Acupuncture, electrotherapy after knee replacement associated with reduced, delayed opioid use

Very low-certainty evidence showed that cryotherapy was associated with a reduction in opioid consumption and pain improvement, while low-certainty or very low-certainty evidence showed that continuous passive motion and preoperative exercise offered no pain improvement or reduction in opioid consumption.


Acupuncture and electrotherapy can potentially reduce and delay opioid use after total knee arthroplasty, a study found.

Researchers included 39 randomized clinical trials with 2,391 patients in the meta-analysis to determine which nonpharmacological interventions used for postoperative pain after total knee arthroplasty are effective. Results were published online Aug. 16 in JAMA Surgery.

The most commonly performed interventions included continuous passive motion, preoperative exercise, cryotherapy, electrotherapy, and acupuncture. Moderate-certainty evidence showed that electrotherapy reduced the use of opioids (mean difference [MD], −3.50 morphine equivalents in mg/kg per 48 hours; 95% CI, −5.90 to −1.10 mg/kg; P=0.004; I2=17%) and that acupuncture delayed opioid use (MD, 46.17 minutes to the first patient-controlled analgesia; 95% CI, 20.84 to 71.50 minutes; P<0.001; I2=19%). There was low-certainty evidence that acupuncture improved pain (MD, −1.14 on a visual analog scale at two days; 95% CI, −1.90 to −0.38; P=0.003; I2=0%).

Very low-certainty evidence showed that cryotherapy was associated with a reduction in opioid consumption (MD, −0.13 morphine equivalents in mg/kg per 48 hours; 95% CI, −0.26 to −0.01; P=0.03; I2=86%) and in pain improvement (MD, −0.51 on the visual analog scale; 95% CI, −1.00 to −0.02 on the visual analog scale; P<0.05; I2=62%). Low-certainty or very low-certainty evidence showed that continuous passive motion and preoperative exercise offered no pain improvement or reduction in opioid consumption. For continuous passive motion, the mean differences were −0.05 on the visual analog scale (95% CI, −0.35 to 0.25; P=0.74; I2=52%) and 6.58 morphine equivalents in mg/kg per 48 hours opioid consumption at one and two weeks (95% CI, −6.33 to 19.49) P=0.32, I2=87%). For preoperative exercise, the mean difference was −0.14 on the Western Ontario and McMaster Universities Arthritis Index Scale (95% CI, −1.11 to 0.84; P=0.78, I2=65%).

The results for continuous passive motion (CPM) were particularly notable, the authors wrote. “These results need to be cautiously considered because CPM is not without risk. Also, CPM is an expensive and time-consuming procedure. Because the results of other studies have suggested that CPM is ineffective in improving functionality and that CPM is associated with increased hospital length of stay, careful consideration should be exercised before applying this treatment.”

Researchers also observed that there was moderate-certainty evidence that electrotherapy and acupuncture reduce or delay opioid consumption, but low certainty or very low certainty that they improve pain. In addition, low or very low certainty evidence showed that CPM and preoperative exercise do not improve pain or reduce opioid consumption and cryotherapy reduces opioid consumption but does not improve pain.

“As prescription opioid use is under national scrutiny and because surgery has been identified as an avenue for addiction, it is important to recognize effective alternatives to standard pharmacological therapy, which remains the first option for treatment,” the study concluded.

In an unrelated research letter published by JAMA Surgery on the same day, opioid-naive individuals identified as having received an opioid prescription were assessed for sustained opioid use, defined as continuous refills of class II or III opioid medications without a lapse between prescriptions of seven days or longer for up to or exceeding six months. The study found that spine and orthopedic disorders were the most prominent specific categories of conditions associated with the initial opioid prescription.

“As we search for causes of the opioid epidemic, we note that hospital events and associated procedures do not appear to be the main drivers. In this cohort, most of the diagnoses used to support the issue of an opioid prescription that led to sustained use were either nonspecific or associated with spinal or other conditions for which opioid administration is not considered standard of care,” the authors wrote.