Risk of bias and methodological issues in randomised controlled trials of acupuncture for knee osteoarthritis: a cross-sectional study

Evidence-Based Complementary and Alternative Orthopedic Veterinary Medicine

The use of complementary and alternative veterinary medicine (CAVM) continues to become more widespread, especially for the management of chronic pain conditions such as canine osteoarthritis. Many patients have comorbidities that preclude traditional medical options, have not adequately responded to conventional therapies, or have owners interested in pursuing a complementary approach. Evidence-based CAVM can serve as a safe and effective adjunct to manage chronic pain conditions. There is growing evidence in the veterinary literature for the use of acupuncture and some herbal supplements in the multimodal management of canine osteoarthritis. The majority of evidence supporting chiropractic is limited to equine and human literature.

Do acupuncture trials have lower risk of bias over the last five decades? A methodological study of 4 715 randomized controlled trials

Objective

To evaluate the change of the risk of bias (RoB) of acupuncture randomized controlled trials (RCTs) in the past five decades.

Methods

Multiple databases were searched. We included RCTs identified from systematic reviews (SRs) on acupuncture. General characteristics and RoB judgment for each domain were extracted. The proportions of RCTs at high and unclear RoB were calculated and the changes were examined by the Mann-Kendall test.

Results

We included 368 SRs including 4 715 RCTs. The rates of RCTs at unclear RoB were the highest in allocation concealment (63%), and at the lowest in incomplete outcome data (35%); in the last five decades, statistically significant reductions were found for random sequence generation (P < 0.001) and selective reporting (P = 0.01), and increases for blinding of participants and personnel (P < 0.001), blinding of outcome assessment (P < 0.001) and incomplete outcome data (P = 0.04). For the proportions of RCTs at high RoB, blinding of participants and personnel (47%) and blinding of outcome assessment (35%) were the poorest domains; there were no significant differences in changes for all domains.

Conclusions

Although improvements concerning unclear risk were observed for random sequence generation and selective reporting, major issues remain for allocation concealment and blinding. It is imperative to use valid randomization, specify how it is conducted, and try to test for selection bias and the success of masking by using the Berger Exner test.

Isometric exercise, acupuncture, and magnet therapy for knee osteoarthritis: randomized clinical trial

Introduction: Knee osteoarthritis is a common disease, particularly in the elderly population. Degenerative disorders of the cartilage cause pain and stiffness in the knee joint. As a result, patients frequently experience limitation in their daily activities. Purpose: To compare the effects of exercise, acupuncture, and magnet therapy on symptoms and physical function among middle-aged and elderly people with knee osteoarthritis. Materials and methods: We carried out a parallel three-arm randomized clinical trial in an outpatient clinic of the Department of Physical Medicine and Rehabilitation at a University Hospital. In total, 60 female patients of age ≥ 40 years with chronic knee osteoarthritis were randomly allocated to one of three groups of isometric exercise, acupuncture, and magnet therapy. The primary outcome measure was subjective pain rated according to the Visual Analog Scale. We also used the Western Ontario McMaster Universities Osteoarthritis Index for assessing and monitoring the symptoms of knee osteoarthritis in order to evaluate the efficacy of the interventions. An isometric exercise program was prescribed, consisting of three sessions per week for six weeks. Participants in the acupuncture group received three treatment sessions per week for six weeks, each lasting for 30 minutes. For pulsed electro-magnetic field therapy, a total of three 30-minute sessions per week for a period of 6 weeks were administered to each patient. Results: There were no statistically significant differences between the study groups in terms of the outcome measures (all p values > 0.05). However, within-group analyses showed that there were significant differences regarding the clinical outcomes in each group (all p values < 0.05). Conclusion: All three therapeutic modalities are effective and could be used as the first line of treatment for knee osteoarthritis. Moreover, it should be noted that the favorable outcomes remained at least two months after treatment concluded.

An overview on the methodological and reporting quality of dose-response meta-analysis on cancer prevention

BACKGROUND

Dose-response meta-analysis (DRMA) has been widely used in exploring cancer risk factors. Understanding the quality of published DRMAs on cancer risk factors may be beneficial for informed prevention for cancer.

METHODS

We searched eligible DRMAs from 1st January 2011 to 31st-July-2017. The modified AMSTAR 1.0 (15 items) and PRISMA checklist (26 items) were used to evaluate the methodological and reporting quality of included DRMAs. We compared the adherence rate of these items by journal type, publication years, region, and funding information, in prior.

RESULTS

We included 260 DRMAs. Colorectal, breast, prostate, and lung were the four most commonly investigated cancers. For methodological quality, 6 out of 15 items were adhered by less than 30% of the DRMAs, 2 by less than 60%, only 7 of which by 80% or more. For reporting quality, 3 out of 26 items were adhered by less than 30% of the DRMAs, 1 by less than 80% (> 30%), and 20 of which by 80% or more. Those published in general journal, published more recently, and received any financial support have better methodological (Rate differences, RDs = 10-36%; P < 0.05) and reporting adherence (RDs = 12-36%; P < 0.05). DRMAs by Asian author tend to be less qualified than by European and American.

CONCLUSIONS

The methodological quality of DRMAs on cancer risk factors is worrisome that the findings of them may be deflective; more efforts are needed to improve the validity of it.

Improving the quality of reporting of systematic reviews of dose-response meta-analyses: a cross-sectional survey

Background

Dose-response meta-analysis (DRMA) is a useful tool to investigate potential dose-response relationship between certain exposure or intervention and the outcome of interest. A large number of DRMAs have been published in the past several years. However, the standard of reporting for such studies is not known.

Methods

Medline, Embase, and Wiley Library were searched for systematic reviews with DRMAs (SR-DRMAs) published from January 2011 to July 2017. We used the combination of PRISMA and MOOSE statements, containing 33 items, to assess the reporting of included SR-DRMAs. The adherence of reporting was defined as the proportion of SR-DRMAs meeting the reporting requirement of an item. We explored the association between five pre-specified variables with the total score of reporting on both fully as well as each domain of the checklist.

Results

In total, 529 SR-DRMAs were eligible. Ten out of 33 items were under reported, and this mainly refers to the methods domain: only a small proportion of SR-DRMAs stated whether a review protocol existed (45, 8.5%); clarified the qualifications of searchers (1.7%); presented full electronic search strategy (25.9%); described any effort to include all available studies (22.9%), described methods for languages other than English (27.4%), and stated the process for selecting studies (20.2%). Multiple regression analysis suggested that studies with more authors (regression coefficient = 0.78; 95% CI: 0.35, 1.20; P <  0.001), published more recently (regression coefficient = 0.38; 95% CI: 0.28 to 0.47; trend P <  0.001), used reporting guideline (regression coefficient = 0.98; 95% CI: 0.68 to 1.32; P <  0.001), and involvement of methodologist (regression coefficient = 0.86; 95% CI: 0.42 to 1.32; P <  0.001) were associated with higher score of reporting. Further regression suggested that the improvement on the quality mainly concentrated on the methods and results domains.

Conclusions

The reporting of SR-DRMAs needs to be further improved, particularly in the issues refer to the methods. The quality of reporting may improve when involving more authors and methodologists and employing any reporting guidelines.

Electronic supplementary material

The online version of this article (10.1186/s12874-018-0623-6) contains supplementary material, which is available to authorized users.

Acupuncture treatment for knee osteoarthritis with sensitive points: protocol for a multicentre randomised controlled trial

INTRODUCTION

There is a lack of curative medical treatment for patients with knee osteoarthritis (KOA). Acupuncture represents an important alternative therapy. According to the theory of traditional Chinese medicine and preliminary clinical evidence, the patients' acupoints and tender points may become sensitised when the body suffers from a disease state; stimulation of such sensitive points could lead to a disease improvement. It is thus hypothesised that acupuncture at highly sensitised points on patients with KOA would achieve better treatment outcomes than acupuncture at low/non-sensitised points. Previously, we conducted a pilot trial to prove the feasibility of further investigation.

METHODS AND ANALYSIS

A three-arm, parallel, multicentre randomised controlled trial of 666 patients will be conducted at four hospitals of China. Eligible patients with KOA who consent to participate will be randomly assigned to a high-sensitisation group (patients receive acupuncture treatment at high-sensitive points), a low/non-sensitisation group (patients receive acupuncture treatment at low/non-sensitive points) or a waiting-list group (patients receive standard acupuncture treatment after the study is concluded) via a central randomisation system using 1:1:1 ratio. The primary outcome is the change of Western Ontario and McMaster Universities Osteoarthritis Index total score from baseline to 16 weeks. Outcome assessors and data analysts will be blinded and participants will be asked not to reveal their allocation to assessors. The outcome analyses will be performed both on the intention-to-treat and per-protocol population. The primary analyses will test if acupuncture at highly sensitised points would achieve statistically better treatment outcomes than acupuncture at low/non-sensitised points and no acupuncture (ie, waiting list), respectively. A small number of prespecified subgroup analyses will be conducted.

ETHICS AND DISSEMINATION

Ethics approval has been granted by the Bioethics Subcommittee of West China Hospital, Sichuan University: 2017 (Number 228). Results will be expected to be published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT03299439.