Systematic Review And Meta - Analysis Of Acute Lumbar Sprain Treated With Acupuncture In Recent 10 Years

Research backgroundIn the West, approximately 70%[1] of all adults experience an episode of lower back pain as a result of work or play and millions of euros and dollars are spent into the diagnosis and treatment of many conditions that include lower back pain as the main symptom. In China, acute lumbar sprain (ALS), account for 5%-25%[2]of all hospital visits to the orthopedic department.Acute Lumbar Sprain, is classified as a non-specific acute type of lower-back pain. This is the most common type of lower back pain, accounting for 80%-85%[1] of all acute types. It’s classified as non-specific since it is not possible to arrive at a diagnosis based on detectable pathological changes. Therefore non-specific acute type of lower-back pain is categorized based on pain distribution, pain behavior, functional disability, clinical signs, etc. The existing clinical guidelines propose a triage to identify "Red flags" (age of onset less than 20 years or more than 55 years old, trauma, thoracic pain, weight loss, neurological symptoms), and exclude specific diseases (including radicular syndrome). Clinicians, through examining patients (physical and imaging), studying their clinical history and identifying and excluding "Red and Yellow Flags", are then able to evaluate the degree of pain and functional disability and thus design a management strategy to match the magnitude of the problem. Therefore ALS, is an acute (present for less than 6 weeks) non-radicular type (doesn’t include nerve root pain referred to the limbs or sciatica), affecting the soft tissues (sprain ligaments) that causes swelling, diffuse back pain, tenderness, stiffness and spasms.The present study followed 4 different types of international clinical guidelines (Europe, USA, Australia and China) in order to study and identify a standard diagnosis, evaluation procedures and treatment for ALS. On the other hand, the use of Acupuncture as an alternative or even as a viable treatment procedure for ALS has increasingly been studied and examined in China as well as in the West. Many high quality studies in China and in the West have examined the use of Acupuncture for low-back pain and acute low-back pain, but so far no High quality standard studies have reported its possibilities for treating ALS. Evidence-based medicine (EBM) is a form of medicine that aims to optimize decision-making by emphasizing the use of evidence from well designed and conducted research (coming from meta-analyses, systematic reviews, and randomized controlled trials). Meta-analysis and systematic reviews collect the strongest level of evidence for treatment plans, providing therefore important decision making clinical tools. Based in Randomized Clinical Trials (RCT), evidence-based medicine is regarded as the ’gold standard’ for clinical practice and research nowadays. This study presents a Meta-analysis study of RCT systematic reviews that follows high quality methodology laid by Cochrane Collaboration (CC). CC organizes medical research information in a systematic way to facilitate the choices that health professionals, patients, policy makers and others face in health interventions according to the principles of evidence-based medicine.Objective:The objective of this study is to explore systematic reviews and conduct a meta-analysis on the use of acupuncture treatment for ALS over the past 10 years, in order to evaluate its efficacy and explore the clinical value in pain reduction when compared to other methods, and consequently provide a future reference for further clinical research and practice.Methodology:Searching method:In February of 2015, an exhaustive computer search for primary studies was conducted through 7 general databases; 4 databases in English (Pubmed, Cochrane Library, Ecam, PlusOne) and 3 databases in Chinese language (CNKI, WANFANG, CQVIP). All the included studies report Acupuncture RCTs in treating ALS (for the last 10 years).Intervention:The set of intervention measures selected for researching the treatment group are limited only to acupuncture, thus excluding:moxibustion, electric acupuncture, auricular acupuncture, cranial acupuncture, injections, intra-dermal threads, etc. On the contrary, the control group has no limit of intervention measures.The present research follows methods of evaluating RCTs of which characteristics are based on the Cochrane Collaboration 5.1.0 handbook version "Cochrane Handbook for Systematic Reviews of Interventions" on assessing risk of bias in included studies. All data was analyzed through the Cochrane Collaboration RevMan5.2 software for meta-analysis, processing data results through clinical heterogeneity, Relative Risk (RR) for dichotomous data, and Mean Difference (MD) for evaluating the effects in continuous data, while also providing a confidence interval of 95% (CI) for the data results. When the clinical heterogeneity test results are in acceptable range, they undergo a quantitative analysis that considers the complexity of acupuncture treatment through the use of a random effect model. If the heterogeneity test results are above acceptable range, the results assume a qualitative analysis.Outcome measures:The main outcome measures in the included studies: ① followed diagnostic and evaluating guidelines for signs of improvement in clinical symptoms which are translated into the efficacy and curing rate results. ② followed non-quantifiable pain measurements and lumbar muscle movement evaluation for an improvement of the clinical symptoms. ③ followed quantifiable pain measurements; Visual Analogue Scale (VAS), Numeric Rating Scale (NRS), Present Pain Intensity (PPI) and or lumbar muscle movement evaluations; Range of Motion (ROM), Modified Japanese Orthopaedics Association (M-JOA) and others evaluation type of procedures such as questionnaires; Roland-Morris Disability Questionnaire (RMDQ), McGill Pain Questionnaire (MPQ), thus to determine an improvement of clinical symptoms in order to establish a better efficacy and curing rate.Results:From the starting 25 included studies, only 11 were chosen for meta-analysis, including 2 studies in English language. From these 11 studies, due to a lack in paired studies, only 8 studies with a comparing baseline were finally integrated and concluded the meta-analysis.The Meta-Analysis on the 8 included studies results concluded:① Efficacy rate:It’s more effective to use acupuncture to treat ALS than to administrate analgesic or anti-inflammatory medication. Also, it’s more effective to use fewer experienced acupoints than to use more acupoints based on acupuncture protocols.② Pain:Based on the VAS results, acupuncture is superior to the administration of analgesic or anti-inflammatory medication in reducing pain caused by ALS. With only a slight difference between studies, the use of fewer experienced points may also be superior to acupuncture protocols in reducing pain caused by ALS.A total of 6 acupoints (阿是穴、腰痛点、后溪、委中、水沟与肾俞) used as point pair combinations or in combinations of 3 acupoints, have demonstrated to be effective in reducing pain and promoting an overall improvement to patients suffering from ALS. These acupoints showed better clinical results in treatment groups when compared either to Western medication or with the use of acupuncture protocols.The qualitative analysis confirms the advantages and efficacy of acupuncture in treating or reducing pain caused by ALS, even though due to limitations in the included studies, other important factors were unable to be determined (safety, pain and physical movement evaluation measures, etc.).Conclusion:The use of acupuncture presents certain advantages for clinical application improving efficacy rate and in reducing pain caused by ALS.Limitations:There is a great portion of several different cases in risk of bias reports among the included studies. The publication of only or mostly positive results constitute a presence of publication bias. Also many studies didn’t include follow up reports or are showing inconsistent or simply incomplete results, constituting a potential time of intervention bias. Many aspects of acupuncture are not explored or even included in the studies, such as:needling depth, acupuncture technique, researcher qualifications or specialization, degree of stimulation, treatment timing, placebo effect, etc. This constitutes potential information bias in the included studies. The quality evaluation results on the 25 included studies showed only 2 studies with a low risk of bias whereas 15 had a high risk of bias and 9 were in moderate risk of bias. In light of such results, it’s then possible to ascertain the lack of high quality rate among the included studies manifest their results and conclusions, therefore a certain degree of attention and caution will be necessary when interpreting them.