Acupuncture Reviews for Disc Herniation Treatment

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TMR | July 2020 | vol. 5 | no. 4 | 282
doi: 10.12032/TMR20190930137
Traditional Chinese Medicine
Acupuncture and/or moxibustion for the treatment of lumbar disc
herniation: quality assessment of systematic reviews
Zi-Han Yin1#
, Chao-Xi Zhu1#
, Gui-Xing Xu1
, Cheng Ying1
, Ai-Ling Huang1
, Ya-Nan Fu1
, Jiao Chen1
, Ling Zhao1
, Fan-Rong
Liang1*
1
Chengdu University of Traditional Chinese Medicine, Chengdu 610075, China.
#
Zi-Han Yin and Chao-Xi Zhu are the co-first authors of this paper.
*Corresponding to: Fan-Rong Liang, Chengdu University of Traditional Chinese Medicine, 37 Shierqiao Road, Chengdu,
China. E-mail: acuresearch@126.com.
Highlights
In the current systematic review on acupuncture and/or moxibustion for lumbar disc herniation (LDH),
the methodology and quality of evidence and reports were evaluated via AMSTAR list, GRADE system and
PRISMA statement and conclusion is that acupuncture and/or moxibustion have some advantages in terms
of efficacy and safety with regard to LDH treatment.
Traditionality
LDH belongs to the category of low back pain (LBP) in Chinese medicine theory. LBP was recorded in the
earliest Chinese medical classic Huangdi Neijing published in Qinhan period of China (the time of writing
is unknown). Subsequently, evidence on the use acupuncture for the treatment of LBP by a large number of
scholars of Ming dynasty of China was recorded in Jingyue Quanshu, Zhenjiu Dacheng, and other ancient
books on acupuncture. With the development of modern medicine, National Institute for Health and Clinical
Excellence guidelines published in 2012 highlighted the need for a treatment course of acupuncture of up to
10 sessions over 12 weeks for patients with LBP.

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Abstract
Objective: In the current systematic review on acupuncture and/or moxibustion for lumbar disc herniation (LDH),
we evaluated the methodology and quality of evidence and reports to provide necessary information for accurate
clinical decision-making regarding acupuncture and/or moxibustion for LDH. Methods: From databases such as
CBM (Chinese biomedical literature database), VIP (China science and technology journal database), CNKI (China
national knowledge infrastructure), WF (Wanfang database), Web of Science, Embase, Medline, and Cochrane
Library, systematic reviews on acupuncture and/or moxibustion for LDH were retrieved, and the methodological
quality of the literature was evaluated according to the assessment of multiple systematic reviews (AMSTAR) list.
Furthermore, the grading of recommendations assessment, development and evaluation (GRADE) system was used
to grade the quality of evidence and the preferred reporting items for systematic reviews and meta-analyses
(PRISMA) statement to evaluate the quality of the report. Results: A total of 18 systematic reviews were included,
and the conclusion is that acupuncture and/or moxibustion have some advantages in terms of efficacy and safety
with regard to LDH treatment. According to the AMSTAR score, there were 4 high-quality studies, 13
moderate-quality studies, and 1 low-quality study. GRADE showed that quality of evidence such as total effective
rate of LDH and VAS was low and that of other forms of evidence was lower. The PRISMA statement showed that
8 articles were in line with 20 or more of the 27 items, and 10 articles were in line with 10-19 of the 27 items.
Conclusion: At present, acupuncture and/or moxibustion for LDH has a good curative effect. More importantly, its
methodological quality was of moderate level and the report quality was generally good and relatively complete.
However, the poor quality of the original research results was reflected in the quality of evidence. More studies are
needed to make sure whether acupuncture is more effective than other treatment methods.
Keywords: Lumbar disc herniation, Acupuncture therapy, Overview of systematic reviews, AMSTAR, GRADE,
PRISMA.
Acknowledgments:
The study was financially supported by the Major Program of the National Natural Science Foundation of China
(No. 81590951).
Abbreviations:
LDH, Lumbar disc herniation; LDD, Lumbar disc disease; LBP, Low back pain; FBSS, Failed back surgery
syndrome; SR, Systematic review; RCTs, Randomized controlled trials; JOA, Japanese orthopaedic association
scores; ODI, Oswestry disability index; AMSTAR, Assessment of multiple systematic reviews; GRADE,
Grading of recommendations assessment, development and evaluation; PRISMA, Preferred reporting items for
systematic reviews and meta-analyses; USA, the United States of America.
Competing interests:
The authors declare that they have no conflict of interest.
Citation:
Zi-Han Yin, Chao-Xi Zhu, Gui-Xing Xu, et al. Acupuncture and/or moxibustion for the treatment of lumbar disc
herniation: quality assessment of systematic reviews. Traditional Medicine Research 2020, 5 (4): 282–294.
Executive editor: Hao-Ran Zhang, Mathew Goss.
Submitted: 10 July 2019, Accepted: 14 September 2019, Online: 30 September 2019.

REVIEW
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doi: 10.12032/TMR20190930137
Background
Lumbar disc herniation (LDH) is a characteristic
feature of lumbar disc disease (LDD). LDD is one of
the most common musculoskeletal diseases [1]. A
country report has shown that LDH is one of the main
causes of lumbar and lower limb movement disorders,
which is as source of heavy burden to individuals,
families, and the society [2]. In China, a study
including 3859 adults showed that the prevalence of
lumbar osteoarthritis increased with an increase in age
[3]. Forty percent of the individuals under 30 years of
age have lumbar intervertebral disc degeneration, and
the prevalence of LDD is increasing progressively to
over 90% by 50-55 years of age [4]. LDH is usually
associated with low back pain (LBP). In the United
States of America (USA), LBP is one of the most
common reasons behind visits to a physician [5].
Although this disease is not a threat to life, it has a
huge impact on the quality of life and it may lead to
many adverse effects, such as development of negative
emotions, on patients' psychology. If the disease does
not heal for a long time, the negative effects on
patients are undeniable. Furthermore, according to a
survey in 2001, family and twin studies have suggested
that sciatica, disc herniation, and disc degeneration
may be influenced to a large degree by genetic factors
[1].
Currently known treatments for LDD are mainly
divided into surgical treatment and conservative
treatment. In some patients, lumbar spine surgery does
not improve the condition, and such patients are
considered to have failed back surgery syndrome
(FBSS).” Most patients with FBSS seek further
treatments for their ongoing pain and impairment [6].
Furthermore, the recurrence of LDH is one of the most
feared complications following surgery [7]. Early
surgery helps achieved a more rapid relief than that
achieved by conservative care in patients with sciatica;
however, outcomes of both the treatments were similar
by the end of the first year and these did not change at
2-year or 8-year follow-up [8-9]. Recent clinical
evidence suggests a health benefit of undergoing
surgery; the cost effectiveness of operative intervention
compared to nonoperative care remains poorly
characterized [10]. Conservative treatment is mainly
suitable for patients with no serious neurological
symptoms or for those with ineffective surgical
outcome. Nonsurgical treatment of adult patients with
a history of < 12 weeks of LBP is recommended by the
Danish Health Authority [11]. Some patients who do
not respond to nonsteroidal anti-inflammatory drugs
may benefit from the use of tramadol, opioids, and
other adjunctive medications. Acupuncture, exercise
therapy, multidisciplinary rehabilitation programs,
massage, behavioral therapy, and spinal manipulation
are effective in certain clinical situations [12-13]. In
the USA, more than 1 million patients received an
epidural steroid injection as part of conservative
treatment for LDH; this excluded those seeking other
conservative treatment methods within and outside the
USA [14]. Furthermore, 42 thousand opioid overdose
deaths were recorded in 2016. Overall prescription
opioid deaths increased by 18% between 2009 and
2016 [15].
Acupuncture is a simple, convenient, inexpensive,
widely used, and safe treatment method for LDH. LDH
belongs to the category of LBP in Chinese medicine
theory. LBP is recorded in the earliest Chinese medical
classic Huangdi Neijing published in Qinhan period of
China (the time of writing is unknown). Subsequently,
evidence on the use acupuncture for the treatment of
LBP by a large number of scholars of Ming dynasty of
China is recorded in some ancient books on
acupuncture including Jingyue Quanshu (published in
1624 C.E.) and Zhenjiu Dacheng (published in 1601
C.E.). With the development of modern medicine,
National Institute for Health and Clinical Excellence
guidelines published in 2012 highlighted the need for a
treatment course of acupuncture of up to 10 sessions
over 12 weeks for patients with LBP [16]. A study
found that the mechanism of action of acupuncture and
electrical acupuncture stimulation could influence the
pain inhibitory system by causing a transient change in
blood flow to sciatic nerve and other regions, including
the cauda equine and nerve root [17]. Besides,
acupuncture is an ideal choice for patients who need
long-term treatment, especially when the curative
effect of Western medicine is not obvious.
Acupuncture has a good application prospect and
promotion value. In this systematic review (SR) on
LDH treatment by acupuncture, the assessment of
multiple systematic reviews (AMSTAR) list [18], the
grading of recommendations assessment, development
and evaluation (GRADE) scale [19] and the preferred
reporting items for systematic reviews and
meta-analyses (PRISMA) statement [20] were used to
conduct methodological quality review, evidence level
review, and report quality study. This method is
expected to play a guiding and normative role in
clinical research and writing on acupuncture for LDH.
Methods
This SR has been registered on PROSPERO
(CRD42019123293).
Eligibility criteria
Type of study. We included the SRs and meta-analyses
that included only randomized controlled trials (RCTs)
on the treatment of lumbar intervertebral disc
herniation using acupuncture, with no limitation on
language.

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Types of participants. Patients who were diagnosed
with LDH, regardless of gender, age, race, region, etc.
Types of interventions. Experimental group:
acupuncture or moxibustion alone or in combination
with other treatment. Control group: drugs, placebo,
sham acupuncture, etc.
Types of outcome measures. Total effective rate, VAS,
Japanese orthopaedic association scores (JOA), and
Oswestry disability index (DOI).
Literature search
The search terms included LDH, acupuncture,
acupuncture therapy, moxibustion, acupuncture point,
acupuncture ear, auriculotherapy, electroacupuncture,
electric stimulation therapy, acupressure, systematic
review, meta-analysis. Subject terms were used for a
separate retrieval. "Or" and "and" were used to connect
the name of terms. The details were adjusted according
to the database; CBM (Chinese biomedical literature
database), CNKI (China national knowledge
infrastructure), WF (Wanfang database), VIP (China
science and technology journal database), Web of
Science, Embase, Medline, and Cochrane Library were
selected for retrieval, and retrieval was performed up
to January 1, 2019. Methods used for the retrieval of
Chinese and English literature were similar; retrieval
from Medline is shown as an example in
Supplementary annex 1.
Exclusion criteria
Articles that was duplicated; not found; not related to
acupuncture, moxibustion, or LDH, and not SRs or
meta-analyses and articles that were SRs but did not
include RCTs.
Screening and data extraction
Two researchers independently conducted literature
retrieval, screening, and data extraction. In case of
disagreement, a third party was consulted to assist
arrival at a judgment; missing information was
obtained by contacting the author of the specific article.
In the literature selection process, the title and abstract
of the literature were first read using NoteExpress.
After excluding obviously overlapping articles, the full
text of each article was read to determine its inclusion
status. According to the title and abstract, the articles
that obviously did not meet the inclusion criteria were
screened out and the articles that might meet the
requirements were downloaded and read completely to
determine whether they meet the inclusion criteria.
Excel2016 was used to establish a table, and the
extracted data included the title, author, year of
publication, number of papers, number of cases,
interventional measures, outcome indicators,
AMSTAR, GRADE, and PRISMA.
Data analysis
Methodological quality of the SRs. The included SRs
on RCTs used the Jadad scale or Cochrane Handbook.
We chose AMSTAR to evaluate the SRs'
methodological quality. According to the 11 items
listed in AMSTAR, methodological quality of SRs on
acupuncture treatment for LDH was evaluated. Each
item was described with “yes”, “no”, or “not clear”.
“Yes” is equivalent to 2 points, “no” is equivalent to 0
points, and unclear is equivalent to 1 point. Finally, we
calculated the total score of each SR according to
AMSTAR to determine their quality: 17-22 points,
high-quality research; 9-16 points, moderate-quality
research; and 0-8 points, low-quality research.
Quality of the report. The PRISMA statement's 27
items were used to evaluate the report quality
specifications of each SR. We used “sufficient” and
“insufficient” to indicate the sufficiency of data
extraction and used statistical analysis to measure and
integrate the included SRs and to prepare a chart.
Quality of the evidence. We summarized the quality
of the evidence in relation to the most important
outcomes by using the GRADE system. The GRADE
system was used to grade five aspects of the obtained
outcome indicators: research limitations, inconsistency,
indirectness, inaccuracy, and publication bias. In the
case of the RCTs, the GRADE classified the evidence
of the outcome indicators evaluated by the system, and
all the outcome indicators were graded by quality
through the GRADE rating standards. Evidence quality
was rated as “high”, “moderate”, “low”, or “very low”
according to the GRADE rating standards.
High-quality evidence indicates that future research is
unlikely to change the existing evidence;
moderate-quality evidence indicates that future
research may have an important impact on the existing
evidence and that it may change the evaluation results;
low-quality evidence indicates that future research is
likely to have a significant impact on the existing
evidence and that it may change the evaluation results;
and very low-quality evidence indicates that all
existing evidence is highly uncertain.
Results
Search results
In the initial examination, 108 articles in Chinese and
10 articles in English are identified, and after the
preliminary screening, 56 articles are excluded.
Subsequently, 18 articles that exclude acupuncture as
the main treatment method, 5 articles that exclude
LDH, 11 articles that exclude SR or meta-analysis, and
10 articles that are SRs but do not include RCT are
excluded. Finally, 18 articles [21-38] are included in
this SR of acupuncture and moxibustion for the

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treatment of LDH. The literature screening process is
shown in Figure 1.
Study description
Among the 18 articles [21-38] included, 16 [21, 23-34,
36-38] are Chinese articles and 2 [22, 35] are English
articles. Seventeen articles are journal articles, and 1 is
a degree article. All these papers were published from
2008 to 2018. The first article was published in 2008, 4,
5, and 2 articles were published in 2016, 2017, and
2018, respectively. As described above, recently, the
use of acupuncture and/or moxibustion for the
treatment of LDH have increased, and acupuncture has
a good curative effect on LDH. In the treatment group,
the intervention measures are acupuncture,
moxibustion, acupuncture combined therapy,
electro-acupuncture, etc., and in the control group, the
intervention measures are placebo, sham acupuncture,
drugs, traction, waiting for treatment, etc. The main
conclusion is that acupuncture and moxibustion are
effective in the treatment of LDH, but all the studies
show large heterogeneity, which questions the
credibility of the conclusion (Table 1).
Methodological quality
AMSTAR scale, which includes 11 items, was used for
the assessment of methodological quality of SRs; the
quality of 4 articles [22-24, 32] is high, 13 articles is
moderate, and 1 article is low. The score is 19 points
for 2 articles [23-24], 18 points for 1 article [22], and
17 points for 1 article [32]. Scores of all moderate
quality articles are in the range of 9-16 points. Among
the 18 included SRs, only 2 articles [23-24] have priori
design (1 item). The gray search (4 items) is generally
lacking; with regard to conflicts of interest (11 items),
66.6% of the articles mentions the funding sources and
only one article mentions the funding sources of the
included references (Table 2).
Figure 1 Flowchart showing the article selection process
CBM, Chinese biomedical literature database; CNKI, China national knowledge infrastructure; WF, Wanfang database; VIP, China
science and technology journal database; WOS, Web of science; LDH, Lumbar disc herniation; SR, Systematic review; RCT,
Randomized controlled trial.

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Table 1 Main characteristics of included systemic reviews
Study Language
Number of
studies
included
Participants Design
Intervention Assessment of risk
of bias in included
studies
Conclusion
Treated group Control group
Chen
2018
Chinese 10 1035 RCT Warm acupuncture
Lumbar
traction and
single
acupuncture
Cochrane Review
Handbook
The therapeutic effect of warm
acupuncture on LDH is clear
and has certain advantages.
Tang
2018
English 30 3503 RCT Acupuncture
Lumbar
traction and
medicine
Cochrane Review
Handbook
Acupuncture treatment shows
a more favorable effect on the
of LDH than lumbar traction,
ibuprofen, diclofenac sodium,
meloxicam, mannitol plus
dexamethasone and
mecobalamin, Chinese patent
drug fugui gutong capsule plus
ibuprofen, mannitol plus
dexamethasone, loxoprofen
and Chinese patent drug
huoxue zhitong decoction.
Sun
2017a
Chinese 10 1116 RCT Deep acupuncture
Shallow
acupuncture
Jadad measuring
scale
Deep acupuncture is helpful to
improve the curative effect of
LDH.
Sun
2017b
Chinese 22 1890 RCT
Acupuncture
manipulation
Single
acupuncture
Jadad measuring
scale
It is believed that acupuncture
is helpful and has better
curative effect against LDH.
Guo
2017
Chinese 28 2429 RCT Single moxibustion
Other positive
treatments
Jadad measuring
scale
Single moxibustion has certain
therapeutic effect.
Liu
2017
Chinese 6 578 RCT
Acupuncture
combined other
treatment
Single
acupuncture
/
The efficacy of acupuncture
combined with other treatment
against LDH is better than that
of acupuncture alone.
Dai
2017
Chinese 5 320 RCT Acupuncture
Other positive
treatments
Cochrane Review
Handbook
Acupuncture for LDH is safe
and effective.
Xuan
2016
Chinese 18 1645 RCT
Acupuncture
combined other
treatment
Other positive
treatments
Cochrane Review
Handbook
against LDH is better than
other positive treatments.
Yang
2016
Chinese 30 2589 RCT
Acupuncture
alone, acupuncture
combined with
cupping therapy,
acupuncture
combined with
tuina, acupuncture
combined with
cupping therapy
and massage
Mutual
control
Cochrane Review
Handbook
Huang
2016
Chinese 20 1861 RCT
Heat-sensitive
moxibustion or
combined other
treatment
Other positive
treatments
Cochrane Review
Handbook
Heat-sensitive moxibustion for
LDH treatment is safe and
effective.

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Table 1 Main characteristics of included systemic reviews (Continued)
Wang
2016
Chinese 17 1539 RCT
Silver acupuncture
or combination
therapy
Other positive
treatments
Jadad measuring
scale
Silver acupuncture for LDH
treatment is superior to other
conservative treatment
methods in short-term
comprehensive efficacy;
long-term efficacy still needs
further studies and
observation.
Li
2014
Chinese 17 2133 RCT
Acupuncture/electr
oacupuncture
combined with
traction
Other positive
treatments
Cochrane Review
Handbook
Acupuncture/electroacupunc-
ture combined with traction is
safe and effective.
Hu
2013
Chinese 13 1432 RCT
Acupuncture
combined other
treatment
Single
acupuncture
Jadad measuring
scale
Wu
2013
Chinese 6 540 RCT Acupuncture Placebo
Cochrane Review
Handbook
Acupuncture for LDH is safe
and effective.
Chen
2012
English 6 580 RCT
Heat-sensitive
moxibustion
Conventional
moxibustion，
diclofenac
sodium
Cochrane Review
Handbook
Compared with conventional
moxibustion, acupuncture, and
diclofenac sodium, efficiency
of heat-sensitive moxibustion
in the treatment of LDH is
superior.
Xiong
2011
Chinese 5 460 RCT
Heat-sensitive
moxibustion
Traditional
moxibustion,
acupuncture
or medicine
Cochrane Review
Handbook
Compared with traditional
moxibustion, acupuncture or
medicine, heat-sensitive
moxibustion has some
advantages in the treatment of
LDH.
Li
2010
Chinese 5 718 RCT Electroacupuncture
Lumbar
traction and
medicine
Cochrane Review
Handbook
Electroacupuncture for LDH is
safe and effective.
Li
2008
Chinese 5 547 RCT Electroacupuncture
Lumbar
traction and
medicine
Cochrane Review
Handbook
Electroacupuncture for LDH is
safe and effective.
LDH, Lumbar disc herniation; RCT, Randomized controlled trial; /, Not mentioned.
Figure 2 Number of reviews that appropriately address each PRISMA element

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Table 2 Methodological quality score
Study Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11
AMSTAR
score
Chen 2018 0 2 2 0 2 0 2 2 2 2 1 15
Tang 2018 0 2 2 0 2 2 2 2 2 2 2 18
Sun 2017a 2 2 2 1 2 1 2 2 2 2 1 19
Sun 2017b 2 2 2 1 2 1 2 2 2 2 1 19
Guo 2017 0 2 2 0 2 2 2 2 2 2 0 16
Liu 2017 0 2 2 0 0 1 0 2 2 2 0 11
Dai 2017 0 2 2 0 0 0 1 2 1 0 0 8
Xuan 2016 0 2 2 1 0 1 2 2 1 0 1 12
Yang 2016 0 2 2 0 2 2 2 2 2 0 1 15
Huang 2016 0 2 2 1 2 1 2 2 1 2 1 16
Wang 2016 0 2 2 0 0 1 2 2 1 2 1 13
Li 2014 0 2 2 1 2 2 2 2 2 2 0 17
Hu 2013 0 0 2 0 1 1 2 2 2 2 0 12
Wu 2013 0 2 2 0 0 1 2 2 2 0 1 12
Chen 2012 0 2 2 0 0 2 2 2 2 2 1 15
Xiong 2011 0 2 2 0 0 1 2 2 2 0 1 12
Li 2010 0 2 2 0 0 2 2 2 2 0 1 13
Li 2008 0 2 2 0 0 2 2 2 2 0 0 12
Q1, A priori design; Q2, Duplicate selection and data extraction; Q3, Comprehensive search; Q4, Gray literature search; Q5, List of
included and excluded studies; Q6, Characteristics of studies; Q7, Scientific quality assessed; Q8, Scientific quality in conclusions; Q9,
Methods used to combine studies; Q10, Publication bias assessment; Q11, Conflict of interest; AMSTAR, Assessment of multiple
systematic reviews.
Table 3 Grading of recommendation assessment, development, and review (GRADE) evidence in the
meta-analysis
Outcome measures Study
Quality assessment
Quality of evidence
Risk of bias Inconsistency Indirectness Imprecision
Publication
bias
Total effective rate
Chen 2018 Serious① No No No Serious④ Low
Tang 2018 Serious① Serious② No No Serious⑤ Very low
Sun 2017a Serious① No No No Serious④ Low
Sun 2017b Serious① No No No Serious④ Low
Guo 2017 Serious① Serious② No No Serious④ Very low
Liu 2017 Serious① No No No No Moderate
Xuan 2016 Serious① No No Serious③ Serious⑤ Very low
Yang 2016 Serious① Serious② No No No Low
Huang 2016 No No No No Serious④ Moderate
Wang 2016 Serious① No No No Serious④ Low
Li 2014 Serious① No No No Serious⑤ Low
Hu 2013 Serious① No No No Serious④ Low
Chen 2012 Serious① No No Serious③ Serious⑤ Very low
Xiong 2011 Serious① No No Serious③ Serious⑤ Very low
Li 2008 Serious① No No Serious③ Serious⑤ Very low

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Table 3 Grading of recommendation assessment, development, and review (GRADE) evidence in the
meta-analysis (Continued)
VAS
Sun 2017a Serious① Serious② No Serious③ Serious④ Very low
Sun 2017b Serious① Serious② No No Serious④ Very low
Xuan 2016 Serious① No No Serious③ Serious⑤ Very low
Huang 2016 No No No Serious③ Serious④ Low
Wu 2013 Serious① Serious② No Serious③ Serious④ Very low
Li 2010 Serious① No No Serious③ Serious④ Very low
JOA
Xuan 2016 Serious① Serious② No Serious③ Serious⑤ Very low
Huang 2016 No No No No Serious④ Moderate
Xiong 2011 Serious① No No Serious③ Serious⑤ Very low
ODI
Wu 2013 Serious① Serious② No Serious③ Serious④ Very low
The cure rate
Yang 2016 Serious① Serious② No Serious③ Serious④ Very low
Li 2014 Serious① Serious② No Serious③ Serious④ Very low
Chen 2012 Serious① No No No Serious⑤ Low
Xiong 2011 Serious① No No No Serious④ Low
Li 2010 Serious① No No Serious③ Serious④ Very low
Recurrence rate
Huang 2016 No No No No Serious⑤ Moderate
Li 2014 Serious① No No Serious③ Serious⑤ Very low
Xiong 2011 Serious① No No No Serious④ Low
Inefficiency
Wu 2013 Serious① No No No Serious④ Low
Dai 2017 Serious① Serious② No Serious③ Serious⑤ Very low
Lumbar function
Chen 2018 Serious① No No Serious③ Serious④ Very low
Pain index Chen 2018 Serious① No No Serious③ Serious④ Very low
IL-6 Guo 2017 Serious① Serious② No No Serious⑤ Very low
EMG Li 2008 Serious① No No Serious③ Serious④ Very low
Note:① Most information is from the medium risk studies, and there are major limitations; ② The size and direction of the effect size
and the overlap of the confidence interval are small, the P value of the heterogeneity test is small, and the combined results of I2
value
is large; ③ The sample is insufficient; ④ The funnel plot is asymmetric or missing; JOA, Japanese orthopaedic association scores;
ODI, Oswestry disability index; EMG, Electromyography.

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Figure 3 Number of PRISMA elements that are appropriately addressed in each systemic review
Quality of evidence
The main outcome indicators were graded according to
the GRADE evidence rating system, and all the SRs'
evidences were further excavated. A total of 36 main
outcome indicators applied in the SRs were selected
for meta-analysis. Main outcome indicators included
total effective rate, VAS, JOA, and ODI. Among them,
the total effective rate was the most frequently used
outcome, but many studies did not have the same
efficacy standard; JOA, VAS, and ODI scores were
also applied very frequently. All outcome indicators
were graded according the GRADE evidence rating
system. Quality grading of all outcome measures was
performed by the GRADE. The evidence quality of
total effective rate and VAS score is low and that of the
other evidences is very low (Table 3).
Reporting quality of included reviews
The 18 included SRs were analyzed according to the
PRISMA statement's 27 items, and the results show
that title, structured summary, rationale, objectives,
eligibility criteria, information sources, summary
measures, results of individual studies, and conclusions
have enough description; however, protocol and
registration are described in only 2 articles [23-24],
summary evidence is provided in 3 articles [22, 27, 34],
data items are presented in only 5 papers [23-25, 30,
33], and clear search method is described in 5 articles
[21, 22, 25, 30, 33, 38] while the remaining articles
specify only the search term (Figure 2). Among all the
studies, 8 articles [21-25, 30, 32, 34] have 20 or more
of the 27 items, 10 articles [26-29, 31, 33, 35-38] have
10-19 of the 27 items, and none of the articles has less
than 10 of the 27 items (Figure 3).
Discussion
Pursuit of high-quality evidence is always the goal of
evidence-based medicine, and SR plays a significant
role in evidence integration. However, the quality of
SRs was currently uneven, which may be related to the
quality of the original study and the difference in
researchers' reviews, resulting in medical workers'
doubts about the clinical decision. Overview came into
being. It is a research method to comprehensively
collect SRs on the treatment, etiology, diagnosis, and
other aspects of the same health problem and
summarize them [39]. The overview of SR is a way to
measure the quality of SRs [40-42].
We found 16 articles [21, 23-34, 36-38] in Chinese
and 2 articles [22, 35] in English to be relevant to our
study. All papers were published from 2008 to 2018
and the first paper was published in 2008. Among the
methodological quality assessment tools, the Jadad
scale was used to assess 5 articles and the Cochrane
Review Handbook was used to assess 12 articles; 1
article was not assessed using any bias risk assessment
tool. The main conclusion is that acupuncture is
associated with a certain level of efficacy and safety
with regard to LDH treatment. In conclusion, as
described above, acupuncture has good curative effect
on LDH. The report is complete and methodological
quality is moderate, but evidence quality is poor. With
a constant self-improvement and development in the
field of evidence-based medicine, more credible
review conclusions, stronger objectivity, lower bias,
and greater clinical significance can be achieved.
AMSTAR scale facilitates an objective review of
methodological quality of meta-analyses and SRs.
AMSTAR scale was used to evaluate the
methodological quality of the included SRs, and the
results showed that the quality of only 4 articles was
high, that of 13 articles was moderate, and that of 1
article was low. There were the following
methodological problems in the articles included in
this study: (1) many articles did not use priori design
(1 item), and only one researcher registered and filled
in the research plan; (2) the inclusion criteria were not
fully considered, especially in gray literature (4 item)
and only 5 papers involved language problems; (3)

REVIEW
TMR | July 2020 | vol. 5 | no. 4 | 292
doi: 10.12032/TMR20190930137
when we were screening articles, we included only the
articles the provided a list of articles reviewed, and 9
articles mentioned the excluded research articles (5
item); (4) the assessment of publication bias (10 item)
was generally mentioned, but there were 8 articles that
did not mention this aspect, which would lead to
suspicion over authenticity of the results. Only 17
articles mentioned the funding sources (11 item), and 1
article mentioned the funding sources of included
literature. In other words, the SRs have improved in
recent years, but there are still some deficiencies.
Therefore, I suggest that researchers refer to AMSTAR
scale to control methodological quality when they
perform SRs.
The GRADE system classifies the evidence on the
outcome indicators evaluated by the system, and all the
outcome indicators are graded by quality using the
GRADE evidence rating system. The results showed
that the total effective rate of the relevant literature on
LDH and the quality of the VAS outcome index were
increasing progressively with time and that the total
effective quality of acupuncture treatment of LDH was
relatively high. The main reasons for the downgrade
were associated with inconsistencies, possible
publication bias, and more specifically, limitations. At
the same time, the evaluation criteria for acupuncture
treatment of LDH was different, which had a certain
level of influence on the objective judgment of
acupuncture efficacy.
The PRISMA statement is an internationally
recognized tool that regulates the writing of SRs.
However, in the current study, we observed that the
PRISMA statement was not widely used in SRs. The
quality of the research report had not been significantly
improved, which also reflects that the normative
PRISMA statement has not been paid attention to by
most scientific researchers. Overall, all the studies had
a high degree of report integrity. Eight articles had 20
or more of the 27 items, 10 articles had 10-19 of the 27
items, and none of the articles had less than 10 of the
27 items. Little attention was paid to protocol and
registration (5 item), summary evidence (24 item), data
items (11 item), and search method (8 item). Title (1
item), structured summary (2 item), rationale (3 item),
objectives (4 item), eligibility criteria (6 item),
information sources (7 item), summary measures (13
item), results of individual studies (20 item), and
conclusions (26 item) were fully described.
Although the language of the included articles was
not limited, the databases in Asia and other countries
such as Japan and South Korea were not searched, and
manual retrieval process was not used. Therefore, there
might be selection bias.
Therefore, this study involves a certain level of basis
towards the clinical treatment of LDH by acupuncture
and moxibustion. According to the current clinical
literature, acupuncture has achieved certain results in
the treatment of LDH, but the quality of evidence was
still very low; verification by high-quality RCTs was
required to achieve the clinical guidance. Therefore,
the use of high-quality clinical trial methods and
AMSTAR list or OQAQ (The Overview Quality
Assessment Questionnaire) list is recommended to
control the methodological quality of clinical studies
regarding the treatment of LDH with acupuncture and
to provide more convincing data on and to promote the
use of acupuncture for LDH; (2) We hope that
researchers can GRADE the outcome indicators of
their studies, to provide accurate clinical decisions; (3)
I hope researchers can strictly follow the PRISMA
statement, to reach more standardized process of SR
writing. (4) Researchers should strictly standardize the
quality of methodological application, to curb the
generation of bias and to improve the quality of
literature and evidence.
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