Acupuncture compared to other physical therapies for osteoarthritis of the knee: a network meta-analysis. Hugh MacPherson University of York
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1 Acupuncture compared to other physical therapies for osteoarthritis of the knee: a network meta-analysis Hugh MacPherson University of York
2 Acupuncture for osteoarthritis 1. Clinical guidance on acupuncture for osteoarthritis Background 2. Is there a way to develop better evidence from the existing literature? A network meta-analysis 3. How does acupuncture compare to other physical interventions? Physical interventions vs. standard care Acupuncture vs. physical interventions
3 Clinical guidelines on acupuncture for osteoarthritis (OA) of the knee ACR - American College of Rheumatology AAOS - American Academy of Orthopaedic Surgeons EULAR European League against Rheumatism NICE National Institute for Clinical Excellence (UK) OARSI - Osteoarthritis Research Society International Guideline AAOS Recommendation of acupuncture? (yes/no?) no ACR EULAR OARSI NICE yes if moderate/severe pain + unwilling to have knee replacement no yes no
4 NICE clinical guidance for osteoarthritis There is not enough consistent evidence of clinical or cost effectiveness (of acupuncture) to allow a firm recommendation. CG 59, NICE, Feb 2008
5 NICE chart for targeting treatment (2008) Braces Heat Insoles Muscle strengthening exercises Aerobic exercise Cold TENS Weight loss Manual therapy
6 Some questions on acupuncture for osteoarthritis 1. Clinical guidance on acupuncture for osteoarthritis? Background 2. Is there a way to develop better evidence from the existing literature? A network meta-analysis 3. How does acupuncture compare to other physical interventions? Physical interventions vs. standard care Acupuncture vs. physical interventions
7 Multiple treatment meta-analysis or network meta-analysis Indirect Comparison? Salanti et al. A case study of multiple-treatments meta-analysis. J Clin Epidemiol (8):
8 Why a network (multiple treatment) meta-analysis? A method of comparing interventions that have not yet been directly compared. Comprehensive combination of both direct (within-trial) and indirect (betweentrial) evidence All treatments are compared equally with each other. Enables ranking of relevant treatments for same condition
9 Some questions on acupuncture for osteoarthritis 1. Clinical guidance on acupuncture for osteoarthritis? Background 2. Is there a way to develop better evidence from the existing literature? A network meta-analysis 3. How does acupuncture compare to other physical interventions? Physical interventions vs. standard care Acupuncture vs. physical interventions
10 Aim of Research network meta-analysis question for OA How does the effectiveness of acupuncture compare with other relevant physical treatments for alleviating pain due to osteoarthritis of the knee in patients seeking additional or alternative therapy to pharmacological analgesics.
11 Network meta-analysis of physical therapies for osteoarthritis Searches 17 electronic databases, trial registers, osteoarthritis websites, and bibliographies of relevant reviews searched. Eligibility Randomised controlled trials Patients with osteoarthritis of the knee Treatments with physical therapies (excluding drugs and surgery) Reporting pain as an outcome.
12 Network meta-analysis of physical therapies for osteoarthritis Suitable data for came form 156 eligible studies 114 trials 9709 patients 18 physical therapies 4 comparators (standard care, sham treatment, placebo, no treatment)
13 22 interventions 9 physical treatments - recommended by NICE 2008 braces aerobic (weight bearing) exercise muscle strengthening (non-weight bearing) exercise heat treatment ice/cooling treatment insoles manual therapy transcutaneous electrical nerve stimulation (TENS); 9 physical treatments - not recommended by NICE 2008 acupuncture balneotherapy interferential therapy neuromuscular electrical stimulation (NMES) pulsed electrical stimulation (PES) pulsed electromagnetic fields (PEMF); static magnets tai chi weight loss laser/light therapy COMPARATORS Standard care, sham acupuncture, placebo, no treatment
14 Results for the any-quality trials Network Meta-analysis
15 Network High for higher-quality trials only trials Thickness of lines represents number of trials that have a comparison in the analysis. Number on lines represents consistency between direct and indirect evidence (zero = totally consistent, 1 = totally inconsistent)
16 Multiple Treatments treatment vs. standard comparison care for osteoarthritis higher-quality of the trials knee Comparator = standard care Acupuncture, balneotherapy, sham acupuncture, muscle-strengthening exercises all outperform standard care
17 Multiple Acupuncture treatment vs. other comparison treatments for osteoarthritis high-quality of the trials knee Comparator = acupuncture Acupuncture outperforms: sham acupuncture, muscle-strengthening exercises, weight loss, standard care, aerobic exercise, and no treatment
18 Publication the network meta-analysis results indicate that acupuncture can be considered as one of the more effective physical treatments
19 Strengths and limitations Focus on clinical decision-making Comparisons available between interventions when direct trial comparisons do not exist It uses more of available evidence Consistent framework for synthesis All interventions compared equally Small sample sizes of trials Mixed quality of methodology End of treatment = primary end-point Heterogeneity across trials
20 Acknowledgments Mark Corbett Stephen Rice Russell Slack Melissa Harden Vichithranie Madurasinghe Alex Sutton Philip Conaghan Nerys Woolacott This is independent research funded by the National Institute for Health Research (NIHR) under Programme Grants for Applied Research (Grant No. RP-PG ). The views expressed in this presentation are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.
21 Publications Corbett M, Rice S, Slack R, Harden M, Madurasinghe V, Sutton A, MacPherson H, Conaghan P, Woolacott N. Acupuncture and other physical treatments for the relief of chronic pain due to osteoarthritis of the knee: a systematic review and network meta-analysis. CRD Report 40. Centre for Reviews and Dissemination; June Available from: Corbett MS, Rice SJC, Madurasinghe V, Slack R, Fayter DA, Harden M, Sutton AJ, MacPherson H, Woolacott NF. Acupuncture and other physical treatments for the relief of pain due to osteoarthritis of the knee: network meta-analysis. Osteoarthritis & Cartilage. 2013; 21(9):
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