Acupuncture for treatment of knee osteoarthritis: A clinical practice guideline

Knee osteoarthritis is one of the most common degenerative joint diseases in adults and is a major cause of physical disability and socioeconomic burden. More than 364 million people worldwide currently have this condition, a number that has more than doubled in the past twenty years. The disease primarily affects older adults and causes symptoms such as intense pain, joint stiffness, and loss of knee function, significantly impacting patients' quality of life. Although various treatment options are available, many have important limitations.

Traditional anti-inflammatory drugs, while effective for pain relief, can cause serious adverse effects such as gastric ulcers and cardiovascular complications, especially in older patients. Other pharmacologic treatments such as glucosamine and hyaluronic acid lack robust scientific evidence of efficacy. On the other hand, nondrug therapies such as exercise, while recommended by major clinical guidelines, face challenges related to low long-term patient adherence. In this context, acupuncture has emerged as a promising therapeutic alternative, increasingly used in clinical practice, although it is still not widely recommended or receives only weak recommendations in major treatment guidelines for knee osteoarthritis.

This study was developed with the goal of creating evidence-based clinical guidelines to inform the use of acupuncture in the treatment of knee osteoarthritis. The central question of the research was to determine whether acupuncture is effective for treating this condition. To answer this question, the researchers used rigorous methodology following the MAGIC (Making GRADE the Irresistible Choice) framework, which is considered a gold standard for clinical guideline development. The process involved different groups of experts working independently: acupuncturists and orthopedists identified the most relevant clinical questions, while an independent evidence synthesis group conducted a comprehensive systematic review of the available scientific literature.

This review analyzed 77 randomized clinical trials involving more than 9,400 patients with knee osteoarthritis, 61% of whom were women with a mean age of approximately 62 years. The researchers evaluated both traditional manual acupuncture and electroacupuncture, comparing them with different types of control, including no treatment and usual care such as anti-inflammatory medications.

The results of the analysis demonstrated significant benefits of acupuncture for patients with knee osteoarthritis. Compared with no treatment, acupuncture showed clinically important improvements in patients' overall health status, measured by the WOMAC (Western Ontario and McMaster Universities Osteoarthritis Index), a widely recognized scale for assessing pain, stiffness, and function in patients with arthritis. Specifically, acupuncture showed reduction in pain, decreased joint stiffness, and improvement in physical function. Compared with usual care, acupuncture was particularly effective in reducing joint stiffness, a symptom especially bothersome for many patients.

The analyses also revealed that the optimal duration of treatment varies between 4 and 8 weeks depending on symptom severity, and that combining acupuncture with anti-inflammatory medications may be more beneficial than acupuncture alone for more severe symptoms. Interestingly, no significant differences were found between manual acupuncture and electroacupuncture in terms of efficacy. Regarding safety, the study showed that adverse effects of acupuncture are rare and generally mild, occasionally including dizziness, pain at the needle insertion site, or small bruises, making it a relatively safe therapy.

For patients and health professionals, these findings have important practical implications. The guidelines recommend acupuncture as a valid therapeutic option for adults with knee osteoarthritis, especially when other treatments prove ineffective or cause unacceptable adverse effects. Acupuncture may be particularly useful for patients who develop gastrointestinal problems with anti-inflammatory drugs or who have cardiovascular conditions that contraindicate the use of these medications. Treatment is recommended for periods of 4 to 8 weeks, with 2 to 4 sessions per week, adjusting duration according to symptom severity and individual response.

For more severe cases, the combination with anti-inflammatory medication may provide additional benefit. It is important that patients and clinicians jointly discuss the decision to use acupuncture, taking into account individual factors such as personal preferences, availability of qualified acupuncturists, treatment costs, and tolerance for needle-based procedures. Acupuncture is especially promising for patients suffering with morning stiffness or joint stiffness at rest, symptoms for which it showed greater efficacy compared with conventional care.

Despite the promising results, the study has several important limitations that should be considered. One significant limitation is the lack of direct evidence on patient values and preferences regarding acupuncture, which means that recommendations were based on the clinical experience of participating experts rather than on specific data about what patients actually want. In addition, the analysis did not include cost-effectiveness assessments, as acupuncture costs vary widely across countries and health systems, including factors such as treatment frequency, cost per session, and insurance coverage. Another area of uncertainty concerns the individual effects of acupuncture, which may vary significantly depending on the acupuncturist's experience, specific techniques used, and individual patient response.

Although the study demonstrated benefits for symptom control, it remains uncertain whether acupuncture can slow disease progression or delay the need for knee replacement surgery. The researchers identified the need for future studies specifically investigating patient preferences and evaluating long-term outcomes, including the possibility that acupuncture may slow osteoarthritis progression and reduce the need for more invasive surgical interventions in the future.