Extracorporeal shockwave therapy improves pain and function in subjects with knee osteoarthritis: A systematic review and meta-analysis of randomized clinical trials

Evaluation and management of knee osteoarthritis

Knee osteoarthritis (KOA) significantly contributes to the global disability burden, with its incidence expected to escalate by 74.9% by 2050. The urgency to comprehend and tackle this condition is critical, necessitating an updated and thorough review of KOA. A systematic review up to February 26, 2024, has elucidated the principal aspects of KOA's pathogenesis, risk factors, clinical manifestations, and contemporary management paradigms. The origins of KOA are intricately linked to mechanical, inflammatory, and metabolic disturbances that impair joint function. Notable risk factors include age, obesity, and previous knee injuries. Diagnosis predominantly relies on clinical assessment, with radiographic evaluation reserved conditionally. The significance of rehabilitation assessments, informed by the International Classification of Functioning, Disability, and Health framework, is highlighted. Treatment strategies are diverse, prioritizing nonpharmacological measures such as patient education, exercise, and weight management, with pharmacological interventions considered adjuncts. Intra-articular injections and surgical options are contemplated for instances where conventional management is inadequate. KOA stands as a predominant disability cause globally, characterized by a complex etiology and profound effects on individuals' quality of life. Early, proactive management focusing on nonpharmacological interventions forms the cornerstone of treatment, aiming to alleviate symptoms and enhance joint function. This comprehensive review underscores the need for early diagnosis, individualized treatment plans, and the integration of rehabilitation assessments to optimize patient outcomes. Further research is needed to refine prevention strategies and improve management outcomes for KOA patients.

A critical overview of systematic reviews and meta-analyses of extracorporeal shockwave therapy for knee osteoarthritis

Knee Osteoarthritis (KOA) has become a serious health issue for elderly patients. Several systematic reviews (SRs) and Meta-Analyses (MAs) have reported extracorporeal shockwave therapy (ESWT) has widely been used in the treatment of KOA. This overview aims to summarize and evaluate the available evidence for the efficacy of ESWT for KOA. Eight databases were searched from inception to December 4, 2022. The methodological quality of the included SRs/MAs was assessed by Assessing the Methodological Quality of Systematic Reviews 2 (AMSTAR 2) and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) tool was used to assess the quality of the included studies in terms of outcome indicators. Eight SRs/MAs were finally included in this study. The results of the methodological quality of the included SRs/MAs were generally unsatisfactory. The limitations were a lack of explaining the reasons for selection, a list of excluded literature, reporting bias assessment, and reporting the potential sources of conflict of interest. A total of 49 outcome indicators were assessed by using the GRADE tool. Only 3 items were assessed as moderate quality and the remaining indicators were rated as low and very low. Limitations were the most common downgraded factors. ESWT is regarded as a safe and therapeutically effective non-pharmacological method for the treatment of KOA. However, the reliability of the results is affected by the generally low methodological and evidential quality of the included SRs/MAs. Future researchers should improve the quality of original studies and SRs/MAs to provide a higher level of evidence-based medical evidence.

The efficacy of extracorporeal shock wave therapy for knee osteoarthritis : an umbrella review

BACKGROUND

An umbrella review was conducted to compare the effectiveness of extracorporeal shock wave therapy (ESWT) versus non-ESWT in the treatment of knee osteoarthritis (KOA).

MATERIALS AND METHODS

Three databases including PubMed, Embase and Web of science were searched up to September 2023. Literature screening, quality evaluation, and data extraction were performed according to inclusion and exclusion criteria. Meta-analysis of outcome indicators was performed using Revman 5.4 software.

RESULTS

A total of eight meta-analysis were included in this umbrella review. All meta-analysis were graded against a Measurement Tool to Assess Systematic Reviews 2 (AMSTAR 2) and scored between 8 and 11. Compared to the sham group, the ESWT group showed better results in WOMAC (Western Ontario and McMaster Universities Arthritis Index) [mean difference (MD)=-2.94, 95% CI: -5.52, -0.37, P=0.03, I²=60%], Visual Analog Scale (VAS) (MD=-2.0, 95% CI: -2.5, -1.5, P<0.01, I²=0%), range of motion (ROM) (MD=17.55, 95% CI: 13.49, 21.61, P<0.00001, I²=0%), and Lequesne index (MD=-2.85, 95% CI: -3.64, -2.07, P<0.00001, I²=48%).

CONCLUSION

Based on the results of our analysis, ESWT is now an effective therapy for improving pain and function in patients with KOA.

Therapeutic implications of extracorporeal shock waves in burn wound healing

Burns are a common type of trauma that seriously affect not only the physical health, but also the mental health and quality of life of the patient. Extracorporeal shock wave therapy (ESWT) is an emerging treatment that has been used in clinical treatment. It has many advantages, including safety, non-invasiveness, efficiency, short treatment duration, fewer complications, and relatively low prices. In clinical settings, ESWT has played an important role in the healing process of burns and the prevention of sequelae. This article reviews the history of ESWT, the mechanism of ESWT to promote burn healing, and the application of ESWT in burns. Current status of ESWT treatment for burns as well as future perspectives for research have been summarized and proposed. However, patients with burns cannot be considered recovered when the wounds have healed, we need some new technology to adjust to the challenges of the future.

Efficacy of Extracorporeal Shockwave Therapy on Pain and Function in Myofascial Pain Syndrome: A Systematic Review and Meta-analysis of Randomized Clinical Trials

OBJECTIVE

The aim of the study is to examine the effectiveness of extracorporeal shockwave therapy in reducing pain, improving functionality, joint range of motion, quality of life, fatigue, and health status self-perception in people with myofascial pain syndrome.

METHODS

PubMed, the Cochrane Library, CINAHL, the Physiotherapy Evidence Database, and SPORTDiscus were systematically searched for only randomized clinical trials published up to June 2, 2022. The main outcome variables were pain, as reported on the visual analog scale and pressure pain threshold, and functionality. A quantitative analysis was conducted using the inverse variance method and the random effects model.

RESULTS

Twenty-seven studies were included ( N = 595 participants in the extracorporeal shockwave therapy group). The effectiveness of extracorporeal shockwave therapy for relieving pain was superior for the extracorporeal shockwave therapy group compared with the control group on the visual analog scale (MD = -1.7 cm; 95% confidence interval = -2.2 to -1.1) and pressure pain threshold (mean difference = 1.1 kg/cm 2 ; 95% confidence interval = 0.4 to 1.7) and functionality (standardized mean difference = -0.8; 95% confidence interval = -1.6 to -0.04) with high heterogeneity. However, no differences were found between extracorporeal shockwave therapy and other interventions as dry needling, exercises, infiltrations, and lasers interventions.

CONCLUSIONS

Extracorporeal shockwave therapy is effective in relieving pain and improving functionality in patients with myofascial pain syndrome compared with control and ultrasound therapy.

TO CLAIM CME CREDITS

Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME.

TO CLAIM CME CREDITS

Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME.

CME OBJECTIVES

Upon completion of this article, the reader should be able to: (1) Determine the effectiveness of radial and focal extracorporeal shockwaves on pain perception, the pressure pain threshold, and functionality in people with myofascial pain syndrome; (2) Describe the intervention protocol of extracorporeal shockwave therapy to improve pain perception in people with myofascial pain syndrome; and (3) Describe the advantages and disadvantages of extracorporeal shockwave therapy versus other intervention such as dry needling.

LEVEL

Advanced.

ACCREDITATION

The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s) ™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

LEVEL

Advanced.

ACCREDITATION

The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s) ™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Extracorporeal Shock Wave Therapy as Regenerative Medicine in Knee Osteoarthritis: Pre-Experiment for Matrix Metalloproteinase-3 Evaluation

BACKGROUND

Knee osteoarthritis (KOA) is currently treated by regenerative therapies that aim to inhibit arthritic degeneration. Extracorporeal shock wave therapy (ESWT) is one of the physical regenerative approaches used for KOA management. However, little is known regarding the impact of shock wave treatment on matrix metalloproteinase-3 (MMP-3), which is one of the enzymes mediating cartilage degradation.

OBJECTIVES

To evaluate the effect of ESWT on MMP-3 levels and pain intensity in patients with KOA.

METHODS

Fourteen patients diagnosed with Kellgren Lawrence, grades 2 and 3 KOA were recruited for the study. ESWT piezo shockwave was applied once a week for six weeks. MMP-3 levels in the blood were measured pre-test, mid-test (three weeks after therapy) and post-test (one week after the last session) by enzyme-linked immunosorbent assay (ELISA). The perceived pain was recorded at each session by the Wong Becker Face Scale.

RESULTS

The median pre-test, mid-test and post-test MMP-3 levels were 19.92 ng/mL, 15.89 ng/mL and 18.82 ng/mL, respectively, and there were significant differences between the pre-test and mid-test, and the pre-test and post-test values (p < 0.05). The pain scores also decreased significantly over the period of intervention.

CONCLUSION

MMP-3 levels decreased significantly in KOA patients after ESWT, and the decline was most obvious after 3 weeks of therapy. Therefore, EWST should be considered as a suitable treatment option for KOA.

Electroacupuncture combined with extracorporeal shock wave therapy improves pain symptoms and inflammatory factor levels in knee osteoarthritis patients

Objective

To compare the clinical efficacy and safety of electroacupuncture combined with extracorporeal shock wave therapy (EESWT) and extracorporeal shock wave therapy (ESWT) in the treatment of knee osteoarthritis (KOA).

Methods

A total of 135 KOA patients who received EESWT treatment were selected as the EESWT group, and 135 KOA patients who received extracorporeal shock wave therapy (ESWT) were selected as the ESWT group. The clinical efficacy, inflammatory factors in joint synovial fluid and adverse events during treatment were compared before and after treatment.

Results

The clinical effective rate of patients in the EESWT group (89.63 %) after treatment was significantly higher than that of the ESWT group (74.81 %) (p < 0.01). The lysholm kness (LKSS) score and range of motion (ROM) of the patients in the EESWT group after treatment were higher than those of the ESWT group, while Lequesne index score, visual analogue scale (VAS) score and Western Ontario and McMaster Universities Arthritis Index (WOMAC) were lower than those of the ESWT group (p < 0.01). Compared with ESWT group, the changes in the expression levels of nitric oxide (NO), superoxide dismutase (SOD), interleukin 1β (IL-1β), tumor necrosis factor-α (TNF-α), matrix metalloproteinase-3 (MMP-3), and transforming growth factor β1 (TGF-β1) in the synovial fluid of the EESWT group after treatment were significantly greater than those of the ESWT group (p < 0.01). No significant difference in the incidence of adverse events between the EESWT group and the ESWT group (p > 0.05).

Conclusion

EESWT significantly improves pain symptoms and inflammatory factor levels in KOA patients and is an optional KOA treatment option worthy of clinical attention.

Chinese guidelines for the rehabilitation treatment of knee osteoarthritis: An CSPMR evidence-based practice guideline

BACKGROUND

Knee osteoarthritis (KOA) is the most common degenerative joint disease in China, causing a huge economic burden on patients, families, and society. Standardized KOA rehabilitation treatment is an important means to prevent and treat the disease and promote the development of high-quality medical services. This guideline is updated on the basis of the 2016 and 2019 editions.

METHODS

Clinical questions regarding rehabilitation assessment and treatment were selected through clinical questions screening and deconstruction, and multiple rounds of Delphi questionnaire consultation. The International Classification of Functioning, Disability and Health (ICF) was used as the theoretical framework, and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) method was used to grade the quality of evidence and recommendations.

RESULTS

The reporting of this guideline followed the standard of Reporting Items for Practice Guidelines in Healthcare (RIGHT). Taking into account patients' preferences and values and the needs of Chinese clinical practice, a total of 11 clinical questions and 28 recommendations were established. The clinical questions were grouped into two categories: KOA assessment (body function, body structure, activity and participation, quality of life, and environmental factors and clinical outcomes assessment, resulting in 9 recommendations) and KOA treatment (health education, therapeutic exercise, therapeutic modalities, occupational therapy, assistive devices, and regenerative rehabilitation approaches, resulting in 19 recommendations).

CONCLUSION

This is the first evidence-based guideline for KOA rehabilitation in China utilizing the ICF framework. This guideline provides key guidance for developing systematic, standardized, and precise rehabilitation protocols for KOA across various healthcare settings.

Rehabilitation interventions in osteoarthritis

The goals of the management of osteoarthritis (OA) are to relieve joint pain and stiffness, maintain or increase joint mobility and stability, improve activities and participation, and enhance quality of life. The first step in the management is to make a comprehensive holistic assessment to understand the impact of the disease on the individual. Then, an individualized management plan can be set via a shared-decision making process between the patient and the clinician taking into account all components of functioning affected by the disease. Rehabilitation interventions serve as the basis of OA management whereas pharmacological modalities are usually administered for additional symptom control. This study aimed to overview the rehabilitation interventions used for people with OA with an update of the recent evidence. First, core management approaches that include patient education, physical activity and exercises, and weight loss were addressed; then adjunctive treatments including biomechanical interventions (e.g. orthoses, assistive devices) and physical modalities were overviewed.

The Short-Term Efficacy of Large-Focused and Controlled-Unfocused (Radial) Extracorporeal Shock Wave Therapies in the Treatment of Hip Osteoarthritis

Although the classical treatments listed in the guidelines for osteoarthritis are widely used, the majority of patients do not fully recover from their pain. It is a fact that new treatment methods are needed both to relieve pain and restore deteriorated joint function. No study has been found to date that evaluated the efficacy of ESWT in hip OA. This pilot trial is the first in the literature to investigate the comparative effects of the two ESWT types (f-ESWT and r-ESWT) in the treatment of hip OA. Briefly, 148 patients were randomly distributed into the three ESWT groups: focused (f-ESWT), radial (r-ESWT), and sham (s-ESWT). Patients were assessed with the Visual Analog Scale (VAS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores just before the treatment (0 week), just after the treatment (4th week), and 1 month after completion of the treatment (8th week). VAS and all WOMAC scores were significantly reduced at follow-up points (4th and 8th weeks) in both the f-ESWT and r-ESWT groups compared with baseline (0 week) (for all, p < 0.001). Statistical comparisons between the f-ESWT and r-ESWT groups showed that f-ESWT was superior to r-ESWT for the decrease in VAS and WOMAC scores from baseline to the 4th and 8th weeks (p < 0.001 or p < 0.002). Both r-ESWT and f-ESWT were found to have significant treatment efficacy compared with s-ESWT. However, f-ESWT produced a superior improvement in follow-up parameters compared to r-ESWT.

Effect of extracorporeal shock wave therapy on pain and function in patients with knee osteoarthritis: a systematic review with meta-analysis and grade recommendations

Objective

To investigate extracorporeal shock wave therapy effect on knee osteoarthritis compared to a sham or kinesiotherapy by a systematic review and meta-analysis of randomized clinical trials.

Data Sources

The search was performed in: Cochrane Library, PubMed, PEDro, Web of Science, EMBASE, Scopus, LILACS, and Scielo.

Review methods

We performed the online search until October, 2022. The following terms were used (Osteoarthritis) AND (“knee joint”) AND (“Extracorporeal Shockwave Therapy”). Eligibility criteria: (1) randomized clinical trials; (2) effects comparison of shockwave therapy to a sham or kinesiotherapy in individuals with knee osteoarthritis; (3) pain and physical function as outcome variables. Risk of bias assessed using the PEDro scale. PROSPERO registration (CRD42021235597).

Results

We identified 4217 studies, and 12 were included in the qualitative synthesis and the meta-analysis, totaling 403 individuals submitted to the intervention and 331 control individuals. Compared to sham, shockwave was favored in short-term for the function outcome (SMD = −1.93; 95%CI: [−2.77; −1.09]; I² = 83%; P < 0.01). For the pain outcome, the shockwave was favored in the short (MD = −2.05; 95%CI: [−2.59; −1.51]; I² = 84%; P < 0.01), medium (MD = −3.46; 95%CI: [−4.03; −2.89]; I² = 0%; P < 0.01) and long-term (MD = −2.01; 95%CI: [−3.36; −0.65]; I² = 98%; P < 0.01). The association with kinesiotherapy was favored in the short term for the function outcome (SMD = -1.88; 95%CI: [−2.98; −0.78]; I² = 94%; P < 0.01) and favored for the pain outcome in the short (MD = −1.44; 95%CI: [−1.81; −1.07]; I² = 37%; P = 0.14), medium (MD = −1,31; 95%CI: [−1.76; −0,85]; I² = 0%; P = 0.41), and long terms (MD = −1.63; 95%CI: [−1.73; −1.52]; I² = 0%; P = 0.43).

Conclusion

Shockwave therapy may improve functionality in patients with knee osteoarthritis in the short term and pain in all follow-up moments, compared with sham. When associated to kinesiotherapy, it may improve function in the short term and pain in all follow-up time points, although improvement in pain may not be clinically significant.

The Institute of Physical Medicine and Rehabilitation, Hospital das Clínicas University of São Paulo School of Medicine comprehensive rehabilitation program for elderly people with knee osteoarthritis

Background

Knee osteoarthritis (OA) is a leading cause of disability in the elderly population. Chronic disabling pain is associated with maladaptive neuroplastic changes in brain networks, commonly associated with central sensitization. The main clinical features of nociplastic pain conditions include combined peripheral and central sensitization, and it is crucial to recognize this type of pain, as it responds to different therapies than nociceptive and neuropathic pain.

Objective

To report the effect of the Institute of Physical Medicine and Rehabilitation (IMREA) comprehensive rehabilitation program to reduce pain and to improve functioning in elderly people with knee OA, under the DEFINE cohort.

Methods

This is a retrospective observational cohort of 96 patients with knee OA, recruited from October 2018 to December 2019. All patients were evaluated by a trained multidisciplinary team using the Kellgren Lawrence classification, bilateral knee ultrasonography, the visual analog scale (VAS), the Western Ontario and McMaster Universities Arthritis Index (WOMAC) pain, rigidity and difficulty scores, the Timed Up and Go Test (TUG), 10-m and 6-min walking test (10 and 6 MWT), Berg Balance Scale, isokinetic dynamometry for knee extension and flexion strength, and pain pressure thresholds. The rehabilitation program included paraspinous lidocaine blocks, focal extracorporeal shockwaves combined with radial pressure waves and functional electrical stimulation according to individual needs. The baseline was compred with the treatment results with a paired t-test.

Results

The study sample is composed of 96 participants, mostly females (n = 81, 84.38%), with bilateral osteoarthritis (n = 91, 94.79%), and a mean age of 68.89 (SD 9.73) years. Functional improvement was observed in TUG (p = 0.019), 6-mwt (p = 0.033), right knee flexion strength (p &lt; 0.0001), WOMAC rigidity and difficulty domains (p &lt; 0.0001). Pain was reduced from baseline as measured by WOMAC pain domain (p &lt; 0.0001), VAS for both knees (p &lt; 0.0001), and SF-36 pain domain (p &lt; 0.0001). Pressure pain threshold was modified above the patella (p = 0.005 and p = 0.002 for right and left knees, respectively), at the patellar tendons (p = 0.015 and p = 0.010 for right and left patellar tendons, respectively), left S2 dermatome (p = 0.017), and L1-L2 (p = 0.008).

Conclusions

The IMREA comprehensive rehabilitation program improved functioning and reduced disabling pain in elderly people with knee OA. We highlight the relevance and discuss the implementation of our intervention protocol. Although this is an open cohort study, it is important to note the significant improvement with this clinical protocol.

Mechanical-based therapies may reduce pain and disability in some patients with knee osteoarthritis: A systematic review with meta-analysis

BACKGROUND

Mechanical-based therapies are not yet recommended to manage osteoarthritis (OA). This systematic review and meta-analysis aim to assess the effects of passive mechanical-based therapies (isolated or combined with other therapies) on patients with knee OA compared to placebo, other isolated or combined interventions.

METHODS

Pubmed, Cochrane, Web of Science and EMBASE were searched up to December 2020. We included randomized and non-randomized trials using therapeutic ultrasound, phonophoresis, extracorporeal shockwave therapy (ESWT) and vibration (single or combined with other therapies) compared to placebo, and/or other physical therapies groups. Biochemical, patient-reported, physical and imaging outcome measures were retrieved. We judged risk of bias using the RoB2 tool for randomized studies, the ROBINS-I tool for non-randomized studies, and the GRADE to interpret certainty of results.

RESULTS

We included 77 clinical studies. Ultrasound and ESWT statistically improved pain and disability comparing to placebo (combined or not with other therapies), and when added to other therapies versus other therapies alone. Ultrasound was statistically inferior to phonophoresis (combined or not with other therapies) in reducing pain and disability for specific therapeutic gels and/or combined therapies. Vibration plus exercise statistically improved pain relief and function versus exercise alone. All meta-analyses showed very-low certainty of evidence, with 15 of 42 (38%) pooled comparisons being statistically significant (weak to large effect).

CONCLUSIONS

Despite the inconsistent evidence with very-low certainty, the potential benefits of passive mechanical-based therapies should not be disregard and cautiously recommended that clinicians might use them in some patients with knee OA.

Comparative Effectiveness of Focused Extracorporeal versus Radial Extracorporeal Shockwave Therapy for Knee Osteoarthritis—Randomized Controlled Study

Both focused extracorporeal shockwave (f-ESWT) and radial extracorporeal shockwave therapy (r-ESWT) can alleviate symptoms in patients with knee osteoarthritis, but no trials have directly compared f-ESWT with r-ESWT for knee osteoarthritis. This study aimed to compare the effectiveness of f-ESWT and r-ESWT on knee osteoarthritis. Forty-two patients with bilateral knee osteoarthritis were randomly assigned to receive three sessions of either f-ESWT or r-ESWT at 1-week intervals. The patients were evaluated at baseline and at 4 and 8 weeks after the final treatment. The primary outcome was the change in pain intensity, as measured on the visual analog scale (VAS). Secondary outcomes included the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), range of motion of the knee joint, and the 6-minute walk test. At the end of 4 weeks, the VAS score was substantially reduced in both groups (f-ESWT, −4.5 ± 2.5 points; r-ESWT, −2.6 ± 2.0 points), with a greater reduction in the f-ESWT group. Both groups showed significant improvement in secondary outcomes; however, the f-ESWT group yielded greater improvement in the VAS score, WOMAC score, and 6-minute walk test. Our results showed that f-ESWT was more effective than r-ESWT in improving pain and physical function in patients with knee osteoarthritis.

Treatment Options for Patellofemoral Arthritis

PURPOSE OF REVIEW

To present a synthesis of recent literature regarding the treatment of patellofemoral arthritis RECENT FINDINGS: Risk factors of PFJ OA include patella malalignment or maltracking, injury to supportive structures including the MPFL, dysfunction of hamstring and quadriceps coordination, lower limb alignment, trochlear dysplasia, patellar trauma, or ACL surgery. Special physical exam maneuvers include patellar grind test, apprehension test, and lateral patellar tilt angle. Radiographs that should be obtained first-line include weight bearing bilateral AP, lateral, and Merchant views. CT and MRI are used to assess trochlear dysplasia, excessive patellar height, and TT-TG distance. Non-operative management options discussed include non-pharmacologic treatment (patient education, self-management, physical therapy, weight loss), ESWT, cold therapy, taping, bracing, and orthotics. Pharmacologic management options discussed include NSAIDs, acetaminophen, oral narcotics, and duloxetine. Injection therapies include glucocorticoids, hyaluronic acid, PRP, and other regenerative therapies (BMAC, adipose, or mesenchymal stem cells). Other treatment options include radiofrequency ablation and botulinum toxin. The algorithm for the surgical treatment of PFJ OA can begin with arthroscopic assessment of the PF articular cartilage to address mechanical symptoms and to evaluate/treat lateral soft tissue with or without overhanging lateral osteophytes. If patients fail to have symptomatic improvement, a TTO can be considered in those patients less than 50 years of age or active patients >50 years old. In patients with severe PFJ OA, refractory to the above treatments, PFA should be considered. While early PFA design and technique were less than encouraging, more recent implant design and surgical technique have demonstrated robust results in the literature. Patellofemoral osteoarthritis is a challenging orthopedic problem to treat, in that it can often affect younger patients, with otherwise well-functioning knees. It is a unique entity compared to TF OA with distinct epidemiology, biomechanics and risk factors and treatment options.

Relative Effect of Extracorporeal Shockwave Therapy Alone or in Combination with Noninjective Treatments on Pain and Physical Function in Knee Osteoarthritis: A Network Meta-Analysis of Randomized Controlled Trials

Extracorporeal shockwave therapy (ESWT) has been recommended for managing pain in patients with knee osteoarthritis (KOA). The difference in therapeutic effects between radial shockwave characteristics (RaSW) and focused shockwave characteristics (FoSW) with different energy levels for KOA remains controversial. The purpose of this network meta-analysis (NMA) was to identify the effects relative to the different ESWT regime and combination treatments on pain and functional outcomes in individuals with KOA. The randomized controlled trials (RCTs) which investigated the efficacy of RaSW, FoSW, and combination treatments in patients with KOA were identified by searches of electronic databases. The included RCTs were analyzed through NMA and risk-of-bias assessment. We analyzed 69 RCTs with a total of 21 treatment arms in the NMA. Medium-energy FoSW plus physical therapy, medium-energy acupoint RaSW plus Chinese medicine, and high-energy FoSW alone were the most effective treatments for reducing pain [standard mean difference (SMD) = −4.51], restoring function (SMD = 4.97), and decreasing joint inflammation (SMD = −5.01). Population area and study quality influenced the treatment outcomes, particularly pain. Our findings indicate that medium-energy ESWT combined with physical therapy or Chinese medicine is beneficial for treating pain and increasing function in adults with KOA.

Efficacy of Acupuncture-Related Therapy in the Treatment of Knee Osteoarthritis: A Network Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

Knee osteoarthritis (KOA) is prevalent in middle-aged and elderly people. This condition negatively affects the quality of life of patients. Although non-steroidal anti-inflammatory drugs (NSAIDs) are often used to relieve symptoms associated with KOA, it is associated with many side effects. Acupuncture and moxibustion therapies have been applied in the treatment of KOA. However, the efficacy of various acupuncture and moxibustion treatments has not been compared.

METHODS

Randomized controlled trials (RCTs) on the application of acupuncture and moxibustion in the treatment of KOA were searched in English databases and Chinese databases. Data were retrieved from establishment of the database to September 2020. Data analysis was performed using Stata14.0 and GeMTC 0.14.3 softwares.

RESULTS

A total of 40 RCTs involving 3215 patients with KOA were retrieved. Network meta-analysis revealed that the fire needle was superior to western medicine, electro-acupuncture, conventional acupuncture, warm needle and sham acupuncture; warm needle was better than conventional acupuncture and western medicine whereas electro-acupuncture was better than conventional acupuncture in improving pain scores in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Moreover, we found that fire needle and warm needle more effectively improved WOMAC stiffness scores than western medicine and sham moxibustion, whereas electro-acupuncture was superior to western medicine and sham moxibustion in improving WOMAC stiffness scores. Further analysis revealed that fire needle, warm needle and electro-acupuncture were more effective in improving WOMAC joint function scores than conventional acupuncture and western medicine. The fire needle was superior to conventional acupuncture and sham acupuncture, whereas electro-acupuncture was better than western medicine, conventional acupuncture and sham acupuncture in improving visual analogue scale scores.

CONCLUSION

This study shows that fire needle is superior to warm needle and electro-acupuncture, whereas warm needle and electro-acupuncture are better than conventional acupuncture, western medicine, sham moxibustion and sham acupuncture.