| Background and Objective knee osteoarthritis(KOA)is a common orthopaedic disease,which is more common in middle-aged and elderly people.It has become a high incidence disease troubling human beings.At present,there is no specific therapy for the treatment of this disease.In clinical practice,individual selection should be made according to the treatment expectations of patients and the degree of disease development,and appropriate treatment plans should be formulated.At present,the treatment of KOA by external treatment of traditional Chinese medicine has been demonstrated in clinical studies,and a number of systematic evaluations on the treatment of KOA by external treatment of traditional Chinese medicine have been published at home and abroad.However,there are great differences in the methodology,evidence quality and outcome index types of these systematic evaluations,which cannot determine the scientific nature and effectiveness of them as the basis for clinical guidance and decision-making.In order to obtain more scientific efficacy evidence and data support,it is necessary to summarize and re-evaluate the existing systematic evaluation of treatment evidence,and screen out high-quality evidence to help decision makers quickly browse the systematic evaluation evidence of external treatment of traditional Chinese medicine for KOA and facilitate clinical decision-making.Such research is called an Overview of systematic reviews(overviews).Methods This study developed inclusion and exclusion criteria based on the PICOS principle,and searched CNKI,Wanfang Data,VIP,Embase,PubMed,and The Cochrane Library using subject words and free words.The search was conducted until February 14,2023,and the language was limited to both Chinese and English.Deduplicate the retrieved literature,and then conduct initial screening based on inclusion and exclusion criteria.After the initial screening,download the full text for a second screening,and extract data after confirming the inclusion of the literature.Describe the overlap of the original literature,generate the original research matrix,and then calculate the corrected covered area(CCA).In the quality evaluation section,the bias risk evaluation results of the original study are extracted and reported.The ROBIS tool is used to conduct methodological quality evaluation on the systematic evaluation of traditional Chinese medicine external treatment for KOA.The GRADEpro software is used to evaluate the evidence quality of the research results of the systematic evaluation.Finally,a descriptive analysis was conducted on all clinical evidence,and a summary table was used to summarize the results of the primary and secondary outcome indicators.Bubble charts were used to display the evidence results.Results 2709 literatures were retrieved,2054 literatures were obtained after removing duplicate literatures,137 literatures were obtained after preliminary screening by reading titles and abstracts,and 72 literatures were finally included after reading the full text.Among them,there were 26 systematic reviews of acupuncture treatment of KOA,9 systematic reviews of acupotomology treatment,8 systematic reviews of moxibustion treatment,8 systematic reviews of massage treatment,7 systematic reviews of traditional Chinese medicine therapy,4 systematic reviews of external treatment of traditional Chinese medicine and 10 systematic reviews of combined external treatment of traditional Chinese medicine.After calculating the CCA,it was found that the overlap of literature in the systematic evaluation of TCM techniques was high,and the rest were mild or moderate.In ROBIS bias risk assessment,9 systematic reviews were identified as low risk,and the remaining 63 were high risk.Among 97 metaanalyses in systematic reviews,2 were evaluated as moderate-quality evidence,7 as low-quality evidence,and 88 as very low-quality evidence.Among the results of 72 systematic reviews,the results of highly concerned efficacy comparison are as follows:Comparison between warm acupuncture and moxibustion and ordinary acupuncture:one medium quality evidence indicates that warm acupuncture and moxibustion has a higher effective rate than ordinary acupuncture(OR=3.44,95%CI 2.25 to 5.27),one low quality evidence indicates that warm acupuncture and moxibustion reduces the VAS score more than ordinary acupuncture(WMD=-1.4,95%CI-1.83 to-0.96),and one very low quality evidence indicates that warm acupuncture and moxibustion reduces the ISOA score more than ordinary acupuncture(SMD=-1.68,95%CI-2.03 to-1.32);Comparison between warm acupuncture and moxibustion and oral western medicine:three very low quality evidences suggest that warm acupuncture and moxibustion is more effective than oral western medicine(OR=4.1,95%CI 2.51 to 6.71)(OR=4.54,95%CI 3.02 to 6.82)(RR=1.27,95%CI 1.03 to 1.56);Comparison between warm acupuncture and moxibustion and electroacupuncture:1 extremely low quality evidence suggests that warm acupuncture and moxibustion may be slightly less effective than electroacupuncture(OR=0.91,95%CI 0.58 to 1.43),2 extremely low quality evidence suggests that warm acupuncture and moxibustion may slightly lower VAS scores than electroacupuncture(WMD=0.82,95%CI-0.08 to 1.72)(SMD=0.32,95%CI-0.11 to 0.76),and 2 extremely low quality evidence suggests that warm acupuncture may slightly lower WOMAC scores than electroacupuncture(WMD=0.98,95%CI-1.76 to 3.71)(SMD=0.08,95%CI-0.15 to 0.32);Comparison between electroacupuncture and ordinary acupuncture:Two low-quality evidence showed that the effective rate of electroacupuncture was higher than that of ordinary acupuncture(OR=3.77,95%CI 1.61 to 8.83)(RR=1.12,95%CI 1.02 to 1.22),and one extremely low-quality evidence showed that the cure rate of electroacupuncture was higher than that of ordinary acupuncture(OR=3.76,95%CI 1.41 to 10.06);Comparison between electroacupuncture and sham acupuncture:1 item of low-quality evidence showed that electroacupuncture reduced WOMAC pain score more than sham acupuncture(SMD=-0.11,95%CI-0.21 to-0.01),1 item of extremely low-quality evidence suggested that electroacupuncture reduced WOMAC functional score more than sham acupuncture(MD=-1.39,95%CI-2.31 to-0.47),and 1 item of extremely low-quality evidence suggested that electroacupuncture may reduce WOMAC stiffness score slightly more than sham acupuncture(MD=-0.11,95%CI-0.48 to 0.27);Comparison between fire needle and ordinary acupuncture:Two extremely low-quality evidence showed that the cure rate of fire needle was higher than that of ordinary acupuncture(OR=1.88,95%CI 1.17 to 3.03)(OR=2.12,95%CI 1.48 to 3.02),one extremely low-quality evidence showed that the effective rate of fire needle was higher than that of ordinary acupuncture(OR=4.5,95%CI 2.34 to 8.68),and one low-quality evidence showed that the cure rate of fire needle was higher than that of ordinary acupuncture(OR=3.93,95%CI 2.65 to 5.81),One medium quality evidence showed that acupuncture reduced WOMAC pain score more than sham acupuncture(SMD=-0.13,95%CI-0.24 to-0.02),and one extremely low quality evidence suggested that acupuncture may slightly lower WOMAC functional score than sham acupuncture(MD=-0.97,95%CI-2.35 to 0.41);Comparison of needle knife and sodium hyaluronate injection:Two extremely low-quality evidence showed that the effectiveness rate of needle knife was higher than that of sodium hyaluronate injection(RR=1.18,95%CI 1.1 to 1.26)(OR=2.25,95%CI 1.55 to 3.28),one lowquality evidence showed that the cure rate of needle knife was higher than that of sodium hyaluronate injection(OR=2.04,95%CI 1.46 to 2.85),and one extremely low-quality evidence showed that needle knife reduced VAS score more than sodium hyaluronate injection(MD=1.21,95%CI-2.06 to-0.36),One extremely low-quality evidence showed that needle knife reduced WOMAC scores more than sodium hyaluronate injection(SMD=-0.74,95%CI-1.11 to-0.37),and one extremely low-quality evidence showed that needle knife adverse events may be slightly more than sodium hyaluronate injection(OR=2.13,95%CI 0.14 to 32.28);Comparison between thermal moxibustion and traditional moxibustion:1 item of extremely low quality evidence showed that the effective rate of thermal moxibustion was higher than that of traditional moxibustion(RR=3.37,95%CI 1.78 to 6.4),1 item of extremely low quality evidence showed that the cure rate of thermal moxibustion was higher than that of traditional moxibustion(RR=2.47,95%CI 1.15 to 5.3),and 1 item of extremely low quality evidence showed that thermal moxibustion reduced VAS scores more than traditional moxibustion(MD=-1.15,95%CI-1.72 to-0.58),One piece of low-quality evidence shows that heat sensitive moxibustion reduces clinical symptom scores more than traditional moxibustion(MD=-2.03,95%CI-2.42 to-1.63);Comparison between moxibustion and oral non steroidal anti-inflammatory drugs:1 item of extremely low quality evidence showed that moxibustion had a higher effective rate than oral non steroidal anti-inflammatory drugs(RR=1.09,95%CI 1.03 to 1.17),and 1 item of extremely low quality evidence showed that moxibustion reduced NRS scores more than oral non steroidal anti-inflammatory drugs(MD=0.64,95%CI 0.02 to 1.27);Comparison between tuina and oral non-steroidal anti-inflammatory drugs:Two extremely low-quality evidence showed that tuina was more effective than oral non-steroidal antiinflammatory drugs(RR=1.14,95%CI 1.07 to 1.21)(RR=1.13,95%CI 1.06 to 1.2),and one extremely low-quality evidence showed that tuina may reduce VAS scores slightly more than oral non-steroidal anti-inflammatory drugs(MD=-0.38,95%CI-1.52 to 0.75),One extremely low-quality evidence suggests that massage reduces WOMAC scores more than oral non steroidal anti-inflammatory drugs(MD=-9.04,95%CI-16.71 to-1.36),another extremely lowquality evidence suggests that massage may slightly lower WOMAC scores than oral non steroidal anti-inflammatory drugs(MD=-2.5,95%CI-15.5 to 10.5),and one extremely lowquality evidence suggests that massage reduces WOMAC stiffness scores more than oral non steroidal anti-inflammatory drugs(MD=-0.9,95%CI-1.05 to-0.75),One extremely low-quality evidence suggests that massage reduces WOMAC function scores more than oral non steroidal anti-inflammatory drugs(MD=-12.48,95%CI-13.91 to-11.05),and one extremely low-quality evidence suggests that massage may have slightly fewer adverse reactions than oral non steroidal anti-inflammatory drugs(OR=0.71,95%CI 0.14 to 3.67).Conclusion The quality of systematic evaluation and evidence in this field is generally low.Through medium quality evidence,only two reliable conclusions can be obtained,that is,warm acupuncture and moxibustion is better than ordinary acupuncture in improving the overall symptoms of KOA patients,and acupuncture is better than sham acupuncture in improving pain symptoms;Through a number of low or extremely low quality evidences,some relatively reliable conclusions can be obtained,that is,warm acupuncture and moxibustion has a stronger pain relief effect than ordinary acupuncture,warm acupuncture and moxibustion and electroacupuncture have the same effect on pain relief,the effective rate and cure rate of electroacupuncture are higher than ordinary acupuncture,the effect of warm acupuncture moxibustion is better than taking western medicine orally,the effective rate of needle knife is higher than sodium hyaluronate injection,and the overall effect of massage and the effect of improving function are stronger than non steroidal anti-inflammatory drugs.The limitations of this study are reflected in five aspects:firstly,the limited available therapeutic evidence;secondly,the widespread clinical heterogeneity;thirdly,the lack of analysis on the impact of confounding factors;fourthly,potential important evidence may be overlooked;and fifthly,the quality of research and evidence affects the interpretation of results. |
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