
==== Front
Medicine (Baltimore)
Medicine (Baltimore)
MD
Medicine
0025-7974
1536-5964
Lippincott Williams & Wilkins Hagerstown, MD

39312376
MD-D-23-11021
00077
10.1097/MD.0000000000039660
3
7000
Research Article
Systematic Review and Meta-Analysis
Effects of different traditional Chinese exercise for knee osteoarthritis patients: A network meta-analysis of randomized controlled trials
https://orcid.org/0009-0009-3960-7559
Tao Tao MM 475710174@qq.com
a
Shi Ming-Peng MD dr.shimingpeng@qq.com
b
Zhang Xian-Shuai MD 1195536787@qq.com
b
Tan Bo-Yang MM 1352671479@qq.com
a
Xiao Ya-Nan MM 807480451@qq.com
a
Sun Feng-Ling BD 3144198280@qq.com
c
Li Shao-Jun MD lizhenhua1972@163.com
c
https://orcid.org/0000-0003-0117-7492
Li Zhen-Hua MD c*
a College of Integrated Chinese and Western Medicine, Changchun University of Chinese Medicine, Changchun, China
b College of Traditional Chinese Medicine, Changchun University of Chinese Medicine, Changchun, China
c Affiliated Hospital of the Changchun University of Chinese Medicine, Changchun, China.
* Correspondence: Li Zhen-Hua, Affiliated Hospital of the Changchun University of Chinese Medicine, Changchun, China (e-mail: lizhenhua1972@163.com).
20 9 2024
20 9 2024
103 38 e3966006 12 2023
17 8 2024
22 8 2024
Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.
2024
https://creativecommons.org/licenses/by-nc/4.0/ This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial License 4.0 (CCBY-NC), where it is permissible to download, share, remix, transform, and buildup the work provided it is properly cited. The work cannot be used commercially without permission from the journal.

Background:

The most popular traditional Chinese exercise (TCE) techniques include Tai Chi, Yijinjing, Baduanjin, Wuqinxi, and Qigong. Exercise is advised as a primary treatment for knee osteoarthritis (KOA) according to clinical standards. According to several studies, TCE may be an effective way to help people with KOA manage their pain, stiffness, and physical function. Which TCE therapy is the most effective and whose particular usefulness is still debatable. The network meta-analysis (NMA) method is used in this study to evaluate and compare the effects of various TCE therapies on KOA patients.

Methods:

We will search PubMed, Embase, Scopus, Cochrane Library, Web of Science, the China National Knowledge Infrastructure, Wanfang, the Chinese Scientific Journal Database (VIP), and the China Biology Medical Literature Database (CBM) for randomized controlled trials reporting TCE therapy for KOA patients published before October 25, 2023. The Stata 16.0 program will compare the effectiveness of various TCE therapies on KOA patients using conventional pairwise and NMA.

Results:

The final 29 studies included 15 articles on Tai Chi, 7 articles on Baduanjin, 4 articles on Wuqinxi, and 3 articles on Yijinjing. Tai Chi was first for the effect sizes of VAS scores, WOMAC pain scores, and WOMAC available scores, while Baduanjin was ranked top for WOMAC stiffness scores. Research should continue to be conducted on the effect of Qigong on KOA intervention.

Conclusions:

This NMA will help determine the best TCE treatment for KOA and offer evidence-based bias for clinical decision-making.

knee osteoarthritis
network meta-analysis
traditional Chinese exercise
Jilin Province Science and Technology Development Plan ProjectNo:20210101205JC Zhenhua LIOPEN-ACCESSTRUE
SDCT
==== Body
pmc1. Introduction

Knee osteoarthritis (KOA) is a chronic degenerative disease typified by damage to the cartilage of the knee joint and secondary periprosthetic bone growth around the knee joint, which can contribute to knee pain, stiffness, and function loss.[1] In China, the prevalence of symptomatic KOA is 8.1%, with a higher proportion of females than males and significant geographical variations.[2] Women are more susceptible to osteoporosis due to variations in hormone metabolism levels following menopause, which may also have an impact on osteoarthritis. The majority of this illness positively correlates with the faster rate at which sociodemographic aging occurs, which significantly negatively impacts the quality of life of the affected population.[3]

KOA can be managed through pharmacotherapy, physical therapy, rehabilitation therapy, acupuncture, massage, surgery (including total knee replacement), and other approaches. At present, the leading oral drugs used for KOA treatment are nonsteroidal anti-inflammatory drugs (NSAIDs), chondroprotective drugs (CP), and opioid drugs. However, long-term use of these drugs poses a risk of various adverse reactions, such as congestive heart failure, hypertension, renal toxicity, gastrointestinal damage, and cardiovascular events.[4] Additionally, physical therapy has some restrictions, including the fact that it is not suitable for terminal patients who require surgery. Treatment of patients with early KOA is nonoperative and does not require surgery.[5] Finding a viable nonsurgical intervention to alleviate symptoms in patients with KOA is imperative, given that early-stage surgery is not recommended. According to the findings of a systematic review on therapeutic exercise for KOA, patients may experience a substantial reduction in joint pain and an enhancement in their overall quality of life and physiological function.[6] The objective of exercise therapy is to enhance the functionality of any body part by utilizing the patient’s strength, the assistance of the therapist, or the rehabilitation apparatus. Therefore, exercise is an effective complementary therapy critical in KOA treatment.

Although there is evidence that[7] the therapeutic benefit of exercise differs depending on the type of exercise, more research is still needed to determine the relative effects of various workouts on various outcomes. Traditional Chinese exercise (TCE) is an aerobic exercise with a long history in China. It is essential for treating knee osteoarthritis as a supplemental and alternative therapy.[8] The commonly used TCE methods include TaiChi, Yijinjing, Baduanjin, Wuqinxi, and Qigong.

Most randomized control trials (RCTs) on exercise therapy for KOA have focused on comparing exercise interventions with nonexercise interventions rather than directly comparing different TCE types. The purpose of the present study was to perform a systematic review and network meta-analysis (NMA) of RCTs to evaluate and compare the effects of various TCE therapies (TaiChi, Yijinjing, Baduanjin, Wuqinxi) on KOA patients.

2. Materials and methods

2.1. Design and registration

This NMA followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses[9] for its reporting. The findings of this study will be reported according to the Preferred Reporting Items for Systematic Reviews and Network Meta-Analysis[10] policy. This study’s NMA protocol was submitted to PROSPERO with the following registration information: CRD42023449262.

2.2. Eligibility criteria

2.2.1. Criteria for Inclusion

2.2.1.1. Types of studies

RCTs are considered the gold standard in clinical research. This study is a qualitative analysis of RCTs using TCE as an intervention. RCTs report the efficacy of TCE for patients with KOA.

2.2.1.2. Types of participants

The survey population comprises anyone who satisfies the American College of Rheumatology (ACR) for Osteoarthritis of the Knee diagnostic standards, the Chinese Medical Association Orthopaedic Branch, or the domestic industry standard for Western or Chinese medicine KOA. There will be no restrictions on participants’ Age, gender, educational background, course of disease of patients, location, or race.

2.2.1.3. Types of interventions

In the experimental group, patients will receive TCE therapies such as Tai Chi, Baduanjin, Wuqinxi, Yijinjing, and Qigong, among others. Those in the control group will receive conventional management, consisting of exercises that are not TCE, customary care, health education, a blank control, and supplemental therapies not administered to the test group.

2.2.1.4. Types of outcomes

The evaluation indexes used in this study were those recommended by the Osteoarthritis Research Society International (OARSI)[11] and Chinese guidelines for rehabilitating KOA[12] for assessing the prognosis of KOA, namely knee pain, stiffness, and physical functionality.

The pain severity of knee discomfort was measured using a visual analog scale (VAS).[13] The total score of Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)[14] incorporates pain, physical functionality, and stiffness. The worse knee function becomes as the global WOMAC score increases.

2.2.2. Disqualification standards

Non-RCTs;

multiple-publication literature;

Editorials, correspondence, in-depth research, animal testing, case studies, conference papers, conference abstracts, books, reviews, and other relevant materials;

Other diseases in participants;

Mixed complementary and alternative interventions in addition to traditional Chinese medicine methods (e.g., tui na, acupuncture, herbal therapy, moxibustion therapy, transcutaneous electrical nerve stimulation, fire cupping therapy, gua sha therapy, or bathing therapy) and combined other complementary and alternative interventions;

Literature with limited data information and the inability to extract data;

Literature for which the complete text was unavailable.

2.3. Search strategy

RCT reporting TCE therapies for KOA patients, published before October 25, 2023, will be searched for in PubMed, Embase, Scopus, Cochrane Library, and Web of Science, the China National Knowledge Infrastructure, Wanfang, the Chinese Scientific Journal Database (VIP), and the China Biology Medical Literature Database (CBM). Additionally, we examined the references in each included study to identify any pertinent papers that may have been overlooked during the search. In addition, manual searches were conducted of the research registry, pertinent gray literature, and consultations with experts in the relevant fields. The search language is not restricted. Appendix 1, Supplemental Digital Content, http://links.lww.com/MD/N579 contains search strategies for all databases.

2.4. Study selection and data analysis

2.4.1. Data source and eligibility

Two researchers will perform the literature review. Disputes were resolved through discussion, and if no consensus could be reached, a third reviewer was involved in making the final determination. The literature was screened using the Endnote X9 software. The software was used to remove duplicates, which were then manually examined; the titles and abstracts of the literature were carefully read; the inclusion and exclusion criteria filtered out those that were incompatible; the entire manuscript was downloaded and read, and any interventions, outcome measures, or study participants that did not meet the parameters of the study were eliminated – the exclusion of studies with insufficient data. The included literature has generated a database of eligible RCTs and has downloaded their unabridged texts.

2.4.2. Data extraction

Two researchers will independently extract data using the inclusion and exclusion criteria, and the data will be eliminated through cross-checking. Disagreements were resolved through dialogue, with a third researcher rendering the final decision. If there are any absent data in the relevant study, the original data will be requested via email; otherwise, they will be excluded. In a table, the essential parameters of the collected literature were summarized. RCT information in experimental and control groups, including authors, year of publication, control group details (e.g., intervention timing, intervention type, frequency), participant baseline characteristics, and measurement tools.

2.4.3. Risk of bias assessment

The Cochrane risk of bias tool for randomized trials (ROB 2)[15] will assess the methodological integrity of included RCTs, which examined potential selection bias (random sequence generation and allocation concealment), performance bias (blinding of patients and personnel), detection bias (blinding of outcome assessment) and attrition bias (incomplete outcome data), reporting bias (selective outcome reporting), and other preferences. Each item will be classified as high-risk, low-risk, or some concerns. Three researchers will be responsible for determining and evaluating the risk of bias based on the RCTs’ descriptions of the abovementioned factors.

2.4.4. Statistical analysis

The procedure for reticulated META-analysis is as follows: Using Bayesian NMA methods, the comparative efficacy of various TCE therapies for KOA patients was evaluated. The Bayesian NMA combines direct and indirect evidence regarding relative treatment effects.[16] The Markov Chain Monte Carlo method was used to estimate posterior densities for unknown variables.[17] A random effects model was chosen as the most suitable and conservative method to account for differences between RCTs.[18]

Using Stata16.0, the data were sequentially analyzed with traditional META-analysis and reticulated META-analysis. The network diagram describes and presents the geometry of the various interventions, with the size of each node weighted according to the number of participants receiving a specific intervention and the thickness of the line connecting 2 nodes weighted according to the number of studies directly comparing their connected interventions.

The combined effect sizes of continuous variables in the conventional META-analysis’s Predictive intervals plot (forest plots) were expressed as mean difference (MD) when the mean values of the outcome indicators differed substantially or when the units of the same hand differed; they were described as standardized mean difference (SMD). In this study, The outcome indicators VAS were using MD and 95% confidence interval (95% CI), with MD < 0 indicating that 1 treatment was superior to the other and MD > 0 indicating the opposite; a 95% CI of 0 indicating that the difference between the 2 groups was not statistically significant. The outcome indicators WOMAC pain, WOMAC stiffness, and WOMAC function score were all continuous variables expressed using standardized mean difference (SMD) and 95% confidence interval (95% CI), with SMD < 0 indicating that the former treatment was superior to the latter, and SMD > 0 indicating the opposite; a 95% CI of 0 indicating that the difference between the 2 groups was not statistically significant.

Two Markov chains with distinct initial values run concurrently. When each intervention had a closed-loop structure, a test for heterogeneity and global design inconsistencies was administered to evaluate the consistency between the direct and indirect comparison results.

The cumulative ranked probability plot under the area of the SUCRA value/% (0 < SUCRA < 1) was used to rank the strengths of the interventions; the closer the SUCRA value was to 1, the more influential the interventions were, and the closer it was to 0, the less effective they were.

Comparison correction funnel plots were plotted to analyze publication bias if ten or more papers were included in this meta-analysis.[19,20] We estimated publication bias by visually scrutinizing the asymmetry of the funnel plots.

3. Result

3.1. Literature search and selection

The initial search yielded 12,278 results. EndNote X9 was used to remove 2994 articles after duplicates were removed, leaving 9334 records. By filtering the titles and abstracts, 9173 articles were eliminated. After reading the full text of the remaining 161 articles, an additional 132 were excluded, including 27 papers with insufficient data, 11 from conferences proceeding, 36 with interventions other than TCE approaches, 4 letters/notes, 5 meeting abstracts, 18 with outcomes not aiming at VAS or WOMAC, 8 that were not RCTs, 11 with participants other than KOA, 4 protocols, 1 that was the short survey,6 with trial registry record, and 1 withdraw a manuscript. One RCT examining Qigong[21] was excluded from the reticulated meta-analysis due to its inability to participate. According to the inclusion and exclusion criteria, a total of 29 RCTs[22–50] that met the inclusion criteria were obtained. After accumulating, organizing, analyzing, and summarizing the pertinent literature, a framework for a comprehensive review was developed. Figure 1 depicts the flowchart for the literature filtering procedure.

Figure 1. Flow chart of literature screening.

3.2. Characteristics of included reviews

The final 29 RCTs included 15 articles on Tai Chi, 7 articles on Baduanjin, 4 on Wuqinxi, and 3 on Yijinjing. Totally, 17 in English and 12 in Chinese. Also, there are 26 journal articles and 3 dissertations. The spectrum of publication years is between 2007 and 2022. 14 (1183 participants) of the 29 (2208 participants) trials reported VAS scores, 19 (1254 participants) reported WOMAC Pain scores, 18 (1211 participants) reported WOMAC Physical function scores, 19 (1254 participants) said WOMAC Stiffness score, and 11 items (704 participants) wrote WOMAC score. The characteristics of the included evaluations are summarized in Table 1.

Table 1 Basic characteristics of included reviews.

Study	Design	Interventions group	Control group	Sample size
(Interventions/control)	Mean age (years)
(Interventions/control)	Treatment duration	Outcomes	
Ariayi 2017[24]	RCT	TC	Isometric exercises	24 (12/12)	51.6 ± 08.69
54.6 ± 92.27	8 wk	VAS	
Callahan 2016[25]	RCT	TC	No intervention	284 (151/133)	66.5 ± 11.1
66.3 ± 11.8	8 wk	VAS	
Cao 2018[26]	RCT	TC	Health education	41 (22/19)	70.89 ± 9.8
68.89 ± 8.9	18 wk	VAS;WOMAC	
Hu 2020[27]	RCT	TC	Health education	92 (52/40)	66.32 ± 4.16
65.54 ± 3.59	12 wk	VAS; WOMAC Pain; WOMAC Stiffness; WOMAC Physical Function	
Kang 2022[28]	RCT	TC	Education	27 (12/15)	63.4 ± 4.6
64.7 ± 6.1	36 wk	VAS	
Lee 2009[29]	RCT	TC	No intervention	44 (29/15)	70.2 ± 4.8
66.9 ± 6.0	8 wk	WOMAC	
Song 2007[30]	RCT	TC	No intervention	43 (22/21)	64.8 ± 6.0
62.5 ± 5.6	10 wk	WOMAC Pain; WOMAC Stiffness	
Song 2009[31]	RCT	TC	Self-help	69 (30/39)	62.36 ± 7.56
59.94 ± 7.83	24 wk	WOMAC Pain; WOMAC Stiffness; WOMAC Physical Function	
Song 2022[32]	RCT	TC	Health education	40 (20/20)	64.15 ± 8.56
64.15 ± 8.56	24 wk	WOMAC Pain; WOMAC Stiffness; WOMAC Physical Function	
Wortley 2013[33]	RCT	TC	No intervention	18 (12/6)	68.1 ± 5.3
70.5 ± 5.0	10 wk	WOMAC Pain; WOMAC Stiffness; WOMAC Physical Function	
Xu 2016[34]	RCT	TC	Anti-inflammatory, analgesic, and other drug treatments, routine health guidance	120 (60/60)	73.44 ± 4.28
69.90 ± 1.46	12 wk	WOMAC Pain; WOMAC Stiffness; WOMAC Physical Function	
Zheng 2019①[35]	RCT	TC	Regular functional exercise	72 (36/36)	61.14 ± 6.26
59.81 ± 6.27	20 wk	VAS;WOMAC	
Zheng 2019②[36]	RCT	TC	Glucosamine Hydrochloride Capsules	80 (40/40)	67.10 ± 6.51
66.25 ± 6.01	20 wk	VAS	
Zhou 2019[37]	RCT	TC	No intervention	30 (15/15)	64.08 ± 1.05
64.21 ± 0.98	18 wk	VAS	
Zhu 2016[38]	RCT	TC	Health education	46 (23/23)	64.61 ± 3.40
64.53 ± 3.43	24 wk	WOMAC Pain; WOMAC Stiffness; WOMAC Physical Function	
An 2008[39]	RCT	BD	No intervention	21 (11/10)	65.4 ± 8.2
64.6 ± 6.7	8 wk	WOMAC Pain; WOMAC Stiffness; WOMAC Physical Function	
Liu 2018[40]	RCT	BD	Routine care	60 (30/30)	NA	4 wk	WOMAC	
Wang 2016[41]	RCT	BD	Meloxicam capsules	60 (30/30)	NA	12 wk	VAS;WOMAC	
Yang 2019[42]	RCT	BD	No intervention	148 (76/72)	NA	12 wk	VAS	
Yang 2021[43]	RCT	BD	Routine care	100 (50/50)	69.82 ± 4.72
71.54 ± 3.12	8 wk	VAS;WOMAC	
Ye 2020①[44]	RCT	BD	No intervention	56 (28/28)	65.11 ± 6.57
63.61 ± 2.63	12 wk	WOMAC	
Ye 2020②[45]	RCT	BD	No intervention	50 (25/25)	64.48 ± 7.81
63.08 ± 3.65	12 wk	WOMAC	
Tian 2012[46]	RCT	WQX	No intervention	40 (20/20)	NA	24 wk	WOMAC	
Xiao 2020[47]	RCT	WQX	Conventional physical therapy	85 (45/40)	70.7 ± 9.36
70.2 ± 10.35	24 wk	WOMAC Pain; WOMAC Stiffness; WOMAC Physical Function	
Xiao 2021①[48]	RCT	WQX	No intervention	266 (132/134)	71 ± 2.92
69 ± 3.72	24 wk;	WOMAC Pain; WOMAC Stiffness; WOMAC Physical Function	
Xiao 2021②[49]	RCT	WQX	Conventional physical therapy	68 (34/34)	70.7 ± 9.36
70.2 ± 10.35	24 wk	WOMAC Pain; WOMAC Stiffness; WOMAC Physical Function	
Li 2018[50]	RCT	YJJ	Conventional physical therapy	129 (62/67)	69.3 ± 4.5
69.5 ± 4.8	8 wk	VAS;WOMAC	
Ye 2019[51]	RCT	YJJ	Proprioceptive training	52 (26/26)	60.83 ± 9.52
61.80 ± 8.26	8 wk	VAS;WOMAC	
Zhang 2021[52]	RCT	YJJ	Quadriceps training and neuromuscular training (STE)	43 (22/21)	55.76 ± 8.37
53.40 ± 10.66	12 wk	VAS; WOMAC Pain; WOMAC Stiffness; WOMAC Physical Function	
BD = Baduanjin group, CG = control group, NA = Not Applicable, TC = Tai Chi, VAS = Visual Analogue Scale, WOMAC = the Western Ontario and McMaster Universities Osteoarthritis Index, WQX = Wuqinxi, YJJ = Yijinjing.

① and ② represent two different articles.

3.3. Results of risk of bias assessment

Among the 29 papers included, 28 (96.55%) reports mentioned “random,” and 17 (58.62%) specified the methods of generating random sequences, such as “random number table,” “computer random number,” etc; 6 (20.69%) papers mentioned “opaque envelopes” and “central allocation” and other allocation concealment methods; 28 (96.55%) studies had comparable baselines; In terms of blinding, 1 (3.45%) of respondents mentioned researchers being blinded, and 1 (3.45%) said that the outcome assessor was a person who did not know the content of the study. Regarding the completeness of the results, 15 (51.72%) mentioned the loss of visits or withdrawal of cases, whereas the remaining studies had complete data. Due to the difficulty of blinding researchers in exercise therapy studies, the risk of bias evaluation determined that 27 (93.1%) articles posed a high risk. The risk of bias in the RCTs is depicted in Figure 2 and Appendix 2, Supplemental Digital Content, http://links.lww.com/MD/N580.

Figure 2. Risk of bias of the included studies (ROB2 bias assessment). (A) Each domain of studies with high, low, or unclear risk of bias and concerns regarding applicability; (B) the proportions of studies with high, low, or unclear risk of bias and concerns regarding applicability.

3.4. Reporting quality assessment

3.4.1. VAS

From the NMA, the comparative effectiveness of Tai Chi was significantly better than that of Conventional management (MD = −1.22, 95% CI: −1.79 to −0.65). Baduanjin was especially effective compared to Conventional management (MD = −0.97, 95% CI: −1.62 to −0.31). However, there were no significant differences between Yijinjing and Conventional management (MD = −0.61, 95% CI: −1.31 to 0.08) or between Baduanjin and Tai Chi (MD = 0.25, 95% CI: −0.62 to 1.12) or between Yijinjing and Tai Chi (MD = 0.61, 95% CI: −0.29 to 1.50) or between Yijinjing and Baduanjin (MD = 0.35, 95% CI: −0.60 to 1.31) (Figure 4A and Table 2). Due to the absence of a closed-loop structure (Fig. 3) in this investigation, the test for heterogeneity and global design inconsistencies between individual results was not assessed. The funnel plot exhibited an imperfect symmetry. There was no substantial evidence of partiality. (Fig. 5A). The SUCRA plot suggested that Tai Chi (87.6%) was ranked first, followed by Baduanjin (67.8%), Yijinjing (43.0%), Conventional management (1.5%) in terms of the effect size for VAS score (Figure 6A and Table 3).

Table 2 League table for pairwise meta-analysis and network meta-analysis.

A: VAS score	
Tai Chi					
−0.25 (−1.12,0.62)	Baduanjin				
−0.61 (−1.50,0.29)	−0.35 (−1.31,0.60)	Yijinjing			
−1.22 (−1.79, −0.65)	−0.97 (−1.62, −0.31)	−0.61 (−1.31,0.08)	Conventional management		
B: WOMAC pain score	
Yijinjing					
−0.18 (−1.52,1.17)	Wuqinxi				
0.31 (−0.92,1.53)	0.48 (−0.44,1.41)	Tai_Chi			
−0.31 (−1.42,0.79)	−0.14 (−0.90,0.63)	−0.62 (−1.15, −0.10)	Conventional management		
−0.71 (−2.07,0.66)	−0.53 (−1.64,0.58)	−1.02 (−1.97, −0.06)	−0.39 (−1.19,0.41)	Baduanjin	
C: WOMAC stiffness score	
Yijinjing					
−0.69 (−1.96,0.58)	Wuqinxi				
−0.17 (−1.34,0.99)	0.52 (−0.36,1.39)	Tai_Chi			
−0.70 (−1.75,0.35)	−0.01 (−0.73,0.71)	−0.52 (−1.02,−.03)	Conventional management		
0.29 (−1.01,1.59)	0.98 (−0.07,2.03)	0.47 (−0.45,1.38)	0.99 (0.22,1.75)	Baduanjin	
D: WOMAC function score	
Yijinjing					
−0.39 (−1.51,0.73)	Wuqinxi				
0.14 (−0.90,1.17)	0.53 (−0.25,1.31)	Tai_Chi			
−0.42 (−1.35,0.50)	−0.03 (−0.66,0.60)	−0.56 (−1.02, −0.09)	Conventional management		
−0.06 (−1.20,1.08)	0.34 (−0.58,1.25)	−0.19 (−1.00,0.62)	0.37 (−0.30,1.03)	Baduanjin	
The results are presented as the mean differences (95% confidence intervals).

The comparison must be read from left to right. A standard mean difference of less than zero indicates that treatment on the left is favored in pairwise and network meta-analyses.

Bold values indicate significant difference between the groups.

Table 3 The SUCRA values.

Treatment	VAS	WOMAC pain	WOMAC stiffness	WOMAC function	
SUCRA	MeanRank	SUCRA	MeanRank	SUCRA	MeanRank	SUCRA	MeanRank	
Conventional management	1.5	4.0	37.3	3.5	15.2	4.4	20.3	4.2	
Tai Chi	87.6	1.4	87.8	1.5	60.0	2.6	79.2	1.8	
Baduanjin	67.8	2.0	12.7	4.5	86.5	1.5	60.6	2.6	
Wuqinxi	NA	NA	50.3	3.0	20.4	4.2	27.8	3.9	
Yijinjing	43.0	2.7	61.9	2.5	67.8	2.3	62.1	2.5	
NA = not applicable.

Figure 3. Network structure formed by VAS score (A), WOMAC pain score (B), WOMAC stiffness score (C), and WOMAC function score (D) intervention. C.G.: Conventional management; T.C.: Tai Chi; B.D.: Baduanjin; WQX: Wuqinxi; YJJ: Yijinjing. Each dot symbolizes an intervention; inversely, the proportion of cases receiving a particular intervention increases with the size of the dot. Without a connecting line, there is no indication that a direct comparison has been made between the 2 interventions; a solid line connecting the 2 points signifies this. The greater the thickness of the solid line, the more direct comparison evidence there is, and conversely.

Figure 4. Forest plots depicting estimates from direct and indirect comparisons for different traditional Chinese exercise interventions with KOA of VAS scores (A), WOMAC pain score (B), WOMAC stiffness score (C), and WOMAC function score (D) intervention.

Figure 5. Funnel plot for assessment of publication bias on functional improvement in the overall network and individual comparisons of VAS scores (A), WOMAC pain score (B), WOMAC stiffness score (C), and WOMAC function score (D) intervention. The symmetrical funnel plot indicates a small sample effect or a low likelihood of publication bias in the results. (A) Conventional management; (B) Tai Chi; (C) Baduanjin; ((D) Wuqinxi; (E) Yijinjing.

Figure 6. Rankings for effects on functional improvement for VAS scores (A), WOMAC pain score (B), WOMAC stiffness score (C), and WOMAC function score (D) intervention. The graph displays the distribution of probabilities for each treatment. The X-axis represents the possible rank of each treatment; the Y-axis represents the cumulative probability for each treatment to be the best option, among the best 2 chances, among the best 3 options, and so on. The numerical percentages in the graph indicate the area under the SUCRA curve; the larger the area, the better the efficacy.

3.4.2. WOMAC

3.4.2.1. WOMAC pain

From the NMA, the comparative effectiveness of Tai Chi was significantly better than that of Conventional management (SMD = −0.62, 95% CI: −1.15 to −0.10). Tai Chi was especially effective compared to Baduanjin (SMD = 1.02, 95% CI: 0.06 to 1.97). However, there were no significant differences between Baduanjin and Conventional management (SMD = 0.39, 95% CI: −0.41 to 1.19) or Wuqinxi and Conventional management (SMD = −0.14, 95% CI: −0.90 to 0.63) or Yijinjing and Conventional management (SMD = −0.31, 95% CI: −1.42 to 0.79) or between Wuqinxi and Tai Chi (SMD = 0.48, 95% CI: −0.44 to 1.41) or between Yijinjing and Tai Chi (SMD = 0.31, 95% CI: −0.92 to 1.53) or Wuqinxi and Baduanjin (SMD = −0.53, 95% CI: −1.64 to 0.58) or Yijinjing and Baduanjin (SMD = −0.71, 95% CI: −2.07 to 0.66) or between Yijinjing and Wuqinxi (SMD = −0.18, 95% CI: −1.52 to 1.17) (Figure 4B and Table 2). The funnel plot exhibited an imperfect symmetry. There was no substantial evidence of partiality. (Fig. 5B). The SUCRA plot suggested that Tai Chi (87.8%) was ranked first, followed by Yijinjing (61.9%), Wuqinxi (50.3%), Conventional management (37.3%), Baduanjin (12.7%) in terms of the effect size for WOMAC pain score (Figure 6B and Table 3).

3.4.2.2. WOMAC stiffness

From the NMA, the comparative effectiveness of Tai Chi was significantly better than that of Conventional management (SMD = −0.52, 95% CI: −1.02 to −0.03), Baduanjin and Conventional management (SMD = −0.99, 95% CI: −1.75 to −0.22). However, there were no significant differences between Wuqinxi and Conventional management (SMD = −0.01, 95% CI: −0.73 to 0.71) or Yijinjing and Conventional management (SMD = −0.70, 95% CI: −1.75 to 0.35) or between Baduanjin and Tai Chi (SMD = 0.47, 95% CI: −1.38 to 0.45) or between Wuqinxi and Tai Chi (SMD = 0.52, 95% CI: −0.36 to 1.39) or between Yijinjing and Tai Chi (SMD = −0.17, 95% CI: −1.34 to 0.99) or Wuqinxi and Baduanjin (SMD = 0.98, 95% CI: −0.07 to 2.03) or Yijinjing and Baduanjin (SMD = 0.29, 95% CI: −1.01 to 1.59) or between Yijinjing and Wuqinxi (SMD = −0.69, 95% CI: −1.96 to 0.58) (Figure 4C and Table 2). The funnel plot exhibited an imperfect symmetry. There was no substantial evidence of partiality. (Fig. 5C). The SUCRA plot suggested that Baduanjin (86.5%) was ranked first, followed by Yijinjing (67.8%), Tai Chi (60.0%), Wuqinxi (20.4%), Conventional management (15.2%), in terms of the effect size for WOMAC stiffness score. (Figure 6C and Table 3).

3.4.2.3. WOMAC physical function

From the NMA, the comparative effectiveness of Tai Chi was significantly better than that of Conventional management (SMD = −0.56, 95% CI: −1.02 to −0.09). However, there were no significant differences between Baduanjin and Conventional management (SMD = −0.37, 95% CI: −1.03 to −0.30) or Wuqinxi and Conventional management (SMD = −0.03, 95% CI: −0.66 to 0.60) or Yijinjing and Conventional management (SMD = −0.42, 95% CI: −1.35 to 0.50) or between Baduanjin and Tai Chi (SMD = 0.19, 95% CI: −0.62 to 1.00) or between Wuqinxi and Tai Chi (SMD = 0.53, 95% CI: −0.25 to 1.31) or between Yijinjing and Tai Chi (SMD = −0.14, 95% CI: −0.90 to 1.17) or Wuqinxi and Baduanjin (SMD = 0.34, 95% CI: −0.58 to 1.25) or Yijinjing and Baduanjin (SMD = −0.06, 95% CI: −1.20 to 1.08) or between Yijinjing and Wuqinxi (SMD = −0.39, 95% CI: −1.51 to 0.73) (Figure 4D and Table 2). The funnel plot exhibited an imperfect symmetry. There was no substantial evidence of partiality. (Fig. 5D). The SUCRA plot suggested that Tai Chi (79.2%) was ranked first, followed by Yijinjing (62.1%), Baduanjin (60.6%), Wuqinxi (27.8%), Conventional management (20.3%), in terms of the effect size for WOMAC function score. (Figure 6D and Table 3).

4. Discussion

TCE is governed by the holistic concept of TCM, the theory of 5 elements and yin-yang, as well as the notion of meridians and zang-fu organs.[51] It has gradually formed a unique system that combines movement and stillness, dredges meridians, regulates qi and blood, focuses on strengthening the body, nourishing and holding, and enhances the body to prevent diseases by combining ancient Chinese philosophy. Wang[52] and Wehner[53] demonstrated that TCE increases lower limb muscle strength due to the lower center of gravity during exercise. Weight is typically transferred between the feet before the ankles, knees, and hips are bent. By contracting the antagonist (stabilizer) muscles in 1 leg with the agonist (motor) muscles in the other, weight is transferred. In addition, the study proves that it improves balance,[54] enhances gait and postural control,[55] improves proprioception,[56] and is similar to neuromuscular training.[57,58] A meta-analysis found[59] that TCE dramatically lowered serum levels of TNF-α and IL-6 in those who attended the majority of the TCE classes. There is also evidence that[60] TCE also increases myokine levels. Furthermore, it is believed that mindfulness and abdominal breathing are the reasons behind the parasympathetic or relaxation response that is observed during mind–body exercises.[61] TCE also mitigates the inflammatory effect of social isolation. TCE has decreased social isolation in older people in community-based classes.[62–64] TCE improves body activity, physical and mental health, and health-related quality of life in sedentary patients with arthritis.

TCE has distinct advantages as both a mental and physical exercise and may be performed at home while afflicted with COVID. TaiChi exercises are prescribed extensively for KOA by the 2019 ACR guidelines,[65] which signifies their global application. Guidelines for TCM treatment of KOA[2] recommend Tai Chi for KOA. Chronic joint conditions, particularly among older people, have been shown to benefit from Tai Chi exercises as a form of physical activity. Yijinjing, rooted in an ancient Chinese health-cultivating practice, has been shown to alleviate joint pain and considerably enhance knee flexion.[66] By combining fitness walking with traditional Chinese theory, Yijinjing can improve equilibrium and coordination between the internal and external environment of the body, strengthen muscles, increase flexibility and endurance, and decrease ligament strains. Baduanjin[67] and Wuqinxi[68] are also used to lessen pain and dysfunction in patients with KOA. These practices improve blood circulation in joint regions, improve flexibility and suppleness in the lower limbs, facilitate the flow of qi and blood through meridians, and encourage precise movement postures. The results suggest that TCE reduces various aspects of KOA patients’ lives, including functional impairment, pain, psychological status, and quality of life.

This NMA is the first report on the effects of TCE on pain, stiffness, and physical function in KOA. The NMA was deemed the most pertinent analysis method due to the comparisons conducted among various types of interventions (Tai Chi, Yijinjing, Baduanjin, and Wuqinxi). This NMA determined statistical power from all included data by analyzing explicit direct and indirect statistical effects for each comparison. The Bayesian approach additionally generated probability estimates regarding the comparative effectiveness of specific interventions, even though standard methods do not consider them significantly different. The outcomes of this meta-analysis are more beneficial to policymakers and primary service providers in facilitating informed decision-making among the diverse array of available options compared to the results of multiple separate paired meta-analyses. We calculated alternative rankings (such as second and third) for an overall feasibility assessment.

The results showed that in terms of the effect size of the VAS score, Tai Chi (87.6%) ranked first, followed by Baduanjin (67.8%), Yijinjing (43.0%), and conventional management (1.5%); in terms of the effect size of WOMAC pain scores, Tai Chi (87.8%) ranked first, followed by Yijinjing (61.9%), Wuqinxi (50.3%), and conventional management (37.3%), and Baduanjin (12.7%); in terms of the effect size of WOMAC stiffness scores, Baduanjin (86.5%) ranked first, followed by Yijinjing (67.8%), Tai Chi (60.0%), Wuqinxi (20.4%), and conventional management (15.2%). In terms of the effect size of WOMAC functionality scores, Tai Chi (79.2%) ranked first, followed by Yijinjing (62.1%), Baduanjin (60.6%), Wuqinxi (27.8%), and conventional management (20.3%). We found that the efficacy of Baduanjin was lower than that of conventional management in the WOMAC pain score, and this result may be due to the inclusion of trials with variable follow-up lengths. Therefore, careful treatment and discussion of all aspects of study design and its implementation is necessary. In addition, higher-quality, large-sample, multicenter RCTs should be conducted to improve the homogeneity of evidence sources and reduce bias. The Cochrane Handbook recommends several methods for analyzing and comparing tests with varying sizes of follow-up, such as conducting meta-analyses of individual patient data and performing precise assessments at specific time points. However, newer methods are being developed to include all time points in the NMA. Our study could not assess the impact of population characteristics (e.g., mean Age and severity of Osteoarthritis) because the included studies were not sufficiently large. In addition, other parameters (e.g., the relationship between knee flexion moment and joint loading) should have been studied in detail. However, we could not include these parameters in our study due to the limited available literature. Finally, in defining “conventional management,” exercises that are not TCE, customary care, health education, a blank control, and supplemental therapies not administered to the test group were all considered the same parameters. Therefore, the relative rankings in our study may not represent the accurate rankings compared with the actual standard of care because of the bias introduced by not accounting for heterogeneity and lack of blinding.

4.1. Limitations

Several limitations exist in our investigation. First, only RCTs were included to enhance the quality of the NMA, resulting in a limited number of studies. Including a limited number of RCTs potentially compromised the reliability of our findings, particularly regarding the evaluations of Baduanjin and Yijinjing. Furthermore, the allocation procedure in most studies lacked clarity, and blinding healthcare practitioners and participants in exercise therapy studies posed a challenging task, thereby contributing to a moderate to high potential for selection bias. Thirdly, inclusion criteria, demographics, endpoint assessment methodologies and points, and degrees of statistical adjustment varied among the RCTs included. Although baseline information varied between studies, it was comparable for all participants in the same survey. Fourth, individual variations in patient indications for exercise and the selected RCTs imposed limitations on the conclusions. Fifthly, the absence of closed loops in the mesh graph does impact the reliability of our consistency and inconsistency tests. Without closed loops, certain relationships may not be fully constrained, which could affect the summary of our results. This NMA is limited to the information reported in the papers and is susceptible to publication bias and other risks of bias, similar to different types of meta-analyses. Its strengths are the exhaustiveness of the literature search and the stringent eligibility requirements. Synthesizing direct and indirect evidence could lead to an increase in heterogeneity.

5. Conclusion

TCE methods such as Tai Chi, Yijinjing, Baduanjin, Wuqinxi, and Qigong can improve KOA pain, stiffness, and physical functionality symptoms. Tai Chi was first for the effect sizes of VAS scores, WOMAC pain scores, and WOMAC available scores, while Baduanjin was ranked top for WOMAC stiffness scores. Research should continue to be conducted on the effect of Qigong on KOA intervention. Moreover, the mechanism of action of TCE for KOA should also be further studied.

Author contributions

Conceptualization: Tao Tao, Ming-Peng Shi, Xian-Shuai Zhang, Bo-Yang Tan, Feng-Ling Sun, Shao-Jun Li, Zhen-Hua Li.

Data curation: Tao Tao, Xian-Shuai Zhang, Bo-Yang Tan, Ya-Nan Xiao, Feng-Ling Sun.

Methodology: Tao Tao, Ming-Peng Shi, Ya-Nan Xiao, Shao-Jun Li, Zhen-Hua Li.

Software: Tao Tao, Ming-Peng Shi, Xian-Shuai Zhang, Bo-Yang Tan, Ya-Nan Xiao, Feng-Ling Sun.

Writing – original draft: Tao Tao, Ming-Peng Shi, Shao-Jun Li.

Writing – review & editing: Zhen-Hua Li.

Supplementary Material

Abbreviations:

CI confidence intervals

KOA knee osteoarthritis

MD mean differences

NMA network meta-analysis

NSAIDs nonsteroidal anti-inflammatory drugs

PRISMA Preferred Reporting Items for Systematic Reviews and Meta-analyses

RCT randomized controlled trial

SMD standardized mean difference

SUCRA the surface under the cumulative ranking

VAS visual analogue score

WOMAC Western Ontario and Mc Master University osteoarthritis index

The research was supported financially by the Jilin Province Science and Technology Development Plan Project (No: 20210101205JC).

This study does not require ethical approval.

Trial registration number is CRD42023449262.

The authors declare that they have no competing interests.

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Supplemental Digital Content is available for this article.

How to cite this article: Tao T, Shi M-P, Zhang X-S, Tan B-Y, Xiao Y-N, Sun F-L, Li S-J, Li Z-H. Effects of different traditional Chinese exercise for knee osteoarthritis patients: A network meta-analysis of randomized controlled trials. Medicine 2024;103:38(e39660).

TT and MPS contributed equally to this work.
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