EFFECTS OF PHYSIOTHERAPY IN COMBINATION WITH INTRA ARTICULAR INJECTION FOR KNEE OSTEOARTHRITIS: A NETWORK META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS

C.-D. Liao¹, S.-W. Huang¹, T.-H. Liou¹

¹Taipei Medical University, New Taipei City, Taiwan

Background: Knee osteoarthritis (KOA) are associated with high risk of sarcopenia and disability. Physical therapy (PT) as well as intra-articular injections (IAI) are effective treatments on pain relief and physical mobility recovery in middle-aged and older people with KOA. The relative effects among treatment regimens of various IAIs and its combination with PT for KOA remain unclear.

Purpose: The purpose of this network meta-analysis (NMA) was to investigate the relative effects among monotherapy of IAIs and PT, and the combined treatment regimens on pain, global function, and walk capability for KOA.

Methods: Seven electronic databases (PubMed, EMBASE, CINAHL, the Cochrane Library, PEDro, the China Knowledge Resource Integrated Database, and Google Scholar) were systematically searched from inception until June 2022. The present study was conducted according to the guidelines recommended by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis. Randomized controlled trials (RCTs) that reported the effects of IAIs alone and the combined treatments IAI plus PT versus PT alone for KOA were identified. No limitation was imposed on the publication year or language. The included RCTs were analyzed through NMA and risk-of-bias assessment. Ranking probabilities of effect estimation among treatments per outcome were expressed by the surface-under-the-cumulative-ranking (SUCRA) score. Network meta-regression was performed to explore the moderators of treatment efficacy on each main outcome.

Results: We included 80 RCTs along with 181 treatment arms in the NMA. A total of 6757 patients who had mean age of 59.6 (range, 42.0-77.9) years and mean body mass index of 29.8 (range, 23.3-34.3) kg/m were recruited. Seven IAIs were identified for NMA including corticosteroid, botulinum toxin type A, hyaluronic acid, ozone, dextrose prolotherapy, plateletrich plasma, and mesenchymal stem cell. In summary, dextrose prolotherapy plus PT were the most effective treatments for reducing pain [standard mean difference (SMD) = −2.02; SUCRA = 0.93] and restoring function (SMD = 1.36; SUCRA = 0.86), whereas hyaluronic acid plus PT was ranked as the most effective (SMD = 0.71; SUCRA = 0.86) among all treatment arms for increasing walk capability. Disease severity (i.e., Kellgren and Lawrence grading system for classification of KOA) influenced the treatment outcome. Trials enrolled a greater number of patients who were classified as moderate to severe disease severity may obtain greater treatment effects on pain (β = −1.34; 95% credible interval = −2.59, −1.18) and global function (β = 0.56; 95% credible interval = 0.09, 1.07).

Conclusions: Combined treatments PT plus IAI exerts additional benefits for middle-aged and older adults with KOA, compared to either IAI alone or PT alone. Such treatment efficacy may be moderated by disease severity.

Implications: Physiotherapy in combination with IAI, especially the dextrose prolotherapy and hyaluronic acid, exert extra benefits in addition to the monotherapy for KOA.

Funding acknowledgements: This study was funded by grants from Taipei Medical University (grant no.111TMU-SHH-13).

Keywords:
Osteoarthritis
Physiotherapy
Injection

Topics:
Orthopaedics
Pain & pain management
Musculoskeletal: lower limb

Did this work require ethics approval? No

Reason: Ethical review and approval were not applicable for this study, due to the research design of systemic review and network metaanalysis. This systemic review and network meta-analysis followed the guidelines the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). All of the included randomized controlled trials obtained individual approvals from the respective local research ethics committee.