Moxibustion treatment for knee osteoarthritis: a multi-centre, non-blinded, randomised controlled trial on the effectiveness and safety of the moxibustion treatment versus usual care in knee osteoarthritis patients

A systematic review on the effects of non-pharmacological interventions for fatigue among people with upper and/or lower limb osteoarthritis

Objectives

To identify non-pharmacological fatigue interventions and determine the effectiveness of these non-pharmacological interventions in reducing fatigue immediately and over time in OA.

Methods

A review protocol (CRD42020163730) was developed and registered with the PROSPERO database. Included studies comprised peer-reviewed randomized controlled trials (RCTs) that examined the effects of conservative interventions on fatigue in people with upper and lower limb OA. Cochrane Collaboration's tool for assessing the risk of bias (ROB-2) was used to assess the quality of evidence of studies. Narrative synthesis was used to summarize the effectiveness of identified fatigue interventions.

Results

Out of 2644 citations identified from databases, 32 reports were included after screening for titles, abstracts and full texts. Of these reports, 30 parallel RCTs, one cluster and one cross-over RCT were included. 13 RCTs were of low ROB, 6 had some concerns and 13 had high ROB. The narrative synthesis identified interventions for fatigue including exercise, activity pacing, cognitive behavioural therapy, telerehabilitation and complementary alternative therapies. Exercise interventions showed the most significant beneficial effects on fatigue.

Conclusions

Diverse interventions for fatigue management among individuals with upper and lower limb OA were identified. Of these, exercise interventions appear to be the most promising with the majority of these interventions favouring fatigue improvement. While cognitive behavioural therapy has limited evidence of beneficial effects, there is insufficient evidence regarding the effectiveness of other identified interventions, including complementary and alternative therapies, and telerehabilitation.

Moxibustion of Zusanli (ST36) and Shenshu (BL23) alleviates the inflammation of rheumatoid arthritis in rats through regulating macrophage migration inhibitory factor/glucocorticoids signaling

OBJECTIVE

To test the hypothesis that moxibustion may inhibit rheumatoid arthritis (RA) synovial inflammation by regulating the expression of macrophage migration inhibitory factor (MIF)/glucocorticoids (GCs).

METHODS

Fifty male Sprague-Dawley rats were randomly divided into five groups (n = 10 each): blank Control (CON) group, RA Model (RA) group, Moxibustion (MOX) group, MIF inhibitor (S,R)-3-(4-hydroxyphenyl)-4,5-dihydro-5-isoxazole acetic acid methyl ester (ISO-1) group, and Moxibustion + MIF inhibitor ISO-1 (MOX + ISO-1) group. Rats in the ISO-1 group and ISO-1 + MOX group were intraperitoneally injected with the inhibitor ISO-1. The rats in the RA group, ISO-1 group, MOX group, and ISO-1 + MOX group were injected with Freund's complete adjuvant (FCA) in the right hind footpad to establish an experimental RA rat model. In the MOX group and MOX + ISO-1 group, rats were treated with Moxa. The thickness of the footpads of the rats in each group was measured at three-time points before, after modeling and after moxibustion treatment. The contents of serum MIF, corticosterone (CORT), tumor necrosis factor-α (TNF-α) and interleukin-1β (IL-1β) were detected by enzyme-linked immunosorbent assay; and the contents of synovial MIF were detected by Western blot. Hematoxylin-eosin (HE) staining method was used to observe the pathological changes of synovial tissue under a section light microscope, and pathological scoring was performed according to the grading standard of the degree of synovial tissue disease.

RESULTS

Moxibustion was found to reduce the level of MIF and alleviate inflammation in RA rats in this study. In addition, after inhibiting the expression of MIF, the level of CORT increased, and the level of TNF-α decreased. Treating RA rats with inhibited MIF by moxibustion, the level of CORT was almost unchanged, but the level of TNF-α further decreased. The correlation analysis data suggested that MIF was positively related to the expression of TNF-α and negatively correlated with the expression of CORT.

CONCLUSION

Reducing MIF to increase CORT and decrease TNF-α by moxibustion treatment in RA. MIF may be a factor for moxibustion to regulate the expression of CORT, but the expression of TNF-α is due to the incomplete regulation of the MIF. This study added to the body of evidence pointing to moxibustion's anti-inflammatory mechanism in the treatment of RA.

Effectiveness of Yijinjing exercise in the treatment of early-stage knee osteoarthritis: a randomized controlled trial protocol

INTRODUCTION

Knee osteoarthritis (KOA) is still a challenging degenerative joint disease with high morbidity and disease burden. Early-stage KOA, the focus of this study, could present a Window of Opportunity to arrest the disease process and reduce the disease burden. Yijinjing exercise is an important part of physical and psychological therapies in Traditional Chinese Exercise and may be an effective treatment. However, there is no clinical efficacy assessment of Yijinjing exercise for patients with early-stage KOA. Therefore, we designed a randomised controlled trial to evaluate the effectiveness of Yijinjing exercise on patients with early-stage KOA.

METHODS AND ANALYSIS

This is a parallel-design, two-arm, analyst assessor-blinded, randomised controlled trial. In total, 60 patients with early-stage KOA will be recruited and randomly assigned to the Yijinjing exercise group (n=30) and health education group (n=30) at a ratio of 1:1, receiving 12 weeks of Yijinjing exercise or health education accordingly. The primary outcome will be measured with the Western Ontario and McMaster Universities Osteoarthritis Index, and the secondary outcomes will include the Visual Analogue Scale, Short-Form 36 Item Health Survey Questionnaire, Beck Depression Inventory, Perceived Stress Scale, Berg Balance Scale, and Gait Analysis for a comprehensive assessment. Outcome measures are collected at baseline, at 12 week ending intervention and at the 12 week, 24 week and 48 week ending follow-up. The primay time point will be 12 weeks postintervention. Adverse events will be recorded for safety assessment.

ETHICS AND DISSEMINATION

This study has been approved by the ethical application of the Shanghai Municipal Hospital of Traditional Chinese Medicine Ethics Committee (2021SHL-KY-78).

TRIAL REGISTRATION NUMBER

ChiCTR2200065178.

Efficacy and safety comparison of infrared laser moxibustion and traditional moxibustion in knee osteoarthritis: study protocol for a Zelen-design randomized controlled non-inferiority clinical trial

BACKGROUND

Knee osteoarthritis (KOA) is the most common chronic degenerative joint disease and places a substantial burden on the public health resources in China. The purpose of this study is to preliminarily evaluate whether infrared laser moxibustion (ILM) is non-inferior to traditional moxibustion (TM) in the treatment of KOA.

MATERIALS AND METHODS

In the designed Zelen-design randomized controlled non-inferiority clinical trial, a total of 74 patients with KOA will be randomly allocated to one of two interventions: ILM treatment or TM treatment. All participants will receive a 6-week treatment and a follow-up 4 weeks after treatment. The primary outcomes will be the mean change in pain scores on the numeric rating scale (NRS) measured at baseline and the end of last treatment at week 6. The secondary outcomes will be the pain scores on the NRS from weeks 1 to 5 after the start of treatment and the changes from baseline to endpoints (weeks 6 and 10) in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), SF-36, knee circumference, and 6-min walking test. In addition, safety assessment will be performed throughout the trial.

CONCLUSION

The results of our study will help determine whether a 6-week treatment with ILM is non-inferior to TM in patients with KOA, therefore providing evidence to verify if ILM can become a safer alternative for TM in clinical applications in the future.

TRIAL REGISTRATION

Clinical Trial Registration Platform (ChiCTR2200065264); Pre-results. Registered on 1 November 2022.

A Multicenter, Randomized, Double-Blinded, Placebo-Controlled Clinical Trial to Evaluate the Efficacy and Safety of a Krill Oil, Astaxanthin, and Oral Hyaluronic Acid Complex on Joint Health in People with Mild Osteoarthritis

Osteoarthritis is a significant global health problem. Many patients seek more effective alternatives to nonsteroidal anti-inflammatory medicines or commercial supplements to manage joint pain and inflammation. FlexPro MD® (FP-MD) combines krill oil, astaxanthin, and lower molecular weight hyaluronic acid to support joint health. A 12-week, randomized, double-blind, placebo-controlled trial compared the efficacy and safety of FP-MD and placebo once daily in participants (n = 100) with mild osteoarthritis of the knee or hip joint. For the primary endpoint of joint pain score, per-protocol participants (n = 75) in the FP-MD group (n = 37) had a statistically significantly greater mean reduction from baseline in the Korean Visual Analog Scale (K-VAS) at week 12 compared with participants in the placebo group (n = 38) (20.8 ± 16.16 mm vs. 10.6 ± 17.58, p = 0.0105). The Korean Western Ontario and McMaster Universities Osteoarthritis Index (K-WOMAC) total score was also significantly improved in the FP-MD group at week 12 compared with placebo (-13.0 ± 13.62 vs. -5.5 ± 18.08, p = 0.0489), especially an improvement in pain score (-2.5 ± 2.92 vs. -1.3 ± 3.94, p = 0.02635). FP-MD group had greater improvement in joint function scoring by investigator assessment (p = 0.0127) and by group participants (p = 0.0070). A statistically significantly greater number of patients reported adverse events in the placebo group compared with the FP-MD group (16% vs. 4%, p = 0.0455), most commonly gastrointestinal disorders in both of the groups. These findings suggest that FP-MD is well tolerated and can be effectively used to address joint pain in patients diagnosed with mild osteoarthritis, the main symptom of this condition.

A comparison of jade moxibustion and traditional moxibustion in the treatment of knee osteoarthritis: A randomized clinical trial

BACKGROUND

This study was developed to compare the relative clinical efficacy of traditional moxibustion and Jade moxibustion in an effort to define the most effective approaches to treating knee osteoarthritis.

METHODS

In total, 94 patients were randomly assigned at a 1:1 ratio to the traditional moxibustion (TM) and Jade moxibustion (JM) groups. For JM, a jade kneepad was preheated for 3 minutes via electrification, with the jade in the kneepad being pressed onto acupoints when reaching an initial temperature of 46°C. For patients in the TM group, moxa cones were applied to acupoints for treatment. In total, 12 treatments were performed for patients in each group, with treatment being conducted 3 times per week. Study outcomes included 36-item short-form health survey and Western Ontario and McMaster Universities Osteoarthritis Index knee stiffness scores. In addition, serum levels of osteoarthritis-related cytokines were measured.

RESULTS

Overall, 89/94 patients completed this study, including 44 and 45 in the TM and JM groups, respectively. The 36-item short-form health survey physical functioning at weeks 12 and 24 (P = .033, 0.001), role-physical at weeks 4 and 24 (P = .030, 0.014), and role-emotional at week 4 (P = .045) were the only scores to differ significantly between the TM and JM groups. Western Ontario and McMaster Universities Osteoarthritis Index stiffness scores in the JM groups improved significantly relative to baseline at weeks 4, 8, 12, and 24 (all P < .01). The scores in the TM group differed significantly at all time points relative to baseline (all P < .01), with no differences between groups (all P > .05). Serum Interleukin-2 levels were lower in both groups (all P < .01). Cartilage oligomeric matrix protein and monocyte chemotactic protein-1 only differed significantly for patients treated via JM (P < .05, P < .01), with the same also being true for Interleukin-1β and Interleukin-8 in the TM group (all P < .01). No significant differences in other cytokines were observed, nor did they differ significantly between groups (all P > .05).

CONCLUSION

These results suggest that JM treatment can improve knee osteoarthritis patient quality of life, alleviating joint stiffness and restoring joint function with a level of efficacy comparable to TM.

Uncertainty analysis and optimization for mild moxibustion

During mild moxibustion treatment, uncertainties are involved in the operating parameters, such as the moxa-burning temperature, the moxa stick sizes, the stick-to-skin distance, and the skin moisture content. It results in fluctuations in skin surface temperature during mild moxibustion. Existing mild moxibustion treatments almost ignore the uncertainty of operating parameters. The uncertainties lead to excessive skin surface temperature causing intense pain, or over-low temperature reducing efficacy. Therefore, the interval model was employed to measure the uncertainty of the operation parameters in mild moxibustion, and the uncertainty optimization design was performed for the operation parameters. It aimed to provide the maximum thermal penetration of mild moxibustion to enhance efficacy while meeting the surface temperature requirements. The interval uncertainty optimization can fully consider the operating parameter uncertainties to ensure optimal thermal penetration and avoid patient discomfort caused by excessive skin surface temperature. To reduce the computational burden of the optimization solution, a high-precision surrogate model was established through a radial basis neural network (RBNN), and a nonlinear interval model for mild moxibustion treatment was formulated. By introducing the reliability-based possibility degree of interval (RPDI), the interval uncertainty optimization was transformed into a deterministic optimization problem, solved by the genetic algorithm. The results showed that this method could significantly improve the thermal penetration of mild moxibustion while meeting the skin surface temperature requirements, thereby enhancing efficacy.

New smokeless moxibustion for knee osteoarthritis: A study protocol for a multicenter, single-blind, randomized controlled trial

INTRODUCTION

Knee osteoarthritis (KOA) is a chronic inflammatory disease with high morbidity and disability. As the aging and obese population increase, so will the medical services for this disease. The purpose of this study is to compare the clinical efficacy of herbal activated carbon smokeless moxibustion and traditional moxibustion in the treatment of KOA and to determine the clinical efficacy of herbal activated carbon smokeless moxibustion in the treatment of KOA.

METHODS/DESIGN

This is a multicenter, two parallel-group, single-blind, randomized controlled trial. Eighty-eight subjects with KOA (Kellgren Lawrence grade II or III) will be recruited and randomly treated with smokeless moxibustion or traditional moxibustion in the ratio of 1:1. The smokeless moxibustion group will use plant herbal activated carbon smokeless moxa cone. The traditional moxibustion group will be treated with pure moxa cone. Subjects in both groups will receive treatment at the affected knee(s) at the acupuncture point ST35, EX-LE2, and EX-LE4. Subjects in both groups will receive 3 sessions per week of moxibustion for 4 weeks. The primary outcome are changes in the Western Ontario and McMaster Universities Osteoarthritis Index pain scores from baseline to week 24. Secondary outcomes include visual analog scale, 50 yards fast walking time, short-form heath survey 36, overall clinical efficacy evaluation, self-assessment of safety, treatment credibility and expectancy, and cytokines related to osteoarthritis in serum.

DISCUSSION

This randomized single-blind controlled trial takes traditional moxibustion as the control group to provide strict evidence for the clinical efficacy and safety of herbal activated carbon smokeless moxibustion in the treatment of KOA.

Quality assessment of conventional and traditional oriental medicine clinical practice guidelines for knee osteoarthritis using AGREE II instrument

INTRODUCTION

Knee osteoarthritis is a degenerative disease and its prevalence tends to increase. Clinical practice guidelines (CPGs) are evidence-based recommendations for treatment that help policymakers, practitioners, and patients make more appropriate and efficient decisions during the course of management. This study aimed to evaluate the quality of knee osteoarthritis CPGs using the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument.

METHOD

The retrieval engines and websites were utilized from January 2010 to December 2020. The search words were "Clinical practice guideline" OR "Critical practice guideline" OR "guideline∗" AND "Osteoarthritis." The quality of the CPGs was independently examined by four appraisers using the AGREE II instrument. Consequently, the selected CPGs were graded as Classes A, B, and C according to the level of recommendation.

RESULT

In this study, 13 CPGs for knee osteoarthritis were selected and evaluated qualitatively using the AGREE II instrument. The overall quality percentage score was as follows: clarity of presentation, 72.6%, scope and purpose, 62.6%, rigor of development, 54.2%, stakeholder investment, 50.5%, editorial independence, 46.5%, applicability, 22.5%.

CONCLUSION

Auxiliary materials for the treatment process of knee OA should be supplemented in future revised versions for quality improvement of knee OA CPGs. Also, more evidence should be accumulated to support the recommendation of traditional oriental medical treatments in the clinical field. From the perspective of integrative medicine, along with conventional pharmacological treatment, exercise, weight loss, and acupuncture can be combined together in clinical situations.

The Effects of Moxibustion on PD-1/PD-L1-Related Molecular Expression and Inflammatory Cytokine Levels in RA Rats

Objective

Rheumatoid arthritis (RA) is an autoimmune disease that starts with inflammation of the synovium. The pain and joint dysfunction caused by RA urgently need an effective treatment to alleviate the inflammatory reaction and delay the progression of the disease. The pathological damage of RA is proposed to associate with the dysfunction of the programmed cell death 1/programmed cell death ligand 1 (PD-1/PD-L1) pathway. Moxibustion, as a main complementary therapy of traditional Chinese medicine (TCM), has been proved effective to reduce chronic inflammatory reaction on RA, but whether the anti-inflammatory effects are mediated by PD-1/PD-L1 pathway is still unclear. Therefore, moxibustion was conducted in the rats with RA to investigate its effect on PD-1/PD-L1.

Methods

The rats' right hind paws were injected with Freund's complete adjuvant (FCA) to establish the model of RA. Seven days after the injection of FCA, moxibustion therapy was performed on the acupoints of Shenshu (BL23) and Zusanli (ST36) once a day for three weeks. Then, ELISA and immunohistochemical methods were used to analyze the influence of moxibustion on the expression of PD-1/PD-L1. If the moxibustion had an effect on the expression of PD-1/PD-L1-related molecules, we would knock down PD-1 with adenovirus vector. After moxibustion therapy, ELISA and histological analysis were performed to observe the anti-inflammatory effect of moxibustion.

Results

The results demonstrated that moxibustion had an effect on the expression of PD-1-related molecules. The results of ELISA manifested that moxibustion decreased the level of IFN-γ and increased the level of IL-4 and IL-10. HE staining revealed that moxibustion alleviated the proliferation of synovial tissue. However, the anti-inflammatory effect and pathological improvement were weakened when PD-1 was blocked.

Conclusions

The results indicate that moxibustion affected the expression of PD-1/PD-L1-related molecules and can effectively treat RA damage. The anti-inflammatory effect of moxibustion was weakened when PD-1 was knocked down.

Comparison of 10.6 μm Laser Moxibustion with Traditional Moxibustion in Knee Osteoarthritic Therapy: A Randomized Noninferiority Clinical Trial

Objective: To investigate the noninferiority of 10.6 μm laser moxibustion (LM) to traditional moxibustion (TM) in knee osteoarthritis (KOA). Methods: Ninety-two patients were recruited and randomly placed into one of two groups: 10.6 μm LM or TM in a 1:1 ratio. Each patient received 12 sessions of LM or TM, focusing on the ST-35 and Ashi acupoint. The sessions took place over 4 weeks, three times a week, and were followed up over 8 weeks. The endpoint outcomes were separated into two categories, primary and secondary. The primary endpoint was assessed at the end of the 4-week treatment, using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain score. The secondary endpoint was evaluated at the end of the trial and consisted of the WOMAC function and stiffness score, visual analog pain [visual analog scale (VAS)] score, and 15-m walking time test. In addition, safety evaluation was performed throughout the trial. Results: Among the 92 randomized participants, 86 (93.48%) completed the trial; 43 in each group. The WOMAC pain score improved dramatically between the LM and TM groups, with a mean difference of 20.61 [95% confidence interval (CI): -2.28 to 43.50]. Given that the lower boundary of 95% CI was greater than -18.49, noninferiority was established. In addition, both LM and TM significantly decreased the WOMAC (pain, function and stiffness) score, VAS score (p < 0.05), and the 15-m walking time at the end of the trial. Interestingly, there were not significant differences between LM and TM (p > 0.05), suggesting that both are equally effective in treating KOA. Finally, among the 92 patients, 17 (18.48%) adverse effects were documented, namely 5 (10.87%) in the LM-treated group and 11 (26.09%) in the TM-treated group. Conclusions: 10.6 μm LM is not inferior to TM in treating KOA. Moreover, both LM and TM dramatically alleviated knee pain and enhanced function of knees. Clinical Trial Registration number: ISRCTN registry trial identifier: 14604492.

Correlation between pain severity and levels of anxiety and depression in osteoarthritis patients: a systematic review and meta-analysis

OBJECTIVES

Osteoarthritis (OA) is a chronic degenerative musculoskeletal disease that causes articular damage and chronic pain, with a prevalence of up to 50% in individuals >60 years of age. Patients suffering from chronic painful conditions, including OA, also frequently report anxiety or depression. A systematic review and meta-analysis were performed to assess the correlation between pain severity and depressive and anxious symptomatology in OA patients.

METHODS

A systematic search was conducted using four databases (PubMed, Medline, Scopus, and Web of Science) from inception up to 14th January of 2020. We included original articles evaluating pain severity and anxiety and/or depression severity in OA-diagnosed patients. Detailed data were extracted from each study, including patients' characteristics and pain, anxiety, and depression severity. When available, the Pearson correlation coefficient between pain and depression severity and pain and anxiety severity was collected and a meta-analysis of random effects was applied.

RESULTS

This systematic review included 121 studies, with a total of 38085 participants. The mean age was 64.3 years old and subjects were predominantly female (63%). The most used scale to evaluate pain severity was the Western Ontario and the McMaster Universities Osteoarthritis Index, while for anxiety and depression, the Hospital Anxiety and Depression Scale was the most used. The meta-analysis showed a moderate positive correlation between pain severity and both anxious (r = 0.31, p < 0.001) and depressive symptomatology (r = 0.36, p < 0.001).

CONCLUSIONS

Our results demonstrate a significant correlation between pain and depression/anxiety severity in OA patients, highlighting the need for its routine evaluation by clinicians.

Traditional Korean Medicine as Collaborating Treatments with Conventional Treatments for Knee Osteoarthritis: A Protocol for a Systematic Review and Meta-Analysis

Background

Knee osteoarthritis (OA) is a degenerative disease of the joint cartilage with no definite treatment in the early stage. Several previous review studies have shown that alternative medical treatments, including acupuncture, moxibustion, and herbal medicines, are effective in improving the symptoms of the disease and the patient’s quality of life. However, no systematic review study has shown the effectiveness of the combination of conventional and alternative therapies. Therefore, the aim of our study is to determine the most effective combination therapies and to provide evidence for the effectiveness and safety of integrated therapies. This article describes the protocol for the methods that will be applied in our systematic review.

Methods

We will conduct an electronic search of nine databases: PubMed, Embase, Cochrane, Google Scholar (first 100 articles), four Korean databases (KoreaMed, Korean Studies Information Service System, Research Information Service System, and Oriental Medicine Advanced Searching Integrated System), and one Chinese database (China National Knowledge Infrastructure). Only randomized controlled studies that reported on both conventional treatment (drugs and hyaluronic acid) and traditional Korean medicine (acupuncture, moxibustion, and herbal medicines) will be selected. The primary outcomes will be pain and function of the joint. The secondary outcomes will include pain relief duration, total effective rate, incidence of adverse events, and quality of life. We will assess the methodological quality of the included studies using the Cochrane risk of bias tool. For the meta-analysis, standardized mean differences and risk ratios with 95% confidence intervals will be applied for continuous and dichotomous data, respectively.

Results

This review will evaluate the effectiveness and safety of several Korean medicine treatments combined with conventional treatments for knee OA.

Conclusion

Our review will provide a good foundation for the integrative treatment of knee OA.

Dropouts in randomized clinical trials of Korean medicine interventions: a systematic review and meta-analysis

BACKGROUND

The dropout rate is an important determinant of outcomes in randomized controlled trials (RCTs) and should be carefully controlled. This study explored the current dropout rate in studies of Korean medicine (KM) interventions by systematic evaluation of RCTs conducted in the past 10 years.

METHODS

Three clinical trial registries (Clinical Research Information Service, ClinicalTrials.gov, and World Health Organization International Clinical Trials Registry Platform) were searched to identify RCT protocols for KM interventions, such as acupuncture, herbal medicine, moxibustion, or cupping, and studies of mixed interventions, registered in Korea from 2009 to 2019. The PubMed, Embase, and OASIS databases were searched for the full reports of these RCTs, including published journal articles and theses. Dropout rates and the reasons for dropping out were analyzed in each report. The risk of bias in each of the included studies was assessed using the Cochrane risk of bias tool. The risk difference for dropping out between the treatment and control groups was calculated with the 95% confidence interval in a random effects model.

RESULTS

Forty-nine published studies were included in the review. The median dropout rate was 10% in the treatment group (interquartile range 6.7%, 17.0%) and 14% in the control group (interquartile range 5.4%, 16.3%) and was highest in acupuncture studies (12%), followed by herbal medicine (10%), moxibustion (8%), and cupping (7%). Loss to follow-up was the most common reason for dropping out. The risk difference for dropping out between the intervention and control groups was estimated to be 0.01 (95% confidence interval - 0.02, 0.03) in KM intervention studies.

CONCLUSIONS

This review found no significant difference in the dropout rate between studies according to the type of KM intervention. We recommend allowance for a minimum dropout rate of 15% in future RCTs of KM interventions.

REVIEW PROTOCOL REGISTRATION

PROSPERO CRD42020141011.

Effect of Moxibustion on Inflammatory Cytokines in Animals with Rheumatoid Arthritis: A Systematic Review and Meta-Analysis

BACKGROUND

This study aims to systematically evaluate the effect of moxibustion on the level of inflammatory cytokines in animal models with rheumatoid arthritis (RA) and to provide evidence for the clinical application of moxibustion to the treatment of RA and related basic researches.

METHODS

The databases employed in this study include PubMed, EMBASE, Web of Science, China National Knowledge Infrastructure (CNKI), Chinese Science and Technology Periodical Database (VIP), SinoMed, and Wanfang Data Information Site. The retrieval time was from the establishment of these databases to March 2020. The reviewers made use of the CAMARADES 10-item checklist to evaluate the quality of each included study. The inflammatory cytokines were considered as the outcome measure. The Revman 5.3 software was used to conduct meta-analysis on the outcome indicators of the studies included.

RESULTS

A total of 648 articles were retrieved and 18 animal experiments were included in this study. The quality scores of the studies ranged from two to eight with a mean of 5.8. Compared with the effect of the control group, moxibustion reduced the expression of TNF-α (SMD 2.95, 95% CI: 1.99-3.92, P < 0.00001), IL-1β (SMD 4.10, 95% CI: 2.37-5.84, P < 0.00001), IFN-γ (MD 25, 95% CI: 16.17-33.82, P < 0.00001), IL-6 (MD 11.83, 95% CI: 6.22-17.44, P < 0.0001), and IL-17 (MD 99.3, 95% CI: 86.83-111.76, P < 0.00001). At the same time, the level of IL-2 (SMD 8.89, 95% CI: 0.93-16.86, P=0.03), IL-4 (MD 1.79, 95% CI: 0.26-3.32, P=0.02), and IL-10 (MD 5.93, 95% CI: 1.37-10.49, P=0.01) increased after moxibustion treatment. Asymmetric funnel plots indicated that there was publication bias.

CONCLUSION

The findings of the present review indicate that moxibustion can protect the synovium of joint in animal models with RA by upregulation of the level of anti-inflammatory cytokines and downregulation of the level of proinflammatory cytokines. Moxibustion has the potential to relieve inflammation of RA.

Effectiveness and safety of electrical moxibustion for knee osteoarthritis: A multicenter, randomized, assessor-blinded, parallel-group clinical trial

BACKGROUND

The prevalence of knee osteoarthritis (KOA) is increasing, and it has emerged as a major health issue. Studies have been reported that moxibustion is effective for treating KOA, but conventional moxibustion is difficult to control the intensity of stimulation and causes smoke, harmful gases, or odors. An electrical moxibustion (EM) device was developed to solve these problems, so we conducted this study to evaluate the effectiveness and safety of EM as a treatment for KOA.

METHODS

This is a multicenter, randomized, assessor-blinded, parallel-group clinical trial. Participants with KOA were randomly allocated into EM, traditional indirect moxibustion (TIM), or usual care groups. The moxibustion groups were received 12 sessions of moxibustion treatment at six acupuncture points (ST36, ST35, ST34, SP9, EX-LE4, SP10) over a period of 6 weeks. The usual care group was received usual treatment and self-care. The primary outcome was the degree of pain measured by numerical rating scale (NRS). The second outcomes were measured using visual analog scale, Korean version of the Western Ontario and McMaster Universities osteoarthritis index, patient global assessment, European quality of life five dimension five level scale, and warm sense threshold and heat pain threshold. For safety assessment, laboratory test and adverse events (AEs) were recorded.

RESULTS

A total of 138 participants were assigned. While there was no significant NRS change in the usual care, EM and TIM showed significant decrease after treatment. Compared to the usual care, the mean change of NRS in the EM and TIM was significantly different, but there was no significance between two groups. Regarding secondary outcomes, EM and TIM also showed significant difference compared to the usual care, but there was no significance between two groups. Regarding safety assessment, while usual care showed significant safety among three groups, EM showed seven treatment-related AEs by four participants compared TIM's 10 events by 10 participants. In addition, there was no blister caused by burns in the EM, which occurred four cases in the TIM.

CONCLUSION

This study shows that EM is effective to improve the pain and function by KOA with a certain level of safety.

Comparison of kidney-tonifying and blood-activating medicinal herbs vs NSAIDs in patients with knee osteoarthritis: A protocol for a systematic review and meta-analysis

BACKGROUND

Knee osteoarthritis (KOA) is one of the most common chronic muscular diseases in old people. In recent years, people are more and more interested in the use of Chinese herbal medicine (CHM) in the treatment of KOA, such as kidney-tonifying and blood-activating medicinal herbs (KTBAMs) in the treatment of KOA. Many studies have confirmed that KTBAMs are effective in the treatment of KOA. However, it is still unknown whether KTBAMs and NSAIDs are more effective in the treatment of KOA. Therefore, we evaluated the efficacy and safety of KTBAMs and NSAIDs in the treatment of KOA.

METHODS

Randomized controlled trials (RCTs) from online databases including PubMed, Embase, the Cochrane Library, China National Knowledge Infrastructure, Chinese Scientific Journal Database, Wanfang Data, and Chinese Biomedical Literature Database that compared the efficacy of KTBAMs and NSAIDs in the treatment of KOA were retrieved. The main outcomes included the evaluation of functional outcomes, pain and adverse effects. The Cochrane risk of bias (ROB) tool was used to assess methodological quality.

RESULTS

The literature will provide a high-quality analysis of the current evidence supporting KTBAMs for KOA based on various comprehensive assessments including the total effective rate, visual analog scale scores, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Lequence scores, Knee Society Scale (KSS) scores, and adverse effects.

CONCLUSION

This proposed systematic review will provide up-to-date evidence to assess the effect of KTBAMs in the treatment for patients with KOA. RESEARCH REGISTRY REGISTRATION NUMBER: : reviewregistry 783.

The Effects of Laser Moxibustion on Knee Osteoarthritis Pain in Rats

Background: Although chronic pain affects the quality of life of patients with osteoarthritis, current medical treatments are either ineffective or have long-term side effects. Recently, low-intensity laser irradiation of corresponding acupoints was demonstrated to alleviate pain. Objective: The aim of the present study was to investigate the effects of 10.6 μm laser moxibustion on a monosodium iodoacetate (MIA)-induced knee osteoarthritis pain model. Methods: Thirty-two rats were randomly assigned to four groups: Saline, MIA, MIA+Laser, and MIA+Sham Laser. The 10.6 μm laser was used to irradiate the ST35 for 10 min once a day for a total of seven applications. The paw withdrawal mechanical threshold and weight-bearing difference were performed to evaluate the analgesic effects of laser moxibustion. At the end of the experiment on days 28, the joint histology, the levels of metalloproteinases-13 (MMP-13) in the cartilage, and TNF-α, IL-1β, and IL-6 in the synovial membrane were measured to determine the chondroprotection and anti-inflammatory effect of laser moxibustion. Results: Early laser moxibustion significantly reversed the MIA-induced mechanical hyperalgesia and weight-bearing difference, especially on the 28th day (p < 0.001). Moreover, laser moxibustion prevented the articular pathological lesions and cartilage destruction on days 28 (p < 0.01). Remarkably, the levels of cartilage MMP-13, and synovial TNF-α, IL-1β, and IL-6 also decreased on day 28 (p < 0.05) after the early treatment of laser moxibustion. Conclusions: 10.6 μm laser moxibustion may have long-lasting analgesic, anti-inflammatory, and chondroprotection effects, suggesting that it may emerge as a potential therapeutic strategy for the chronic pain treatment of osteoarthritis.

Are Kidney-Tonifying and Blood-Activating Medicinal Herbs Better than NSAIDs for Knee Osteoarthritis? A Systematic Review and Meta-Analysis

Objective

To compare the efficacy and safety of kidney-tonifying and blood-activating medicinal herbs (KTBAMs) and nonsteroidal anti-inflammatory drugs (NSAIDs) in the treatment of knee osteoarthritis (KOA).

Methods

Randomized controlled trials (RCTs) from online databases that compared the efficacy of KTBAMs and NSAIDs in the treatment of KOA were retrieved. The main outcomes included the evaluation of functional outcomes, pain, and adverse effects. The Cochrane risk-of-bias (ROB) tool was used to assess methodological quality.

Results

A total of 38 RCTs (3994 participants) were included in our meta-analysis. We found that KTBAMs had a significantly higher total effective rate (P < 0.00001, risk ratio (RR) = 1.08, confidence interval (CI) = 1.05 to 1.11, I² = 4%) and a lower gastrointestinal adverse reaction rate (P < 0.00001, RR = 0.36, CI = 0.24 to 0.53, I² = 33%) than NSAIDs. KTBAMs showed greater improvements in the Knee Society Scale (KSS) scores (mean difference (MD) = 7.17, 95% CI 0.71 to 13.64, P=0.03). Regarding the visual analog scale (VAS) scores, WOMAC scores, and Lequence scores, there were no significant differences between the KTBAM group and the NSAID group. The GRADE quality level of this systematic review indicated that the very low-quality evidence showed that KTBAMs had a higher total effective rate, while the moderate-quality evidence showed that the adverse reactions of KTBAMs were lower and the KSS scores were higher. Low-quality evidence showed no significant differences in improving VAS scores, WOMAC scores, or Lequence scores.

Conclusion

KTBAMs were superior to NSAIDs in terms of a higher total effective rate, a lower adverse reaction rate, and a higher KSS score. There were no significant differences between KTBAMs and NSAIDs in improving VAS scores, WOMAC scores, and Lequence scores of patients with KOA. Therefore, KTBAMs may be an alternative effective method for treating KOA. However, high-quality, well-designed RCTs with long-term follow-up are still required.

The Effectiveness and Safety of Moxibustion for Treating Knee Osteoarthritis: A PRISMA Compliant Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background

Knee osteoarthritis (KOA) seriously affects people's life. Therefore, it has already become a worldwide health concern. Moxibustion has a significant clinical effect on KOA. This systematic review and meta-analysis is performed to renew previous studies and strictly evaluate the quality of RCT and thus test the effect and safety of moxibustion for KOA.

Objective

To evaluate the effectiveness and safety of moxibustion treatment for alleviating pain and improving lower limb function for patients with KOA.

Materials and Methods

CNKI (1979∼2019), CBM (1979∼2019), VIP (1989∼2019), WF (1998∼2019), PubMed (1966∼2019), Embase (1980∼2019), Cochrane Library, and Web of Science (1900∼2019) were all retrieved by a computer from their inception to June 02, 2019, replenished by manual retrieval of relevant bibliographies. Randomized controlled trials (RCTs) were included if moxibustion was compared to western medicine or negative control (placebo moxibustion or no treatment or UC) for treating KOA. The primary outcomes were the total effect and the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC scale). The secondary outcomes include VAS, Symptom score, Lysholm score, and Lequesne score. RCTs were collected, and the quality of evidence was evaluated by using the Jadad scale and Cochrane risk assessment tools. We used RevMan5.3.0 software for meta-analysis.

Results

A total of 39 RCTs were included, including 3293 patients. In the assessment of the quality, the evidence differs from low to high based on the Cochrane Bias Evaluation Tools and Jadad scale. Fourteen trials were of high quality, ten were of moderate quality, and 15 were of low quality. Therefore, the quality of the included studies was moderate. In this study, there were 66.67% of the literature, and only 17.95% of the literature correctly reported randomized grouping and allocation of hidden information, respectively. In adverse reactions, only 13 trials included were reported in the study. The main adverse reactions of moxibustion are burns and blisters, whereas the western medicine group was in epigastric discomfort. As for the total effective rate, the meta-analysis of 27 RCTs showed a significant effect of moxibustion VS western medicine (RR = 1.20, 95% CI = 1.16 to 1.25, I² = 45%, P=0.007); as for the WOMAC scale, the subgroup meta-analysis of 13 trials showed that there was a statistically significant effect of moxibustion VS western medicine (MD = −11.08, 95% CI = −11.72 to −10.44, I² = 98%, P < 0.00001) and 2 trials on moxibustion VS negative control (MD = −8.38, 95% CI = −12.69 to −4.06, I² = 0%, P=0.77); as for the VAS score, the meta-analysis of 6 trials showed that there was a significant effect of moxibustion VS western medicine (MD = −2.12, 95% CI = −2.30 to −1.93, I² = 98%, P < 0.00001); as for the symptom score, the meta-analysis of 7 trials showed that there was a significant effect of moxibustion VS western medicine (MD = −0.81, 95% CI = −1.24 to −0.37, I² = 50%, P=0.06); as for the Lysholm score, the meta-analysis of 5 trials showed that there was a significant effect of moxibustion VS western medicine (MD = 7.61, 95% CI = 6.04 to 9.17, I² = 95%, P < 0.00001); and as for the Lequesne score, the meta-analysis of 3 trials showed that there was a significant effect of moxibustion VS western medicine (MD = 3.29, 95% CI = 2.93 to 3.65, I² = 99%, P < 0.00001).

Conclusion

Moxibustion treatment for KOA is more effective than the positive control (western medicine) or negative control (placebo moxibustion or no treatment or UC), and there were fewer adverse reactions to moxibustion. Due to the universally low quality of the eligible trials, it still needs further large-scale and high-quality randomized controlled trials to verify the effectiveness and safety of moxibustion in the treatment of KOA.

Effectiveness, safety, and economic evaluation of adjuvant moxibustion therapy for aromatase inhibitor-induced arthralgia of postmenopausal breast cancer stage I to III patients: Study protocol for a prospective, randomized, assessor-blind, usual-care controlled, parallel-group, pilot clinical trial

INTRODUCTION

This study is a prospective, assessor-blinded, parallel-group, randomized controlled pilot trial to explore the effectiveness of 12-week adjuvant moxibustion therapy for arthralgia in menopausal females at stage I to III breast cancer on aromatase inhibitor (AI) administration, compared with those receiving usual care.

METHODS/DESIGN

Forty-six menopausal female patients with breast cancer who completed cancer therapy will be randomly allocated to either adjuvant moxibustion or usual care groups with a 1:1 allocation ratio. The intervention group will undergo 24 sessions of adjuvant moxibustion therapy with usual care for 12 weeks, whereas the control group will receive only usual care during the same period. The usual care consists of acetaminophen administration on demand and self-directed exercise education to manage AI-related joint pain. The primary outcome is the mean change of the worst pain level according to the Brief Pain Inventory-Short Form between the initial visit and the endpoint. The mean changes in depression, fatigue, and quality of life will also be compared between groups. Safety and pharmacoeconomic evaluations will also be included.

DISCUSSION

Continuous variables will be compared by an independent t test or Wilcoxon rank-sum test between the adjuvant moxibustion and usual care groups. Adverse events will be analyzed using the chi-square or Fisher exact test. The statistical analysis will be performed by a 2-tailed test at a significance level of .05.

Comparison of the effects of 10.6-μm infrared laser and traditional moxibustion in the treatment of knee osteoarthritis

Based on two separate randomized controlled trials (RCTs) on traditional Chinese medicine (TCM) moxibustion and 10.6-μm infrared laser moxibustion in treating knee osteoarthritis (OA), we did an indirect and preliminary comparison of the effects of the 10.6-μm laser moxibustion with the traditional moxibustion for knee osteoarthritis. The objective was to see whether the laser moxibustion is non-inferior to the traditional moxibustion in alleviating symptoms of knee osteoarthritis such as pain, stiffness, and joint dysfunction as well as improving quality of life for the patients with knee osteoarthritis, and whether a further RCT directly comparing the laser and traditional moxibustion is necessary. Pooled data from two RCTs in patients with knee osteoarthritis, trial ISRCTN68475405 and trial ISRCTN26065334, were used. In the two RCTs, the eligibility criteria were almost identical, the treatment procedure (i.e., sessions, duration, and points) were similar, and the outcome measurements (i.e., WOMAC for symptoms and SF-36 for quality of life) were the same. The double robustness method was used for the WOMAC scale and the SF-36 endpoints to detect the difference between traditional and laser moxibustion. The analysis comprised 55 patients from ISRCTN68475405 in real moxibustion arm (moxibustion group) and 88 patients from ISRCTN26065334 in real laser moxibustion arm (laser group). Demographic characteristics and course of disease were similar between the two groups. Causal inference, using the doubly robust estimating approach to correct for bias due to baseline differences, showed that there was no statistically significant difference in the WOMAC pain, stiffness, and physical function between the two treatments at midterm, end of treatment, and 4 weeks after the end of treatment (P > 0.05). The exception was that there was statistically significantly more benefit associated with laser moxibustion compared with traditional moxibustion in physical function at the follow-up of 4 weeks after the end of treatment (P=0.006). There was no statistically significant difference in most SF-36 endpoints (P > 0.05) except that physical functioning (PF), mental health (MH), and bodily pain (BP) were statistically significantly better in the laser group than in the traditional moxibustion group at the follow-up of 4 weeks after the end of treatment (P = 0.005, 0.034, 0.002). The benefits of 10.6-μm infrared laser moxibustion and the traditional moxibustion for knee osteoarthritis were comparable in pain, stiffness, physical dysfunction, and in most of the quality of life subdimensions. The laser moxibustion might be more beneficial in terms of physical function, body pain, and mental health in the long term. RCTs directly comparing 10.6-μm laser moxibustion with traditional moxibustion are warranted.

Comparison of the Efficacy between Conventional Moxibustion and Smoke-Free Moxibustion on Knee Osteoarthritis: A Randomized Controlled Trial

Objective

The aim of this study was to investigate the difference of efficacy between conventional moxibustion (CM) and smoke-free moxibustion (SM) for patients with osteoarthritis of the knee (KOA).

Methods

This is a multicentre, randomized, single blinded, parallel-group clinical trial. Patients with KOA were randomly allocated to CM group (69) and SM group (69) in 7 hospitals of China. Moxibustion treatment in 12 sessions over 4 weeks was administrated at 3 acupuncture points (EX-LE4, ST35, and ST36). Patients completed standard questionnaires at baseline and after 2 weeks, 4 weeks, 8 weeks, and 12 weeks. The primary outcome was the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) from the baseline to 4 weeks. The secondary outcomes include Visual Analogue Scale (VAS) and Patient Global Assessment score (PGA).

Results

Analyses showed that the WOMAC score improved in pain (95% CI,-0.1[-1.2 to 0.9], p=0.76), stiffness (95% CI,-0.1 [-0.5 to 0.3], p=0.71), and function (95% CI, 2.2 [-1.3 to 5.8], p=0.22) compared between the two groups at 4 weeks, as well as the VAS score (95% CI,0.1 [-0.3 to 0.6], p=0.60). Similar results presented at 8 and 12 weeks. No statistically significant difference was observed between CM and SM groups for outcome measurements.

Conclusions

It suggested that smoke generated during moxibustion treatment does not affect the efficacy of moxibustion in the treatment of KOA, which should be taken into account to be removed for the sake of reducing environmental pollution or moxa smoke exposure of acupuncturists or patients. This trial is registered with Clinical Trials.gov, NCT02772055.

Acutherapy for Knee Osteoarthritis Relief in the Elderly: A Systematic Review and Meta-Analysis

Purpose

This systematic review and meta-analysis was conducted to investigate the effects of various acutherapies on knee osteoarthritis (KOA) relief in the elderly.

Methods

Five databases were accessed from inception to July 2017 for searching randomized controlled trials (RCTs) on acutherapy for KOA relief in the elderly. Data were pooled after trial quality assessment for meta-analysis. Outcomes were the scores of knee pain, knee stiffness, and physical function accessed by Western Ontario and McMaster Universities Osteoarthritis (WOMAC) Index.

Results

17 RCTs including 4774 subjects were included. The results indicated that acutherapy significantly affected knee pain (standardized mean difference, i.e., SMD = - 0.73, [95% CI, -0.98 to -0.47], P <0.001), knee stiffness (SMD = -0.66, [95%CI, -0.85 to -0.47], P <0.001), and physical function (SMD = -1.56, [95%CI, -2.17 to -0.95], P<0.001) when compared with control condition without intervention of any acutherapy. Moreover, acutherapy was more effective than corresponding sham (placebo) intervention applied on nonacupoints (SMD = -0.16, [95% CI, -0.32 to -0.01], P = 0.04). However, no significant differences were found on treatment effects between acutherapy and sham acutherapy at the same acupoints (SMD= - 0.09, [95%CI, -0.40 to 0.21], P = 0.55).

Conclusions

Acutherapy was an effective approach for KOA relief in the elderly. The selection of acupoints position could be a crucial factor that influences the treatment efficacy of acutherapy.

Moxibustion of Zusanli (ST36) and Shenshu (BL23) Alleviates Cartilage Degradation through RANKL/OPG Signaling in a Rabbit Model of Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a systemic and chronic autoimmune inflammatory disease characterized by severe synovial hyperplasia associated with progressive cartilage degradation. Due to the severe pain and disability caused by RA, effective therapeutic strategies that could simultaneously alleviate the inflammatory response and delay the disease progression are urgently needed. As a major alternative therapy in traditional Chinese medicine, moxibustion has been demonstrated that it could reduce the chronic inflammatory responses of a series of musculoskeletal diseases; however, whether moxibustion has protective effects on RA is still unclear. To investigate the effects of moxibustion on RA, moxibustion was applied to Zusanli (ST36) and Shenshu (BL23) acupoints in a RA rabbit model. HE staining of articular cartilage showed that moxibustion alleviated the cartilage degradation and bone destruction. In addition, moxibustion decreased the osteoclast number in RA rabbits. Real-time PCR revealed that moxibustion decreased the expression of RANKL mRNA while increased the expression of OPG mRNA, indicating a restoration of the balance between osteogenesis and osteoclastogenesis. Taken together, our results indicated that moxibustion had promising antiarthritic effects and could be an useful alternative method in RA therapeutics.

Acupuncture for hip osteoarthritis

BACKGROUND

Hip osteoarthritis (OA) is a major cause of pain and functional limitation. Few hip OA treatments have been evaluated for safety and effectiveness. Acupuncture is a traditional Chinese medical therapy which aims to treat disease by inserting very thin needles at specific points on the body.

OBJECTIVES

To assess the benefits and harms of acupuncture in patients with hip OA.

SEARCH METHODS

We searched Cochrane CENTRAL, MEDLINE, and Embase all through March 2018.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) that compared acupuncture with sham acupuncture, another active treatment, or no specific treatment; and RCTs that evaluated acupuncture as an addition to another treatment. Major outcomes were pain and function at the short term (i.e. < 3 months after randomization) and adverse events.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

Six RCTs with 413 participants were included. Four RCTs included only people with OA of the hip, and two included a mix of people with OA of the hip and knee. All RCTs included primarily older participants, with a mean age range from 61 to 67 years, and a mean duration of hip OA pain from two to eight years. Approximately two-thirds of participants were women. Two RCTs compared acupuncture versus sham acupuncture; the other four RCTs were not blinded. All results were evaluated at short term (i.e. four to nine weeks after randomization).In the two RCTs that compared acupuncture to sham acupuncture, the sham acupuncture control interventions were judged believable, but each sham acupuncture intervention was also judged to have a risk of weak acupuncture-specific effects, due to placement of non-penetrating needles at the correct acupuncture points in one RCT, and the use of penetrating needles not inserted at the correct points in the other RCT. For these two sham-controlled RCTs, the risk of bias was low for all outcomes.The combined analysis of two sham-controlled RCTs gave moderate quality evidence of little or no effect in reduction in pain for acupuncture relative to sham acupuncture. Due to the small sample sizes in the studies, the confidence interval includes both the possibility of moderate benefit and the possibility of no effect of acupuncture (120 participants; Standardized Mean Difference (SMD) -0.13, (95% Confidence Interval (CI) -0.49 to 0.22); 2.1 points greater improvement with acupuncture compared to sham acupuncture on 100 point scale (i.e., absolute percent change -2.1% (95% CI -7.9% to 3.6%)); relative percent change -4.1% (95% CI -15.6% to 7.0%)). Estimates of effect were similar for function (120 participants; SMD -0.15, (95% CI -0.51 to 0.21)). No pooled estimate, representative of the two sham-controlled RCTs, could be calculated or reported for the quality of life outcome.The four other RCTs were unblinded comparative effectiveness RCTs, which compared (additional) acupuncture to four different active control treatments.There was low quality evidence that addition of acupuncture to the routine primary care that RCT participants were receiving from their physicians was associated with statistically significant and clinically relevant benefits, compared to the routine primary physician care alone, in pain (1 RCT; 137 participants; mean percent difference -22.9% (95% CI -29.2% to -16.6%); relative percent difference -46.5% (95% CI -59.3% to -33.7%)) and function (mean percent difference -19.0% (95% CI -24.41 to -13.59); relative percent difference -38.6% (95% CI -49.6% to -27.6%)). There was no statistically significant difference for mental quality of life and acupuncture showed a small, significant benefit for physical quality of life.The effects of acupuncture compared with either advice plus exercise or NSAIDs are uncertain.We are also uncertain whether acupuncture plus patient education improves pain, function, and quality of life, when compared to patient education alone.In general, the overall quality of the evidence for the four comparative effectiveness RCTs was low to very low, mainly due to the potential for biased reporting of patient-assessed outcomes due to lack of blinding and sparse data.Information on safety was reported in four RCTs. Two RCTs reported minor side effects of acupuncture, which were primarily minor bruising, bleeding, or pain at needle insertion sites. Four RCTs reported on adverse events, and none reported any serious adverse events attributed to acupuncture.

AUTHORS' CONCLUSIONS

Acupuncture probably has little or no effect in reducing pain or improving function relative to sham acupuncture in people with hip osteoarthritis. Due to the small sample size in the studies, the confidence intervals include both the possibility of moderate benefits and the possibility of no effect of acupuncture. One unblinded trial found that acupuncture as an addition to routine primary physician care was associated with benefits on pain and function. However, these reported benefits are likely due at least partially to RCT participants' greater expectations of benefit from acupuncture. Possible side effects associated with acupuncture treatment were minor.

Efficacy and safety of electrical moxibustion for knee osteoarthritis: study protocol for a randomized controlled trial

Background

Knee osteoarthritis (KOA) is a significant health issue because it causes pain and functional limitation. Many studies have reported that moxibustion, a treatment in traditional Korean medicine, is effective in treating KOA. However, conventional moxibustion produces smoke, harmful gases, and odors that can adversely affect the eyes, skin, and throat. It is also difficult to control the intensity of stimulation in conventional moxibustion. An electrical moxibustion device was developed to circumvent these problems, but there are few studies of that device. We will evaluate the efficacy and safety of electrical moxibustion as a treatment for KOA, and compare it with traditional indirect moxibustion and usual care.

Methods

This is a multicenter, randomized, open, assessor-blinded, parallel-group clinical trial. A total of 138 eligible participants with KOA will be randomly allocated into three groups (electrical moxibustion, traditional indirect moxibustion, or usual care) with a 1:1:1 ratio. Participants in each moxibustion group will receive 12 sessions of moxibustion treatment at 6 acupoints (ST36, ST35, ST34, SP9, EX-LE4, SP10) plus up to 2 points of “ashi”, if needed, over a period of 6 weeks (2 sessions per week). A specifically designed device that provides thermal stimulation using electrical energy will be used for the electrical moxibustion group. Participants in the usual care group will receive usual treatment and self-care. The primary outcome measure is change in pain on a numerical rating scale (NRS) from week 1 to week 6. The secondary outcome measures are pain assessed on a visual analog scale (VAS), the Korean version of the Western Ontario and McMaster osteoarthritis index (K-WOMAC), patient global assessment (PGA), and the European quality of life five dimension five level scale (EQ-5D-5 L). Safety will be assessed by monitoring adverse events at each visit. Follow-up measurements will be performed at 12 weeks after baseline measurements.

Discussion

This trial will provide evidence on the efficacy and safety of electrical moxibustion as a treatment for KOA.

Trial registration

ClinicalTrials.gov, NCT03287570. Registered on 19 September 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2514-x) contains supplementary material, which is available to authorized users.

Cultural Factors Influencing Osteoarthritis Care in Asian Communities: A Review of the Evidence

With the prevalence of osteoarthritis (OA) increasing internationally, there is a need to study the impact of this disease on culturally diverse populations. Individuals of Asian descent make up more than 60% of the world population, yet comprehensive information on the cultural factors that impact OA care is not available. Scoping review methodology using directed content analysis was employed to identify and analyze existing research on OA care for Asians. A categorization matrix was developed using the six care areas from the OA clinical practice guidelines along with an additional three non-clinical areas (cross-cultural adaptation of clinical tools; psychological well-being; family systems and informal care) identified in an initial scan resulting in a total of nine OA care areas to guide initial coding. A full scoping review was conducted across five databases resulting in 656 abstracts screened. All text was coded using the categorization matrix and resulting subthemes were identified. A total of 74 articles were analyzed with 23 subthemes identified across the nine categories. Four new perspectives emerged to support OA care for Asian populations: (1) the importance of family and peer assistance, (2) the importance of culturally specific activities, (3) distrust in western medicine, and (4) impact of positive coping mechanisms on health appraisals. While Asians are more susceptible to knee and hand OA because of their cultural lifestyle factors (e.g. squatting for chores, hygiene and religious activities), and traditional beliefs on OA management (e.g. traditional diet, topical oils, physical therapy), many do not present themselves for conventional treatments (e.g. surgery) until all traditional treatments are exhausted. The results suggest that cultural factors influence the uptake of OA management practices among Asians. Greater awareness of these cultural factors may improve diagnosis, treatment, and management of OA among Asian patients.

Evaluating the Risk of Bias of a Study

OBJECTIVE

This first article of a series of 4 is aimed at guiding dental practitioners on how to evaluate the internal validity (risk of bias,) of randomized controlled trials (RCT). All RCT's contain different areas and potential sources of bias. Understanding risk of bias (ROB) will allow dental practitioners to improve the quality of dental treatments.

METHODS

The following areas of bias were elucidated: sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting, and "other bias". The reader determines the ROB level by evaluating the areas or potential source of bias in the first phase. Normally, ROB levels are classified as low, high and unclear ROB.

RESULTS

This article reported the concepts and methods of evaluation of ROB in several areas of an RCT. An RCT with low ROB in all evaluated areas gives the dental practitioners more certainty and confidence that a specific clinical procedure is in fact effective and relevant to the patient.

CONCLUSIONS

The information provided here may guide dental practitioners in the evaluation of ROB in an RCT. The correct evaluation of ROB may improve the quality of dental treatments.

Autologous Stem Cells Combined Core Decompression for Treatment of Avascular Necrosis of the Femoral Head: A Systematic Meta-Analysis

OBJECTIVE

This study aims to systematically evaluate the efficacy and safety of core decompression combined transplantation of autologous bone marrow stem cells (CDBMSCs) for treatment of avascular necrosis of the femoral head (ANFH).

METHODS

Randomized controlled trials (RCTs) regarding effectiveness of core decompression combined transplantation of autologous bone marrow stem cells for treating ANFH were searched in 8 comprehensive databases prior to September 2016. The data analysis was performed by using the RevMan version 5.3.

RESULTS

A total of 11 studies with 507 participants were included. Results showed that CDBMSCs group was more effective than CD group in increasing Harris hip score, decreasing necrotic area of femoral head, collapse of femoral head, and conversion to total hip replacement incidence. In the subgroup analysis, the results did not change in different intervention measure substantially. In addition, the safety of CDBMSCs for ANFH is reliable.

CONCLUSION

Based on the systematic review, our findings suggest that core decompression combined transplantation of autologous bone marrow stem cells appeared to be more efficacious in the treatment at early stages of ANFH.

Moxibustion treatment for primary osteoporosis: A systematic review of randomized controlled trials

Primary osteoporosis (POP) has a serious impact on quality of life for middle-aged and elderly, which particularly increase the risk of fracture. We conducted the systematic review to evaluate the effects of moxibustion for POP in randomized controlled trials (RCTs).Eight databases were searched from their inception to July 30, 2016. The RCTs reporting the moxibustion as a monotherapy or in combination with conventional therapy for POP were enrolled. The outcomes might be fracture incidence, quality of life, clinical symptoms, death attributed to osteoporosis, adverse effect, bone mineral density (BMD), and biochemical indicators. Literature selection, data abstraction, quality evaluation, and data analysis were in accordance with Cochrane standards.Thirteen trials including 808 patients were included. Meta-analysis was not conducted because of the obvious clinical or statistical heterogeneity. Limited evidence suggested that moxibustion plus anti-osteoporosis medicine might be more effective in relieving the pain (visual analogue scale scores average changed 2 scores between groups, 4 trials), increasing the BMD of femoral neck (average changed 0.4 g/cm2 between groups, 3 trials), and improving the level of bone gla protein, osteoprotegerin and bone alkaline phosphatase (2 trials) compared with anti-osteoporosis medicine alone. However, the quality of previous studies was evaluated as generally poor. The safety evidence of moxibustion was still insufficient. Due to the paucity of high-quality studies, there was no definite conclusion about the efficacy and safety of moxibustion treating POP although parts of positive results were presented. Future research should pay attention to the dose-response relation and fracture incidence of moxibustion for POP.

The Efficacy of Acupuncture for the Treatment of Cervical Vertigo: A Systematic Review and Meta-Analysis

Objective

This study aims to evaluate the efficacy and safety of acupuncture for the treatment of cervical vertigo (CV).

Methods

Randomized controlled trials (RCTs) regarding effectiveness of acupuncture for treating CV were searched in 7 comprehensive databases prior to April 2016. The data analysis was performed by using RevMan version 5.3.

Results

A total of 10 studies with 914 participants were included. Results showed that acupuncture was more effective than conventional medicine therapy (CMT) in effectiveness, improvement rate of vertigo and headache, and increased average blood flow velocity of vertebral-basilar artery. In the subgroup analysis, the results did not change in different acupuncture methods and drug categories substantially. Sensitivity analysis demonstrated that the results of this meta-analysis were stable. Meanwhile, the long-term safety of acupuncture for CV still remains uncertain. GRADE analysis indicated that the quality of evidence for all outcomes was from very low to low which limited the value of the meta-analysis.

Conclusion

Based on the systematic review, acupuncture appeared to be a promising therapeutic approach for CV based on low or very low quality of evidence. However, large-scale and high-quality trials are required to provide stronger evidence for the conclusion.

Comparison of the efficacy between conventional moxibustion and smoke-free moxibustion on knee osteoarthritis: study protocol of a randomized controlled trial

BACKGROUND

Conventional moxibustion is a representative non-drug intervention in traditional Chinese medicine, and it has been reported to produce encouraging results and benefits in relieving symptoms and improving the quality of life for patients with knee osteoarthritis (KOA) in previous clinical trials and systematic reviews. Given that increasing concerns on the safety of generated smoke from conventional moxibustion have received much attention, smoke-free moxibustion is regarded as a potential alternative. However, whether smoke-free moxibustion would display a similar efficacy to that of conventional moxibustion still remains unclear. Therefore, this randomized controlled trial attempts to investigate the difference of efficacy between conventional moxibustion and smoke-free moxibustion in patients with KOA.

METHODS/DESIGN

This is a multicenter, randomized, single-blinded, parallel-group clinical trial. A total of 138 eligible participants with KOA will be randomly allocated to two groups (conventional moxibustion group and smoke-free moxibustion group) in seven hospitals in China. Participants will receive 12 sessions of moxibustion treatment at three acupoints (EX-LE4, ST35, and ST36) over a period of 4 weeks (3 sessions per week). A smoke-removing device is placed at the top of the moxibustion device for the smoke-free moxibustion group (n = 69), while the conventional moxibustion group (n = 69) is treated with traditional moxibustion. The primary outcome measure will be the change of the global scale of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) from the baseline to 4 weeks. Secondary outcomes include the visual analog scale VASand Patient Global Assessment scores. Follow-up measurements will be performed on the 8th and 12th weeks after random allocation.

DISCUSSION

This study will contribute to providing a solid foundation for the selection of moxibustion in clinical application as well as future research in moxibustion therapy.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02772055 . Registered on 12 May 2016.

Moxibustion versus diclofenac sodium gel for the treatment of knee osteoarthritis: a study protocol for a double-blinded, double-placebo, randomised controlled trial

INTRODUCTION

Knee osteoarthritis is a common form of arthritis in elderly patients that is characterised by pain and functional limitation. Moxibustion has been employed to relieve chronic pain as an alternative therapy for knee osteoarthritis. However, the evidence of its efficacy is equivocal due to the low methodological quality in most clinical studies. Therefore, we are performing a double-blinded, double-placebo, randomised controlled trial to evaluate the efficacy of moxibustion in participants with knee osteoarthritis.

METHODS AND ANALYSIS

This is a multicentre, double-blinded, double-placebo, randomised controlled clinical trial. 144 eligible participants with knee osteoarthritis will be randomly assigned to two different groups in a 1:1 ratio. Participants in the moxibustion group will undergo active moxibustion plus placebo gel, whereas participants in the control group will receive diclofenac sodium gel plus placebo moxibustion. Each participant will receive 12 sessions of active/placebo moxibustion at three acupoints (ST35, ST36 and EX-LE4) as well as 2 months of follow-up. Diclofenac sodium gel or placebo gel at a dose of 4 g per knee will be applied three times per day for 4 weeks. The primary outcome measure will be the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score change at the end of the intervention period from baseline. The secondary outcome measures include changes of other subscales (pain, stiffness and function) of WOMAC, visual analogue scale and patient globalassessment. The safety of moxibustion and diclofenac sodium gel will be assessed at every visit.

ETHICS AND DISSEMINATION

This trial has been approved by the Sichuan Regional Ethics Review Committee (permission number: 2015KL-014). The results of this study are expected to provide clinical evidence on the efficacy of moxibustion for pain relief and physical function improvement in patients with knee osteoarthritis. The findings will be submitted for publication in peer-reviewed medical journals and presented at relevant academic conferences.

TRIAL REGISTRATION NUMBER

NCT02769572.

Moxibustion for the treatment of osteoarthritis: An updated systematic review and meta-analysis

The aim of this study was to update previous reviews and examine recent evidence from randomised clinical trials (RCTs) of the use of moxibustion for osteoarthritis (OA). Twelve databases were searched from inception through to September 2016 with no language limits applied. Data extraction and risk-of-bias assessments were performed by two independent reviewers. A total of 19 RCTs met all inclusion criteria and were evaluated. Three RCTs compared the effects of moxibustion with those of sham moxibustion in patients with knee OA (KOA) and found favourable effects of moxibustion on pain reduction (n=305; SMD, -0.46; 95% CI: -0.86 to -0.06, P=0.02, I²=65%), including at follow-up (n=305; SMD, -0.36; 95% CI: -0.70 to -0.01, P=0.04, I²=54%). Eleven RCTs compared the effects of moxibustion with those of conventional oral drug therapies. Eight RCTs reported a total symptom score and the meta-analysis showed superior effects of moxibustion compared with drug therapies for this measure (n=691; SMD, -0.24; 95% CI: -0.78 to 0.29; P=0.37, I²=91%) and response rate (n=758 knees; RR, 1.10; 95% CI: 1.05-1.16, P <0.0001, I²=0%). Three RCTs found superior or equivalent effects of moxibustion on symptom score compared with intra-articular injection or topical drug therapy. The existing trial evidence is sufficiently convincing to suggest that moxibustion, compared with sham moxibustion and oral drugs, is effective for pain reduction and symptom management in KOA. The level of evidence is moderate, given the high risk of bias and small sample size.

Low-dose SoluMatrix diclofenac in patients with osteoarthritis pain: impact on quality of life in a controlled trial

Low-dose SoluMatrix diclofenac was developed to provide effective pain relief for osteoarthritis pain. We evaluated the effects of SoluMatrix diclofenac on health-related quality of life (HRQoL) measures in patients with osteoarthritis, hypothesizing that SoluMatrix-treated patients would experience significant improvement compared with placebo. In this 12-week, phase 3 randomized controlled trial, 305 patients with osteoarthritis of the hip or knee received SoluMatrix diclofenac 35 mg three times (TID) or twice (BID) daily or placebo. Measures included HRQoL, assessed by Short Form 36 (SF-36, version 2), and pain, stiffness, and physical function, assessed by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) at baseline and at week 12. Descriptive statistics were calculated for mean changes from baseline; inferential statistics compared treatment groups with placebo. SoluMatrix diclofenac 35 mg BID (6.2 [0.75]; P = 0.0048) or TID (6.6 [0.80]; P = 0.0014) produced large improvements in the SF-36 physical component summary (PCS) scores at week 12 (least squares mean change from baseline [SE]) compared with placebo (3.5 [0.78]). Minimum clinically important differences were observed in six out of eight SF-36 domains among patients in SoluMatrix diclofenac groups and five out of eight domains in the placebo group; treatment with SoluMatrix diclofenac 35 mg TID produced significant improvements (P ≤ 0.03) in five out of eight domains versus placebo. SoluMatrix diclofenac 35 mg TID significantly improved responses to 23 out of 24 questions in the WOMAC versus placebo (P ≤ 0.0334). Low-dose SoluMatrix diclofenac 35 mg TID and BID significantly improved HRQoL, pain, stiffness, and physical function in patients with osteoarthritis of the hip or knee.

Fire-Needle Moxibustion for the Treatment of Knee Osteoarthritis: A Meta-Analysis

Objectives. The aim of this study was to evaluate the effectiveness of fire-needle moxibustion as an intervention in the treatment of knee osteoarthritis (KOA). Methods. An updated meta-analysis of randomized controlled trials (RCTs) on fire-needle moxibustion in treating KOA was conducted by searching PubMed, Embase, the Cochrane Library, Web of Science, Wanfang database, and the Chinese Medical Database (CNKI) since their inception through March 2016. The meta-analysis was performed using RevMan 5.3. Results. Thirteen RCTs were identified in the systematic study which consisted of 1179 participants. Fire-needle moxibustion treatment group had a statistical significance on recovery rate as well as recovery and marked-improvement rate compared with control group. Subgroup analysis indicated that there was significant difference between fire-needle moxibustion group and control group. However, GRADE analysis indicated that the quality of evidence for all outcomes was relatively low. Only two of 13 studies reported adverse reactions (difficulty in movement and intolerance of cold). Conclusion. This meta-analysis suggests that fire-needle moxibustion is more effective than control group in symptom management of KOA. Further high quality trials should be conducted to evaluate the effectiveness of fire-needle moxibustion on KOA.

Three Cases of Cutaneous Warts Treated With Moxibustion

Moxibustion is a treatment that uses thermal stimulation generated when herbal materials are burned, indirectly or directly, on the affected area or acupoint. Three cases are presented to report the efficacy of direct moxibustion on cutaneous warts. Three patients with chronic cutaneous warts received direct moxibustion made of Artemisia argyi (Dongbang Inc., Chungnam, Korea). Moxa burning was performed using moxa cones. Approximately 80% of a cone was burned, until patients reported feeling a burning sensation, at which time the cone was removed and another one burned. As part of this approach, patients underwent 5-19 moxibustion procedures during and after wart removal. After warts were completely eliminated, moxa burning was performed on each patient until approximately 60% of a cone was burned or the patient felt heat sensitization but no pain. In these cases, moxibustion seemed to have an effect on cutaneous warts. A possible mechanism is that direct moxibustion likely induces tissue damage from burning and, subsequently, a wound healing effect at a different temperature level. Our reports suggest that it would be worthwhile to conduct further studies on the safety and efficacy of moxibustion on warts or to develop a medical device that uses modified moxibustion.

Moxibustion Treatment for Knee Osteoarthritis: A Systematic Review and Meta-Analysis

To determine whether the administration of moxibustion is an effective treatment for knee osteoarthritis (KOA).We conducted a search of relevant articles using Medline, EMBASE, the Web of Science, and the Cochrane Library published before October 2015. The Western Ontario and McMaster Universities' Osteoarthritis Index (WOMAC scale) and the short form 36 questionnaire (SF-36 scale) were assessed. Evidence grading was evaluated according to the Grading of Recommendations, Assessment, Development and Evaluation system.Four studies containing 746 participants fulfilled the inclusion criteria in the final analysis. In terms of quality of life (QOL), the meta-analysis of 2 randomized clinical trials (RCTs) showed significantly effects of moxibustion only in bodily pain (BP) compared with those in the control group (n = 348; weighted mean difference [WMD], 4.36; 95% confidence intervals [CIs], 2.27-6.44; P < 0.0001; heterogeneity: χ = 1.53, P = 0.22, I = 34%) in all of the subcategories of the SF-36 scale, with moderate quality. The meta-analysis of the 2 included trials showed that there was not a statistically significant difference in the pain or function subscale for the WOMAC scale when the 2 groups were compared (n = 322; WMD, 17.63; 95% CI, -23.15-58.41; P = 0.40; heterogeneity: χ = 19.42, P < 0.0001, I = 95%), with low or moderate quality separately.The administration of moxibustion can to some extent alleviate the symptoms of KOA. More rigorous, randomized controlled trials are required in the future.

Moxibustion is an Alternative in Treating Knee Osteoarthritis: The Evidence From Systematic Review and Meta-Analysis

Knee osteoarthritis (KOA) is a common disorder in elderly. There is no known cure for KOA, and thus therapeutic strategies of alleviating symptoms are increasingly emphasized. Moxibustion has been widely used to treat KOA; however, results are inconclusive. The aim of our study is to critically reassess the effects of moxibustion on KOA.We searched PubMed, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), and Chinese Biomedical Literature database (CBM) through 25 November 2015. Two independent reviewers selected studies and abstracted information, as well as assessed the risk of bias using Cochrane risk of bias tool. The random-effects meta-analyses were performed based on abstracted data.We initially captured 163 citations and added 4 records through checking review. After critical appraisal, 13 RCTs were included. Meta-analyses indicated that moxibustion is not statistically different from oral drug in improving the response rate (MD = 1.09; 95% CI = 1.00, 1.20; P = 0.05), alleviating pain and improving physical function. Our meta-analysis also found that moxibustion is superior to usual care and sham moxibustion in reducing WOMAC score (MD = 7.56; 95% CI = 4.11, 11.00; P = 0.00), pain and function, as well as increasing QoL. Moreover, most AEs caused by moxibustion can heal without medical care.We concluded that moxibustion treatment is equal to the oral drugs and intra-articular injections and may be an alternative in treating patients with KOA.

Evidence of Chinese herbal medicine Duhuo Jisheng decoction for knee osteoarthritis: a systematic review of randomised clinical trials

OBJECTIVES

Duhuo Jisheng decoction (DJD) is considered beneficial for controlling knee osteoarthritis (KOA)-related symptoms in some Asian countries. This review compiles the evidence from randomised clinical trials and quantifies the effects of DJD on KOA.

DESIGNS

7 online databases were investigated up to 12 October 2015. Randomised clinical trials investigating treatment of KOA for which DJD was used either as a monotherapy or in combination with conventional therapy compared to no intervention, placebo or conventional therapy, were included. The outcomes included the evaluation of functional activities, pain and adverse effect. The risk of bias was evaluated using the Cochrane Collaboration tool. The estimated mean difference (MD) and SMD was within a 95% CI with respect to interstudy heterogeneity.

RESULTS

12 studies with 982 participants were identified. The quality presented a high risk of bias. Meta-analysis found that DJD combined with glucosamine (MD 4.20 (1.72 to 6.69); p<0.001) or DJD plus meloxicam and glucosamine (MD 3.48 (1.59 to 5.37); p<0.001) had a more significant effect in improving Western Ontario and McMaster Universities Arthritis Index (total WOMAC scores). Also, meta-analysis presented more remarkable pain improvement when DJD plus sodium hyaluronate injection (MD 0.89 (0.26 to 1.53); p=0.006) was used. These studies demonstrated that active treatment of DJD in combination should be practiced for at least 4 weeks. Information on the safety of DJD or comprehensive therapies was insufficient in few studies.

CONCLUSIONS

DJD combined with Western medicine or sodium hyaluronate injection appears to have benefits for KOA. However, the effectiveness and safety of DJD is uncertain because of the limited number of trials and low methodological quality. Therefore, practitioners should be cautious when applying DJD in daily practice. Future clinical trials should be well designed; more research is needed.

Effectiveness and Safety of Manufactured Chinese Herbal Formula for Knee Osteoarthritis: Insights from a Systematic Review

Objective. To assess the current clinical evidence of manufactured Chinese herbal formulae (MCHF) for knee osteoarthritis (KOA). Methods. Seven databases were searched from inception to May 2015. Eligible randomized controlled trials investigating the effectiveness of MCHF for KOA were included. Data extraction, methodological assessment, and meta-analyses were conducted according to the Cochrane standards. Results. A total of 17 kinds of MCHF were identified from the twenty-six included trials. Meta-analyses showed that MCHF significantly relieved the global pain of knee joints, either used alone or combined with routine treatments. Additionally, MCHF plus routine treatments significantly decreased the scores of WOMAC and Lequesne index. However, there were no statistical differences between MCHF group and routine treatment group in walk-related pain and WOMAC scores. No significant differences were found in Lysholm scores. There were twenty-one trials that mentioned adverse events. A pooled analysis showed that adverse events occurred more frequently in control group compared with MCHF group. Conclusions. Our results indicated that MCHF showed some potential benefits for KOA. However, we still cannot draw firm conclusions due to the poor methodological quality of included trials. More high-quality RCTs would help to confirm the evidence.