| Objective To understand the differences in curative effect between warm needling with other Tradtional Chinese Medicine external medication methods towards knee osteoarthritis by running a Meta analysis along with a systematic review for clinical trial reports targeting knee osteoarthritis.Methods This searching criteria for clinical trial reports are as follows:keywords: “???”and “??????”;or,“???”and “?????????”;or,“???”and “??????”;or,“???” and “??????”;or,“warm needle”and “KOA”,paper publishing date ranging from1/1/2003 to 31/21/2016,data base including CNKI,Wanfang Data,Pub Med and MEDLINE,paper language is restricted to Chinese and English only.Grey resources are not included in this research.After searching,the identified papers are screened with further details,mainly: 1.the report result has to be come from a randomized clinical trial;2.the target group has to be diagnosed with knee osteoarthritis through clinically or other valid methods,and;3.the treatment method has to be warm needling and the compare methods are restricted to any kind of TRADTIONAL CHINESE MEDICINE external treatment methods besides warm needling with the exclusion of any western medicinal treatment that may interfere with the treatment result for both treatment and compare group patients.After screening there are total 66 clinical trial reports,which fulfilled all the criteria,included in this study.The said reports' data and details are then examined and extracted with the aid of 2computer programme,Review Manager(ver3.4)and Microsoft Excel 2010,after the required information is collected,the Review Manager programme is used for data processing and making necessary calculation for the META analysis.Results Using the data from all the reports extracted previously and perform a META analysis for the curative effectiveness – effective category,the result of RR = 3.12,95% CI [2.67,3.65] can be acquired,while the curative effectiveness – outstanding category will produced a result with RR = 2.47,95% CI [2.21,2.76].Both results indicate patients with knee osteoarthritis who undergone the treatment of warm needling would have a higher treatment sensitivity than those who received other TRADTIONAL CHINESE MEDICINE external medication.While the META analysis result of pain scale(Visual Analog Scale,VAS in short),and other possible evaluation methods for knee conditions including The Western Ontario and Mc Master Universities Osteoarthritis Index(in short,WOMAC),Lysholm scale,Lequesne index and Clinical Guidelines for New Chinese Medicine Testing(??????????)for all the included studies shows warm needling acupuncture is a better methods to treat knee osteoarthritis in terms with clinical effectiveness,the heterogeneity test for curative effectiveness – outstanding,pain scale,WOMAC and Lysholm index(with the result of I2= 44%?I2= 92%?I2= 94%?I2= 93% respectively),indicates there are indeed hidden variables with great influential properties among the studies,thus the inconsistence results of various reports.In this research one of the goal is to identify those variables and try to figure out the relation between the variables and the curative effectiveness and the treatment sensitivity,thus helping fellow TRADTIONAL CHINESE MEDICINE practitioners to choose a much more appropriate treatment method when facing a knee osteoarthritis patient with identified properties mentioned earlier,leading to a better clinical result if possible.Therefore after performing META analysis using the data from all the included studies,it is necessary to separate the studies in groups according to their settings,including the patients' inclusion criteria,treatment and compare groups' intervention,and other possible deference and perform META analysis again with the new grouping,hoping to find the fluctuation causing variables in the process.Using data from all the studies with acupuncture,electro-acupuncture with TDP heating and baseline intervention as compare group treatment methods and perform META analysis for the curative effectiveness and pain scale(VAS),the results show that warm needling has a better treatment sensitivity and pain reduction property for patient with knee osteoarthritis(acupuncture group's effectiveness: RR = 1.49,95% CI [1.36,1.62]?pain scale: MD =-0.24,95%CI [-0.3,-0.18];electro-acupuncture with TDP heating group effectiveness:RR = 1.40,95% CI [1.18,1.67];baseline intervention group effectiveness:RR = 1.40,95% CI [1.18,1.67]?pain scale: MD = 0.08,95% CI [-0.03,0.19]).Although the heterogeneity test results for the above analyst are not satisfactory,all the studies result flavor treatment group(warm needling group)with variable degree.This sufficiently shows there are although some variables hidden among the studies,but the impact they produced are now powerful enough to overcome the effect that caused by the treatment effect different of treatment and compare group.Studies with electro-acupuncture as intervention method for the compare group are then identified,and proceed META analysis for the studies' results,including treatment sensitivity,pain scale and the score of knee osteoarthritis condition evaluation form(WOMAC).The analysis results are as follows: for treatment sensitivity RR = 1.33,95% CI [1.23,1.44];for pain scale MD =-0.26,95% CI [-0.57,0.05] and for WOMAC score MD = 0.86,95% CI[-0.86,2.59].While the result of treatment sensitivity shows patients underwent warm needling have a better responsive rate when comparing to electro-acupuncture,the META analysis of pain scale and WOMAC score for studies using warm needling verses electro-acupuncture do not have a statistically significant result.Moreover the heterogeneity of the 3 results are I2= 74%,I2= 94%,I2= 0% respectively,those results indicate there are some varietals with significant influence towards the treatment response,especially the sensitivity and pain reduction property,but the reasons behind have yet identified at this point.The META analysis results for sensitivity,pain scale and knee osteoarthritis evaluation score after separating the studies in group with following identification: treatment time used per session,time between two sessions and time required for a complete treatment suggest warm needling has a better all round effectiveness,but the subgroup heterogeneity results indicate there are other influences causing difference in the results between studies.With the attempt to perform META analysis of clinical related results after grouping the studies using the TRADTIONAL CHINESE MEDICINE pattern identification system,knee osteoarthritis patients with pattern of yang deficiency with congealing cold,those with pattern of wind-cold-dampness pattern,dampness pattern,and those with kidney deficiency pattern,overall show a better treatment response to warm needling,mainly in sensitivity and pain reduction.However the result also identified a specific setting in electro-acupuncture(continuous,5Hz)from 3 studies which can cause a better clinical results in patients with kidney deficiency pattern and those with blood stasis pattern.There is no significant results for the META analysis for the stimulant strength in warm needling,including the size of moxa cone,number of moxa cone used per session and the length per session unfortunately,which is masked by other factors with more influence toward the treatment.The above are the results from META analysis from the included studies.This study also performed a systematic review on the clinical reports collected,including inclusion criteria of patients,TCM pattern identification and the subsequence influence on treatment,selection of acupuncture points,and the choices for knee condition evaluation.For the acupuncture point selection,after counting the choices from the included studies,the results are as follows.The mostly used acupuncture points are from around the pain area(knee),including ST35(??),which was used 61 times;EX – LE5(??),which was used 59 times.While other frequently used acupuncture points are close to the knee,including ST36(???),which was used 49 times;GP34(???),which was used 48 times;and SP10(??),which was used 44 times;ST34(??),which was used 36 times;EX – LE2(??),which was used 35 times;and the least used acupuncture point that is closed to the knee area is SP9(???),which was used 27 times.While other acupuncture points,including those which are close to the knee or those far from it,have a less frequent use when compare to the acupuncture points previously mentioned,only counting 10 uses or less for those acupuncture points.For the included studies,the target group diagnostic criteria for the knee osteoarthritis are mostly used the standard issued from the American College of Rheumatology,but version varied,including the use of the criteria from 1986,1991 and 2001,but nonetheless all criteria are worldwide recognized,or some of the studies used the criteria issued by authentic medical resources from Chinese including Chinese Bone Hurt Academy(??????),although different diagnostic guildline have a different criteria for knee osteoarthritis,but the differences are minimal,and the result will lead to a group of target patients with similar sign of knee disease.While some of the studies take one step further after the diagnosis of knee osteoarthritis,which is to perform a syndrome differentiation from the system of Tradtional Chinese Medicine,and then include or exclude patients according to the pattern identified,thus ensure the accepted patients are not only diagnosis with knee osteoarthritis,but also a specific syndrome pattern that is related to the Tradtional Chinese Medicine system.Under this setting,the studies can make an attempt to connect the syndrome pattern related to knee osteoarthritis with the Tradtional Chinese Medicine external method being investigated in those researches,thus establishing a data base for future research for syndrome pattern and external method,and perhaps a proof for ‘same treatment for different disease' which is an unique perk for Tradtional Chinese Medicine.Other studies do include syndrome pattern recognition,not as inclusion criteria like the studies previously mentioned,but as an indicator for choosing assisting acupuncture points,thus the result of such studies cannot be used to make a similar connection between treatment methods and syndrome pattern identified as the previous group which had patients' syndrome pattern differentiation as the inclusion criteria.For the treatment result quantification,3 directions can be used to determine the effectiveness of the treatment,which includes the patients' signs and symptoms responsiveness towards the intervention method;the degree of pain for the patients' knee;and,the overall condition(including the degree of pain and uncomfortable with different onset,the degree of movement,and the ability to perform daily activities)of the affected knee.The first one sensitivity,is widely used in the included studies,which is carried out by finding out the portion of patients,who received certain degree of knee condition improvement,be it of pain or ability to move.It is worth to point out that treatment with high curability is not necessary equal to high treatment sensitivity,a treatment can have a high curability but have a low responsiveness and vice versa.The second one is the degree of pain,Visual analog scale is one of the simplest and easy to understand pain scale to use,but nonetheless this scale is effective to reflect the seriousness of pain(overall).While degree of pain and treatment sensitivity alone is not enough to produce a full picture of knee osteoarthritis,thus a complete assessment form is required to evaluate the condition of affected knee,and WOMAC is one of the most suitable choice,as it cover the necessary symptoms and signs as well as afflicted knee's function,and the ability to perform daily acts,more than that the scale used by the assessment form is suitable for statistic calculation,making it easier to carry out further evaluation.WOMAC also features a wide range of knee condition assessment,allowing the evaluation of different Tradtional Chinese Medicine external methods on different aspects of knee osteoarthritis,provide the researchers release the related data.For the different methods involving heat energy stimulation(including moxibustion,acupuncture along with heat energy produced by TDP,warm needling and fire needling),previous laboratory experiments revealed that there are differences in terms of heat energy distribution and pattern between moxibustion and warm needling,while the warm needling method proved the ability to produce a deeper heat stimulant in the area where the treatment is performed when comparing to moxibustion,the clinical result for comparing both methods in knee osteoarthritis patients had yet shown any significant differences in statistic point of view.And for And for the comparison of fire needling and warm needling on the treatment response of knee osteoarthritis,there is only 1 report states that fire needling has a better sensitivity and effectiveness,but upon the research of fire needling for the detail(both procedure and related discussion),it is clear that fire needling has a higher risk then warm needling,which,including adverse event has yet mentioned from that report.Since there are insufficient report for the related subjects,which include moxibustion,warm needling and fire needling,there is not enough information to make a sounds suggestion about moxibustion,warm needling and fire needling for treating knee osteoarthritis.Conclusion Warming needles as a Tradtional Chinese Medicine external method is one of the better choice when it comes to treat knee osteoarthritis if the same acupuncture points are chosen for other external methods,including a better treatment sensitively and higher improvement in patient's signs and symptoms.This improvement is more significant in knee osteoarthritis patients with certain symptoms pattern,namely yang deficiency with congealing cold,wind-cold-dampness pattern,dampness pattern,and those with kidney deficiency pattern,but with an exception.Using electro-acupuncture with the setting of continuous wave may have a better treatment results when comparing with warm needling when it comes to knee osteoarthritis patients with kidney deficiency pattern and blood stasis pattern.And it is needed to have more large scale,multi-centered randomized control trail to prove the following,minimizing possible bias due to small sample group: the similar treatment response of moxibustion and warm needling for knee osteoarthritis;knee osteoarthritis patients who have fire needling as treatment will have a better improvement then those who have warm needling,and possible yet common adverse effects of fire needling.This research also shows symptoms pattern differentiation of Tradtional Chinese Medicine system can be directly applied to patients with a western medicine diagnosis when using Tradtional Chinese Medicine external methods as intervention,result in improved clinical responsiveness.More than that,it is strongly suggested further research can be focus on the disease location(in terms of depth),which leads to the yet unknown field of relation between stimulant depth and pathological location;the effect of the stimulant strength,(including moxa size,number of moxa used per session),the session frequency,the length of treatment of warm needling and their clinical impact. |
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