Acute ankle sprain (AAS) is defined as an acute injury of the ankle ligament [
Acupuncture belongs to complementary and alternative medicine and is commonly used for relieving acute and chronic pain [
This systematic review was registered on PROSPERO (no. CRD42020156280). It was conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement [
Parallel-group randomized controlled trials (RCTs) were included regardless of language or publication date.
Participants with AAS were included regardless of age, sex, race, nationality, or diagnostic criteria for AAS.
The experimental interventions included acupuncture alone or in combination with traditional therapies. The control interventions included no treatment, placebo, or traditional therapies. Traditional therapies for acute ankle sprain involve nonsteroidal anti-inflammatory drugs, Rest, Ice, Compression, and Elevation (RICE), functional support, exercise, manual mobilization, etc. There were no restrictions on frequency or duration of acupuncture. The following comparisons were considered if possible: (1) acupuncture alone versus no treatment/placebo/traditional therapies; (2) acupuncture plus traditional therapies versus traditional therapies alone; and (3) acupuncture plus traditional therapies versus traditional therapies plus placebo.
The primary outcome was the Kofoed ankle score. The secondary outcomes included visual analogue scale (VAS), duration of pain, use of painkiller, ankle circumference, effective rate, cure rate, and adverse events. Kofoed ankle score is comprised of pain, function, and mobility domain and ranges from 0 to 100 with higher score indicating less pain [
Two authors (SWG and AFL) independently searched PubMed, Embase, Cochrane Library, Web of Science, China National Knowledge Infrastructure, Wanfang Digital Periodicals, and Chinese Science and Technology Periodicals database from inception to September 10, 2020, to identify potentially eligible studies. World Health Organization International Clinical Trials Registry Platform (WHO ICTRP),
All studies identified from the electronic search were imported into EndNote software. Two reviewers (SWG and AFL) independently checked the title and abstract to remove duplicates and irrelevant studies. Full texts of the remaining studies were read to identify potentially eligible studies. The selection process was summarized using a PRISMA flow diagram.
The following information was extracted independently by two reviewers (JXC and SWG). Disagreements were resolved by consensus or consultation with a third review author (JBZ). Study details: title, first author, country, year of publication, design, methods of randomization, allocation, and blinding Patients: age, sample size Interventions: type, frequency, and duration Outcome measures: Kofoed ankle score, VAS, duration of pain, use of painkiller, ankle circumference, effective rate, cure rate, and adverse events
Two reviewers (JXC and SWG) independently assessed the risk of bias in eligible studies using the Cochrane Collaboration’s tool [
Mean difference (MD) with 95% confidence intervals (CIs) was calculated for continuous variables if the same tool was used to measure a certain outcome across different studies. Otherwise, standardized mean difference (SMD) was calculated. Risk ratio (RR) with 95% CIs was used for dichotomous variables. If clinical heterogeneity was low, meta-analysis was used to estimate the overall effect. Statistical heterogeneity was evaluated by chi-square test or
The initial search yielded 1857 potentially eligible studies. We deleted 540 duplicates and 1264 irrelevant studies by checking the title and abstract. After reading full texts of the remaining records, 36 studies were excluded. Finally, 17 studies [
Flow diagram for study retrieval and selection.
The characteristics of the included studies are summarized in Table
Characteristics of included studies.
First author | Year | Sample size (E/C) | Experimental interventions | Control interventions | Frequency of acupuncture | Duration of acupuncture | Outcomes |
---|---|---|---|---|---|---|---|
Yu (1) [ | 1999 | 30 in each group/30 in each group | Acupuncture; acupuncture + RICE(ice pack) + dimethyl sulfoxide | RICE(ice pack); dimethyl sulfoxide | Twice a day | 7 days | Effective rate |
Yu (2) [ | 1999 | 50 in each group/50 | Acupuncture; acupuncture + dimethyl sulfoxide | Dimethyl sulfoxide | Not reported | 7 days | Effective rate |
Jiao and Wang [ | 2004 | 48/48 | Acupuncture + Chinese medicine (shujin huoxue pill + jiejing zhitong tincture) | Chinese medicine (shujin huoxue pill + jiejing zhitong tincture) | Once a day | 7 days | Effective rate, cure rate |
Wang [ | 2005 | 27/30 | Acupuncture | Infrared radiation | Once a day | 5 days | Effective rate, cure rate |
Hao and Wang [ | 2006 | 63/63 | Acupuncture + Chinese medicine (herbs) | Chinese medicine (herbs) | Once two days | 7 days | Effective rate, cure rate |
Wu [ | 2007 | 31/30 | Acupuncture | No treatment | Once a day | 5 days | Effective rate, cure rate, VAS |
Ni and Li [ | 2010 | 64/59 | Acupuncture | Ice and hot pack + Chinese medicine | Once a day | 3 days | Effective rate, cure rate |
Sun and Ju [ | 2011 | 41/41 | Acupuncture | RICE (elastoplast) | Once a day | 14 days | Effective rate, cure rate, duration of pain |
Zhang and Zhang [ | 2011 | 90/70 | Acupuncture + Chinese medicine (qili powder) | Chinese medicine (qili powder) | Once a day | 10 days | Effective rate, cure rate |
Suo [ | 2014 | 36/35 | Acupuncture + Chinese medicine (yunnan baiyao tincture) | Chinese medicine (yunnan baiyao tincture) | Not reported | Not reported | Effective rate, cure rate |
Du [ | 2014 | 20 in each group/20 | Acupuncture; acupuncture + massage | Massage | Once a day | 3 days | Effective rate, cure rate |
Li [ | 2016 | 30/30 | Acupuncture | RICE | Once a day | 7 days | VAS, Kofoed ankle score, ankle circumference |
Zou [ | 2016 | 20/20 | Acupuncture + Chinese medicine (sunshang emplastrum) | Chinese medicine (sunshang emplastrum) | Once two days | 7 days | VAS, effective rate, cure rate |
Pei and Wei [ | 2017 | 35/35 | Acupuncture + RICE | RICE | Not reported | 14 days | Effective rate, cure rate |
Wu and Chen [ | 2017 | 42/40 | Acupuncture + massage | Massage | Once two days | 14 days | VAS, ankle circumference, use of painkiller |
Wu [ | 2018 | 45/45 | Acupuncture + RICE (plaster immobilization) | RICE (plaster immobilization) | Once two days | 21 days | Effective rate, cure rate, VAS |
Li [ | 2018 | 40/40 | Acupuncture + Chinese medicine (shexiang zhuanggu emplastrum) | Chinese medicine (shexiang zhuanggu emplastrum) | Once a day | 10 days | Effective rate, cure rate, duration of pain |
E, experimental group; C, control group; RICE, Rest, Ice, Compression, and Elevation; VAS, visual analogue scale.
Risk of bias graph and summary are presented in Figures
Risk of bias graph.
Risk of bias summary.
One study [
Narrative analyses were provided because of the heterogeneity of interventions. Wu [
Li et al. [
Wu et al. [
Wu et al. [
Fifteen studies reported the effective rate. It is defined as a ratio of the number of patients labelled as cure, excellent, or effectivity divided by the number of patients in a certain group. Wu [
Forest plots of acupuncture versus other treatments on the effective rate.
Forest plots of acupuncture plus other treatments versus other treatments on effective rate.
Thirteen studies reported the cure rate. It is defined as a ratio of the number of patients labelled as cure divided by the number of patients in a certain group. Figure
Forest plots of acupuncture versus other treatments on cure rate.
A meta-analysis showed that acupuncture plus Chinese medicine could significantly increase the cure rate (
Forest plot of acupuncture plus Chinese medicine versus Chinese medicine on cure rate.
Forest plot of acupuncture plus RICE versus RICE on cure rate.
Three included studies reported the information on adverse events. Yu [
No funnel plots were provided to assess publication bias because no meta-analyses involving more than ten studies were performed.
The present study critically assessed the efficacy and safety of acupuncture for AAS. Overall, risk of bias assessment was limited because of incomplete reporting on risk of bias items. In view of the heterogeneity of interventions, main findings were interpreted based on comparisons between experimental and control groups.
Rest, ice, compression, and elevation (RICE) are generally used to treat acute ankle sprain in clinical practice [
Massage belongs to nonpharmacological therapies and usually is used for the management of musculoskeletal disorders. A study found that massage might improve the flexibility and balance function of the ankle joint [
Patients with AAS often experience acute pain and swelling associated with inflammatory reactions [
The present study provided some insights into the management of AAS. Combined-modality therapy may provide additional benefits in patients with AAS. These findings may be useful for updating clinical practice guidelines. Moreover, a review reported that acupuncture could relieve pain by activating acupoints and transmitting signals to the spinal cord and brain associated with the regulation of inflammatory factors [
This systematic review had several limitations. Firstly, effect size might be overestimated because of small sample size. Secondly, performing the meta-analysis was limited because of the heterogeneity of interventions. Thirdly, the results should be interpreted cautiously because of methodological flaws and rarely reported objective outcomes in included studies.
The findings of the present study suggest that acupuncture may be beneficial for AAS. However, more large-scale and well-designed RCTs are warranted.
All datasets presented in this study are included in the article or supplementary material.
AFL and SWG are considered as co-first authors. AFL and JBZ are considered as corresponding authors.
The authors declare that they have no conflicts of interest.
AFL and JBZ conceived the study. SWG and AFL designed the protocol. SWG and AFL searched and selected studies. JXC and SWG extracted data and assessed the risk of bias. JBZ performed statistical analysis. AFL and SWG drafted the manuscript. JBZ reviewed and revised the manuscript. All authors have read and approved the final version of the manuscript. AFL and SWG contributed equally to this work.
This work was supported by the National Natural Science Foundation of China (grant no. 81873316).
Detailed search strategy is shown in the Supplementary Material.