| Objective: A systematic review and network meta-analysis was conducted to evaluate the effectiveness and safety of four different therapies of Chinese herbal medicine,acupuncture,moxibustion,and western medicine,to help physicians in making strategies for patients with AS.Methods: Based on the inclusion criteria and exclusion criteria,the Cochrane Library,Pub Med,EMBASE,Web of science,China Biology Medicine Data,CNKI,VIP,and Wanfang database were searched for randomized controlled trials,and quality assessment of the included trials was conducted according to the Cochrane Risk of Bias Tool,GRADE and CINe MA were used to assess the certainty of evidence for the outcomes from the network meta-analysis.STATA 14.0 were used for all included studies,and the results were analyzed and ranked by network meta analyses.Results: One hundred and twenty-six trials with a total of 9384 patients were included and the sample size between 36 to 351.The main results of network analyses were as follow: 1.The network results showed that compared with western medicine,acupuncture(MD=-1.43,95%CI [-1.97,-0.88])and Chinese herb medicine(MD=-1.08,95%CI [-1.33,-0.82])showed a favorable effect in lowering Visual analogue scale(VAS)scores;While there were no significant different between moxibustion and western medicine(MD=-0.64,95%CI [-1.40,0.12]).The order of efficacy is as followed: acupuncture(SUCRA=94.4)> Chinese herbal medicine(SUCRA=66.0> moxibustion(SUCRA=38.0)> western medicine(SUCRA=1.7).2.In the outcomes of Bath Ankylosing Spondylitis Disease Activity Index(BASDAI),the comparison between different treatment showed a superior impact in acupuncture(MD=-2.90,95%CI [-5.10,-0.70])and Chinese herbal medicine(MD=-1.95,95%CI [-2.79,-1.10])compared with medicine;And no significant difference were found between moxibustion and western medicine(MD=-0.36,95%CI [-3.08,2.36]).The order of efficacy is as followed: acupuncture(SUCRA=90.3)> Chinese herbal medicine(SUCRA=69.1)> moxibustion(SUCRA=27.0)> western medicine(SUCRA=13.5).3.In the outcomes of Bath Ankylosing Spondylitis Functional Index(BASFI),the comparison between different treatment showed a favorable effect in acupuncture(MD=-2.39,95%CI [-3.5,-1.27])and Chinese herbal medicine(MD=-1.17,95%CI [-1.60,-0.74])compared with medicine;And acupuncture were also superior to Chinese herbal medicine(MD=-1.22,95%CI [-2.38,-0.06])and moxibustion(MD=-2.44,95%CI [-4.58,-0.30]),while no significant difference were found between moxibustion and western medicine(MD=0.05,95%CI [-1.79,1.89]).The order of efficacy is as followed: acupuncture(SUCRA=98.9)> Chinese herbal medicine(SUCRA=64.0)> moxibustion(SUCRA=19.7)> western medicine(SUCRA=17.4).4.The comparison between different treatment showed that there were no significant difference in the outcomes of erythrocyte sedimentation rate(ESR),and the order of efficacy is moxibustion(SUCRA=86.2)> Chinese herbal medicine(SUCRA=57.8)> acupuncture(SUCRA=48.1)> western medicine(SUCRA=7.8).5.The results demonstrated that there were no significant difference in the outcomes of C-reactive protein(CRP),and according to the NMA the order of efficacy is Chinese herbal medicine(SUCRA=66.8)> acupuncture(SUCRA=57.5)> moxibustion(SUCRA=52.9)> western medicine(SUCRA=22.8).6.The network results showed that compared with western medicine,acupuncture(MD=-7.22,95%CI [-13.15,-1.29])and Chinese herb medicine(MD=-4.70,95%CI [-8.99,-0.41])showed a favorable effect in Tumor necrosis factor-alpha(TNF-?);While there were no significant different between moxibustion and western medicine(MD=-4.55,95%CI [-10.18,1.08]).The order of efficacy is as followed:acupuncture(SUCRA=84.5)>Chinese herbal medicine(SUCRA=58.1)>moxibustion(SUCRA=54.6)> western medicine(SUCRA=2.8).7.The comparison between different treatment in Schober showed a favorable effect in Chinese herbal medicine(MD=0.52,95%CI [0.33,0.71])and moxibustion(MD=0.51,95%CI [0.01,1.02])compared with medicine;And no significant difference were found between acupuncture and western medicine(MD=0.33,95%CI [-0.20,0.86]).The order of efficacy is as followed: Chinese herbal medicine(SUCRA=74.9)> moxibustion(SUCRA=74.0)> acupuncture(SUCRA=46.9)> western medicine(SUCRA=4.2).8.The network results showed that compared with western medicine,moxibustion(MD=0.40,95%CI [0.06,0.75])and Chinese herb medicine(MD=0.31,95%CI [0.16,0.45])showed a favorable effect in thoracic expansion;While there were no significant different between acupuncture and western medicine(MD=0.24,95%CI [-0.12,0.60]).The order of efficacy is as followed: moxibustion(SUCRA=82.9)> Chinese herbal medicine(SUCRA=64.4)> acupuncture(SUCRA=49.5)> western medicine(SUCRA=3.2).9.In the outcomes of finger-to floor distance,the comparison between different treatment showed a superior impact in moxibustion(MD=-5.92,95%CI [-8.76,-3.08]),acupuncture(MD=-4.58,95%CI [-7.94,-1.22)and Chinese herbal medicine(MD=-3.75,95%CI [-4.92,-2.59])compared with medicine.The order of efficacy is as followed: moxibustion(SUCRA=90.2)> acupuncture(SUCRA=63.0)> Chinese herbal medicine(SUCRA=46.7)> western medicine(SUCRA=0.1).Conclusion: According to the cluster analyses in VAS and BASFI,acupuncture demonstrated a superior effect to other treatments,and had the highest probability to become the best therapy in AS treatment.The global clinical state and pain was alleviated,which were demonstrated by VAS,BASDAI,and BASFI score.Given the adverse reactions of Chinese herbs,moxibustion had less adverse effects and done well in Schober,thoracic expansion and finger-to-floor distance,indicating that moxibustion may improve the lumbar function of AS patients.Therefore,we speculate that the combination of acupuncture and moxibustion can improve the clinical curative effect of AS.Thus,due to the low quality of included studies,the credibility of our evidence reduced.Therefore,multi-center,large sample and high-quality randomized controlled trials are needed in the future to further confirm the conclusion,to help physicians to make better treatment schedule for patients with AS. |
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