Effectiveness of moxibustion alone on lumbar disc herniation: a Meta-analysis of randomized controlled trials

doi:10.19852/j.cnki.jtcm.20221108.001

Abstract

Abstract:

OBJECTIVE: To evaluate the available evidence from randomized controlled trials (RCTs) of moxibustion alone for lumbar disc herniation (LDH) treatment.
METHODS: A systematic search of 10 databases (until August 30, 2021) was used to identify studies that reported the response rate, visual analogue scale (VAS) score, Japanese Orthopedic Association (JOA) score, and Oswestry Disability Index (ODI) score. Study selection and data extraction were independently performed by two reviewers. Cochrane criteria for risk of bias were used to assess the methodological quality of the trials. The Grading of Recommendations Assessment, Development, and Evaluation Methodology (GRADE) were also used to test the quality of the result evidence.
RESULTS: Nineteen RCTs, including 1888 patients, met the inclusion criteria. Five studies showed no difference between moxibustion and acupuncture on response rate [risk ratio (RR) = 1.07, 95%CI (0.98, 1.16), P = 0.11]. Meanwhile, six studies suggested that there is no significant difference between moxibustion and acupuncture on VAS score [mean difference (MD) = －0.43, 95% CI (－0.91, 0.05), P = 0.08]. Eight studies implied that there is no significant difference between moxibustion and acupuncture on JOA score [MD = 0.84, 95% CI (－1.27, 2.96), P = 0.44]. Two studies indicated that moxibustion may have equivalent effects for treating LDH in the VAS score in comparison with drug therapy [MD = －1.16, 95%CI (－2.63, 0.31), P = 0.12]. The evidence level of results was determined to be very low to low.
CONCLUSIONS: Based on the existing evidence, moxibustion may not be suitable for treating LDH alone, but it may be applied as an adjuvant treatment. Furthermore, well-designed RCTs with high quality and larger samples are still needed to evaluate the efficacy and safety of moxibustion alone for LDH treatment.

Key words: moxibustion, lumbar disc herniation, randomized controlled trial, systematic review, Meta-analysis

YAO Yao, ZHAO Zhenni, CHEN Fengqin, LENG Yufei, PANG Xiangtian, XU Xiao, SUN Zhiling. Effectiveness of moxibustion alone on lumbar disc herniation: a Meta-analysis of randomized controlled trials[J]. Journal of Traditional Chinese Medicine, 2023, 43(1): 14-26.

Figures/Tables 7

References 47

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Study	Sample size	Mean age (years)		Duration (months)		Intervention					Follow up			Adverse events			Outcomes
Study	Sample size	Mean age (years)		Duration (months)		Experimental group			Control group		Follow up			Adverse events			Outcomes
Chen RX et al 2014³⁸	456	E1: 45.5±10.6 E2: 47.3±11.2 C: 46.6±10.5		n.r.		(E1) Suspended moxa (2 times daily in the first 4 d, one time daily in remaining 10 d, 2 weeks, n = 152) (E2) Suspended moxa (1session = 45 min, 2 times daily in the first 4 d, 1 time daily in the remaining 10 d, 2 weeks, n = 152)			Drug therapy (20% mannitol, Voltaren tablets in the first 3 d. Voltaren tablets in subsequent 11 d.) Plus acupuncture (1session = 30 min, 1/d, 2 weeks, n = 152)		2 weeks, 6 months			None related to moxa.			JOA
Fu Y et al 2014³⁷	180	E1: 54.55±6.24 E2: 57.22±6.37 C: 56.21±5.27		E1: 5.45±3.46 E2: 5.00±2.12 C: 5.32±3.18		(E1) Suspended moxa (2 times daily in the first four days, 1 time daily in the remaining 10 d, 2 weeks, n = 60) (E2) Suspended moxa (1 session = 30 min, 2 times daily in the first 4 d, 1 time daily in the remaining 10 d, 2 weeks, n = 60)			Drug therapy (20% mannitol, 1/d, fortalin tablets, in the first 3 d, only taken fortalin tablets in subsequent 11 d.) Plus acupuncture, (1 session = 30 min, once daily, 2 weeks, n = 60)		2 weeks, 6 months			n.r.			JOA
Hu XW et al 2019²⁵	90	E: 40.19±5.16 C1: 38.32±6.71 C2: 40.32±7.92		E: 10.58±2.33 C1: 8.90±1.80 C2: 9.68±1.74		Indirect moxa (once a week, 1 month, n = 31)			(C1) Acupuncture (1 session = 30 min, 1/d, 10 times as a course, rest for 2 d between courses, 1 month, n = 28) (C2) Drug therapy (Diclofenac sodium tablets, 25 mg, 3 times a day, 1 month, n = 31)		1 month			n.r.			Response rate; VAS; ODI;
Li H et al 2012³¹	60	E: 41.7 C: 41.9		E: 7.4 C: 7.2		Suspended moxa (2 times daily in the first 4 d, 1 time daily in the remaining 10 d, 2 weeks, n = 30)			Acupuncture (1 session = 30 min, 1/d, 6 times/ week, 8 weeks, n = 30)		2 weeks			n.r.			Response rate
Li L 2016³⁴	60	E: 39.62±5.26 C: 40.80±4.68		E (yr): 3.60±1.09 C(yr): 3.57±1.12		Indirect moxa (1 session = 1.5 h, 2 times/week, 8 weeks, n = 30)			Acupuncture (1 session = 30 min, 1/d, 6 times/ week, 8 weeks, n = 30)		8 weeks			n.r.			VAS; JOA
Lin WP 2012³⁶	60	E: 42.73±11.77 C: 41.73±10.65		E(d): 18.77±19.58 C(d): 20.53±23.56		Indirect moxa (1 session = 50 min, once daily, 10 d, n = 30)			Acupuncture (1session = 30 min, plus cup, 1 session = 30 min, 1/d, 10 d, n = 30)		10 d			n.r.			Response rate
Liu Q et al 2012³⁹	80	E: 43.20±10.26 C: 42.77±10.50		E (yr): 4.81±2.96 C (yr): 4.67±3.16		Indirect moxa (once every other one day, 3 times/week, 3 weeks, n = 40)			Acupuncture plus TDP irradiation (1 session = 30 min, 1/d, 5 times/ week, 3 weeks, n = 40)		3 weeks			n.r.			Response rate
Liu CY et al 2021⁴⁰	60	E: 52.42±3.17 C: 52.38±3.25		n.r.		Suspended moxa (1 session = 15 min, 1/d, 6 d/course, rest for 1 d between courses, 4 weeks, n = 30)			Drug therapy (Citicoline sodium injection 0.5 g, salvia miltiorrhiza injection 20 mL, respectively, added to 5% of the glucose solution 250 mL intravenous injection，1/d, 4 weeks, n = 30)		4 weeks			n.r.			VAS; JOA
Lu YJ 2015³⁵	60	E: 52.20±7.14 C: 52.53±7.53		E(yr): 5.63±2.94 C(yr): 5.57±2.87		Indirect moxa (1 session = 1.5 h, 2 times/week, 8 weeks, n = 30)			Acupuncture (1 session = 25 min, 1/d, 6 times/week, 8 weeks, n = 30)		8 weeks			n.r.			VAS; JOA
Ma S et al 2010³³	120	E1: 41.5±12.8 E2: 38.3±11.3 C: 37.9±11.2		E1(d): 261.2±47.7 E2(d): 267.3±34.5 C(d): 274.8±50.2		(E1) Indirect moxa (once daily, 3 weeks, n = 30) (E2) Indirect moxa plus Acupuncture, (3 weeks, n = 60)			Acupuncture (1session = 30 min, 1/d, 3 weeks, n = 30)		3 weeks			n.r.
Ma S et al 2010³³	120	E1: 41.5±12.8 E2: 38.3±11.3 C: 37.9±11.2	E1(d): 261.2±47.7 E2(d): 267.3±34.5 C(d): 274.8±50.2		(E1) Indirect moxa (once daily, 3 weeks, n = 30) (E2) Indirect moxa plus Acupuncture, (3 weeks, n = 60)		Acupuncture (1session = 30 min, 1/d, 3 weeks, n = 30)			3 weeks		n.r.			JOA
Mai ZM, Tang JD 2017²⁹	94	E: 42.81±9.31 C: 43.17±9.63		E: 13.45±6.41 C: 13.63±6.55		Suspended moxa (1 session = 40 min, 1/d, 5 d/course, rest for 2 d between courses, 4 weeks, n = 47)		Acupuncture (1 session = 30 min, 1/d, 5 d/course, rest for 2 d between courses, 4 weeks, n = 47)		4 weeks			n.r.			VAS; JOA
Mao LF 2017²⁶	60	E: 51.53±8.66 C: 51.93±11.30		n.r.		Suspended moxa (5 d/course, rest for 2 d between courses of treatment, n = 30)		Drug therapy (Yaotongning capsule, 4-6 pieces, 3/d, 10 d, n = 30)		10 d			5 patients developed dry and thirst, normal after hydration			JOA
Song LJ et al 2016²²	60	E: 27.76±3.67 C: 28.83±3.33		E: 15 d-3 yr C: 20 d-2.5 yr		Suspended moxa (1session = 15-20 min, 1/d, 5 d/course, 10 d, n = 30)		Conventional therapy (10 d, n = 30)		10 d			n.r.			ODI
Wang XY 2008²⁸	72	E: 48.8±11.8 C: 46.8±13.7		n.r.		Indirect moxa (once every other one day, 3 weeks, n = 36)		Acupuncture (1 session = 30 min, once every other one day, 3 weeks, n = 36)		1/2/3 week(s), 1 month			None related to moxa.			Response rate; JOA
Xu JF et al 2012²⁷	60	E: 41.1±11.6 C: 40.1±10.1		E: 29.2±8.4 C: 32.3±8.2		Suspended moxa (1 session = 1 h, 1/d, 3 weeks, n = 30)		Acupuncture (1 session = 30 min, 1/d, 3 weeks, n = 30)		3 weeks			n.r.			VAS; JOA
Yang DL et al 2014³²	40	E: 42±13 C: 45±12		E: 29.2±8.4 C: 32.3±8.2		Suspended moxa (1 session = 1 h, 1/d, 3 weeks, n = 20)		Acupuncture (1 session = 30 min, 1/d, 3 weeks, n = 20)		3 weeks			n.r.			JOA
Yi GQ et al 2015³⁰	70	E: 47.09±9.06 C: 45.49±10.48		E: 14.40±16.83 C: 11.49±17.70		Suspended moxa (1 session = 30 min, 1/d, 5 d/course, rest for 2 d between courses, 3 weeks, n = 35)		Acupuncture (1 session = 30 min, 1/d, 5 d/course, rest for 2 d between courses, 3 weeks, n = 35)		3 weeks			n.r.			Response rate; VAS; JOA
Zhang LZ 2018²³	106	E: 47.58±10.30 C: 47.15±10.07		E (yr): 6.08±3.64 C(yr): 6.34±3.51		Suspended moxa (1 session = 20-30 min, 1/d, n = 53), plus Conventional therapy		Conventional therapy (n = 53)		14-21 d			n.r.			VAS
Zheng CH et al 2019²⁴	100	E: 54.26±8.24 C: 54.49±8.19		E: 3.79±2.88 C: 3.86±2.91		Suspended moxa (5 times every week, 2 weeks, n = 50)		Fixed-point rotation reduction (once every other one day, 2 weeks, n = 50)		2 weeks			n.r.			Response rate; VAS; JOA; ODI

Study	Sample size	Mean age (years)		Duration (months)		Intervention					Follow up			Adverse events			Outcomes
Study	Sample size	Mean age (years)		Duration (months)		Experimental group			Control group		Follow up			Adverse events			Outcomes
Chen RX et al 2014³⁸	456	E1: 45.5±10.6 E2: 47.3±11.2 C: 46.6±10.5		n.r.		(E1) Suspended moxa (2 times daily in the first 4 d, one time daily in remaining 10 d, 2 weeks, n = 152) (E2) Suspended moxa (1session = 45 min, 2 times daily in the first 4 d, 1 time daily in the remaining 10 d, 2 weeks, n = 152)			Drug therapy (20% mannitol, Voltaren tablets in the first 3 d. Voltaren tablets in subsequent 11 d.) Plus acupuncture (1session = 30 min, 1/d, 2 weeks, n = 152)		2 weeks, 6 months			None related to moxa.			JOA
Fu Y et al 2014³⁷	180	E1: 54.55±6.24 E2: 57.22±6.37 C: 56.21±5.27		E1: 5.45±3.46 E2: 5.00±2.12 C: 5.32±3.18		(E1) Suspended moxa (2 times daily in the first four days, 1 time daily in the remaining 10 d, 2 weeks, n = 60) (E2) Suspended moxa (1 session = 30 min, 2 times daily in the first 4 d, 1 time daily in the remaining 10 d, 2 weeks, n = 60)			Drug therapy (20% mannitol, 1/d, fortalin tablets, in the first 3 d, only taken fortalin tablets in subsequent 11 d.) Plus acupuncture, (1 session = 30 min, once daily, 2 weeks, n = 60)		2 weeks, 6 months			n.r.			JOA
Hu XW et al 2019²⁵	90	E: 40.19±5.16 C1: 38.32±6.71 C2: 40.32±7.92		E: 10.58±2.33 C1: 8.90±1.80 C2: 9.68±1.74		Indirect moxa (once a week, 1 month, n = 31)			(C1) Acupuncture (1 session = 30 min, 1/d, 10 times as a course, rest for 2 d between courses, 1 month, n = 28) (C2) Drug therapy (Diclofenac sodium tablets, 25 mg, 3 times a day, 1 month, n = 31)		1 month			n.r.			Response rate; VAS; ODI;
Li H et al 2012³¹	60	E: 41.7 C: 41.9		E: 7.4 C: 7.2		Suspended moxa (2 times daily in the first 4 d, 1 time daily in the remaining 10 d, 2 weeks, n = 30)			Acupuncture (1 session = 30 min, 1/d, 6 times/ week, 8 weeks, n = 30)		2 weeks			n.r.			Response rate
Li L 2016³⁴	60	E: 39.62±5.26 C: 40.80±4.68		E (yr): 3.60±1.09 C(yr): 3.57±1.12		Indirect moxa (1 session = 1.5 h, 2 times/week, 8 weeks, n = 30)			Acupuncture (1 session = 30 min, 1/d, 6 times/ week, 8 weeks, n = 30)		8 weeks			n.r.			VAS; JOA
Lin WP 2012³⁶	60	E: 42.73±11.77 C: 41.73±10.65		E(d): 18.77±19.58 C(d): 20.53±23.56		Indirect moxa (1 session = 50 min, once daily, 10 d, n = 30)			Acupuncture (1session = 30 min, plus cup, 1 session = 30 min, 1/d, 10 d, n = 30)		10 d			n.r.			Response rate
Liu Q et al 2012³⁹	80	E: 43.20±10.26 C: 42.77±10.50		E (yr): 4.81±2.96 C (yr): 4.67±3.16		Indirect moxa (once every other one day, 3 times/week, 3 weeks, n = 40)			Acupuncture plus TDP irradiation (1 session = 30 min, 1/d, 5 times/ week, 3 weeks, n = 40)		3 weeks			n.r.			Response rate
Liu CY et al 2021⁴⁰	60	E: 52.42±3.17 C: 52.38±3.25		n.r.		Suspended moxa (1 session = 15 min, 1/d, 6 d/course, rest for 1 d between courses, 4 weeks, n = 30)			Drug therapy (Citicoline sodium injection 0.5 g, salvia miltiorrhiza injection 20 mL, respectively, added to 5% of the glucose solution 250 mL intravenous injection，1/d, 4 weeks, n = 30)		4 weeks			n.r.			VAS; JOA
Lu YJ 2015³⁵	60	E: 52.20±7.14 C: 52.53±7.53		E(yr): 5.63±2.94 C(yr): 5.57±2.87		Indirect moxa (1 session = 1.5 h, 2 times/week, 8 weeks, n = 30)			Acupuncture (1 session = 25 min, 1/d, 6 times/week, 8 weeks, n = 30)		8 weeks			n.r.			VAS; JOA
Ma S et al 2010³³	120	E1: 41.5±12.8 E2: 38.3±11.3 C: 37.9±11.2		E1(d): 261.2±47.7 E2(d): 267.3±34.5 C(d): 274.8±50.2		(E1) Indirect moxa (once daily, 3 weeks, n = 30) (E2) Indirect moxa plus Acupuncture, (3 weeks, n = 60)			Acupuncture (1session = 30 min, 1/d, 3 weeks, n = 30)		3 weeks			n.r.
Ma S et al 2010³³	120	E1: 41.5±12.8 E2: 38.3±11.3 C: 37.9±11.2	E1(d): 261.2±47.7 E2(d): 267.3±34.5 C(d): 274.8±50.2		(E1) Indirect moxa (once daily, 3 weeks, n = 30) (E2) Indirect moxa plus Acupuncture, (3 weeks, n = 60)		Acupuncture (1session = 30 min, 1/d, 3 weeks, n = 30)			3 weeks		n.r.			JOA
Mai ZM, Tang JD 2017²⁹	94	E: 42.81±9.31 C: 43.17±9.63		E: 13.45±6.41 C: 13.63±6.55		Suspended moxa (1 session = 40 min, 1/d, 5 d/course, rest for 2 d between courses, 4 weeks, n = 47)		Acupuncture (1 session = 30 min, 1/d, 5 d/course, rest for 2 d between courses, 4 weeks, n = 47)		4 weeks			n.r.			VAS; JOA
Mao LF 2017²⁶	60	E: 51.53±8.66 C: 51.93±11.30		n.r.		Suspended moxa (5 d/course, rest for 2 d between courses of treatment, n = 30)		Drug therapy (Yaotongning capsule, 4-6 pieces, 3/d, 10 d, n = 30)		10 d			5 patients developed dry and thirst, normal after hydration			JOA
Song LJ et al 2016²²	60	E: 27.76±3.67 C: 28.83±3.33		E: 15 d-3 yr C: 20 d-2.5 yr		Suspended moxa (1session = 15-20 min, 1/d, 5 d/course, 10 d, n = 30)		Conventional therapy (10 d, n = 30)		10 d			n.r.			ODI
Wang XY 2008²⁸	72	E: 48.8±11.8 C: 46.8±13.7		n.r.		Indirect moxa (once every other one day, 3 weeks, n = 36)		Acupuncture (1 session = 30 min, once every other one day, 3 weeks, n = 36)		1/2/3 week(s), 1 month			None related to moxa.			Response rate; JOA
Xu JF et al 2012²⁷	60	E: 41.1±11.6 C: 40.1±10.1		E: 29.2±8.4 C: 32.3±8.2		Suspended moxa (1 session = 1 h, 1/d, 3 weeks, n = 30)		Acupuncture (1 session = 30 min, 1/d, 3 weeks, n = 30)		3 weeks			n.r.			VAS; JOA
Yang DL et al 2014³²	40	E: 42±13 C: 45±12		E: 29.2±8.4 C: 32.3±8.2		Suspended moxa (1 session = 1 h, 1/d, 3 weeks, n = 20)		Acupuncture (1 session = 30 min, 1/d, 3 weeks, n = 20)		3 weeks			n.r.			JOA
Yi GQ et al 2015³⁰	70	E: 47.09±9.06 C: 45.49±10.48		E: 14.40±16.83 C: 11.49±17.70		Suspended moxa (1 session = 30 min, 1/d, 5 d/course, rest for 2 d between courses, 3 weeks, n = 35)		Acupuncture (1 session = 30 min, 1/d, 5 d/course, rest for 2 d between courses, 3 weeks, n = 35)		3 weeks			n.r.			Response rate; VAS; JOA
Zhang LZ 2018²³	106	E: 47.58±10.30 C: 47.15±10.07		E (yr): 6.08±3.64 C(yr): 6.34±3.51		Suspended moxa (1 session = 20-30 min, 1/d, n = 53), plus Conventional therapy		Conventional therapy (n = 53)		14-21 d			n.r.			VAS
Zheng CH et al 2019²⁴	100	E: 54.26±8.24 C: 54.49±8.19		E: 3.79±2.88 C: 3.86±2.91		Suspended moxa (5 times every week, 2 weeks, n = 50)		Fixed-point rotation reduction (once every other one day, 2 weeks, n = 50)		2 weeks			n.r.			Response rate; VAS; JOA; ODI

Item		Effect size (95% CI)	No. of participants (studies)	Quality of the evidence (GRADE)
Response rate	Moxibustion vs Acupuncture	RR 1.07 higher (0.98 higher to 1.16 higher)	321 (5 RCTs)	⊕○○○ VERY LOW
	Moxibustion vs Drug therapy	RR 1.26 higher (1.00 higher to 1.58 higher)	62 (1 RCTs)	⊕○○○ VERY LOW
	Moxibustion vs Acupuncture plus TDP irradiation	RR 1.08 higher (0.97 higher to 1.21 higher)	80 (1 RCTs)	⊕○○○ VERY LOW
	Moxibustion vs Fixed-point rotation reduction	RR 1.22 higher (1.00 higher to 1.49 higher)	100 (1 RCTs)	⊕○○○ VERY LOW
	The diagnostic and therapeutic criteria for diseases and syndrome patterns of TCM	RR 1.10 higher (1.02 higher to 1.18 higher)	442 (6 RCTs)	⊕⊕○○ LOW
	The guiding principle of clinical research on new drugs of TCM	RR 1.17 higher (1.02 higher to 1.35 higher)	121 (1 RCTs)	⊕○○○ VERY LOW
VAS score	Moxibustion vs Acupuncture	MD 0.43 lower (0.91 lower to 0.05 higher)	403 (6 RCTs)	⊕○○○ VERY LOW
	Moxibustion vs Drug therapy	MD 1.16 lower (2.63 lower to 0.31 higher)	122 (2 RCTs)	⊕○○○ VERY LOW
	Moxibustion vs Conventional therapy	MD 0.64 lower (0.87 lower to 0.41 lower)	106 (1 RCTs)	⊕○○○ VERY LOW
	Moxibustion vs Fixed-point rotation reduction	MD 1.05 lower (1.22 lower to 0.88 lower)	100 (1 RCTs)	⊕○○○ VERY LOW
JOA score	Moxibustion vs Acupuncture	MD 0.84 higher (1.27 lower to 2.96 higher)	516 (8 RCTs)	⊕⊕○○ LOW
	Moxibustion vs Drug therapy	MD 4.15 higher (0.05 higher to 8.26 higher)	120 (2 RCTs)	⊕○○○ VERY LOW
	Moxibustion vs Fixed-point rotation reduction	MD 8.69 higher (5.08 higher to 12.30 higher)	100 (1 RCTs)	⊕○○○ VERY LOW
ODI score	Moxibustion vs Acupuncture	MD 1.16 lower (3.75 lower to 1.43 higher)	59 (1 RCTs)	⊕○○○ VERY LOW
	Moxibustion vs Drug therapy	MD 16.03 lower (20.04 lower to 12.02 lower)	62 (1 RCTs)	⊕○○○ VERY LOW
	Moxibustion vs Conventional therapy	MD 10.67 lower (12.72 lower to 8.62 lower)	60 (1 RCTs)	⊕○○○ VERY LOW
	Moxibustion vs Fixed-point rotation reduction	MD 8.19 lower (8.78 lower to 7.60 lower)	100 (1 RCTs)	⊕○○○ VERY LOW

Item		Effect size (95% CI)	No. of participants (studies)	Quality of the evidence (GRADE)
Response rate	Moxibustion vs Acupuncture	RR 1.07 higher (0.98 higher to 1.16 higher)	321 (5 RCTs)	⊕○○○ VERY LOW
	Moxibustion vs Drug therapy	RR 1.26 higher (1.00 higher to 1.58 higher)	62 (1 RCTs)	⊕○○○ VERY LOW
	Moxibustion vs Acupuncture plus TDP irradiation	RR 1.08 higher (0.97 higher to 1.21 higher)	80 (1 RCTs)	⊕○○○ VERY LOW
	Moxibustion vs Fixed-point rotation reduction	RR 1.22 higher (1.00 higher to 1.49 higher)	100 (1 RCTs)	⊕○○○ VERY LOW
	The diagnostic and therapeutic criteria for diseases and syndrome patterns of TCM	RR 1.10 higher (1.02 higher to 1.18 higher)	442 (6 RCTs)	⊕⊕○○ LOW
	The guiding principle of clinical research on new drugs of TCM	RR 1.17 higher (1.02 higher to 1.35 higher)	121 (1 RCTs)	⊕○○○ VERY LOW
VAS score	Moxibustion vs Acupuncture	MD 0.43 lower (0.91 lower to 0.05 higher)	403 (6 RCTs)	⊕○○○ VERY LOW
	Moxibustion vs Drug therapy	MD 1.16 lower (2.63 lower to 0.31 higher)	122 (2 RCTs)	⊕○○○ VERY LOW
	Moxibustion vs Conventional therapy	MD 0.64 lower (0.87 lower to 0.41 lower)	106 (1 RCTs)	⊕○○○ VERY LOW
	Moxibustion vs Fixed-point rotation reduction	MD 1.05 lower (1.22 lower to 0.88 lower)	100 (1 RCTs)	⊕○○○ VERY LOW
JOA score	Moxibustion vs Acupuncture	MD 0.84 higher (1.27 lower to 2.96 higher)	516 (8 RCTs)	⊕⊕○○ LOW
	Moxibustion vs Drug therapy	MD 4.15 higher (0.05 higher to 8.26 higher)	120 (2 RCTs)	⊕○○○ VERY LOW
	Moxibustion vs Fixed-point rotation reduction	MD 8.69 higher (5.08 higher to 12.30 higher)	100 (1 RCTs)	⊕○○○ VERY LOW
ODI score	Moxibustion vs Acupuncture	MD 1.16 lower (3.75 lower to 1.43 higher)	59 (1 RCTs)	⊕○○○ VERY LOW
	Moxibustion vs Drug therapy	MD 16.03 lower (20.04 lower to 12.02 lower)	62 (1 RCTs)	⊕○○○ VERY LOW
	Moxibustion vs Conventional therapy	MD 10.67 lower (12.72 lower to 8.62 lower)	60 (1 RCTs)	⊕○○○ VERY LOW
	Moxibustion vs Fixed-point rotation reduction	MD 8.19 lower (8.78 lower to 7.60 lower)	100 (1 RCTs)	⊕○○○ VERY LOW

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