*5.3.1 Previous quality of evidence*

Liang et al. examined the research situation and trends pertaining to the global use of acupuncture for low back pain during the past 20 years (1997–2016) and concluded that according to clinical practice guidelines from the United States,

*The Use of Evidence-Based Acupuncture: Current Evidence DOI: http://dx.doi.org/10.5772/intechopen.100519*

acupuncture for LBP was only weakly suggested in 2007. However, moderate-quality evidence was reported in 2017, which demonstrated that acupuncture has been widely utilized to treat LBP [49]. Acupuncture has high-quality evidence whereas acupressure, on the other hand, offers moderate-quality evidence for the treatment of low back pain, according to Wellington et al. [50]. In the short term, acupuncture alone or as an addition to standard care improved pain and function in people with LBP, evidence ranging from low to high quality, and it should be recommended in ordinary clinical practice [51]. According to the findings of another study, acupuncture had moderate-quality evidence for pain and function in chronic low back pain but low-quality evidence for pain and function in acute low back pain [52].

#### *5.3.2 Current quality of evidence*

A large number of acupuncture randomized controlled trials have indicated that the treatment is ineffective. These findings are based on acupuncture randomized controlled trials in which a real acupuncture group was compared to a sham acupuncture (SA) or placebo acupuncture (PA) group. The argument over placebo effects presents a conundrum for those working in the field of acupuncture. Xiang et al. reviewed seven meta-analyses of SA or PA for LBP and found statistically significant differences in post-intervention pain reduction between SA or PA and routine or waiting list care, with moderate and high quality of evidence, but low in disability [20]. Procedures that are comparable to real acupuncture may be used in clinical trials, which may cause the results to be biased [51]. After reviewing 14 trials (2110 participants) comparing the efficacy of acupuncture to that of sham therapy or placebo for NSLBP, Xiang et al. reported statistically significant differences in pain reduction between acupuncture and sham therapy or placebo. The GRADE findings indicate that post-intervention and follow-up pain intensity in both acute/subacute and chronic LBP are of moderate quality of evidence [21]. Mu et al. assessed the effectiveness of acupuncture with a sham intervention, no therapy, or usual care in the treatment of chronic nonspecific low back pain. Acupuncture may not be more effective than sham treatment in alleviating pain immediately after treatment, did not appear to be significantly more effective in alleviating pain immediately after treatment, did not appear to be more effective in improving function immediately after treatment, and did not appear to improve the quality of life in the short term when compared to usual care. Acupuncture was found to be more effective than no treatment in terms of pain alleviation and functional improvement right after treatment. There maybe no difference in adverse event rates between acupuncture and sham. The evidence's certainty ranged from low to moderate. Problems with masking acupuncturists or participants were found in many experiments. A small sample size resulted in inconsistent and imprecise results [22]. Although the Cochrane systematic review (CSR) is regarded as the highest level of evidence, it cannot be ruled out that the CSR in acupuncture may have methodological flaws [53].

#### *5.3.3 Conclusion*

Acupuncture had a significant effect on pain intensity but not on function in patients with (sub)acute and chronic nonspecific LBP when compared to sham acupuncture or placebo. Acupuncture, on the other hand, is more effective in the short run than no treatment at improving pain and function. Acupuncture as a treatment for chronic low back pain is a popular choice. The availability, cost, and patient preference may all influence the guidelines for evaluating SA or PA control procedures to establish the specific effect of acupuncture on placebo pain.

### **5.4 Knee osteoarthritis**

Knee osteoarthritis (OA) is a complex, degenerative joint disease marked by chronic pain and functional impairment [54]. The pathophysiology of osteoarthritis is complicated, involving mechanical, inflammatory, and metabolic processes that eventually contribute to structural destruction and synovial joint failure [55]. Knee OA pain is usually intermittent and primarily weight bearing (mechanical) in origin. Intermittent pain is frequently predictable, but when it gets more severe, more frequent, or unpredictable, patients are more certain to describe it as unacceptable [56]. The major goals of treatment have been to alleviate pain, restore function, and delay the disease's progression [57]. Recently, there has been no consensus on the optimal treatment for knee OA symptoms. In individuals with knee OA, standard pharmacological treatment always begins with analgesics and nonsteroidal anti-inflammatory drugs (NSAIDs). However, it frequently results in noticeable deleterious consequences, such as gastrointestinal problems, hepatorenal toxicity, and adverse events associated with an increased risk of cardiovascular disease [58, 59]. Apart from the aforementioned therapies, acupuncture has emerged as a viable option for treating knee OA as a complementary therapy. Additionally, several randomized controlled trials have shown acupuncture's efficacy in treating knee OA. Acupuncture has been widely used as a complementary and alternative therapy for patients with knee OA due to its high safety and lack of side effects [60]. Although numerous trials have examined the usefulness of acupuncture for knee OA, its efficacy remains debatable. Emerging concerns about blinding, the validity of sham controls, sample size, effect size, and expectations have arisen [61]. Evidence from non-Cochrane reviews indicates that acupuncture may be beneficial in relieving symptomatic pain associated with knee OA.

#### *5.4.1 Previous quality of evidence*

Acupuncture, similar to balneotherapy, is superior to sham acupuncture, muscle-strengthening exercises, Tai Chi, weight loss, standard care, and aerobic exercise for knee OA (in order of rank). According to a sub-analysis of moderate- to high-quality studies, acupuncture is superior to routine care and musclestrengthening exercises [62].

#### *5.4.2 Current quality of evidence*

The GRADE results suggest that acupuncture has a higher overall effective rate, short-term effective rate, and fewer adverse reactions than Western medicine as a treatment for knee OA. In 2019, an overview of non-Cochrane SRs, which included a meta-analysis, concluded that acupuncture was beneficial for alleviating pain associated with knee OA. Due to the following constraints, evidence was reduced to "medium" or "low" quality: Most results were produced by a limited sample size and were based on imprecision. Because of the insufficient literature search, some of the results had a significant potential for publication bias, which could not be ruled out [23]. Regarding patients with knee OA, Zhang et al. compared the therapeutic efficacy of acupuncture + hyaluronic acid injection to hyaluronic acid injection alone. These studies, which were all published between 2012 and 2018, found that the combined therapy was more effective than hyaluronic acid injections alone in reducing pain. According to the GRADE system, the evidence quality for the key outcomes ranged from very low to low [24].
