Abstract
Background.
Clinical studies on the efficacy of warm needle moxibustion to treat lumbar disc herniation are increasing, while studies on the assessment of its efficacy are still lacking.
Objective.
To assess the clinical effect of warm needle moxibustion on lumbar disc herniation.
Methods.
We searched relevant trials that compared warm needle moxibustion with other methods for lumbar disc herniation from 9 databases.
Results.
Warm needle moxibustion showed statistical significance efficiency rate compared with acupuncture and manipulation but had a similar rate with nonsteroidal anti-inflammatory drugs (NSAIDs). It showed a statistically significanty excellent rate when compared with acupuncture and manipulation but had a similar rate with NSAIDs. Regarding Japanese Orthopedic Association scores, it showed statistical significance with acupuncture and manipulation, but the rate was similar with Chinese medicine and NSAIDs. Regarding visual analog scale score, it demonstrated statistical significance when compared with acupuncture, manipulation, and NSAIDs but had a similar rate with Chinese medicine.
Conclusion.
Warm needle moxibustion is superior to acupuncture and manipulation in terms of efficiency rate, excellent rate, and controlling of pain for lumbar disc herniation, but it is similar when compared with NSAIDs and Chinese medicine.
Lumbar disc herniation is also known as a slipped, ruptured, or prolapsed disc. Whatever name is given, it all refers to the medical condition wherein the soft material in the middle of the lumbar disc takes so much pressure that it ruptures. When it occurred, one or more of the nerves in the spine are under pressure. The main symptom of lumbar disc herniation is low back pain and sciatica. 1 In China, about 80% of adults are suffering from low back and leg pain, and 20% of them are diagnosed with lumbar disc herniation. 2 In the United States, there are about 2 million people who are suffering from lumbar disc herniation each year. 3 According to statistics from the World Health Organization, lumbar disc herniation has become one of the most important causes of disability as expressed in disability-adjusted life years both in developed and developing countries. 4
As a result of the significant financial and social burdens associated with lumbar disc herniation, many researches have focused on the identification of effective treatments. Complementary and alternative medicine is widely advocated to face the increasing demand for nonpharmacological approaches.
5
Acupuncture, as a mainstream complementary and alternative medicine therapy, has been widely used and accepted by people across the word. In 2002, the World Health Organization proposed 107 indications suitable for acupuncture intervention, in which low back pain and sciatica caused by lumbar disc herniation were included.
6
Moxibustion is a modality of traditional acupuncture that involves burning moxa, the herb
Method
Inclusion Criteria and Exclusion Criteria
Studies were included according to the following criteria: (
Studies were excluded according to the following criteria: (
Search Strategy
The research was done independently by 2 authors (Li XH and Han YC), and disagreement was resolved by the corresponding author (Di Z). Electronic retrieval was used. The publication language was limited to English and Chinese. The databases were the Chinese Biological Medical Literature Database (CBM, 1979-2015.6), China National Knowledge Internet (CNKI, 1979-2015.6), Weipu Database (VIP, 1989-2015.6), and Wanfang Digital Journal (WF, 1998-2015.6). Online databases searched were PubMed (1966-2015.6), EMBASE (1980-2015.6), and the Cochrane Library (Issue 1-2015.6). Search terms in Chinese included “Wen Zhen Jiu,” “Wen Zhen,” “Zhen Bing Jiu,” “Shao Zhen Bing” (all translated to warming needle moxibustion), “Jiu” (moxibustion), “yao zhui jian pan tu chu” (intervertebral disc herniation), and “yao zhui jian pan yi wei” (intervertebral disc displacement). Search terms in English included “acupuncture and moxibustion,” “warm needle,” “warm acupuncture,” “warming needle moxibustion,” “intervertebral disc herniation,” “protrusion of lumbar intervertebral disc,” and “intervertebral disc displacement.” All the terms were searched with various combinations of the operators “AND,” “NOT,” and “OR.”
Data Extraction and Quality Evaluation
Data from the included studies were extracted and summarized independently by 2 of the authors (Li XH and Han YC), and disagreement was resolved by the adjudicating senior author (Di Z). The following data were extracted from the trials: (
Characteristics of the Trials Included.
Abbreviations: JOA score, Japanese Orthopedic Association score; NSAID, nonsteroidal anti-inflammatory drug.
The methodological quality of the included studies were evaluated by the Cochrane Risk of Bias Tool (version 5.1.0). 15 Each of the research results would be judged explicitly by the following criteria: low (low risk of bias), high (high risk of bias), or unclear (uncertain risk of bias). Two authors (Li XH and Han YC) double checked the evaluation results by exchanging information with each other. The eligibility of the trials would be assessed by discussion to resolve disagreements on inclusion or not, or the decision would be made by the third decision maker (Di Z).
Statistical Analysis
The statistical analysis was conducted with Review Manager 5 (version 5.3; Cochrane Collaboration 2014). The studies for inclusion were determined by inspection for heterogeneity;
Results
The clinical outcomes were assessed according to 4 indexes: the efficient rate, the excellent rate, VAS score, and JOA score. The efficiency of warm needle moxibustion can be classified into 4 class, according to a widely used diagnose standard in China. 13 The class of “excellent” can be defined as follows: the disappearing of leg and back pain, Lasegue test backing to negative, patient restored the original function, without recurrence after half year’s follow-up. The class “good” was defined as follows: the leg and back pain of patients almost relieved, the above-mentioned symptom did not aggravate after half year’s follow-up. The class “fair” clinical effects was concluded as follows: the symptom of leg and back pain reduce slightly. The “poor” outcomes were defined as follows: without any change of sign and symptom, before and after the treatment. The “excellent,” “good,” and “fair” classes were combined and regarded as efficient rate in our study.
The outcomes of relieving of pain was done according to JOA and VAS. JOA score is a pain score rating system made by the Japanese Orthopedic Association. A full JOA scores is 29 points, based on 3 subjective symptoms (9 points), 3 clinical signs (6 points), and 7 activities of daily living measures (14 points). Patients with a scores of 25 points or more were rated as “satisfactory,” with scores less than 25 points labeled as “unsatisfactory.” 14 In our study, we used the improved JOA scores (the difference between pretreatment and posttreatment scores) as an index. The pain VAS is self-completed by the respondent. The respondent is asked to place a line perpendicular to the VAS line at the point that represents their pain intensity (VAS: 0 = no pain at all; 10 = worst pain imaginable).
Search Results
At the primary search of electronic database searches, a total of 466 relevant studies were identified. After reviewing of the titles and abstracts, 417 studies were excluded for the following reasons: unrelated topic, working on animals, no control studies, case reports, review articles, or other forms of investigation. Subsequently, 30 studies were excluded due to failure to meet the inclusion criteria. A further 4 studies were excluded due to duplicate reports, or other intervention. Finally, 15 studies were included in the final analysis (Figure 1). Among the 15 studies, 7 studies were retrieved from CNKI, 7 studies from the Wanfang database, and 1 study 16 from PubMed. Twelve of the 15 articles were full-text articles, and 3 of the publications 17 –19 were master’s thesis. The agreement between the 2 reviewers (Li XH and Han YC) was 95% for study selection and 93% for quality assessment of trials.
Flow diagram detailing study inclusion.
Demographic Characteristics and Quality Assessment
The characteristics of each selected study are provided in Table 1. Fifteen studies including 1146 cases (563 cases for the group of warm needle moxibustion and 583 cases for control group) fulfilled the predefined inclusion criteria and were included in the final analysis. All the 15 studies were published in Chinese. In terms of the method of randomization, among the 15 included studies, 2 trials 20,21 used the computer to produce the randomization sequence, 4 trials 17,19,22,23 used a random table method, 5 trials 24 –26 mentioned randomization but without a description of the randomization method, and 2 trials 17,27 used a wrong random method. The side effects that happened during the process of treatment are described in one study. 21 In general, the quality of the included studies was generally low to moderate (Figures 2 and 3).
Analysis of the risk of bias of included trials.
Summary of the risk of bias of trials included.
Clinical Outcome Analysis
Efficient Rate
Among these studies, there was a low statistical heterogeneity (
Subgroup analysis of the effectiveness rate.
Excellent Rate
A there was no statistical heterogeneity among these studies (
Subgroup analysis of the excellence rate.
JOA Scores
In terms of the JOA scores, heterogeneity was detected among this analysis (
Subgroup analysis of the JOA score.
VAS Scores
Nine trials in this analysis used the VAS as the outcome measurement. Among the findings, there appears heterogeneity (
Subgroup analysis of the VAS score.
Relief from pain was still one of main targets in the treatment of lumbar disc herniation. VAS and JOA scores are common indexes used in the assessment of hurt relief treatment. In this meta-analysis, we can see that warm needle moxibustion had a remarkable effect on relieving of pain when compared with manipulation and acupuncture.
Discussion
This meta-analysis summarized the evidence from 15 trials consisting of 1146 cases (563 cases for the group of warm needle moxibustion and 583 cases for control group) with regard to the advantages of warm needle moxibustion in the treatment of lumbar disc herniation. To acquire a more accuracy assessment on efficient rate and excellent rate in this meta-analysis, we chose the trials using the same evaluation criterion. Regarding efficient rate and excellent rate, the group of warm needle moxibustion was superior to that of acupuncture and manipulation. In terms of JOA and VAS scores, warm needle moxibustion showed a more favorable effect on relieving of pain than acupuncture and manipulation.
Taking the above-mentioned findings into consideration, warm needle moxibustion, as a method that combines acupuncture with moxibustion, has achieved a favorable effect in the treatment lumbar disc herniation. How does this combination method work so effectively? Generally speaking, the effect of warm needle moxibustion can be divided into an acupuncture part and a moxibustion part. In general, the therapeutic effects of acupuncture are thus brought about through its regulatory actions on various systems, so that it can be regarded as a nonspecific therapy with a broad spectrum of indications. 6 In terms of Western scientific principles, it is uncertain how acupuncture may help lumbar disc herniation and the leg pain and back pain caused by lumbar disc herniation. It is hypothesized that acupuncture works through the gate control theory of pain, in which the sensory input is inhibited in the central nervous system by inputting of the needle. Another theory suggests that the presence of the needle stimulates vascular and immunomodulatory factors such as mediators of inflammation. Elevated levels of adrenocorticotrophic hormone after acupuncture seem to support this theory. 28
In terms of moxibustion, the mechanisms of action of moxibustion therapy are still largely unknown. Some authors held that it may enhance the effect of curing disease by producing some factors to certain points or areas on the surface of the body through regulation of the function of meridians and visceral organs. The following factors are likely to be included: temperature, infrared radiation, smoke, odor, and the type of moxa. 32 Many authors advocated that moxibustion might have an effect of anti-inflammation. 17 –19 Yang and Huang 29,33 reported that when the moxibustion was burned, it can produce a kind of infrared ray that can both furnish the energy for cells’ metabolism and the immunity function and provide viable energy for those energy-lacking cells. Zhong 34 held that the warmth and light produced in the process of burning the moxibustion can enhance the cell’s ability to phagocytosis, improve blood circulation, reduce nerve excitability, and eliminate inflammation surrounding the nerves.
What is more, little side effects were reported during the treatment among those original articles included in this study. Therefore, warm needle moxibustion, as an effective method for the treatment of lumbar disc herniation, might be introduced into the clinic practice with great advantages due to its little side effects.
There are several limitations in this meta-analysis. First, in general, the samples are not enough and the quality of our included studies is not high. Of the 15 studies, 5 trials mentioned randomization but without a description of the randomization method; 2 trials 16,18 used an incorrect random method; only 1 trial 21 described the implementation of allocation concealment. These might have caused selection bias. All the trials included in our study were published in Chinese, which might have caused publication bias. Second, there are some limitations in terms of outcome assessment index such as VAS and efficient rate, for it is largely dependent on the subjectivity of patients. Third, there is a variable length of follow-up among the studies. In short, the low quality of the trials might lead to clinical heterogeneity and bias of the results. Care is needed in the evaluation of these results in clinical practice.
Conclusions
In short, this analysis demonstrates that warm needle moxibustion is superior in efficient rate and excellent rate in the treatment of lumbar disc herniation, when compared with acupuncture and manipulation. Warm needle moxibustion has a better effect on relieving of pain, when compared with acupuncture and manipulation but with a similar effect for NSAIDs and Chinese medicine. Given the varied nature of the methodological quality of the randomized controlled trials, we suggest the usage of warm needle moxibustion could be considered as an adjunct to routine practice in the treatment of lumbar disc herniation, whereas future efforts could focus on improving the methodological and reporting quality of the trials. Additionally, longer term follow-up is needed in future research to examine the lasting effect of warming needle moxibustion.
Footnotes
Authors’ Note
Xinhua Li and Yingchao Han contributed equally to this study and are co–first authors.
Acknowledgments
The authors acknowledge all the authors of the original studies that were included in this meta-analysis.
Author Contributions
Xinhua Li and Yingchao Han contributed to conception and design, or acquisition of data, or analysis and interpretation of data; Jian Cui and Ping yuan drafted the article or revised it critically for important intellectual content; Lijun Li and Zhi Di contributed to revise, review the research manuscript, and fnal approval of the version to be published.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by grants from National Natural Science Foundation of China (No. 81171700).
Ethical Approval
As this article is a review study, ethical approval was not required.