Department of Sports Medicine, The First Affiliated Hospital, Guangdong Provincial Key Laboratory of Speed Capability, The Guangzhou Key Laboratory of Precision Orthopedics and Regenerative Medicine, Jinan University, Guangzhou, China
Department of Sports Medicine, The First Affiliated Hospital, Guangdong Provincial Key Laboratory of Speed Capability, The Guangzhou Key Laboratory of Precision Orthopedics and Regenerative Medicine, Jinan University, Guangzhou, China
Department of Sports Medicine, The First Affiliated Hospital, Guangdong Provincial Key Laboratory of Speed Capability, The Guangzhou Key Laboratory of Precision Orthopedics and Regenerative Medicine, Jinan University, Guangzhou, China
State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, Department of Pharmaceutical Sciences, Faculty of Health Sciences, University of Macau, Macau, China
Department of Rheumatology and Immunology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
Department of Rheumatology and Immunology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
Background: Electroacupuncture (EA) has been proven to be efficacious and safe in patients with knee osteoarthritis (KOA), yet the superior intensity current for pain control in KOA remains unspecified. The present meta-analysis aimed to assess the efficiency of high-intensity and low-intensity EA in pain relief and functional improvement in KOA. Methods: A thorough and comprehensive literature search for randomized controlled trials (RCTs), all looking at the intensity of EA for KOA, was carried out in PubMed, EMBASE, Cochrane Library, clinicaltrials.gov, China National Knowledge Infrastructure (CNKI), China Science Journal Citation Report (VIP) and Wanfang database. All databases were searched from the available date of inception until the latest issue (Apr 2022). The study quality was evaluated via the Jadad five-point scale. Ultimately, a meta-analysis of all eligible RCTs was conducted utilizing Review Manager 5.3. Results: Three studies with 472 individuals were included in the Meta-analysis. The pain intensity reductions are significantly different between the high-intensity EA group and low-intensity EA group (MD=-0.22, 95%CI=-0.26 to -0.18, P< 0.00001). There is no significant difference between the two groups in the WOMAC index (MD=-3.62, 95%CI=-12.22 to 4.98, P= 0.41). High-intensity EA group significantly improve the emotional scale (ES) in comparison to the low-intensity EA group (MD=-0.72, 95%CI=-0.76 to -0.67, P< 0.00001). Conclusion: The findings of this work indicated that high-intensity EA provides superior pain relief and emotional scale in KOA patients. Moreover, both high-intensity and low-intensity EA exert a significant functional improvement effect in KOA.
This is an Open Access article, distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution and reproduction in any medium or format, provided the original work is properly cited.
High Intensity, Electroacupuncture, Knee Osteoarthritis, Meta-Analysis
1. Introduction
Knee osteoarthritis (KOA) is a common degenerative joint disease among elderly adults and is characterized by progressive erosion of the articular cartilage. The prevalence of symptomatic KOA is about 8.1% in China, which varies according to sociodemographic, economic, and geographic factors
[1]
Tang X, Wang S, Zhan S, et al. The Prevalence of Symptomatic Knee Osteoarthritis in China: Results From the China Health and Retirement Longitudinal Study. Arthritis Rheumatol. 2016; 68(3): 648-653.
. KOA is the leading cause of chronic knee pain and dysfunction worldwide, and the quality of life is also impaired in the advanced stage. Nonpharmacological treatment, including health education, weight control, joint activity, acupuncture, and biomechanical therapies, plays a crucial role in the early-to-middle stages of KOA
[2]
Hunter DJ, Bierma-Zeinstra S. Osteoarthritis. Lancet. 2019; 393(10182): 1745-1759.
Electroacupuncture (EA), an essential form of acupuncture, has been widely used to treat KOA for a long time. EA has been proven to be efficacious and safe for relieving pain and improving physical functions in patients with KOA
[3]
Wang TQ, Li YT, Wang LQ, et al. Electroacupuncture versus manual acupuncture for knee osteoarthritis: a randomized controlled pilot trial. Acupunct Med. 2020; 38(5): 291-300.
Shim JW, Jung JY, Kim SS. Effects of Electroacupuncture for Knee Osteoarthritis: A Systematic Review and Meta-Analysis. Evid Based Complement Alternat Med. 2016; 2016: 3485875.
. Previous studies indicated some influence factors, such as current intensity, frequency of EA, and acupoints selection, which are the significant factors affecting the curative effect
[5]
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. Acupunct Med. 2009; 27(1): 3-8.
Tu JF, Yang JW, Shi GX, et al. Efficacy of Intensive Acupuncture Versus Sham Acupuncture in Knee Osteoarthritis: A Randomized Controlled Trial. Arthritis Rheumatol. 2021; 73(3): 448-458.
Ju Z, Guo X, Jiang X, et al. Electroacupuncture with different current intensities to treat knee osteoarthritis: a single-blinded controlled study. Int J Clin Exp Med. 2015; 8(10): 18981-18989. Published 2015 Oct 15.
[5-7]
. There is no consensus or guidelines for the optimal intensity of EA, and direct evidence of evidence-based medicine is also lacking. The purpose of this meta-analysis was to compare the effectiveness of high-intensity and low-intensity EA for pain relief and functional improvement in KOA.
2. Materials and Methods
2.1. Search Strategy
A thorough and comprehensive literature search for RCTs, looking at the intensity of EA for KOA, was carried out according to the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. The following bibliographic databases were searched: PubMed, EMBASE, Cochrane Library, Clinicaltrials.gov, China National Knowledge Infrastructure (CNKI), China Science Journal Citation Report (VIP), and Wanfang database. The search strategy was: (osteoarthritis OR osteoarthrosis OR degenerative arthritis) AND (electroacupuncture OR electrical acupuncture) AND (randomized controlled trial OR randomized OR clinical trial). All words were searched as free text and, where applicable, also as keywords. We conducted searches across all databases from their respective inception dates up to April 2022. No restrictions in language or publication year were applied. We also searched for relevant studies by reviewing the reference lists of retrieved studies and previous systematic reviews.
2.2. Study Eligibility Criteria
The inclusion criteria were as follows: (1) Study design: RCT; (2) Study population: patients with KOA; (3) Intervention: high-intensity EA vs. low-intensity EA. The high-intensity EA group was defined as intensity of currently more than 2mA, which was strong enough to reach the patients’ tolerance threshold value. The intensity of the low-intensity EA group was between 0 and 0.5mA; (4) Outcome measurement: provides an assessment of pain intensity, recorded using Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) or visual analog scale (VAS); (5) Study has full text that could be obtained. Studies were excluded if they did not meet these criteria.
Exclusion criteria: (1) Review, Meta-analysis or commentaries; (2) Animal studies; (3) Meeting abstract and data were not available; (4) Not randomized controlled trial; (5) Intensity of current was not reported in the article.
The search results from the seven databases were imported into EndNote X7 software for data management. Articles were independently screened by two reviewers based on the inclusion and exclusion criteria. In cases of disagreement, a third reviewer was consulted, and included articles were rechecked.
2.3. Informed Consent
This research does not involve human participants or patient data, so we do not need to provide a statement of informed consent. Informed consent is typically only required when the research involves human participants and the data.
2.4. Data Extraction
Two reviewers extracted data from the included studies manually. A standard data extraction form was developed for data collection. The following information was systematically extracted as characteristics of each randomized trial: study design, demographic characteristics, study duration, quality criteria, intervention details, outcome measures, and risk of bias. If multiple papers originated from the same study, only the complete study or the most recent one was included. Any discrepancies in data extraction and quality assessment between the two reviewers were resolved through discussion with a third reviewer.
2.5. Quality Assessment
Methodological quality was assessed using version 2 of the Cochrane risk-of-bias tool for randomized trials (RoB2)
[8]
Sterne JAC, Savović J, Page MJ, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019; 366: l4898. Published 2019 Aug 28.
. Bias was assessed as a judgment (high, low, or unclear) for elements from five domains: (1) randomization process; (2) deviations from intended interventions; (3) missing outcome data; (4) measurement of the outcome; and (5) selection of the reported result. The RoB 2 was used to evaluate the reliability of the evidence.
2.6. Statistical Analysis
All data analyses were conducted by Review Manager Software Version 5.3 (Cochrane Collaboration, Oxford, UK). The continuous data for Meta-analysis were expressed as mean difference (MD) with a 95% confidence interval (CI), while dichotomous data were presented as risk ratio (RR) with 95%CI. The heterogeneity across studies was estimated using the Chi-square and Higgins tests. If heterogeneity was at P>0.10 or ≤ 50%, a fixed-effects model was used; otherwise, a random-effects model was used. The overall effect was tested using a Z-score with significance at P<0.05.
3. Results
3.1. Study Selection
The literature selection process and results were shown in Figure 1. According to the PRISMA flow diagram screening sequence, the search strategy retrieved 388 related articles. After reviewing titles and abstracts based on the inclusion criteria, 41 articles were retained for full-text review. Ultimately, three studies with 472 individuals were included in the Meta-analysis
[7]
Ju Z, Guo X, Jiang X, et al. Electroacupuncture with different current intensities to treat knee osteoarthritis: a single-blinded controlled study. Int J Clin Exp Med. 2015; 8(10): 18981-18989. Published 2015 Oct 15.
[9]
Lv ZT, Shen LL, Zhu B, et al. Effects of intensity of electroacupuncture on chronic pain in patients with knee osteoarthritis: a randomized controlled trial. Arthritis Res Ther. 2019; 21(1): 120. Published 2019 May 14.
Shen LL, Huang GF, Tian W, et al. Electroacupuncture inhibits chronification of the acute pain of knee osteoarthritis: study protocol for a randomized controlled trial. Trials. 2015; 16: 131. Published 2015 Apr 1.
. The total sample size was based on the intent-to-treat (ITT) population.
3.2. Study Characteristics and Quality Assessment
Essential characteristics of the included studies are presented in Table 1. The included RCTs were published between 2015 and 2019, all published in English. Moreover, all three RCTs were conducted in China. Details of the baseline patient characteristics are described in Table 2.
A graphic summarizing the risk of bias was produced from discussions among the authors, as shown in Figure 2. All RCTs reported the specific method of the random sequence generation and described the dropout or withdrawal. One study
[9]
Lv ZT, Shen LL, Zhu B, et al. Effects of intensity of electroacupuncture on chronic pain in patients with knee osteoarthritis: a randomized controlled trial. Arthritis Res Ther. 2019; 21(1): 120. Published 2019 May 14.
Ju Z, Guo X, Jiang X, et al. Electroacupuncture with different current intensities to treat knee osteoarthritis: a single-blinded controlled study. Int J Clin Exp Med. 2015; 8(10): 18981-18989. Published 2015 Oct 15.
[10]
Shen LL, Huang GF, Tian W, et al. Electroacupuncture inhibits chronification of the acute pain of knee osteoarthritis: study protocol for a randomized controlled trial. Trials. 2015; 16: 131. Published 2015 Apr 1.
had some concerns about bias risk due to deviations from intended interventions.
3.3. Pain Intensity Reduction
All three RCTs evaluating the pain intensity utilize VAS score reduction as the primary or secondary outcome. VAS scores were assessed using a numerical rating scale of 0-10, in which a decreasing score represents the reduction in pain intensity. The pain intensity reductions are significantly different between the high-intensity EA group and the low-intensity EA group (MD=-0.22, 95%CI=-0.26 to -0.18, P< 0.00001; Figure 3), suggesting that high-intensity EA is favorable for pain intensity reduction. These studies show a moderate degree of heterogeneity (P =0.10, I^2=56%).
3.4. Functional Improvement
Two RCTs provide specific, relevant data for comprehensive analysis of WOMAC. The WOMAC index consists of three domains; the final score ranges from 0 to 96, and a low score indicates function improvement and less pain. There is no significant difference between the two groups in the WOMAC index (MD=-3.62, 95%CI=-12.22 to 4.98, P= 0.41; Figure 4). These studies show a moderate degree of heterogeneity (P =0.06, I2=71%).
3.5. Emotional Scale (ES)
ES was available in two studies. Meta-analysis reveals that the high-intensity EA group significantly improves the ES compared to the low-intensity EA group (MD=-0.72, 95%CI=-0.76 to -0.67, P< 0.00001; Figure 5). No significant heterogeneity was observed between studies (P = 0.42, I^2= 0%).
VAS, WOMAC, CPM function, NPRS, ES, PPI, adverse events
VAS, WOMAC, TNFα, IL-1β, IL-6, apelin levels
DNIC, VAS, NPRS, ES
*RCT: randomized controlled trial; H group: high-intensity EA group; L group: low-intensity EA group; VAS: visual analog scale; WOMAC: Western Ontario and McMaster Universities Osteoarthritis Index; CPM: Conditioned pain modulation; NPRS: numeric pain rating scale; ES: emotional scale; PPI: present pain intensity; DNIC: Diffuse injury inhibitory controls
Table 2. Baseline patient characteristics.
Study
Group
N
Gender (Female,%)
Age, (years)
BMI
Lv 2019
High intensity EA
145
73.1
64.6
22.67
Low intensity EA
72
79.2
63.7
22.46
Sham EA
75
80.0
61.9
22.93
Ju 2015
High intensity EA
40
65.0
62.0
27.4
Low intensity EA
37
73.0
61.0
26.7
Shen 2015
High intensity EA
55
80.0
66.1
/
Low intensity EA
20
80.0
69.3
/
Sham EA
12
50.0
68.9
/
4. Discussion
Drawing on the existing literature, to our knowledge, this Meta-analysis is the first to assess high-intensity and low-intensity EA with KOA patients. Three RCTs with 472 patients were included, and the overall methodological quality of the included studies was moderate. The results of this meta-analysis suggested that high-intensity EA provides superior pain relief and emotional scale in KOA patients. Moreover, both high-intensity and low-intensity EA exert a significant functional improvement effect in KOA.
EA is widely used in the clinical treatment of KOA, which has the advantages of definite curative effects, few side effects, and low cost
[11]
Chen J, Liu XX. Tackling Osteoarthritic Knee Pain with Electroacupuncture. Chin J Integr Med. 2018; 24(11): 803-805.
Wang Q, Lv H, Sun ZT, et al. Effect of Electroacupuncture versus Sham Electroacupuncture in Patients with Knee Osteoarthritis: A Pilot Randomized Controlled Trial. Evid Based Complement Alternat Med. 2020; 2020: 1686952. Published 2020 Jul 30.
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. Am J Chin Med. 2017; 45(5): 965-985.
. However, the application of EA on KOA pain lacks a standardized parameter and optimized program. In recent years, most trials of EA in KOA patients were performed using the maximum tolerable intensity of current
[5]
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. Acupunct Med. 2009; 27(1): 3-8.
Ahsin S, Saleem S, Bhatti AM, Iles RK, Aslam M. Clinical and endocrinological changes after electro-acupuncture treatment in patients with osteoarthritis of the knee. Pain. 2009; 147(1-3): 60-66.
Sangdee C, Teekachunhatean S, Sananpanich K, et al. Electroacupuncture versus diclofenac in symptomatic treatment of osteoarthritis of the knee: a randomized controlled trial. BMC Complement Altern Med. 2002; 2: 3. Published 2002 Mar 21.
Zhang L, Yuan H. Effectiveness and clinical benefit of a therapy of combined non-pharmaceutical Traditional Chinese Medicine for knee osteoarthritis: a randomized controlled study. J Tradit Chin Med. 2020; 40(3): 447-454.
, or description of needles began to vibrate slightly
[6]
Tu JF, Yang JW, Shi GX, et al. Efficacy of Intensive Acupuncture Versus Sham Acupuncture in Knee Osteoarthritis: A Randomized Controlled Trial. Arthritis Rheumatol. 2021; 73(3): 448-458.
Wang Q, Lv H, Sun ZT, et al. Effect of Electroacupuncture versus Sham Electroacupuncture in Patients with Knee Osteoarthritis: A Pilot Randomized Controlled Trial. Evid Based Complement Alternat Med. 2020; 2020: 1686952. Published 2020 Jul 30.
. One study adopted the fixed current intensity of 0.2 mA
[3]
Wang TQ, Li YT, Wang LQ, et al. Electroacupuncture versus manual acupuncture for knee osteoarthritis: a randomized controlled pilot trial. Acupunct Med. 2020; 38(5): 291-300.
. In addition, some articles do not mention the intensity of EA
[18]
Lee YJ, Han CH, Jeon JH, et al. Effectiveness and safety of polydioxanone thread-embedding acupuncture (TEA) and electroacupuncture (EA) treatment for knee osteoarthritis (KOA) patients with postoperative pain: An assessor-blinded, randomized, controlled pilot trial. Medicine (Baltimore). 2020; 99(30): e21184.
Jubb RW, Tukmachi ES, Jones PW, Dempsey E, Waterhouse L, Brailsford S. A blinded randomised trial of acupuncture (manual and electroacupuncture) compared with a non-penetrating sham for the symptoms of osteoarthritis of the knee. Acupunct Med. 2008; 26(2): 69-78.
Many trials investigated the efficiency and safety of EA in KOA, yet the superior intensity current for pain control in KOA remains unspecified. Lv et al. undertook an RCT to compare the effect of high-intensity EA with low-intensity EA or sham EA on chronic pain in patients with KOA. They concluded that high-intensity EA is the most effective in alleviating pain intensity in KOA. Moreover, at least 2 weeks duration is necessary for EA to exert a clinical effect on KOA
[9]
Lv ZT, Shen LL, Zhu B, et al. Effects of intensity of electroacupuncture on chronic pain in patients with knee osteoarthritis: a randomized controlled trial. Arthritis Res Ther. 2019; 21(1): 120. Published 2019 May 14.
. Another study by Ju et al. revealed that both high-intensity and low-intensity EA treatment effectively reduces pain symptoms and improves function in KOA patients
[7]
Ju Z, Guo X, Jiang X, et al. Electroacupuncture with different current intensities to treat knee osteoarthritis: a single-blinded controlled study. Int J Clin Exp Med. 2015; 8(10): 18981-18989. Published 2015 Oct 15.
[7]
. In a mouse model of KOA, the optimized parameters of EA inhibiting chronic pain were low frequency and high-intensity (2 Hz + 1 mA)
[20]
Yuan XC, Zhu B, Jing XH, et al. Electroacupuncture Potentiates Cannabinoid Receptor-Mediated Descending Inhibitory Control in a Mouse Model of Knee Osteoarthritis. Front Mol Neurosci. 2018; 11: 112. Published 2018 Apr 6.
So far, the mechanism of EA for KOA has yet to be fully illuminated. EA may potentiate the endogenous cannabinoid system and the expression of CB1 receptors on GABAergic neurons in the midbrain to enhance the 5-HT-related descending inhibitory control and diffuse noxious inhibitory controls (DNIC) function during KOA
[20]
Yuan XC, Zhu B, Jing XH, et al. Electroacupuncture Potentiates Cannabinoid Receptor-Mediated Descending Inhibitory Control in a Mouse Model of Knee Osteoarthritis. Front Mol Neurosci. 2018; 11: 112. Published 2018 Apr 6.
. Some animal experiments have confirmed that EA could relieve neuropathic pain via the upregulation of glutamate transporters in the spinal cord of rats
[21]
Zeng J, Cui LY, Feng Y, Ding MX. Electroacupuncture relieves neuropathic pain via upregulation of glutamate transporters in the spinal cord of rats. Neurosci Lett. 2016; 620: 38-42.
Liao HY, Hsieh CL, Huang CP, Lin YW. Electroacupuncture Attenuates CFA-induced Inflammatory Pain by suppressing Nav1.8 through S100B, TRPV1, Opioid, and Adenosine Pathways in Mice. Sci Rep. 2017; 7: 42531. Published 2017 Feb 13.
Ju’s study showed that plasma levels of IL-6 and apelin were significantly inhibited by high-intensity EA, which may contribute to the effects of high-intensity EA in treating KOA
[7]
Ju Z, Guo X, Jiang X, et al. Electroacupuncture with different current intensities to treat knee osteoarthritis: a single-blinded controlled study. Int J Clin Exp Med. 2015; 8(10): 18981-18989. Published 2015 Oct 15.
[7]
. Moreover, high-intensity EA may strengthen the conditioned pain modulation (CPM) function, thus preventing the development of chronic pain in KOA.
The intensity of EA is one of the critical factors that can influence treatment efficacy, in addition to the dose and frequency of EA, placebo effects, and expectations. A systematic review demonstrated that the effect of acupuncture might be dose-dependent, with a higher dosage related to better treatment outcomes in terms of relief of pain and dysfunction in patients with KOA
[23]
Sun N, Tu JF, Lin LL, et al. Correlation between acupuncture dose and effectiveness in the treatment of knee osteoarthritis: a systematic review. Acupunct Med. 2019; 37(5): 261-267.
. Tu et al. assessed the efficacy of intensive acupuncture 3 times weekly for 8 weeks in KOA patients. They demonstrated that intensive EA results in less pain and better function at week 8, and these effects persist through week 26
[6]
Tu JF, Yang JW, Shi GX, et al. Efficacy of Intensive Acupuncture Versus Sham Acupuncture in Knee Osteoarthritis: A Randomized Controlled Trial. Arthritis Rheumatol. 2021; 73(3): 448-458.
The results of these analyses may be scientifically and clinically important. For the first time, we have demonstrated that high-intensity EA is superior to low-intensity EA in pain relief for KOA patients. What we have done will add evidence of evidence-based medicine to consensus or guidelines for the treatment of KOA in the future. Nevertheless, there are some limitations in this study. One limitation of the study is the relative paucity of high-quality RCTs referring to the current intensity of EA. More RCTs are needed to verify our results in the future. Another potential limitation is that adverse events of high-intensity and low-intensity EA were not reported in detail in these RCTs, so it is still necessary to further validate the safety of high-intensity and low-intensity EA. Finally, a publication bias was not performed due to the inadequate number of eligible studies.
5. Conclusions
The findings of this work indicated that high-intensity EA provides superior pain relief and emotional scale in KOA patients. Moreover, both high-intensity and low-intensity EA exert a significant functional improvement effect in KOA.
Abbreviations
EA: Electroacupuncture
KOA: Knee Osteoarthritis
RCTs: Randomized Controlled Trials
CNKI: China National Knowledge Infrastructure
PRISMA: Preferred Reporting Items for Systematic Review and Meta-Analyses
CNKI: China National Knowledge Infrastructure
WOMAC: Western Ontario and McMaster Universities Osteoarthritis Index
VAS: Visual Analog Scale
RoB2: Risk-of-Bias Tool for Randomized trials
MD: Mean Difference
CI: Confidence Interval
RR: Risk Ratio
ITT: Intent-to-Treat
ES: Emotional Scale
DNIC: Diffuse Noxious Inhibitory Controls
CPM: Conditioned Pain Modulation
Acknowledgments
We would like to express our sincere thanks to all those who have contributed to this research. We are particularly grateful to Hainan Province Clinical Medical Center for their generous support. We would also like to acknowledge the valuable feedback and guidance provided by Professor Zheng Xiaofei of the Sports Medicine Center of the First Affiliated Hospital of Jinan University throughout the research process. Finally, we would like to thank our families and loved ones for their unwavering support and encouragement.
Author Contributions
Chen Zihang: searched and extracted the publications, drafted the manuscript
Liang Xingsen: drafted the manuscript
Wang Huajun: searched and extracted the publications.
Zheng Xiaofei: designed the study, drafted the manuscript
All the authors: designed the study, analyzed, reviewed, and approved the contents of the manuscript.
Funding
This study is funded by the following funds:
National Natural Science Foundation of China (82074511 and 82374558).
Project of Clinical Medical Research in the First Affiliated Hospital of Jinan University (2018009).
The Fundamental Research Funds for the Central Universities (21623119).
Science and Technology Innovation and Sports Culture Development Research Project of Guangdong Provincial Sports Bureau (GDSS2022M002).
Project of China University Sports Association (202203007).
Data Availability Statement
The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.
Conflicts of Interest
The authors declare no conflicts of interest.
References
[1]
Tang X, Wang S, Zhan S, et al. The Prevalence of Symptomatic Knee Osteoarthritis in China: Results From the China Health and Retirement Longitudinal Study. Arthritis Rheumatol. 2016; 68(3): 648-653.
Wang TQ, Li YT, Wang LQ, et al. Electroacupuncture versus manual acupuncture for knee osteoarthritis: a randomized controlled pilot trial. Acupunct Med. 2020; 38(5): 291-300.
Shim JW, Jung JY, Kim SS. Effects of Electroacupuncture for Knee Osteoarthritis: A Systematic Review and Meta-Analysis. Evid Based Complement Alternat Med. 2016; 2016: 3485875.
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. Acupunct Med. 2009; 27(1): 3-8.
Tu JF, Yang JW, Shi GX, et al. Efficacy of Intensive Acupuncture Versus Sham Acupuncture in Knee Osteoarthritis: A Randomized Controlled Trial. Arthritis Rheumatol. 2021; 73(3): 448-458.
Ju Z, Guo X, Jiang X, et al. Electroacupuncture with different current intensities to treat knee osteoarthritis: a single-blinded controlled study. Int J Clin Exp Med. 2015; 8(10): 18981-18989. Published 2015 Oct 15.
[8]
Sterne JAC, Savović J, Page MJ, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019; 366: l4898. Published 2019 Aug 28.
Lv ZT, Shen LL, Zhu B, et al. Effects of intensity of electroacupuncture on chronic pain in patients with knee osteoarthritis: a randomized controlled trial. Arthritis Res Ther. 2019; 21(1): 120. Published 2019 May 14.
Shen LL, Huang GF, Tian W, et al. Electroacupuncture inhibits chronification of the acute pain of knee osteoarthritis: study protocol for a randomized controlled trial. Trials. 2015; 16: 131. Published 2015 Apr 1.
Wang Q, Lv H, Sun ZT, et al. Effect of Electroacupuncture versus Sham Electroacupuncture in Patients with Knee Osteoarthritis: A Pilot Randomized Controlled Trial. Evid Based Complement Alternat Med. 2020; 2020: 1686952. Published 2020 Jul 30.
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. Am J Chin Med. 2017; 45(5): 965-985.
Ahsin S, Saleem S, Bhatti AM, Iles RK, Aslam M. Clinical and endocrinological changes after electro-acupuncture treatment in patients with osteoarthritis of the knee. Pain. 2009; 147(1-3): 60-66.
Sangdee C, Teekachunhatean S, Sananpanich K, et al. Electroacupuncture versus diclofenac in symptomatic treatment of osteoarthritis of the knee: a randomized controlled trial. BMC Complement Altern Med. 2002; 2: 3. Published 2002 Mar 21.
Zhang L, Yuan H. Effectiveness and clinical benefit of a therapy of combined non-pharmaceutical Traditional Chinese Medicine for knee osteoarthritis: a randomized controlled study. J Tradit Chin Med. 2020; 40(3): 447-454.
Lee YJ, Han CH, Jeon JH, et al. Effectiveness and safety of polydioxanone thread-embedding acupuncture (TEA) and electroacupuncture (EA) treatment for knee osteoarthritis (KOA) patients with postoperative pain: An assessor-blinded, randomized, controlled pilot trial. Medicine (Baltimore). 2020; 99(30): e21184.
Jubb RW, Tukmachi ES, Jones PW, Dempsey E, Waterhouse L, Brailsford S. A blinded randomised trial of acupuncture (manual and electroacupuncture) compared with a non-penetrating sham for the symptoms of osteoarthritis of the knee. Acupunct Med. 2008; 26(2): 69-78.
Yuan XC, Zhu B, Jing XH, et al. Electroacupuncture Potentiates Cannabinoid Receptor-Mediated Descending Inhibitory Control in a Mouse Model of Knee Osteoarthritis. Front Mol Neurosci. 2018; 11: 112. Published 2018 Apr 6.
Zeng J, Cui LY, Feng Y, Ding MX. Electroacupuncture relieves neuropathic pain via upregulation of glutamate transporters in the spinal cord of rats. Neurosci Lett. 2016; 620: 38-42.
Liao HY, Hsieh CL, Huang CP, Lin YW. Electroacupuncture Attenuates CFA-induced Inflammatory Pain by suppressing Nav1.8 through S100B, TRPV1, Opioid, and Adenosine Pathways in Mice. Sci Rep. 2017; 7: 42531. Published 2017 Feb 13.
Sun N, Tu JF, Lin LL, et al. Correlation between acupuncture dose and effectiveness in the treatment of knee osteoarthritis: a systematic review. Acupunct Med. 2019; 37(5): 261-267.
@article{10.11648/j.jb.20240801.12,
author = {Chen Zihang and Liang Xingsen and Wang Huajun and Zheng Xiaofei and Zhao Jing and Qing Peng and Zhu Mingmin and Ji Chang and He Kejie and Zeng Hai and Lek Hang Cheang and Man Seng Tam and Guan Jian and Jia Li and Yanping Gao and Ling Li},
title = {Meta-Analysis of Randomized Controlled Trials: High-Intensity Electroacupuncture Outperforms Low-Intensity Electroacupuncture for Knee Osteoarthritis
},
journal = {Journal of Biomaterials},
volume = {8},
number = {1},
pages = {15-22},
doi = {10.11648/j.jb.20240801.12},
url = {https://doi.org/10.11648/j.jb.20240801.12},
eprint = {https://article.sciencepublishinggroup.com/pdf/10.11648.j.jb.20240801.12},
abstract = {Background: Electroacupuncture (EA) has been proven to be efficacious and safe in patients with knee osteoarthritis (KOA), yet the superior intensity current for pain control in KOA remains unspecified. The present meta-analysis aimed to assess the efficiency of high-intensity and low-intensity EA in pain relief and functional improvement in KOA. Methods: A thorough and comprehensive literature search for randomized controlled trials (RCTs), all looking at the intensity of EA for KOA, was carried out in PubMed, EMBASE, Cochrane Library, clinicaltrials.gov, China National Knowledge Infrastructure (CNKI), China Science Journal Citation Report (VIP) and Wanfang database. All databases were searched from the available date of inception until the latest issue (Apr 2022). The study quality was evaluated via the Jadad five-point scale. Ultimately, a meta-analysis of all eligible RCTs was conducted utilizing Review Manager 5.3. Results: Three studies with 472 individuals were included in the Meta-analysis. The pain intensity reductions are significantly different between the high-intensity EA group and low-intensity EA group (MD=-0.22, 95%CI=-0.26 to -0.18, P< 0.00001). There is no significant difference between the two groups in the WOMAC index (MD=-3.62, 95%CI=-12.22 to 4.98, P= 0.41). High-intensity EA group significantly improve the emotional scale (ES) in comparison to the low-intensity EA group (MD=-0.72, 95%CI=-0.76 to -0.67, P< 0.00001). Conclusion: The findings of this work indicated that high-intensity EA provides superior pain relief and emotional scale in KOA patients. Moreover, both high-intensity and low-intensity EA exert a significant functional improvement effect in KOA.
},
year = {2024}
}
TY - JOUR
T1 - Meta-Analysis of Randomized Controlled Trials: High-Intensity Electroacupuncture Outperforms Low-Intensity Electroacupuncture for Knee Osteoarthritis
AU - Chen Zihang
AU - Liang Xingsen
AU - Wang Huajun
AU - Zheng Xiaofei
AU - Zhao Jing
AU - Qing Peng
AU - Zhu Mingmin
AU - Ji Chang
AU - He Kejie
AU - Zeng Hai
AU - Lek Hang Cheang
AU - Man Seng Tam
AU - Guan Jian
AU - Jia Li
AU - Yanping Gao
AU - Ling Li
Y1 - 2024/04/28
PY - 2024
N1 - https://doi.org/10.11648/j.jb.20240801.12
DO - 10.11648/j.jb.20240801.12
T2 - Journal of Biomaterials
JF - Journal of Biomaterials
JO - Journal of Biomaterials
SP - 15
EP - 22
PB - Science Publishing Group
SN - 2640-2629
UR - https://doi.org/10.11648/j.jb.20240801.12
AB - Background: Electroacupuncture (EA) has been proven to be efficacious and safe in patients with knee osteoarthritis (KOA), yet the superior intensity current for pain control in KOA remains unspecified. The present meta-analysis aimed to assess the efficiency of high-intensity and low-intensity EA in pain relief and functional improvement in KOA. Methods: A thorough and comprehensive literature search for randomized controlled trials (RCTs), all looking at the intensity of EA for KOA, was carried out in PubMed, EMBASE, Cochrane Library, clinicaltrials.gov, China National Knowledge Infrastructure (CNKI), China Science Journal Citation Report (VIP) and Wanfang database. All databases were searched from the available date of inception until the latest issue (Apr 2022). The study quality was evaluated via the Jadad five-point scale. Ultimately, a meta-analysis of all eligible RCTs was conducted utilizing Review Manager 5.3. Results: Three studies with 472 individuals were included in the Meta-analysis. The pain intensity reductions are significantly different between the high-intensity EA group and low-intensity EA group (MD=-0.22, 95%CI=-0.26 to -0.18, P< 0.00001). There is no significant difference between the two groups in the WOMAC index (MD=-3.62, 95%CI=-12.22 to 4.98, P= 0.41). High-intensity EA group significantly improve the emotional scale (ES) in comparison to the low-intensity EA group (MD=-0.72, 95%CI=-0.76 to -0.67, P< 0.00001). Conclusion: The findings of this work indicated that high-intensity EA provides superior pain relief and emotional scale in KOA patients. Moreover, both high-intensity and low-intensity EA exert a significant functional improvement effect in KOA.
VL - 8
IS - 1
ER -
Department of Sports Medicine, The First Affiliated Hospital, Guangdong Provincial Key Laboratory of Speed Capability, The Guangzhou Key Laboratory of Precision Orthopedics and Regenerative Medicine, Jinan University, Guangzhou, China
Department of Sports Medicine, The First Affiliated Hospital, Guangdong Provincial Key Laboratory of Speed Capability, The Guangzhou Key Laboratory of Precision Orthopedics and Regenerative Medicine, Jinan University, Guangzhou, China
Zheng Xiaofei
Department of Sports Medicine, The First Affiliated Hospital, Guangdong Provincial Key Laboratory of Speed Capability, The Guangzhou Key Laboratory of Precision Orthopedics and Regenerative Medicine, Jinan University, Guangzhou, China
Zhao Jing
State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, Department of Pharmaceutical Sciences, Faculty of Health Sciences, University of Macau, Macau, China
Qing Peng
Department of Acupuncture, First Hospital of Jinan University, Guangzhou, China
Zhu Mingmin
Department of Acupuncture, First Hospital of Jinan University, Guangzhou, China
Ji Chang
Department of Acupuncture, First Hospital of Jinan University, Guangzhou, China
He Kejie
Department of Acupuncture, First Hospital of Jinan University, Guangzhou, China
Zeng Hai
Department of Acupuncture, First Hospital of Jinan University, Guangzhou, China
Lek Hang Cheang
Department of Orthopedic Surgery, Centro Hospitalar Conde de Sao Januario, Macau, China
Man Seng Tam
IAN WO Medical Center, Macao Special Administrative Region, Macau, China
Guan Jian
Department of Orthopedic Surgery, Third Hospital of Shijiazhuang, Shijiazhuang, China
Jia Li
Department of Rheumatology and Immunology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
Yanping Gao
Department of Traditional Chinese Medicine Orthopedics & Traumatology, The Third Affiliated Hospital of Southern Medical University, Guangzhou, China
Ling Li
Department of Rheumatology and Immunology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
@article{10.11648/j.jb.20240801.12,
author = {Chen Zihang and Liang Xingsen and Wang Huajun and Zheng Xiaofei and Zhao Jing and Qing Peng and Zhu Mingmin and Ji Chang and He Kejie and Zeng Hai and Lek Hang Cheang and Man Seng Tam and Guan Jian and Jia Li and Yanping Gao and Ling Li},
title = {Meta-Analysis of Randomized Controlled Trials: High-Intensity Electroacupuncture Outperforms Low-Intensity Electroacupuncture for Knee Osteoarthritis
},
journal = {Journal of Biomaterials},
volume = {8},
number = {1},
pages = {15-22},
doi = {10.11648/j.jb.20240801.12},
url = {https://doi.org/10.11648/j.jb.20240801.12},
eprint = {https://article.sciencepublishinggroup.com/pdf/10.11648.j.jb.20240801.12},
abstract = {Background: Electroacupuncture (EA) has been proven to be efficacious and safe in patients with knee osteoarthritis (KOA), yet the superior intensity current for pain control in KOA remains unspecified. The present meta-analysis aimed to assess the efficiency of high-intensity and low-intensity EA in pain relief and functional improvement in KOA. Methods: A thorough and comprehensive literature search for randomized controlled trials (RCTs), all looking at the intensity of EA for KOA, was carried out in PubMed, EMBASE, Cochrane Library, clinicaltrials.gov, China National Knowledge Infrastructure (CNKI), China Science Journal Citation Report (VIP) and Wanfang database. All databases were searched from the available date of inception until the latest issue (Apr 2022). The study quality was evaluated via the Jadad five-point scale. Ultimately, a meta-analysis of all eligible RCTs was conducted utilizing Review Manager 5.3. Results: Three studies with 472 individuals were included in the Meta-analysis. The pain intensity reductions are significantly different between the high-intensity EA group and low-intensity EA group (MD=-0.22, 95%CI=-0.26 to -0.18, P< 0.00001). There is no significant difference between the two groups in the WOMAC index (MD=-3.62, 95%CI=-12.22 to 4.98, P= 0.41). High-intensity EA group significantly improve the emotional scale (ES) in comparison to the low-intensity EA group (MD=-0.72, 95%CI=-0.76 to -0.67, P< 0.00001). Conclusion: The findings of this work indicated that high-intensity EA provides superior pain relief and emotional scale in KOA patients. Moreover, both high-intensity and low-intensity EA exert a significant functional improvement effect in KOA.
},
year = {2024}
}
TY - JOUR
T1 - Meta-Analysis of Randomized Controlled Trials: High-Intensity Electroacupuncture Outperforms Low-Intensity Electroacupuncture for Knee Osteoarthritis
AU - Chen Zihang
AU - Liang Xingsen
AU - Wang Huajun
AU - Zheng Xiaofei
AU - Zhao Jing
AU - Qing Peng
AU - Zhu Mingmin
AU - Ji Chang
AU - He Kejie
AU - Zeng Hai
AU - Lek Hang Cheang
AU - Man Seng Tam
AU - Guan Jian
AU - Jia Li
AU - Yanping Gao
AU - Ling Li
Y1 - 2024/04/28
PY - 2024
N1 - https://doi.org/10.11648/j.jb.20240801.12
DO - 10.11648/j.jb.20240801.12
T2 - Journal of Biomaterials
JF - Journal of Biomaterials
JO - Journal of Biomaterials
SP - 15
EP - 22
PB - Science Publishing Group
SN - 2640-2629
UR - https://doi.org/10.11648/j.jb.20240801.12
AB - Background: Electroacupuncture (EA) has been proven to be efficacious and safe in patients with knee osteoarthritis (KOA), yet the superior intensity current for pain control in KOA remains unspecified. The present meta-analysis aimed to assess the efficiency of high-intensity and low-intensity EA in pain relief and functional improvement in KOA. Methods: A thorough and comprehensive literature search for randomized controlled trials (RCTs), all looking at the intensity of EA for KOA, was carried out in PubMed, EMBASE, Cochrane Library, clinicaltrials.gov, China National Knowledge Infrastructure (CNKI), China Science Journal Citation Report (VIP) and Wanfang database. All databases were searched from the available date of inception until the latest issue (Apr 2022). The study quality was evaluated via the Jadad five-point scale. Ultimately, a meta-analysis of all eligible RCTs was conducted utilizing Review Manager 5.3. Results: Three studies with 472 individuals were included in the Meta-analysis. The pain intensity reductions are significantly different between the high-intensity EA group and low-intensity EA group (MD=-0.22, 95%CI=-0.26 to -0.18, P< 0.00001). There is no significant difference between the two groups in the WOMAC index (MD=-3.62, 95%CI=-12.22 to 4.98, P= 0.41). High-intensity EA group significantly improve the emotional scale (ES) in comparison to the low-intensity EA group (MD=-0.72, 95%CI=-0.76 to -0.67, P< 0.00001). Conclusion: The findings of this work indicated that high-intensity EA provides superior pain relief and emotional scale in KOA patients. Moreover, both high-intensity and low-intensity EA exert a significant functional improvement effect in KOA.
VL - 8
IS - 1
ER -
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