Rehabilitation Effects of Acupuncture on the Diaphragm Dysfunction in Chronic Obstructive Pulmonary Disease: A Systematic Review

Figures & data

Table 1 The Physiotherapy Evidence Database Scale

1. Eligibility criteria were specified	No	Yes
2. Subjects were randomly allocated to groups (in a crossover study, subjects were randomly allocated an order in which treatments were received)	No	Yes
3. Allocation was concealed	No	Yes
4. The groups were similar at baseline regarding the most important prognostic indicators	No	Yes
5. There was blinding of all subjects	No	Yes
6. There was blinding of all therapists who administered the therapy	No	Yes
7. There was blinding of all assessors who measured at least one key outcome	No	Yes
8. Measures of at least one key outcome were obtained from more than 85% of the subjects initially allocated to groups	No	Yes
9. All subjects for whom outcome measures were available received the treatment or control condition as allocated or, where this was not the case, data for at least one key outcome was analysed by “intention to treat”	No	Yes
10. The results of between-group statistical comparisons are reported for at least one key outcome	No	Yes
11. The study provides both point measures and measures of variability for at least one key outcome	No	Yes

Table 2 Characteristics of Studies Included in This Review

First Author(Year)	Patients	Intervention		Outcome
		Observation Group	Control Group	Diaphragm Function	Pulmonary Function	Arterial Blood Gases
Deng YQ (2019)^Citation22	GOLD II–III, stable COPD	Warming acupuncture+ Standard therapy+ Rehabilitation training (n=45)	Standard therapy+ Rehabilitation training (n=45)	MIP^#	FVC^#	PaO2^# PaCO2^#
Suzuki M (2012)^Citation23	GOLD II–IV, stable COPD	Filiform needle acupuncture+ Standard therapy (n=34)	Sham acupuncture+ Standard therapy (n=34)	MIP^#	FVC^# FEV1%pred^#	PaO2^†
Xu YG (2008)^Citation24	GOLD III, stable COPD	Big-needle acupuncture + Standard therapy (n=20)	Filiform needle group: Filiform needle acupuncture+ Standard therapy (n=20)	MIP*^#	/	/
			Blank group: Standard therapy (n=20)
Lin LJ (2015)^Citation25	Stable COPD	Warming acupuncture+ Chinese materia medica+ Standard therapy (n=40)	Standard therapy (n=40)	MIP*^#	FEV1*^# FVC%*^# FEV1/FVC*^#	/
Wu LL (2019)^Citation26	GOLD II–IV	Filiform needle acupuncture+ Shenmai injection + Standard therapy (n=46)	Standard therapy (n=45)	DE*^# D-RSBI*^# DTF*^# DE/TPIAdia*^#	/	PaO2*^# PaCO2*^#
Guan W (2016)^Citation16	AECOPD	Abdominal acupuncture+ Standard therapy (n=33)	Standard therapy (n=34)	ARMM	FEV1/FVC**^## FEV1%pred**^## MVV%**^##	PaO2**^## PaCO2**
Wang Y (2020)^Citation27	AECOPD	Abdominal acupuncture+ Standard therapy (n=50)	Standard therapy (n=50)	ARMM*^#	FEV1/FVC** MVV%**	PaO2**^## PaCO2*
Wang JY (2015)^Citation17	AECOPD	Filiform needle acupuncture + Standard therapy (n=32)	Standard therapy (n=31)	MIP**^##	FVC^## FEV1/FVC MVV**^##	PaO2**^# PaCO2*
Cheng YY (2017)^Citation28	AECOPD	Abdominal acupuncture+ Standard therapy (n=34)	Standard therapy (n=34)	ARMM*^#	VC%* FEV1/FVC*^# FEV1%pred*^# MVV%*	PaO2* PaCO2*

Notes: /, not reported; *Compare the data between post-intervention and pre-intervention in the observation group, P value < 0.05; ^#Compare the post-intervention data between observation group and control group, P value < 0.05; **Compare the data between post-intervention and pre-intervention in the observation group, P value < 0.01; ^##Compare the post-intervention data between observation group and control group, P value < 0.01; ^†Compare the changes from baseline to post-intervention data between the observation group and the control group, P value < 0.05.

Abbreviations: ARMM, the scale for accessory respiratory muscle mobilization; DE, diaphragmatic excursion; DTF, diaphragm thickening fraction; DE/TPIA_dia, diaphragm contraction speed; FVC, forced vital capacity; FEV1, forced expiratory volume in one second; FEV1%pred, forced expiratory volume in one second/prediction; FEV1/FVC%, FEV1/FVC ratio; MIP, maximal inspiratory pressure; MVV, maximal voluntary ventilation; PaO₂, arterial partial pressure of oxygen; PaCO₂, arterial partial pressure of carbon dioxide; D-RSBI, diaphragmatic-rapid shallow breathing index; VC, vital capacity.

Figure 1 Systematic search flowchart.

Table 3 PEDro Rating for Trials Included

Trials	Eligibility Criteria	Random Allocation	Concealed Allocation	Baseline Similar	Blinding (Subject)	Blinding (Therapist)	Blinding (Assessor)	Measures >85%	ITT	Group Comparison	Point Measures	PEDro Score
Wang JY^Citation17	Yes	1	0	1	0	0	0	1	1	1	1	6
Deng YQ^Citation22	Yes	1	0	1	0	0	0	1	1	1	1	6
GuanW^Citation16	Yes	1	0	1	0	0	1	1	1	1	1	7
Suzuki M^Citation23	Yes	1	1	1	1	0	0	1	1	1	1	8
WangY^Citation27	Yes	1	0	1	0	0	0	1	1	1	1	6
Xu YG^Citation24	Yes	1	0	1	0	0	0	1	1	1	1	6
Lin LJ^Citation25	Yes	1	0	1	0	0	0	1	1	1	1	6
Wu LL^Citation26	Yes	1	0	1	0	0	0	1	1	1	1	6
Cheng YY^Citation28	Yes	1	0	1	0	0	0	1	1	1	1	6

Note: 1, PEDro criteria met; 0, PEDro criteria not met.

Abbreviation: ITT, intention-to-treat analysis.

Table 4 Characteristics of Acupuncture Schemes of Included Study for Diaphragm Dysfunction in COPD

First Author(Year)	Acupoints	Type of Acupuncture	Stimulation Time	Acupuncture Frequency	Treatment Duration
Deng YQ (2019)^Citation22	BL13, BL23, BL12, BL43, CV17, EX-B1, ST36, LU7, LU5, ST40, SP10	Warming acupuncture	3–4 Zhuang	5 times a week	/
Suzuki M (2012)^Citation23	LU1, LU9, ST32, CV4, CV12, ST36, KI3, SI4, BL13, BL20, BL23	Filiform needle acupuncture	50 min	Once a week	12 weeks
Xu YG (2008)^Citation24	CV17	Big-needle acupuncture	4 h	5 times a week	4 weeks
		Filiform needle acupuncture	30 min
Lin LJ (2015)^Citation25	ST36, CV6, BL13, BL20, BL23, EX-B1	Warming acupuncture	5 Zhuang	Once a day	8 weeks
Wu LL (2019)^Citation26	BL21, BL20, BL23, BL13, LU9, KI3, ST36	Filiform needle acupuncture	30 min	Once pre 12 h	/
Guan W (2016)^Citation16	CV12, CV10, CV6, CV4, ST24, ST25, SP15, GB26	Abdominal acupuncture	30 min	Once a day for the first 3 days; once every other day for the next 11days	14 days
Wang Y (2020)^Citation27	CV12, CV10, CV4, ST25, GB26, SP15	Abdominal acupuncture	18 min	/	2 weeks
Wang JY (2015)^Citation17	ST36, ST40, SP6, SP15, CV12, CV13, CV6, CV4, LU9, LU5, LU6, EX-B1	Filiform needle acupuncture	30 min	Once a day	40 days
Cheng YY (2017)^Citation28	CV12, CV10, CV6, CV4, ST24, ST25, SP15, GB26	Abdominal acupuncture	30 min	Once a day for the first 3 days; once every other day for the next 11days	7days

Note: /, not reported.

Figure 2 High-frequency selected acupoints.

Notes: a, Yangming Stomach Meridian of Foot; ①, ST36; b, Ren Meridian; ②, CV2; ③, CV6; ④, CV4; c, Taiyin Spleen Meridian of Foot; ⑤, SP15; d, Taiyang Bladder Meridian of Foot; ⑥, BL13; ⑦, BL23.

Figure 3 Mechanism of acupuncture on diaphragm dysfunction in COPD.

Notes: On the one hand, acupuncture inhibits UPS activity by downregulating proinflammatory factors or reduce ROS production by upregulating NADPH oxidase and respiratory chain complexes in mitochondrial to regulate the inflammatory response and oxidative stress on diaphragm protein degeneration and damage; on the other hand, acupuncture may reduce neural respiratory drive by regulating OX content to affect diaphragm activity.

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