of RWDs are not intended for research, their secondary use in research necessitates complex study designs to account for bias and confounding. To conduct a robust analysis of RWD in integrative medicine, a comprehensive study design process that reflects the characteristics of integrative therapies is necessary. In this paper, we present a guide for designing comparative effectiveness RWE research in integrative medicine. We discuss key factors to consider when selecting RWDs for research on integrative medicine. We provide practical steps for developing a research question, formulating the PICOT objectives (population, intervention, comparator, outcome, and time horizon), and selecting and defining covariates with a summary table. Specific study designs are depicted with corresponding diagrams. Finally, data analysis procedures are introduced. We hope this article clarifies the importance of RWE research design and related processes in order to improve the rigor of RWD studies in the field of integrative medicine research.

Placebo response in sham-acupuncture-controlled trials for migraine: A systematic review and meta-analysis

AIM

To understand the placebo response of acupuncture and its effect on migraine and optimize the design of future acupuncture clinical trials on migraine treatment.

METHODS

Randomized controlled trials with sham acupuncture as a control in migraine treatment were searched in four English databases from inception to September 1, 2022. The primary outcome was placebo response rate. Secondary outcomes were migraine symptoms, emotional condition, and quality of life. Factors associated with placebo response were also explored. Results were combined using risk difference (RD) or standardized mean difference (SMD) and 95% confidence interval (CI) with a random effects model.

RESULTS

The final analysis included 21 studies involving 1177 patients. The pooled response rate of sham acupuncture was 0.34 (RD, 95% CI 0.23-0.45, I2 89.8%). The results (SMD [95% CI]) showed significant improvements in migraine symptoms (pain intensity -0.56 [-0.73 to -0.38], and episode conditions -0.55 [-0.75 to -0.35]); emotional condition (anxiety scale -0.49 [-0.90 to -0.08] and depression scale -0.21 [-0.40 to -0.03]); and quality of life on the Migraine-Specific Quality-of-Life Questionnaire (restrictive 0.78 [0.61-0.95]; preventive 0.52 [0.35-0.68]; and emotional 0.45 [0.28-0.62]) and on the Medical Outcomes Study Short-Form (physical 0.48 [0.34-0.62] and mental 0.21 [0.02-0.41]). Only acupuncture treatment frequency had a significant impact on the placebo response rate (RD 0.49 vs. 0.14; p = 0.00).

CONCLUSIONS

The effect sizes for placebo response of sham acupuncture varied across migraine treatment trials. Further studies should routinely consider adjusting for a more complete set of treatment factors.