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The effect of acupuncture used for cervical
spondylosis of vertebral artery type
A protocol for systematic review and meta-analysis
Jinxian Lu, MM
a
, Quanmei Song, MM
a
, Yongzheng Zhu, MD
b
, Hongling Jia, MD
b
, Yongchen Zhang, MD
a,∗
Abstract
Background: Cervical spondylosis of vertebral artery type is a common clinical disease. With the change of people’s lifestyle and
the improvement of people who work at desks, its incidence is also increasing, which can seriously affect people’s normal life and
work. Acupuncture has been gradually accepted and recognized by the public for its green, simple and safe characteristics. In this
systematic review, we aimed to evaluate the effect and safety for patients with cervical spondylosis of vertebral artery type to provide
evidence for clinical decision making.
Methods: We will search the following 8 databases from their inception to November 2021: Web of Science, the Cochrane Library,
PubMed, Embase, Chinese Biomedicine, China National Knowledge Infrastructure, Chinese Scientific Journals Database, and the
WanFang Database. All relevant randomized controlled trials (RCTs) that meet the inclusion criteria will be included in our analysis.
Literature screening, data extraction and literature quality assessment will be carried out in a step. Data analysis will be performed
using RevMan 5.4 software.
Results: Based on the results of this study, we will evaluate the safety and effectiveness of acupuncture in the treatment of vertebral
artery type cervical spondylosis.
Conclusion: This study will provide strong evidence-based medical evidence for acupuncture in treating cervical spondylosis of
vertebral artery type.
PROSPERO registration number: CRD42021293053.
Abbreviations: CSA =cervical spondylosis of vertebral artery type, RCTs =randomized controlled trials.
Keywords: acupuncture, cervical spondylosis of vertebral artery type, meta-analysis, protocol
1. Introduction
Cervical spondylosis of vertebral artery type (CSA) is a clinical
syndrome in which vertebral-basal artery blood supply is
insufficient due to degenerative changes of the cervical spine.
[1,2]
The clinical manifestations are mainly cervical vertigo, which
may be accompanied by a series of symptoms such as dizziness,
headache, insomnia, tinnitus, blurred vision, nausea, vomiting,
neck and shoulder or occipital neck pain, and even cataplexy.
[3,4]
Its incidence increases with age,
[5]
most of which occur in middle-
aged and elderly people.
[6]
In recent years, with the acceleration
of people’s life rhythm and the increase in the proportion of desk
staff, its incidence has increased year by year and tends to be
younger. It accounts for about 20% of cervical spondylosis.
[7,8]
There are many clinical treatment therapies for CSA,
[9]
with
differences and similarities in methods and efficacy. Due to its
long course of disease, slow onset and high recurrence rate,
treatment is difficult.
[10]
Western medicine mainly uses nonsur-
gical treatment and surgical treatment. The high risk and trauma
of surgery make conservative treatment the first choice for most
patients.
[11]
Although the former has a certain treatment effect,
the long-term effect is poor,
[12]
adverse reactions may occur, and
the recurrence rate is high.
[13]
Acupuncture, as one of the external treatments of Chinese
medicine, has always been valued and recognized by many
physicians. Acupuncture has the functions of dredging the
meridians, regulating qi and blood. It can not only improve
the symptoms of local insufficiency of blood supply and control
the course of the disease, but also alleviate the suffering of
patients.
[14,15]
Relevant studies
[16–19]
have shown that acupunc-
ture can bring vitality to the diseased place by strengthening the
body and removing evils, eliminate the adhesion and edema
This work was supported by the Natural Science Foundation of Shandong
Province (No. ZR2019MH079).
The authors have no conflicts of interest to disclose.
Data sharing not applicable to this article as no datasets were generated or
analyzed during the current study.
a
College of Acupuncture and Massage, Shandong University of Traditional
Chinese Medicine, Jinan, Shandong, China,
b
Department of Acupuncture, The
Second Affiliated Hospital of Shandong University of Traditional Chinese
Medicine, Jinan, Shandong, China.
∗
Correspondence: Yongchen Zhang, College of Acupuncture and Massage,
Shandong University of Traditional Chinese Medicine, No. 16369 Jingshi Road,
Jinan, Shandong 250014, China (e-mail: zhangyc58@sina.com).
Copyright ©2022 the Author(s). Published by Wolters Kluwer Health, Inc.
This is an open access article distributed under the Creative Commons
Attribution License 4.0 (CCBY), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
How to cite this article: Lu J, Song Q, Zhu Y, Jia H, Zhang Y. The effect of
acupuncture used for cervical spondylosis of vertebral artery type: a protocol for
systematic review and meta-analysis. Medicine 2022;101:8(e28956).
Received: 10 February 2022 / Accepted: 11 February 2022
http://dx.doi.org/10.1097/MD.0000000000028956
Study Protocol Systematic Review Medicine®
OPEN
1
between the local cervical nerves and surrounding tissues, and
improve the ischemic and hypoxic state. The clinical effect is
significant.
[20]
Therefore, Acupuncture therapy is widely used in
clinical practice, and its treatment methods are diverse. With its
advantages of small adverse reaction, good efficacy, quick effect,
simple operation and low cost,
[21]
it demonstrates irreplaceable
clinical superiority.
[22]
However, as a traditional Chinese
medicine treatment technique, the biggest problem of acupunc-
ture treatment is the existence of scientific clinical effect
certification. Most of the current studies only emphasizes the
influence of acupuncture treatment on the hemodynamics of
patients, but lacks the clinical efficacy and safety assessment.
[23]
In order to prove whether acupuncture therapy is really effective
for vertebral artery type cervical spondylosis, evidence-based
medicine should be adopted to summarize and analyze data with
high-quality RCTs, and evaluate its effectiveness and safety, so as
to provide evidence for clinical practice.
2. Methods
2.1. Study registration
The study has been registered in PROSPERO (https://www.crd.
york.ac.uk/prospero/). The approved registration number is
CRD42021293053. And it was built on the guidelines of
Preferred Reporting Items for Systematic Reviews and Meta-
Analysis Protocols.
[24]
2.2. Inclusion criteria for study selection
2.2.1. Types of studies. For RCTs on humans, language
restrictions were Chinese or English. Reviews, case reports,
animal experiments, mechanism studies, data mining, expert
clinical experience and nonrandomized controlled trials were
excluded.
2.2.2. Types of participants. The included studies should be
patients who have been clearly diagnosed with CSA, regardless of
gender, race, nationality, course of disease, and severity of
disease.
2.2.3. Types of interventions. The experimental group received
acupuncture-related therapies (including body acupuncture,
scalp acupuncture, electric acupuncture, ear acupuncture, fire
acupuncture, warm acupuncture, fast acupuncture, skin acu-
puncture, moxibustion, cupping, blood pricking, acupoint catgut
embedding) or combined with other treatments. No matter the
choice of acupoints, the amount of stimulation or the length of
treatment. The experimental group could receive the same basic
treatment as the control group. The control group received
conventional symptomatic treatment, drug treatment, placebo
acupuncture, sham acupuncture or no treatment. The control
group using acupuncture-related therapies or studies comparing
the effects of different acupuncture were excluded.
2.2.4. Types of outcome measures
2.2.4.1. Primary outcomes. The main outcome is the total
effective rate. The calculation formula is the number of cases in
the group (cured + markedly effective + improved)/total number
of cases in the group100%.
2.2.4.2. Secondary outcomes. Include visual analogue scale,
Evaluation Scale for Cervical Vertigo, hemodynamic indexes,
clinical symptom evaluation table and adverse reactions.
2.3. Data sources
2.3.1. Search strategy. The following databases will be
searched from their inception to November 2021: Web of
Science, the Cochrane Library, PubMed, Embase, Chinese
Biomedicine, China National Knowledge Infrastructure, Chinese
Scientific Journals Database, and the WanFang Database.
The search strategy used Medical Subject Heading terms and
free words and then used Boolean logic operators to connect each
search item. In this study, we will take PubMed database
(Table 1.) as an example to show the retrieval strategy.
2.3.2. Searching for other resources. We will search for
ongoing or unpublished studies from ClinicalTrials.gov, PROS-
PERO, China Clinical Trials Registry, National Institutes of
Health Registry and World Health Organization International
Clinical Trials Registry. Manually retrieve any potential gray
literature such as conference papers, scientific research results
reports and related references.
2.4. Data collection and analysis
2.4.1. Selection of studies. All retrieved studies were imported
into Endnote X9.1 for management and duplicate documents
were removed. Two researchers (JXL and QMS) independently
screened the literature according to the inclusion and exclusion
criteria. After reading the title and abstract, the studies that did
not meet the requirements were deleted. Any problems arising
from the screening of the literature will be resolved by the 2
authors through consultation. If the opinions cannot be unified,
we will consult and discuss with the third party (YZZ) until
Table 1
Search strategy used in PubMed database.
Number Search terms
#1 acupuncture therapy [MeSH]
#2 acupuncture [Title/Abstract]
#3 acupuncture points[Title/Abstract]
#4 acupuncture treatment[Title/Abstract]
#5 acupuncture,ear[Title/Abstract]
#6 electroacupuncture[Title/Abstract]
#7 fire needle[Title/Abstract]
#8 warm acupuncture[Title/Abstract]
#9 blood-pricking[Title/Abstract]
#10 bloodletting[Title/Abstract]
#11 cupping[Title/Abstract]
#12 fast acupuncture[Title/Abstract]
#13 skin acupuncture[Title/Abstract]
#14 scalp acupuncture[Title/Abstract]
#15 catgut implantation at acupoint[Title/Abstract]
#16 auricular needle[Title/Abstract]
#17 acupuncture-moxibustion[Title/Abstract]
#18 body acupuncture[Title/Abstract]
#19 #1 OR #2 OR #3 OR #4 OR 5 #6 OR #7 OR #8 OR #9 OR #10
OR #11 OR #12 OR #13 OR #14 OR #15 OR #16 OR #17 OR #18
#20 vertebral artery cervical spondylopathy[Title/Abstract]
#21 cervical spondylosis of vertebral artery type[Title/Abstract]
#22 vertebral artery type of cervical spondylosis[Title/Abstract]
#23 cervical spondylotic vertebral arteriopathy[Title/Abstract]
#24 #20 OR #21 OR #22 OR #23
#25 Randomized controlled trial[Publication Type]
#26 placebo[Title/Abstract]
#27 randomized[Title/Abstract]
#28 #25 OR #26 OR #27
#29 #19 AND #24 AND #28
Lu et al. Medicine (2022) 101:8 Medicine
2
consensus is reached. The screening process of this study was
shown in the Figure 1.
2.4.2. Data extraction. Regarding the extraction of data, 2
researchers (JXL and QMS) need to independently extract and
check with each other. Any disputes should be resolved through
consultation with the third party (YZZ) and record the extracted
data with the Microsoft Excel 2010 table. The extracted content
included the first author, publication year, study type, age,
sample size, average course of disease, intervention measures for
the treatment group and control group, and the usage and dosage
of drugs, course of treatment and outcome indicators.
2.4.3. Dealing with missing data. For missing or ambiguous
data, we will contact the corresponding author via email or
phone for more detailed content and information. If there is no
reply, the relevant data and article will be excluded due to
incomplete access.
2.4.4. Risk of bias assessment. Two reviewers (JXL and QMS)
independently assessed the quality of RCTs with the “risk of bias
assessment tool”
[25]
recommended by Cochrane Handbook 5.1.0.
The Cochrane Risk of Bias Assessment Tool included 7 domains:
random sequence generation, allocation concealment, blinding of
participants and personnel, blinding of outcome assessment,
incomplete outcome data, selective reporting and other bias. They
made a judgment of low riskof bias, high risk of bias or unclear risk
of bias for each item. Disagreements were resolved through mutual
discussion or negotiation with the third party (YZZ).
2.4.5. Statistical analysis. RevMan 5.4 software provided by
the Cochrane Collaboration was used for data analysis and
synthesis. Choose different measurement indexes according to
different data types. Relative risk or odds ratio with 95%
confidence intervals was used for dichotomous outcomes, while
mean differences or standard mean differences (SMD) with 95%
confidence interval was used for continuous outcomes. Accord-
ing to heterogeneity test, fixed effect model or random effect
model must be selected for effect size combination. When P>.05
or I
2
<50%, fixed effect model was selected. When P<.05 or I
2
>50%, random effect model was selected. When quantitative
synthesis is not applicable, we will separately list the relevant
results and report them descriptively.
Figure 1. The PRISIMA flow diagram.
Lu et al. Medicine (2022) 101:8 www.md-journal.com
3
2.4.6. Sensitivity analysis. We would observe the robustness of
the single study to the overall meta-analysis results by eliminating
the literature one by one.
[26]
2.4.7. Subgroup analysis. We will conduct subgroup analysis
according to the following groups to explore the causes of
heterogeneity.
1. Length of treatment: The first group is 2 weeks, the second
group is 4 weeks.
2. Oral western medicine used in the treatment.
2.4.8. Assessment of reporting biases. If more than 10 studies
are finally included, we will use the funnel plot drawn by Revman
5.4 software to test whether the publication bias has occurred.
2.4.9. Quality of evidence. The quality of evidence will be
evaluated through the Grading of Recommendations Assessment,
Development and Evaluation approach.
[27]
There are 4 levels of
evidence: very low, low, medium or high.
3. Discussion
CSA involves a series of syndromes caused by the stimulation and
compression of cervical nerve roots, spinal cord, vertebral
arteries, and cervical sympathetic nerves.
[28]
Its pathogenesis is
complex, and some of the pathological mechanisms are not yet
fully understood. Vasospasm caused by mechanical compression
and vertebral artery sympathetic nerve stimulation is currently
recognized and the 2 main pathogenic factors influence each
other or cause each other.
[29]
But it is undeniable that
acupuncture has played an important role in reducing symptoms
and improving hemodynamics, which can better relieve the
discomfort of the patient’s head and neck.
High-quality meta-analyses/systematic evaluations are one of
the important sources of evidence-based medicine for obtaining
the best evidence and one of the best bases for clinical decision
making in acupuncture.
[30]
The conclusions of this study can
provide guidance for clinical acupuncture treatment of vertebral
artery type cervical spondylosis. Only by focusing on the quality
of methodology and the collection of large-sample, multi-center
high-quality RCTs, can the reliability and accuracy of meta-
analysis conclusions be better improved and the safety and
effectiveness of acupuncture treatment be objectively evaluated.
Author contributions
Investigation: Jinxian Lu.
Methodology: Jinxian Lu, Quanmei Song, Yongzheng Zhu.
Resources: Jinxian Lu, Yongzheng Zhu, Hongling Jia.
Software: Jinxian Lu, Quanmei Song.
Supervision: Hongling Jia, Yongchen Zhang.
Validation: Quanmei Song, Yongzheng Zhu.
Writing –original draft: Jinxian Lu.
Writing –review & editing: Yongchen Zhang.
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