Traditional Chinese Medicine for Neck Pain and Low Back Pain

37 Pages·2015·7.01 MB·English

RESEARCHARTICLE
Traditional Chinese Medicine for Neck Pain
and Low Back Pain: A Systematic Review and
Meta-Analysis
Qi-lingYuan1,Tuan-maoGuo2,LiangLiu1,FuSun1,3,Yin-gangZhang1*
1 DepartmentofOrthopaedicsoftheFirstAffiliatedHospital,MedicalSchool,Xi’anJiaotongUniversity,Xi’an
710061,China,2 SeconddepartmentofOrthopaedics,XianyangCentralHospital,Xianyang,Shaanxi,P.R.
712000,China,3 DepartmentofOrthopaedicsoftheAffiliatedHospitalofXi’anMedicalCollege,Xi’an
710077,China
* [email protected]
Abstract
Background
Neckpain(NP)andlowbackpain(LBP)arecommonsymptomsbotheringpeopleindaily
life.TraditionalChinesemedicine(TCM)hasbeenusedtotreatvarioussymptomsanddis-
easesinChinaandhasbeendemonstratedtobeeffective.Theobjectiveofthepresent
OPENACCESS studywastoreviewandanalyzetheexistingdataaboutpainanddisabilityinTCMtreat-
mentsforNPandLBP.
Citation:YuanQ-l,GuoT-m,LiuL,SunF,ZhangY-g
(2015)TraditionalChineseMedicineforNeckPain
andLowBackPain:ASystematicReviewandMeta- Methods
Analysis.PLoSONE10(2):e0117146.doi:10.1371/
Studieswereidentifiedbyacomprehensivesearchofdatabases,suchasMEDLINE,
journal.pone.0117146
EMBASE,andCochraneLibrary,uptoSeptember1,2013.Ameta-analysiswasper-
AcademicEditor:JanP.A.Baak,Stavanger
formedtoevaluatetheefficacyandsafetyofTCMinmanagingNPandLBP.
UniversityHospital,NORWAY
Received:February24,2014
Results
Accepted:December18,2014
Seventyfiverandomizedcontrolledtrials(n=11077)wereincluded.Almostallofthestudies
Published:February24,2015 investigatedindividualsexperiencingchronicNP(CNP)orchronicLBP(CLBP).Wefound
Copyright:©2015Yuanetal.Thisisanopen moderateevidencethatacupuncturewasmoreeffectivethansham-acupunctureinreducing
accessarticledistributedunderthetermsofthe painimmediatelypost-treatmentforCNP(visualanaloguescale(VAS)10cm,meandiffer-
CreativeCommonsAttributionLicense,whichpermits
ence(MD)=-0.58(-0.94,-0.22),95%confidenceinterval,p=0.01),CLBP(standardized
unrestricteduse,distribution,andreproductioninany
medium,providedtheoriginalauthorandsourceare meandifference=-0.47(-0.77,-0.17),p=0.003),andacuteLBP(VAS10cm,MD=-0.99
credited. (-1.24,-0.73),p<0.001).CuppingcouldbemoreeffectivethanwaitlistinVAS(100mm)
Funding:Theauthorsaregratefulforthesupportof (MD=-19.10(-27.61,-10.58),p<0.001)forCNPormedications(e.g.NSAID)forCLBP
theNaturalScientificFundofChina(no.81371987, (MD=-5.4(-8.9,-0.19),p=0.003).Noseriousorlife-threateningadverseeffectswerefound.
81171761).Thefunderhadnoroleinstudydesign,
datacollectionandanalysis,decisiontopublish,or
Conclusions
preparationofthemanuscript.
Acupuncture,acupressure,andcuppingcouldbeefficaciousintreatingthepainanddisabil-
CompetingInterests:Theauthorshavedeclared
thatnocompetinginterestsexist. ityassociatedwithCNPorCLBPintheimmediateterm.Guasha,taichi,qigong,and
PLOSONE|DOI:10.1371/journal.pone.0117146 February24,2015 1/37
TraditionalChineseMedicineforNeckandLowBackPain
Chinesemanipulationshowedfaireffects,butwewereunabletodrawanydefiniteconclu-
sions,andfurtherresearchisstillneeded.Theefficacyoftuinaandmoxibustionisunknown
becausenodirectevidencewasobtained.TheseTCMmodalitiesarerelativelysafe.
Introduction
Neckpain(NP)andlowbackpain(LBP)arecommonsymptomsbotheringpeopleindaily
life.Indevelopedcountries,morethan70%ofpeopleexperienceLBP[1],whereasapproxi-
matelytwo-thirdsofpeopleexperienceNP[2,3]atsomepointintheirlifetimes.Thesetwodis-
ordersoccurmostfrequentlyamongthemiddle-agedpopulation,inwhichtheproportionof
femalesishigherthanthatofmales[4].AmajorityoftheacuteNPandLBPsufferersobtain
spontaneousreliefwithindaysorweeks,althoughapproximately10%ofacuteNP[2]and20%
ofacuteLBP[5]suffersexperiencetheconditionaschronicorpersistent.NPandLBPcanbe
causedbyspecificpathologicaldiseases,suchastumors,infection,fracture,andinflammation.
However,thepaininmostindividuals(approximately85%forLBP)[1]isnon-specific,which
indicatesthatthepainisnotattributabletooneofthedefiniteabovepathologiesbutinsteadto
someambiguousetiology.Conventionaltreatments,suchasmedications[6]andsurgery[7],
havedemonstratedsomeefficacy.Nonetheless,thesetreatmentswerenotalwayseffective,and
evenhadsomeseriousadverseeffects[7,8].Consequently,tofindsomemoreeffectivethera-
peuticmethods,manyindividualshaveturnedtheirattentiontosomeothertreatments,such
ascomplementaryandalternativemedicine(CAM).AlthoughCAMmayalsohavesomead-
verseeffectsofitself,giventhenumeroustherapeuticmethodsofCAManditspositiveeffec-
tivenesstosomeextent,agrowingnumberofresearchershavefocusedonvariousCAM
therapies,suchasacupuncture,massage,exercise,andhydrotherapy[9].Mostsignificantly,as
atypeoftraditionalChinesemedicine(TCM),acupuncturehasshownrespectableefficacyand
isbroadlyacceptedinternationally[10–12].
TCMisbasedonthefundamentaltheoryofbalanceamongyinandyang,fivebasicele-
ments,andarelationshipbetweenhumansandnature[13,14].TCMhasbeenusedtotreatvar-
iousdiseasesinChinaandeventhroughoutEastAsiaformorethan2000years,anditstill
remainsthefirstchoiceoftreatmentformanypeople.However,thedifferentmodelsof
thoughtthatarethefoundationsofTCMandmodernsciencearenotcompatible,hindering
thespreadofTCMworldwide.Nevertheless,therearemanyarticlespublishedinvariousscien-
tificjournalsthathaveattemptedtoexplainsomephenomenaandmechanismsoftreatments
inTCMfromtheperspectiveofmodernmedicine.
AlthoughacupunctureisatypicalrepresentativeofTCM,itisonlyoneofthevariousgener-
altherapiesforNPandLBP,suchasacupressure,cupping,moxibustion,tuina,guasha,taichi,
qigong,Chineseherbalmedicine,andChinesemanipulation(fordefinitions,seeS1Table).
Theobjectiveofthepresentstudywastoreviewandanalyzetheexistingdataaboutpainand
disabilityassociatedwithTCMtreatmentsforNPandLBP.Thequestionofourstudyis
“whetherTCMtreatmentsaremoreeffectiveinpainreliefordisabilityimprovementascom-
paredwithothertreatmentsforpeoplewithNPorLBP?”.
Methods
DataSourcesandSearchStrategy
Studieswereidentifiedbyacomprehensivesearchinthefollowingdatabases:MEDLINE,
EMBASE,theCochraneLibraryandtheTraditionalChineseMedicalLiteratureAnalysisand
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RetrievalSystem(TCMLARS)andChinaNationalKnowledgeInfrastructure(CNKI)andthe
WanFangdatabase.Thesearchwasconductedbetweentheinceptionofeachdatabaseand
September1,2013,andupdatedonMay25,2014usingdisease-specificsearchstringcombina-
tions,partlyaccordingtothestrategyoutlinedbytheCochraneBackReviewGroup(CBRG)
(S2Table),withsubjectlimitationswithintheEnglishorChineselanguage.Therewerenore-
strictionsaboutpublicationstatusofthesearchedtrials.Thereferencelistsofidentifiedstudies
werescreenedmanuallyformorestudiesrelated.Expertsintherepresentativefieldswerealso
contactedforunpublishedtrials.Thesearchwasconductedbyaveteranlibrarian.
StudySelectionCriteria
Weincludedanyrandomizedcontrolledtrial(RCT)meetingallofthefollowingcriteria:(1)
theworkispublishedintheEnglishorChineselanguage;(2)thesubjectsincludedaremenor
women(age(cid:1)17years)withNPorLBP(withorwithoutradiatingpain)ofanyduration;(3)
atleastoneofthetherapiesassessedpertainstoTCM;(4)acomparisonshouldbedonebe-
tweenTCMandothertreatment(e.g.TCMversusothertreatment,TCMversusnotreatment,
TCMplusothertreatmentversusothertreatment);(5)atleastoneofthefollowingoutcomes
wasevaluated:painintensityordisability;(6)theprinciplesummarymeasuresshouldbetter
becommonlyused,suchaspainintensity(e.g.,visualanaloguescale,VAS;numericalrating
scale,NRS)anddisability(e.g.,OswestryDisabilityIndex,ODI;NeckDisabilityIndex,NDI);
(7)thedurationoffollow-upshouldbeatleastonedayafteralltreatmentsessionswerecon-
cludedaccordingtothestudydesignofeachcorrespondingtrial.
Weexcludedtrialsofneckorbackpaincausedbytrauma,infection,caudaequinasyn-
drome,bonerarefaction,compressionfractureofavertebralbody,tumor,orfibromyalgia.
DataExtraction
TwoevaluatorsindependentlyextractedthedatafromthestudiesorSRs,anddiscrepancies
wereresolvedbynegotiationorathirdparty.
Thedurationofpainwasdefinedasfollows:(1)chronic((cid:1)3months);(2)sub-acute(~1–3
months);and(3)acute(<1month).Incontrast,thefollow-up(post-intervention)timeswere
definedasfollows:(1)immediateterm((cid:3)1week);(2)shortterm((cid:3)3months);(3)intermedi-
ateterm(~3–12months);and(4)longterm((cid:1)1year).
Primaryoutcomesincludedpainintensity(e.g.,visualanaloguescale,VAS;numericalrating
scale,NRS)anddisability(e.g.,OswestryDisabilityIndex,ODI0–60points).Additionally,side
effects(includingthenamesofadverseeffectsandthenumberorproportionofindividuals
experiencingthem)wererecorded.
Thestudy,treatment,population,andoutcomecharacteristicsaresummarizedintables.
AssessmentofStudyQualityandReporting
Twoindependentassessorsevaluatedthequalityofeverytrialincludedinourreview.Discrep-
ancieswereresolvedbynegotiationoranauthoritativethirdparty.
ThequalityoftheindividualtrialswasratedaccordingtothecriteriaoftheCochraneBack
ReviewGroup(Table1)[15].Dependingonthenumberof“Yes”responses(codedas“1”)for
fourparticularitems(e.g.,allocationconcealment,baselinesimilarity,patientblinding,and
numberoforreasonfordropouts),yieldingarangeofscoresfrom0–4,thequalityofindividu-
altrialswasgradedaccordingtothefollowingthreeranks:good(score=4),fair(score=2–3),
orpoor(score=0–1).Becausethenumberof“Yes”responseswasrecordedfor4domains,in
caseofasinglestudy,Nwasawholenumber(0,1,2,3,or4);incaseofmultiplestudies,Nwas
theaveragenumber,whichmayhavebeeneitherawholenumberorafraction(S3Table).
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Table1.UpdatedMethodGuidelinesforSystematicReviewsintheCochraneCollaborationBackReviewGroup—a12ItemTool.
Question Item Rating
Q1 Wasthemethodofrandomizationadequate? Yes/No/Unsure
Q2 Wasthetreatmentallocationconcealed? Yes/No/Unsure
Q3 Werethegroupssimilaratbaselineregardingthemostimportantprognosticindicators? Yes/No/Unsure
Q4 Wasthepatientblindedtotheintervention? Yes/No/Unsure
Q5 Wasthecareproviderblindedtotheintervention? Yes/No/Unsure
Q6 Wastheoutcomeassessorblindedtotheintervention? Yes/No/Unsure
Q7 Wereco-interventionsavoidedorsimilar? Yes/No/Unsure
Q8 Wasthecomplianceacceptableinallgroups? Yes/No/Unsure
Q9 Wasthedrop-outratedescribedandacceptable? Yes/No/Unsure
Q10 Wasthetimingoftheoutcomeassessmentinallgroupssimilar? Yes/No/Unsure
Q11 Didtheanalysisincludeanintention-to-treatanalysis? Yes/No/Unsure
Q12 Arereportsofthestudyfreeofsuggestionofselectiveoutcomereporting? Yes/No/Unsure
doi:10.1371/journal.pone.0117146.t001
QuantitativeSynthesis
Wegroupedtheresultswithrespecttotheinterventionsused(e.g.,acupuncture),thegeneral
locusofthepain(e.g.,neckorlowback),thepersistenceofthepain(e.g.,acute,sub-acute,or
chronic),andthecauseofpain(e.g.,specificornon-specific).
Thedataabstractedwereclassifiedintocontinuousanddichotomousvariables.Generally,
fixed-effectsmodels(inverse-variancemethod)wereusedinthemeta-analysis.However,we
alsousedrandom-effectsmodels(DerSimonian-Lairdmethod)topooldataifthestatistical
heterogeneitywashigh(I2(cid:1)50%).Thesourceofheterogeneitywasexploredbyfittingcovari-
ables(ie,interventioncharacteristics,meanage,baselinetotalsymptomscores)onebyonein
themeta-regression.Weanalyzedthesubgroupsaccordingtothesourceofheterogeneityif
possible,andsensitivitiesiftherewereunaccountablesourcesofheterogeneity.Weusedcon-
tour-enhancedfunnelplotsandEggertesttoexaminepublicationbiasifthenumberofpooled
trialswerenearorabove10[16,17].AllanalyseswereperformedinSTATA12.0(StataCorp
LP,CollegeStation,TX).
Ifthedatapermittedtheassessmentandtherewerestatisticallysignificantdifferencesacross
thepooleddatainpainreliefordisabilityimprovement,clinicalimportancewasassessedac-
cordingtoCohen’s3levels(Table2)[18].
RatingtheStrengthofEvidence
Theoverallstrengthofevidencewasevaluatedwiththeaidofthegradingsystemoutlinedin
theMethodsGuidepreparedbytheAHRQEvidence-basedPracticeCenter(EPC)program
Table2.RatingofClinicalImportance.
Rating Range
Small aweightedmeandifference(WMD)lessthan10%ofthescale(e.g.,<10mmona100mmVAS);astandardizedmeandifference(SMD)or
“d”score<0.5;arelativeriskof<1.25or>0.8(dependingonwhetherthereportreferredtotheriskofbenefitortheriskofharm,respectively)
Medium aWMDfrom10–20%ofthescale;anSMDor“d”scorefrom0.5to0.8;arelativeriskbetween1.25and2.0orbetween0.5and0.8
(dependingonthefactordescribedabove)
Large aWMD>20%ofthescale;anSMDor“d”score(cid:1)0.8;arelativerisk>2.0or<0.5(dependingonthefactordescribedabove)
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Table3.GradingofEvidence.
Grade Domain
High All4domainsaremet(e.g.,lowriskofbias,precise,direct,consistent)
Moderate 1ofthedomainsisnotmet(e.g.,mediumriskofbias,precise,direct,consistent)
Low 2–4ofthedomainsarenotmet(e.g.,highriskofbias,precise,indirect,inconsistent)
Insufficient Noevidence/absenceofevidence
doi:10.1371/journal.pone.0117146.t003
[19].Theratingschemefocuseson4majordomains:riskofbias(high,medium,low),consis-
tency,directness,andprecision.Consistencyindicatedthat75%ofthetrialsshowedthateffects
wereinthesamedirection(positiveornegative)orthatheterogeneitywaslow(i.e.,I2<50%).
Thestrengthofevidencewasclassifiedintooneoffourlevels:high,moderate,low,orinsuffi-
cient(noevidence)(Table3,S4Table)[19].Thelevelwasloweredonestageifanyoftheafore-
mentioneddomainswasnotmetandwasdirectlyloweredtwostagesifthetrialhadahighrisk
ofbias.Additionally,thelevelwasloweredonestageifthesamplesizewassmallerthan40pa-
tientspergroup(toenableadequatepower)[20].
Results
Aftersearchingthedatabasesrigorouslyandsystematically,658uniquerecordswereidentified,
andthetitlesandabstractswerescreened.Thefull-textof243articleswereassessedforeligibility,
75studies[21–93]wereincludedinthesystematicreview(Fig.1).Ofthesestudies,12studies
[35,36,59,78–81,90–93]wereinChinese(2unpublishedtrialsaboutChineseherbalmedicine),
othersinEnglish.Thekappavalueforagreementbetweenthereviewers(YQLandLL)was0.90
whichindicatedanexcellentagreement.Wefoundthatmostoftheincludedstudieswereprinci-
pallyaboutacupuncture,acupressure,andcupping(Table4).Incontrast,thenumberofstudies
ontheotherseventreatmentswaslessthan3(most=1)foreachtreatment.Thetreatment
Fig1.FlowDiagram.
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Table4.Thespecificnumberofstudiesincludedandbasiccharacteristicsoftreatmentsforeachintervention.
Intervention Condition Study Patients Durationofone Treatment Courseof Numberof
(N) (N) treatment(minutes)$ sessions(times)$ Treatment(weeks)$ acupointsselected$
Acupuncture NP 17 1434 25(20,30) 8.5(5.8,10.5) 4(3,4.5) 6(5.8,10)
LBP 31 6656 25(20,30) 10(6,12) 4.5(3.3,7) 9.8(6,14)
Acupressure NP 1 32 35–40 8 3 7
LBP 5 417 15or30 8(6,9) 4(3,4) 7or18
Cupping NP 5 251 10or15 5(4,6) 2 n.a.
LBP 6 415 15or20 7.5(3.5,10) 3(1.9,3) n.a.
Guasha NP 2 69 15or30 1 n.a.
LBP 1 19 15 1 n.a.
Qigong NP 3 378 60(45,90) 18(12,18) 12 n.a.
LBP 0 0
Taichi NP 0 0
LBP 1 170 40 18 10 n.a.
Chineseherbal NP 3 840 n.a. 8(8,12) 4
medicine
LBP 0 0
Chinese NP 3 396 20 8(8,10) 4(4,5) n.a.
manipulation
LBP 0 0
Moxibustion NP 0 0
LBP 0 0
Tuina NP 0 0
LBP 0 0
Total 75* 11077
LBP,lowbackpain;NP,neckpain;N,number;RCT,randomizedcontrolledtrial;n.a.,notapplicable.
*Someofthestudieswereincludedintotwoormorerows.
$Theresultswereshownasmedianandinterquartilerange.
doi:10.1371/journal.pone.0117146.t004
sessionsandtreatmentdurationsofinterventionsalsowereshowninTable4.Thespecificresults
ofourmeta-analysiswereshowninS5Table.
Studycharacteristics
Seventyfivestudiesinvolving11077subjectsrangingfrom17to90yearswereincluded.Ama-
jorityoftheparticipantswerefemales(>60%)withchronicneckpain(CNP)orchroniclow
backpain(CLBP).ThebasiccharacteristicsofthetrialswerepresentedinS6Table.Forthe
findingsofourrisk-of-biasassessmentwereshowninFig.2(andS7Table).Themedianand
interquartilerange(IQR)ofthequalityscoreofthestudieswas6(4.5to8),whichmeantthat
theoverallqualitywereofhigher-quality.Mostofthestudiesdidn’tprovideadequateinforma-
tiononoutcomeassessorblinding,co-interventionandcompliance.Giventhecharacteristics
ofsomeinterventions,theblindingofthecareproviderwasunapplicable.Thestrengthofevi-
denceanditsclinicalimportancewaspresentedinS8Table.
AcupunctureinCNP
Therewereseventeenstudies(n=1434individuals)identified[21–37].Twoofthestudies
werepublishedinChinese[35,36].TheIQRofthequalityscoreofthestudieswas5(4to7).
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Fig2.Risk-of-Biasofstudiesincluded.Q,question.
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Acupunctureversussham-acupuncture
Therewereseventrials(428subjects)identified[21–24,27,28,30].Weobservedsignificantdif-
ferencesinpainreliefinfavorofacupuncturecomparedwiththeshamgroup(VAS10cm,MD,
-0.58[-0.94,-0.22],I2=46.3%)(Fig.3andS5Table)[21–24,27,28,30],.Thecontour-enhanced
funnelplotindicatedsymmetry(Fig.4)andtheEggertestsuggestedtherewasnoevidenceof
publicationbias(coefficient=1.00;SE=1.05;P=0.39).Thissuperioritypersisteduntil1month
post-intervention(MD,-0.72[-1.07,-0.37])[21,23],whereasafter3monthsoffollow-up,this
effectgraduallydiminisheduntiltherewerenodifferencesbetweenthegroups(MD,-0.32[-0.68,
0.04])[21–23].However,withrespecttodisability(Fig.5)[21,23,24,27],thistendencyinfavorof
acupuncturewasalsodisplayedintheseterms.
Acupunctureversusshamtreatments(inactivetreatments)
Therewerethreetrials(272subjects)identifiedthatholdcomparisonsbetweenacupuncture
andshamtranscutaneouselectricalnervestimulation(TENS)[25,26,31].Comparedwith
shamTENSforpain,acupuncturedidn’tdisplayanydifferencesinpainrelief(Fig.6)anddis-
abilityimprovement(Fig.7)forCNPatimmediatetermandevenatshortterm(p>0.10),
andtheseresultswerestillrobustinsensitivityanalysis[25,26,31].Onetrial(108subjects)com-
paredacupunctureandshamlaser[29].Similarly,nodifferencewasfoundbetweenacupunc-
tureandshamlaserinpainreliefimmediatelypost-treatment(p=0.202)(S5Table)[29].
Acupunctureversuswaitlist(notreatment)
Onlyonetrial(30subjects)showedasignificantdifferenceinpainforCNPimmediately
post-treatmentonVAS10cm,withanoddsratioof26.00(3.69to183.42,p=0.001)[37].
Acupunctureversusactivetreatments
Withrespecttofindingscomparingacupuncturewithotheractivetreatments,suchasmed-
icationswithaSMDof-0.57[-1.14,-0.01][30,32–34],massagewithaMDof-1.63[-2.68,-0.58]
onVAS10cm[29],significantsuperiorityfavoringacupuncturewasfoundaboutpainreliefat
immediateterm(p<0.05)(Fig.8andS5Table),buttheresultwasnotrobustaftersensitivity
analysiswasperformed(p=0.06).Whereas,acupuncturewaseveninferiortomanipulation
(SMD,-0.08[-0.49,0.32],I2=38.4%)(Fig.9)[32,33,35]andcervicaltraction(VAS10cm,MD,
1.31[0.78,1.84])(S5Table)[36].
Sideeffects
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Fig3.Meta-AnalysisofAcupunctureversusSham-AcupunctureforCNPinPainIntensityontheVAS(0–10mm).Fixed-effectsmodelwasused;CI,
confidenceinterval;CNP,chronicneckpain;SD,standarddeviation;VAS,visualanaloguescale;WMD,weightedmeandifference.
doi:10.1371/journal.pone.0117146.g003
Fig4.Contour-enhancedfunnelplotofAcupunctureversusSham-AcupunctureforCNPinPain.
Visualinspectionofthefunnelplotsuggestedsymmetry.Specifically,thereweremostoftrialswithnegative
results(i.e.,moretrialsinareasofstatisticalnonsignificance),indicatingnoevidenceofpublicationbias.
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Fig5.Meta-AnalysisofAcupunctureversusSham-AcupunctureforCNPinDisability.Fixed-effectsmodelwasused;CI,confidenceinterval;CNP,
chronicneckpain;SD,standarddeviation;SMD,standardizedmeandifference.
doi:10.1371/journal.pone.0117146.g005
Thereweresomecomplaintsreportedinthetrials,suchaslocalbleeding,numbness,pain,
andfaintingwhenneedleswereinsertedinsomesubjects.Allthesesideeffectsweretransient
andmild.Nolife-threateningsideeffectswerereported[21,25,26,29].
Summary
Severalstudiesshowedthattherewasmoderateevidencewithsmallclinicalimportance
thatacupuncturewasmoreeffectivethansham-acupunctureinreducingpainanddisabilityas-
sociatedwithCNPintheimmediatetermandattheone-monthfollow-up.
AcupunctureinLBP
Thirtyonestudieswithatotalof6656patientscomparedacupuncturewithothertreat-
mentsinlowbackpainaboutpainordisability[32,33,38–48,50–65,94].TheIQRofthequality
scoreofthestudieswas7(5to9).
Acupunctureversussham-acupuncture
Thirteenstudies[38–48,50,51]comparedacupunctureandsham-acupuncture,ofwhichten
studies[38–47]wereaboutCLBP(n=1864)andtheremainingthree[48,50,51]aboutacuteLBP
(n=188).Withrespecttopainreduction,ninestudies[38,39,41–47](n=1387)showedthatacu-
puncturewasclinicallysuperiortoshamacupunctureforCLBPimmediatelypost-treatment
(SMD=-0.49,95%CI-0.76to-0.21)andupto3monthspost-treatment(SMD=-0.45,95%CI-
0.76to-0.14),butthesewerehighlyheterogeneousacrossstudies(I2=72.8%and76.9%,respec-
tively)(Fig.10).Thesourceoftheseheterogeneitieswasnotapparent.Asensitivityanalysisstill
yieldedrobustresultsanddecreasedtheheterogeneities(I2=39.7%and56.2%,respectively)after
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Fig6.Meta-AnalysisofAcupunctureversusSham-TENSforCNPinpainonVAS10cm.I-V,inverse-variancemethod(fixed-effectsmodel);D+L,
DerSimonian-Lairdmethod(random-effectsmodel);CI,confidenceinterval;CNP,chronicneckpain;SD,standarddeviation;WMD,weighted
meandifference.
doi:10.1371/journal.pone.0117146.g006
smallstudieswithfavorabletreatmenteffectwereremoved(S5Table).TheEggertestindicated
publicationbiasduetosmall-studyeffects(coefficient=-2.18;P=0.031)aboutpainatimmedi-
ateterm.Thecontour-enhancedfunnelplotshowedanasymmetry(Fig.11),andadjustingfor
thisbiasremovedasmallstudy[42]withfavorabletreatmenteffect(coefficient=-1.37;95%CI,
-3.05to0.30;P=0.092).Weperformedmetatrim,andtwoassumedstudieswithfavorableeffect
wereaddedandthepooledresultwasstillrobustandinfavorofacupuncture(SMD=-0.65,95%
CI-1.00to-0.30,random)(Fig.12).Thispositiveeffectivenessalsopersistedinindividualswith
acuteLBPintheimmediatetermwithaMDof-0.99(VAS10cm,95%CI-1.24to-0.73)(Fig.13)
[48,50,51].However,regardingdisabilityimprovement,nosignificantdifferenceswereobserved
betweengroupsforCLBP(Fig.14andS5Table).
Acupunctureversuswaitlist(notreatment)
Fourtrials[44,52,53,55](n=2911)comparedacupuncturewithnotreatmentwithrespectto
painreliefanddisabilityimprovementforCLBP.Allfourstudiesthatevaluatedtheimmediate
reliefofpainshowedsuperiorityinfavorofacupuncture(SMD=-0.73,95%CI-0.96to-0.49)
(Fig.15).Meanwhile,threestudies[44,52,55]werepooledaccordingtothelevelsoffunction,a
significantadvantageemergedfavoringacupunctureimmediatelypost-treatment(SMD=-0.95
(-1.42,-0.48)).Theresultsabovewerestillrobustinsensitivityanalyses(S5Table).
AcupunctureversusTENS
Twostudies[56,57](n=70)comparedacupuncturewithTENSandshowednosignificant
differencesbetweengroupswithrespecttopain(Fig.16),notonlyintheimmediateterm(p=
0.81)butalsoatshorttermfollow-up(p=0.33).However,functionalstatuswasnotassessed.
Acupunctureversusmedications
PLOSONE|DOI:10.1371/journal.pone.0117146 February24,2015 10/37