Does Thunder-Fire Moxibustion Really Augment Therapeutic Efficacy in Knee Osteoarthritis? Methodological Critique of A Recent Pairwise Meta-Analysis [Letter]

We appreciate Wei et al's meta-analysis 1 assessing Thunder-Fire Moxibustion (TFM) combined with other Traditional Chinese Medicine (TCM) modalities for knee osteoarthritis (KOA).However, we would like to raise some points for further discussion, as we believe that addressing these could enhance future studies and improve the robustness of the evidence in this field.First, the title's phrasing "Osteoarthritis Knee" is non-standard."Knee Osteoarthritis" or "Osteoarthritis of the Knee" are clinically accepted terms.Second, while the study aimed to evaluate TFM combined with other TCM therapies for KOA through parallel-group RCTs, five included trials used controls that deviate from optimal methodological standards, such as waitlist controls, perfectly matched placebos, or guideline-recommended standard care (eg, land or aquatic exercise, topical/oral NSAIDs, intra-articular corticosteroid injections, or surgical treatment). 2 We acknowledge that excluding non-standard comparators is ideal, but may not always be feasible due to ethical or practical considerations.Thus, should the authors opt to include these trials with non-standard controls to enhance review comprehensiveness, a network meta-analysis approach, as discussed later, would be preferable, as it can effectively address inherent heterogeneity and better estimate comparative efficacy among multiple interventions.Third, the exclusive reliance on clinical efficacy rate as the sole outcome measure is problematic due to substantial heterogeneity in calculation methods across studies and incomplete reporting of derivation procedures in some trials (Table 1).These methodological limitations fundamentally compromise the validity of pooled estimates.More standardized outcome measures, such as the Visual Analog Scale, Numeric Rating Scale, Western Ontario and McMaster Universities Arthritis Index, and Knee Injury and Osteoarthritis Outcome Score, would have better captured clinical efficacy and contributed to mitigating heterogeneity.Fourth, in Wei et al's meta-analysis, heterogeneous TCM modalities (eg, various topical and oral herbal medicines, and different acupuncture or acupressure methods) were combined into broad subgroups, with minimal justification provided for this aggregation.This approach, coupled with the mixing of conventional and traditional medicine controls,

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