Musculoskeletal disorders present an increasing global health care problem, being the number one self-reported medical condition in the United States (US) according to the National Health Interview Survey (NHIS) in 2012. These disorders are the most common cause of chronic severe pain and physical dysfunction and they affect hundreds of millions of people around the world. The economic impact of these conditions in the US is also astounding, costing the US an estimated $874 billion in treatment costs and lost wages annually, or 5.7% of the 2011 Gross Domestic Product [
Chuna (Korea) or Tuina is a manipulation treatment that addresses biomechanical function, diagnostics, pathology, and theories to balance orthopaedic structure and function. Chuna or Tuina works along the meridians throughout the body, corrects the displacement of the structures, and prescribes exercises based on symptoms and the results of a functional assessment. It represents techniques such as thrust, mobilization, distraction of the spine and joints, visceral manipulation, soft tissue release, craniosacral therapy, and the diaplasis technique [
So far, we have found 27 systematic reviews about these diseases. Of these, 20 studies were about musculoskeletal disease [
The following electronic databases were searched up to December 2016. We searched 4 worldwide databases (PubMed, Ovid LWW Medline, EMBASE, and Cochrane Library), 3 Chinese databases (China National Knowledge Infrastructure [CNKI], Wanfang, and VIP), 1 Japanese database (J-stage), and 7 Korean databases (Korean Medical Database [KMBASE], Korean Studies Information Service System [KISS], National Discovery for Science Leaders [NDSL], Database Periodical Information Academic [DBpia], Korean National Assembly Digital Library [KNADL], Oriental Medicine Advanced Searching Integrated System [OASIS], and Korean Traditional Knowledge Portal [KTKP]).
The search terms used for PubMed were as follows: (((Tuina) OR Chuna)) AND ((((Randomized Controlled Trial) OR Randomised Controlled Trial) OR rct) OR Randomized) OR Randomised. For other databases, the search terms were slightly modified but still included terms such as (Tuina OR Chuna) AND (Randomised Controlled Trials). Furthermore, the references regarding our articles were manually searched for further relevant articles.
This systematic review included parallel or crossover RCTs that evaluated the effects of Chuna (or Tuina) manual therapy (C[T]MT) on pain and function for musculoskeletal diseases.
Patients who reported any kind of musculoskeletal disorders were eligible for inclusion. This review included patients regardless of gender, age, and race. The patients with musculoskeletal disorders were classified according to affected area (spine, upper extremity, and lower extremity) and then subclassified according to exact diagnosis.
For interventions, we included C(T)MT intervention only and excluded other types of manual therapy. Studies that assessed the combined effects of Chuna (or Tuina) plus other interventions were also considered when the identical intervention was administered to both the Chuna (or Tuina) group and the control group.
For control groups, we considered sham treatment or other active interventions, except other kinds of Chuna (or Tuina). The sham Chuna (or Tuina) treatment(s) were regarded as those that employed the same/similar Chuna techniques, but with no active components. Other interventions included traction, physical therapy, drug therapy, and surgery.
We only included pain and function outcome measurements for musculoskeletal conditions. For pain, we used a visual analogue scale (VAS) and a numerical rating scale (NRS). For function, we used the neck pain disability index (NDI), the Oswestry disability index (ODI), and the Constant-Murley score (CMS). Additionally, we included complications to assess safety outcomes.
Eventually, we included three types of study model: (1) Chuna (or Tuina) versus sham, (2) Chun (or Tuina) versus other interventions, and (3) Chuna (or Tuina) plus other interventions versus same other interventions.
Regarding types of research, we excluded quasi-RCTs that did not allocate participants to a treatment group in a truly random way, for example, according to hospital record number or alternation and date of birth, or RCTs that did not clearly report that a random method was used and those that adopted inappropriate methods.
For Chuna (or Tuina) manual interventions, we excluded studies that employed other kinds of manual treatments, or those in which there was no clear description of methods.
Trials comparing different types of Chuna (or Tuina) were excluded, because the effectiveness of Chuna (or Tuina) compared to other interventions could not be assessed.
We did not include patients with musculoskeletal disorders found to be caused by psychogenic and neurologic conditions, or other reasons, except for musculoskeletal aetiologies.
Two independent reviewers (Nam-Woo Lee and Gee-Heon Kim) screened the titles and abstracts for potentially eligible studies identified by the primary search and then reviewed the full texts to evaluate their final eligibility. All Chinese articles were reviewed by Nam-Woo Lee who graduated from Beijing University of Chinese Medicine. All English and Korean articles were reviewed by Gee-Heon Kim. The two authors cross-checked each other’s articles and if there were any disagreements regarding extracted data, we contacted the original authors via e-mail or telephone to request additional information.
After selecting articles for inclusion, we extracted the following data: authors, publication year, types of disease, study design, sample size, treatment and follow-up duration, interventions, outcome measures on pain and function, and the main results (Table
Categories of musculoskeletal conditions and number of randomized controlled trials (
Musculoskeletal conditions | Number of studies | ||||
---|---|---|---|---|---|
C(T)MT versus sham | C(T)MT versus OIs | C(T)MT + OIs vs. OIs | Number | Total | |
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Cervical | 26.6% | ||||
Cervical spondylotic radiculopathy | 11 | 1 | 12 | ||
Cervical spondylosis | 7 | 7 | |||
Lower cervical vertebral degenerative instability | 2 | 2 | |||
Atlantoaxial joint disorder | 1 | 1 | |||
Curvature abnormality | 1 | 1 | |||
Cervical shoulder pain | 1 | 1 | |||
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Thoracolumbar | 24.3% | ||||
Lumbar disc herniation | 5 | 4 | 9 | ||
Lumbar muscle strain | 3 | 3 | |||
Thoracolumbar fracture | 2 | 2 | |||
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Others | |||||
Scoliosis | 1 | 1 | 2 | ||
Sacrococcygeal pain | 1 | 1 | |||
Ankylosing spondylitis | 1 | 1 | |||
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Shoulder | 27.3% | ||||
Periarthritis of shoulder | 2 | 2 | 4 | ||
Acromioclavicular dislocation | 1 | 1 | |||
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Arm and hand | |||||
Humeral fracture | 3 | 3 | |||
Radius fracture | 2 | 2 | |||
Lateral epicondylitis of humerus | 1 | 1 | 2 | ||
Brachial plexus block | 1 | 1 | |||
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Knee | |||||
Knee osteoarthritis | 4 | 1 | 5 | ||
Post knee surgery pain or dysfunction | 2 | 2 | |||
Kaschin-Beck disease | 1 | 1 | |||
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Leg and foot | |||||
Calcaneal fracture | 1 | 1 | |||
Ankle fracture | 1 | 1 | |||
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Total |
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C(T)MT: Chuna (or Tuina) manual therapy; OIs: other interventions.
Quality assessment was conducted using the Cochrane risk of bias criteria tools [
All outcome measurements were extracted as mean and standard deviation (or transformed) or total and events. The outcome measures at the end of the treatments were used in data pooling.
The risk estimates (relative risk: RR) were calculated for dichotomous data. For continuous data, standardized mean differences (SMDs) were employed because different scales were used for studies (e.g., VAS 0–10 or VAS 0–100). Weighted mean differences (WMDs) were used for continuous data if authors evidently reported that identical scales were used for the outcomes. Additionally, 95% confidence intervals (CIs) were calculated in the meta-analysis. For studies with more than one control group, we restricted our analyses to compare C(T)MT and control groups. The statistical heterogeneity was assessed using the
Our search terms yielded 5,840 records. There were 262 from the Cochrane library, EMBASE, Ovid LWW Medline, and PubMed. There were 4,056 from CNKI, Wanfang data, VIP, and J-stage. There were 1,522 studies from domestic Korean databases and relevant journals. After removing duplicated studies, 5,462 records were screened. Based on the title and abstract, 4,373 records were excluded (Figure
Flowchart of the RCT selection process. CCTs: controlled clinical trials; RCTs: randomized controlled trials; C(T)MT: Chuna (or Tuina) manual therapy.
All RCTs (
Of the 66 RCTs, 1 RCT was C(T)MT versus sham C(T)MT [
The control therapies contained sham C(T)MT, block therapy, Chinese patent drugs, general rehabilitation treatment, intravenous injection, oral drugs, pharmacopuncture and surgical interventions in cases of fracture, physical therapy (including intermediate frequency therapy, micro current therapy, ultrasonic treatment, and TENS), traditional Chinese medicine, and traction (Table
The types of diseases/disorders were very diverse and heterogeneous. Thus, we classified them according to body parts such as spine, upper extremity, and lower extremity (Table
Outcome measures reported in the included studies were very diverse because of the various types of disease reported on. For pain, the McGill Pain Questionnaire (MPQ), the McGill Pain Questionnaire-Short Form (MPQ-SF), or a NRS, VAS, or visual numeric rating scale (VNRS) was used. For functional measurements, the clinical assessment scale for cervical spondylosis (CASCS), a NDI, an ODI, or a range of motion (ROM) or straight leg raising test (SLRT) was used. For both pain and function assessment, CMS, hospital for special surgery (HSS), or total score of symptoms and signs (TSS) was used, and activities of daily living (ADL) or SF-36 were used for quality of life (QOL) (Table
Most of the selected trials were judged as having a high ROB. The particulars of the ROB assessments are described in Figure
Of the 66 studies, only 3 RCTs [
Regarding incomplete outcome data, we evaluated 62 studies as having a low ROB. Many of them had no missing data or few missing data. In studies that had missing outcome data, the frequencies and causes for drop-outs in each group did not differ much. Moreover, the drop-out percentage in the short-term did not surpass 20%, and, in the long-term, the rate did not go over 30%. We could not calculate the drop-out rates of 4 trials [
For the selective outcome reporting, it was not possible to locate and study the protocols of any of the selected studies. In response, we discerned the ROB using the reported methods in each study. One study [
The key outcomes from the included studies are provided in Figure
Effect estimates of C(T)MT for pain and function on musculoskeletal conditions.
Outcomes | Number of |
Number of patients | Effect estimate |
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|
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C(T)MT versus sham | 1 [ |
69 | SMD −3.09 [−3.59, −2.59] |
|
NA |
C(T)MT versus traction | 9 [ |
829 | SMD −0.64 [−0.87, −0.40] |
|
61 |
C(T)MT versus physical therapy | 3 [ |
214 | WMD −0.97 [−1.46, −0.48] |
|
32 |
C(T)MT versus drug | 5 [ |
848 | WMD −0.44 [−0.85, −0.02] |
|
77 |
C(T)MT + traction versus traction | 3 [ |
190 | WMD −1.08 [−1.81, −0.35] |
|
95 |
C(T)MT + drug versus drug | 6 [ |
442 | WMD −0.99 [−1.70, −0.28] |
|
91 |
C(T)MT + surgery versus surgery | 2 [ |
92 | WMD −0.47 [−1.60, 0.66] |
|
90 |
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C(T)MT versus traction | 3 [ |
226 | SMD −1.45 [−2.92, 0.02] |
|
96 |
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C(T)MT + drug versus drug | 3 [ |
184 | SMD −1.79 |
|
96 |
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C(T)MT versus surgery | 2 [ |
158 | WMD 3.33 |
|
99 |
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C(T)MT versus surgery | 5 [ |
384 | RR 0.45 [0.26, 0.76] |
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0 |
ref: reference; CMS: Constant-Murley score; C(T)MT: Chuna (or Tuina) manual therapy; NA: not applicable; NDI: neck disability index; ODI: Oswestry disability index; RR: relative risk; SMD: standard mean difference; VAS: visual analogue scale; WMD: weight mean difference.
Summary of randomized controlled trials of C(T)MT for pain and function for musculoskeletal diseases.
Author (Year) |
Types of disease | Design | Sample size |
Duration weeks | Follow-up weeks | Intervention | Outcome measures | Main results | |
---|---|---|---|---|---|---|---|---|---|
Treatment | Control | ||||||||
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Sousa et al. [ |
Working-related musculoskeletal disorder of professional orchestra musicians | Patient blind, |
69 |
Immediate effect | nr | C(T)MT (real acupoints) | Sham C(T)MT (nonspecific skin points) | (1) VNRS (pain) | (1) |
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Zhu et al. [ |
Cervical spondylotic radiculopathy | Parallel |
116 |
4 | nr | C(T)MT |
TR |
(1) VAS | (1) |
|
|||||||||
Chen et al. [ |
Cervical spondylotic radiculopathy | Parallel |
400 |
34 d | nr | C(T)MT |
TCM |
(1) VAS |
(1) |
|
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Wang et al. [ |
Cervical spondylotic radiculopathy | Parallel |
110 |
2 | 4 | C(T)MT |
TR |
(1) VAS |
(1) |
|
|||||||||
Huang [ |
Cervical spondylotic radiculopathy | Parallel |
60 |
4 | 6 m | C(T)MT |
TR |
(1) VAS |
(1) |
|
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Liao et al. [ |
Cervical spondylotic radiculopathy | Parallel |
111 |
4 | nr | C(T)MT |
CPD |
(1) MPQ | (1) |
|
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Jiang et al. [ |
Cervical spondylotic radiculopathy | Parallel |
79 |
2 | nr | C(T)MT |
TR |
(1) VAS | (1) |
|
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Qin et al. [ |
Cervical spondylotic radiculopathy | Parallel |
60 |
2 | nr | C(T)MT |
TR |
(1) TSS |
(1) TSS |
|
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Xu [ |
Cervical spondylotic radiculopathy | Parallel |
36 |
4 | nr | C(T)MT |
TR |
(1) VAS |
(1) |
|
|||||||||
Xue [ |
Cervical spondylotic radiculopathy | Parallel |
130 |
2 | nr | C(T)MT |
TR |
(1) VAS |
(1) |
|
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Yang [ |
Cervical spondylotic radiculopathy | Parallel |
72 |
2 | nr | C(T)MT |
TR |
(1) VAS |
(1) |
|
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Liu [ |
Cervical spondylotic radiculopathy | Parallel |
114 |
NA | 1 m | C(T)MT |
B: TR |
(1) VAS |
(1) |
|
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Zhu et al. [ |
Cervical spondylosis | Parallel |
210 |
2 | 1 m | C(T)MT |
TR |
(1) VAS | (1) |
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Lin et al. [ |
Cervical spondylosis | Parallel |
70 |
4 | nr | C(T)MT |
CPD |
(1) NRS |
(1) |
|
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Yan et al. [ |
Cervical spondylosis | Parallel |
70 |
2 | nr | C(T)MT |
TCM external preparation |
(1) VAS |
(1) |
|
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Li and Zhou [ |
Cervical spondylosis (sympathetic nerve type) | Parallel |
80 |
2 | nr | C(T)MT |
OD | (1) CASCS |
(1) |
|
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Jin [ |
Cervical spondylosis (vertebral artery type) | Parallel |
55 |
2 | 3 m | C(T)MT |
TR |
(1) TSS |
(1) |
|
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Gao et al. [ |
Cervical spondylosis (vertebral artery type) | Parallel |
177 |
14 d | nr | C(T)MT |
TR |
(1) ROM | (1) |
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Zeng [ |
Cervical spondylosis (vertebral artery type) | Parallel |
45 |
4 | nr | C(T)MT |
B: MCT |
(1) VAS |
(1) NA |
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Sun [ |
Atlantoaxial joint disorder | Parallel |
93 |
2 | 1 m | C(T)MT | TR |
(1) TSS | (1) |
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Wang [ |
Lower cervical vertebral degenerative instability | Parallel |
60 |
2 | 1 m | C(T)MT |
TR |
(1) VAS |
(1) |
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Yang et al. [ |
Lower cervical vertebral degenerative instability | Parallel |
97 |
2 | nr | C(T)MT |
TR |
(1) NDI | (1) |
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Chen et al. [ |
Cervical shoulder pain | Parallel |
68 |
6 d | nr | C(T)MT |
OD |
(1) VAS | (1) |
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Chen et al. [ |
Lumbar disc herniation | Parallel |
233 |
4 | nr | C(T)MT |
TR |
(1) VAS |
(1) |
|
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Wang [ |
Lumbar disc herniation | Parallel |
62 |
3 | nr | C(T)MT |
TR |
(1) VAS |
(1) |
|
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Zhou et al. [ |
Lumbar disc herniation | Parallel |
65 |
12 d | nr | C(T)MT |
TR |
(1) VAS |
(1) |
|
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Luo et al. [ |
Lumbar disc herniation | Parallel |
60 |
1 m | C(T)MT |
TR |
(1) VAS |
(1) |
|
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Deng et al. [ |
Lumbar disc herniation | Parallel |
290 |
2 | A: 3 w |
C(T)MT |
OD |
(1) VAS | (1) A: NS |
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Zhang et al. [ |
Lumbar muscle strain | Parallel |
105 |
5–7 d | nr | C(T)MT |
OD | (1) ALBP clinical score | (1) |
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Xue [ |
Lumbar muscle strain | Parallel |
63 |
3-4 | 3 m | C(T)MT |
TR |
(1) VAS | (1) |
|
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Zhang [ |
Lumbar muscle strain | Parallel |
62 |
8 | nr | C(T)MT |
CPD |
(1) Symptom score |
(1) NA |
|
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Tian et al. [ |
Degenerative scoliosis | Parallel |
38 |
10–15 | nr | C(T)MT |
OD | (1) VAS |
(1) |
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Wang et al. [ |
Sacrococcygeal pain | Parallel |
184 |
2 | 3 m | C(T)MT |
EM (external medicine) |
(1) VAS |
(1) |
|
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Wang et al. [ |
Periarthritis of shoulder | Parallel |
120 |
20 d | nr | C(T)MT |
TCM external preparation | (1) SF-36 |
(1) |
|
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Chen et al. [ |
Periarthritis of shoulder | Parallel |
120 |
4 | nr | C(T)MT |
B: EA |
(1) VAS |
(1) |
|
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Xu [ |
Acromioclavicular dislocation | Parallel |
120 |
NA | nr | C(T)MT | PT (upper limb abduction splint) | (1) IC | (1) |
|
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Xu [ |
Humeral fracture | Parallel |
94 |
7 d | 7 d | C(T)MT | Surgery | (1) CMS |
(1) CM |
|
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Pan [ |
Humeral fracture | Parallel |
64 |
6 | 12 m | C(T)MT | Surgery | (1) CMS |
(1) NS |
|
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Yang [ |
Humeral fracture | Parallel |
68 |
6 | nr | C(T)MT | Surgery | (1) IC |
(1) 2 w: NS |
|
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Pan [ |
Radius fracture | Parallel |
60 |
NA | nr | C(T)MT | Surgery | (1) IC | (1) |
|
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Li [ |
Radius fracture | Parallel |
80 |
NA | NA | C(T)MT | Surgery | (1) Recovery rate of joint function |
(1) |
|
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Ding et al. [ |
Lateral epicondylitis of humerus | Parallel |
76 |
2 | nr | C(T)MT | PT (IFT) |
(1) VAS |
(1) |
|
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Gao and Yan [ |
Brachial plexus block | Parallel |
200 |
3 | 3 m | C(T)MT |
BT |
(1) VAS |
(1) |
|
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Tian [ |
Knee osteoarthritis | Parallel |
60 |
31 d | nr | C(T)MT |
CPD |
(1) MPQ-SF |
(1) |
|
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Chen [ |
Knee osteoarthritis | Parallel |
60 |
1 m | nr | C(T)MT |
OD |
(1) WOMAC |
(1) |
|
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Jin [ |
Knee osteoarthritis | Parallel |
120 |
4 | nr | C(T)MT |
OD |
(1) WOMAC |
(1) WOMAC |
|
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Li et al. [ |
Knee osteoarthritis | Parallel |
60 |
4 | nr | C(T)MT |
OD |
(1) VAS |
(1) |
|
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Ren [ |
Ankle fracture, trimalleolar fracture | Parallel |
110 |
NA | nr | C(T)MT | Surgery | (1) IC | (1) |
|
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Zhao et al. [ |
Calcaneal Fracture | Parallel |
66 |
NA | 9–15 m | C(T)MT | Surgery | (1) IC |
(1) |
|
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|
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Chen and Tang [ |
Cervical spondylotic radiculopathy | Parallel |
60 |
3 | nr | C(T)MT plus TR |
TR |
(1) VAS |
(1) |
|
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Zhang and Hai [ |
Curvature abnormality | Parallel |
70 |
2 | nr | C(T)MT plus TR |
TR |
(1) VAS | (1) |
|
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Dong and Wang [ |
Lumbar disc herniation | Parallel |
80 |
30 d | nr | C(T)MT plus OD (tid), IV (qd) | OD (tid), IV (qd) | (1) ODI |
(1) |
|
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Song et al. [ |
Lumbar disc herniation | Parallel |
60 |
10 d | nr | C(T)MT plus TR | TR | (1) VAS |
(1) |
|
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Yin et al. [ |
Lumbar disc herniation | Parallel |
50 |
2 | 6 m | C(T)MT plus IV (qd) | IV |
(1) VAS |
(1) |
|
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Wu et al. [ |
Lumbar disc herniation | Parallel |
60 |
10 d | nr | C(T)MT plus TR |
TR |
(1) VAS | (1) |
|
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Zhang et al. [ |
Thoracolumbar fracture | Parallel |
40 |
1 d | 1 d, 3 d | C(T)MT plus Surgery | Surgery (PPF) | (1) VAS | (1) |
|
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Yu et al. [ |
Thoracolumbar fracture | Parallel |
52 |
1 d | 3 d, 2 w, 6 m | C(T)MT plus Surgery | Surgery (PKP) | (1) VAS | (1) NS |
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Sun et al. [ |
Degenerative Scoliosis | Parallel |
60 |
3 | nr | C(T)MT plus OD | OD |
(1) VAS |
(1) |
|
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Jia and Sha [ |
Ankylosing spondylitis | Parallel |
60 |
4 | nr | C(T)MT plus OD | OD |
(1) VAS |
(1) |
|
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Zhang [ |
Periarthritis of shoulder | Parallel |
78 |
4 | nr | C(T)MT (28 sessions) plus PP (4 sessions) | PP |
(1) VAS |
(1) |
|
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Shen et al. [ |
Periarthritis of shoulder | Parallel |
120 |
1 m | nr | C(T)MT plus PP | PP |
(1) VAS | (1) |
|
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Wu [ |
Lateral epicondylitis of humerus | Parallel |
22 |
9 d | nr | C(T)MT plus PT (UT + IFT) |
PT (UT + IFT) |
(1) VAS | (1) |
|
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Xiao [ |
Knee osteoarthritis | Parallel |
70 |
4 | nr | C(T)MT plus RT |
RT | (1) HSS Score |
(1) HSS |
|
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Zhang and Deng [ |
After knee surgery pain or function | Parallel |
80 |
Immediate effect | nr | C(T)MT plus RT |
RT | (1) Pain score | (1) |
|
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Wang et al. [ |
After knee surgery pain or function | Parallel |
66 |
4 | nr | C(T)MT + CPM |
CPM | (1) WOMAC |
(1) WOMAC |
|
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Wang et al. [ |
Kaschin-Beck disease | Parallel |
120 |
6 m | nr | C(T)MT plus OD | OD | (1) VAS |
(1) |
C(T)MT on pain outcomes (visual analogue scale) for musculoskeletal conditions. C(T)MT: Chuna (or Tuina) manual therapy; LDH: lumbar disk herniation; POS: periarthritis of shoulder.
Risk of bias assessment.
Only 7 studies reported on the incidence of complications. In 5 studies, they compared C(T)MT with surgical interventions and reported complications, such as impaired wound healing, nerve or tendon injury, infection, and traumatic arthritis in C(T)MT and surgery group [
The purpose of our systematic review was to evaluate the current evidence of the effectiveness of C(T)MT for patients with musculoskeletal disease. As a main finding, we found meaningful evidence of the effectiveness of C(T)MT on pain reduction through our meta-analyses. Although our analyses included only 1 sham-controlled RCT comparing C(T)MT to sham C(T)MT [
The meta-analysis also looked at 6 RCTs on improvement of functional status. In studies where drugs were given to both groups and C(T)MT to the experimental group, the improvement of low back function was shown to be favourable [
To explore the impact of C(T)MT on musculoskeletal diseases through pain reduction and functional improvement, the meta-analysis included only studies with adequate randomization. By doing this, a large number of quasi-RCTs (
Furthermore, our analysis assumed that C(T)MT did not cause serious complications compared to other interventions [
Previously, there were clinical guidelines or systematic reviews of manual therapies for lumbar or cervical disease. The clinical guidelines in two countries, the United States in 2007 [
We analysed all RCTs that investigated the effects of C(T)MT on any musculoskeletal disorders published worldwide until December 31, 2016. The results helped to set priorities and directions for future research on C(T)MT by analysing all studies, regardless of the kind of disease. More specifically, once we collected all studies on C(T)MT, we took steps to divide collected studies into subgroups to provide a clearer picture on the present state of studies on C(T)MT. This was an unprecedented type of study. Additionally, we confined our research to traditional Chinese and Korean manual techniques by limiting interventions to Chuna and Tuina to clarify the effects of C(T)MT. By focusing on qualified RCTs, we managed to categorize a large volume of quantitative and qualitative data on the in depth assessment of C(T)MT with regard to pain and function in musculoskeletal diseases. We also sought to suggest the wide range of applicability of C(T)MT. We classified all studies with various control groups into three designs such as C(T)MT versus Sham C(T)MT, C(T)MT versus OIs, and C(T)MT plus OIs versus OIs to suggest alternative or cooperative treatments for C(T)MT.
Our meta-analysis had some limitations. Even though we searched through numerous databases and collected published studies from the US, the EU, China, Japan, and South Korea, all studies except seven were written in Chinese and published in Chinese journals that were not registered in Medline. Seven remaining studies were published in journals that were indexed in Medline. One of them was written in English and conducted in Portugal [
Moreover, out of 66 studies analysed in this review, there was only one study that included sham C(T)MT [
Most studies included in this study had methodological weaknesses. Of 66 RCTs with adequate randomization, only 18 of these studies (27.3%) managed to have appropriate allocation concealment. This is concerning for two reasons. The overestimation of treatment effects is known to be caused by inadequate allocation concealment or random sequence generation [
Fortunately, studies in our review had comparatively good average sample sizes per arm: 46.7 in the treatment groups and 45.2 in the control groups. Moore et al. [
Additionally, the clinical heterogeneities of some of our meta-analyses might limit the translation of our results [
Since the review included all musculoskeletal conditions/diseases, we were mindful of the possibility that the focus of our review might seem unclear. Therefore, we made extra efforts to increase the statistical/clinical homogeneity. To do so, we tried to find studies that matched perfectly with one another in PICO: population, intervention, comparison, and outcomes. However, the number of studies satisfying this requirement was too small. Therefore, discussing comparative effects between particular treatments in control groups requires a cautious approach. Although it presents a very difficult methodological problem, sham research should be continued and a comparative effectiveness study also is recommended.
This review demonstrated the possibilities of using C(T)MT through clinical applicability, but we did not consider analysing the standardization of C(T)MT. The lack of standardization may be due to the fact that the effectiveness of C(T)MT can be influenced by many variables, including C(T)MT techniques, application of time duration for each treatment and the number of treatments, their lengths and repeats. In this review, many of these variables were present in most studies, and they were widely heterogeneous on clinical factors. To move forward, future studies should not only carry out investigations into the effectiveness and safety of C(T)MT but also investigate the effectiveness of interventions based on standardized guidelines.
Our systematic review of 66 RCTs demonstrated that C(T)MT might have favourable effects on pain and functional improvements caused by musculoskeletal diseases, but the evidence for functional improvement was not as strong as for pain relief. Moreover, this study indicated that C(T)MT is a safe intervention. However, given the low quality of the included studies and the diverse methods of intervention techniques, the available evidence is insufficient to determine the effects of C(T)MT. In conclusion, to prove the effects of C(T)MT on the pain and dysfunction associated with musculoskeletal disease, high-quality RCTs such as sham-controlled studies with standardized interventions are needed.
The authors declare that there are no conflicts of interest regarding the publication of this article.
Byung-Cheul Shin, Nam-Woo Lee, and Gee-Heon Kim designed this review. Nam-Woo Lee and Gee-Heon Kim searched the databases, screened studies for inclusion, and extracted data independently. In Heo and Eui-Hyoung Hwang evaluated the quality of the included studies and if there was a conflict, they achieved a consensus by discussion among authors. Nam-Woo Lee and Gee-Heon Kim conducted the analyses and discussed their findings with all coauthors. Nam-Woo Lee wrote the first draft of the article, and Byung-Cheul Shin provided the important intellectual content for the draft. Koh-Woon Kim, Jun-Hwan Lee, In-Hyuk Ha, and Byung-Cheul Shin supervised the meta‐analysis and draft, and they critically revised the article. All authors read and approved the final paper.
This study was supported by the Traditional Korean Medicine R&D program funded by the Ministry of Health & Welfare through the Korea Health Industry Development Institute (KHIDI) (Grant no. HI15C0103).