Abstract
Objective This meta-analysis aimed to investigate the effectiveness of acupuncture therapy plus hyaluronic acid injection versus hyaluronic acid injection alone for patients with knee osteoarthritis. Methods Relevant randomized controlled trials that compared the combined effect of acupuncture therapy and hyaluronic acid injection with hyaluronic acid injection alone for knee osteoarthritis patients were included. 10 studies were included in this meta-analysis, and the relative risk (RR) and weight mean difference (MD) with 95% CI for the Lysholm knee score (LKSS), visual analogue scale (VAS), and effective rate (ER) were evaluated by using RevMan 5.3 software. Besides, the bias assessment of the included studies was evaluated using the Cochrane risk of bias tool, and the GRADE (Grading of Recommendations, Assessment Development, and Evaluation) system was applied to assess the overall quality of the evidence. Results A total of 10 studies involving 998 participants were included in this study. Compared to hyaluronic acid injection alone, the combined therapy significantly reduced pain on the visual analogue scale (VAS) and improved the ER and knee function on the Lysholm knee score (LKSS). Of these, the pooled LKSS (MD = 8.09, 95% CI = [7.02, 9.16], p < 0.00001, 7 studies) and ER (RR = 1.23, 95% CI 1.15 to 1.31, p < 0.00001, 8 studies) suggested that combination therapy yielded a significantly higher ER and improved the LKSS scores to a greater degree than hyaluronic acid injection alone in patients with KOA. The VAS (MD = −1.39, 95% CI = [−1.99, −0.79], p < 0.00001, 7 studies) showed that the combined therapy significantly reduced pain than hyaluronic acid injection alone. The quality of evidence for the main outcomes was from very low to low according to the GRADE system. Conclusion Current evidence suggests that acupuncture therapy combined with hyaluronic acid injection is more effective in alleviating pain, improving the ER and knee function compared with hyaluronic acid injection alone. However, considering the low quality, small size, and high risk of the studies identified in this meta-analysis, more higher methodological quality, rigorously designed randomized controlled trials with large sample sizes are needed to confirm the results.
Highlights
Knee osteoarthritis is a highly common chronic degenerative disease in middle-aged and elderly people, with more female patients than males, which seriously affects joint function and the quality of life, and becomes a serious public health problem worldwide [1,2,3]
We identified 1071 studies based on our retrieval strategies, of which 992 studies were removed by screening the titles and abstracts since they were not qualified according to the predefined inclusion criteria
For warm acupuncture (WA), mean difference (MD) − 1.21, 95% confidence interval (CI) [− 1.80, − 0.62], p < 0.0001, p for heterogeneity 0.02, and I2 82%; for MA, MD − 2.34, Records identified through database searching (n = 1071): Pubmed (n = 20), EMBASE (n = 37), Cochrane Library (n = 22), CBM (n = 235), China National Knowledge Infrastructure (CNKI)(n = 241), Wanfang (n = 291), VIP (n = 225)
Summary
Knee osteoarthritis is a highly common chronic degenerative disease in middle-aged and elderly people, with more female patients than males, which seriously affects joint function and the quality of life, and becomes a serious public health problem worldwide [1,2,3]. Among these conservative therapies, acupuncture, known as an ancient, complementary, and alternative therapeutic technique [11], has been empirically practiced and improved over thousands of years in Asian countries and verified to be the most effective and popular therapies in treating the pain symptoms and functional disability of patients with KOA based on integral concepts and syndrome differentiation of the TCM system. Hyaluronic acid products, commonly used as alternative intraarticular injection and recommended by the Food and Drug Administration for treatment of KOA in 1997 [19], have the function of viscoinduction properties and increasing intraarticular lubrication, inhibiting inflammatory mediators and promoting repair of cartilage to delay the progression of KOA [20, 21]. Altman et al [22] has reported that HA injections are generally well tolerated, provide a longer duration of symptomatic relief, and improve knee function for patients with knee OA
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