A Review of Acupuncture Treatment Methods for Lumbar Herniated Intervertebral Disc

Article information

J Acupunct Res. 2018;35(4):158-168

Publication date (electronic) : 2018 November 26

doi : https://doi.org/10.13045/jar.2018.00234

Sung Jin Kim, Seong Mok Jeong, Chang Hee Lee, Jin-Young Yoon, Sung Eun Shim, Jeong Hyon Kim, Bon Hyuk Goo, Yeon Cheol Park, Yong-Hyun Baek, Sang Soo Nam, Byung-Kwan Seo

Department of Acupuncture & Moxibustion Medicine, College of Korean Medicine, Kyung Hee University, Seoul, Korea

^*Corresponding author. Department of Acupuncture & Moxibustion Medicine, Kyung Hee University Hospital at Gangdong, 892, Dongnam-ro, Gangdong-gu, Seoul, 134-727, Korea E-mail: seohbk@hanmail.net

Received 2018 September 19; Revised 2018 October 17; Accepted 2018 November 2.

Abstract

The purpose of this study was to review clinical studies of lumbar herniated intervertebral disc (LHIVD) treatment using acupuncture. Online database (PubMed, COCHRANE Library, EMBASE, CNKI, KISS, NDSL, KoreaMed, KMbase, OASIS, and KISTI) searches were conducted in May 2018. Studies that used acupuncture, electroacupuncture or warm needle acupuncture were included, along with participants who had lower back pain and radiating pain of their lower limbs consistent with radiological findings. Animal studies and nonclinical data were excluded. Data on treatment methods, site, time, frequency, period, and scales used were analyzed. There were 69 studies including 38 randomized controlled trials, 14 retrospective observational studies, and 17 clinical case studies. There were 51 acupoints selected for acupuncture treatment of LHIVD. The most frequently treated acupoints were BL23, BL25, BL24, and BL40. The mean treatment time, frequency, and duration were 26.06±6.70 mins, 6.29±1.70 times/week, and 20.57±11.04 days, respectively, in randomized controlled trials (RCT), and 18.62±4.60 mins, 11.58±3.99 times/week, and 34.43±17.62 days, respectively, in case/retrospective studies (mean±SD). This review collates information about acupuncture treatment methods for LHIVD.

Keywords: acupuncture; electroacupuncture; herniated disc; intervertebral disc; traditional medicine

Introduction

Lumbar herniated intervertebral disc (LHIVD) is a disorder in which part of or all of the nucleus herniates to the nerve roots. This is either due to degeneration of the intervertebral disc or external force, and results in the rupture of the fibrous ring. Symptoms include abnormal pain at the level of the affected vertebrae, lower back pain, and radiating pain of lower extremities caused by the neuromuscular stimulation of the herniated nucleus. In severe cases of LHIVD, motor neuron palsy such as foot drop syndrome, and sexual dysfunction may also occur [1].

Treatment of LHIVD can be classified into either surgical or conservative treatments. Only 5% to 10% of patients who complain of pain due to disc herniation require surgery because of failure of conservative treatment. Eighty percent of LHIVD patients experienced good results with non-surgical therapy. Therefore, there is a growing interest in Traditional Korean Medicine (TKM) treatment methods, focusing on conservative treatment [2]. TKM treatment includes acupuncture, moxibustion, herbal medicine, chuna, and herbal medicine [3]. Acupuncture treatment is based on the basic theories of TKM such as the yin and yang and meridian theories, which certain parts of the body are physically stimulated to cause reaction in the body. It is a typical treatment method of TKM, widely used for pain and paralytic diseases [4].

The purpose of this study was to review clinical studies that focused on acupuncture treatment of LHIVD. Shin et al [5] reported research trends in acupuncture treatment of LHIVD by searching PubMed. However, studies of acupuncture treatment in LHIVD using various databases other than PubMed were insufficient. Therefore, this study aimed to investigate the research trends of acupuncture treatment for LHIVD through assessment of various databases including PubMed. This review aimed to evaluate factors involved in TKM treatment, such as the treatment site, duration, frequency, period and scales. The results from this study may provide useful information to help optimize acupuncture treatment for LHIVD in clinical practice, and provide the basis for designing further research studies to look at clinical practice using acupuncture.

Materials and Methods

Data sources and searches

The following electronic databases were searched from their inception to May 2018: PubMed, Excerpta Medica dataBASE (EMBASE), COCHRANE Library, China National Knowledge Infrastructure (CNKI), Korean Studies Information Service System (KISS), National Digital Science Library (NDSL), KoreaMed, Korean Medical Database (KMbase), Oriental Medicine Advanced Searching Integrated System (OASIS), and Korea Institute of Science and Technology Information (KISTI).

The search terms were a combination of [diagnosis & treatment]. There are details of each strategy for PubMed, EMBASE, COCHRANE, CNKI, and Korean databases in Appendix 1. The search terms of diagnosis were based on a systematic review of LHIVD [6] and consisted of ‘HIVD (herniation of intervertebral disc),’ ‘HNP (herniated nucleus pulposus),’ ‘spinal disc herniation,’ ‘lumbar disc herniation,’ ‘intervertebral disc displacement,’ ‘nucleus pulposus hernia,’ and ‘disc degeneration.’ We conducted a search using ‘acupuncture’ for the treatment term.

Study selection and exclusion criteria

Type of intervention & studies

We selected research that used acupuncture as a main treatment of LHIVD. Studies that used electroacupuncture or warm needle acupuncture were also selected. However, pharmaco-acupuncture and acupotomy were excluded because their treatment mechanisms are distinct from those of acupuncture treatment. Only studies where participants diagnosed with LHIVD, disc bulging, protrusion, extrusion, and sequestration, and classification of LHIVD were included. Studies that were not examining the effect of acupuncture treatment for LHIVD were excluded. We also excluded non-human experimental studies. The research was conducted by each of the following methods of assessment (meta-analysis, systematic review of literature, randomized clinical study, retrospective observational study, and case study). Studies that did not provide clinical data were excluded.

Type of participants

Studies which treated patients diagnosed with LHIVD with acupuncture were included. Patients included in this study had lower back pain and radiating pain of lower limbs that were consistent with radiologic findings such as MRI, and CT. In addition, patients who were admitted to hospital or outpatient clinics were both included.

Data extraction

After removing duplicate studies, 2 independent reviewers conducted the first screening process by reading titles and abstracts of acquired research lists to exclude irrelevant studies. The reviewers read the full text of each article to exclude improper studies. Disagreement between the 2 reviewers was resolved by discussion with other reviewers. Reviewers extracted data from selected research related to the treatment method, site (acupoints or non-acupoints), time/frequency, period, and scales.

Data analysis

Analysis by treatment methods

The studies were analyzed according to treatment method. Treatment methods were classified into acupuncture alone, warm needle acupuncture alone, electroacupuncture alone, acupuncture and other TKM treatment, acupuncture and other Western medical treatment, electroacupuncture and other TKM treatment, electroacupuncture and other Western medical treatment, warm needle acupuncture and other TKM treatment, and warm needle acupuncture and other Western medical treatment. Treatment sites of acupuncture were classified into acupoints and non-acupoints, and we analyzed which acupoints or which parts of the body were treated. Additionally, the mean and standard deviation of treatment time, frequency, and period were calculated. The analysis of treatment time, frequency, period and usage frequency of acupoints was conducted in RCT studies and case/retrospective studies separately. In addition, the proportion of each treatment method and additional TKM treatment was calculated.

Analysis by scales

The scales used for measuring the effect of acupuncture treatment of LHIVD were analyzed.

Results

Study selection and description

A total of 2413 articles were acquired and 1,627 articles were screened after duplicates were excluded. In the first screening process, 1,511 articles were excluded for the following reasons: 812 were not LHIVD studies, 99 were non-human experimental studies, 527 studies were about improper treatment, and 72 were review articles. In the second screening process by reading the full text, 47 articles were excluded; 32 were not about the effect of acupuncture treatment, 11 studies were a non-human experimental model, and 4 were review articles. As a result, 69 clinical studies about acupuncture treatment of LHIVD were retained for inclusion in the analysis (Fig. 1). There were 38 randomized controlled trials, 14 retrospective observational studies, and 17 case studies (Table 1).

Fig. 1.

Flow chart of study inclusion/exclusion criteria.

EMBASE, Excerpta Medica dataBASE; CNKI, China national knowledge infrastructure; LHIVD, lumbar herniated intervertebral disc.

Table 1.

Characteristics of the Studies Included in This Review.

Treatment methods

Treatment methods were classified into acupuncture alone, warm needle acupuncture alone, electroacupuncture alone, acupuncture and other TKM treatment, acupuncture and other Western medical treatment, electro-acupuncture and other TKM treatment, electroacupuncture and other Western medical treatment, warm needle acupuncture and other TKM treatment, and warm needle acupuncture and other Western medical treatment.

Among the 69 studies analyzed, there were 8 studies examining the effect of acupuncture treatment alone, 11 on electroacupuncture alone, 3 studies about warm needle acupuncture alone, 41 studies about acupuncture and other TKM treatment, 2 studies about acupuncture and other Western medical treatment, 2 studies about electroacupuncture and other TKM treatment, 1 study about electroacupuncture and other Western medical treatment, and 1 study about warm needle acupuncture and other TKM treatment (Table 2). There were 44 studies that used TKM treatment as an additional treatment to acupuncture. Among them, 2 studies used moxibustion alone, 10 studies used chuna therapy alone, 6 studies used herbal medicine alone as an additional treatment, and 26 studies used complex TKM treatments including bee venom acupuncture, pharmacoacupuncture, moxibustion, herbal medicine, chuna, bloodletting therapy, and fumigation (Table 3). Traction, ozone injection, laser needle knife, and nerve block were used as Western medical treatments in addition to the acupuncture treatment.

Table 2.

Treatment Methods of Acupuncture for LHIVD.

Table 3.

TKM Treatment Used in Addition to Acupuncture.

Table 4.

Acupoints Used to Treat LHIVD in RCT Studies.

Treatment site

Acupoints

There were 62 studies that used acupoints as the treatment site. A total of 51 acupoints were selected for acupuncture treatment of LHIVD. BL40, EX-B2, GB30, BL25 and BL23 were the most frequently used acupoints in RCT studies (Table 4). BL23, BL25, BL24, GB30, and BL40 were the most frequently treated acupoints in case/retrospective studies (Tables 5,6).

Table 5.

Acupoints Used to Treat LHIVD in Case Studies and Retrospective Studies.

Table 6.

Outcome Domains and Scales Used to Evaluate Treatment Effect.

Non-acupoints

There were 7 studies that used non-acupoints. Muscles and trigger points were used as the treatment site in 4 studies. These studies treated the soft tissue around the spine and painful area based on anatomical position without mentioning acupuncture points. The gluteus maximus, gluteus medius, quadratus lumborum, multifidus, and erector spinae were treated with acupuncture. Two studies treated LHIVD with equilibrium acupuncture and 1 study examined the effect of scalp acupuncture in treating LHIVD.

Treatment time, frequency, and period

For the time of acupuncture treatment, the mean treatment duration was 26.06±6.70 mins in RCT studies and 18.62±4.60 mins in case/retrospective studies (mean±SD). The treatment duration of treatment groups ranged from a minimum of 5 mins to a maximum of 45 mins (Figs. 2,3). The mean frequency of acupuncture treatment was 6.29 ±1.70 times/week in RCT studies and 11.58 ± 3.99 times/week (mean±SD) in case/retrospective studies (Figs. 4,5). The treated period ranged from 3 to 84 days, with an average of 20.57±11.04 days in RCT studies, and 34.43±17.62 days in case/retrospective studies (Figs. 6,7).

Fig. 2.

Duration of treatment time in RCT studies.

RCT, randomized controlled trial.

Fig. 3.

Duration of treatment time in case studies and retrospective studies.

Fig. 4.

Frequency of treatment in RCT studies.

RCT, randomized controlled trial.

Fig. 5.

Frequency of treatment in case studies and retrospective studies.

Fig. 6.

Duration of treatment period in RCT studies.

RCT, randomized controlled trial.

Fig. 7.

Duration of treatment period in case studies and retrospective studies.

Outcome domains and scales

Effective rate, back specific dysfunction, and quality of life were used to measure outcome. Pain was the most frequently used outcome parameter (52 times). VAS (Visual Analogue Scale) was the most frequently used scale to measure pain (43 times). PRI (Pain Rating Index), NRS (Numerical Rating Scale), SF-MPQ (Short Form McGill Pain Questionnaire), PPI (Present Pain Intensity) were also used as scales to evaluate the pain intensity. Effective rate was the next most frequently used outcome measurement (35 times). GPE (Global Perceived Effect) was used to measure the effective rate after the acupuncture treatment. Back specific dysfunction was used to measure outcome on 18 occasions. ODI (Oswestry Disability Index) and JOA (Japanese Orthopedic Association) were used as scales to evaluate back specific dysfunction. Quality of life was used as an outcome measurement twice. SF-36 (Short Form Health Survey 36) and EQ-5D (EuroQOL-5 Dimensions) were used as scales to assess quality of life (Table 6).

Discussion

Acupuncture has been an effective treatment method in TKM for many years. There have been many studies investigating factors that can influence the treatment effect of acupuncture. Treatment site, time, frequency, and duration have been thought to be important contributing factors influencing the effect of acupuncture treatment [77], and studies are being conducted to determine the influence of these factors. In this study, an investigation was conducted to examine these acupuncture treatment methods for LHIVD, with the aim of providing information to determine the treatment methods in clinical practice or designing further clinical research on acupuncture treatment for LHIVD.

The analysis of treatment site showed that acupoints located in the waist such as BL23, BL24, BL25, and GB30, were frequently used in both RCT studies and case/retrospective studies. BL40 which is in other parts of the body, such as the legs or hips, were also frequently used.

There are 2 ways of selecting acupoints based on the distance from the lesion, either by treating local acupoints or distal acupoints. Local acupoints are those points near to the painful sites, whilst distal acupoints are those located further away [78]. Local acupoints are usually used to treat musculoskeletal pain and pain due to trigger points, and tender points that are painful on pressure, through peripheral mechanisms such as vasodilation and segmental inhibition [79]. Nanna et al [80] revealed the anti-nociceptive effect of local acupoints in the treatment of musculoskeletal pain. It was proposed that the pain relief mechanism resulted from inhibition of the adenosine binding to the adenosine A1 receptor in the proximal rather than the central pathway. As shown in this study, most of the RCT and case/retrospective studies used the local acupoints like BL23, BL24, BL25, and GB30, mainly to treat lower back pain caused by LHIVD.

There are studies examining the effects of different duration of needle retention during acupuncture treatment. Cui et al [81] investigated the effect of different retaining needle time on pain threshold, and concluded that 25-30 mins of retaining time was the most effective in pain control. In addition, adenosine, a neuromodulator with anti-nociceptive properties, was released and an analgesic effect was strongest when the retaining needle time was 30 mins [82]. The treatment duration was different between RCT studies and case/retrospective studies. The mean treatment duration was 26.06±6.70 mins in RCT studies and 18.62±4.60 mins in case/retrospective studies (mean±SD). The reason for this difference may be explained by differences in retaining time. To obtain the best therapeutic effect for treating patients, at least more than 25 mins, and ideally 30 mins of retaining needle time, appeared to provide the best therapeutic benefit. However, there are practical concerns to consider such as manpower and cost in the clinical practice. In the process of satisfying these factors, retaining needle time would have been modulated.

The North American Spine Society recommends conservative treatment for LHIVD for 6 weeks before considering surgical treatment [82]. The results from this analysis suggest that 6 weeks of treatment period would be efficient for treating LHIVD with acupuncture in clinical practice. The treatment duration appeared to be different between RCT studies and case/retrospective studies, with an average of 20.57±11.04 days in RCT studies and 34.43±17.62 days in case/retrospective studies. The reason for this difference seems to be the differences in the type of participants. In every case/retrospective study, the patients treated by acupuncture were those who were admitted to the TKM hospital. In contrast, almost all the RCT studies were conducted in the outpatients department. Acupuncture treatment would have to be conducted for longer periods in patients who were admitted to obtain optimal therapeutic effect, but there are many obstacles such as cost, and loss of patients when conducting long-term follow-up studies. So, considering factors like treatment effect, cost, and possibility of patient loss, it may be better if the treatment period in RCT studies were designed to be shorter than in case/retrospective studies.

In summary, this process will provide more information to help TKM practitioners to decide the appropriate treatment methods for clinical practice, or for designing clinical research studies.

The limitation of this study is that the search database was limited to specific databases and did not cover all the studies. Several studies have been written in Japanese or in other languages regarding the treatment methods of acupuncture used for treating LHIVD. Therefore, it is difficult to conclude that all the research trends of acupuncture treatment for LHIVD are included in this study, as the number of final retrieved documents is small. Additionally, the process of evaluating the quality of searched studies was not conducted and the treatment effects of acupuncture or risk of bias of studies were not evaluated. Retaining a larger number of studies through searching more databases and improving the processes of analyzing the risk of bias and comparative analysis of treatment effects are necessary to provide more evidence for treating LHIVD with acupuncture treatment in clinical practice.

Conclusion

A total of 69 studies were selected based on the search strategies set out in this study. There were 38 randomized controlled trials, 14 retrospective observational studies, and 17 clinical case studies. The results of the analysis are as follows.

1. Treatment methods were classified as acupuncture treatment alone, electro-acupuncture alone, warm needle acupuncture alone, acupuncture and other TKM treatment, acupuncture and other Western medical treatment, electroacupuncture and other TKM treatment, electroacupuncture and other Western medical treatment, warm needle acupuncture and other TKM treatment, and warm needle acupuncture and other Western medical treatment. A combination of acupuncture and TKM treatments used as additional treatment were most frequently used.

2. BL23, BL25, BL24, and BL40 were the most frequently treated acupoints. Mean of treatment time, frequency, and duration were 26.06±6.70 mins, 6.29±1.70 times/week, and 20.57±11.04 days, respectively, in RCT studies, and 18.62±4.60 mins, 11.58±3.99 times/week, and 34.43±17.62 days, respectively, in case/retrospective studies (mean±SD).

3. Pain, Effective rate, back specific dysfunction, and quality of life were used as outcome measurements. Pain was the most frequently used outcome parameter. VAS, PRI, NRS, SF-MPQ, PPI, GPE, ODI, JOA, and SF-36 were used as scales for evaluating outcome measurements. (Table 6).

Notes

The authors declare that there are no conflicts of interest regarding the publication of this manuscript.

Acknowledgements

This study was supported by the TKM R&D program, which is funded by the Ministry of Health and Welfare through the Korea Health Industry Development Institute (HB16C0061).

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Appendices

Appendix 1.

Search strategy for each database.

1.1. MEDLINE - PubMed

#1 Intervertebral Disc Displacement [Mesh]

#2 Sciatica [Mesh]

#3 Polyradiculopathy [Mesh]

#4 (disc OR discs OR disk OR disks OR nucleus pulposus OR sacroilia^* OR Sacroiliac-joint)

#5 (displacement OR degeneration OR hernia^* OR protru^* OR perfora^* OR ruptur^* OR degenerat^* OR degradat^* OR displac^* OR prolaps^* OR avuls^* OR extru^*)

#6 #4 AND #5

#7 (nerve root OR nerve roots OR nerve)

#8 (compress^* OR entrap^* OR inflammat^* OR disorder^*)

#9 #7 AND #8

#10 (polyradiculopathy OR radiculopath^* OR radiculiti^* OR sciatic)

#11 {or #1, #2, #3, #6, #9, #10}

#12 (Acupuncture)

#13 #11 AND #12

1.2. CENTRAL - Cochrane

#1 Intervertebral disk displacement [ti, ab, kw]

#2 sciatica [ti, ab, kw]

#3 polyradiculopathy [ti, ab, kw]

#4 (disc OR discs OR disk OR disks OR nucleus pulposus OR sacroilia^* OR Sacroiliac-joint) [ti, ab, kw]

#5 (displacement OR degeneration OR hernia^* OR protru^* OR perfora^* OR ruptur^* OR degenerat^* OR degradat^* OR displac^* OR prolaps^* OR avuls^* OR extru^* ) [ti, ab, kw]

#6 #4 AND #5

#7 (nerve root OR nerve roots OR nerve) [ti, ab, kw]

#8 (compress^* OR entrap^* OR inflammat^* OR disorder^*) [ti, ab, kw]

#9 #7 AND #8

#10 (polyradiculopathy OR radiculopath^* OR radiculiti^* OR sciatic) [ti, ab, kw]

#11 {or #1-#3, #6, #9, #10}

#12 (Acupuncture) [ti, ab, kw]

#13 #11 AND #12

1.3. EMBASE

#1 ‘Intervertebral disk displacement’/exp

#2 ‘sciatica’/exp

#3 ‘polyradiculopathy’/exp

#4 (disc OR discs OR disk OR disks OR nucleus pulposus OR sacroilia^* OR Sacroiliac-joint): ab,ti

#5 (displacement OR degeneration OR hernia^* OR protru^* OR perfora^* OR ruptur^* OR degenerat^* OR degradat^* OR displac^* OR prolaps^* OR avuls^* OR extru^*): ab, ti

#6 #4 AND #5

#7 (nerve root OR nerve roots OR nerve): ab, ti

#8 (compress^* OR entrap^* OR inflammat^* OR disorder^*): ab, ti

#9 #7 AND #8

#10 (polyradiculopathy OR radiculopath^* OR radiculiti^* OR sciatic): ab, ti

#11 {or #1-#3, #6, #9, #10}

#12 (Acupuncture): ab, ti

#13 #11 AND #12

1.4. CNKI

“HIVD” OR “Herniated Intervertebral disc” OR “HNP” OR “Herniated nucleus pulposus” OR “spinal disc herniation” OR “intervertebral disc herniation” OR “herniated disc” OR “Intervertebral disc displacement” AND “Acupuncture“

1.5. KoreaMed

((disc [ALL] OR nucleus pulposus [ALL]) AND (displacement [ALL] OR degeneration [ALL] OR hernia [ALL])) AND (Acupuncture [ALL])

1.6. KMbase

((([ALL=disc] OR [ALL=nucleus pulposus]) AND ([AHLL=displacement] OR [ALL=degeneration] OR [ALL=hernia^*])) AND [ALL=Acupuncture]

1.7. KISS

(((disc OR nucleus pulposus) AND (displacement OR degeneration OR hernia^*))) AND Acupuncture

1.8. NDSL

(((disc OR nucleus pulposus) AND (displacement OR degeneration OR hernia^*)) AND (Acupuncture)

1.9. KISTI

(BI: disc hernia^*) OR (BI: nucleus pulposus hernia^*) OR (BI: disc displacement) OR (BI: nucleus pulposus displacement) OR (BI: disc degeneration) OR (BI: nucleus pulposus degeneration) AND (BI: Acupuncture)

1.10. OASIS

(((disc OR nucleus pulposus) AND (displacement OR degeneration OR hernia^*)) AND (Acupuncture)

Article information Continued

This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Table 1.

Characteristics of the Studies Included in This Review.

	Type of study	Treatment method	Treatment site (acupoints/non-acupoints)	Treatment time/frequency/period	Outcome domain (scale)
Xue Z [7] (2018)	RCT	Electroacupuncture	BL25, EX-B2	20 min, 4 times/wk, 28 d	Pain (NRS),
Xue Z [7] (2018)	RCT	Electroacupuncture	BL25, EX-B2	20 min, 4 times/wk, 28 d	Back specific dysfunction (ODI)
EH Tuzun [8] (2017)	RCT	Acupuncture	Non-acupoints (Gleuteus medius, quadratus lumborum, multifidus)	Not recorded, 2 times/wk, 21 d	Pain (VAS, SF-MPQ)
Hu J [9] (2014)	RCT	Acupuncture	BL25, EX-B2, GB30, BL40, GB34, ST36, GB40, BL57	Not recorded, 1 time/d, 10 d	Pain (VAS)
Hu J [9] (2014)	RCT	Acupuncture	BL25, EX-B2, GB30, BL40, GB34, ST36, GB40, BL57	Not recorded, 1 time/d, 10 d	Effective rate (GPE)
Hou S [10] (2009)	RCT	Acupuncture	BL25, BL23, GV4, BL26, BL24, GB30, EX-B2, BL56, GB31, GB39, BL40, GB34	30 min, 1 time/d, 10 d	Effective rate (GPE)
Hou S [10] (2009)	RCT	Acupuncture		30 min, 1 time/d, 10 d	Pain (PRI)
Ding W [11] (2014)	RCT	Acupuncture	Non-acupoints (Equilibrium Acupuncture)	Not recorded, 1 time/d, 3 d	Effective rate (GPE),
Ding W [11] (2014)	RCT	Acupuncture	Non-acupoints (Equilibrium Acupuncture)	Not recorded, 1 time/d, 3 d	Pain (VAS, PRI)
Chen MR [12] (2009)	RCT	Warm needle acupuncture	BL23, BL25, GB30, BL40, BL60	20 min, 1 time/d, 10 d	Effective rate (GPE),
Chen MR [12] (2009)	RCT	Warm needle acupuncture	BL23, BL25, GB30, BL40, BL60	20 min, 1 time/d, 10 d	Pain (VAS)
Chen XH [13] (2006)	RCT	Electroacupuncture	BL23, BL24, BL25, BL26, GB30, BL37, BL57, BL40, BL60	30 min, 1 time/d, 28 d	Pain (VAS)
Du Z [14] (2009)	RCT	Electroacupuncture	EX-B2	45 min, 3 times/wk, 28 d	Effective rate (GPE),
					Pain (VAS),
					Back specific dysfunction (JOA)
Li YQ [15] (2006)	RCT	Acupuncture	BL23, BL25, BL54, BL40, BL54	30 min, 1 time/d, 30 d	Effective rate (GPE),
Li YQ [15] (2006)	RCT	Acupuncture	BL23, BL25, BL54, BL40, BL54	30 min, 1 time/d, 30 d	Pain (VAS)
Shan YL [16] (2011)	RCT	Electroacupuncture	EX-B2, BL24, BL26, BL25, BL54, GB34, BL60, SP9	30 min, 1 time/d, 14 d	Effective rate (GPE),
Shan YL [16] (2011)	RCT	Electroacupuncture	EX-B2, BL24, BL26, BL25, BL54, GB34, BL60, SP9	30 min, 1 time/d, 14 d	Pain (VAS)
Lu W [17] (2002)	RCT	Electroacupuncture	EX-B2	20 min, 1 time/d, 14 d	Pain (VAS)
Fan Y [18] (2009)	RCT	Warm needle acupuncture	BL54, GB30, BL36, BL37, BL40, BL57, BL60	30 min, 1 time/d, 30 d	Effective rate (GPE),
Fan Y [18] (2009)	RCT	Warm needle acupuncture	BL54, GB30, BL36, BL37, BL40, BL57, BL60	30 min, 1 time/d, 30 d	Pain (VAS)
Li LX [19] (2006)	RCT	Acupuncture	EX-B2, BL40, BL63, KI3, GB30, GB36	20 min, 1 time/d, 10 d	Effective rate (GPE),
Li LX [19] (2006)	RCT	Acupuncture	EX-B2, BL40, BL63, KI3, GB30, GB36	20 min, 1 time/d, 10 d	Pain (VAS)
Zhang ZH [20] (2004)	RCT	Electroacupuncture	BL23, BL24, BL25, GB30, GB34, BL40, EX-B2	20 min, 1 time/d, 20 d	Effective rate (GPE),
Zhang ZH [20] (2004)	RCT	Electroacupuncture	BL23, BL24, BL25, GB30, GB34, BL40, EX-B2	20 min, 1 time/d, 20 d	Pain (VAS)
Feng H [21] (2012)	RCT	Acupuncture	Non-acupoints (Trigger points, gluteus maximus, multifidus, erector spinae)	15 min, 1 time/3 d, 60 d	Effective rate (GPE),
Feng H [21] (2012)	RCT	Acupuncture		15 min, 1 time/3 d, 60 d	Pain (PRI)
Geng X [22] (2009)	RCT	Electroacupuncture	EX-B2, BL54, GB30, BL40, GB34	30 min, 1 time/d, 20 d	Effective rate (GPE)
Wang XG [23] (2008)	RCT	Warm needle acupuncture	EX-B2, BL54, BL40, GB34	Not recorded, 1 time/d, 14 d	Effective rate (GPE)
Wang XG [23] (2008)	RCT	Warm needle acupuncture	EX-B2, BL54, BL40, GB34	Not recorded, 1 time/d, 14 d	Pain (PRI)
Wu YC [24] (2004)	RCT	Electroacupuncture	GV3, GB30, EX-B2	20 min, 1 time/d, 20 d	Effective rate (GPE)
Zhang BM [25] (2008)	RCT	Electroacupuncture	EX-B2, GV3, GB30, GB43, GB34, BL37, BL62	20 min, 1 time/d, 20 d	Effective rate (GPE)
Gao H [26] (2007)	RCT	Acupuncture	BL23, BL25, EX-B2, BL54, BL40, BL56, GB30, GB31, GB34, GB39	30 min, 1 time/d, 10 d	Effective rate (GPE),
Gao H [26] (2007)	RCT	Acupuncture	BL23, BL25, EX-B2, BL54, BL40, BL56, GB30, GB31, GB34, GB39	30 min, 1 time/d, 10 d	Pain (PPI)
Huang CH [27] (2007)	RCT	Electroacupuncture	BL25, BL26, BL23, BL40, Ashi point, LR13, BL62	30 min, 1 time/d, 10 d	Effective rate (GPE)
Ma LX [28] (2010)	RCT	Electroacupuncture	BL40, GB30, GB34, BL23, EX-B2, BL25, ST36, BL60, LR3	30 min, 1 time/d, 20 d	Effective rate (GPE)
Liu DM [29] (2018)	RCT	Acupuncture + Moxibustion	BL23, BL25, Ashi point, BL26, BL56, BL36, GB31, ST36, GB39, GB40, LR3, BL60	20 min, 1 time/d, 20 d	Effective rate (GPE),
					Pain (NRS)
					Back specific dysfunction (JOA)
Jiang JJ [30] (2017)	RCT	Acupuncture + Western medical treatment	BL40, GB43	20 min, 1 time/d, 14 d	Effective rate (GPE),
					Pain (NRS),
					Back specific dysfunction (JOA, ODI)
Guo JG [31] (2013)	RCT	Acupuncture + Chuna	Non-acupoints (Equilibrium Acupuncture)	10 min, 1 time/d, 10 d	Effective rate (GPE),
					Pain (VAS),
					Back specific dysfunction (ODI)
He Q [32] (2010)	RCT	Electroacupuncture + Chuna	EX-B2, BL23, BL25, BL40, GB30, GB34, BL60	30 min, 1 time/d, 10 d	Effective rate (GPE),
He Q [32] (2010)	RCT	Electroacupuncture + Chuna	EX-B2, BL23, BL25, BL40, GB30, GB34, BL60	30 min, 1 time/d, 10 d	Pain (VAS)
Ji XL [33] (2015)	RCT	Acupuncture + Western medical treatment	BL23, BL25, GB30, GB43, BL40, BL56	30 min, 1 time/d, 28 d	Effective rate (GPE),
Ji XL [33] (2015)	RCT	Acupuncture + Western medical treatment	BL23, BL25, GB30, GB43, BL40, BL56	30 min, 1 time/d, 28 d	Pain (VAS)
Qu M [34] (2010)	RCT	Electrocupuncture + Western medical treatment	EX-B2, GB30, BL54, GB34, BL37, BL40, BL57, BL60, GB31, GB39, GB40, KI16	30 min, 1 time/2 d, 28 d	Effective rate (GPE),
					Pain (VAS),
					Back specific dysfunction (ODI)
Hong DF [35] (2013)	RCT	Acupuncture + Chuna	EX-B2	30 min, 1 time/d, 20 d	Effective rate (GPE)
Chen Y [36] (2010)	RCT	Acupuncture + Chuna	EX-B2, BL54, BL40, BL23	20 min, 1 time/d, 20 d	Back specific dysfunction (JOA),
Chen Y [36] (2010)	RCT	Acupuncture + Chuna	EX-B2, BL54, BL40, BL23	20 min, 1 time/d, 20 d	Pain (PRI)
Zhao BX [37] (2008)	RCT	Acupuncture + Chuna	BL23, BL25, BL31, BL32, BL33, BL34, BL54, BL40, KI16, GB37	30 min, 1 time/5 d, 40 d	Back specific dysfunction (JOA)
Zhao BX [37] (2008)	RCT	Acupuncture + Chuna	BL23, BL25, BL31, BL32, BL33, BL34, BL54, BL40, KI16, GB37	30 min, 1 time/5 d, 40 d	Quality of life (EQ-5D)
Ma S [38] (2010)	RCT	Acupuncture + Moxibustion	BL23, BL25, BL24, BL40, BL56, GB34, GB43	30 min, 1 time/d, 21 d	Effective rate (GPE),
Ma S [38] (2010)	RCT	Acupuncture + Moxibustion	BL23, BL25, BL24, BL40, BL56, GB34, GB43	30 min, 1 time/d, 21 d	Back specific dysfunction (JOA)
Chen RH [39] (2000)	RCT	Acupuncture + Chuna	EX-B2, GB30, GB34, BL36, BL40	30 min, 1 time/d, 20 d	Effective rate (GPE),
Chen RH [39] (2000)	RCT	Acupuncture + Chuna	EX-B2, GB30, GB34, BL36, BL40	30 min, 1 time/d, 20 d	Pain (PRI)
Fu XS [40] (2011)	RCT	Acupuncture + Chuna	EX-B2, BL23, GV3, BL25, GB30, BL40, GB34, KI3, Ashi point	20 min, 1 time/d, 42 d	Effective rate (GPE)
Hu Y [41] (2013)	RCT	Acupuncture + Chuna	BL23, BL54, GB30, BL36, BL37, BL40, GB31, GB34, BL56	30 min, 1 time/d, 10 d	Effective rate (GPE)
Liu X [42] (2009)	RCT	Warm needle acupuncture + Chuna	EX-B2, BL54, BL32, GB30, BL40, GB34, BL60, ST36	30 min, 1 time/d, Not recorded	Effective rate (GPE)
Xiong J [43] (2013)	RCT	Acupuncture + Chuna	BL22, BL23, BL24, BL25, BL26, BL54, GB30, BL37, BL60	30 min, 1 time/d, 28 d	Effective rate (GPE)
Liu L [44] (2009)	RCT	Electroacupuncture + Herbal medicine	BL25, BL26, BL27, GV3	30 min, 1 time/d, 20 d	Effective rate (GPE)
Kim SJ [45] (2010)	Retrospective	Acupuncture + Herbal medicine	BL23, BL24, BL25, BL52, BL31, BL32, BL33, BL34, GB30	20 min, 2 times/d, 28 d	Effective rate (GPE)
Lee EK [46] (2008)	Retrospective	Acupuncture + Herbal medicine	BL22, BL23, BL24, BL25, BL52, BL31, BL32, BL33, BL34, GB30	20 min, 2 time/d, 20 d	Effective rate (GPE)
Yang MS [47] (2010)	Retrospective	Acupuncture + TKM treatment	BL23, BL52, BL25, GB30, GB34, BL60, KI3, ST36	20 min, 2t ime/d, not recorded	Pain (VAS)
Lee EJ [48] (2016)	Retrospective	Acupuncture + TKM treatment	Non-acupoints (Ashi point, Trigger point)	20 min, 2 times/d, 21 d	Pain (VAS)
Oh SK [49] (2005)	Retrospective	Acupuncture + TKM treatment	BL22, BL23, BL24, BL25, EX-B2	5 min, 2 time/d, 30 d	Pain (VAS)
Jang SG [50] (2003)	Retrospective	Acupuncture + Herbal medicine	Non-acupoints (Scalp Acupuncture)	15 min, 2 time/d, 30 d	Effective rate (GPE)
Kim JH [51] (2003)	Retrospective	Acupuncture + TKM treatment	BL23, BL24, BL25, GB30, BL32, BL52	20 min, 1 time/d, 21 d	Pain (VAS)
Youn YS [52] (2008)	Retrospective	Acupuncture + TKM treatment	BL22, BL23, BL24, BL25, BL26, GV3	15 min, 2 time/d, 56 d	Pain (VAS),
					Quality of life (SF-36)
					Back specific dysfunction (ODI),
Lee EG [53] (2009)	Retrospective	Acupuncture + TKM treatment	Ashi point, ST36, SP6, LR3	15 min, 2 time/d, 34 d	Pain (VAS)
Kim JS [54] (2015)	Retrospective	Acupuncture + TKM treatment	BL23, BL24, BL25, BL26, BL51, BL52, BL40, GB34, BL60, BL62	15 min, 2 times/d, 32 d	Pain (VAS)
Song HG [55] (2009)	Retrospective	Acupuncture + TKM treatment	BL23, BL24, BL25, BL26, BL52, GV3, BL40, GB34, BL60, BL56, BL56, GB30, GB34	20 min, 2 times/d, 21 d	Pain (VAS),
Song HG [55] (2009)	Retrospective	Acupuncture + TKM treatment		20 min, 2 times/d, 21 d	Back specific dysfunction (ODI)
Lim SS [56] (2016)	Retrospective	Acupuncture + TKM treatment	BL23, BL24, BL25, BL26, BL31, BL40, BL52, BL53, GB30, GB34, GB35, GB39, GB40, GB43	15 min, 2 times/d, 21 d	Pain (VAS),
Lim SS [56] (2016)	Retrospective	Acupuncture + TKM treatment		15 min, 2 times/d, 21 d	Back specific dysfunction (ODI)
Lee SY [57] (2011)	Retrospective	Acupuncture + TKM treatment	BL23, BL52, BL25, Ashi point, BL56, BL56, BL60	20 min, 2 times/wk, 84 d	Pain (VAS),
Lee SY [57] (2011)	Retrospective	Acupuncture + TKM treatment	BL23, BL52, BL25, Ashi point, BL56, BL56, BL60	20 min, 2 times/wk, 84 d	Back specific dysfunction (ODI)
Kym YH [58] (2017)	Retrospective	Acupuncture + TKM treatment	BL23, BL24, BL25, BL26, BL56	15 min, 2 times/d, 14 d	Pain (VAS)
Kim HS [59] (2017)	Case study	Acupuncture + TKM treatment	BL23, BL24, BL25, BL26, GV3, BL31, BL32, BL33, BL34, GB30, BL54, BL40, ST36, GB34, GB39, BL56, BL56, BL60	15 min, 2 times/d, 40 d	Pain (VAS),
Kim HS [59] (2017)	Case study	Acupuncture + TKM treatment		15 min, 2 times/d, 40 d	Back specific dysfunction (ODI)
Kim JY [60] (2006)	Case study	Acupuncture + TKM treatment	BL23, BL24, BL25, BL26, GV4, GV3, BL56, GB30, BL36, BL40	15 min, 4 times/wk, 35 d	Pain (VAS)
Song KC [61] (2017)	Case study	Acupuncture + TKM treatment	BL23, BL40, SP6, GB39	20 min, 1 time/d, 35 d	Pain (VAS)
Hong SP [62] (2016)	Case study	Acupuncture + TKM treatment	BL22, BL23, BL24, BL25, BL26, BL27, BL28, BL31, BL32, BL33, BL34, BL53, BL54, EX-B2	20 min, 2 times/d, 19 d	Pain (NRS)
Hong SP [62] (2016)	Case study	Acupuncture + TKM treatment		20 min, 2 times/d, 19 d	Back specific dysfunction (ODI)
Kwon HK [63] (2014)	Case study	Acupuncture + TKM treatment	GV4, GB36, BL23, BL28	20 min, 2 times/d, 13 d	Pain (VAS),
Kwon HK [63] (2014)	Case study	Acupuncture + TKM treatment	GV4, GB36, BL23, BL28	20 min, 2 times/d, 13 d	Back specific dysfunction (ODI)
Cho HS [64] (2012)	Case study	Acupuncture + TKM treatment	EX-B2, BL22, BL23, BL24, BL25	20 min, 1 time/d, 40 d	Pain (VAS),
Cho HS [64] (2012)	Case study	Acupuncture + TKM treatment	EX-B2, BL22, BL23, BL24, BL25	20 min, 1 time/d, 40 d	Back specific dysfunction (ODI)
Kim JH [65] (2011)	Case study	Acupuncture + TKM treatment	BL23, BL25, GV3, BL40	15 min, 1 time/d, 37 d	Pain (VAS)
`Lee BH [66] (2001)	Case study	Acupuncture + TKM treatment	BL23, BL24, BL25, BL26, GB30, BL32, ST36, BL40, SP6	20 min, 1 time/d, 45 d	Pain (VAS)
Rhee SH [67] (2006)	Case study	Acupuncture + TKM treatment	BL22, BL23, BL24, BL25, EX-B2, GB30, BL40, BL65, GB34	20 min, 2 time/d, 12 d	Pain (VAS)
Kim SJ [68] (2006)	Case study	Acupuncture + TKM treatment	Non-acupoints (Quadratus lumborum, Erector spinae, Gluteus maximus, Gluteus medius, piriformis)	30 min, 2 times/d, 30 d	Pain (VAS)
Lim GM [69] (2011)	Case study	Acupuncture + TKM treatment	BL23, BL52, BL24, BL25, BL26, GV3, Ashi point, SI3, TE3, GB30, BL40, GB34, BL56, BL56, BL60, GB41	20 min, 2 time/d, 42 d	Pain (VAS, SF-MPQ)
Lim GM [69] (2011)	Case study	Acupuncture + TKM treatment		20 min, 2 time/d, 42 d	Back specific dysfunction (ODI)
Park HH [70] (2008)	Case study	Acupuncture + Herbal medicine	BL40. GB34, ST36, GB39	30 min, 1 time/d, 20 d	Pain (VAS)
Kim JY [71] (2010)	Case study	Acupuncture + TKM treatment	BL22, BL23, BL24, BL25, BL26, SP9, ST36, BL67	20 min, 2 times/d, 28 d	Pain (VAS)
Kang JH [72] (2004)	Case study	Acupuncture + Herbal medicine	BL22, BL23, BL24, BL25, BL26, GV4, GV3, BL40, GB30, BL56, GB31, ST36, GB39, GB40	20 min, 2 times/d, 47 d	Pain (VAS)
You KG [73] (2011)	Case study	Acupuncture + TKM treatment	EX-B2, Ashi point	20 min, 2 times/d, 84 d	Pain (VAS)
Kim SN [74] (2005)	Case study	Acupuncture + TKM treatment	CV3, CV2, CV6, CV4, SP6, SP9, CV1, BL31, BL32, BL33, BL34	20 min, 2 time/d, 49 d	Pain (VAS)
Hwang GT [75] (2005)	Case study	Acupuncture + TKM treatment	BL25, BL23, GB30, Ashi point, SI3, BL60	20 min, 3 times/wk, 45 d	Pain (VAS)

GPE, global perceived effect; NRS, numerical rating scale; VAS, visual analogue scale; ODI, Oswestry disability index; JOA, Japanese orthopedic association; SF-MPQ, short form McGill pain questionnaire; SF-36, short form health survey 36; PRI, pain rating index; EQ-5D, EuroQOL-5 dimensions; PPI, present pain intensity.

Treatment	N (%)
Acupuncture	8 (11.6)
Electroacupuncture	11 (15.9)
Warm needle acupuncture	3 (4.4)
Acupuncture + TKM treatment	41 (59.4)
Acupuncture + Western medical treatment	2 (2.9)
Electroacupuncture + TKM treatment	2 (2.9)
Electroacupuncture + Western medical treatment	1 (1.5)
Warm needle acupuncture + TKM treatment	1 (1.5)
Warm needle acupuncture + Western medical treatment	0
Total	69

TKM	N (%)
Moxibustion	2 (4.5)
Chuna	10 (22.7)
Herbal medicine	6 (13.6)
Complex TKM treatment	26 (59.1)
Total	44 (100)

Acupoints	N
BL40	24
EX-B2	21
GB30	20
BL25	19
BL23	17
GB34	16
BL54	13
BL60	10
BL26	7
BL24	6
BL56	6
BL37	6
GB31	5
ST36	4
GV3	4
BL57	4
Ashi point	3
GB40	3
BL32	2
LR3	2
KI3	2
BL62	2
KI16	2
BL22	1
BL31	1
BL33	1
BL34	1
GV4	1
SP9	1
GB36	1
BL27	1
LR13	1
BL63	1
GB37	1

Outcome domains	Study Number	Scales (N)
Pain	52	VAS (43), PRI (6), NRS (4), SF-MPQ (2), PPI (1)
Effective rate	35	GPE (35)
Back specific dysfunction	18	ODI (13), JOA scale (6),
Quality of life	13	EQ-5D (1), SF-36 (1)