Efficacy of Mongolian medicines warm acupuncture for knee osteoarthritis: a systematic review and meta-analysis.

OBJECTIVE: This study aimed to systematically evaluate the efficacy of Mongolian medicines warm acupuncture for knee osteoarthritis (KOA). METHODS: Eight databases, including China National Knowledge Infrastructure (CNKI), Wanfang, Chinese Science and Technology Periodical Database (VIP), Chinese Biomedical Literature Database (CBM), PubMed, the Web of Science, the Cochrane Library, and EMBASE, were searched from their inception to 31 December 2025 for randomized controlled trials (RCTs) evaluating Mongolian medicines warm acupuncture for KOA. The primary outcome was the clinical response rate (CR), whereas the secondary outcomes included the visual analog scale (VAS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores. Risk of bias was assessed using the Cochrane risk of bias 2 (RoB 2) tool. Pooled effect sizes were calculated using RevMan 5.4 with fixed- or random-effects models. The certainty of evidence was graded using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. The protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) (CRD420261362311). RESULTS: A total of 10 RCTs (n = 882) were included. In add-on design trials (2 studies, n = 120), the benefit was non-significant (risk ratio [RR] = 1.11, 95% confidence interval [CI]: 1.00-1.25; p = 0.06; I 2 = 0%). In head-to-head comparisons (6 studies, n = 630), Mongolian medicines warm acupuncture significantly improved the clinical response rate compared with oral medications (RR = 1.25, 95%CI:1.17-1.33; p < 0.00001; I 2 = 0%). Subgroup analysis by treatment duration showed no significant difference (P for subgroup difference = 0.55). Pain (VAS) was significantly reduced (3 trials; MD = -1.50, 95%CI:-1.99 to -1.01; p < 0.00001; I 2 = 87%). WOMAC total score also preferred Mongolian medicines warm acupuncture (4 trials; MD = -12.45, 95%CI:-19.08 to -5.82; p = 0.0002; I 2 = 95%). The certainty of evidence was moderate for the secondary analysis and low for the primary analysis, VAS, and WOMAC. CONCLUSION: Mongolian medicines warm acupuncture is effective in improving the clinical response rate and reducing pain in KOA when used as an alternative to oral medications. However, evidence from add-on design trials remains inconclusive due to the limited number of studies. High-quality, large-scale add-on RCTs are warranted. SYSTEMATIC REVIEW REGISTRATION: https://www.crd.york.ac.uk/PROSPERO/myprospero, Unique Identifier CRD420261362311.