**4. Discussion**

CPGs are systematically developed statements to assist practitioners and patient decisions about the appropriate healthcare for specific clinical circumstances.

Among the several standard methods used to develop CPGs, we mainly used the GRADE to assess the quality of evidence.

We applied seven types of interventions to the clinical question. In a preliminary study, it was found that the studied interventions were used frequently in the actual clinical field [7]. The studied interventions are often used alone or in combination with other treatments.

When the intervention was applied alone, acupuncture and Tuina manual therapy were evaluated as A grade, herbal medicine and TEA were evaluated as B grade, and moxibustion was evaluated as GPP grade. Each single treatment was compared to active control treatments, including drugs, injection therapy, and physical therapy. This comparison showed that KM treatment can be used as an alternative to conventional treatment.

For herbal medicine, the level of evidence was lowered by two grades due to the inconsistency and imprecision observed in terms of pain and function improvement. For TEA, the level of evidence was lowered by one grade due to the risk of bias. Further research is required to expand the evidence.

When intervention was applied as combination therapy, the combination of acupuncture with active control treatment, combination of moxibustion with acupuncture or Tuina manual therapy, combination of herbal medicine with active control treatment, and combination of Tuina manual therapy with active control treatment were evaluated as A grade, and the combination of pharmacopuncture with active control treatment, combination of TEA with active control treatment, and combination of cupping treatment with active control treatment were evaluated as B grade. Conventional therapies include Western medicine and KM treatments. This comparison showed that KM treatment can be used as a complementary treatment to conventional treatments.

Regarding the combination of pharmacopuncture with active control treatment, the level of evidence was lowered by one grade due to imprecision because the overall number of evidence documents and the number of subjects included in the studies were small. For the combination of Tuina manual therapy with active control treatment and combination of TEA with active control treatment, the level of evidence was evaluated as one level lower due to the inconsistency owing to the high heterogeneity between studies. Further research is required to expand the evidence.

In actual clinical practice, KM techniques have different treatment techniques. Among them, we developed recommendations for the depth of acupuncture, thermal and electrical stimulation with acupuncture, and deqi sensation caused by moxibustion. Additional heat or electrical stimulation during acupuncture was classified as grade A. Deep-insertion acupuncture was evaluated as B grade, and moxibustion causing deqi sensation was evaluated as C grade. For deep-insertion acupuncture, the level of evidence was evaluated as one level lower due to inconsistency owing to the high heterogeneity between studies. Regarding moxibustion that causes deqi sensation, the level of evidence was evaluated at two levels lower due to the risk of bias and imprecision owing to the lack of quality of the supporting data and the n umber of subjects included. Further research is required to expand the evidence.
