Evaluating the Characteristics, Reporting and Methodological Quality of Systematic Reviews of Acupuncture for Low Back Pain by Using the Veritas Plot

Figures & data

Figure 1 The literature retrieval and screening process.

Table 1 Descriptive Characteristics of the Included Systematic Reviews

Author (Data)/Country	Patient Population	Number of RCTs Included (Patients)	Intervention Study		Quality of Original Studies Scale/Level	Main Results (Meta-Analysis)	Author’s Main Conclusions
			Intervention Group	Control Group
Furlan (2012)/Canada^Citation28	LBP	15 (3982)	SMT, Acupuncture, Massage, Mobilization	No treatment, Physical therapy (exercise and/or electrotherapy), Usual care immediately or at short-term follow-up	Cochrane risk of bias tool/Low	Acupuncture vs Inactive treatment 1. Short-term posttreatment pain intensity [pooled VAS=−1.19 (95% CI −2.17, −0.21)] 3 RCTs	Subjects with chronic nonspecific LBP receiving acupuncture had statistically significantly better short-term posttreatment pain intensity and less immediate-term functional disability Subjects with acute/subacute nonspecific LBP, acupuncture did not significantly differ from placebo on pain or disability outcomes
						2. Immediate-posttreatment follow up pain intensity [pooled VAS=−0.59 (95% CI −0.9, −0.25)] 10 RCTs
Rubinstein (2010)/The Netherlands^Citation29	NSCLBP	35 (8298)	SMT, Acupuncture, Herbal medicine	Sham, Placebo, Passive Modalities	Cochrane risk of bias tool/Low	Acupuncture vs No treatment or Waiting list control	Acupuncture provides a short-term clinically relevant effect when compared with a waiting list control or when acupuncture is added to another intervention.
						1.1 Pain [MD=−24.10 (95% CI −31.52, −16.68)] 1 RCT
						1.2 Disability [SMD=−0.61 (95% CI −0.90, −0.33)] 1 RCT
						2. Acupuncture vs Sham/Placebo/Passive modalities
						2.1 Pain at 3 months [MD=−7.81 (95% CI −12.66, −1.89)] 4 RCTs
						2.2 Disability at 3months [SMD=−0.28 (95% CI −0.41, −0.16)]3 RCTs
						2.3 Recovery at 3 months [RR=3.53 (95% CI 0.91, 13.62)] 1 RCT
						3. Acupuncture plus an intervention vs Intervention alone
						3.1 Pain at 3 months [MD=−16.91 (95% CI −25.18, −8.61)] 3 RCTs
						3.2 Disability at 3months [SMD=−0.66 (95% CI −0.74, −0.58)] 4 RCTs
						3.3 Recovery at 3 months [RR=5.90 (95% CI 1.96, 17.70)] 1 RCT
						4. Acupuncture vs Any other intervention
						4.1 Pain at 3 months [MD=−9.40 (95% CI −12.13, −6.67)] 1 RCT
						4.2 Disability at 3months [SMD=−0.64 (95% CI −0.79, −0.49)] 1 RCT
Lee (2013)/Korea^Citation30	Acute LBP	11 (1139)	Acupuncture	Nonsteroidal anti inflammatory drugs, Medication, Sham acupuncture	Cochrane risk of bias tool/Low	Acupuncture vs Medication Overall improvement [RR=1.11 (95% CI 1.06, 1.16), p<0.001, I^2=0%] 5 RCTs	Acupuncture may be more effective than medication for symptom improvement or relieve pain better than sham acupuncture in acute LBP.
						2. Acupuncture vs Sham acupuncture Pain intensity [MD=−9.38 (95% CI −17.00, −1.76), p=0.02, I^2=27%] 2 RCTs
Ernst (1998)/England^Citation31	LBP	12 (472)	Acupuncture	Sham (placebo) acupuncture	Jadad scale/Low	Acupuncture vs Control intervention Pain intensity [OR=2.30 (95% CI 1.28, 4.13)] 9 RCTs	Acupuncture was shown to be superior to various control interventions, although there is insufficient evidence to state whether it is superior to placebo.
						2. Acupuncture vs Sham-controlled, Evaluator-blinded studies Pain intensity [OR=1.37 (95% CI 0.84, 2.25)] 4 RCTs
Xu (2013)/China^Citation32	CLBP	13 (2678)	Acupuncture	Sham acupuncture, Conventional care, Other alternative therapies	Cochrane risk of bias tool/Low	Acupuncture vs Blank treatments, Sham acupuncture and Other treatments Pain intensity [SMD=−0.43 (95% CI −0.61, −0.21), I^2=85%] 18 RCTs	Acupuncture achieved better outcomes when compared with other treatments.
						2. Disability as a result of pain [SMD=−0.43 (95% CI −0.66, −0.21), I^2=72.3%] 12 RCTs
						3. Spinal flexion [SMD=−0.15 (95% CI −0.63, 0.34), I^2=77.4%] 5 RCTs
						4. Quality of life [SMD=0.47 (95% CI 0.15, 0.78), I^2=85.1%] 5 RCTs
Vickers (2018)/America^Citation33	CLBP	39 (20827)	Acupuncture	Sham (placebo) acupuncture, No-acupuncture	None	Acupuncture vs Sham acupuncture Pain intensity [SD=0.30 (95% CI 0.21, 0.38)] 10 RCTs	Acupuncture is effective for the treatment of chronic pain, with treatment effects persisting over time.
						2. Acupuncture vs No-acupuncture control Pain intensity [SD=0.54 (95% CI 0.50, 0.57)] 12 RCTs
Vickers (2012)/America^Citation34	CLBP	31 (17922)	Acupuncture	Sham (placebo) acupuncture, No-acupuncture	None	Acupuncture vs Sham acupuncture Pain intensity [SD=0.37 (95% CI 0.27, 0.46)] 8 RCTs	Acupuncture is effective for the treatment of chronic pain.
						2. Acupuncture vs No-acupuncture control Pain intensity [SD=0.55 (95% CI 0.51, 0.58)] 7 RCTs
Trigkilidas (2010)/UK^Citation35	CLBP	4 (NR)	Acupuncture	Usual care treatment	None	Qualitative description only	Acupuncture could be effective in managing patients with LBP.
Machado (2009)/Australia^Citation36	NSLBP	76 (6865)	Acupuncture	Placebo treatment, Sham treatment	Cochrane risk of bias tool/Low	Qualitative description only	Acupuncture has a clinically relevant, persistent effect on chronic pain that is not completely explained by placebo effects.
Keller (2007)/Norway^Citation37	LBP	41 (NR)	TENS, Nonsteroidal anti inflammatory drugs, Manipulation, Acupuncture, Behavioral therapy, Exercise therapy	Placebo treatment, Sham treatment, No-treatment	Cochrane risk of bias tool/Low	Acupuncture vs Sham acupuncture or No treatment Pain intensity [SMD=0.61 (95% CI 0.41, 0.81), I^2=0%] 7 RCTs	The effect of treatments for LBP is only small to moderate. there is a dire need for developing more effective interventions.
Yuan (2008)/Northern Ireland^Citation38	NSLBP	23 (6359)	Acupuncture (follow the STRICTA guidelines)	Therapy other than acupuncture	Van Tulder scale/Low	Qualitative description only	Acupuncture versus no treatment, and as an adjunct to conventional care, should be advocated.
Manheimer (2005)/USA^Citation39	LBP	33 (2214)	Acupuncture	Sham acupuncture, No treatment, Conventional therapy, Manipulation	1997 CBRGC and Jadad scale/Low	Acupuncture vs Sham acupuncture	Acupuncture effectively relieves chronic low back pain, but evidence about acupuncture’s effectiveness compared with other active treatments or for patients with acute back pain is inconclusive.
						Short-term effects of acupuncture on pain [SMD=0.58 (95% CI 0.36, 0.80)] 4 RCTs
						2. Long-term effects of acupuncture on pain [SMD=0.59 (95% CI −0.10, 1.29)] 2 RCTs
Ammendolia (2008)/Canada^Citation40	CLBP	19 (5001)	Acupuncture	Waiting list, Conventional therapy, Sham therapy	2003 CBRGC/Low	Qualitative description only	When compared with no treatment, there is evidence that acupuncture is effective in pain relief and functional improvement immediately after a series of treatment sessions and in the short-term follow-up.
Hutchinson (2012)/UK^Citation41	NSCLBP	7 (13874)	Acupuncture	TENS, Minimal (sham) acupuncture, Conventional treatment, Placebo No treatment	None	Qualitative description only	Acupuncture as more effective than no treatment.
Lam (2013)/Republic of Ireland^Citation42	NSCLBP	25 (5709)	Acupuncture	SMT, TENS, Medication, Physiotherapy, Exercise, A sham intervention	Cochrane risk of bias tool/Low	Acupuncture vs No treatment	Acupuncture may have a favorable effect on self -reported pain and functional limitations on NSCLBP.
						1.1 Pain Post-Intervention [SMD=−0.72 (95% CI −0.94, −0.49), I^2=51%] 5 RCTs
						1.2 Disability Post-Intervention [SMD=−0.94 (95% CI −1.41, −0.47), I^2=78%] 5 RCTs
						2. Acupuncture vs Medication (NSAIDs, muscle relaxants and analgesics)
						2.1 Pain Post-Intervention [MD=−10.56 (95% CI −20.34, −0.78), I^2=0%] 3 RCTs
						2.2 Activity limitation[SMD=−0.36 (95% CI −0.67, −0.04), I^2=7%] 3 RCTs
						3. Acupuncture vs Sham acupuncture
						3.1 Pain Post-intervention [MD=−16.76 (95% CI −33.33, −0.19), I^2=90%] 4 RCTs
						3.2 Pain Follow-up [MD=−9.55 (95% CI −16.52, −2.58), I^2=40%] 3 RCTs
						4. Acupuncture in addition to usual-care vs Usual-care
						4.1 Pain Post-intervention [MD=−13.99 (95% CI −20.48, −7.50), I^2=34%] 4 RCTs
						4.2 Pain Follow-up [MD=−12.91 (95% CI −21.97, −3.85), I^2=63%] 4 RCTs
						4.3 Disability Post-intervention [SMD=−0.87 (95% CI −1.61, −0.14), I^2=71%] 3 RCTs
						4.4 Disability Follow-up [SMD=−0.51 (95% CI −0.91, −0.12), I^2=0%] 2 RCTs
						5. Electro-acupuncture vs Self-care or Usual-care
						5.1 Pain Post-intervention [SMD=−1.39 (95% CI −2.37, −0.41), I^2=92%] 5 RCTs
						5.2 Pain Follow-up [SMD=−0.66 (95% CI −1.17, −0.15), I^2=66%] 4 RCTs
Johnston (2008)/Canada^Citation43	LBP	12 (NR)	SMT, Electro-acupuncture (High frequency), Moxibustion, Deep acupuncture, Electrical stimulation of auricular acupuncture points	TENS, SMT, Electro acupuncture (low frequency), Moxibustion	None	Qualitative description only	Investigators designing acupuncture or SMT trials should consider expertise-based randomization to increase the validity and feasibility of their efforts.
Liang (2016)/China^Citation44	LBP	10 (751)	Acupuncture, Needle warming moxibustion	Sham acupuncture, Traction therapy, Medication, Massage, Epidural injection	Cochrane risk of bias tool/Low	Acupuncture vs No-acupuncture control	Pure acupuncture may have a favorable effect on self reported pain and functional limitations in LBP patients.
						JOA [MD=2.83 (95% CI −1.17, −0.15), I^2=0%] 3 RCTs
						2. ODI [MD=−5.07 (95% CI −7.50, −2.65), I^2=0%] 2 RCTs
						3. VAS [MD=−1.32 (95% CI –1.41, −1.22), I^2=0%] 8 RCTs
						4. RMDQ [MD=−2.80 (95% CI −3.49, −2.11), I^2=0%] 2 RCTs
Xiang (2018)/China^Citation45	NSCLBP	7 (1768)	Acupuncture with or without electroacupuncture	Conventional treatment, Standard therapy, Routine care, Waiting list	Cochrane risk of bias tool/Low	Sham acupuncture/Placebo acupuncture vs Routine care or Waiting list	Sham acupuncture or placebo acupuncture was more efficacious for pain relief post-intervention. Concluding that SA or PA is appropriate for acupuncture research would be premature.
						1. Pain (VAS) [SMD=−0.36 (95% CI −0.52, −0.20), I^2=16%] 6 RCTs
						2. Pain (CPGS) [SMD=−0.35 (95% CI −0.49, −0.20)] 1 RCT
						3. Disability (RMDQ) [SMD=0.11 (95% CI −0.78, 1.00), I^2=94%] 3 RCTs
						4. Disability (PDI) [SMD=−0.42 (95% CI −0.90, 0.05), I^2=66%] 2 RCTs
						5. Disability (ODI) [SMD=−0.30 (95% CI −0.69, 0.10), I^2=16%] 1 RCT
Furlan (2005)/Canada^Citation46	Acute/subacute or chronic nonspecific LBP.	35 (2861)	Acupuncture or dry-needling	No treatment, Placebo/Sham acupuncture or Other sham procedure, and Other therapeutic interventions	Cochrane risk of bias tool/Low	Qualitative description only	Acupuncture and dry-needling may be useful adjuncts to other therapies for chronic low back pain.

Abbreviations: LBP, low back pain; CLBP, chronic low back pain; NSLBP, non-specific low back pain; NSCLBP, non-specific chronic low back pain; TENS, transcutaneous electrical nerve stimulation; SMT, spinal manipulative therapy; CBRGC, Cochrane Back Review Group Criteria; UK, the United Kingdom; USA, United States of America; SD, standard difference; MD, mean difference; SMD, standard mean difference; MWD, mean weighted difference; CPGS, Chronic Pain Grade Scale; ODI, Oswestry Disability Index; PDI, Pain Disability Index; RMDQ, Roland-Morris Disability Questionnaire; OR, the odds ratio; RR, the risk ratio; 95% CI, 95% confidence interval; NR, not recorded.

Table 2 Multivariate Evaluation and Rank Number in 6 Dimensions of the Included Literature

Study or Subgroup	Year of Publication	Type of Included Studies	AMSTAR 2 Score	PRISMA Score	Homogeneity	Publication Bias	Average Score of Rank Number
Furlan^Citation28	2012 [13]	RCT + CCT [1]	8.5 [11]	25.5 [19]	2.265[16]	Assessed [Egger’s test] [19]	13.17
Rubinstein^Citation29	2010 [10]	RCT [19]	9 [14]	17.5 [9]	0 [12]	Not assessed [16]	13.33
Lee^Citation30	2013 [16]	RCT [19]	9 [14]	20.5 [16]	3 [19]	Not assessed [16]	16.67
Ernst^Citation31	1998 [1]	RCT [19]	3.5 [2]	15.5 [5]	0 [12]	Assessed [Funnel plot] [19]	9.67
Xu^Citation32	2013 [16]	RCT [19]	10 [16]	20 [13]	2 [13]	Assessed [Begg’s test] [19]	16.00
Vickers^Citation33	2017 [18]	RCT [19]	5 [5]	14 [2]	0 [12]	Not assessed [16]	12.00
Vickers^Citation34	2012 [13]	RCT [19]	10.5 [17]	21.5 [17]	0 [12]	Not assessed [16]	15.67
Trigkilidas^Citation35	2010 [10]	RCT [19]	4.5 [4]	14 [2]	0 [12]	Not assessed [16]	10.50
Machado^Citation36	2009 [8]	RCT [19]	7.5 [10]	18.5 [10]	0 [12]	Not assessed [16]	12.50
Keller^Citation37	2007 [4]	RCT [19]	4 [3]	14.5 [3]	2.5 [17]	Not assessed [16]	10.33
Yuan^Citation38	2008 [7]	RCT [19]	9 [14]	16.5 [7]	0 [12]	Not assessed [16]	12.50
Manheimer^Citation39	2005 [3]	RCT [19]	6 [7]	23.5 [18]	0 [12]	Not assessed [16]	12.50
Ammendolia^Citation40	2008 [7]	RCT [19]	6.5 [8]	15 [4]	0 [12]	Not assessed [16]	11.00
Hutchinson^Citation41	2012 [13]	RCT [19]	3.5 [1]	20 [13]	0 [12]	Not assessed [16]	12.33
Lam^Citation42	2013 [16]	RCT [19]	11.5 [19]	20 [13]	2.09 [14]	Not assessed [16]	16.17
Johnston^Citation43	2008 [7]	RCT [19]	6 [7]	16 [6]	0 [12]	Not assessed [16]	11.17
Liang^Citation44	2016 [17]	RCT [19]	9.5 [15]	20.5 [16]	3 [19]	Not assessed [16]	17.00
Xiang^Citation45	2018 [19]	RCT [19]	9.5 [15]	20.5 [16]	2.25 [15]	Not assessed [16]	16.67
Furlan^Citation46	2005 [3]	RCT [19]	7 [9]	17.5 [9]	0 [12]	Not assessed [16]	11.33
Average score of rank number	10.58	18.05	10.05	10.42	13.53	16.47	13.18

Note: Square brackets indicate the score of Veritas.

Figure 2 The Veritas plots.

Table 3 Multivariate Linear Regression Analysis for Variables Associated with Better AMSTAR2 Score (n = 19)

Variables	B	S.E	t	p	95% CI
Constant	4.197	0.289	14.528	<0.001	3.568~4.826
Literature selected	1.483	0.544	2.729	0.018	0.299~2.668
Appropriate tools to assess the risk of bias	2.262	0.606	3.732	0.003	0.941~3.582

Abbreviation: S.E, standard error.

Table 4 Multivariate Linear Regression Analysis for Variables Associated with Better PRISMA Score (n = 19)

Variables	B	S.E	t	p	95% CI
Constant	7.594	2.455	3.093	0.013	2.040~13.148
Summary of evidence	6.993	2.458	2.845	0.019	1.433~12.533

Abbreviation: S.E, standard error.

Table 5 Quality of Evidence of the Included Systematic Reviews

First Author	Study Type	Outcome Indicator	Degradation Factors					Upgrade Factors	Quality of Evidence
			Risk of Bias	Inconsistency	Indirection	Inaccuracy	Publication Bias
Furlan^Citation28	RCT+CCT	VAS	−1	0	0	0	0	0	Low
		ODI	−1	0	0	−1	−1	0	Very Low
		RMDQ	−1	0	0	−1	−1	0	Very Low
Rubinstein^Citation29	RCT	RMDQ	0	0	0	0	−1	0	Moderate
		HFAQ	0	0	0	−1	−1	0	Low
		PDI	0	0	0	0	−1	0	Moderate
Lee^Citation30	RCT	VAS	0	0	0	0	0	0	High
		RMDQ	0	0	0	−1	0	0	Moderate
Ernst^Citation31	RCT	VAS	0	−1	0	0	−1	0	Low
Xu^Citation32	RCT	VAS	−1	−1	0	0	0	0	Low
		RMDQ	−1	0	0	0	0	0	Moderate
		PDI	−1	0	0	0	0	0	Moderate
		Aberdeen Low Back Pain Scale	−1	0	0	−1	0	0	Low
		ODI	−1	0	0	0	0	0	Moderate
		Fingertip-To-Floor Distance	−1	0	0	0	−1	0	Low
		Range of Movement of Spinal Flexion	−1	0	0	0	−1	0	Low
		SF-12	−1	−1	0	0	−1	0	Very Low
		SF-36	−1	−1	0	0	−1	0	Very Low
Vickers^Citation33	RCT	Time Course of Acupuncture Effects	−1	0	0	0	−1	0	Low
Vickers^Citation34	RCT	VAS	−1	0	0	0	−1	0	Low
Trigkilidas^Citation35	RCT	RMDQ	−1	0	0	0	−1	0	Low
		Bothersomeness	−1	0	0	0	−1	0	Low
		SF-36	−1	0	0	0	−1	0	Low
		VAS	−1	0	0	0	−1	0	Low
Machado^Citation36	RCT	Analgesic efficacy (100-point scale)	−1	0	0	0	−1	0	Low
Keller^Citation37	RCT	PDI	−1	0	0	0	−1	0	Low
Yuan^Citation38	RCT	PDI	0	0	0	0	−1	0	Moderate
Manheimer^Citation39	RCT	VAS	−1	0	0	0	−1	0	Low
		RMDQ	−1	0	0	0	−1	0	Low
Ammendolia^Citation40	RCT	PDI	−1	0	0	0	−1	0	Low
Hutchinson^Citation41	RCT	SF-36	−1	0	0	0	−1	0	Low
		HFAQ	−1	0	0	0	−1	0	Low
		Low Back Pain Rating Scale	−1	0	0	0	−1	0	Low
		Von Korff chronic pain scale	−1	0	0	0	−1	0	Low
		SF-12	−1	0	0	0	−1	0	Low
		RMDQ	−1	0	0	0	−1	0	Low
		Pain Disability Index	−1	0	0	0	−1	0	Low
		ODI	−1	0	0	0	−1	0	Low
		McGill Present Pain Index	−1	0	0	0	−1	0	Low
		Low Back Pain Rating Scale	−1	0	0	0	−1	0	Low
Lam^Citation42	RCT	VAS	−1	−1	0	0	−1	0	Very Low
		PDI	−1	−1	0	0	−1	0	Very Low
		RMDQ	−1	−1	0	0	−1	0	Very Low
Johnston^Citation43	RCT	None
Liang^Citation44	RCT	JOA	−1	0	0	0	−1	0	Low
		ODI	−1	0	0	0	−1	0	Low
		VAS	−1	0	0	0	−1	0	Low
		RMDQ	−1	0	0	0	−1	0	Low
Xiang^Citation45	RCT	VAS	−1	−1	0	0	0	0	Low
		RMDQ	−1	0	0	0	−1	0	Low
		ODI	−1	0	0	−1	−1	0	Very Low
		PDI	−1	−1	0	0	−1	0	Very Low
Furlan^Citation46	RCT	VAS	−1	0	0	−1	−1	0	Very Low

Abbreviations: VAS, Visual Analogue Scale; ODI, Oswestry Disability Index; RMDQ, Roland-Morris Disability Questionnaire; HFAQ, Hannover Functional Ability Questionnaire; PDI, Pain Disability Index; JOA, Japanese Orthopaedic Association Scores.

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