Traditional Chinese medicine for neck pain and low back pain: a systematic review and meta-analysis

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.

Fig 1. Flow Diagram.

Fig 2. Risk-of-Bias of studies included.

Q, question.

Fig 3. Meta-Analysis of Acupuncture versus Sham-Acupuncture for CNP in Pain Intensity on the VAS (0–10 mm).

Fixed-effects model was used; CI, confidence interval; CNP, chronic neck pain; SD, standard deviation; VAS, visual analogue scale; WMD, weighted mean difference.

Fig 4. Contour-enhanced funnel plot of Acupuncture versus Sham-Acupuncture for CNP in Pain.

Visual inspection of the funnel plot suggested symmetry. Specifically, there were most of trials with negative results (i.e., more trials in areas of statistical nonsignificance), indicating no evidence of publication bias.

Fig 5. Meta-Analysis of Acupuncture versus Sham-Acupuncture for CNP in Disability.

Fixed-effects model was used; CI, confidence interval; CNP, chronic neck pain; SD, standard deviation; SMD, standardized mean difference.

Fig 6. Meta-Analysis of Acupuncture versus Sham-TENS for CNP in pain on VAS 10 cm.

I-V, inverse-variance method (fixed-effects model); D+L, DerSimonian-Laird method (random-effects model); CI, confidence interval; CNP, chronic neck pain; SD, standard deviation; WMD, weighted mean difference.

Fig 7. Meta-Analysis of Acupuncture versus Sham-TENS for CNP in Disability.

I-V, inverse-variance method (fixed-effects model); D+L, DerSimonian-Laird method (random-effects model); CI, confidence interval; CNP, chronic neck pain; SD, standard deviation; SMD, standardized mean difference.

Fig 8. Meta-Analysis of Acupuncture versus Medications for CNP in Pain and Disability.

I-V, inverse-variance method (fixed-effects model); D+L, DerSimonian-Laird method (random-effects model); CI, confidence interval; CNP, chronic neck pain; SD, standard deviation; SMD, standardized mean difference.

Fig 9. Meta-Analysis of Acupuncture versus Manipulation for CNP in Pain and Disability.

Fixed-effects model was used; CI, confidence interval; CNP, chronic neck pain; SD, standard deviation; SMD, standardized mean difference.

Fig 10. Meta-Analysis of Acupuncture versus Sham-acupuncture for CLBP in Pain.

CI, confidence interval; CLBP, chronic low back pain; SD, standard deviation; SMD, standardized mean difference.

Fig 11. Contour-Enhanced Funnel Plot of Acupuncture versus Sham-acupuncture for CLBP in Pain at immediate term.

Visual inspection of the funnel plot suggested some degree of asymmetry. Specifically, there was a relative lack of trials with negative results (i.e., fewer trials in areas of statistical nonsignificance), indicating a potential for publication bias; meanwhile, the dot on the lower left part of the Figure suggested an evidence of small-study effect.

Fig 12. Metatrim Funnel Plot of Acupuncture versus Sham-acupuncture for CLBP in Pain at immediate term.

The dots in the squares were the studies filled. There were two trials with positive effects filled.

Fig 13. Meta-Analysis of Acupuncture versus Sham-acupuncture for acute LBP in pain on VAS 10 cm.

Fixed-effects model was used; CI, confidence interval; LBP, low back pain; SD, standard deviation; WMD, weighted mean difference.

Fig 14. Meta-Analysis of Acupuncture versus Sham-acupuncture for CLBP in Disability.

CI, confidence interval; CLBP, chronic low back pain; SD, standard deviation; SMD, standardized mean difference.

Fig 15. Meta-Analysis of Acupuncture versus Notreatment for CLBP in Pain and Disability.

I-V, inverse-variance method (fixed-effects model); D+L, DerSimonian-Laird method (random-effects model); CI, confidence interval; CLBP, chronic low back pain; SD, standard deviation; SMD, standardized mean difference.

Fig 16. Meta-Analysis of Acupuncture versus TENS for CLBP in pain on VAS 10 cm.

TENS, transcutaneous electrical nerve stimulation; CI, confidence interval; CLBP, chronic low back pain; SD, standard deviation; WMD, weighted mean difference.

Fig 17. Meta-Analysis of Acupuncture versus Medications for CLBP in pain on VAS 10 cm.

Fixed-effects model was used; CI, confidence interval; CLBP, chronic low back pain; SD, standard deviation; WMD, weighted mean difference.

Fig 18. Meta-Analysis of Acupuncture versus Medications for CLBP in disability.

I-V, inverse-variance method (fixed-effects model); D+L, DerSimonian-Laird method (random-effects model); CI, confidence interval; CLBP, chronic low back pain; SD, standard deviation; SMD, standardized mean difference.

Fig 19. Meta-Analysis of Acupuncture plus UC versus UC for CLBP in pain on VAS 10 cm.

UC, usual care; CI, confidence interval; CLBP, chronic low back pain; SD, standard deviation; WMD, weighted mean difference.

Fig 20. Meta-Analysis of Acupuncture plus UC versus UC for CLBP in Disability.

UC, usual care; CI, confidence interval; CLBP, chronic low back pain; SD, standard deviation; standardized mean difference.

Fig 21. Meta-Analysis of Acupuncture versus Usual Care for CLBP in pain.

CI, confidence interval; CLBP, chronic low back pain; SD, standard deviation; standardized mean difference.

Fig 22. Meta-Analysis of Acupressure versus Physical Therapy for CLBP in Pain.

CI, confidence interval; CLBP, chronic low back pain; SD, standard deviation; standardized mean difference.

Fig 23. Meta-Analysis of Acupressure versus Sham-Acupressure for CLBP in Pain.

CI, confidence interval; CLBP, chronic low back pain; SD, standard deviation; standardized mean difference.

Fig 24. Meta-Analysis of Cupping versus Waitlist for CNP in Pain (VAS 100) and Disability (NDI 100).

Fixed-effects model was used; NDI, neck disability index; CI, confidence interval; CNP, chronic neck pain; SD, standard deviation; WMD, weighted mean difference.

Fig 25. Meta-Analysis and Subgroup-Analysis of Cupping versus Medications for CLBP in Pain on VAS 10 cm.

CI, confidence interval; CLBP, chronic low back pain; SD, standard deviation; WMD, weighted mean difference.

Fig 26. Meta-Analysis and Subgroup-Analysis of Cupping versus Medications for CLBP in Disability on ODI 50.

ODI, oswestry disability index; CI, confidence interval; CLBP, chronic low back pain; SD, standard deviation; WMD, weighted mean difference.

Fig 27. Meta-Analysis of Qigong versus Waitlist for CNP in Pain (VAS 100) and Disability (NDI 100).

Fixed-effects model was used; NDI, neck disability index; CI, confidence interval; CNP, chronic neck pain; SD, standard deviation; WMD, weighted mean difference.

Fig 28. Meta-Analysis of Qigong versus Exercise for CNP in Pain (VAS 100) and Disability (NDI 100).

Fixed-effects model was used; NDI, neck disability index; CI, confidence interval; CNP, chronic neck pain; SD, standard deviation; WMD, weighted mean difference.

Fig 29. Meta-Analysis of Chinese Herbal Medicine for CNP in Pain (NRS 3).

NRS, numerical rating scale; CI, confidence interval; CNP, chronic neck pain; SD, standard deviation; WMD, weighted mean difference.

Fig 30. Meta-Analysis of Chinese Manipulation versus Chinese Massage for CNP in Pain (NRS 10).

Fixed-effects model was used; NRS, numerical rating scale; CI, confidence interval; CNP, chronic neck pain; SD, standard deviation; WMD, weighted mean difference.