Sciatica

Sciatique : évaluation de l'acupuncture

Articles connexes: - conduites thérapeutiques - pathologies - qigong - acupuncture expérimentale -

1. Systematic Reviews and Meta-Analysis

☆☆☆ Evidence for effectiveness and a specific effect of acupuncture.
☆☆ Evidence for effectiveness of acupuncture.
Evidence for effectiveness of acupuncture mais limitées qualitativement et/ou quantitativement.
Ø No evidence or insufficient evidence.

1.1. Generic Acupuncture

1.1.1. Ji 2015 ★★

Ji M, Wang X, Chen M, Shen Y, Zhang X, Yang J. The Efficacy of Acupuncture for the Treatment of Sciatica: A Systematic Review and Meta-Analysis. Evid Based Complement Alternat Med 2015;2015:192808. doi: 10.1155/2015/192808. [183273]

Purpose This study aims to assess the effectiveness of acupuncture therapy for sciatica.
Methods Comprehensive searches of 8 databases were conducted up until April 2015. Outcomes included effectiveness (proportion of patients who improved totally or partly in clinical symptoms), pain intensity, and pain threshold. Effect sizes were presented as risk ratio (RR) andmean difference (MD). Pooled effect sizes were calculated by fixed effects or randomeffects model.
Results A total of 12 studies (involving 1842 participants) were included. Results showed that acupuncture was more effective than Conventional Western medicine (CWM) in outcomes effectiveness (RR 1.21, 95% CI: 1.16–1.25), pain intensity (MD −1.25, 95% CI:−1.63 to −0.86), and pain threshold (MD: 1.08, 95% CI: 0.98–1.17). Subgroup and sensitivity analysis found that the results did not change in different treatment method and drug categories substantially. The reported adverse effects were acceptable.
Conclusion Acupuncture may be effective in treating the pain associated with sciatica.

1.1.2. Qin Z 2015 ★

Qin Z, Liu X, Wu J, Zhai Y, Liu Z. Effectiveness of Acupuncture for Treating Sciatica: A Systematic Review and Meta-Analysis. Evid Based Complement Alternat Med 2015;2015:425108. doi: 10.1155/2015/425108.[184934]

Purpose 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.
Methods In this review, a total of 11 randomized controlled trials were included.
Results 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.
Conclusion 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. But because of the insufficient number of relevant and rigorous studies, the evidence is limited.

1.1.3. Lewis 2015 ★★

Lewis RA, Williams NH, Sutton AJ, Burton K, Din NU, Matar HE, Hendry M, Phillips CJ, Nafees S, Fitzsimmons D, Rickard I, Wilkinson C. Comparative clinical effectiveness of management strategies for sciatica: systematic review and network meta-analyses. Spine J. 2015 Jun 1;15(6):1461-77.[170143]

Purpose To compare the clinical effectiveness of different treatment strategies for sciatica simultaneously.
Methods We searched 28 electronic databases and online trial registries, along with bibliographies of previous reviews for comparative studies evaluating any intervention to treat sciatica in adults, with outcome data on global effect or pain intensity. Network meta-analysis methods were used to simultaneously compare all treatment strategies and allow indirect comparisons of treatments between studies. The study was funded by the UK National Institute for Health Research Health Technology Assessment program; there are no potential conflict of interests.
Results We identified 122 relevant studies; 90 were randomized controlled trials (RCTs) or quasi-RCTs. Interventions were grouped into 21 treatment strategies. Internal and external validity of included studies was very low. For overall recovery as the outcome, compared with inactive control or conventional care, there was a statistically significant improvement following disc surgery, epidural injections, nonopioid analgesia, manipulation, and acupuncture. Traction, percutaneous discectomy, and exercise therapy were significantly inferior to epidural injections or surgery. For pain as the outcome, epidural injections and biological agents were significantly better than inactive control, but similar findings for disc surgery were not statistically significant. Biological agents were significantly better for pain reduction than bed rest, nonopioids, and opioids. Opioids, education/advice alone, bed rest, and percutaneous discectomy were inferior to most other treatment strategies; although these findings represented large effects, they were statistically equivocal.
Conclusion The findings support the effectiveness of nonopioid medication, epidural injections, and disc surgery. They also suggest that spinal manipulation, acupuncture, and experimental treatments, such as anti-inflammatory biological agents, may be considered. The findings do not provide support for the effectiveness of opioid analgesia, bed rest, exercise therapy, education/advice (when used alone), percutaneous discectomy, or traction.

1.1.4. Han 2014 ★

Han Chao, Sun Zhongren, Yue Jinhuan, Zhang Qinhong, Wang Delong. [Clinical efficacy on acupuncture on patients with sciatica: a systematic review]. Liaoning Journal of Traditional Chinese Medicine. 2014;2:324-326.[187038].

ObjectiveTo evaluate the clinical effect of sciatica with acupuncture and provide ideas and reference for making clinical decision.
MethodsThe databases of Pubmed, CNKI, Wanfang, CBM, Science Paper Online and Cochrane Library were searched and 878 related articles were found. Clear NPT system was used to evaluate the quality of the included studies, 19 RCTs (2521 Participants) were finally selected to find out the clinical efficacy of acupuncture of sciatica at home and abroad.
ResultsAnalysis obtained from the final literature included 19 pieces of paper (2521 Participants). The acupuncture treatment of sciatica at home and abroad has some clinical effect. But there is lack of strong evidence to confirm due to the incorporation comprehensive experimental quality limit.
ConclusionLarge sample, multi-center, high-quality trail RCTs are needed to conform the clinical efficacy of acupuncture therapy on sciatica.

1.1.5. Lewis 2011 ★

Lewis R, Williams N, Matar H, Din N, Fitzsimmons D, Phillips C, Jones M, Sutton A, Burton K, Nafees S, Hendry M, Rickard I, Chakraverty R, Wilkinson C. The clinical effectiveness and cost-effectiveness of management strategies for sciatica: systematic review and economic model. Health Technol Assess. 2011;15(39):1-578. [86704]

Objectifs Sciatica is a symptom characterised by well-localised leg pain with a sharp, shooting or burning quality that radiates down the back of the leg and normally to the foot or ankle. It is often associated with numbness or altered sensation in the leg. To determine the clinical effectiveness and cost-effectiveness of different management strategies for sciatica.
Méthodes Data sources: Major electronic databases (e.g. MEDLINE, EMBASE and NHS Economic Evaluation Database) and several internet sites including trial registries were searched up to December 2009. Review methods: Systematic reviews were undertaken of the clinical effectiveness and cost-effectiveness of different treatment strategies for sciatica. Effectiveness data were synthesised using both conventional meta-analyses and mixed treatment comparison (MTC) methods. An economic model was then developed to estimate costs per quality-adjusted life-year gained for each treatment strategy.
Résultats The searches identified 33,590 references, of which 270 studies met the inclusion criteria and 12 included a full economic evaluation. A further 42 ongoing studies and 93 publications that could not be translated were identified. The interventions were grouped into 18 treatment categories. A larger number of studies evaluated invasive interventions and non-opioids than other non-invasive interventions. The proportion of good-quality studies for each treatment category ranged from 0% to 50%. Compared with studies of less invasive interventions, studies of invasive treatments were more likely to confirm disc herniation by imaging, to limit patients included to those with acute sciatica (< 3 months' duration) and to include patients who had received previous treatment. The MTC analyses gave an indication of relative therapeutic effect. The statistically significant odds ratios of global effect compared with inactive control were as follows: disc surgery 2.8, epidural injection 3.1, chemonucleolysis 2.0 and non-opioids 2.6. Disc surgery and epidural injections were associated with more adverse effects than the inactive control. There was some evidence for the effectiveness of biological agents and acupuncture. Opioid medication and activity restriction were found to be less effective than the comparator interventions and opioids were associated with more adverse effects than the inactive control. The full economic evaluations were of reasonable to good quality, but were not able to fully address our research question. Although individual studies raised a number of important issues, it was difficult to draw meaningful conclusions across studies because of their heterogeneity. The economic model demonstrated that stepped-care approaches to patient management were likely to be cost-effective, relative to strategies that involved direct referral to disc surgery. Limitations: The limited number of studies for some comparisons, the high level of heterogeneity (within treatment comparisons) and the potential inconsistency (between treatment comparisons) weaken the interpretation of the MTC analyses.
Conclusions These findings provide support for the effectiveness of currently used therapies for sciatica such as non-opioid medication, epidural corticosteroid injections and disc surgery, but also for chemonucleolysis, which is no longer used in the UK NHS. These findings do not provide support for the effectiveness of opioid analgesia, which is widely used in this patient group, or activity restriction. They also suggest that less frequently used treatments, such as acupuncture, and experimental treatments, such as anti-inflammatory biological agents, may be effective. Stepped-care approaches to treatment for patients with sciatica are cost-effective relative to direct referral for surgery. Future research should include randomised controlled trials with concurrent economic evaluation of biological agents and acupuncture compared with placebo or with currently used treatments. Development of alternative economic modelling approaches to assess relative cost-effectiveness of treatment regimes, based on the above trial data, would also be beneficial.

1.1.6. Luijsterburg 2007 Ø

Liujterbrug PA et al. Effectiveness of conservative treatments for the lumbosacral radical syndrome; a systematic review. Eur Spine J. 2007;16(7):881-899.[145428].

Purpose To assess the effectiveness of conservative treatments of the lumbosacral radicular syndrome (sciatica).
Methods Relevant electronic databases and the reference lists of articles up to May 2004 were searched. Randomised clinical trials of all types of conservative treatments for patients with the lumbosacral radicular syndrome selected by two reviewers. Two reviewers independently assessed the methodological quality and the clinical relevance. Because the trials were considered heterogeneous we decided not to perform a meta-analysis but to summarise the results using the rating system of levels of evidence.
Results Thirty trials were included that evaluated injections, traction, physical therapy, bed rest, manipulation, medication, and acupuncture as treatment for the lumbosacral radicular syndrome. Because several trials indicated no evidence of an effect it is not recommended to use corticosteroid injections and traction as treatment option. Whether clinicians should prescribe physical therapy, bed rest, manipulation or medication could not be concluded from this review.
Conclusion At present there is no evidence that one type of treatment is clearly superior to others, including no treatment, for patients with a lumbosacral radicular syndrome.

1.1.7. Wang 2007

Wang Fan, Zhang Tong, Liu Yi. [Systematic review of acupuncture and moxibustion treatment of sciatica]. 针灸治疗坐骨神经痛的系统. World Chinese Medicine. 2007;2(6):354-5. [169232].

2. Clinical Practice Guidelines

⊕ positive recommendation (regardless of the level of evidence reported)
Ø negative recommendation (or lack of evidence)

2.1. Danish Health and Medicines Authority (DHMA, Danemark 2018) Ø

Stochkendahl MJ, Kjaer P, Hartvigsen J, Kongsted A, Aaboe J, Andersen M et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Eur Spine J. 2018;27(1):60-75. [195990].. {National Clinical Guideline: interventions for recent onset lumbar radiculopathy Danish Health Authority]. 2016 [193124].

Guidelines recommend against acupuncture.

2.2. Philippine Academy of Rehabilitation Medicine (PARM) 2017 ⊕

Low back pain management guideline. Philippine Academy of Rehabilitation Medicine (PARM). 2017:294P. [198246].

Acute low back pain with radiculopathy: There is some evidence to use acupuncture in acute low back pain with radiculopathy. PARM Endorses use of acupuncture as treatment for low back pain with radiculopathy.

2.3. Danish Health Authority (DHA, Denmark) 2016 ∅

National clinical guideline for the nonsurgical treatment of recent onset lumbar nerve root compression (lumbar radiculopathy) quick guide. Danish Health Authority. 2016;:. [208649]. URL

It is not good practice to offer acupuncture on a routine basis to patients with recent onset lumbar nerve root Compression.

2.4. National Institute for Health and Clinical Excellence (NICE, UK) 2016 Ø

National Institute for Health and Clinical Excellence. Low back pain and sciatica in over 16s: assessment and management (NG59). Evidence-based recommendations on assessing and managing low back pain and sciatica in people aged 16 and over London (UK): National Institute for Health and Clinical Excellence (NICE). 2016. [158090]. Données relatives à l'acupuncture : [158090-b].

1.2.8, Do not offer acupuncture for managing low back pain with or without sciatica.

2.5. North American Spine Society (NASS) 2014) Ø

Kreiner DS, Hwang SW, Easa JE, Resnick DK, Baisden JL, Bess S et al ; North American Spine Society. An evidence-based clinical guideline for the diagnosis and treatment of lumbar disc herniation with radiculopathy. Spine J. 2014;14(1):180-91. [200343].

Question 15: what is the role of ancillary treatments such as bracing, electrical stimulation, acupuncture, and transcutaneous electrical stimulation in the treatment of lumbar disc herniation with radiculopathy? There is an insufficient evidence to make a recommendation for or against the use of ultrasound or low-power laser in the treatment of lumbar disc herniation with radiculopathy [40]. Grade of recommendation: I (insufficient evidence).

2.6. Accident Compensation Corporation (ACC, New-Zealand) 2011 Ø

Hardaker N, Ayson M. Pragmatic Evidence Based Review. The efficacy of acupuncture in the management of musculoskeletal pain. Accident Compensation Corporation (ACC, New-Zealand). 2011. [182414].

There is no evidence to recommend the use of acupuncture for lumbar disc herniation related radiculopathy (LDHR)

2.7. Philippine Academy of Rehabilitation Medicine (PARM, Philippine) 2011 ⊕

Clinical Practice Guidelines on the Diagnosis and Management of Low Back Pain. Philippine Academy of Rehabilitation Medicine (PARM). 2011. [199237]. Voir rappel des recommandations 2011 dans : Low back pain management guideline. Philippine Academy of Rehabilitation Medicine (PARM). 2017:294P. [198246].

There is some evidence to use acupuncture in acute low back pain with radiculopathy (Low Volume – Current)

2.8. Instituto di Recovero e Cura a Caraterre Scientifico (IRCCS, Italia) 2006 Ø

Negrini S, Giovannoni S, Minozzi S, Barneschi G, Bonaiuti D, Bussotti A, D'Arienzo M, Di Lorenzo N, Mannoni A, Mattioli S, Modena V, Padua L, Serafini F, Violante FS. Diagnostic therapeutic flow-charts for low back pain patients: the Italian clinical guidelines. Eura Medicophys. 2006;42(2):151-70. [199104].

Treatment of Low back pain patient. Physical therapies: acupuncture is not effective (strenght of evidence : A).
Treatment of sciatica patient. Physical therapies: acupuncture is not effective (strenght of evidence : A).

3. Randomized Controlled Trials

3.1. Sources

  • a = Ji 2015: Ji M, Wang X, Chen M, Shen Y, Zhang X, Yang J. The Efficacy of Acupuncture for the Treatment of Sciatica: A Systematic Review and Meta-Analysis. Evid Based Complement Alternat Med 2015;2015:192808. [183273]
  • b = Qin 2015: Qin Z, Liu X, Wu J, Zhai Y, Liu Z. Effectiveness of Acupuncture for Treating Sciatica: A Systematic Review and Meta-Analysis. Evid Based Complement Alternat Med 2015;2015:425108. [184934]
  • c = Lewis 2015: Lewis R, Williams N, Matar H, Din N, Fitzsimmons D, Phillips C, Jones M, Sutton A, Burton K, Nafees S, Hendry M, Rickard I, Chakraverty R, Wilkinson C. The clinical effectiveness and cost-effectiveness of management strategies for sciatica: systematic review and economic model. Health Technol Assess. 2011;15(39):1-578. [86704]

3.2. List

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  2. Zhan WZ, Liang W. Different methods for the treatment of 2100 cases of sciatica. Journal of GanSu College of TCM. 1993;10(2):47.(a)
  3. Wehling P. Reinecke J. Acupuncture together with cytokine depressing herbs in comparison to injection therapy with steroids in sciatic pain. Schmerz 1997:11:180-4.©
  4. Wang BX, La LJ. Therapeutic effects of electroacupuncture and diclofenic on herniation of lumbar i intervertebral disc. Chinese Journal of Clinical Rehabilitation. 2004;8(17):3413–3415. (b)
  5. Zhao RH. [Clinical study of electro-acupuncture onHuangtiao point to treat sciatica]. Unpublished data, 2004.(b)
  6. Chen MR, Wang P, Cheng G et al. A clinical observation on acupuncture for 30 cases of sciatica. Journal of Traditional Chinese Médicine. 2007;48(3): 238–240.(a)160890
  7. Dong QJ, Wu BH, Zhang YM. Observation on the therapeutic effect of searching-needling method of acupuncture for 60 cases of primary sciatica. New Medical Science. 2008;7(4):135–136.(a)
  8. Wang XG. [Clinical study of acupuncture for treating 52 cases of lumber intervertebral disc herniation]. Asia-Pacific Traditional Medicine. 2008;4(9):39–40.(b)
  9. Zhang BM, Wu YC, Shao P, Shen J, Jin RF. [Electroacupuncture therapy for lumbar intervertebral disc protrusion: a randomized controlled trial]. Journal of Clinical Rehabilitative Tissue Engineering Research. 2008;12(2);353–355.(b)
  10. Chen Mr, Wang P, Cheng G, Guo X, Wei Gw, Cheng Xh. The warming acupuncture for treatment of sciatica in 30 cases. J Tradit Chin Med. 2009;29(1):50-3. Gera[160890].(b)©
  11. Du Z, Shao P, He YH. [Clinical observation on 32 cases of lumber intervertebral disc herniation treated by electroacupuncture on Huatuo jiaji points]. Journal of Traditional Chinese Medicine. 2009;50(7):617–619.(b)
  12. Chen WK. Clinical study of acupuncture in sciatica patients [M.S. thesis], Guangzhou University of Chinese Médicine. Guangdong, China, 2010.(a)(b)
  13. Hu ZC, Shen LH, Wu YC. [Observations on the therapeutic effect of electro-acupuncture on lumbar intervertebral disc herniation]. Shanghai Journal of Acupuncture and Moxibustion. 2010;29(11):722–724.(b)
  14. Zhu JH, Chen HY, Chen JY. Treating 30 cases of backbone of sciatica by hip three-needle-based acupuncture. Clinical Journal of Chinese Médicine. 2011;3(5).78–79.(a)
  15. Zhang Z. Clinical observation of 145 cases of sciatica treated by acupuncture. Chinese Journal of Modern Drug Application. 2012;6(4).124–125.(a)
  16. Liu BL. Clinical analysis of 80 cases of acupuncture and moxibustion for treatment of sciatica. Guide of China Médicine. 2012;10(24):590–591.(a)
  17. Zeng YY. [Slow twist combined with pricking blood therapy by Qi stagnation and Blood stasis type of root ciatica in clinical research]. Unpublished data, 2012.(b)
  18. Zhai H. Clinical observation of sciatica treated by acupuncture. Medical Information. 2012;25(2):562. (a)
  19. Ren YX. [Clinical observation on 30 cases of lumber intervertebral disc herniation treated by warm needling combined with medicine]. Jiangsu Journal of Traditional Chinese Medicine. 2013;45(9):62–63.(b)
  20. Huang WD. Clinical observation of 76 cases of sciatica treated by acupuncture. Contemporary Medicine Forum. 2014;12(1):178–179.(a)
  21. Meng Rong. [Efficacy of electroacupuncture therapy and medication treatrnent on lumbar discherniation]. Journal Of Clinical Acupuncture And Moxibustion. 2014;30(9):30-32. gera[173485].(b)173485
  22. Wang CH. Clinical observation of sciatica treated by acupuncture. Asia-Pacific Traditional Médicine. 2014;10(6):94–95.(a)
  23. Qin Z, Liu X, Yao Q, Zhai Y, Liu Z; Acupuncture for treating sciatica: a systematic review protocol, BMJ Open; 2015;5(4).ID e007498, 2015. (a)
  24. Ye XC, Zhao P, Wang L et al. Clinical observation on the treatment of root scitica by electro acupuncture at jiaji point. Information on Traditional Chinese Médicine. 2015;32(1):108–111.(a)