温针灸治疗膝骨关节炎随机对照试验Meta分析

Meta Analysis of Randomized Controlled Trials of Warming Needle Moxibustion for Knee Osteoarthritis

目的:系统评价温针灸与单纯针刺或电针治疗膝骨关节炎(KneeOsteoarthritis,KOA)的有效性。方法:检索中国期刊全文数据库、万方数据库、维普中文科技期刊数据库、PubMed、Embase,获得从建库至2018年6月期间有关温针灸与单纯针刺或电针治疗KOA的RCT文献;根据Cochrane评价手册5.0.2的要求筛选试验、提取资料,并根据改良Jadad评分进行方法学质量评价;选择总有效率、膝关节主观疼痛(VAS评分)、WOMAC总评分、病情缓解时间(疼痛、僵硬和平均治愈)、Lequesne膝OA严重性指数(ISOA)作为Meta分析的评价指标;采用State12.0软件进行Meta分析,检验异质性,并选择相应的效应模型分析,应用Begg's秩相关检验和Egger's线性回归法来检验文献发表偏倚;计数、计量资料分别采用RR值、SMD及其95%CI表示。结果:(1)共纳入12篇文献,全部为RCT文献,其中6篇研究为温针灸与单纯针刺治疗KOA的疗效,6篇研究为温针灸与电针治疗KOA的疗效;所有研究均来自中国,共包含1176例研究对象。(2) Meta分析结果显示,2组在治疗KOA的总有效率方面无统计学差异,RR=1.04(95%CI:1.00～1.08),漏斗图Begg's检验P=0.086,Egger's检验P=0.296。治疗后VAS评分方面,根据干预措施行亚组分析,结果示:与单纯针刺比,2组治疗后VAS评分的差异有统计学意义,SMD=-1.57(95%CI:-1.83～-1.80);与电针比,2组差异无统计学意义,SMD=0.32(95%CI:-0.11～0.76)。温针灸组与电针组治疗后WOMAC总评分的差异无统计学意义,SMD=0.08(95%CI:-0.15～0.32)。病情缓解时间方面,温针灸组与电针组疼痛及僵硬缓解时间的差异均有统计学意义,SMD及95%CI分别为0.69(95%CI:0.46～0.92)、-0.60(95%CI:-0.82～-0.37);2组平均治愈时间的差异无统计学意义,SMD=-0.04(95%CI:-0.27～0.18)。温针灸组与单纯针刺组治疗后ISOA指数的差异有统计学意义,SMD=-1.68(95%CI:-2.03～-1.32)。结论:与单纯针刺治疗KOA相比,温针灸能更好地缓解主观疼痛及降低Lequesne膝OA严重性指数,但在总有效率上,两者疗效相当。与电针治疗KOA相比,温针灸能更快地缓解膝关节僵硬,但在总有效率、缓解主观疼痛、降低WOMAC总评分及平均治愈时间上,两者无显著性差异,且在疼痛缓解时间上,温针灸不及电针。鉴于纳入文献质量偏低及研究间存在统计学异质性,故尚需高质量的RCT来验证上述结论。

Objective:To systematically evaluate the effectiveness of warming needle moxibustion and simple acupuncture or electroacupuncture in treating knee osteoarthritis.Methods:Retrieve the CNKI,Wanfang database,VIP, PuhMed,Embase,and obtain the RCT literature about warm acupuncture and simple acupuncture or electroacupuncture in the treatment of KOA from the database to June 2018.According to the requirements of Cochrane evaluation manual 5.0.2,the experiment was screened and the data were extracted,and the methodological quality was evaluated according to the modified Jadad score.Total effective rate,VAS score,WOMAC score,remission time(pain,stiffness and average cure),and ISOA were selected as the indicators for meta-analysis.State 12.0software was used for metaanalysis,heterogeneity was tested,and the corresponding effect model was selected for analysis.Begg's rank correlation test and Egger's linear regression were used to test the literature publication bias.The counting and measurement data were expressed by RR,SMD and 95% CI respectively.Results:Twelve RCT papers were included,of which 6 were about the efficacy of warming acupuncture and simple acupuncture in the treatment of KOA,6 were about the efficacy of warming acupuncture and electroacupuncture in the treatment of KOA,all of which were from China and included 1176 subjects.Meta-analysis showed that there was no significant difference in the total effective rate of KOA between the two groups,RR =1.04(95%CI:1.00-1.08),Begg's test P =0.086,Egger's test P =0.296.After treatment,VAS scores were subgroup analyzed according to intervention measures.The results showed that there were significant differences in VAS scores between the two groups after treatment,SMD =-1.57(95%CI:-1.83^-1.80),and SMD =0.32 (95%CI:-0.11~0.76)as compared with electroacupuncture.There was no significant difference in total WOMAC score between warm acupuncture group and electroacupuncture group after treatment,SMD =0.08(95%CI:-0.15-0.32). In terms of remission time,there were significant differences in pain and stiffness between warm acupuncture group and electroacupuncture group,SMD and 95%CI were 0.69(95%CI:0.46-0.92)and -0.60(95%CI:-0.82-0.37),respectively,and there was no significant difference in mean cure time between the two groups,SMD=-0.04(95%CI:-0.27-0.18).The difference of ISOA index between warm acupuncture group and simple acupuncture group was statistically significant,SMD =-1.68(95%CI:-2.03- ~1.32).Conclusion:Compared with acupuncture alone in the treatment of KOA,warm acupuncture can better relieve subjective pain and reduce the severity index of KOA in Lequesne,but the total effective rate is the same.Compared with electroacupuncture in treating KOA,warm acupuncture can alleviate knee stiffness more quickly,but there is no significant difference in total effective rate,subjective pain relief,WOMAC score reduction and average healing time,and in pain relief time,warm acupuncture is inferior to electroacupuncture. In view of the low quality of the included literature and the statistical heterogeneity between studies,high quality RCT is needed to verify the above conclusions.