膝骨关节炎的治疗措施:随机对照试验及系统评价分析

Therapeutic methods for knee osteoarthritis: Randomized controlled trial and systemic evaluation

目的:膝骨关节炎至今还没有统一的治疗标准,应用各种非手术疗法评价其在治疗骨关节炎的有效性和安全性上的不同。资料来源:应用计算机检索MEDLINE的Ovid全文数据库March25,2004和Cochrane数据库2004,同时纳入了已经证实的随机对照实验和相关综述。搜索关键词包括:膝,骨关节炎,有效性,安全性,非手术疗法,随机对照实验等。资料选择:对检索到的资料进行综合分析,纳入关于评价膝骨关节炎治疗措施安全性和有效性的随机对照实验和系统评价。非阿司匹林类非类固醇类抗炎药比较的随机对照实验共16组纳入系统评价,涉及了8种药物;非类固醇类抗炎药和安慰剂比较的随机对照实验共6组,包括1689例患者被纳入了研究,平均年龄60.8岁,男25%,女75%。葡糖胺分别与安慰剂和非类固醇类抗炎药比较的随机对照实验共16组纳入评估,共有2029例患者参与了试验。另外透明质酸和中草药分别有26组和5组随机对照实验进行了系统评价。非药物治疗中运动锻炼共有17组随机对照实验共2562例纳入系统评价;其他物理疗法中共有28组1453例患者纳入系统评价。资料提炼:根据关键词,共收集到相关文章89篇,因部分文章不符合标准,或相互引用,排除35篇,引用文献30篇。资料综合:药物治疗能明显减轻膝关节的疼痛,缓解功能障碍,促进关节软骨的新陈代谢,修复关节结构,全面提高患者的生活质量,不同种类的药物在骨关节炎的不同阶段疗效不同。体育锻炼可改善关节活动度,增强疼痛耐受,减轻抑郁和焦虑症状,增强肌肉力量和柔韧性,减轻疲劳感,减轻疼痛,改善功能。冷疗对增强股四头肌肌力,减轻肿胀,提高关节的活动范围和柔韧性。药物治疗和非药物治疗,在改善膝关节活动度和疼痛方面都有效,但在安全性和有效性的评价上各有优缺点。结论:非类固醇抗炎药、葡糖胺、透明质酸、肢体锻炼、经皮电刺激神经疗法、肌肉电刺激疗法等方式在有效性和安全性上有着不同的优点,但是针灸和中医药因缺乏统一的结果评估标准,故疗效不确定,尚需更多的实验支持。

OBJECTIVE：There has been no uniform therapeutic standard for knee os-teoarthritis by now.Different kinds of non-operative treatments were applied to evaluate their validity and reliability on knee osteoarthritis. DATA SOURCES：A computer-based online search of Ovid full text database （March 25, 2004） in Medline and Cochrane database （2004） was under taken to include randomized controlled trials which had been confirmed and relevant reviews by using the keywords of “knee, osteoarthritis, validity, reliability, non-operative treatment, randomized controlled trial”. STUDY SELECTION：All the retrieved data were comprehensively analyzed, and randomized controlled trials and system evaluations which evaluated the reliability and validity of the therapeutic methods for knee osteoarthritis were included.There were 16 groups of randomized controlled trials to compare among 8 kinds of non-aspirin and non-steroidal anti-inflammatory drugs and 6 groups of randomized controlled trials to compare non-steroidal anti-inflammatory drugs with placebo,in which totally 1 689 cases （25% males and 75%females） with an average age of 60.8 years, were involved. In another evaluation, there were 16 groups of randomized controlled trials including 2 029 patients to compare glucosamine with placebo and non-steroidal anti-inflammatory drugs respectively.Besides, there were 26 groups of randomized controlled trials about hyaluronic acid and 5 about herbal medicine in the system evaluation. In the system evaluation of non-medication,there were 17 groups of randomized controlled trials about exercise involving 2 562 cases.Among the rest physiotherapy, there were 28 groups including 1 453 cases in the system evaluation. DATA EXTRACTION：According to the keywords, totally 89 relevant articles were collected,but 35 pieces were excluded for unqualified arti-cles or cross reference,and 30 thirty were cited. DATA SYNTHESIS：Medication is able to apparently alleviate the ache of knee joint,remit dysfunction,promote metabolism of articular cartilage, repair joint structure,and improve the sufferer’ quality of life entirely,different kinds of drugs produce different curative effects on the different phases of osteoarthritis.Exercise can improve the motion of joint,enhance ache endurance,alleviate depression and anxiety, enhance muscle strength and flexibility,alleviate tiredness and ache, and improve the function. Psychrotherapy can enhance the muscle force of quadriceps muscle of thigh, alleviate swelling,and improve the articulatory activity range and flexibility.Both medication and non-medication are effective in improving the motion range and alleviating pain of knee joint,but there are respective merits and demerits in the reliability and validity. CONCLUSION：Non-steroidal anti-inflammatory drugs, glucosamine, hyaluronic acid, exercise of limbs, transcutaneous electrical nerve stimulation, muscular electrical stimulating therapy etc. all have different merits in the validity and reliability respectively, but acupuncture and traditional Chinese medicine are indeterminate in the curative effects for lack of uniform criteria for evaluation.,so more experiments are needed for support.