Background

Acupuncture is recognized as an alternative therapy for rheumatoid arthritis (RA) pain, but its efficacy evaluations are often confounded by variability in sham acupuncture techniques. The accurate selection of sham acupuncture controls, which are administered at either therapeutic acupuncture points or non-acupuncture points, is crucial for the validity of assessment outcomes.

Objective

To assess the efficacy of acupuncture in treating RA pain and identify the most effective acupuncture methods.

Search strategy

Databases including MEDLINE, Embase, PubMed, Cochrane Library, Scopus, Web of Science, China National Knowledge Infrastructure Database, Chinese Science and Technology Journal Database, and Wanfang Database were searched from inception to October 11, 2024. Keywords included “rheumatoid arthritis,” “acupuncture,” “electroacupuncture,” and “pain.”

Inclusion criteria

Randomized controlled trials (RCTs) in adults with RA that assessed pain using a visual analog scale and joint swelling by swollen joint count. Eligible trials compared electroacupuncture, conventional acupuncture, or sham acupuncture, against standard pain medication.

Data extraction and analysis

Two reviewers independently extracted data on study design, participant characteristics, interventions and outcomes. Risk of bias was evaluated using the Cochrane Risk of Bias 2 tool, and evidence certainty was assessed via the confidence in network meta-analysis framework. A frequentist network meta-analysis with random-effect models was conducted, and standardized mean difference (SMD) and 95% confidence interval (CI) were reported.

Results

Ten RCTs involving 704 participants were analyzed. Electroacupuncture (SMD: –1.42; 95% CI: [–1.87, –0.98]) and conventional acupuncture (SMD: –1.11; 95% CI: [–1.49, –0.73]) outperformed conventional therapy and non-acupoint sham needling. Surface under cumulative ranking curve showed that electroacupuncture was most effective for pain reduction (97.7%), followed by conventional acupuncture (75.1%), non-acupoint sham (29.1%), same-acupoint sham (28.6%), and conventional therapy (19.5%).

Conclusion

Electroacupuncture demonstrated the highest efficacy for RA pain relief. Same-acupoint sham acupuncture may underestimate acupuncture’s true effect and is not recommended as a placebo control. Non-acupoint sham acupuncture is a more valid control for future trials.

Key words: Electroacupuncture, Acupuncture, Rheumatoid arthritis, Pain, Systematic review, Meta-analysis