Abstract
Study Background
Establishing an evidence-informed expert consensus on the use of acupuncture for managing chronic musculoskeletal pain at the primary care level in Hong Kong, using the GRADE Evidence to Decision (EtD) framework. Two-rounds of Delphi study were conducted guided by the GRADE-ADOLOPMENT approach and informed by systematic review.
Methods
Sixteen local experts, including eight traditional Chinese medicine practitioners and eight biomedically trained doctors, were purposively sampled based on their clinical experience in pain management. A structured questionnaire was developed based on seven chronic musculoskeletal conditions and aligned with the six GRADE EtD criteria. Experts rated the appropriateness of acupuncture for each condition using a 4-point Likert scale. Consensus was defined as ≥75.0% agreement. Participants reviewed diagnostic criteria and selected core outcomes for evaluating treatment effectiveness.
Results
Positive consensus supported acupuncture for adhesive capsulitis, knee osteoarthritis, lumbar spinal stenosis with neurogenic claudication, and non-specific low back pain. Full agreement was reached on diagnostic criteria for all seven conditions. Pain relief, functional improvement, and health-related quality of life were identified as core outcomes. No consensus was reached for hip osteoarthritis, cervical radiculopathy, or lumbar radiculopathy. Experts highlighted the need for individualised treatment plans and further research on implementation and patient preferences.
Conclusion
This study presents the first expert-endorsed list of acupuncture recommendations for chronic musculoskeletal pain in Hong Kong. The findings support interprofessional collaboration and provide a foundation for developing referral pathways and clinical guidelines. However, the study is limited by reliance on expert opinion and indirect evidence, a potentially non-representative panel, and the absence of physiotherapist and patient perspectives. Future research should focus on implementation strategies and incorporate input from various stakeholder groups to strengthen the clinical integration of acupuncture.
Keywords: acupuncture, complementary therapies, musculoskeletal pain, primary care, delphi technique
1. Introduction
Chronic musculoskeletal pain adversely affects individuals’ physical, psychological, and social wellbeing, while also placing a substantial financial burden on healthcare systems and economies around the world. 1 In the United States alone, chronic pain, including musculoskeletal pain, is estimated to cost at least USD 560 billion annually in direct healthcare expenses and productivity losses. 2 As such, chronic musculoskeletal pain is increasingly recognised as a public health priority, warranting comprehensive understanding and targeted policy responses.3,4
In Hong Kong, a cross-sectional study conducted in 2016 found that 28.7% of the respondents had experienced chronic musculoskeletal pain in the preceding twelve months. Among these individuals, 83.1% reported pain in more than one body site, and 5.8% experienced pain in eight or more sites across the body. 5 Regression analysis further identified that individuals aged 50 years or older were significantly more likely to experience chronic musculoskeletal pain. 5 With the elderly population in Hong Kong projected to grow from 1.45 million in 2021 to 2.74 million by 2046, 6 the prevalence and incidence of chronic musculoskeletal pain are expected to rise substantially.
Typically managed at the primary care level, chronic musculoskeletal pain in Hong Kong is addressed through pharmacological treatments—including non-opioid analgesics, opioids, and adjuvant medications7,8—as well as non-pharmacological interventions. The latter encompass supervised exercise programmes, psychological therapies, electrical physical modalities (e.g., transcutaneous electrical nerve stimulation), and acupuncture.7,8 Acupuncture is practised and officially regulated in over 100 Member States of the World Health Organization as a component of traditional Chinese medicine (TCM) and other complementary and alternative medicine practices. 9 Over the past decades, extensive research has evaluated the effectiveness and safety of acupuncture to support its clinical application across a range of conditions and disorders.10,11 A recent individual patient data meta-analysis of high-quality trials found that acupuncture produces clinically relevant and lasting effects in managing osteoarthritis (OA), chronic headache, shoulder pain, and non-specific musculoskeletal pain, when compared to no acupuncture or sham acupuncture. 12
Despite the widespread use of acupuncture services and the high burden of chronic musculoskeletal pain in Hong Kong, a systematically developed and evidence-informed list of acupuncture recommendations remains unavailable. While the development of comprehensive clinical practice guidelines (CPGs) could address this gap, such efforts are often resource-intensive and time-consuming. As a pragmatic alternative, a focused list of acupuncture recommendations—grounded in both evidence and expert consensus—could offer clear guidance on the role of acupuncture in managing specific chronic musculoskeletal conditions in the territory. This would support clinical decision-making, inform referral pathways, and ultimately enhance interprofessional collaborations across healthcare professionals at the primary care level.
Similar to CPGs, the development of recommendation lists should adhere to robust evidence-based approach such as GRADE-ADOLOPMENT.13,14 This approach combines the advantages of adoption, adaptation, and de novo development of clinical recommendations, guided by an expert panel and structured around the Evidence to Decision (EtD) framework developed by the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) working group. 15 As a core component, the EtD framework provides concise summaries of the best available evidence for each rating criterion—namely, (i) priority of the problem, (ii) benefits and harms of the options, (iii) resource use, (iv) equity, (v) acceptability, and (vi) feasibility. 15 It enables participants to consider each criterion thoroughly before formulating a recommendation and ensures that the rationale behind the direction, strength, and implementability of the endorsed recommendations is clearly structured and transparently documented. 15
However, although existing systematic reviews and clinical practice guidelines suggest potential benefits of acupuncture for some chronic musculoskeletal conditions, recommendations vary across conditions and healthcare contexts. As much of this evidence is generated outside Hong Kong, its direct applicability to the local healthcare setting may be limited. Therefore, rather than re-evaluating effectiveness, this study aims to contextualise existing evidence through a structured, multidisciplinary consensus process. By applying the GRADE EtD framework within a Delphi approach, we address the gap between global evidence and context-specific clinical decision-making in Hong Kong primary care.
The present study aimed to develop an evidence-informed expert consensus on the use of acupuncture for managing chronic musculoskeletal pain in Hong Kong through expert consensus, using the GRADE EtD framework.
2. Methods
The reporting of this Delphi survey is guided by the Guidance on Conducting and REporting DElphi Studies and the RIGHT-Ad@pt Checklist.16,17 Before the study commencement, we sought written informed consent from all participants prior to data collection. The workflow of the study and details are presented in Figure 1. The RIGHT-Ad@pt Checklist is provided in Table S1, Supplemental File 1.
Figure 1.
The workflow of developing an evidence-based list of recommendations for acupuncture in the management of chronic musculoskeletal pain in Hong Kong
GRADE: Grading of Recommendations Assessment, Development, and Evaluation
Part 1. Preparation of the Delphi Survey Questionnaire
Prior to conducting the survey, we undertook a systematic review to synthesise and critically appraise recent CPGs on the use of acupuncture for the management of OA, low back pain, neck pain, and shoulder pain. The review focused on recommendations related to pain relief, functional improvement, and health-related quality-of-life improvement, and included CPGs published between January 2014 and November 2024. 18 Only guidelines developed by recognised guideline development committees were included, provided they offered evidence-informed recommendations that were explicitly linked to clearly defined levels of evidence. We used the standardised approach proposed by the Oxford Centre for Evidence-Based Medicine to assess the levels of evidence in each guideline. 19 All included CPGs were of at least moderate methodological quality, defined as achieving an overall score above 50% on the Appraisal of Guidelines for Research and Evaluation II instrument. 20 The review covered seven chronic musculoskeletal conditions—adhesive capsulitis, knee OA, hip OA, cervical radiculopathy, lumbar radiculopathy, lumbar spinal stenosis (with neurogenic claudication), and non-specific low back pain—resulting in eight clinical recommendations.
The Delphi survey questionnaire was organised by individual chronic musculoskeletal conditions identified in the mentioned systematic review and comprised three sections. The first section asked participants to recommend a set of diagnostic criteria for initiating acupuncture treatment for that specific condition. One commonly used set of diagnostic criteria in routine practice was included for consideration, although participants were encouraged to suggest alternative or additional criteria based on their clinical experience.
The second section of the questionnaire was structured around the six criteria of the GRADE EtD framework. 15 For each clinical recommendation related to chronic musculoskeletal conditions, relevant information from the included CPGs was extracted and mapped to the corresponding criteria within the questionnaire. For the “benefits and harms” criterion, we incorporated evidence on the clinical effectiveness and potential risks of acupuncture from meta-analyses reported in the CPGs, alongside standardised levels of evidence and recommendation grades. Where necessary, we manually searched for supplementary meta-analyses to ensure the inclusion of the most up-to-date evidence. For the remaining domains, we also identified and incorporated relevant evidence to support panel deliberation. Upon completing their review of the six criteria, participants proceeded to the third section of the questionnaire.
In this final section, we asked the participants to rate whether acupuncture should be recommended for the management of the mentioned chronic musculoskeletal conditions within the Hong Kong health system. Recommendations were rated using a four-point Likert scale: “recommend against this option” (i.e., strongly disagree with the use of acupuncture for the condition), “suggest not this option” (i.e., disagree with the use of acupuncture for the condition), “suggest this option” (i.e., agree with the use of acupuncture for the condition), and “recommend this option” (i.e., strongly agree with the use of acupuncture for the condition). We also invited the participants to provide qualitative comments, including their rationale for the recommendations, any additional considerations, and suggestions for future research. Furthermore, they were asked to select or propose core outcome(s) for monitoring and evaluating the effectiveness of acupuncture for each condition.
A sample of the questionnaire is provided in Supplemental File 2.
Part 2. Sampling and Invitation of Local Experts
We purposively sampled two groups of local experts for this study. The first group comprised eight traditional Chinese medicine practitioners (TCMPs), each with a minimum of ten years’ clinical experience in pain management and registered with different professional societies accredited by the Chinese Medicine Council of Hong Kong. Four were required to work in private practice, while the remaining four were based in practices operated by non-governmental organisations or universities. The second group consisted of eight biomedically trained doctors (BMDs), also with at least ten years of clinical experience in pain management. Among them, four were general practitioners registered with the Hong Kong College of Family Physicians, and four were orthopaedic surgeons registered with the Hong Kong College of Orthopaedic Surgeons. As with the TCMPs, two general practitioners and two orthopaedic surgeons were required to work in private practice, with the remainder employed in public hospitals.
This sampling arrangement enabled participants from different professional disciplines involved in pain management to contribute unique and diverse insights in a balanced manner. 21 The sample size (8 + 8) also adheres to established guidance for consensus development, which recommends six to twelve participants per group to maximise reliability while minimising the risk of diminishing marginal returns. 22 All participants were de-identified to protect their confidentiality and ensure the independence of their judgements throughout the process.
The 16 participants were recruited through the authors’ professional networks. Initial contact was made via email in March 2025, accompanied by the study objectives, detailed information, and a written informed consent form. Upon receipt of the signed consent, each participant was provided with a guidance document for the Delphi survey, along with the first-round questionnaire.
Part 3. Round 1 Delphi Survey Data Collection and Analysis
Each participant was asked to complete and return the questionnaire via email within two weeks. For each acupuncture recommendation, we calculated the median recommendation rating, along with the interquartile range (IQR), to illustrate the extent of agreement among participants. The use of medians and IQRs was chosen because they are less affected by outliers compared to means and standard deviations. 22 Expert consensus on the recommendations was expressed as a percentage. Following the standards set in previous studies, the consensus threshold for this study was set at 75.0%. 23 Specifically, an acupuncture recommendation would achieve a positive consensus if ≥75.0% of participants rated it as “suggest this option” or “recommend this option” on the 4-point Likert scale. Conversely, negative consensus would be reached if ≥75.0% rated it as “suggest not this option” or “recommend against this option”. The qualitative comments provided by panel members were screened for relevance to this study. Relevant comments were collated and fed back to the expert panel in anonymised form in subsequent rounds to inform rating reconsideration and support consensus development. Irrelevant or non-substantive comments were excluded from the feedback process. The strength for recommendations achieving positive consensus was determined by the proportion of responses rated as “suggest this option” or “recommend this option”, corresponding to a weak and strong recommendation, respectively.
Part 4: Round 2 Delphi Survey Data Collection and Analysis
The same panel of experts was invited to reassess the acupuncture recommendations that did not reach either positive or negative consensus in Round 1. In addition to the revised questionnaire, the participants were provided with the following information to support their reassessment: (i) their own ratings from Round 1, (ii) aggregated responses from all other participants for each EtD framework criterion question, and (iii) anonymised qualitative comments from the panel. Following a similar process of data analysis, a final list of expert-endorsed acupuncture recommendations for the management of chronic musculoskeletal pain.
3. RESULTS
Participants
A total of eight TCMPs and eight BMDs (four general practitioners and four orthopaedic surgeons) participated in this two-round Delphi survey, with a 100% response rate across both rounds. Four participants (25.0%) were female, nine (56.3%) were aged between 41 and 50 years, and nine (56.3%) had over 21 years of clinical experience. At the time of the study, half of the panel worked in the private sector, while the other half were employed in public hospitals, non-governmental organisations, or universities. Further details about the expert panel are provided in Table 1.
Table 1.
Characteristics of the Participants in the Two-Round Delphi Survey (n=16)
| Characteristics | Number of participant (%) |
|---|---|
| Female | 4 (25.0) |
| Age group (years) | |
| 31–40 | 3 (18.8) |
| 41–50 | 9 (56.2) |
| 51–60 | 2 (12.5) |
| >61 | 2 (12.5) |
| Profession | |
| Traditional Chinese medicine practitioner | 8 (50.0) |
| General practitioner | 4 (25.0) |
| Orthopaedic surgeon | 4 (25.0) |
| Years of clinical experience | |
| 11 to 15 | 3 (18.8) |
| 16 to 20 | 4 (25.0) |
| >21 | 9 (56.2) |
| Work setting | |
| Private clinic or hospital | 8 (50.0) |
| Public hospital | 4 (25.0) |
| Non-governmental organisation or university | 4 (25.0) |
Expert Consensus in Round 1 Delphi Survey
Overall Consensus Ratings & Consensus-Based Diagnostic Criteria for Acupuncture Initiation
Five of the eight acupuncture recommendations achieved a positive consensus in the first round, with the exceptions of hip OA, cervical radiculopathy, and lumbar radiculopathy [Table 2]. The median ratings for these five recommendations ranged from 2.0 to 3.0 on the 4-point Likert scale, and the percentage positive consensus ranged from 81.3% to 100%.
Table 2.
List of Acupuncture Recommendations and Corresponding Consensus Results in the Two-Round Delphi Survey
| Acupuncture recommendation | Round 1 | Round 2 | ||||
|---|---|---|---|---|---|---|
| Type of recommendation, median [IQR] * (TCMPs; BMDs) | Positive agreement † (TCMPs; BMDs) | Consensus (If yes, positive or negative?) ‡ | Type of recommendation, median [IQR] * (TCMPs; BMDs) | Positive agreement † (TCMPs; BMDs) | Consensus (If yes, positive or negative?) ‡ | |
| Acupuncture for adhesive capsulitis at any clinical stage | 2.5 [1.0] (3.0 [0.5]; 2.0 [0.5]) | 87.5% (100%; 75.0%) | Yes [Positive] | Not applicable | ||
| Warm acupuncture for adhesive capsulitis at any clinical stage | 2.0 [1.0] (3.0 [1.0]; 2.0 [0.5]) | 81.3% (87.5%; 75.0%) | Yes [Positive] | Not applicable | ||
| Acupuncture for knee osteoarthritis | 3.0 [1.0] (3.0 [0.0]; 2.0 [1.0]) | 87.5% (100%; 75.0%) | Yes [Positive] | Not applicable | ||
| Acupuncture for hip osteoarthritis | 2.0 [1.5] (2.5 [1.5]; 1.0 [1.0]) | 56.3% (75.0%; 37.5%) | No | 1.5 (1.5) (1.0 [1.5]; 1.5 [1.0]) | 43.8% (37.5%; 50.0%) | No |
| Acupuncture for cervical radiculopathy | 2.0 [2.0] (3.0 [1.0]; 1.0 [0.5]) | 56.3% (87.5%; 25.0%) | No | 1.5 (2.0) (2.0 [2.0]; 1.0 [0.5]) | 43.8% (62.5%; 25.0%) | No |
| Acupuncture for lumbar radiculopathy | 2.0 [1.5] (3.0 [1.0]; 1.5 [1.0]) | 68.8% (87.5%; 50.0%) | No | 2.0 (2.0) (2.5 [1.5]; 1.5 [1.0]) | 62.5% (75.0%; 50.0%) | No |
| Acupuncture for lumbar spinal stenosis | 2.0 [1.0] (3.0 [1.0]; 2.0 [0.0]) | 93.8% (100%; 87.5%) | Yes [Positive] | Not applicable | ||
| Acupuncture for non-specific low back pain | 2.5 [1.0] (3.0 [0.5]; 2.0 [0.0]) | 100% (100%; 100%) | Yes [Positive] | Not applicable | ||
BMD: Biomedically trained doctor; IQR: Interquartile range; TCMP: traditional Chinese medicine practitioner.
*The type of recommendation was assessed using a four-point Likert scale: (0) “recommend against this option”, (1) “suggest not this option”, (2) “suggest this option”, and (3) “recommend this option”.
†Positive agreement refers to the proportion of participants who selected either “suggest this option” or “recommend this option”.
‡The consensus threshold was set at 75.0%. An acupuncture recommendation was considered to have reached positive consensus if ≥75.0% of participants rated it as either “suggest this option” or “recommend this option”. Negative consensus would be reached if ≥75.0% rated it as either “suggest not this option” or “recommend against this option”.
All participants expressed full endorsement of the proposed sets of diagnostic criteria for initiating acupuncture treatments in routine practice for each chronic musculoskeletal condition. Table 3 illustrates all the agreed diagnostic criteria and their references. Table 4 presents the 5 consensus statements.
Table 3.
Consensus Statements on the Diagnostic Criteria of the 7 Musculoskeletal Conditions
| Chronic musculoskeletal condition | Diagnostic criteria |
|---|---|
| Adhesive capsulitis [i] | •History: A gradual onset of shoulder pain, often anterolateral at first; pain at night; there may be minimal trauma associated with the time of onset. •Examination: Painful movement restriction, passive external rotation below 30°, and passive elevation below 100°; internal rotation can be reduced in cases where the disease affects the posterior capsule more than the anterior capsule. •Investigations: Plain radiographs to check for arthritis in the glenohumeral joint; clinical features and differential diagnoses may dictate the use of ultrasound and magnetic resonance imaging. |
| Knee osteoarthritis [ii] | •Knee pain plus at least three of: ⁃Age > 50 years ⁃Morning stiffness < 30 minutes ⁃Crepitus ⁃Bony tenderness ⁃Bony enlargement ⁃No palpable warmth ⁃Erythrocyte sedimentation rate < 40 mm/hour ⁃Rheumatoid factor ≤ 1:40 ⁃Synovial fluid signs of osteoarthritis (clear, viscous, or white blood cell count < 2,000/mm3) |
| Hip osteoarthritis [iii] | •A patient was classified as having hip osteoarthritis if pain was present in combination with either: ⁃Hip internal rotation ≥15°, pain present on internal rotation of the hip, morning stiffness of the hip for ≤60 minutes, and age >50 years; OR ⁃Hip internal rotation <15° and an erythrocyte sedimentation rate (ESR) ≤45 mm/hour (if no ESR was obtained, hip flexion ≤115° was substituted). •Plus at least two of: ⁃Osteophytes (femoral or acetabular) ⁃Joint space narrowing (superior, axial, and/or medial) ⁃ESR <20 mm/hour. |
| Cervical radiculopathy [iv] | •Suspect cervical radicular pain and radiculopathy as a possible diagnosis in patients who report an electric-like, shooting sensation that radiates from the neck into the arm or shoulder, which may be associated with numbness, weakness, and paraesthesia in the affected cervical dermatome. •Perform a neurologic exam and consider use of provocative testing, such as the Spurling test, upper limb tension test, shoulder abduction test, and others, to diagnose cervical radicular pain and radiculopathy and determine the location of the affected cervical dermatome or nerve root. •Diagnosis of cervical radicular pain or radiculopathy is usually made with a thorough clinical exam. However, diagnostic testing may include: ⁃Imaging with magnetic resonance imaging, computed tomography, or x-ray to confirm spinal cord pathology (not typically necessary unless “red flags” are present on physical exam or if pain persists after 4–6 weeks of conservative management) ⁃Electrodiagnostic testing (such as nerve conduction studies and electromyography) to correlate imaging and related symptoms to the single nerve root level ⁃Selective segmental nerve blocks to determine where radicular pain originates and identify multiple levels of cervical degeneration |
| Lumbar radiculopathy [v] | •Lumbar radiculopathy is a clinical diagnosis based on symptoms and signs: ⁃Unilateral leg pain more severe than low back pain ⁃Pain most commonly radiating posteriorly at the leg and below the knee ⁃Numbness and/or paraesthesia in the involved lower leg ⁃Positive neural tension test with provocation of pain in the affected leg (straight leg raise test/femoral nerve test/slump test) ⁃With or without neurological deficit associated with the involved nerve root (muscle weakness/absence of tendon reflexes/sensory deficit) |
| Lumbar spinal stenosis with neurogenic claudication [vi] | •The cardinal symptom is neurogenic claudication (spinal claudication), defined as diffuse buttock and leg pain, paraesthesia, and cramping of one or both lower extremities induced by walking, which is relieved when sitting and forward bending. •Evidence of anatomic narrowing of spinal canal or nerve root impingement on imaging, preferably with magnetic resonance imaging. |
| Non-specific low back pain [vii] | •Non-specific low back pain is defined as pain in the lower back (between the costal margin and inferior gluteal folds) that cannot be attributed to a specific, identifiable pathology such as infection, tumour, osteoporosis, lumbar radiculopathy, or structural deformity. •It is typically mechanical in nature and may be influenced by factors such as poor posture, muscle strain, or dysfunctional movement patterns. |
[i] Ramirez J. Adhesive Capsulitis: Diagnosis and Management. Am Fam Physician. 2019 Mar;99(5):297-300.
[ii] Altman R, Asch E, Bloch D, Bole G, Borenstein D, Brandt K, et al. Development of criteria for the classification and reporting of osteoarthritis. Classification of osteoarthritis of the knee. Diagnostic and Therapeutic Criteria Committee of the American Rheumatism Association. Arthritis Rheum. 1986 Aug;29(8):1039-49.
[iii] Altman R, Alarcón G, Appelrouth D, Bloch D, Borenstein D, Brandt K, et al. The American College of Rheumatology criteria for the classification and reporting of osteoarthritis of the hip. Arthritis Rheum. 1991 May;34(5):505-14.
[iv] Bono CM, Ghiselli G, Gilbert TJ, Kreiner DS, Reitman C, Summers JT, et al. An evidence-based clinical guideline for the diagnosis and treatment of cervical radiculopathy from degenerative disorders. Spine J. 2011 Jan;11(1):64-72.
[v] Jensen RK, Kongsted A, Kjaer P, Koes B. Diagnosis and treatment of sciatica. BMJ. 2019 Nov;367:l6273.
[vi] Kreiner DS, Shaffer WO, Baisden JL, Gilbert TJ, Summers JT, Toton JF, et al. An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spinal stenosis (update). Spine J. 2013 Jul;13(7):734-43.
[vii] Hartvigsen J, Hancock MJ, Kongsted A, Louw Q, Ferreira ML, Genevay S, et al. What low back pain is and why we need to pay attention. Lancet. 2018 Jun;391(10137):2356-67.
Table 4.
Consensus Statements on Acupuncture for Chronic Musculoskeletal Pain
| Condition | Acupuncture | Strength of recommendation | Certainty of evidence |
|---|---|---|---|
| Knee osteoarthritis | We recommend acupuncture rather than no treatment to relieve pain, improve function, and improve health-related quality of life in patients with diagnosed knee osteoarthritis | Strong | Moderate |
| Non-specific low back pain | We suggest acupuncture rather than no treatment to relieve pain, improve function, and improve health-related quality of life in patients with diagnosed non-specific low back pain | Weak | Moderate |
| Lumbar spinal stenosis with neurogenic claudication | We suggest acupuncture rather than no treatment to relieve pain, improve function, and improve health-related quality of life in patients with diagnosed lumbar spinal stenosis | Weak | Moderate |
| Adhesive capsulitis | We suggest acupuncture rather than no treatment to relieve pain, improve function, and improve health-related quality of life in patients with diagnosed adhesive capsulitis at any clinical stage. | Weak | Low |
| We suggest warm acupuncture rather than no treatment to relieve pain, improve function, and improve health-related quality of life in patients with diagnosed adhesive capsulitis at any clinical stage | Weak | Low |
Evidence to Decision Framework Ratings for Acupuncture Recommendations With Positive Consensus
Table S2, Supplemental File 1, presents the proportion of positive responses to the GRADE EtD framework criteria for the five acupuncture recommendations. The response rates are summarised in Box 1.
Box 1.
Positive responses rates across Evidence to Decision framework criteria for acupuncture recommendations with positive consensus.
Problem priority: Over 80.0% of the expert panel indicated that all five recommendations with positive consensus in Round 1 are urgent priorities for pain management in clinical practice [Box 1(a)]. The median proportion of positive responses across these recommendations was high (87.5%).
Benefits & harms of acupuncture: There was notable variation in expert-rated certainty of evidence across the recommendations [Box 1(a)]. Only 37.5% and 43.8% of participants rated the evidence supporting the use of warm acupuncture and traditional acupuncture, respectively, for adhesive capsulitis as being of moderate or high overall certainty. In contrast, 75.0% of participants considered the evidence supporting acupuncture for lumbar spinal stenosis to be of moderate or high certainty.
Similarly, only 37.5% and 50.0% of the panel gave positive responses indicating no important uncertainty or known undesirable variability in how individuals with adhesive capsulitis value pain relief, functional improvement, and quality-of-life improvement when receiving warm acupuncture and traditional acupuncture, respectively, for managing their condition]. By comparison, 75.0% of participants responded positively regarding the use of acupuncture for lumbar spinal stenosis.
The use of acupuncture for knee osteoarthritis and non-specific low back pain were the only ones to receive a high proportion (≥75.0%) of positive responses from the panel across all three related criterion questions: large desirable anticipated effects, small undesirable anticipated effects, and an overall judgement that the desirable effects of the intervention outweigh its undesirable effects.
Resources use: A high proportion of the panel indicated that providing acupuncture services for adhesive capsulitis (81.3%), lumbar spinal stenosis (87.5%), and non-specific low back pain (87.5%) would require a relatively small investment of resources [Box 1(b)]. Moreover, the majority agreed that the cost of delivering acupuncture services for adhesive capsulitis (75.0%), knee OA (75.0%), non-specific low back pain (87.5%), and lumbar spinal stenosis (93.8%) would likely be outweighed by the net clinical benefits.
Equity, acceptability, and feasibility: In general, the participants did not agree that providing acupuncture services for managing adhesive capsulitis, knee OA, or lumbar spinal stenosis would reduce health inequities among individuals with the conditions [Box 1(b)]. However, 75.0% of the panel gave positive responses regarding acupuncture for non-specific low back pain. Between 75.0% and 87.5% of the participants recognised that acupuncture for adhesive capsulitis, knee OA, lumbar spinal stenosis, and non-specific low back pain is acceptable to all key stakeholders in Hong Kong, including individuals with the conditions and healthcare professionals providing the treatment. Similarly, 75.0% to 100% agreed that implementing acupuncture interventions different clinical settings in Hong Kong would be feasible.
Balance of consequences: Finally, after considering the above criteria and corresponding questions, 75.0% of the participants reflected that the desirable consequences of using acupuncture for adhesive capsulitis, knee osteoarthritis, lumbar spinal stenosis, and non-specific low back pain probably or clearly outweigh the undesirable consequences [Box 1(b)]. In contrast, only 50.0% of the panel gave positive responses regarding the use of warm acupuncture for adhesive capsulitis.
Consensus-Based Core Outcomes for Monitoring and Evaluating Treatment Effectiveness
Across the seven chronic musculoskeletal conditions, pain was the most consistently selected core outcome for monitoring and evaluating acupuncture treatment effectiveness, included in all cases of adhesive capsulitis, knee osteoarthritis, lumbar radiculopathy, and non-specific low back pain, and in 93.8% of those involving hip osteoarthritis, cervical radiculopathy, and lumbar spinal stenosis. Functional outcomes were also highly prioritised, with levels of consensus ranging from 81.3% to 100%. Health-related quality of life was frequently selected, with agreement rates between 81.3% and 87.5% across conditions. An overview of the specified core outcomes, along with other reported outcomes, is provided in Table S3, Supplemental File 1.
Expert Consensus in Round 2 Delphi Survey
In the second round of the Delphi survey, the panel re-evaluated the remaining three acupuncture recommendations (hip OA, cervical radiculopathy, and lumbar radiculopathy) based on previously provided evidence and first-round results. None of the recommendations reached a positive or negative consensus. Median ratings ranged from 1.5 to 2.0 on the 4-point Likert scale, with positive consensus percentages between 43.8% and 62.5% [Table 2].
Only 25.0% to 31.3% of participants rated the evidence supporting ac upuncture for these conditions as moderate or high overall certainty after two survey rounds. Similarly, 37.5% to 43.8% believed acupuncture has large desirable anticipated effects for these conditions, and less than half (up to 37.5%) felt the desirable consequences of acupuncture outweigh the undesirable ones. Table S4, Supplemental File 1, presents the proportion of positive responses to the GRADE EtD framework criteria for the three acupuncture recommendations.
Qualitative Comments From the Two Rounds of Delphi Survey
Some participants supported their recommendations for acupuncture by citing its long history of use, while others raised concerns about the lack of conclusive evidence demonstrating clinical benefits for certain recommendations. In terms of additional considerations, several participants emphasised the importance of individualising treatment plans according to the patient’s clinical stage and TCM diagnostic pattern (i.e., the summary of clinical features based on the condition’s location, cause, and nature). Acupuncture was also deemed unsuitable for patients at high risk of bleeding or those who are immunocompromised. For future research, participants recommended high-quality randomised controlled trials with larger sample sizes. Additional qualitative comments on the acupuncture recommendations are presented in Table S5, Supplemental File 1.
4. Discussion
Summary of Findings
In this study, a panel of local TCMPs and BMDs reached positive consensus on five of eight acupuncture recommendations considered suitable for clinical practice in Hong Kong. These included: (i) acupuncture for adhesive capsulitis, (ii) warm acupuncture for adhesive capsulitis, (iii) acupuncture for knee OA, (iv) acupuncture for lumbar spinal stenosis with neurogenic claudication, and (v) acupuncture for non-specific low back pain.
The panel also achieved full consensus on the diagnostic criteria for initiating acupuncture treatment for both the above-mentioned chronic musculoskeletal conditions and those for which consensus on recommendation was not reached (i.e., hip OA, cervical radiculopathy, and lumbar radiculopathy). Pain relief was identified as the most important core outcome for monitoring and evaluating acupuncture effectiveness, followed by functional outcomes and health-related quality of life.
Implications for Practice and Research
TCM services were formally introduced into inpatient settings by the Hong Kong Hospital Authority in 2014 through the launch of the “Integrated Chinese–Western Medicine” pilot programme. 24 Under this initiative, TCMPs in the quasi-public sector collaborate with BMDs in public hospitals to co-develop patient management plans and provide services such as Chinese herbal prescriptions, acupuncture, and Chinese massage. 25 The programme offers affordable inpatient care for eligible patients requiring stroke rehabilitation, chronic musculoskeletal pain management, and cancer care. 24 However, these services remain limited to inpatient settings, and an expert consensus-based list of acupuncture recommendations, defining conditions deemed appropriate for acupuncture, has yet to be developed.
To facilitate interprofessional collaboration among healthcare professionals and maximise the role of acupuncture at the primary care level in Hong Kong, we developed a consensus-based list of recommendations for acupuncture in the management of chronic musculoskeletal conditions. This list was generated through a rigorously conducted Delphi study involving public and private TCMPs, general practitioners, and orthopaedic surgeons in Hong Kong. It is intended to serve as a reference for developing standardised interprofessional referral pathways in primary care and across care transitions, from inpatient to outpatient settings, thereby promoting continuous and person-centred care. Furthermore, this list may serve as a contextual reference for policymakers when considering potential service development options, including subsidisation models such as specialised healthcare voucher schemes. This approach has also been suggested by local experts in integrative oncology in a separate Delphi study. 26 Such mechanisms could potentially improve access to acupuncture services in the community for individuals with conditions such as adhesive capsulitis, knee osteoarthritis, lumbar spinal stenosis, and non-specific low back pain.
To provide detailed implementation guidance for acupuncture in clinical practice, it is imperative to develop a comprehensive CPG. This CPG should encompass expert-endorsed information such as relevant acupoint selections, electric pulse intensity (when electroacupuncture is used), treatment frequency and duration, and contraindications. 27 To enhance relevance to TCM, it is recommended that different implementation plans for specific recommendations be developed based on TCM diagnostic patterns, as suggested by some panel participants. Existing TCM textbooks and CPGs may propose common diagnostic patterns for various chronic musculoskeletal conditions; however, these are often described in a “one-size-fits-all” manner 28 and may not be applicable to the Hong Kong population, given the geographical and climatic characteristics of the territory.29,30 Consequently, a cross-sectional study is advised to assess the distribution of diagnostic patterns for these acupuncture recommendations in Hong Kong, thereby laying the foundation for a local, TCM-relevant acupuncture CPG. 31 Furthermore, latent tree analysis could be employed to derive standardised rules for pattern differentiation, further strengthening the evidence base of the guideline and enhancing its clinical applicability. 32
Healthcare professionals may be reluctant to adopt evidence-based interventions in routine practice due to personal, guideline-related, and external factors. 27 Such reluctance not only undermines the value of efforts invested in developing recommendation lists and CPGs, but also results in unstandardised treatment approaches, making it difficult to compare clinical effectiveness across patients and to monitor service quality. In light of this, a potential research direction is to investigate the implementation determinants of clinical recommendations for acupuncture in the management of chronic musculoskeletal conditions in Hong Kong. Specifically, semi-structured interviews could be conducted to explore local stakeholders’ perspectives on the barriers and facilitators to implementation. 33 This process should be guided by established implementation science theories, models, or frameworks, such as the Theoretical Domains Framework and the Behaviour Change Wheel,34,35 with the ultimate goal of designing context-specific strategies to support the adoption of evidence-based acupuncture in routine practice.
Strengths and Limitations
We adopted the GRADE-ADOLOPMENT framework to systematically develop a list of evidence-based recommendations for acupuncture in the management of chronic musculoskeletal pain, with input from a multidisciplinary expert panel comprising local TCMPs, general practitioners, and orthopaedic surgeons. Experts were able to base their decisions on both international and local evidence presented across the various criteria of the GRADE EtD framework, including but not limited to the benefits and harms of the interventions.
This study has several limitations. First, there was a lack of direct evidence regarding the cost-effectiveness of acupuncture for chronic musculoskeletal pain, its impact on health inequalities, and its acceptability and feasibility within the Hong Kong context. As a result, the expert panel had to rely on members’ own clinical experience, international literature, or other indirect information to assess these EtD criteria, which may have introduced subjectivity and variability in the decision-making process. Second, the 16-member expert panel was recruited through purposive sampling via the authors’ professional networks to ensure inclusion of clinicians with relevant expertise in acupuncture and musculoskeletal pain management within the Hong Kong healthcare system, where such expertise is concentrated in established clinical and academic networks. While this approach may introduce selection bias and limit representativeness, steps were taken to mitigate this by ensuring balanced representation across key stakeholder groups, including public and private TCMPs, general practitioners, and orthopaedic surgeons with extensive clinical experience. Nonetheless, we acknowledge that the use of network-based recruitment may have influenced participant selection and that the findings should be interpreted in light of this potential bias. Third, the list of recommendations was developed without the participation of physiotherapists who also offer acupuncture services in Hong Kong. However, as physiotherapists are required to obtain referrals from TCMPs or BMDs before providing treatment, their exclusion is unlikely to have significantly affected the validity of the recommendations determined by the panel. Lastly, this study did not include patients and caregivers, limiting insight into patients’ preferences and acceptability. Future research should include these perspectives to improve the relevance of acupuncture recommendations.
Conclusions
Five evidence-based recommendations for acupuncture in the management of chronic musculoskeletal pain were identified through positive agreement among experts participating in this GRADE-ADOLOPMENT-based Delphi survey. The panel also reached full consensus on the diagnostic criteria for initiating acupuncture treatment and on the core outcomes for monitoring and evaluating its effectiveness for these conditions. These recommendations may inform clinical practice in Hong Kong and support interprofessional collaboration, as well as the appropriate integration of acupuncture within primary care settings.
Supplemental Material
Supplemental Material for Adapted Evidence-Informed Expert Consensus on the use of Acupuncture in Managing Chronic Musculoskeletal Pain in Hong Kong: A Delphi Consensus Study by Leonard Ho, Vanessa Cheuk Yan Li, Claire Chenwen Zhong, Haiyong Chen, Sheung Wai Law, Edwin Chau Leung Yu, Fiona Pui Yan Lam, Yi Chung Cheung, Irene Xinyin Wu, Samual Yeung Shan Wong, Regina Wing Shan Sit in Journal of Evidence-Based Integrative Medicine
Acknowledgements
We gratefully acknowledge all the experts who generously contributed their time, insights, and clinical experience to the Delphi panel.
Author Contributions: LH: Methodology; data curation; investigation; formal analysis; visualisation; project administration; writing—original draft.
VCYL: formal analysis; writing—review and editing.
CCZ: formal analysis; writing—review and editing.
HC, ECLY: Resources; validation; writing—review and editing.
FPYL, YCC: Writing—review and editing.
IXW, SYSW: Conceptualisation; writing—review and editing.
RWSS: Conceptualisation; funding acquisition; supervision; writing—review and editing.
All authors read and approved the final manuscript.
Funding: The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by the Chinese Medicine Development Fund of the Hong Kong Special Administrative Region Government (Reference number: 23B2/021A).
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Supplemental Material: Supplemental material for this article is available online.
ORCID iDs
Leonard Ho https://orcid.org/0000-0001-8353-9631
Regina Wing Shan Sit https://orcid.org/0000-0002-4717-7773
Ethical Considerations
This study is approved by the Survey and Behavioural Research Ethics Committee of the Chinese University of Hong Kong (Ref no. SBRE-24-0520B).
Consent to Participate
Respondents gave written consent for review and signature before participating the study.
Data Availability Statement
All data supporting the findings of this study are available within the paper and its Supplementary File.*
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Supplemental Material for Adapted Evidence-Informed Expert Consensus on the use of Acupuncture in Managing Chronic Musculoskeletal Pain in Hong Kong: A Delphi Consensus Study by Leonard Ho, Vanessa Cheuk Yan Li, Claire Chenwen Zhong, Haiyong Chen, Sheung Wai Law, Edwin Chau Leung Yu, Fiona Pui Yan Lam, Yi Chung Cheung, Irene Xinyin Wu, Samual Yeung Shan Wong, Regina Wing Shan Sit in Journal of Evidence-Based Integrative Medicine
Data Availability Statement
All data supporting the findings of this study are available within the paper and its Supplementary File.*