Traditional Chinese Medicine for Neck Pain and Low Back Pain: A Systematic Review and Meta-Analysis

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Abstract

Background

Neck pain (NP) and low back pain (LBP) are common symptoms bothering people in daily life. Traditional Chinese medicine (TCM) has been used to treat various symptoms and diseases in China and has been demonstrated to be effective. The objective of the present study was to review and analyze the existing data about pain and disability in TCM treatments for NP and LBP.

Methods

Studies were identified by a comprehensive search of databases, such as MEDLINE, EMBASE, and Cochrane Library, up to September 1, 2013. A meta-analysis was performed to evaluate the efficacy and safety of TCM in managing NP and LBP.

Results

Seventy five randomized controlled trials (n = 11077) were included. Almost all of the studies investigated individuals experiencing chronic NP (CNP) or chronic LBP (CLBP). We found moderate evidence that acupuncture was more effective than sham-acupuncture in reducing pain immediately post-treatment for CNP (visual analogue scale (VAS) 10 cm, mean difference (MD) = -0.58 (-0.94, -0.22), 95% confidence interval, p = 0.01), CLBP (standardized mean difference = -0.47 (-0.77, -0.17), p = 0.003), and acute LBP (VAS 10 cm, MD = -0.99 (-1.24, -0.73), p< 0.001). Cupping could be more effective than waitlist in VAS (100 mm) (MD = -19.10 (-27.61, -10.58), p < 0. 001) for CNP or medications (e.g. NSAID) for CLBP (MD = -5.4 (-8.9, -0.19), p = 0.003). No serious or life-threatening adverse effects were found.

Conclusions

Acupuncture, acupressure, and cupping could be efficacious in treating the pain and disability associated with CNP or CLBP in the immediate term. Gua sha, tai chi, qigong, and Chinese manipulation showed fair effects, but we were unable to draw any definite conclusions, and further research is still needed. The efficacy of tuina and moxibustion is unknown because no direct evidence was obtained. These TCM modalities are relatively safe.

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Small study effects in meta-analyses of osteoarthritis trials: meta-epidemiological study

Eveline Nüesch, Sven Trelle, Stephan Reichenbach … (2010)

Objective To examine the presence and extent of small study effects in clinical osteoarthritis research. Design Meta-epidemiological study. Data sources 13 meta-analyses including 153 randomised trials (41 605 patients) that compared therapeutic interventions with placebo or non-intervention control in patients with osteoarthritis of the hip or knee and used patients’ reported pain as an outcome. Methods We compared estimated benefits of treatment between large trials (at least 100 patients per arm) and small trials, explored funnel plots supplemented with lines of predicted effects and contours of significance, and used three approaches to estimate treatment effects: meta-analyses including all trials irrespective of sample size, meta-analyses restricted to large trials, and treatment effects predicted for large trials. Results On average, treatment effects were more beneficial in small than in large trials (difference in effect sizes −0.21, 95% confidence interval −0.34 to −0.08, P=0.001). Depending on criteria used, six to eight funnel plots indicated small study effects. In six of 13 meta-analyses, the overall pooled estimate suggested a clinically relevant, significant benefit of treatment, whereas analyses restricted to large trials and predicted effects in large trials yielded smaller non-significant estimates. Conclusions Small study effects can often distort results of meta-analyses. The influence of small trials on estimated treatment effects should be routinely assessed.

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Size is everything--large amounts of information are needed to overcome random effects in estimating direction and magnitude of treatment effects.

A. Moore, David Gavaghan, R M Tramèr … (1998)

Variability in patients' response to interventions in pain and other clinical settings is large. Many explanations such as trial methods, environment or culture have been proposed, but this paper sets out to show that the main cause of the variability may be random chance, and that if trials are small their estimate of magnitude of effect may be incorrect, simply because of the random play of chance. This is highly relevant to the questions of 'How large do trials have to be for statistical accuracy?' and 'How large do trials have to be for their results to be clinically valid?' The true underlying control event rate (CER) and experimental event rate (EER) were determined from single-dose acute pain analgesic trials in over 5000 patients. Trial group size required to obtain statistically significant and clinically relevant (0.95 probability of number-needed-to-treat within -/+0.5 of its true value) results were computed using these values. Ten thousand trials using these CER and EER values were simulated using varying group sizes to investigate the variation due to random chance alone. Most common analgesics have EERs in the range 0.4-0.6 and CER of about 0.19. With such efficacy, to have a 90% chance of obtaining a statistically significant result in the correct direction requires group sizes in the range 30-60. For clinical relevance nearly 500 patients are required in each group. Only with an extremely effective drug (EER > 0.8) will we be reasonably sure of obtaining a clinically relevant NNT with commonly used group sizes of around 40 patients per treatment arm. The simulated trials showed substantial variation in CER and EER, with the probability of obtaining the correct values improving as group size increased. We contend that much of the variability in control and experimental event rates is due to random chance alone. Single small trials are unlikely to be correct. If we want to be sure of getting correct (clinically relevant) results in clinical trials we must study more patients. Credible estimates of clinical efficacy are only likely to come from large trials or from pooling multiple trials of conventional (small) size.

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A randomized trial comparing acupuncture, simulated acupuncture, and usual care for chronic low back pain.

Daniel Cherkin, Karen Sherman, Andrew Avins … (2009)

Acupuncture is a popular complementary and alternative treatment for chronic back pain. Recent European trials suggest similar short-term benefits from real and sham acupuncture needling. This trial addresses the importance of needle placement and skin penetration in eliciting acupuncture effects for patients with chronic low back pain. A total of 638 adults with chronic mechanical low back pain were randomized to individualized acupuncture, standardized acupuncture, simulated acupuncture, or usual care. Ten treatments were provided over 7 weeks by experienced acupuncturists. The primary outcomes were back-related dysfunction (Roland-Morris Disability Questionnaire score; range, 0-23) and symptom bothersomeness (0-10 scale). Outcomes were assessed at baseline and after 8, 26, and 52 weeks. At 8 weeks, mean dysfunction scores for the individualized, standardized, and simulated acupuncture groups improved by 4.4, 4.5, and 4.4 points, respectively, compared with 2.1 points for those receiving usual care (P .05). Although acupuncture was found effective for chronic low back pain, tailoring needling sites to each patient and penetration of the skin appear to be unimportant in eliciting therapeutic benefits. These findings raise questions about acupuncture's purported mechanisms of action. It remains unclear whether acupuncture or our simulated method of acupuncture provide physiologically important stimulation or represent placebo or nonspecific effects.

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Author and article information

Contributors

Jan P. A. Baak: Role: Academic Editor

Journal

Journal ID (nlm-ta): PLoS One

Journal ID (iso-abbrev): PLoS ONE

Journal ID (publisher-id): plos

Journal ID (pmc): plosone

Title: PLoS ONE

Publisher: Public Library of Science (San Francisco, CA USA )

ISSN (Electronic): 1932-6203

Publication date (Electronic): 24 February 2015

Publication date Collection: 2015

Volume: 10

Issue: 2

Electronic Location Identifier: e0117146

Affiliations

[1 ]Department of Orthopaedics of the First Affiliated Hospital, Medical School, Xi’an Jiaotong University, Xi’an 710061, China

[2 ]Second department of Orthopaedics, Xianyang Central Hospital, Xianyang, Shaanxi, P.R. 712000, China

[3 ]Department of Orthopaedics of the Affiliated Hospital of Xi’an Medical College, Xi’an 710077, China

Stavanger University Hospital, NORWAY

Author notes

Competing Interests: The authors have declared that no competing interests exist.

Conceived and designed the experiments: QLY TMG YGZ. Performed the experiments: QLY YGZ LL FS TMG. Analyzed the data: QLY YGZ TMG. Contributed reagents/materials/analysis tools: QLY YGZ LL FS TMG. Wrote the paper: QLY YGZ.

* E-mail: zyingang@ 123456mail.xjtu.edu.cn

Article

Publisher ID: PONE-D-14-02650

DOI: 10.1371/journal.pone.0117146

PMC ID: 4339195

PubMed ID: 25710765

SO-VID: 823e75f1-7bea-48fa-b626-b5a55f104940

License:

This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited

History

Date received : 24 February 2014

Date accepted : 18 December 2014

Page count

Figures: 30, Tables: 4, Pages: 37

Funding

The authors are grateful for the support of the Natural Scientific Fund of China (no. 81371987, 81171761). The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Traditional Chinese Medicine for Neck Pain and Low Back Pain: A Systematic Review and Meta-Analysis

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Most cited references 64

Small study effects in meta-analyses of osteoarthritis trials: meta-epidemiological study

Size is everything--large amounts of information are needed to overcome random effects in estimating direction and magnitude of treatment effects.

A randomized trial comparing acupuncture, simulated acupuncture, and usual care for chronic low back pain.

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