不同针灸疗法治疗肩周炎的系统评价再评价和网状Meta分析

Different acupuncture therapies for treating periarthritis of the shoulder:overview of systematic reviews and network Meta-analysis

背景:针灸治疗肩周炎的系统评价越来越多,结果均表明针灸疗法较西药有更好的疗效。然而,这些系统评价的方法学质量及不同针灸疗法之间的疗效差异均是不清楚的。目的:评价现有关于针灸疗法治疗肩周炎的系统评价的方法学质量,以比较不同针灸疗法治疗肩周炎的疗效。方法:在7个国内外数据库中检索不同针灸疗法治疗肩周炎的系统评价,检索时间从建库至2019-12-28。使用AMSTAR2工具评估纳入系统评价的方法学质量,从纳入系统评价的随机对照试验中及更新至2019-12-28的随机对照试验中筛选符合条件的研究。采用Cochrane风险偏倚工具评价纳入研究的偏倚风险,采用随机效应模型进行两两荟萃分析,采用频率学框架对纳入的随机对照试验进行网络荟萃分析,数据分析均在Stata 14.0实施。结果与结论:①从5个极低质量的系统评价的随机对照试验中,及更新的随机对照试验中筛选出34个合格的随机对照试验(n=3098),涉及5种干预措施;②基于网状Meta分析中的排序结果显示,与西药相比,温针灸[OR=1.26,95%CI(1.15,1.39)]有最高的可能性改善肩周炎症状,其次是热敏灸[OR=1.26,95%CI(1.15,1.39)]、电针[OR=1.21,95%CI(1.10,1.33)]、毫针[OR=1.21,95%CI(1.01,1.24)];③在目测类比评分方面,与西药相比,热敏灸[OR=0.12,95%CI(0.03,0.46)]有最高的可能性降低目测类比评分,其次依次为温针灸[OR=0.28,95%CI(0.11,0.75)]和电针[OR=0.34,95%CI(0.12,0.96)];④综合考虑此次研究的直接Meta分析和网状Meta分析结果,在纳入的4种针灸疗法中,热敏灸和温针灸可被考虑作为治疗肩周炎的补充替代疗法,但是鉴于纳入系统评价极低的方法学质量及随机对照试验报告不佳的风险偏倚,未来需更严格的设计和更规范的报告来进一步论证此次研究的可靠性。

BACKGROUND:Increasing systematic reviews of acupuncture treatment for periarthritis of shoulder indicate that acupuncture treatment has better efficacy than western medicine.However,the methodological quality of these systematic reviews and the differences in efficacy between different acupuncture therapies are unclear.OBJECTIVE:To evaluate the methodological quality of systematic reviews regarding acupuncture therapy for periarthritis of shoulder and to compare the efficacy of different acupuncture therapies in treating periarthritis of the shoulder.METHODS:A total of seven electronic databases were searched for systematic reviews regarding different acupuncture therapies for periarthritis of the shoulder,from inception to December 28,2019.The AMSTAR2 instrument was used to evaluate the methodological quality of included systematic reviews.The eligible randomized controlled trial(RCTs)were selected from the included systematic reviews and updated RCTs from the above systematic reviews to December 28,2019.Cochrane risk of bias tool was used for the risk of bias of the included RCTs.Pairwise meta-analyses were performed using the random-effects model,and network meta-analysis of the included RCTs were performed the frequentist framework.All data analyses were completed in Stata 14.0.RESULTS AND CONCLUSION:Thirty-four qualified RCTs(n=3098)were included from five critically low-quality systematic reviews and updated RCTs.Five interventions were ranked based on the ranking probability in the network meta-analysis.Compared with western medicine,warm acupuncture[odds ratio(OR)=1.26,95%confidence interval(CI)(1.15,1.39)]has the highest possibility to improve the symptoms of periarthritis of the shoulder,followed by thermo-sensitive moxibustion[OR=1.26,95%CI(1.15,1.39)],electroacupuncture[OR=1.21,95%CI(1.10,1.33)],filiform needle[OR=1.21,95%CI(1.01,1.24)].In terms of visual analogue scale score,compared with western medicine,thermo-sensitive moxibustion[OR=0.12,95%CI(0.03,0.46)]had the highest possibility of reducing visual analogue scale score followed by warm acupuncture[OR=0.28,95%CI(0.11,0.75)]and electroacupuncture[OR=0.34,95%CI(0.12,0.96)].Considering the pairwise meta-analyses and network meta-analysis of this study,among the four acupuncture therapies included,thermo-sensitive moxibustion and warm acupuncture can be considered as a complementary alternative to the treatment of periarthritis of the shoulder.However,given the critically low methodological quality of the included systematic reviews and poor reporting risk bias of RCTs,more rigorous design and standardized reporting are needed to further demonstrate the reliability of this study.