OBJECTIVE:: To evaluate the efficacy and safety of a homeopathic gel vs an NSAID (piroxicam) gel in the treatment of osteoarthritis of the knee.

METHOD:: One hundred and eighty-four out-patients with radiographically confirmed symptomatic osteoarthritis of the knee were entered into a pragmatic, randomized, double-blind controlled trial and treated with 1 g of gel three times daily for 4 weeks. Main outcome measures were pain on walking as a Visual Analogue Score (VAS) and a single-joint Ritchie index.

RESULTS:: One hundred and seventy-two of the 184 enrolled patients had endpoints for the main outcome parameters. The pain reduction was 16.5 mm VAS in the homeopathy group (n = 86) and 8.1 mm in the piroxicam group (n = 86); the difference between treatment groups was 8.4 mm (95% confidence interval 0.8-15.9), and after adjustment for pain at baseline it was 6.8 mm (95% confidence interval -0.3 to 13.8). There was no significant difference between treatment groups in the single-joint Ritchie index (P = 0.78). Adverse events occurred in 28 patients (12 homeopathy group, 5 withdrawn; 16 piroxicam group, 9 withdrawn); 18 of the events involved a local reaction (7 homeopathy group, 2 withdrawn; 11 piroxicam group, 5 withdrawn).

CONCLUSION:: The homeopathic gel was at least as effective and as well tolerated as the NSAID gel. The presence of a clinically relevant difference between treatment groups cannot be excluded. The homeopathic gel supplemented by simple analgesics if required may provide a useful treatment option for patients with osteoarthritis.

Mud-bath therapy plays a primary role in the treatment and prevention of osteoarthritis that has been recognised since antiquity. Numerous studies have demonstrated its clinical benefits and its effects on inflammatory mediators (interleukins), the immune system, cenesthesic factors (endorphins), and the diencephalic-pituitary-adrenal axis. This study was conducted to assess the efficacy of mud-bath therapy with mineral water from the Sillene Spring at Italy's Chianciano Spa in patients with osteoarthritis of the knee. Patients (n = 61) were divided into two groups. Group A underwent three cycles of mud-based spa therapy over a year's time, whereas group B did not. Clinical conditions, visual analogue scale pain ratings, and Lequesne indexes of the two groups were compared. We also compared these same parameters in the patients of the two groups that were following the therapy with drugs and in the patients of the group A before and after spa treatment. The percentage of patients with no symptoms or mild symptoms was higher in group A than in group B. Within group A, this percentage was higher after treatment than before spa therapy. Even in the comparison between the patients of the two groups that were following the therapy with drug, the results was that in group A the percentage of patients with no symptoms or mild symptoms was higher than in group B. Statistical analyses based on various tests revealed that almost all these differences were highly significant. No adverse effects were observed in any of the patients in group A. In conclusion, the mud-bath therapy performed at Chianciano Spa with Sillene Spring water remarkably improved the clinical conditions of patients with knee arthritis and significantly reduces the frequency and severity of symptoms and the disability they cause.

OBJECTIVE:This was a secondary data analysis of a cluster-randomized clinical trial that tested the efficacy of a 20-week Sun-style Tai Chi (TC) program in reducing pain in community-dwelling elders with cognitive impairment and knee osteoarthritis (OA). The study also examined whether elders' level of cognitive function was related to the outcomes of the TC program.

METHOD:Elders (N=55) were recruited from 8 study sites. Each site was randomly assigned to participate in either a 20-week TC or an education program. Verbal report of pain was measured by a Verbal Descriptor Scale (VDS) at weeks 1, 5, 9, 13, 17 and 21 (designated as times 1-6). Pain behaviors and analgesic intake were also recorded at times 1-6.

RESULTS:At post-test, scores on the VDS and observed pain behaviors were significantly better in the TC group than in the control group (p=0.008-0.048). The beneficial effects of TC were not associated with cognitive ability.

CONCLUSION:These results suggest that TC can be used as an adjunct to pharmacological intervention to relieve OA pain in elders with cognitive impairment.

TRIAL REGISTRATION:Clinical Trial.gov NCT01528566.

OBJECTIVE:This was a secondary data analysis of a cluster-randomized clinical trial that tested the efficacy of a 20-week Sun-style Tai Chi (TC) program in reducing pain in community-dwelling elders with cognitive impairment and knee osteoarthritis (OA). The study also examined whether elders' level of cognitive function was related to the outcomes of the TC program.

METHOD:Elders (N=55) were recruited from 8 study sites. Each site was randomly assigned to participate in either a 20-week TC or an education program. Verbal report of pain was measured by a Verbal Descriptor Scale (VDS) at weeks 1, 5, 9, 13, 17 and 21 (designated as times 1-6). Pain behaviors and analgesic intake were also recorded at times 1-6.

RESULTS:At post-test, scores on the VDS and observed pain behaviors were significantly better in the TC group than in the control group (p=0.008-0.048). The beneficial effects of TC were not associated with cognitive ability.

CONCLUSION:These results suggest that TC can be used as an adjunct to pharmacological intervention to relieve OA pain in elders with cognitive impairment.

TRIAL REGISTRATION:Clinical Trial.gov NCT01528566.

OBJECTIVES: To assess the efficacy of an aromatic essential oil (1% Zingiber officinale and 0.5% Citrus sinesis) massage among the elderly with moderate-to-severe knee pain. METHOD: Fifty-nine older persons were enrolled in a double-blind, placebo-controlled experimental study group from the Community Centre for Senior Citizens, Hong Kong. The intervention was six massage sessions with ginger and orange oil over a 3-week period. The placebo control group received the same massage intervention with olive oil only and the control group received no massage. Assessment was done at baseline, post 1-week and post 4 weeks after treatment. Changes from baseline to the end of treatment were assessed on knee pain intensity, stiffness level and physical functioning (by Western Ontario and McMaster Universities Osteoarthritis index) and quality of life (by SF-36). RESULTS: There were significant mean changes between the three time-points within the intervention group on three of the outcome measures: knee pain intensity (p=0.02); stiffness level (p=0.03); and enhancing physical function (p=0.04) but these were not apparent with the between-groups comparison (p=0.48, 0.14 and 0.45 respectively) 4 weeks after the massage. The improvement of physical function and pain were superior in the intervention group compared with both the placebo and the control group at post 1-week time (both p=0.03) but not sustained at post 4 weeks (p=0.45 and 0.29). The changes in quality of life were not statistically significant for all three groups. CONCLUSION: The aroma-massage therapy seems to have potential as an alternative method for short-term knee pain relief.

BACKGROUND:Knee osteoarthritis is considered as one of the most prevalent musculoskeletal disorders which leads to joint degeneration and consequently disability in activities of daily living. This study aimed to evaluate the effects of aromatherapy massage with lavender essence on activities of daily living of patients with knee osteoarthritis.

METHODS:This is a single-blinded, randomized clinical trial. A total of 90 patients with osteoarthritis of the knee referring to the outpatient rheumatology clinics affiliated to Birjand University of Medical Sciences were selected via convenience sampling method. The participants were randomly assigned into three groups: intervention group (aromatherapy massage with lavender essential oil), placebo group (massage with almond oil) and control group (without massage). The activities of daily living of patients was evaluated according to the Western Ontario and McMaster Universities Osteoarthritis index (WOMAC) at baseline, immediately after the intervention, 1 week, and 4 weeks after the intervention. Data were analyzed using SPSS statistical software version 16.

RESULTS:The activities of daily living of patients were significantly improved immediately and 1 week after the intervention in the intervention group compared with their initial status (p < .001) and that of the control group (p < .001 and p = .03 respectively). However, 4 weeks after the intervention, there was no significant difference between the groups according to the Western Ontario and McMaster Universities Osteoarthritis index (p = .95).

CONCLUSION:Aromatherapy massage with lavender essential oil may reduce the incidence of activities of daily living disability in patients with osteoarthritis of the knee. However, further studies are required to confirm findings of this study.

OBJECTIVE:The aim of the trial was to determine the effectiveness of oxygen-ozone injections on knee osteoarthritis concerning pain reduction, joint functional improvement, and quality of life.

METHODS:In this randomized, double-blinded, placebo controlled clinical trial, 98 patients with symptomatic knee osteoarthritis (OA) were randomized into two groups receiving intra-articular 20μg/ml of ozone (OZ) or placebo (PBO) for 8 weeks. The efficacy outcomes for knee OA were the Visual Analogue Scale (VAS), Lequesne Index, Timed Up and Go Test (TUG Test), SF-36, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Geriatric Pain Measure (GPM).

RESULTS:After 8 weeks of treatment, ozone was more effective than the placebo: VAS [mean difference (MD) = 2.16, p<0.003 (CI 95% 0.42-3.89)], GPM [MD = 18.94, p<0.004 (CI 95% 3.43-34.44)], LEQ [MD = 4.05, p<0.001 (CI 95% 1.10-7.00)], WOMAC (P) [median of diff = 9.999, p = 0.019 (CI 95% 0.000-15.000)], WOMAC (JS) [median of diff = 12.499, p<0.001 (CI 95% 0.000-12.500)], WOMAC (PF) = [median of diff = 11.760, p = 0.003 (CI 95% 4.409-19.119)], TUG (no statistical difference) and SF-36 (FC) [(MD = -25.82, p<0.001 (CI 95% 33.65-17.99)], SF-36 (PH) [MD = -40.82, p<0.001 (CI 95% -54.48-27.17)], SF-36 (GSH) [MD = -3.38, p<0.001 (CI 95% -4.83-1.93)], SF-36 (SA) [MD = 2.17, p<0.001 (CI 95% -19.67-8.24), SF-36 (EA) [MD = -35.37, p<0.001 (CI 95% -48.86-21.89)]. Adverse events occurred in 3 patients (2 in the placebo group and 1 in the ozone group) and included only puncture accidents.

CONCLUSIONS:The study confirms the efficacy of ozone concerning pain relief, functional improvement, and quality of life in patients with knee osteoarthritis.

TRIAL REGISTRATION:International Standard Randomized Controlled Trial Number Register ISRCTNR55861167.

OBJECTIVE: The aim of this study was to reveal the efficacy of mud pack treatment in patients with knee osteoarthritis and to find the contribution of chemical factors to the build up of these effects. METHODS: Sixty patients were randomly assigned to directly applied mud pack (study) group or to nylon-covered mud pack (control) group. Thirty patients in the study group had mud application 15 times to both knees: heated mud, up to 43 degrees C, was applied to skin directly for 30 minutes. Thirty patients in the control group had the same treatment as the study group except heated mud was applied over an impermeable nylon pack. Primary outcome measures of the study were the Western Ontario and McMaster Universities (WOMAC) index, pain intensity on a visual analog scale (VAS), patient's assessment of disease severity index, physician's assessment of disease severity index, and analgesic consumption. The patients were evaluated before and after (end of 15th application) the intervention and followed up for 24 weeks at 4-week intervals. The results were assessed on an intent-to-treat basis. RESULTS: As compared to the baseline, significant decreases were observed in WOMAC, pain intensity, disease severity index scores, and analgesic consumption in both groups after the intervention. Observed improvements in the study group were found to be superior to the control during the whole postintervention follow-up, except for analgesic consumption in the third week. A significant number of patients in the study group showed minimal clinically important improvement as compared to the control group. CONCLUSION: Mud pack treatment significantly improved the pain and functional status of patients with knee osteoarthritis, whether applied directly or coated with nylon. Direct application was found to be superior, which implies chemical properties of the mud contribute to the build up of therapeutic effect.

OBJECTIVE:To observe the effect of acupuncture or electroacupuncture (EA) combined with usual medical care for treating knee osteoarthritis (KOA) .

METHODS:A total of 90 patients with KOA were randomly allocated to 3 groups: usual care group (UC group, n = 30) was treated by pharmacological treatment of non-steroidal anti-inflammatory drugs (NSAIDs) and drugs for activating blood circulation (Ds-ABC), acupuncture (AP) combined with usual care group (UC group) (AP + UC group, n = 30) and EA combined with UC group (EA + UC group, n = 30). The primary outcome measurements included pain visual analogue scale/score (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC Index) and its subscales. Secondary outcome measurement was Assessment of Quality of Life instrument version of the 36-item Short Form Health Survey (AQoL-SF36).

RESULTS:By the end of the 1st week, AP + UC group and EA + UC group exhibited statistically significant improvements in primary outcome measures, except for WOMAC stiffness, compared with the UC group (P<0.05). Moreover, the energy/fatigue domain of AQoL-SF36 in the AP + UC group showed better results than UC group (P<0.05). By the end of the 2nd week, all the primary outcome measures revealed that either the AP + UC or EA + UC group demonstrating remarkable advantages compared with the UC group (P<0.05). The social functioning and general health domains of AQoL-SF36 in the two acupuncture-intervention groups were improved significantly than UC group (P<0.05). We also found the energy/fatigue and emotional wellbeing domains of AQoL-SF36 in the EA + UC group demonstrated better results than UC group (P<0.05).

CONCLUSION:AP or EA combined with usual care is more effective than usual care alone for the treatment of KOA, the intervention of electric current in the process of acupuncture may improve more domains of AQoL-SF36 in KOA patients.

BACKGROUND:Osteoarthritis of the knee is the most common chronic joint disease that involves middle aged and elderly people. The purpose of this study was to investigate the effect of aromatherapy massage with lavender essential oil on pain in patients with osteoarthritis of the knee.

METHODS:In this single-blinded, randomized clinical trial, 90 patients with osteoarthritis of the knee who referred to the outpatient rheumatology clinics affiliated with Birjand University of Medical Sciences were selected through convenience sampling method. They were randomly assigned to three groups: intervention (aromatherapy massage with lavender essential oil), placebo (massage with almond oil) and control (without massage). The patients were evaluated at baseline, immediately after the intervention, 1 week, and 4 weeks after the intervention in terms of pain via visual analogue scale. The data were analyzed in SPSS (version 16) using the repeated measure ANOVA, one-way ANOVA, and chi-squared test.

RESULTS:Pain severity of the patients in the intervention group was significantly different immediately and 1 week after the intervention compared with their initial status (p < 0.001) and that of the control group (p < 0.001 and p = 0.009 respectively). However, at the third phase of follow-up (i.e., 4 weeks after the intervention), there was no significant difference between the groups according to the visual analogue scale (p = 0.67).

CONCLUSION:Aromatherapy massage with lavender essential oil was found effective in relieving pain in patients with knee osteoarthritis. However, further studies are needed to confirm findings of this study.

This study aimed to investigate whether balneotherapy (BT) applied in combination with physical therapy (PT) has a more positive effect in patients aged 65 years and older with knee osteoarthritis (KOA) compared to PT alone. A total of 305 individuals were randomized into two groups. Group I was applied PT alone; group II was applied PT + BT. Assessments were made using the Pain (VAS), EQ-5D-3L Scale, Western Ontario And McMaster Universities Osteoarthritis Index (WOMAC), Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) Scale, Epworth Sleepiness scale (EPWORTH) and the Outcome Measures in Rheumatology-The Osteoarthritis Research Society International set of responder criteria for osteoarthritis (OMERACT-OARSI) at the beginning (T0) and at the end (T1) of treatment. Statistically significant interactions found between treatment (PT alone or PT + BT) and time (before treatment and after treatment) in terms of Pain-VAS, Pain-WOMAC, Stiffness-WOMAC, Physical Function-WOMAC, Total-WOMAC, EQ-5D, EQ-VAS, FACIT-F, and EPWORTH scores (p < 0.0001 for all). According to OMERACT-OARSI criteria, the responder rate was 89.04% in PT alone group and 98.74% in PT + BT group. Balneotherapy plus physical therapy was more effective than physical therapy alone in KOA patients aged over 65 years. Reducing pain, especially, positively contributes to functionality, quality of life, fatigue and sleepiness of KOA patients.

BACKGROUND/OBJECTIVE:The aim of this study is to investigate the effect of mud compress (MC) therapy compared to hot pack (HP) therapy on cartilage destruction and subchondral bone alterations detected by urine levels of C telopeptide fragment of collagen type-II (uCTX-II) in patients with knee osteoarthritis (OA).

METHODS:Fifty-nine patients between 49-74 years of age with bilateral knee OA divided into 2 groups. Twenty-five patients (16 females, 9 males) and 34 patients (22 females, 13 males) were given HP and local natural organic and mineral-rich MC therapy respectively for 2 weeks as a total of 12 sessions. uCTX-II, Visual Analog Scale (VAS), 15 m walking time, Western Ontario and McMaster Universities multifunctional (WOMAC) index were measured at baseline, after-treatment and 3 months after treatment.

RESULTS:uCTX-II level did not show any difference between the two groups, however it decreased significantly in MC and HP groups 3 months after treatment (p<0.017). WOMAC stiffness sore was significantly lower in MC group 3 months after treatment (p<0.05). Both MC and HP therapies lowered VAS, WOMAC total and subscores significantly up to 3 months (p<0.017).

CONCLUSIONS:HP and MC therapies for OA of knee are not superior to one another with respect to the level of uCTX-II. MC may probably decrease the ongoing cartilage destruction and related subchonral bone interactions earlier compared to HP treatment in patients with knee OA as evidenced by decreased uCTX-II levels after-treatment.

INTRODUCTION:Our objective was to compare the effectiveness and safety of traditional Chinese moxibustion to that of sham moxibustion in patients with chronic knee osteoarthritis (KOA) pain.

METHODS:We conducted a randomized placebo-controlled trial involving 110 patients with KOA who met the inclusion criteria. These patients randomly received either active moxibustion (n = 55) or sham moxibustion control (n = 55) at acupoints Dubi (ST 35), extra-point Neixiyan (EX-LE 4), and an Ashi (tender) point three times a week for 6 weeks. Effects were evaluated with Western Ontario and McMaster Universities' Osteoarthritis Index (WOMAC VA 3.1) criteria at the end ofthe course of treatment and 3, 12, and 24 weeks after the initial treatment.

RESULTS:The WOMAC pain scores showed greater improvement in the active treatment group than in control at weeks 3 (P = 0.012), 6 (P<0.001), 12 (P = 0.002), and 24 (P = 0.002) as did WOMAC physical function scores of the active treatment group at week 3 (P = 0.002), 6 (P = 0.015), and 12 (P<0.001) but not 24 (P = 0.058). Patients and practitioners were blinded successfully, and no significant adverse effects were found during the trial.

CONCLUSIONS:A 6-week course of moxibustion seems to relieve pain effectively and improve function in patients with KOA for up to 18 weeks after the end of treatment. Moxibustion treatment appears to be safe, and the usefulness of the novel moxa device was validated.

TRIAL REGISTRATION:Current controlled trial: ISRCTN68475405. Registered 4 April 2014.

AIM:To investigate the effects of aromatherapy massage on pain, functional state and life quality of elderly individuals with knee osteoarthritis.

METHODS:This controlled and experimental study was conducted in two nursing homes. In this study, 90 elderly individuals with knee osteoarthritis were randomized as aromatherapy, massage and control groups. Data were collected in weeks 0, 4, and 8 using Patient Information Form, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) Knee Osteoarthritis Evaluation Scale, OsteoArthritis Knee and Hip Quality of Life Scale (OAKHQoL). Aromatherapy and massage groups received a total of 15-20 min total classic leg massage twice weekly for 3 weeks. In the aromatherapy group, two essential oils (ginger and rosemary) were added to the black seed oil.

RESULTS:In the aromatherapy group, WOMAC (pain and functional state) scores were lower and quality of life scores were higher than the massage and control groups in week 4, and these differences were statistically significant (p < .001). These significant differences were present in the massage group when compared with the control (p < .001). These significant differences in the aromatherapy group were also sustained decreasingly in week 8 (p < .001), while the means were not different from baseline in the massage group (p > .05).

CONCLUSIONS:Aromatherapy massage performed in elderly patients with knee osteoarthritis reduced pain and improved functional status and quality of life. The week 8 findings showed that aromatherapy has more favorable and longer sustained effects than the massage.

Knee osteoarthritis (OA) is a degenerative disease which is expected to become one of the leading causes of disability by the next years. This work aims to assess if balneotherapy and spa therapy can significantly improve Quality of Life (QoL) of patients with knee OA. Medline via PubMed, Scopus, Web of Science, Cochrane Library, and PEDro were systematically searched for articles about trials involving patients with knee OA and measuring the effects of balneotherapy and spa therapy on study participants' QoL with validated scales. A qualitative and quantitative syntheses were performed. Seventeen studies were considered eligible and included in the systematic review. Fourteen trials reported significant improvements in at least one QoL item after treatment. Ten studies were included in quantitative synthesis. When comparing balneological interventions with standard treatment, results favored the former in terms of long-term overall QoL [ES = - 1.03 (95% CI - 1.66 to - 0.40)]. When comparing balneological interventions with sham interventions, results favored the former in terms of long-term pain improvement [ES = - 0.38 (95% CI - 0.74 to - 0.02)], while no significant difference was found when considering social function [ES = - 0.16 (95% CI - 0.52 to 0.19)]. In conclusion, even though limitations must be considered, evidence shows that BT and spa therapy can significantly improve QoL of patients with knee OA. Moreover, reduction of drug consumption and improvement of algofunctional indexes may be other beneficial effects. Further investigation is needed because of limited available data.

The objective of our study was to assess the efficacy of external qigong therapy (EQT), a traditional Chinese medicine practice, in reducing pain and improving functionality of patients with knee osteoarthritis (OA). One hundred twelve adults with knee OA were randomized to EQT or sham treatment (control); 106 completed treatment and were analyzed. Two therapists performed EQT individually, five to six sessions in 3 weeks. The sham healer mimicked EQT for the same number of sessions and duration. Patients and examining physician were blinded. Primary outcomes were Western Ontario MacMaster (WOMAC) pain and function; other outcomes included McGill Pain Questionnaire, time to walk 15 m, and range of motion squatting. Results of patients treated by the two healers were analyzed separately. Both treatment groups reported significant reduction in WOMAC scores after intervention. Patients treated by healer 2 reported greater reduction in pain (mean improvement -25.7 +/- 6.6 vs. -13.1 +/- 3.0; p<0.01) and more improvement in functionality (-28.1 +/- 9.7 vs. -13.2 +/- 3.4; p<0.01) than those in sham control and reduction in negative mood but not in anxiety or depression. Patients treated by healer 1 experienced improvement similar to control. The results of therapy persisted at 3 months follow-up for all groups. Mixed-effect models confirmed these findings with controlling for possible confounders. EQT might have a role in the treatment of OA, but our data indicate that all EQT healers are not equivalent. The apparent efficacy of EQT appears to be dependent on some quality of the healer. Further study on a larger scale with multiple EQT healers is necessary to determine the role (if any) of EQT in the treatment of OA and to identify differences in EQT techniques.

OBJECTIVE:To determine the effects of low-magnitude whole body vibration (WBV) on the structure and function of subchondral trabecular bones, cartilage degradation, bone/cartilage turnover, and osteoarthritis (OA) joint function.

METHODS:Knee osteoarthritis model was established in 96 rabbits through left anterior cruciate ligament transaction (ACLT). The rabbits were randomly divided into six groups: ACLT control group, WBV+ACLT group (five subgroups, each comprising 16 rabbits receiving 5 Hz, 10 Hz, 20 Hz, 30 Hz and 40 Hz WBV, respectively, with 2-4 mm amplitude for 40 min/d and 5 d/week over a period of 8 weeks). Joint function was tested via weight-bearing asymmetry. The microarchitecture of subchondral trabecular bones was examined using vivo micro-computed tomography (micro-CT). Cartilage samples from knee joints were taken for gross morphology and histology examinations. Serum samples were taken to detect cartilage oligomeric matrix protein (COMP), C-terminal telopeptide of typeⅠ collagen (CTX)-Ⅰ and urine CTX-Ⅱ.

RESULTS:Knee joint pain decreased with 10 Hz (P<0.05) and 20 Hz WBV treatment (P<0.05) , but increased with 40 Hz treatment (P<0.05). The micro-CT results showed that articular cartilage increased first, peaked at 20 Hz, and then decreased (P<0.05) . With increased frequency of WBV, the trabecular number, subchondral bone thickness and bone volume fraction increased, serum CTX-Ⅰ decreased, COMP and CTX-Ⅱ increased, especially at 20 Hz (P<0.05).

CONCLUSION:Lower frequency (20 Hz) WBV can improve bone microstructure, increase bone turnover, delay cartilage degeneration and improve limb function of rabbits with OA.

Background:Osteoarthritis (OA) is the most common musculoskeletal disease in the world. OA is the result of an inflammatory and degenerative process affecting the entire joint. Osteoarthritis, especially involving the knee, has a relevant socioeconomic impact in terms of drugs, hospital admissions, work absences, and temporary or permanent invalidity. Therapy of knee osteoarthritis is based on pharmacological and nonpharmacological measures.

Methods:We conducted a systematic review of the studies published between 2002 and 2017 on spa therapy, mud-pack therapy, balneotherapy, and mud-bath therapy in the treatment of knee osteoarthritis in order to investigate the evidence of the efficacy of such treatment on pain, functional limitation, drug use, and quality of life. Overall, 35 studies were examined among which 12 were selected and included in the review if they are trial comparative. We have been able to illustrate the main results obtained in the individual studies and to elaborate these results in order to allow as much a unitary presentation as possible and hence an overall judgment.

Results:Because the studies we reviewed differed markedly from one another in terms of the methods used, we were unable to conduct a quantitative analysis (meta-analysis) of pooled data from the 12 studies. For the purposes of the present review, we reevaluated the results of the different studies using the same statistical method, Student's-test, which is used to compare the means of two frequency distributions. Among all the studies, the most relevant indexes used to measure effectiveness of spa therapy were improved including VAS, Lequesne, and WOMAC Score.

Conclusions:The mud-pack therapy, balneotherapy, mud-bath therapy, and spa therapy have proved to be effective in the treatment and in the secondary prevention of knee osteoarthritis, by reducing pain, nonsteroidal anti-inflammatory drug consumption, and functional limitation and improving quality of life of affected patients.

Knee osteoarthritis (KOA) is a common chronic degenerative disease of the elderly. Electro-acupuncture (EA) is considered as a beneficial treatment for KOA, but the conclusion is controversial. This systematic review compiled the evidence from 11 randomized controlled trials to objectively assess the effectiveness and safety of EA for KOA. Eight databases including PubMed, Cochrane Library, Clinic trials, Foreign Medical Literature Retrial Service (FMRS), Science Direct, China National Knowledge Infrastructure (CNKI), Chinese Scientific Journal Database (VIP), and Wanfang Data were extensively searched up to 5 July 2016. The outcomes included the evaluation of effectiveness, pain and physical function. Risk of bias was evaluated according to the Cochrane risk of bias tool. Eleven RCTs with 695 participants were included. Meta-analysis indicated that EA was more effective than pharmacological treatment (RR [Formula: see text] 1.14; 95% CI [Formula: see text] 1.01,1.28; [Formula: see text]) and manual acupuncture (RR [Formula: see text] 1.12; 95% CI [Formula: see text] 1.02,1.22; [Formula: see text]). Also, EA had a more significant effect in reducing the pain intensity (SMD [Formula: see text]; 95% CI [Formula: see text]; [Formula: see text]) and improving the physical function in the perspective of WOMAC (MD [Formula: see text]; 95% CI [Formula: see text], 5.56; [Formula: see text]) and LKSS (pharmacological treatment: MD [Formula: see text]; 95% CI [Formula: see text], 6.64; [Formula: see text]). Furthermore, these studies implied that EA should be performed for at least 4 weeks. Conclusively, the results indicate that EA is a great opportunity to remarkably alleviate the pain and improve the physical function of KOA patients with a low risk of adverse reaction. Therefore, more high quality RCTs with rigorous methods of design, measurement and evaluation are needed to confirm the long-term effects of EA for KOA.

OBJECTIVE:We aimed to explore the feasibility of evaluating the comparative effectiveness and safety of electroacupuncture (EA) relative to manual acupuncture (MA) for the treatment of knee osteoarthritis (KOA).

METHODS:A multicenter randomized controlled clinical trial was conducted in Beijing from September 2017 to January 2018. A total of 60 participants with KOA were randomly allocated to either EA ( = 30) or MA ( = 30) groups. Participants in the EA group were treated with EA at six to seven local traditional acupuncture points orpoints, and two to three distal points. Participants in the MA group had the same schedule as the EA group except that the electrical apparatus featured a working power indicator without actual current output, constituting a sham EA procedure, in order to blind participants. Both groups received 24 sessions over 8 weeks. The primary outcome was response rate, defined as a change of ⩾50% from baseline in the total scores of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) after 8 weeks. Secondary outcomes included pain, stiffness, function, quality of life, and acupuncture-related adverse events (AEs) at 4 and 8 weeks.

RESULTS:Of 60 participants randomized, 53 (88%) completed the study. Response rates were 43% for the EA group and 30% for the MA group by the intention-to-treat analysis. Although significant differences were observed in WOMAC pain, stiffness, and function scores within both groups, between-group differences at 8 weeks did not reach statistical significance (odds ratio = 1.75 (95% confidence interval = 0.593-5.162)). Rates of AEs were low and similarly distributed between groups.

CONCLUSION:Both EA and MA interventions in KOA were feasible and appeared safe. Whether or not EA may have a stronger impact on pain and function requires further evaluation through larger, adequately powered, randomized controlled trials.

TRIAL REGISTRATION NUMBER:NCT03274713.