This is a systematic review and meta-analysis, which aimed to assess the current evidence on the effects and safety of acupuncture for treating sciatica. In this review, a total of 11 randomized controlled trials were included. As a result, we found that the use of acupuncture may be more effective than drugs and may enhance the effect of drugs for patients with sciatica, but because of the insufficient number of relevant and rigorous studies, the evidence is limited. Future trials using rigorous methodology, appropriate comparisons, and clinically relevant outcomes should be conducted.
Sciatica is a syndrome involving nerve root impingement or inflammation that has progressed sufficiently to cause neurological symptoms in the areas that are supplied by the affected nerve roots [
Frymoyer reported that the prevalence of sciatica varies widely from 13% to 40% [
Acupuncture is a tried and tested system of traditional Chinese medicine, which has been used in China and other Eastern cultures for thousands of years. While acupuncture has been proposed for persistent sciatica, its efficacy has not been shown [
This systematic review aimed to assess the current evidence on the effects and safety of acupuncture for sciatica.
We conducted this systematic review according to a published protocol [
All randomized controlled trials (RCTs) in English, Chinese, and Japanese on acupuncture treatment for sciatica were included for this review. Non-RCTs, quasi-RCTs, and randomized controlled trial protocol were excluded.
Patients with sciatica were included, including those diagnosed with sciatica synonyms, such as radiculopathy, nerve root compromise, nerve root compression, nerve root pain, and pain radiating below the knee, with no restriction on gender and age. We excluded trials if they included lower back pain without sciatica.
Any type of invasive acupuncture were included, such as acupuncture, electroacupuncture, elongated needle acupuncture, auricular acupuncture, abdominal acupuncture, and warm acupuncture. Control interventions may include no treatment, sham acupuncture/placebo (e.g., acupuncture same acupuncture point without needle insertion or acupuncture the point close to it but it is not an acupuncture point), and Western medicine. As this review aims to assess the effectiveness and safety of acupuncture for treating sciatica, we excluded trials comparing two different types of acupuncture. Furthermore, the effectiveness of Chinese medicine is hard to assess, so we excluded trials comparing acupuncture with Chinese medicine.
The primary outcome of interest was pain intensity. Any validated measurement scales were included (e.g., Visual Analogue Scale (VAS), Numeric Rating Scale (NRS), and Short-Form McGill Pain Questionnaire (SF-MPQ)). Secondary outcomes were (1) global assessment (the proportion of patients improved or cured); (2) quality of life, for example, as assessed using the Medical Outcomes Study 36-Item Short Form health survey (SF-36); (3) physical examinations; (4) patient satisfaction; and (5) adverse effects.
A search strategy was used and conducted according to the Cochrane handbook guidelines [
The strategy for searching the PUBMED database is shown in Table
Search strategy used in PubMed database.
Number | Search items |
---|---|
1 | randomized controlled trial.pt |
2 | controlled clinical trial.pt |
3 | randomized.ti,ab |
4 | randomly.ti,ab |
5 | groups.ti,ab |
6 | trial.ti,ab |
7 | or 1–6 |
8 | acupuncture.ti,ab |
9 | electro-acupuncture.ti,ab |
10 | elongated needle.ti,ab |
11 | three edged needle.ti,ab |
12 | (fire needle or warming needle).ti,ab |
13 | auricular acupuncture.ti,ab |
14 | abdominal acupuncture.ti,ab |
15 | warm acupuncture.ti,ab |
16 | pyonex.ti,ab |
17 | or 8–16 |
18 | sciatica.ti,ab |
19 | sciatic neuralgia.ti,ab |
20 | ischialgia.ti,ab |
21 | ischioneuralgia.ti,ab |
22 | discogenic sciatica.ti,ab |
23 | bilateral sciatica.ti,ab |
24 | disc herniation-induced sciatica.ti,ab |
25 | or 18–24 |
26 | 7 and 17 and 25 |
This search strategy will be modified as required for other electronic databases.
Two authors (Zongshi Qin and Xiaoxu Liu) extracted the data independently. Before beginning extraction, a small scope trial with one database was conducted to confirm that there were no differences between the two authors. After a common understanding was reached, standard extraction forms were used to collect data from included trials. Any disagreements were discussed and judged by an arbiter (Zhishun Liu).
Two authors (Zongshi Qin and Xiaoxu Liu) used Endnote X7 (Thomson Reuters, New York, NY, USA) software to manage the trials that have been searched and remove duplicates. Data extracted were put into Revman V.5.3.3 software for analysis.
The Cochrane Collaboration tool for assessing the risk of bias was used to facilitate the assessment of the risk of bias for trials included [
Dichotomous data were analysed using risk ratio (RR) and 95% confidence interval (CI). Continuous outcomes were analysed using mean differences (MD) with 95% CI or standardized mean differences (SMD) with 95% CI if different measurement scales are used.
The listed corresponding author was contacted in an attempt to obtain any missing information from their trial. We excluded 1 trial after 3 unsuccessful attempts to contact the authors to obtain missing data from the data synthesis [
We used Higgins
A funnel plot was used to assess the reporting biases when 10 or more trials were included in a meta-analysis. However, the number of studies included in our analysis may have been too small to test for funnel plot asymmetry [
Details of acupuncture and control interventions were extracted on the basis of the revised Standard for Reporting Interventions in Clinical Trials of Acupuncture (STRICTA) [
Acupuncture interventions in the included studies based on the STRICTA recommendation.
Author | Insertion depth | Response sought | Details of needling Stimulation method | Retention time | Needle type | Treatment regimen | Practitioner background |
---|---|---|---|---|---|---|---|
Wang and La 2004 [ |
NR | De-chi response manual | EA | 25 min | NR | 1 session once a day for 7 days | Physician |
Chen et al. 2009 [ |
NR | De-chi response manual | WA | 20–35 min | 0.3 × 60 mm | 3 sessions once daily for 10 days | NR |
Zeng 2012 [ |
60 mm (GB 30/BL 54) |
De-chi response manual | Manipulated every 10 min, pricking blood | 30 min | 0.3 × 75 mm | 2 sessions once daily for 10 days | NR |
Zhang et al. 2008 [ |
40–60 mm | De-chi response manual | Manipulated every 10 min and EA | 20 min | 0.3 × 40–75 mm | 2 sessions once daily for 10 days | Professional acupuncturists |
Hu et al. 2010 [ |
60 mm (GB 30) |
De-chi response manual | Manipulated every 10 min and EA | 30 min | 0.3 × 50–75 mm | 2 sessions once daily for 10 days | NR |
Du et al. 2009 [ |
45–60 mm | De-chi response manual | EA | 45 min | 0.45 × 75 mm | 4 sessions 3 times per week | NR |
Chen 2010 [ |
40–75 mm | De-chi response manual | Manipulated every 10 min | 30 min | 0.3 × 25–40 mm | 2 sessions 3 times per week | NR |
Wang 2008 [ |
NR | De-chi response manual | WA | NR | 0.4 × 75 mm | 2 sessions once daily for 10 days | NR |
Meng 2014 [ |
NR | NR | EA | 30 min | NR | 2 sessions once daily for 7 days | Qualified acupuncturist |
Ren 2013 [ |
40–75 mm | De-chi response manual | WA | 30 min | NR | 1 session once a day for 10 days | NR |
Zhao 2004 [ |
50–75 mm | De-chi response manual | EA | 30 min | 0.25 × 75 mm | 2 sessions once a day for 10 days | NR |
NR: not reported, De-chi: a needle sensation of soreness and numbness, EA: electroacupuncture, WA: warm acupuncture, and STRICTA: standards for reporting interventions in controlled trials of acupuncture.
We used Revman V.5.3.3 software to perform meta-analysis of the trials included. Dichotomous data were determined by using RR with 95% CI, and continuous outcomes were analysed using WMD with 95% CI or SMD with 95% CI if different measurement scales are used. When statistical heterogeneity was observed, the random effects model was used; otherwise the fixed effect model was used to combine the data. When quantitative synthesis was not appropriate, we provided systematic narrative synthesis to describe the characteristics and findings of the included trials.
We planned to conduct subgroup and sensitivity analyses in the published protocol as follows: we hypothesized a greater reduction in pain intensity and improvement in global assessment with acupuncture than with sham acupuncture; we also predicted that different types of sciatica or risks of bias in different trials would lead to moderate statistical heterogeneity.
Our search strategy yielded a total of 1489 records. After 435 duplicate records were excluded, 1054 unique records were screened for eligibility. A total 1005 records were excluded based on review of the title and abstract. The remaining 49 records were deemed potentially relevant. After the full-text articles were reviewed, 7 studies were excluded because they were not true RCTs, 24 studies were excluded because they included inappropriate interventions, and 7 studies were excluded due to inappropriate design. One study was published in French and the full-text was unavailable; thus, we were unable to extract the data, and the study was therefore excluded from review [
Figure
Study flow diagram.
We included 11 trials that enrolled a total of 962 participants in our systematic review [
The characteristics of the included studies are summarized in Table
Summary of studies included in the review.
Author | Design | Number of subjects | Intervention type (A) | Control group (B) | Treatment regimen | Follow-up periods | Outcome measure | Results reported | Adverse events |
---|---|---|---|---|---|---|---|---|---|
Wang and La 2004 [ |
Parallel, 2 arms | 40 |
EA | Diclofenac sodium 50 mg tid for 7 d | 1 session once a day for 7 days | NR | (1) Laseque's sign angles |
(1) (A) versus (B): 76.67 ± 1.63 versus 70.88 ± 2.11 |
NR |
|
|||||||||
Chen et al. 2009 [ |
Parallel, 3 arms | 90 |
WA | (1) Nimesulide 0.1 g bid |
3 sessions once daily for 10 days | NR | (1) Response rate |
(1) (A) significantly better than (B) ( |
NR |
|
|||||||||
Zeng 2012 [ |
Parallel, 2 arms | 60 |
MA |
Ibuprofen 3 mg bid + Vb2 10 mg tid | 2 sessions once daily for 10 days | NR | (1) Response rate |
(A) significantly better than (B) (1) ( |
NO |
|
|||||||||
Zhang et al. 2008 [ |
Parallel, 2 arms | 194 |
EA | Meloxicam 7.5 mg qd | 2 sessions once daily for 10 days | NR | Response rate | (A) significantly better than (B) |
3 patients reported hypodermal bleeding in intervention group; 21 patients in control group reported GI problems |
|
|||||||||
Hu et al. 2010 [ |
Parallel, 2 arms | 100 |
EA | Meloxicam 7.5 mg qd | 2 sessions once daily for 10 days | Six month | Response rate | (A) significantly better than (B) |
5 patients in control group reported GI problems |
|
|||||||||
Du et al. 2009 [ |
Parallel, 2 arms | 62 |
EA | Diclofenac sodium 75 mg qd | 4 sessions 3 times per week | NR | (1) JOA for total score |
(1) 20.16 ± 3.54 versus 17.63 ± 3.23 |
NR |
|
|||||||||
Chen 2010 [ |
Parallel, 2 arms | 60 |
MA | Ibuprofen 0.2 g tid + prednisone 30 mg qd | 2 sessions 3 times per week | NR | (1) Response rate |
(1) (A) significantly better than (B) |
2 patients reported hypodermal bleeding in intervention group |
|
|||||||||
Wang 2008 [ |
Parallel, 2 arms | 104 |
WA | Ibuprofen 0.6 g bid + Vb1 30 mg tid | 2 sessions once daily for 10 days | NR | Response rate | (A) significantly better than (B) |
NR |
|
|||||||||
Meng 2014 [ |
Parallel, 2 arms | 60 |
EA + drugs |
Ibuprofen 20 mg bid + Vb1 30 mg tid | 2 sessions once daily for 7 days | NR | (1) Response rate |
(1) (A) significantly better than (B) |
NO |
|
|||||||||
Ren 2013 [ |
Parallel, 2 arms | 60 |
WA + drugs |
Mannitol 150 mL + dexamethasone 10 mg i.v.gtt and mecobalamin tablets 0.5 mg I.M. | 1 session once a day for 10 days | NR | Response rate | (A) significantly better than (B) |
NR |
|
|||||||||
Zhao 2004 [ |
Parallel, 2 arms | 60 |
EA | Sham acupuncture | 2 sessions once a day for 10 days | NR | Response rate | (A) significantly better than (B) |
NO |
NR: not reported, EA: electroacupuncture, WA: warm acupuncture, i.v.gtt: intravenous drip, I.M.: intramuscular injection, VAS: Visual Analogue Scale, SF MPQ: Short-Form McGill Pain Questionnaire, PT: pain threshold, JOA: Japanese Orthopaedic Association score, BRS-6: 6-point behavior rating scale, MOS SF-36: the medical outcome study item short form health survey, GI: gastrointestinal, and GH: general health.
In general, all of the studies adopted a treatment theory based on traditional Chinese medicine theory and clinical experience. Many acupuncturists choose acupuncture points or corresponding acupuncture interventions based on their clinical experience during treatment. Electroacupuncture was used in most of the trials (6 studies) [
Acupoints of each trial.
Wang and La 2004 [ |
Huantiao (GB 30), Weizhong (BL 40) |
|
|
Chen et al. 2009 [ |
Shenshu (BL 23), Dachangshu (BL 25), Huantiao (GB 30), Weizhong (BL 40), and Kunlun (BL 60) |
|
|
Zeng 2012 [ |
Huantiao (GB 30), Zhibian (BL 54), Chengfu (BL 36), Fengshi (GB 31), Weizhong (BL 40), Yanglingquan (BL 67), Chengshan (BL 57), Xuanzhong (GB 39), Kunlun (BL 60), and Zulinqi (GB 41) |
|
|
Zhang et al. 2008 [ |
Jiaji (EX-B2), Yaoyangguan (DU 3), Huantiao (GB 30), and Yanglingquan (BL 67) |
|
|
Hu et al. 2010 [ |
Yaoyangguan (DU 3), Shiqizhui (EX-B7), Huantiao (GB 30), Yanglingquan (BL 67), Weizhong (BL 40), and Chengshan (BL 57) |
|
|
Du et al. 2009 [ |
Jiaji (EX-B2) |
|
|
Chen 2010 [ |
Jiaji (EX-B2), Zhibian (BL 54), Huantiao (GB 30), Yinmen (BL 37), Weizhong (BL 40), Chengshan (BL 57), and Kunlun (BL 60) |
|
|
Wang 2008 [ |
Jiaji (EX-B2), Zhibian (BL 54), Weizhong (BL 40), and Yanglingquan (BL 67) |
|
|
Meng 2014 [ |
Jiaji (EX-B2), Huantiao (GB 30), Juegu (GB 39), Weizhong (BL 40), and Zhibian (BL 54) |
|
|
Ren 2013 [ |
Dachangshu (BL 25), Shenshu (BL 23), Mingmen (DU 4), Guanyuanshu (BL 26), Qihaishu (BL 24), Zhibian (BL 54), Huantiao (GB 30), and Jiaji (EX-B2) |
|
|
Zhao 2004 [ |
Huantiao (GB 30), Weizhong (BL 40) |
In 8 trials [
Five studies measured pain intensity using VAS [
All of the included RCTs mentioned randomization and 7 studies reported adequate sequence generation [
The key results from the included trials are summarized in Figures
Sciatica affects many people and is a common reason for seeking medical advice. It has considerable economic consequences in terms of health care resources and lost productivity [
In terms of global assessment, the combined results of 6 RCTs showed that acupuncture was superior to medication in improving global assessment (6 trials, 578 participants, RR 1.21, 95% CI 1.12 to 1.30, and
Acupuncture appears to be associated with fewer adverse effects compared with NSAIDs. Six of the included 11 RCTs mentioned adverse events and only 2 of them reported adverse events in the acupuncture group (5 cases of hypodermal bleeding) [
Given the characteristics of sciatica, the presence of inflammation and well-established nociceptive pathways may necessitate a threshold dose or duration of acupuncture treatment prior to clinical effect [
The quality of trials is not sufficiently high and efforts to improve trial reporting are necessary; subsequent trials should comply with the CONSORT statement and STRICTA recommendations [
In this systematic review, 2 of the included trials were multicentre in nature [
This review may be limited by the inherent methodological limitations of the included RCTs.
We chose to consider acupuncture treatment regardless of the frequency of administration, duration of each session, and number and location of acupoints in our published protocol. Any of these variables may have influenced the effects of acupuncture.
Because of the language barrier, we were unable to include other trials that may have met our inclusion criteria.
In conclusion, the results of this systematic review suggest that the use of acupuncture may more effectively relieve leg pain/lumbago and improve global assessment of sciatica when compared with NSAID (ibuprofen, meloxicam, and diclofenac) treatment. Moreover, adjuvant acupuncture may enhance the effect of medications in leg pain/lumbago relief. To patients, acupuncture points appear more effective than nonacupoints. Acupuncture is relatively safe and is rarely associated with serious adverse events in patients with sciatica. However, this meta-analysis was lacking in relevant and rigorous RCTs. Because the evidence was limited, higher quality and more rigorously designed clinical trials with larger sample sizes will be needed to further confirm our findings.
The data used in this systematic review was not individual data and there were no privacy issues to address.
The authors declare that there is no conflict of interests regarding the publication of this paper.
Zhishun Liu and Zongshi Qin contributed to the conception of the study. The paper was drafted by Zongshi Qin and revised by Zhishun Liu. The search strategy was developed by Yanbing Zhai and Xiaoxu Liu and updated by Jiani Wu. Zongshi Qin and Xiaoxu Liu independently screened the potential studies, extracted data from the included studies, and completed the data synthesis. Jiani Wu and Yanbing Zhai assessed the risk of bias. Zhishun Liu arbitrated in cases of disagreement and ensured the absence of errors. All authors contributed to the interpretation of the results and gave their final approval for the version to be published.