Can Acupuncture Improve Chronic Spinal Pain? A Systematic Review and Meta-Analysis
Authors: Ai-Min Wu
Xuan-Qi Zheng
Jia-Liang Lin
Wen-Xian Zhou
Jin-Feng Huang
Hui Wang
Dong Chen
Zongshi Qin
Journal: Global Spine Journal (2020)
Discipline: NEUROSCIENCE & BEHAVIOR
Keywords: acupuncture; chronic low back pain; chronic neck pain; chronic spinal pain; sciatica.
Affiliations: Orthopaedic Hospital, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China, The University of Hong Kong, Hong Kong, China

Abstract:  Study design: Systematic review and meta-analysis. Objective: To investigate the effect and safety of acupuncture for the treatment of chronic spinal pain. Methods: MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, the WHO Clinical Trial Registry, and the US National Library of Medicine clinical trial registry were searched from January 1, 2000, to November 1, 2019. Randomized controlled trials (RCTs) involving patients with chronic spinal pain treated by acupuncture versus sham acupuncture, no treatment, or another treatment were included. Results: Data was extracted from 22 RCTs including 2588 patients. Pooled analysis revealed that acupuncture can reduce chronic spinal pain compared to sham acupuncture (weighted mean difference [WMD] -12.05, 95% confidence interval [CI] -15.86 to -8.24), mediation control (WMD -18.27, 95% CI -28.18 to -8.37), usual care control (WMD -9.57, 95% CI -13.48 to -9.44), and no treatment control (WMD -17.10, 95% CI -24.83 to -9.37). In terms of functional disability, acupuncture can improve physical function at immediate-term follow-up (standardized mean difference [SMD] -1.74, 95% CI -2.04 to -1.44), short-term follow-up (SMD -0.89, 95% CI -1.15 to -0.62), and long-term follow-up (SMD -1.25, 95% CI -1.48 to -1.03). Conclusion: In summary, compared to no treatment, sham acupuncture, or conventional therapy such as medication, massage, and physical exercise, acupuncture has a significantly superior effect on the reduction in chronic spinal pain and function improvement. Acupuncture might be an effective treatment for patients with chronic spinal pain and it is a safe therapy. 

Retracted: No

PubPeer comments:
 Pseudoreplication in the main results -------------------------------------------------- I think there are methodological errors in the meta-analysis. Letu2019s take a look at the forest plot for figure 3A, which shows the most data for the outcomes the authors were interested in. We can see u201cau201d and u201cbu201d entries entries for Giles 2003, Cho 2013, Seo 2017 and Leibing 2002. In the case of Seo 2017 the u201cau201d and u201cbu201d refer to separate studies which is fine. The remaining trials with parts u201cau201d and u201cbu201d have been included in this meta-analysis erroneously. For the Giles 2003 study the authors have made multiple comparisons of the same treatment group to separate control groups and entered both comparisons into the meta-analysis separately, thus u201cdouble-countingu201d the acupuncture group. In this case the acupuncture group was compared to u201cmanipulationu201d and the same acupuncture group was compared to u201cmedicationu201d. The appropriate course of action would be to combine the two control groups or perhaps select one appropriate control group to compare the acupuncture group to. For the Leibing 2002 trial a similar mistake was made by comparing the same acupuncture treatment group to the u201csham groupu201d and the u201ccontrol groupu201d and then entering results from both comparisons into the meta-analysis u201cdouble-countingu201d the acupuncture group again. For the Cho 2013 study the authors have made separate entries of the same comparison at two different time points; u201creal acupunctureu201d compared to u201csham acupunctureu201d at u201cend of treatmentsu201d and then u201creal acupunctureu201d compared to u201csham acupunctureu201d at u201cprimary endpointu201d are entered as separate comparisons under u201cCho 2013au201d and u201cCho 2013bu201d. The correct course of action would be to choose a single appropriate time point to enter into their meta-analysis. The first two instances of u201cpseudo-replicationu201d are critical (but common) errors when dealing with trials that have multiple treatment groups. The Chocrane handbook for systematic reviews (Version 5.1.0) makes a couple of comments on this; Section 16.5.4: u201cOne approach that must be avoided is simply to enter several comparisons into the meta-analysis when these have one or more intervention groups in common. This u2018double-countsu2019 the participants in the u2018sharedu2019 intervention group(s) and creates a unit-of-analysis error due to the unaddressed correlation between the estimated intervention effects from multiple comparisons.u201d Also refer to section 9.3.9: u201cA serious unit-of-analysis problem arises if the same group of participants is included twice in the same meta-analysis (for example, if u2018Dose 1 vs Placebou2019 and u2018Dose 2 vs Placebou2019 are both included in the same meta-analysis, with the same placebo patients in both comparisons).u201d The thought process behind the error with Leibing 2002a b seems more difficult to understand. Due to these mistakes the forest plots in figure 3 have several more entries than they deserve generating an impression of an abundance of trial data that doesnu2019t really exist and the summary estimates should be revised with the pseudo-replication removed. I m also not convinced of the merits of plotting an overall estimate derived from neck pain, back pain, and sciatica when this estimate was derived from at least some patients in the same trials who were questioned on separate items - there will be an unaddressed correlation in this case. This is a revision of a comment initially posted to Edzard Ernst s blog and revised for pubpeer by the same author. , 
 #1 Thank you very much for your question. There are many literatures included two outcomes of one research into one meta-analysis. In other words, parts u201cau201d and u201cbu201d have been included in one meta-analysis. This research method can be easily found in many literatures which published in JAMA, BMJ, ARD and so on. We all believe these articles published in such high-quality journals are very valuable. So, we think this research method does not affect the quality and the summary estimates of articles. Here are some screenshots of high-quality articles used the same research method. These articles published in BMJ, ARD or some recognized professional journals. ![file] ![file] ![file] ![file] ![file] ![file] ![file] ![file] , 
 #2 With all due respect pointing to other examples of the same mistake published in the scientific literature does not excuse your mistake (no matter how prestigious the journal). Please refer to the methodological literature on how to conduct meta-analysis which will clearly explain why this approach is wrong. Senn lists a number of published examples of this same mistake in his piece:  Overstating the evidence u2013 double counting in meta-analysis and related problems . The methodological issue is also well described in the Chocrane handbook for systematic reviews (Version 5.1.0), Section 16.5.4. In the future it would be better to avoid repeating this mistake just because others have made it. Senn, Stephen J.  Overstating the evidenceu2013double counting in meta-analysis and related problems. BMC Medical Research Methodology 9.1 (2009): 1-7. HigginsJPT, GreenS.  Cochrane handbook for systematic reviews of interventions version 5.1. 0 [updated March 2011]. The cochrane collaboration 20011 (2011). ,