Please wait a minute...
TMR Integrative Nursing  2018, Vol. 2 Issue (3): 115-122    DOI: 10.12032/TMRIN20180720
Meta-analysis     
Moxibustion treatment for knee osteoarthritis: cumulative meta-analysis and trial sequential analysis
Jun-Chen Fan1, Hui-Min Zhang1, Miao Zhang1, Fan-Mei Kong1, Wen-Rui Wang2, Yu-Ling Wang2()
1Tianjin University of Traditional Chinese Medicine, Tianjin, 300100, China
2Nan Kai Hospital of Tianjin, Tianjin, 300100, China.
Download: HTML     PDF(1103KB)
Export: BibTeX | EndNote (RIS)      

Abstract  

Highlights:

This article evaluated the effect of moxibustion on knee osteoarthritis patients with cumulative meta-analysis, and trial sequential analysis was applied to test the authenticity of results.

Editor’s summary:

Pain is a major problem in patients with knee Osteoarthritis. Moxibustion, a traditional non-invasive treatment in China, stimulates specific acupuncture points by the heat from the burning strips to alleviate symptoms, such as muscle strain, osteoarthritis, shoulder pain, neck and back pain.

Abstract

Objective: To evaluate the effect of moxibustion on knee osteoarthritis patients with cumulative meta-analysis, and trial sequential analysis was applied to test the authenticity of results. Methods: We searched PubMed, EMbase, The Cochrane Library, CNKI and CBM to collect RCTs about moxibustion on knee osteoarthritis patients. The selection of literature, data extraction and evaluation of eligible literature were carried out independently by two reviewers. Then Stata11.0 software was used for data analysis. Result: Totally 11 RCTs involved 1005 patients were recruited. The results of meta-analysis showed that no significant differences were found between the two groups in VAS, moxibustion is better than drug therapy in effective rate [OR = 0.40, 95%CI (0.27, 0.60)] and knee score [SMD = -0.70, 95%CI (-1.22, -0.19)]. The result of trial sequential analysis indicated that the sample size didn’t reach the TSA Boundary on VAS, the sample size of effectiveness achieved Require Information Size. In the indicator of knee score has obtained certain result before reaching the Require Information Size. Conclusion: moxibustion is superior to drug therapy on treatment knee osteoarthritis. However, large sample size and high-quality studies are still needed.



Key wordsMoxibustion      Knee osteoarthritis      Cumulative meta-analysis      Trial sequential analysis     
Published: 24 September 2018
Cite this article:

Jun-Chen Fan, Hui-Min Zhang, Miao Zhang, Fan-Mei Kong, Wen-Rui Wang, Yu-Ling Wang. Moxibustion treatment for knee osteoarthritis: cumulative meta-analysis and trial sequential analysis. TMR Integrative Nursing, 2018, 2(3): 115-122.

URL:

https://www.tmrjournals.com/in/EN/10.12032/TMRIN20180720     OR     https://www.tmrjournals.com/in/EN/Y2018/V2/I3/115

Figure 1 PRISMA flow diagram of search and selection of literature.
Study Sample Size Age
(T/C)
Intervention Outcomes
T (M/F) C (M/F) T C
Su 2007 30 (11/19) 30 (9/21) 53.0±7.8
55.6±7.2
Monkshood-cake mild moxibustion, 6 days a week for 4 week, 30min/time; Acupoint: Ex-LE4, ST36 Xianling Gubao capsule, 3 granule once, twice a day, total 4 week VAS, ISOA, ER
Yang 2008 33 (14/19) 31 (11/20) 59.27±9.53
59.29±9.05
Cake separated moxibustion, once a day, 10 times a session, total 2 session; Acupoint:Ex-LE4, EX-LE5, Ex-LE2, SP9, GB34 Diclofenac sodium, 75 mg, once a day,
consecutive 20 days
SSR, ER
Sun 2008 29 (11/18) 27 (12/15) 59.93±8.62
61.67±9.1
Cake separated moxibustion, once a day, 5 times, rest for 1 or 2 days,10 times a session, total 2 sessions; Acupoint: EX-LE4, ST35, SP9, GB34, SP10, ST34, EX-LE2, BL18, BL23 Diclofenac sodium, 75 mg, 1/d, 20 days SSR, ER
Cheng 2008 60 (11/49) 60 (14/46) 57.8±5.4
58.8±5.7
Sandwiched moxibustion, once every 2 days, 10 times a session, rest for 10 days between sessions, total 2 sessions; Acupoint: Ex-LE4, EX-LE5, Ex-LE2, SP9 Diclofenac sodium, 75 mg, once a day, consecutive 15 days SSR, NRS, VRS, ER
Nie 2009 58 (22/36) 58 (25/33) 36-83
39-81
Convention moxibustion, once a day, 5 weeks a session, rest for weekends; Acupoint: ST35, Ex-LE4, SP10, ST36, GB34 Ibuprofen, 0.3g/time, twice a day, consecutive 5 weeks, rest for weekends ER
Zhou 2010 35 (15/20) 35 (12/23) 59±10
61±9
Herbs-partitioned moxibustion, once a day, 10 times a session, total 2 sessions; Acupoint: ST 35, EXLE4, GB34, SP9, SP10, ST36 Diclofenac sodium, 75 mg, once a day, consecutive 15 days SSR, VAS, ER
Zhang 2011 30 (-) 30 (-) 46-73 Convention moxibustion, 30 min/time, once a day, 7 days a session, total 6 sessions; Acupoint: Ex-LE4, ST35, ST34, SP9, GB34, SP10, Ashi point Celebrex, 200 mg/time, once a day, total 6 weeks VAS, ER
Zhou 2014 39 (14/25) 22 (5/17) 67±10
66±12
Convention moxibustion, 30-40 min/time, 3 times every week, total 4 weeks; Acupoint: Ex-LE4, ST34, SP10, ST36 Celebrex, 200 mg/time, once a day, total 4 weeks VAS, KFS, ER
Yuan 2015 74 (28/46) 74 (26/48) 63±10
63±9
Heat-sensitive moxibustion, 10-15min/time, once a day, 30 times a session; Acupoint: ST35, GB34, ST36 Diclofenac sodium, 50g/time, twice a day, 30 times a session VAS, WOMAC, ER
Huang 2015 60 (27/33) 60 (29/31) 57.9±6.8
55.4±5.2
Herbs-partitioned moxibustion, once a day, 5 days a week, 10 times a session, total 2 sessions; Acupoint: ST35, Ex-LE4, ST34, SP10, ST36, GB34, SP9 Diclofenac sodium, 75g/time, once a day, consecutive 20 days WOMAC, ER
Nie 2017 30 (14/16) 30, (13/17) 58.23±6.46
58.67±6.28
Convention moxibustion, twice a week, 30min/time, 4 week a session Acupoint: ST 35, EXLE4, GB34, SP9 Celebrex, 0.2g/time, once a day, 4 week a session VAS, ISOA, ER
Huang 2015 60 (27/33) 60 (29/31) 57.9±6.8
55.4±5.2
Herbs-partitioned moxibustion, once a day, 5 days a week, 10 times a session, total 2 sessions Acupoint: ST35, Ex-LE4, ST34, SP10, ST36, GB34, SP9 Diclofenac sodium, 75g/time, once a day, consecutive 20 days WOMAC, ER
Nie 2017 30 (14/16) 30 (13/17) 58.23±6.46
58.67±6.28
Convention moxibustion, twice a week, 30min/time, 4 week a session; Acupoint: ST 35, EXLE4, GB34, SP9 Celebrex, 0.2g/time, once a day, 4 week a session VAS, ISOA, ER
Table 1 Basic characteristics of all included studies
Figure 2 Assessment of risk of bias
Figure 3 Funnel plot of publication bias
Figure 4 Cumulative meta-analysis on VAS
Figure 6 Cumulative meta-analysis on effectiveness
Figure 7 Trial sequential analysis on effectiveness
Figure 8 Cumulative meta-analysis on knee score
1.   Loeser RF.Age-related changes in the musculoskeletal system and the development of osteoarthritis.Clin Geriatr Med, 2010:26371-386.
doi: 10.1016/j.cger.2010.03.002 pmid: 20699160
2.   Wang F. The global burden of disease: 2004 update The global burden of disease: published by the Harvard School of Public Health on behalf of the World Health Organization and the World Bank. 208,4-4.
3.   Iversen MD, Price LL, Heideken JV, et al. Physical examination findings and their relationship with performance-based function in adults with knee osteoarthritis. BMC Musculoskelet Disord 2016, 17:1-12.
4.   Heidari B, .Knee osteoarthritis prevalence, risk factors, pathogenesis and features: Part I. Caspian J Intern Med 2011, 2:205.
pmid: 3766936
5.   Zhang Y, Jordan JM.Epidemiology of osteoarthritis. Clin Geriatr Med 2013, 39:1-19.
6.   Klu?mann A, Gebhardt H, Liebers F, et al.Individual and occupational risk factors for knee osteoarthritis - Study protocol of a case control study. BMC Musculoskelet Disord 2008, 9:1-8.
7.   Michael JW, Schlüterbrust KU, Eysel P.The epidemiology, etiology, diagnosis, and treatment of osteoarthritis of the knee. Dtsch Arztebl Int 2010, 107:152-62.
doi: 10.3238/arztebl.2010.0152 pmid: 20305774
8.   Dor A, Kalichman L.A myofascial component of pain in knee osteoarthritis. J Bodyw Mov Ther 2017:642-647.
doi: 10.1016/j.jbmt.2017.03.025 pmid: 28750978
9.   Harish S, Kashif R.Effect of Maitland Mobilization and Myofascial Release Technique in Patients with Knee Osteoarthritis. Indian J Physiother Occup Ther 2013, 7:181.
10.   Zhang W, Moskowitz RW, Nuki G, et al.OARSI recommendations for the management of hip and knee osteoarthritis, Part II: OARSI evidence-based, expert consensus guidelines. Osteoarthr. Cartil. 2008, 16:137-162.
11.   Nelson FR.A background for the management of osteoarthritic knee pain. Pain Manag 2014, 4:427-36.
doi: 10.2217/pmt.14.40 pmid: 25494694
12.   Luigi A J D. Complementary and Alternative Medicine in Osteoarthritis. Pm R, 2012, 4:S122.
13.   Ren YL, Zeng F, Zhao L, et al.Considerations about developing a clinical decision support system for evidence-based diagnosis and treatment of acupuncture-moxibustion. Acupunct Res 2009, 34:349.
14.   Kim TH, Kim KH, Kang JW, et al.Moxibustion treatment for knee osteoarthritis: a multi-centre, non-blinded, randomised controlled trial. Inte Med Res 2015, 4:13-13.
15.   Higgins JPT, Green S.Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0.London:The Cochrane Collaboration 2011.
16.   Brok J, Thorlund K, Gluud C, et al.Trial sequential analysis reveals insufficient information size and potentially false positive results in many meta-analyses. Clin Epidemiol 2008, 61:763.
17.   Thorlund K, Engstr?m J, Wetterslev J, et al.User manual for trial sequential analysis (TSA). Copenhagen Trial Unit.
18.   Su X.The clinical observation of mild moxibustion for the treatment of liver and renal insufficiency of the knee osteoarthritis. Hubei college of tradit Chin med 2007.
19.   Yang YH, Sun K, Su GH, et al.Clinical study panax notoginsengs cake separated moxibustion treatment of qi stagnation blood stasis type for primary knee osteoarthritis. Clin J Tradit Chin Med 2008, 20:53-55.
20.   Sun K, Yang J, Shen DK.Clinical observation on treatment of primary knee osteoarthritis of liver and kidney deficiency type with Aconite cake-separated moxibustion. Zhongguo zhen jiu Chin Acupunct Moxibustion 2008, 28:87-90.
21.   Cheng HL, Han W, Hu PJ, et al.Clinical study of differential selection of objects separated moxibustion for treatment of knee osteoarthritis. Clin J Tradit Chin Med 2008, 20:114-116.
22.   Nie B, Zhang L, Xu K, et al.The clinical observation of zhao's fire moxibustion for knee osteoarthritis. Jilin J Tradit Chin Med 2009, 29:313-314.
23.   Zhou ZL, Sun K, Cheng HL, et al.Observations on the therapeutic effect of herbal cake-separated moxibustion on knee osteoarthritis of blood stasis type. Shanghai J Acup Mox 2010, 29:45-47.
24.   Zhang QJ, Cao LH, Li ZD, et al.The clinical effects and safety of moxibustion and celecoxib for obteoarthritis of knee. Chin J Tradit Med Trauma Orthop 2011;19:13-15.
25.   Zhou YL, Li J, Hou WG, et al.Clinical observation of moxibustion in treatment of knee osteoarthritis. Shanghai [J] Acup Moxi. 2014, 33:1086-1087.
26.   Yuan QD, Guo X, Han YC, et al.Observations on the Therapeutic Effect of Heat-sensitive Point Thunder-fire Moxibustion on Knee Osteoarthritis. J Acupunct and Tuina Sci 2015:665-668.
27.   Zhen H, Song SL.Observation on clinical effects of herbal cake-partitioned moxibustion for knee osteoarthritis. J Acupunct& Tuina Sci 2015, 13:242-245.
doi: 10.1007/s11726-015-0860-8
28.   Nie B, Tan Y, Sun ZP, et al.Clinical Observation on the Treatment of Yang-deficiency-and-cold-coagulation Type Knee Osteoarthritis with Strengthening-yang Moxibustion. Rheum and Arthritis 2017, 6:22-25.
29.   Peat G, Mccarney R, Croft AP.Knee pain and osteoarthritis in older adults: a review of community burden and current use of primary health care. Ann Rheum Dis 2001, 60:91-97.
30.   Xiang YJ, Dai SM.Prevalence of rheumatic diseases and disability in China. Rheumatol Int 2009, 29:481.
doi: 10.1007/s00296-008-0809-z pmid: 19066899
31.   Cui GQ, Chen QM.Expression of Nitric Oxide Synthase (NOS) on Osteoarthritis- Affected Cartilage and Osteophytes. Chin J Orthop 1998:619-621.
32.   Li G, Gan L, Zhong MR.Study on the role of COX -2mRNA in the process of inflammatory lesion of bone and joint . Hebei Med J 2015:3064-3066.
33.   Xiong Y, Peng R, Xia SS.Effect of moxibustion on the expressions of interleukin-1 beta and tumor necrosis factor alpha in joint synovial fluid of rabbits with knee osteoarthritis. J Clin Reha Tiss Engi Res 2010, 14:7700-7703.
34.   Li CR, Han Y, Dong BQ.Research of RANTES and MCP-1 expressions in knee osteoarthritis after acupuncture moxibustion and message treatment. J Liaoning Univ of Tradit Chin Med 2013:79-81.
35.   Dong BQ, Zhang SJ, Li CR, et al.Research of RANKL and OPG expression with moxibustion treatment in knee osteoarthritis through meridian-muscle-lesion-rules. J Liaoning Univ of Tradit Chin Med 2013:5-7.
36.   Zheng SG, Chen B, Ma SB, et al.Regulative effect of moxibustion on experimental knee osteoarthritis in rabbit. [J] Beijing Univ Trad Chin Med. 2008, 31:358-360.
37.   Li XB, Li ZX, Wang XL, et al.Effects of Indirect Mild Moxibustion on Hemorheology of Knee Osteoarthritis. Chin Archives of Tradit Chin Med 2012, 2098-2099.
[1] Wei Xie, Yu Leng, Ping Li, Ping Liu, Hai-Bo Li, Hua-Qian Dong, Wan-Feng Yang. Design and application of automatic constant temperature moxibustion box[J]. TMR Integrative Nursing, 2018, 2(4): 160-164.
[2] Li Ma, Li-Juan Yi, Xu Tian. Jinhuang powder for the treatment of diabetic foot ulcers: an updated meta -analysis with power analysis and trial sequential analysis[J]. TMR Integrative Nursing, 2018, 2(4): 178-185.
[3] Ya-Qian Liu, Meng-Jie Lei, Ting-Ting Liu, Yu-Feng Li, Chu-Yun Cui, Li-Jia Ni, Chang-De Jin. Efficacy and safety of the heated gel mattress for prevention of hypothermia in preterm infants during intra-hospital transport: a meta-analysis[J]. TMR Integrative Nursing, 2018, 2(3): 132-140.