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Efficacy of acupuncture for primary osteoporosis: a systematic review and meta-analysis of randomized controlled trials

Journal of Orthopaedic Surgery and Research volume 20, Article number: 127 (2025) Cite this article

Abstract

Background

Primary osteoporosis (POP) is a common metabolic bone disorder that has a devastating effect on their quality of life in patients. Acupuncture, a traditional Chinese therapy, has been used to treat osteoporosis for over 2000 years. This study aimed to determine the efficacy of acupuncture in treating POP compared to conventional medicine or placebo.

Methods

We searched for potentially relevant studies in PubMed, Web of Science, Embase, Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure, China Biology Medicine disc, Wanfang database and ClinicalTrials.gov up to December 20, 2024. Randomized controlled trials investigating treatment of POP for which acupuncture was administered as a stand-alone treatment or combined with conventional medicine compared to conventional medicine or placebo, were included. The outcomes included bone mineral density (BMD), visual analogue scale (VAS) scores, clinical effectiveness rate, estradiol (E2), Oswestry Disability Index (ODI), and levels of serum alkaline phosphatase (ALP). Data were synthesized using a random-effects meta-analysis model, and the observed heterogeneity was investigated using subgroup analyses. Study quality was appraised using the Cochrane RoB 2 tools, and the quality of the aggregated evidence was evaluated using the GRADE guidelines. Publication bias was assessed by funnel plots and validated by Egger's test.

Results

Forty eligible articles with 2654 participants were identified. Compared to the control group, acupuncture effectively increased the BMD (MD 0.04 [0.03–0.06], P < 0.001, I2 = 92%), clinical efficacy (RR 1.24 [1.14–1.34], P < 0.001, I2 = 81%), and levels of E2 (SMD 0.30 [0.09–0.52], P = 0.006, I2 = 0%), and reduced the VAS scores (SMD − 1.79 [− 2.29 to − 1.29], P < 0.001, I2 = 95%). Data on ODI and ALP were insufficient for meta-analysis.

Conclusion

The current evidence suggests that the efficacy of acupuncture in improving the symptoms of POP are encouraging for its use in clinical practice as a physical intervention for patients with POP. However, since the included patients were all from China, there was a risk of sample bias, high-quality multicenter studies in different countries or regions should be conducted in the future.

Introduction

Osteoporosis (OP) is defined by low bone quality, strength and increased fracture risk [1]. Approximately 21.7% of the world’s population is affected by osteoporosis with a predominance in elderly females as compared to males (35.3% vs 12.5%) [2]. Given the progressive ageing of populations, osteoporosis-related fragility fractures become common in the elderly, leading to a significant increase in disability and mortality and a devastating impact on their quality of life [3].

OP can be divided into primary and secondary osteoporosis based on the factors affecting bone metabolism [4]. Primary osteoporosis (POP) develops due to aging or menopause-related bone demineralization. Postmenopausal and senile osteoporosis are the two subtypes of POP. Secondary osteoporosis is caused by pathological conditions and medications other than aging or menopause. Corticosteroid-induced osteoporosis is the most common type of secondary osteoporosis, leading to fractures and increased morbidity and mortality [5].

Currently approved drugs for POP can be divided into anti-resorptive and anabolic medications [6]. The most commonly prescribed agents are anti-resorptive drugs (e.g. denosumab, romosozumab, ibandronate, alendronate and raloxifene), which are safer and effective in preventing fractures [7, 8]. However, the extended efficacy of these agents is limited and associated with serious adverse events [9]. Therefore, many researchers are dedicated to more advanced concepts and therapies, such as individualized therapy [10], acupuncture, exercises, and Chinese herbal medicines.

Acupuncture is a traditional Chinese medical therapy and has been widely used for OP in Asia throughout its long history [11]. It is a physical therapy that works by inserting a needle at a specific point called the acupoint. Some studies reported that acupuncture showed very clear efficacy in the treatment of POP. At present, the effect mechanism of POP by acupuncture has been not completely found. According to the related research reported that multiple mechanisms could be involved in this effect of acupuncture. Acupuncture has been shown to regulate estrogen levels in the body, which is crucial for bone metabolism [12]. Additionally, acupuncture stimulates the nervous system to release endorphins and other substances that help alleviate pain [13], and improves the blood flow to bone tissue, thereby aiding in the repair and regeneration of bone [14]. Moreover, some studies indicated that acupuncture may improve bone metabolism by promoting the proliferation and differentiation of osteoblasts while reducing the activity of osteoclasts [15, 16].

Since 2018, several systematic reviews and meta-analyses have investigated the use of acupuncture in treating OP [17,18,19,20,21,22]. Most reported encouraging results, but many systematic reviews and meta-analyses tested acupuncture in conjunction with Chinese herbal medicine or moxibustion interventions [17, 22, 23], which made it difficult to distinguish the effects of acupuncture. In this review we included newly published randomized controlled trials (RCTs) and encompasses a broader range of acupuncture modalities to determine the efficacy of acupuncture in treating POP compared to conventional medicine or placebo.

Materials and methods

Guidelines followed

This review protocol has been registered in the International Prospective Register of Systematic Reviews as CRD42024540470. We have reported our findings in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) 2020 guidelines [24].

Search strategy

Seven major electronic bibliographic databases were searched: (1) English databases: EMBASE, the Cochrane Library, Web of Science, and PubMed; and (2) Chinese databases: China Biological Medicine Database, Wanfang database, and China National Knowledge Infrastructure. Unpublished and gray literature was sought through registries of past and ongoing trials (e.g., ClinicalTrials.gov). A combination of subject terms and free words was used in the search. The search terms included “acupuncture”, “warming needle”, “electroacupuncture”, “acupoints”, “auriculoacupuncture”, and “osteoporosis” and were adapted for each database. Additionally, we manually retrieved the reference lists of the included studies. The original search was performed in February 2024, and an updated search was conducted on December 20, 2024. The details of the search strategies are in Supplementary Material (Fig. 1).

Fig. 1
figure 1

PRISMA flow diagram of literature search

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Inclusion criteria

Included studies have to meet the following PICOS (participant, intervention, comparator, outcome, study design) criteria: (1) Participants: patients with POP regardless of age, sex, or ethnic origin; (2) Interventions: traditional acupuncture inserting needles into traditional meridian points tradititional, including manual acupuncture, warm acupuncture, electroacupuncture, and auriculoacupuncture; (3) Comparators: comparing acupuncture to sham acupuncture, blank, or a conventional medicine control, but in addition one form of acupuncture comparing with another form of active acupuncture or a different type of Traditional Chinese Medicine (TCM) (e.g. Chinese herbal medicine), and allowing adjuvant treatments, either conventional medicine or TCM, as long as they had been given to both intervention groups; (4) Outcomes: reporting at least one primary outcome: bone mineral density (BMD) or visual analogue scale (VAS) scores, and secondary outcomes such as clinical effectiveness rate, estradiol (E2), Oswestry Disability Index (ODI), and levels of serum alkaline phosphatase (ALP) to be reported selectively. The efficacy of acupuncture-related therapies is determined based on the criteria of Chinese medicine clinical evidence points for the clinical standard, and the overall clinical effectiveness rate is divided into four levels: (1) clinically cured, (2) markedly effective, (3) effective, and (4) invalid [25]. The overall clinical effectiveness rate was calculated as follows: overall clinical effectiveness rate (%) = ([number of patients clinically cured + markedly effective + effective]/number of patients * 100); (5) Study design: RCTs of four weeks or longer duration irrespective of blinding, publication status or language. Studies were excluded if they met any of the following criteria: patients with secondary osteoporosis, observational studies, protocols, case reports, animal experimental studies, duplicated publications, or full-text unavailable articles.

Data extraction

The results of the literature search were imported into the NoteExpress reference management software. Two researchers (Tianyi Ma and TianTian Zhang) independently completed the standard literature screening process, removing duplicate studies and excluding ineligible studies by reading the title, abstract, and full text and then extracting data from eligible studies using a predesigned form, including first author name, year of publication, age, sample size, key contents of intervention, acupoints, and outcomes. In studies where meta-analysis data were missing or unavailable, attempts were made to contact the corresponding authors by email. If necessary, the need for extraction of incomplete data was waived. Any disagreements were discussed and arbitrated by a third reviewer (Le Zhang).

Quality assessment

Two reviewers (Tianyi Ma and TianTian Zhang) Independently assessed the methodological quality of RCTs based on the Cochrane RoB 2 tools [26]. Each study was evaluated on based seven items: random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessments, incomplete outcome data, selective reporting, and other biases. Each item was ranked low, unclear, or at a high risk of bias. Any disagreements were discussed and arbitrated by a third reviewer (Le Zhang). Additionally, we calculated Cohen's kappa coefficient and the Kappa scores for the inter-reviewer agreement were as follows: bad, < 0.20; normal, 0.40–0.59; good, 0.60–0.74; and very good, ≥ 0.75.

Credibility of evidence

The credibility of the aggregated evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) [27]. Evidence may be reduced by five factors: study limitations, inconsistency, indirectness, imprecision, and publication bias; factors that may improve the credibility of evidence from observational studies: large effect sizes, negative bias, and dose–effect relationships. The results of studies with moderate or large effect sizes may lead to an improved credibility of evidence. Four credibility levels were used: high, moderate, low, and very low credibility.

Statistical analyses

A meta-analysis was performed using Review Manager Software version 5.4. For dichotomous variables, the relative risk (RR) with a 95% confidence interval (CI) was calculated. For continuous variables, mean difference (MD) and standardized mean difference (SMD) with a 95% CI were calculated. Statistical heterogeneity was tested using the χ2 test (significance level P < 0.1) and I2 statistic. When I2 ≥ 50% or P < 0.1, it indicates the presence of significant heterogeneity [28]. We used a random-effects model because of variations in the participants’ personal characteristics, treatment frequency and duration, acupuncture points for injection, and types of comparators [29]. The sources of heterogeneity were explored using subgroup analysis, and the potential effects on the results are discussed. Publication bias was assessed using a funnel plot and Egger’s test. All publication bias analyses were performed using Stata 14 (StataCorp LP, 2015). Furthermore, we performed a sensitivity analysis by using one out remove method to estimate the robustness of the results of meta-analysis.

Results

Study selection

The flowchart of the study selection process is described in Fig. 1. A total of 2117 titles were retrieved from the databases and registries. After the removal of duplicate records, we screened the abstracts and titles of 1003 reports. After screening of the title and abstract, 116 titles remained for full text review. Overall, 40 studies totalling 2654 participants were eligible [30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68]. During an updated search on 20 December 2024, no further studies were included.

Descriptive analysis

Essential characteristics of the included studies are described in Table 1. A total of 2654 subjects, including 1339 patients from the treatment group and 1315 patients served as controls, were included into this systematic review. The participants’ mean ages ranged from 51 to 70 years. One study had 3 study arms, which compares acupuncture to conventional medicine to a combination of acupuncture and conventional medicine [57]. The remaining 39 studies had 2 study arms, of which 18 studies [34,35,36,37,38, 42, 44, 49, 50, 53,54,55, 61, 66, 67, 69] chose needling, 8 studies [33, 40, 41, 51, 52, 58, 62, 63] chose electroacupuncture as the intervention method and 12 studies [31, 32, 43, 45,46,47, 59, 60, 64, 65, 68] chose warm acupuncture as the intervention method. In these trials, frequency of acupuncture intervention was at least three times one week and the total duration of treatment ranged from 1 to 6 months.

Table 1 Summary of studies included in meta-analysis
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Risk of bias in included trials

The overall Kappa score for the consistency of methodological quality assessment between the two evaluators was 0.890 (Additional file 1). The methodological quality of the included studies is described in Fig. 2. Of the 40 included studies, only two study [36, 43] did not provide detailed information regarding random sequence generation. Five trials [32, 33, 51, 58] clearly reported the allocation concealment. Two studies [34, 43] clearly described the blinding of participants and personnel, and four studies [34, 37, 51, 58] distinctly reported the blinding of outcome assessment. Incomplete outcome data was high risk in three studies [39, 51, 66], since the reason of withdrawal and loss of follow-up are not described. Selective reporting could not be judged in all the studies because of the insufficient information provided. Other bias was evaluated to be of low risk in all the studies.

Fig. 2
figure 2

Risk of bias graph

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Acupoints

After analysis of points adopted in these trials, we found that Shenshu (BL23), Zusanli (ST36), Pishu (BL20) were the top three commonly used acupoints. The top 10 commonly used acupoints for OP were presented in Fig. 3.

Fig. 3
figure 3

The highest frequency acupoints adopted in these studies

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Bone mineral density

A total of 36 studies [30, 31, 34, 36,37,38,39,40,41,42,43,44,45,46, 49, 51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68] reported the BMD. Meta-analysis found that compared with the control group, acupuncture can effectively improve the BMD of patients with POP (MD 0.04 [0.03–0.06], P < 0.001, I2 = 92%) (Fig. 4). To more accurately evaluate the therapeutic effect of acupuncture, we conducted subgroup analysis based on different types of acupuncture used, including needling, electroacupuncture, and warm acupuncture. Firstly, a subgroup analysis with 16 studies [34, 36,37,38, 42, 44, 49, 53,54,55, 61, 66, 67, 69] showed needling significantly improved the BMD of patients with OP (MD 0.05 [0.02–0.07], P < 0.001, I2 = 80%), whether needling versus control group (MD 0.05 [0.02–0.07], P < 0.001, I2 = 64%) or needling plus conventional medicine versus control group (MD 0.05 [0.00–0.09], P < 0.001, I2 = 89%), respectively 11 [36, 38, 39, 44, 49, 53,54,55, 67, 69] and 5 [34, 37, 42, 61, 66] studies. The differences between subgroups were not significant (P = 0.96), thus the two types of interventions did not appear to differentially affect the primary outcome. Secondly, a subgroup analysis of 9 studies [30, 40, 41, 51, 57, 59, 62, 63] indicated that there was no statistical significance for the BMD between the electroacupuncture groups and controls (MD 0.03 [− 0.03–0.09], P = 0.03, I2 = 97%). Finally, a subgroup analysis with 12 studies [30,31,32,33, 43, 45, 46, 59, 60, 64, 65, 68] found that warm acupuncture presented a significant improvement in BMD (MD 0.06 [0.04–0.08], P < 0.001, I2 = 89%), whether warm acupuncture versus control group (MD 0.07 [0.02–0.13], P < 0.05, I2 = 65%) or warm acupuncture plus conventional medicine versus conventional medicine (MD 0.05 [0.03–0.08], P < 0.001, I2 = 93%), respectively 5 [30, 43, 45, 46, 65] and 7 [31, 32, 47, 59, 60, 64, 68] studies. The differences between subgroups were not significant (P = 0.47), thus the two types of interventions did not appear to differentially affect the primary outcome.

Fig. 4
figure 4

Meta-analysis of bone mineral density acupuncture versus conventional medicine

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Pain visual analog scale (VAS)

A total of 23 [30, 33, 35, 38, 41, 46, 48, 50,51,52,53, 56, 57, 59,60,61,62, 66] studies reported VAS after acupuncture treatment. Compared with the control group, meta-analysis found that acupuncture can effectively reduce the pain scores (SMD − 1.79 [− 2.29 to − 1.29], P < 0.001, I2 = 95%) (Fig. 5). We next performed subgroup analysis. Firstly, a subgroup analysis with 10 studies [25, 28, 40, 53, 56, 61, 67, 68] showed needling significantly improved the VAS of patients with POP (SMD − 1.81 [− 2.45 to − 1.16], P < 0.001, I2 = 95%), whether needling versus conventional me conventional medicine (SMD − 1.94 [− 2.52 to − 1.37], P < 0.001, I2 = 82%) or needling plus conventional medicine versus conventional medicine (SMD − 1.50 [− 2.62 to − 0.38], P < 0.05, I2 = 96%), respectively 7 [35, 38, 53, 54, 56, 67, 69] and 3 [50, 61, 66] studies. The differences between subgroups were not significant (P = 0.49), thus the two types of interventions did not appear to differentially affect the primary outcome. Secondly, a subgroup analysis of 8 studies [30, 33, 41, 51, 52, 57, 62, 63] indicated that electroacupuncture can effectively improve the VAS of patients with POP (SMD − 1.28 [− 2.14 to − 0.42], P < 0.05, I2 = 100%), whether electroacupuncture versus conventional medicine (SMD − 0.72 [− 1.19 to − 0.25], P < 0.05, I2 = 94%) or electroacupuncture plus conventional medicine versus conventional medicine (SMD − 1.53 [− 1.90 to − 1.15], P < 0.05, I2 = 72%),. respectively 5 and 4 studies [33, 51, 57, 63]. The differences between subgroups were significant (P = 0.009), thus the effect size for VAS is larger in electroacupuncture plus conventional medicine group. But both subgroups contain considerable statistical heterogeneity suggesting factors other than intervention type likely contribute to the observed heterogeneity. Finally, a subgroup analysis of 6 studies [30, 46, 48, 59, 68] proved that warm acupuncture presented a significant improvement in VAS (SMD − 0.98 [− 1.28 to − 0.68], P < 0.001, I2 = 85%), whether warm acupuncture versus control group (SMD − 2.23 [− 4.43 to − 0.13], P < 0.05, I2 = 80%) or warm acupuncture plus conventional medicine versus conventional medicine (SMD − 0.98 [− 1.29 to − 0.67], P < 0.001, I2 = 60%), respectively 3 [30, 46, 48] and 3 [59, 60, 68] studies. The differences between subgroups were not significant (P = 0.25), thus the two types of interventions did not appear to differentially affect the primary outcome.

Fig. 5
figure 5

Meta-analysis of VAS acupuncture versus conventional medicine

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Clinical effectiveness rate

Twenty-eight articles reported the effective rate of acupuncture and meta-analysis results showed that the acupuncture significantly improved the clinical effectiveness (RR 1.24 [1.14–1.34], P < 0.001, I2 = 81%) (Fig. 6) [33, 34, 36,37,38, 42,43,44,45, 48, 49, 52, 53, 55,56,57, 60, 61, 64, 65, 67, 68]. We next performed subgroup analysis. Firstly, 14 studies [24, 36,37,38, 42, 44, 49, 53, 55, 56, 61, 66, 67] reported the findings of needling therapy for POP. Compared with the control group, needling can effectively improve the clinical effectiveness of patients with POP (RR 0.23 [0.14–0.32], P < 0.001, I2 = 76%), whether needling versus control group (RR 0.17 [0.04–0.31], P < 0.001, I2 = 78%) or needling plus conventional medicine versus conventional medicine (RR 0.23 [0.14–0.32], P < 0.001, I2 = 59%), respectively 10 [36, 38, 39, 44, 49, 53, 55, 56, 67, 69] and 4 [34, 37, 42, 61] studies. The differences between subgroups were not significant (P = 0.42), thus the two types of interventions did not appear to differentially affect the primary outcome. Secondly, a subgroup analysis of 5 studies [33, 52, 57, 58, 62] indicated that electroacupuncture can effectively improve the clinical effectiveness of patients with POP (RR 0.22 [0.09–0.35], P < 0.001, I2 = 67%). whether electroacupuncture versus control group (RR 0.13 [0.03–0.22], P < 0.05, I2 = 0%) or electroacupuncture plus conventional medicine versus conventional medicine (RR 0.40 [0.10–0.70], P < 0.05, I2 = 82%), respectively 4 [52, 57, 58, 62] and 2 [33, 57] studies. The differences between subgroups were not significant (P = 0.09), thus the two types of interventions did not appear to differentially affect the primary outcome. Finally, a subgroup analysis of 9 studies [32, 43, 45, 46, 48, 60, 64, 65, 68] found that warm acupuncture presented a significant improvement on clinical effectiveness of patients with POP (RR 1.11 [1.01–1.22], P < 0.05, I2 = 76%). whether warm acupuncture versus control group (RR 1.06 [0.98–1.16], P = 0.16, I2 = 44%) or warm acupuncture plus conventional medicine versus conventional medicine (RR 1.11 [1.01–1.22], P = 0.20, I2 = 90%), respectively 5 [43, 45, 46, 48, 65] and 4 [32, 60, 65, 68] studies. The differences between subgroups were not significant (P = 0.42), thus the two types of interventions did not appear to differentially affect the primary outcome.

Fig. 6
figure 6

Meta-analysis of clinical therapeutic effect acupuncture versus conventional medicine

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Level of estradiol (E 2 )

A meta-analysis of 5 studies [32, 36, 39, 57, 65] suggested that the acupuncture group had a improvement in the level of E2 compared to the control group (SMD 0.30 [0.09–0.52], P = 0.006, I2 = 0%) (Fig. 7).

Fig. 7
figure 7

Meta-analysis of ODI acupuncture versus conventional medicine

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Other outcomes

There were only two studies reporting the ALP and ODI, respectively. Therefore, we performed a narrative synthesis for these two outcomes. Both studies showed that acupuncture has a superior effect over the conventional medicine in the ALP and ODI.

Sensitivity analysis

A method of one study excluded at a time was used to detect the source of heterogeneity and to assess whether the results could have been influenced. The results showed that there was no significant influence on the pooled MD, SMD or RR value.

Publication bias

Based on Egger’s tests, there was not significant publication bias observed for BMD (P = 0.093), VAS (P = 0.101), clinical effectiveness rate (P = 0.309) and E2 (P = 0.95). This was in accordance with the results of funnel plot. Details of the publication bias are in Supplementary Material (Figs. 2, 3, 4, 5 and 6 and Table 1).

Credibility of evidence

The credibility of the evidence was assessed by the GRADE system [27]. The summary of findings indicated that there was moderate certainty in the BMD and low certaintyin the VAS. In consideration of the high heterogeneities and high or unclear risks found in the included studies, we downgraded the quality of evidence. Results of this assessment are in Supplementary Material (Fig. 7).

Discussion

In our meta-analysis, we observed that acupuncture resulted in a increase in BMD compared to that in the control group. This is consistent with previous meta-analyses and trials of acupuncture as a stand-alone treatment for OP or in combination with other active treatments [17,18,19,20]. Additionally, this meta-analysis proved that acupuncture had a positive effect on reducing VAS scores compared to that in the control group. This is consistent with the fact that acupuncture is used as an analgesic therapy to relieve pain [70, 71]. The health insurance-funded German Acupuncture Randomized Trials and Acupuncture in Routine Care study programs found that acupuncture was superior to non-treatment [72, 73], but not superior to control acupuncture, which was performed with placebo needles [74]. Similarly, a prospective, randomized, double-blind study on the treatment of pain in patients with hip osteoarthritis demonstrated comparable effects between verum acupuncture and control acupuncture [75, 76]. A high-quality meta-analysis including data from 29 randomized clinical trials showed that acupuncture was more effective than control acupuncture and no acupuncture in treating chronic pain in the axial skeleton [77]. A Cochrane meta-analysis of six randomized controlled trials, which were considered by the authors to be of high quality, concluded that acupuncture is more effective than placebo treatment and non-treatment in reducing pain and improving physical function among patients with low back pain [78].

Moreover, our study showed that acupuncture can enhance the level of E2 compared to that of the control group. An animal experiment showed that acupuncture improves OP while increasing circulating estrogen levels, which may be closely related to postmenopausal extragonadal aromatization [16]. According to previous studies, ALP is recommended as a marker of bone turnover that can predict OP and osteoporotic fractures [80]. Current studies have suggested that bALP may be a useful, valid, and reliable tool for therapy monitoring in postmenopausal osteoporosis [81, 82]. The number of reported literature on these two indicators, ODI and ALP, is too small. Therefore, we did not perform a meta-analysis on them, and more studies focusing on these two indicators are needed to help us determine whether acupuncture has an ameliorative effect on these two indicators. In the future research, the prevalence of OP and related complications such as vertebral compression fractures is expected to increase due to aging population [83]. Therefore, there is a growing need for clinical predictors to prevent early OP, such as weight and genetic screening [84, 85].

Several systematic reviews and meta-analyses have investigated the use of acupuncture in treating OP. Most reported encouraging results, but many systematic reviews did not consider the impact of factors that could contribute to the high heterogeneity and the results, such as the type of OP (primary or secondary), acupuncture points for injection, treatment frequency and duration of treatment, type of outcome measure (clinician rated or self-reported), and personal characteristics (e.g. age, sex) [17,18,19,20]. Future studies should improve the methodology quality and be consistent in acupuncture frequency and duration of treatment.

Although limited superior effects of acupuncture were found in bone mineral density and visual analog scale scores, the enhancement of clinical effectiveness rate was encourging for clinical practice. Even modest increases in BMD over the long-term clinical course can significantly reduce fracture risk in OP patients [79] and diminish the patients’ requirements for subsequent invasive treatments such as surgery. Furthermore, as an alternative or complementary therapy, acupuncture can decrease reliance on medications like analgesics and other drugs, thus reducing their associated side effects. Current results have showed sustained effects of acupuncture for pain reductions persisting for 3–6 months [80, 86]. Non-pharmacological therapies are the main active methods used in physical rehabilitation medicine. These therapies involve the development of personalized home-based exercise programs and the use of flexible trunk orthoses to improve posture. Finally, a meta-analysis demonstrated that acupuncture is beneficial in improving anxiety and depression, improving neurotransmitter levels in the brain, reducing serum inflammatory factors, and improving the ability to perform daily activities in patients with spinal cord injury [87]. In conclusion, acupuncture provides physiological and psychological benefits to patients and holds considerable clinical significance.

Limitations

The generalizability of the findings of this meta-analysis is limited by the lack of racial and ethnic diversity in the included studies; all participants were from China across all included trials, resulting in a homogeneous sample that is not representative of the general population. Moreover, the overall heterogeneity of the studies was high, which may be due to differences in sample size, study population, personal characteristics (e.g. age, sex), and experimental methods of individual studies. Finally, methodological limitations reduced confidence in the effect estimates in the current systematic review.

Conclusions

The findings of this review on the efficacy of acupuncture in treating POP are encouraging for its use in clinical practice as a alternative or complementary intervention for patients with POP. However, high-quality multicenter studies in different countries or regions should be conducted in the future.

Availability of data and materials

No datasets were generated or analysed during the current study.

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Funding

The work was supported by National Natural Science Foundation of China (82405447), Hunan Provincial Administration of Traditional Chinese Medicine (A20240125), Hunan Provincial Health Commission (20230479), and Hunan University of Chinese Medicine (2024CX135).

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  1. Tianyi Ma, Tiantian Zhang, and Le Zhang have contributed equally to this work and shared co-first authorship.

Authors and Affiliations

  1. Hunan University of Chinese Medicine, Changsha, China

    Tianyi Ma, Le Zhang, Haoming Zhao & Ke Liu

  2. Hunan Academy of Chinese Medicine, 58 Lushan Street, Changsha, 410006, China

    Tianyi Ma, Tiantian Zhang, Jianjun Kuang & Liang Ou

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Contributions

Data curation: Tianyi Ma, TianTian Zhang, Liang Ou, Le Zhang. Writing—original draft: Tianyi Ma, TianTian Zhang Writing—review & editing: Tianyi Ma, Liang Ou, Jianjun Kuang. Methodology: Le Zhang, Liang Ou. Software: TianTian Zhang. Funding acquisition: Liang Ou, Jianjun Kuang. Supervision: Liang Ou, Haoming Zhao. Validation: Liang Ou, Haoming Zhao, Ke Liu. Visualization: Ke Liu.

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Ma, T., Zhang, T., Zhang, L. et al. Efficacy of acupuncture for primary osteoporosis: a systematic review and meta-analysis of randomized controlled trials. J Orthop Surg Res 20, 127 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s13018-025-05513-9

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Journal of Orthopaedic Surgery and Research

ISSN: 1749-799X