Acupuncture for sudden-onset ankle sprains in adults

An acute ankle sprain is a sudden-onset injury of the ankle ligaments (tough strands of tissue that connect and stabilise the bones at the ankle). It is one of the most common injuries in the general population as well as in athletes. Acupuncture is frequently used for treating ankle sprains in eastern Asian countries. This review aimed to assess the benefits and harms of acupuncture for the treatment of ankle sprains in adults. We searched the medical literature for studies up to May 2013.

Our review includes 20 studies involving 2012 people with ankle sprains. These studies differed from each other in many ways and compared various types of acupuncture with a variety of standard control interventions. Most studies reported only the 'cure rate' - the number of participants who had recovered at a set time. No study reported on patient-reported assessment of function. Only one study reported on adverse events and found skin problems in individuals receiving over-the-counter traditional Chinese herbal patches as a control intervention. Most trials had flaws in the way they were conducted, which makes their results less reliable; for example, most studies failed to ensure participants did not know which intervention they were receiving.

One study, which compared acupuncture with no treatment, found more people were cured with acupuncture. Most of the eight studies comparing acupuncture plus another standard treatment versus that standard treatment alone found higher cure rates in the acupuncture group. However, we found that pooling these results did not provide conclusive evidence that acupuncture resulted in a better cure rate.

Fourteen studies compared acupuncture with a variety of other non-surgical treatments, such as Chinese herbal patches, hot and cold water, ice packs, Chinese oral herbal medicine and elastic bandages. Some studies found in favour of acupuncture, some in favour of the other treatment and some found a lack of evidence for a difference between the two interventions under test. The pooled results from 11 studies comparing acupuncture versus another non-surgical intervention tended to favour acupuncture, but this evidence was not conclusive.

Currently, we are unable to conclude whether or not acupuncture is more effective than other standard methods for the treatment of ankle sprains in adults because of the very low quality of the available evidence. Because the adverse effects of acupuncture treatment were not described in most of the studies, we are also unable to draw any conclusions about the safety of acupuncture. Large, high quality studies of acupuncture for sudden-onset ankle sprains in adults are needed.

Authors' conclusions: 

The currently available evidence from a very heterogeneous group of randomised and quasi-randomised controlled trials evaluating the effects of acupuncture for the treatment of acute ankle sprains does not provide reliable support for either the effectiveness or safety of acupuncture treatments, alone or in combination with other non-surgical interventions; or in comparison with other non-surgical interventions. Future rigorous randomised clinical trials with larger sample sizes will be necessary to establish robust clinical evidence concerning the effectiveness and safety of acupuncture treatment for acute ankle sprains.

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Background: 

An acute ankle sprain is a sudden-onset injury of one or more of the ankle ligaments. It is one of the most common musculoskeletal injuries in the general population as well as in athletes. In some countries, such as China and Korea, acupuncture is frequently used in the treatment of ankle sprains, either as a single treatment or a secondary intervention accompanied by standard medical treatment.

Objectives: 

To assess the effects (benefits and harms) of acupuncture for the treatment of ankle sprains in adults.

Search strategy: 

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (May 2013), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2013, Issue 4), MEDLINE (1948 to May week 2 2013), EMBASE (1980 to May week 2 2013), China National Knowledge Infrastructure databases (1994 to August week 4 2013), the Cumulative Index to Nursing and Allied Health Literature (1937 to May 2013), the Allied and Complementary Medicine Database (1985 to May 2013), Science Links Japan (1996 to August week 4 2013), several Korean medical databases (August week 4 2013), the World Health Organization International Clinical Trials Registry Platform (August week 4 2013), the bibliographic references of included trials and conference proceedings.

Selection criteria: 

We included randomised and quasi-randomised controlled trials involving adults with acute ankle sprains. We included all types of acupuncture practices, such as needle acupuncture, electroacupuncture, laser acupuncture, pharmacoacupuncture, non-penetrating acupuncture point stimulation (e.g. acupressure and magnets) and moxibustion. Acupuncture could be compared with control (no treatment or placebo) or another standard non-surgical intervention.

Data collection and analysis: 

Two review authors independently screened the search results, assessed trial eligibility, assessed risk of bias and extracted data from the included trials. We calculated risk ratios (RRs) for dichotomous outcomes and mean differences for continuous outcomes. We conducted meta-analyses using the fixed-effect method or, where appropriate, the random-effects method, and used 95% confidence intervals (CI) throughout.

Main results: 

We included a total of 20 heterogeneous studies (2012 participants with acute ankle sprains); three of which included more than one comparison. Seventeen trials were conducted in China. All of the studies had a high risk of bias due to lack of blinding. The results may also have been affected by selection bias, particularly as five studies were quasi-randomised controlled trials and 12 studies gave no information on their method of randomisation. Of our three prespecified primary outcomes, only cure rate was reported by the majority of studies. No study reported on patient-reported assessment of function and only one reported on adverse events (in which three participants receiving a control intervention experienced skin problems from over-the-counter Chinese herbal patches). The other 19 studies did not record or report on adverse events. We assessed the quality of evidence for cure rates as very low for all comparisons, which means we are very uncertain about the reliability of any of the estimates.

The single study comparing acupuncture treatment with no treatment found acupuncture to be more effective with regard to cure rate at five days (31/31 versus 1/30; RR 20.34, 95% CI 4.27 to 96.68). Acupuncture plus another standard treatment versus that standard treatment alone was tested in eight studies; with cure rate data available for seven. Most of these studies reported higher cure rates in the acupuncture plus another standard treatment group than in the standard treatment alone group. However, while the results of an exploratory meta-analysis of cure rate data from eight trials testing acupuncture versus no acupuncture tended to favour acupuncture, the results were very inconsistent across the studies and the estimated effect was very imprecise (383/396 versus 272/355; RR 1.32, 95% CI 0.95 to 1.84; P value = 0.1; I2 = 98%).

Fourteen studies compared acupuncture with a variety of other non-surgical treatments, such as Chinese drug patches, hot and cold water, ice packs, oral Chinese herbal medicine and elastic bandage. Some studies found in favour of acupuncture, some in favour of the other treatment and some found a lack of evidence for a difference between the two interventions under test. The results of an exploratory meta-analysis of cure rate data from 11 trials testing acupuncture versus another non-surgical intervention tended to slightly favour acupuncture, but these were not statistically significant and the data were very heterogeneous (404/509 versus 416/497; RR 1.07, 95% CI 0.94 to 1.22; P value = 0.30; I2 = 92%).

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