Chen Elekctroakp Jurnal

The American Journal of Chinese Medicine, Vol. 45, No.
5, 1–21
© 2017 World Scientific Publishing Company
Institute for Advanced Research in Asian Science and Medicine
DOI: 10.1142/S0192415X17500513
Electro-Acupuncture is Beneficial for

Knee Osteoarthritis: The Evidence from
Meta-Analysis of Randomized
by UNIVERSITY OF CALIFORNIA @ SAN DIEGO on 06/30/17. For personal use only.
Controlled Trials
Am. J. Chin. Med. Downloaded from www.worldscientific.com
Na Chen,* Jing Wang,† Attilio Mucelli,‡ Xu Zhang§ and Changqing Wang*

*School of Health Economics and Management
†The
First Clinical Medical College
Nanjing University of Chinese Medicine
Nanjing 210023, P. R. China
‡
School of Economics “Giorgio Fua”
Polytechnic University of Marche,
Ancona 60121, Italy
§JiangsuCollaborative Innovation Center of Traditional
Chinese Medicine Prevention and Treatment of Tumor
Nanjing 210023, P. R. China
Published 29 June 2017
Abstract: 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 con-
trolled trials to objectively assess the effectiveness and safety of EA for KOA. Eight data-
bases 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. Eleven RCTs with
695 participants were included. Meta-analysis indicated that EA was more effective than
Correspondence to: Prof. Changqing Wang, Prof. Xu Zhang and Prof. Attilio Mucelli, School of Health Eco-
nomics and Management, Nanjing University of Chinese Medicine, 138 Xian Lin Road, Nanjing 210023, P. R.
China. Tel: (+86) 25-858-1109, Fax: (+86) 25-858-1109, E-mail: cqwang1962@163.com (C. Wang); Jiangsu
Collaborative Innovation Center of Traditional Chinese Medicine Prevention and Treatment of Tumor, Nanjing
University of Chinese Medicine, 138 Xian Lin Road, Nanjing 210023, P. R. China. Tel: (+86) 25-8581-1058,
Fax: (+86) 25-8581-1058, E-mail: zhangxu@ njucm.edu.cn (X. Zhang); School of Economics “Giorgio Fuà”,
Polytechnic University of Marche, Piazzale Martelli, Ancona 60121, Italy. Tel: (+39) 071-220-7183, Fax: (+39)
071-220-7183, E-mail: attilio.mucelli@gmail.com (A. Mucelli)
1
2 N. CHEN et al.
pharmacological treatment (RR ¼ 1.14; 95% CI ¼ 1.01,1.28; P ¼ 0:03) and manual acu-
puncture (RR ¼ 1.12; 95% CI ¼ 1.02,1.22; P ¼ 0:02). Also, EA had a more significant
effect in reducing the pain intensity (SMD ¼ 1:11; 95% CI ¼ 1:33, 0:88; P <
0:00001) and improving the physical function in the perspective of WOMAC (MD ¼ 9:81;
95% CI ¼ 14:05, 5.56; P < 0:00001) and LKSS (pharmacological treatment: MD ¼ 5:08;
95% CI ¼ 3:52, 6.64; P < 0:00001). Furthermore, these studies implied that EA should be
performed for at least 4 weeks. 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.
Keywords: Electro-Acupuncture; Knee Osteoarthritis; Systematic Review; Meta-Analysis;

Chinese Medicine; Review.
Introduction
Knee osteoarthritis (KOA) is a common chronic disorder of knee and the leading cause of
pain in the elderly (Altman et al., 1996). The incidence of symptomatic KOA is approx-
imately 10% in adults aged 60 years or older in the United States (Zhang and Jordan, 2010)
and 10% of adults older than 55 in the UK (Peat et al., 2001). In China, 19.4% of the
elderly population more than 60 years of age suffer from KOA (Xiang and Dai, 2009). Pain
symptoms related to KOA result in walking and physical disability, low personal self-
efficacy and depression (Doherty, 2001), which in turn impairs the quality of life (QOL)
(Dawson et al., 2005; Palmer et al., 2007) and increases the risk of all-cause mortality (da
Costa et al., 2016). According to the Bulletin of the World Health Organization (Woolf and
Pfleger, 2003), osteoarthritis is predicted to be the fourth leading cause of disability by
2020. Therefore, with the development of an aging society, an improved understanding and
treatment for KOA are urgent and compulsory.
So far, there has been an ongoing debate on intervention options, including pharmaco-
logical, non-pharmacological and alternative treatments (McAlindon et al., 2008), which are
primarily aimed at alleviating the symptoms of the disease and slowing its progression (Zhang
et al., 2008; Ren et al., 2015). Among these treatments, pharmacological treatment, especially
anti-inflammatory drugs and intra-articular hyaluronic acid or corticosteroids (Navarro-Sarabia
et al., 2011; Hou et al., 2015; Richette et al., 2015) were often adopted in clinical practice. And
if the treatment above is ineffective, replacement surgery is commonly recommended (Skou
et al., 2012; Leung et al., 2015). However, anti-inflammatory drugs are associated with serious
adverse reactions in some patients (Hou et al., 2015). In terms of both efficacy and adverse
effects, non-pharmacological treatments including education, exercise and stress reduction
(Burks, 2005) or alternative treatments including acupuncture (Hinman et al., 2014), moxi-
bustion (Ren et al., 2015), pricking cupping (Wang et al., 2016), herbal preparations (Tsai
et al., 2014) and tai chi (Wang et al., 2014) become options for clinicians and KOA patients.
Acupuncture, known as one of the typical therapeutics of alternative treatment (Chen
et al., 2015; Mallory et al., 2015; Pang et al., 2015), has been verified to be effective in
ELECTRO-ACUPUNCTURE FOR KNEE OSTEOARTHRITIS 3
treating the dysfunction and pain of patients with KOA through plenty of randomized
controlled trials (Witt et al., 2005; Manheimer et al., 2010; Hinman et al., 2014) and
systematic reviews (Selfe and Taylor, 2008; Cao et al., 2012). According to the ACR
guidelines on KOA, acupuncture is conditionally recommended (Hochberg et al., 2012)
because of pain relief (Leung, 2012; Choi et al., 2015), safety (Manheimer et al., 2010) and
affordability (Kim et al., 2012). EA is the application of electrical stimulation to the
acupuncture treatment. The procedure includes inserting the needle by hand manipulation
until the deqi reaction, and then providing electric current by attaching an electrode to the
pairs of needles, commonly lasting for 20–30 min (Chen et al., 2013; Liu et al., 2016). So
far, the mechanism of EA for KOA has not been fully illuminated, but some animal
experiments indicated that the EA could reduce the expression levels of the IL-1 in proteins
and IL-1β in mRNA (Fang et al., 1994). Other researchers showed that EA might improve
PROM, decrease the expression of Bax and Caspase-3 proteins of the rectus femoris,
increase the ratio of Bcl-2/Bax protein (Huang et al., 2014) and promote pathological
changes in the cartilage cells (Xi et al., 2016). A recent Cochrane review (Manheimer
et al., 2010) indicated the EA was characterized by significant analgesic effects for people
with KOA than just manual acupuncture. Meanwhile many RCTs (Shen et al., 2015; Gang
et al., 2016) have demonstrated significant efficacy and safety of EA for KOA.
However, the clinical effectiveness of EA for the treatment of KOA remains contro-
versial. There were few systematic reviews of RCTs of EA in treating KOA. Due to the
long history of acupuncture and a large amount of RCTs evidence of EA in the treatment of
KOA, the current meta-analysis aims to critically evaluate the efficacy and safety of EA in
the management of patients with KOA.
Methods
Eligibility Criteria
Studies that met the following criteria were included in the review: (i) studies published in
the Chinese or the English language; (ii) patients that must have been diagnosed with KOA;
(iii) randomized or quasi-randomized clinical trials; (iv) any of the EA that were used.
Studies that met the following criteria were excluded: (i) participants with knee pain,
but no symptoms of KOA; (ii) randomized crossover trials, reviews, case reports, animal
experiments or qualitative studies; (iii) interventions that included a mixed treatment of
more than the EA strategy; (iv) studies comparing interventions grouped under different
forms or different acupuncture points of EA; (v) studies focused on a special syndrome or
stage of KOA.
Outcomes
Effectiveness was the primary outcome analysis of this research, including the percentage
of patients who are cured,markedly improved and improved in their clinical symptoms
(Ji et al., 2015). According to the guiding principles of clinical research on new drugs
4 N. CHEN et al.
of traditional Chinese medicine, the Nimodipine method is adopted to evaluate the effec-
tiveness, which is used to calculate the change in the WOMAC score during the treatment
over the WOMAC score before the therapy. If the percentage is over 80%, it means
“cured”. Meanwhile 50–80% is related to “markedly improved”, and 25–50% stands for
“improved” (Fu, 2013). The secondary outcome was measured by a physical function
index (LKSS or WOMAC) and a pain index (WOMAC-pain or VAS).
Information Sources and Search Strategy

Five English language databases (PubMed, Cochrane Library, Clinic trials, Foreign
Medical Literature Retrial Service (FMRS), Science Direct) and three Chinese language
databases (China National Knowledge Infrastructure (CNKI), Chinese Scientific Journal
Database (VIP), Wanfang Data) were extensively searched until 5 July, 2016. The search
strategy included the following group terms: English (“osteoarthritis, knee” [MeSH Terms]
OR ((osteoarthritis OR arthritis OR arthralgia OR joint disease OR osteoarthrosis OR
gonarthrosis OR degenerative arthritis) AND (knee OR knee-joint)) AND EA); Chinese
((“xiguguanjieyan” OR “xiguxingguanjieyan” OR “xiguguanjiebianxing” OR “xigu-
guanjiezhongda” OR “xiguguanjiezengsheng” OR “xiguguanjiefeida” OR “bizheng” OR
“gubi” OR “xitong” OR “hexifeng” OR “xiyanfeng”) AND “dianzhen”).
Study Selection and Data Collection Process Quality Assessment
Two reviewers (NC and JW) independently screened articles for relevance from the per-
spective of the title and the abstract. Disagreements were discussed with a third reviewer
(CQW). The list of data abstraction included general information (first author, publication
date), diagnostic criteria, patient characteristics (size, age, disease duration before treat-
ment), outcome measurements (effectiveness, VAS, WOMAC-pain index, WOMAC,
LKSS), adverse events, withdrawal and follow up.
According to Standards for Reporting Interventions in Clinical Trials of Acupuncture
(STRICTA) reporting guidelines (Yang et al., 2015), the checklist included details of
needling (acupuncture points, points for electricity, depth of insertion, needle type,
equipment of EA), electro-stimulation regimen (frequency, retention time, course of
treatment) and control interventions was done to improve the completeness of the reporting
of RCTs of EA on KOA.
Assessment of Study Quality and Risk of Bias
Two reviewers (NC and JW) assessed the quality of each trial independently according to
the Cochrane risk of bias tool. Disagreements, if any, were resolved by discussion with a
third reviewer (CQW).
The risk of bias was assessed from seven aspects: sequence generation, allocation
concealment binding of participants and personnel, binding of outcome assessment,
incomplete outcome data, selective reporting and other potential sources of bias. Each
domain was classified as one of the followings: high risk, uncertain risks, or low risk.
Data and Statistical Analyses
Cochrane Collaboration Review Manager software (Rev-Man 5.3) was used for statistical
analysis. The pooled effect was expressed as a mean difference (MD) when the same scale
was used or standard mean difference (SMD) when different scales for the same outcome
were used with 95% confidence intervals (CIs) for continuous outcome, while risk ratio
(RR) was adopted with 95% CIs for a dichotomous outcome. Heterogeneity across studies
was assessed by Cochran’s Q-test with p-value. Furthermore, I 2 statistic was used to
measure the degree of heterogeneity. I 2 values of 75, 50 and 25%, were nominally viewed
as high, moderate and low estimates respectively (Higgins and Thompson, 2002). I 2 <
50% and P > 0:1 indicate homogeneity in the included studies (Song et al., 2016).
In addition, the random effects model was adopted (I 2 =50%) while the fixed effects model
was used (I 2 < 50%) in the qualitative analysis. Based on the prior outcome, subgroup
analysis performed according to various control intervention, was used to investigate the
possible causes from a clinical perspective.
Results
Study Selection
2043 records (1844 records from Chinese databases and 199 records from English data-
bases) were obtained for further study. Following the removal of duplicates, 1523 records
remained. After reading the abstracts and titles, 1435 trials were excluded due to the lack of
relevance. The full text of the remaining 88 articles was analyzed in detail, with 10 papers
finally being included in the meta-analysis. This flow diagram for screening was described
in Fig. 1. One study was conducted in the UK (Tukmachi et al., 2004), while others were
in China (Ku et al., 2009; Wu, 2012; Bao et al., 2013; Fu, 2013; Gao, 2013; Miao et al.,
2014; Wu, 2014; Zhou et al., 2015; Huang et al., 2016).
Study Characteristics
All the trials, including 695 participants (312 in treatment groups and 383 in control
groups), were adopted into the meta-analysis. Four different diagnostic criteria of KOA
were used in the included trials: seven trials (Ku et al., 2009; Wu, 2012; Bao et al., 2013;
Fu, 2013; Gao, 2013; Zhou et al., 2015) used the American College of Rheumatology
guidelines for the medical management of osteoarthritis (ACR criteria), two trials (Miao
et al., 2014; Huang et al., 2016) used the 2007 Chinese Medical Association guidelines for
the diagnosis and treatment of osteoarthritis (CMA criteria-2007), one trail (Wu, 2014)
used the Guiding Principle of Clinical Research on New Drug (GPCRND) and one trial
(Tukmachi et al., 2004) used the Kellgren–Lawrence Grade (K–L grade). The four sets of
6 N. CHEN et al.
Figure 1. Flow diagram of literature retrieval and selection: 2043 potential citations were initially captured and
eventually 10 eligible studies including 11 RCTs were incorporated into our systematic review and meta-analysis.
RCTs ¼ randomized controlled trials.
criteria for KOA were basically similar, mostly depending on the knee joint X-ray and the
diagnosis of clinical manifestation. The average age of patients enrolled in the review
ranged from 35 to 81. Among them, male participants accounted for 44.46%. All of the
included studies demonstrated no significant difference with the baseline. Essential char-
acteristics of the included trails are described in Table 1, while Table 2 presents details of
the EA treatment and the control interventions of studies included in the review.
Table 1. Basic Characteristics of 11 RCTs Included into this Systematic Review and Meta-Analysis
Diagnostic Sample Disease Duration Intergroup Withdrawal/

Included Trials Group Criteria Size (M/F) Age (year)* Before Treatment Outcome Difference Adverse/Follow up
Bao et al. (2013) EA ACR 15(3/12) 55 11 7.2 5.7y LKSS P < 0:05 n.r./n.r./n.r.
Physiotherapy (1995) 15(3/12) 57 2 6.5 4.4y
Fu (2013a) EA ACR 70(34/36) 57.41 10.98 52.33 44.31m 1. Effectiveness 1. P < 0:05 r./n.r./r.
Ibuprofen (1995) 70(39/31) 58.13 11.52 55.27 45.37m 2. SF-36 2. P < 0:01
Fu (2013b) EA ACR 70(34/36) 57.41 10.98 52.33 44.31m 1. Effectiveness 1. P < 0:05 r./n.r./r.
Acupuncture (1995) 68(30/38) 59.36 11.3 50.46 43.32m 2. SF-36 2. P < 0:01
Gao (2013) EA ACR 30(7/23) 64.2 8.03 4.57 1.57y 1. VAS 1. P < 005 n.r./r./n.r.
Glucosamine Sulfate (2000) 30(4/26) 64.97 8.06 4.66 1.34y 2. LKSS 2. P < 0:01
Capsules 3. Effectiveness 3. P < 0:05
Huang (2016) EA CMA 30(13/17) 40–70 1m-10y LKSS P < 0:05 r./n.r./n.r.
Celebrex (2007) 30(14/16) 40–70 n.r.
Ku et al. (2009) EA ACR 20(8/12) 40–81 n.r. 1. WOMAC-pain index 1. P < 0:05 n.r./n.r./n.r.
Tuina (1995) 20(5/15) 47–78 n.r. 2. WOMAC 2. P < 0:05
Miao et al. (2014) EA CMA 35(9/26) 56.3 8.9 6.4 4.2y 1. LKSS 1. P < 0:05 n.r./n.r./n.r.
Celebrex (2007) 35(7/28) 60.4 10.5 6.8 3.3y 2. VAS 2. P < 0:05
Tukmachi et al. (2004) EA K-L 9(3/6) 61 10.3y 1. WOMAC-pain index 1. P < 0:001 n.r./n.r./r.
ELECTRO-ACUPUNCTURE FOR KNEE OSTEOARTHRITIS
Oral-medication grade 10(2/8) 61 9.95y 2. VAS 2. P < 0:001

7
Table 1. (Continued)
Diagnostic Sample Disease Duration Intergroup Withdrawal/

Included Trials Group Criteria Size (M/F) Age (year)* Before Treatment Outcome Difference Adverse/Follow up
Wu (2014) EA GPCRND-KOA 33(33/0) 36–73 20d-2y Effectiveness P < 0:05 n.r./n.r./n.r.

Acupuncture 35(35/0) 35–75 15d-2y
Wu (2012) EA ACR 30(11/19) 60.63 6.44 3.47 1.27y 1. WOMAC-pian index 1. P < 0:05 n.r./n.r./n.r.
Acupuncture (1995) 30(13/17) 59.87 6.77 3.23 1.48y 2. WOMAC 2. P < 0:01
3. Effectiveness 3. P < 0:05
Zhou et al. (2015) EA ACR 40(17/23) 54.6 5.3 17.2 2.2m 1. VAS 1. P < 0:05 n.r./n.r./n.r.
Diclofenac sodium (2001) 40(19/21) 53.8 7.6 15.6 3.0m 2. LKSS 2. P < 0:05
N. CHEN et al.
Note: ACR ¼ American College of Rheumatology, CMA ¼ Chinese Medical Association, GPCRND-KOA ¼ Guiding Principle of Clinical Research on New Drugs in the
Treatment of Knee Osteoarthritis Score, K–L grade: Kellgren–Lawrence grade, EA ¼ Electro-acupuncture, M/F: number of males/number of females, n ¼ number, n.r. ¼ not
reported, r. ¼ reported, RCTs ¼ randomized controlled trials, VAS ¼ visual analog scale, WOMAC ¼ Western Ontario and McMaster Universities Questionnaire, LKSS ¼
lysholm knee score scale, y ¼ year, m ¼ month, d ¼ day.
*Age and duration were shown in mean standard deviation or minimum-maximum or average data.
Table 2. Details of Acupuncture Treatment and Control Interventions of Studies Included in the Meta-Analysis
Details of Needling ES Regimen

Depth of
Insertion/ Needle Type ES ES
Response (Diameter/ Electro- Frequency Duration
Study ID Acupuncture Points Sought Length) Equipment (Hz) (min) Times Control Intervention
Bao et al. Neixiyan (Ex-LE 4), Dubi (ST 35), Heding n.r./De qi 0.3 mm 40 mm KWD-808II 20 20 12 (3 times per Physiotherapy (Computer IF treatment
(2013) (Ex-LE 2), Xuehai (SP 10), Qimen week, for 4 of sine wave, triangle wave and ex-
(LR14), Liangqiu (ST 34), Zusanli weeks) ponential wave alternately, IF
(ST 36) 3000 Hz, the low-frequency 0.5–
EA points: Neixiyan (Ex-LE 4), Dubi (ST 120 Hz for 30 mins, 5 times for four
35) Xiyan (EX-LE5), Yinglingquan weeks)
(SP9), Yanglingquan (GB34), Weiz-
hong (BL40), Heding (EX-LE2)
Fu (2013a, Individualized points: Shenshu (BL23), n.r./De qi 0.35 mm (50– G6805-I n.r. 30 24 (qd, 6 times per Medication (ibuprofen 0.3g bid, 7 days a
2013b) Zhongji (CV3), Xuehai (SP10), 60) mm course for 4 course for 4courses)/MA (same
Chengshan (BL57) or Shenshu courses) pints, 6 days a course for 4 courses)
(BL23), Dachangshu (BL25), Zusanli
(ST36), Sanyingjiao (SP6) or Shenshu
(BL23), Taixi (K3), Diji (SP8), Feng-
long (ST40)
EA points: Xiyan (EX-LE5), Yinglingquan
(SP9), Yanglingquan (GB34)
Gao (2013) Xiyan (EX-LE5), Xuehai (SP 10), Liang- n.r./De qi 0.3 mm 40 mm ZJ-12H n.r. 40 24 (qd, 6 times per Glucosamine Sulfate Capsules 0.628 g
qiu (ST 34), Zusanli (ST 36), Ashi week, and 4 tid, 2 weeks a course for 4 weeks
points of lesion side, Hegu (LI 4) and weeks per
Taichong (LR 3) of bilateral side course)
Individualized points: Quchi (LI11), Gua-

nyuan (RN4), Sanyingjiao (SP6),
Yinglingquan (SP9), Yanglingquan
(GB34), Qiuxu (G40), Taixi(K3)
EA points: Xiyan (EX-LE5), Xuehai (SP
10), Liangqiu (ST 34), Zusanli (ST
36), Taichong (LR 3)
9
10
Depth of
Huang Xiyan (EX-LE5), Xuehai (SP 10), 2-3 cm/De qi 0.3 mm 50 mm G6805-II 2 30 12 (3 times per Celebrex 0.2 g qd, for 4 weeks
(2016) Liangqiu (ST 34) week, for 4
EA points: Neixiyan (Ex-LE 4) 1 , Xuehai weeks)
(SP 10) 1
Liangqiu (ST 34) 2 , Waixiyan (EX-LE5) 2
Ku et al. Neixiyan (Ex-LE 4), Dubi (ST 35), Ququan n.r./n.r. 0.25 mm G6805 5 20 15 (once every Tuina (5 min of Na-grasping manipula-
(2009) (LR 8), Zusanli (ST 36), Liangqiu (ST 40 mm other day, for tion at a frequency of 60 times per
34), Xuehai (SP 10), Heding (Ex-LE 2), 1 month) minute þ 5 min of Gun-rolling ma-
Yanglingquan (GB 34), Taixi (KI 3), nipulation at a frequency of 80 times
Xuanzhong (GB 39), Xiyangguang per minuteþ5 min of one-thumb
(GB 33), Xiguan (LR 7), Ashi points pushing at a frequency of 100 times
EA points: two pairs of points were per minute. Follow this with 5 min of
selected each time tolerable Tan Bo-plucking manipu-
N. CHEN et al.
lation at a frequency of 100 times per

minute. Then, apply 20 times of
passive flexion and extension of the
knee-joint. Finally, apply 5 min of
Ca-rubbing manipulation to the knee
joint at a frequency of 80 times per
minute. The treatment was carried
out for1 month, once every other day,
30 min for each treatment)
Miao et al. NeiXiyan (EX-LE4), Xuehai (SP 10), n.r./De qi 0.3 mm 50 mm G6805-II 20 30 30 (qd, 10 days a Celebrex 0.2 g qd for 30 days
(2014) Liangqiu (ST 34) of bilateral side course,for 30
EA points: Neixiyan (Ex-LE 4) 1 , Xuehai days)
(SP 10) 1
Liangqiu (ST 34) 2 , Waixiyan (EX-LE5) 2

Depth of
Tukmachi Hegu (LI4), Xuehai (SP10), Xiyan (EX- 1–1.5 cm/ 0.25 mm/30 mm AS Super 4 6 20 10 (2 per week, for Medication (current medication, n.r.)
et al. LE5), Yinglingquan (SP9), Liangqiu Deqi 5 weeks)
(2004) (GB34), Zusanli (ST36),Taichong
(LR3), Weizhong (BL40), Chengshan
(BL57)
EA points: Xiyan (EX-LE5) 1 , Yinglingquan
(SP9) 2 , Liangqiu (GB34) 2 , Weizhong
(BL40) 3 , Chengshan (BL57) 3
Wu (2014) Yanglingquan(GB 34), Liangqiu(ST 34), 0.5–0.8 inch/ 1.5-inch needle G6805 2 (Rarefac- 20 10 (2 per week, for Manual acupuncture (same points) for
Xuehai(SP 10), Zusanli(ST 36), Yin- Mild tion) 60 5 weeks) 20 minutes
glingquan(SP 9), Neixiyan(Ex-LE 4), swelling (Dense
Dubi(ST 35), Heding(Ex-LE 2), wave)
Weizhong(BL40), Ashi points
EA points: n.r.
Wu (2012) Neixiyan (Ex-LE 4), Dubi (ST 35), Xuehai n.r./n.r. 0.3 mm 50 mm KWD-808I n.r. 30 26 (qd, 6 times per Manual acupuncture (Neixiyan (Ex-LE
(SP 10), Liangqiu (ST 34) course, for 30 4), Dubi (ST 35), Yanglingquan
EA points: cross-connect Neixiyan (Ex-LE days) (GB 34), Zusanli (ST 36), Liangqiu
4), Dubi (ST 35), Xuehai (SP 10), (ST 34), Xuehai (SP 10)) for
Liangqiu (ST 34) 30 minutes
Zhou et al. Xiyan (EX-LE5), Dubi (ST 35), Heding n.r./De qi 0.25 mm n.r. 2 20 28 (qd, 14 times Diclofenac sodium 0.05 g qd, for
(2015) (Ex-LE 2), Zusanli (ST 36), fang- 40 mm per course, for 28 days
shijingyanxue (Medial bone gap of 45 2 courses)
degree when your knees bend 90 de-
gree), Juegu (GB 39)
EA points: n.r.
Note: EA ¼ electro-acupuncture, ES ¼ electrical stimulation, Hz ¼ hertz, min ¼ minutes, n.r. ¼ not reported, qd ¼ once a day, bid ¼ twice a day, tid ¼ three times a day, qid
11
¼ four times a day. 1first pair of electrodes, 2second pair of electrodes, 3third pair of electrodes.
12 N. CHEN et al.
Assessment of Risk of Bias and Quality of Studies
The risk of bias assessment is shown in Fig. 2. Six RCTs (Tukmachi et al., 2004; Wu,
2012; Bao et al., 2013; Fu, 2013; Gao, 2013) reported the specific method of the random
sequence generation with a random number table, while one RCT (Zhou et al., 2015) refers
to simple randomized method. Only one RCT (Tukmachi et al., 2004) performed the
appropriate concealment of the allocation using sealed envelopes, double-blind strategy
and outcome assessment, with the remainder providing incomplete information. The out-
come data of all RCTs were complete. Even if some RCTs mentioned the dropout or
withdrawal, the number and reasons existed at the same time.
(A) Risk of bias graph
(B) Risk of bias summary
Figure 2. Assessment of risk of bias: (A) risk of bias graph and (B) risk of bias summary.
Effectiveness: Results of Meta-Analysis
Among all eligible RCTs, five reported the effectiveness as dichotomous data in which
control regimens included pharmacological treatment (Fu, 2013; Gao, 2013) or manual
acupuncture (Wu, 2012; Fu, 2013; Wu, 2014). Therefore, we performed subgroup to
analyze these data. Pooled analysis of 233 patients in the EA group, 100 in pharmaco-
logical treatment group and 133 in manual acupuncture group revealed that EA showed a
better effect comparing with the other medication (pharmacological treatment: RR ¼ 1.14;
95% CI ¼ 1.01, 1.28; P ¼ 0.03; heterogeneity: I 2 ¼ 0%, P ¼ 0:72; manual acupuncture:
RR ¼ 1:12; 95% CI ¼ 1:02, 1.22; P ¼ 0:02; heterogeneity: I 2 ¼ 0%, P ¼ 0:58) (Fig. 3).
Pain Intensity: Results of Meta-Analysis

For pain intensity, four studies (Tukmachi et al., 2004; Gao, 2013; Miao et al., 2014; Zhou
et al., 2015) adopted VAS while three (Tukmachi et al., 2004; Ku et al., 2009; Wu, 2012)
measured by WOMAC-pain index. Among them, Tukmachi adopted both of the index to
assess the pain intensity. Due to the different scales for the same outcome, we adopted the
SMD model. The result implied that EA group experienced a greater reduction in pain
intensity than those who received other medications (SMD ¼ 1:11; 95% CI
¼ 1:33, 0:88; P < 0:00001; heterogeneity: I 2 ¼ 41%, P ¼ 0:11) (Fig. 4).
Physical Function: LKSS
LKSS was available in five studies (Bao et al., 2013; Gao, 2013; Miao et al., 2014; Zhou
et al., 2015; Huang et al., 2016). Meta-analysis revealed that EA significantly improved
the physical function in comparison to the other medications when looking at their LKSS
Figure 3. The forest plot: Effectiveness of electro-acupuncture versus pharmacological treatment and manual
acupuncture.
14 N. CHEN et al.
Figure 4. The forest plot: pain intensity of electro-acupuncture versus other treatment.
score improvement (pharmacological treatment: MD ¼ 5:08; 95% CI ¼ 3:52, 6:64; P <

0:00001; heterogeneity: I 2 ¼ 23%, P ¼ 0:27; other alternative treatments (physiotherapy):
MD ¼ 11; 95% CI ¼ 1:95, 20:05; P ¼ 0:02) (Fig. 5).
Physical Function: WOMAC
As shown in Table 1, only two trials (Ku et al., 2009; Wu, 2012) mentioned WOMAC
scores (MD ¼ 9:81; 95% CI ¼ 14:05, 5:56; P < 0:00001; heterogeneity:
I 2 ¼ 5%, P ¼ 0:30) (Fig. 6). The result was homogenous and a fixed effects model was
applied to illustrate that EA was better at decreasing the WOMAC score than other
alternative treatments.
Adverse Events and Follow Up
As shown in Table 1, six trials (Wu, 2012; Fu, 2013; Gao, 2013; Zhou et al., 2015; Huang
et al., 2016) mentioned withdrawal criteria and two trials (Fu, 2013; Huang et al., 2016)
reported withdrawal cases. Furthermore, two trials (Tukmachi et al., 2004; Fu, 2013)
Figure 5. The forest plot: Lysholm scores of electro-acupuncture versus pharmacologic and other alternative
treatment: fixed-effects analysis.
Figure 6. The forest plot: The total WOMAC scores of electro-acupuncture versus other treatment.
mentioned follow-up. Only one trial mentioned adverse effects. Gao (Gao, 2013) reported
the adverse effects of the EA treatment versus Glucosamine Sulfate Capsules. Among 30
patients in the EA group, only one had the mild symptom of fainting, which was a common
phenomenon during the acupuncture treatment. Comparatively, four patients out of the 30
suffered from serious adverse effects in the control group, experiencing symptoms that
included nausea, abdomen distends or constipation.
Discussion
Summary of Evidence
A total of 10 studies involving 695 participants examining the effects of EA treatment on

the management of KOA were identified in this review. All trials used EA individually in
the experimental group, while the interventions for the control group used other routine
treatments, such as pharmacological treatments (Ibuprofen, Celebrex, Diclofenac sodium,
Glucosamine Sulfate) and alternative treatments (Physiotherapy, Acupuncture, Tuina). The
pooled result suggested that the EA treatment was more efficient than the other routine
treatments in the aspects of effectiveness, pain intensity and physical function. In the
analysis of effectiveness, about 91.4% (213/233) of patients could acquire significant
benefits from EA in comparison to the 79% (79/100) from pharmacological treatments and
82.7% (110/133) from the manual acupuncture. In terms of pain intensity, four studies
(Tukmachi et al., 2004; Gao, 2013; Miao et al., 2014; Zhou et al., 2015) reported positive
results using the VAS, while three studies (Tukmachi et al., 2004; Ku et al., 2009; Wu,
2012) adopting WOMAC-pain index, indicating that EA could obviously relieve the pain
of KOA patients. Meanwhile EA remarkably improved the physical function ability, as
reported in the WOMAC (Ku et al., 2009; Wu, 2012) or LKSS (Bao et al., 2013; Gao,
2013; Miao et al., 2014; Zhu et al., 2015; Huang et al., 2016). Furthermore, it should be
noted that no serious adverse event was reported in any of the EA groups, except the mild
symptom of fainting during acupuncture treatment (Gao, 2013). The percentage of the
adverse events of EA versus other treatments was 3.3% to 13.3%. An in-depth descriptive
study based on the 11 RCTs indicated the following details from the clinical trials. The
main acupuncture points were Xiyan (EX-LE5), Xuehai (SP 10), Liangqiu (ST 34) and
Zusanli (ST 36), in which EA points were Xiyan (EX-LE5), Xuehai (SP 10) and Liangqiu
(ST 34). The individual acupuncture points were associated with different syndromes, stage
and basic characteristic of patients. In addition, EA should last for at least four weeks and
20–30 min per course.
16 N. CHEN et al.
Previous meta-analyses of alternative treatments on KOA focused on the Chinese Herbal

Formula (Zhu et al., 2015; Chen et al., 2016), Chinese herbal medicine (Zhang et al., 2016a),
tai chi (Xie et al., 2015), acupotomy (Liu et al., 2012) and Moxibustion (Li et al., 2016; Song
et al., 2016). Meanwhile there were many meta-analyses about EA in different diseases,
including stroke (Liu et al., 2015) and depression (Zhang et al., 2016b). To the best of our
knowledge, there were a few systematic reviews of RCTs of EA in treating KOA. In this
circumstance, our review will offer a systematic objective evaluation of EA for KOA.
Limitations
The limitations include the bias of the included trials, the decision to pool the results, the
deficiency of QOL and the depth of needle insertion, might have interfered with our
findings in this study. As stated above, the primary limitation was the risk of bias. All of the
eligible studies mentioned randomization, but only six studies declared the specific
methods of random sequence generation and one study described that they adopted a
simple randomized method. Allocation concealment and blinding strategy were only de-
scribed in one study, while others were unclear. The reason might be that the EA is widely
used for the treatment of KOA in China and has a long history. However, not only tertiary
referral centers, but also small hospitals had the clinical research, in which some were pilot
scheme. What is more, the treatment duration of the included trials was short, varying from
four weeks to five weeks. Only one study explicitly mentioned a nine-week follow-up
study. But according to a recent review, in order to avoid diluting the effects of acu-
puncture, continuing treatment is recommended (Manheimer et al., 2010). Another limi-
tation was the method to pool the results of the RCTs. The diversified treatments were used
in the control group. Even if we performed the subgroup analysis, we could not analyze
them comprehensively, such as the different oral drugs with various pharmacological
functions and so on. A further limitation was that the criteria of effectiveness merely
focused on the pain and functional scales measured by VAS, WOMAC and LKSS.
However, QOL is becoming an important factor to evaluate the effectiveness of the
medication on KOA nowadays (Li et al., 2016; Song et al., 2016). In addition, it was
verified that the depth of needle insertion was a mystery of the acupuncture technique
whether in Neijing (internal Classic) and Nanjing (Classic of Medical Problems) (Li and
Shi, 2015) or in current scientific research (Perez et al., 2016). Moreover, some literature
research showed that the depth of needle insertion, angle and direction were the three key
factors in acupuncture analgesia (Fan et al., 2010). Therefore, the depth of needle insertion
may also be a limitation, which affects the evaluation of our conclusion since the insertion
depth was expressed clearly only in three out of the 10 articles. Finally, a publication bias
was not performed due to the inadequate number of eligible studies.
Implications for Practice
In an aging society, our conclusion could not only provides new insights for the patients
and the medical staff of KOA, but also offers suggestions for the government in making
policy and guidance for KOA. Our meta-analysis certificated 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. According to the evidence of clinical experiences, EA is an
economical treatment which is especially suitable for the chronic disease. Conclusively,
EA is cost-effective clinical therapy, which will ease the economic burden placed on
patients and improve their quality of life.
Implications for Research

More research, especially those with rigorous methods of design, measurement and eval-
uation (DME) (Zhang et al., 2016a) following the Cochrane Handbook, is needed to
evaluate the long-term effects of EA for KOA. Furthermore, consideration of the treatment
associated with the specific syndrome or level of KOA is necessary to find the best choice
for subgroups. In addition, the details of EA, including the depth of needle insertion, angle
and direction are worthy of further investigation. If possible, the CEA should be applied to
conduct a comprehensive quantitative research to evaluate the effectiveness of EA on KOA
from the perspective of the economy.
Conclusions
This review indicates that EA has had considerable clinical effects in the treatment of KOA
with no serious adverse effects. Based on the meta-analyses, EA has more significant
advantages for relieving pain and improving the comprehensive function than pharmaco-
logical treatments and manual acupuncture. But the limitations mentioned above still exist
which may influence the effects found in our systematic review. Therefore, future studies
and actual clinical practice should be designed strictly and comprehensively to guarantee
definitive conclusions about the efficacy of EA in the treatment of KOA.
Acknowledgments
The project was supported by the grant of National Social Science Foundation of China
(No. 15CRK015); National Nature Science Foundation of China (No. 71573139) and
grants from the People Program (Marie Curie Actions) of the European Union’s Seventh
Framework Program FP7/2007-2013/under REA Grant (No. PIR SES-GA-2013-612589).
We are grateful to those contributors who offered any help in the article.
References
Altman, R., K. Brandt, M. Hochberg, R. Moskowitz, N. Bellamy, D.A. Bloch, J. Buckwalter,

M. Dougados, G. Ehrlich, M. Lequesne, S. Lohmander, W.A. Murphy, Jr., T. Rosario-Jansen,
B. Schwartz and S. Trippel. Design and conduct of clinical trials in patients with osteoarthritis:
Recommendations from a task force of the osteoarthritis research society. Osteoarthr. Cartil.
4: 217–243, 1996.
18 N. CHEN et al.
Bao, F., Y. Zhang, W.Z. Hong, Y. Wang, M. Sheng, N. Hu, F. FENG, D.H. Wang, Y.X. Zhang, T.
Li and H. Sun. Efficacy observation on knee osteoarthritis treated with electro-acupuncture
and its influence on articular cartilage with T2 mapping. Chin. J. Acupunct. 33: 193–197,
2013.
Burks, K. Osteoarthritis in older adults: Current treatments. J. Gerontol. Nurs. 31: 11–19, 2005.
Cao, L., X.L. Zhang, Y.S. Gao and Y. Jiang. Needle acupuncture for osteoarthritis of the knee. A
systematic review and updated meta-analysis. Saudi. Med. J. 33: 526–532, 2012.
Chen, B., H. Zhan, J. Marszalek, M. Chung, X. Lin, M. Zhang, J. Pang and C. Wang. Traditional
Chinese medications for knee osteoarthritis pain: A meta-analysis of randomized controlled
trials. Am. J. Chin. Med. 44: 677–703, 2016.
Chen, C.Y., M.D. Ke, C.D. Kuo, C.H. Huang, Y.H. Hsueh and J.R. Chen. The influence
of electro-acupuncture stimulation to female constipation patients. Am. J. Chin. Med. 41:

301–313, 2013.
Chen, F.P., C.M. Chang, J.H. Shiu, J.H. Chiu, T.P. Wu, J.L. Yang, Y.Y. Kung, F.J. Chen, C.M.
Chern and S.J. Hwang. A clinical study of integrating acupuncture and Western medicine in
treating patients with Parkinson’s disease. Am. J. Chin. Med. 43: 407–423, 2015.
Choi, J.W., S.Y. Kang, J.G. Choi, D.W. Kang, S.J. Kim, S.D. Lee, J.B. Park, Y.H. Ryu and H.W.
Kim. Analgesic effect of electroacupuncture on paclitaxel-induced neuropathic pain via spinal
opioidergic and adrenergic mechanisms in mice. Am. J. Chin. Med. 43: 57–70, 2015.
da Costa, B.R., S. Reichenbach, N. Keller, L. Nartey, S. Wandel, P. Juni and S. Trelle. Effectiveness
of non-steroidal anti-inflammatory drugs for the treatment of pain in knee and hip osteoar-
thritis: A network meta-analysis. Lancet. 387: 2093–2105, 2016.
Dawson, J., L. Linsell, K. Zondervan, P. Rose, A. Carr, T. Randall and R. Fitzpatrick. Impact of
persistent hip or knee pain on overall health status in elderly people: A longitudinal population
study. Arthritis Rheum. 53: 368–374, 2005.
Doherty, M. Risk factors for progression of knee osteoarthritis. Lancet. 358: 775–776, 2001.
Fan, G.Q., Y. Zhao and Z.H. Fu. Acupuncture analgesia and the direction, angle and depth of needle
insertion. Chin. J. Acupunct. 30: 965–968, 2010.
Fang, J.Q., Y.L. Liu and X.M. Mo. Clinical and experimental studies on analgesic effects of ipsi-
lateral and contralateral stimulations with electro-acupuncture. Chin. J. Integr. Med. 14: 579–
582, 1994.
Fu, M.Y. Treating knee osteoarthritis with dialectical acupoint selection and electro-acupuncture: A
randomized controlled study. Tianjin J. Tradit. Chin. Med. 30: 597–600, 2013.
Gang, J., Y. Mi and H. Wang. Clinical efficacy comparison between electroacupuncture and
meloxicam in the treatment of knee osteoarthritis at the early and middle stage: A randomized
controlled trial. Chin. J. Acupunct. 36: 467–470, 2016.
Gao, X.H. Clinical oberservation of music electro-acupuncture on knee osteoarthritis pain inter-
vention effect. Master Thesis, Heilongjiang University of Chinese Medicine, 2013.
Higgins, J.P. and S.G. Thompson. Quantifying heterogeneity in a meta-analysis. Stat. Med. 21: 1539–
1558, 2002.
Hinman, R.S., P. McCrory, M. Pirotta, I. Relf, A. Forbes, K.M. Crossley, E. Williamson, M. Kyr-
iakides, K. Novy, B.R. Metcalf, A. Harris, P. Reddy, P.G. Conaghan and K.L. Bennell.
Acupuncture for chronic knee pain: A randomized clinical trial. Jama. 312: 1313–1322, 2014.
Hochberg, M.C., R.D. Altman, K.T. April, M. Benkhalti, G. Guyatt, J. McGowan, T. Towheed,
V. Welch, G. Wells and P. Tugwell. American college of rheumatology 2012 recommenda-
tions for the use of nonpharmacologic and pharmacologic therapies in osteoarthritis of the
hand, hip, and knee. Arthritis Care Res. (Hoboken). 64: 465–474, 2012.
Hou, C.F., S. Wei, Z.H. Chen, X.H. Li, S.T. Wang and J. Guo. Treatment of knee osteoarthritis by
tendons of minimally invasive therapy combined drug therapy: A clinical observation of sixty
cases. Chin. J. Integr. Tradit. West Med. 35: 678–681, 2015.
Huang, D.E., H. Gao, X.L. Lai and Y. Lin. The influence of electro-acupuncture on knee osteoar-
thritis from the aspects of IL-1 and TGF-β1. J. Shaanxi Coll. Tradit. Chin. Med. 2: 66–68,
2016.
Huang, Y.R., Y.L. Jin, N. Li, L.D. Lei, F. Yu, Y.B. Li, L. Tao, Q. Zhang and C.Q. Guo. Effects of
acupotomy, electroacupuncture or round-sharp acupuncture needle interventions on expression
of Bcl-2, bax, Caspase-3 proteins of rectus femoris in rabbits with knee ostarthritis. Acupunc.
Res. 39: 100–105, 123, 2014.
Ji, M., X. Wang, M. Chen, Y. Shen, X. Zhang and J. Yang. The efficacy of acupuncture for the
treatment of sciatica: A systematic review and meta-analysis. Evid. Based Complement.
Alternat. Med. 2015: 1–12, 2015.
Kim, S.Y., H. Lee, Y. Chae, H.J. Park and H. Lee. A systematic review of cost-effectiveness analyses
alongside randomised controlled trials of acupuncture. Acupunct. Med. 30: 273–285, 2012.
Ku, X.J., S.Y. Jiang and L.X. Zhu. Clinical efficacy evaluation on electroacupuncture for osteoar-
thritis and observation on biomechanical indexes. J. Acupunct. Tuina. 7: 261–264, 2009.
Leung, L. Neurophysiological basis of acupuncture-induced analgesia-an updated review. J. Acu-
punct. Meridian Stud. 5: 261–270, 2012.

Leung, Y.Y., J.C. Allen, Jr., M. Noviani, L.W. Ang, R. Wang, J.M. Yuan and W.P. Koh. Association
between body mass index and risk of total knee replacement, The Singapore Chinese health
study. Osteoarthr. Cartil. 23: 41–47, 2015.
Li, A., Z.J. Wei, Y. Liu, B. Li, X. Guo and S.Q. Feng. Moxibustion treatment for knee osteoarthritis:
A systematic review and meta-analysis. Medicine (Baltimore). 95: e3244, 2016.
Li, X. and Z. Shi. On the depth of needle insertion. Chin. J. Acupunct. 35: 913–916, 2015.
Liu, A.J., J.H. Li, H.Q. Li, D.L. Fu, L. Lu, Z.X. Bian and G.Q. Zheng. Electroacupuncture for acute
ischemic stroke: A meta-analysis of randomized controlled trials. Am. J. Chin. Med. 43: 1541–
1566, 2015.
Liu, F.S., D.Z. Jin and X. Wu. Acupotomy vesus acupuncture for knee osteoarthritis: A meta-analysis
of randomized controlled trials. Chin. J. Tissue Eng. 3: 8235–8239, 2012.
Liu, Y., X.J. Wang, N. Wang, C.L. Cui and L.Z. Wu. Electroacupuncture ameliorates propofol-
induced cognitive impairment via an opioid receptor-independent mechanism. Am. J. Chin.
Med. 44: 705–719, 2016.
Mallory, M.J., K.A. Croghan, N.P. Sandhu, V. Lemaine, A.C. Degnim, B.A. Bauer, S.S. Cha and I.T.
Croghan. Acupuncture in the postoperative setting for breast cancer patients: A feasibility
study. Am. J. Chin. Med. 43: 45–56, 2015.
Manheimer, E., K. Cheng, K. Linde, L. Lao, J. Yoo, S. Wieland, D.A. van der Windt, B.M. Berman
and L.M. Bouter. Acupuncture for peripheral joint osteoarthritis. Cochrane Database Syst.
Rev. 1: Cd001977, 2010.
McAlindon, T., N.V. Zucker and M.O. Zucker. 2007 oarsi recommendations for the management of
hip and knee osteoarthritis: Towards consensus? Osteoarthr. Cartil. 16: 636–637, 2008.
Miao, G.D., Z.F. Jiang and Z.J. Tian. The observation of clincal effects of acupuncture on knee
osteoarthritis. Hebei J. Tradit. Chin. Med. 5: 725–726, 2014.
Navarro-Sarabia, F., P. Coronel, E. Collantes, F.J. Navarro, A.R. de la Serna, A. Naranjo, M. Gimeno
and G. Herrero-Beaumont. A 40-month multicentre, randomised placebo-controlled study to
assess the efficacy and carry-over effect of repeated intra-articular injections of hyaluronic acid
in knee osteoarthritis: The amelia project. Ann. Rheum. Dis. 70: 1957–1962, 2011.
Palmer, K.T., I. Reading, M. Calnan, C. Linaker and D. Coggon. Does knee pain in the community
behave like a regional pain syndrome? Prospective cohort study of incidence and persistence.
Ann. Rheum. Dis. 66: 1190–1194, 2007.
Pang, R., S. Wang, L. Tian, M.C. Lee, A. Do, S.M. Cutshall, G. Li, B.A. Bauer, B.S. Thomley and
T.Y. Chon. Complementary and integrative medicine at Mayo Clinic. Am. J. Chin. Med. 43:
1503–1513, 2015.
20 N. CHEN et al.
Peat, G., R. McCarney and P. Croft. Knee pain and osteoarthritis in older adults: A review of
community burden and current use of primary health care. Ann. Rheum. Dis. 60: 91–97, 2001.
Perez, R., A.A. Neves, F.G. Belladonna, E.J. Silva, E.M. Souza, S. Fidel, M.A. Versiani, I. Lima, C.
Carvalho and G. De-Deus. Impact of the needle insertion depth on the removal of hard-tissue
debris. Int. Endod. J., 50(6): 560–568, 2016.
Ren, X., C. Yao, F. Wu, Z. Li, J. Xing and H. Zhang. Effectiveness of moxibustion treatment in
quality of life in patients with knee osteoarthritis: A randomized, double-blinded, placebo-
controlled trial. Evid. Based Complement Alternat. Med. 2015: 523–569, 2015.
Richette, P., X. Chevalier, H.K. Ea, F. Eymard, Y. Henrotin, P. Ornetti, J. Sellam, M. Cucherat and
M. Marty. Hyaluronan for knee osteoarthritis: An updated meta-analysis of trials with low risk
of bias. RMD Open. 1: e000071, 2015.
Selfe, T.K. and A.G. Taylor. Acupuncture and osteoarthritis of the knee: A review of randomized,
controlled trials. Fam. Community Health. 31: 247–254, 2008.
Shen, L.L., G.F. Huang, W. Tian, L.L. Yu, X.C. Yuan, Z.Q. Zhang, J. Yin, C.Y. Ma, G.W. Cai, J.W.
Li, M.Q. Ding, W. He, X.Y. Gao, B. Zhu, X.H. Jing and M. Li. Electroacupuncture inhibits
chronification of the acute pain of knee osteoarthritis: Study protocol for a randomized con-
trolled trial. Trials. 16: 131, 2015.
Skou, S.T., E.M. Roos, M.B. Laursen, M.S. Rathleff, L. Arendt-Nielsen, O. Simonsen and S. Ras-
mussen. Efficacy of multimodal, systematic non-surgical treatment of knee osteoarthritis for
patients not eligible for a total knee replacement: A study protocol of a randomised controlled
trial. BMJ Open. 2: 2224–2236, 2012.
Song, G.M., X. Tian, Y.H. Jin, Y.H. Deng, H. Zhang, X.L. Pang and J.G. Zhou. Moxibustion is an
alternative in treating knee osteoarthritis: The evidence from systematic review and meta-
analysis. Medicine (Baltimore). 95: e2790, 2016.
Tsai, C.C., Y.Y. Chou, Y.M. Chen, Y.J. Tang, H.C. Ho and D.Y. Chen. Effect of the herbal drug
guilu erxian jiao on muscle strength, articular pain, and disability in elderly men with knee
osteoarthritis. Evid. Based Complement Alternat. Med. 2014: 297–314, 2014.
Tukmachi, E., R. Jubb, E. Dempsey and P. Jones. The effect of acupuncture on the symptoms of knee
osteoarthritis — An open randomised controlled study. Acupunct. Med. 22: 14–22, 2004.
Wang, B., X. Liu, Z. Hu, A. Sun, Y. Ma, Y. Chen, X. Zhang, M. Liu, Y. Wang, S. Wang, Y. Zhang,
Y. Li and W. Shen. Yang’s pricking-cupping therapy for knee osteoarthritis: A multi-center
randomized controlled trial. Chin. J. Acupunct. 36: 113–118, 2016.
Wang, C., M.D. Iversen, T. McAlindon, W.F. Harvey, J.B. Wong, R.A. Fielding, J.B. Driban, L.L.
Price, R. Rones, T. Gamache and C.H. Schmid. Assessing the comparative effectiveness of tai
chi versus physical therapy for knee osteoarthritis: Design and rationale for a randomized trial.
BMC Complement. Altern. Med. 14: 333, 2014.
Witt, C., B. Brinkhaus, S. Jena, K. Linde, A. Streng, S. Wagenpfeil, J. Hummelsberger, H.U.
Walther, D. Melchart and S.N. Willich. Acupuncture in patients with osteoarthritis of the knee:
A randomised trial. Lancet. 366: 136–143, 2005.
Woolf, A.D. and B. Pfleger. Burden of major musculoskeletal conditions. Bull. World Health Org.
81: 646–656, 2003.
Wu, B.Q. The 33 case analysis of electropu-acupuncture on knee osteoarthritis. Shandong J. Tradit.
Chin. Med. 9: 750–752, 2014.
Wu, J.L. Clincal observation on elelectro-acupuncture for treatment of knee osteoarthritis. Master,
Heilongjiang University of Chinese Medicine, 2012.
Xi, X.F., X.Z. Li, F. Liu, N.N. Fu, Y. Ren, X.G. Yang and Y. Zhang. Effects of short thrust needing
plus electroacupuncture intervention on cartilage tissue in rabbits with knee osteoarthritis.
Acupunc. Res. 41: 124–130, 2016.
Xiang, Y.J. and S.M. Dai. Prevalence of rheumatic diseases and disability in China. Rheumatol. Int.
29: 481–490, 2009.
Xie, Y., G. Wei, Y.K. Guo, L. Lu, J.M. Chen, X.L. Shi, W. Ji and X. Qian. The systematic review
and meta-analysis of taichi on knee osteoarthritis. Chin. J. Rehab. Medicine 5: 483–489, 2015.
Yang, L., Z. Yang, H. Yu and H. Song. Acupuncture therapy is more effective than artificial tears for
dry eye syndrome: Evidence based on a meta-analysis. Evid. Based Complement. Alternat.
Med. 2015: 143858, 2015.
Zhang, W., R.W. Moskowitz, G. Nuki, S. Abramson, R.D. Altman, N. Arden, S. Bierma-Zeinstra,
K.D. Brandt, P. Croft, M. Doherty, M. Dougados, M. Hochberg, D.J. Hunter, K. Kwoh, L.S.
Lohmander and P. Tugwell. Oarsi recommendations for the management of hip and knee
osteoarthritis, part II: Oarsi evidence-based, expert consensus guidelines. Osteoarthr. Cartil.
16: 137–162, 2008.
Zhang, W., S. Wang, R. Zhang, Y. Zhang, X. Li, Y. Lin and X. Wei. Evidence of Chinese herbal
medicine duhuo jisheng decoction for knee osteoarthritis: A systematic review of randomised
clinical trials. BMJ Open. 6: e008973, 2016a.
Zhang, Y., S.S. Qu, J.P. Zhang, Y.L. Sun, W.L. Liu, L. Xie, Y. Huang and J.Q. Chen. Rapid onset of
the effects of combined selective serotonin reuptake inhibitors and electroacupuncture on
primary depression: A meta-analysis. J. Altern. Complement. Med. 22: 1–8, 2016b.

Zhang, Y. and J.M. Jordan. Epidemiology of osteoarthritis. Clin. Geriatr. Med. 26: 355–369, 2010.
Zhou, T., C.F. Chen, Y.L. Qian, J.J. Zhu, H.J. Gu and H.Y. Zhao. Clincal analysis of low-frequency
electro-acupuncture for knee osteoarthritis Shanghai J. Tradit. Chin. Med. 49: 56–57, 2015.
Zhu, L., S. Yang, S. Wang, H. Gong, L. Li and X. Wei. Effectiveness and safety of manufactured
Chinese herbal formula for knee osteoarthritis: Insights from a systematic review. Evid. Based
Complement Alternat. Med. 2015: 328–342, 2015.

Chen Elekctroakp Jurnal

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Chen Elekctroakp Jurnal

Uploaded by

Copyright:

Available Formats

The American Journal of Chinese Medicine, Vol. 45, No.

Electro-Acupuncture is Beneﬁcial for

Na Chen,* Jing Wang,† Attilio Mucelli,‡ Xu Zhang§ and Changqing Wang*

Published 29 June 2017

Keywords: Electro-Acupuncture; Knee Osteoarthritis; Systematic Review; Meta-Analysis;

Information Sources and Search Strategy

Study Selection and Data Collection Process Quality Assessment

Assessment of Study Quality and Risk of Bias

Data and Statistical Analyses

Diagnostic Sample Disease Duration Intergroup Withdrawal/

Oral-medication grade 10(2/8) 61 9.95y 2. VAS 2. P < 0:001

Diagnostic Sample Disease Duration Intergroup Withdrawal/

Wu (2014) EA GPCRND-KOA 33(33/0) 36–73 20d-2y Effectiveness P < 0:05 n.r./n.r./n.r.

Details of Needling ES Regimen

Individualized points: Quchi (LI11), Gua-

lation at a frequency of 100 times per

Details of Needling ES Regimen

Assessment of Risk of Bias and Quality of Studies

(A) Risk of bias graph

(B) Risk of bias summary

Effectiveness: Results of Meta-Analysis

Pain Intensity: Results of Meta-Analysis

Physical Function: LKSS

score improvement (pharmacological treatment: MD ¼ 5:08; 95% CI ¼ 3:52, 6:64; P <

Physical Function: WOMAC

Adverse Events and Follow Up

A total of 10 studies involving 695 participants examining the effects of EA treatment on

Previous meta-analyses of alternative treatments on KOA focused on the Chinese Herbal

Implications for Practice

Implications for Research

Altman, R., K. Brandt, M. Hochberg, R. Moskowitz, N. Bellamy, D.A. Bloch, J. Buckwalter,

of electro-acupuncture stimulation to female constipation patients. Am. J. Chin. Med. 41:

punct. Meridian Stud. 5: 261–270, 2012.

primary depression: A meta-analysis. J. Altern. Complement. Med. 22: 1–8, 2016b.

You might also like