Ji-Ae Roh
Jungtae Leem
Beom-Joon Lee
Kwan-Il Kim
Hee-Jae Jung1,2*
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- 1Department of Clinical Korean Medicine, College of Korean Medicine, Graduate School, Kyung Hee University, Seoul, Republic of Korea
- 2Division of Allergy, Immune and Respiratory System, Department of Internal Medicine, College of Korean Medicine Kyung Hee University, Kyung Hee University Medical Center, Seoul, Republic of Korea
- 3Department of Diagnostics, College of Korean Medicine, Wonkwang University, Iksan, Republic of Korea
- 4Department of Il-won Integrated Medicine, Wonkwang University Korean Medicine Hospital, Iksan, Republic of Korea
Chronic obstructive pulmonary disease (COPD) is a major global public health concern. In this study, we examined the comparative efficacy of non-pharmacological interventions within East Asian traditional medicine (EATM-NPI) for enhancing pulmonary function and exercise capacity in patients with stable COPD. A thorough search of electronic databases conducted until May 22, 2022, identified studies employing EATM-NPI in such patients. The evaluation focused on the impact adjunctive therapies on pulmonary function (forced expiratory volume in 1 s [FEV1]) and exercise capacity (6-min walking distance [6MWD]). The qualitative assessment encompassed 142 studies, with 133 studies included in one of three network meta-analyses. Participants, aged 49–76 years, ranged from 9 to 139 per group, predominantly from China (87.7% of studies). Overall study quality was generally low, and reported adverse events were mild. Notably, moxibustion and qigong adjunctive therapies demonstrated significant improvements in FEV1 (L) and FEV1 (%). Additionally, chuna, acupuncture, qigong and moxibustion adjunctive therapies were associated with significant improvements in 6MWD. In conclusion, EATM-NPI adjunctive therapy, when combined with standard pharmacological treatment, exhibited effects on pulmonary function and exercise capacity in patients with COPD.
Systematic review registration: The protocol was registered with PROSPERO (CRD42023389431), https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023389431.
1 Introduction
Chronic obstructive pulmonary disease (COPD) is a disease marked by irreversible airway obstruction on the pulmonary function test along with symptoms such as chronic dyspnea, cough, and sputum (1). COPD is a major disease that poses economic and social burdens, and its global burden is consistently increasing (2–4). In 2017, COPD was the third leading cause of death globally (5). In 2019, the global prevalence of COPD was 10.3% with approximately 391.9 million people estimated to be have been affected by the disease (5, 6). Its prevalence in East Asia has been reported to be slightly higher than the global average. The trends in the prevalence of COPD in South Korea were reported within the range of approximately 13.1 to 14.6% during the period from 2010 to 2015 (7), and that in China was 13.6% during 2014–2015 (8). COPD typically manifests in individuals aged 40 years and older; thus, its prevalence is expected to increase in an aging society. Therefore, COPD has been incorporated into the WHO Global Action Plan to prevent and control non-communicable diseases.
To mitigate the mounting burden of respiratory illnesses that have surged since the 20th century, it is important to explore alternative strategies that can more effectively manage COPD in conjunction with the standard pharmacological therapy proposed by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) (9). Pharmacological therapy alone falls short of effectively managing these chronic, irreversible symptoms and respiratory exacerbations, along with systemic repercussions. Therefore, non-pharmacological therapy plays a pivotal role in managing patients with stable COPD (1).
The non-pharmacological intervention of East Asian traditional medicine (EATM-NPI) represents an enticing alternative that can be added to standard pharmacological therapy. The EATM-NPI encompasses various traditional medicine practices. Although acupuncture, which stimulates the surface of the body using needles, is the most well-known method, other EATM-NPIs include moxibustion, which involves thermal stimulation of the body’s surface; cupping therapy, which creates negative pressure on the skin; qigong, which involves breathing regulation and mental focus; and chuna, a manual therapy that alters the body’s function and structure through the practitioner’s hands. These EATM-NPIs have been sporadically studied for their potential to provide additional benefits to patients with COPD.
A network meta-analysis (NMA) comparing traditional exercise therapies revealed that Wuqinxi improved pulmonary function and exercise capacity, whereas Yijinjing improved quality of life (QOL) (10). A meta-analysis of studies on acupuncture-related treatments showed that acupressure enhances QOL, whereas acupuncture improves pulmonary function, exercise capacity, and QOL (11, 12). Furthermore, the 2023 GOLD guidelines presented acupuncture and acupressure as elective adjunctive therapies for dyspnea (1). In a meta-analysis on chuna therapy, the authors could not draw a concrete conclusion on whether chuna improves pulmonary function and exercise capacity, but they found that non-pharmacological therapies generally are effective on COPD, indicating that non-pharmacological therapies could be promising for COPD (13).
There is a dearth of comprehensive evidence for EATM-NPI as a new potential approach for the management and treatment of stable COPD. Nearly all studies on EATM-NPIs for patients with COPD show that they have been ethically designed as add-on therapies in conjunction with standard pharmacological treatments. Additionally, in actual East Asian clinical practice, various combinations of EATM-NPI therapies are used concurrently to treat patients with COPD (14–16), so clinicians face the challenge of determining which EATM-NPI therapy to prioritize for patients with COPD. While traditional pairwise meta-analysis (PMA) is limited to analyzing one intervention at a time, NMA allows for a relative ranking of the therapeutic efficacy of multiple interventions, thereby empowering clinicians and patients to make more informed decisions. This study aimed to investigate the comparative effects of EATM-NPIs added to standard pharmacological therapy for patients with stable COPD by using NMA. Therefore, here we aimed to investigate the therapeutic efficacy and comparative advantages of non-pharmacological therapies and derive treatment strategies for patients with stable COPD in an aging society.
2 Methods
This study adheres to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses NMA guideline (Supplement 1) (17), and the protocol was registered with PROSPERO (CRD42023389431).
2.1 Criteria for inclusion and exclusion
The eligibility criteria were established based on the participant, intervention, comparison, outcome, and study design (PICOS) framework.
2.1.1 Study types
Studies that made the diagnosis based on the GOLD guideline (1) or “forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) <0.7” and specified the diagnosis were included. Randomized controlled trials (RCTs) and crossover RCTs were included, whereas non-RCTs, observational studies, case reports, and animal studies were excluded. If a particular arm did not meet the eligibility criteria in a multi-arm trial, that study was still included, but the data from the specific arm were not used.
2.1.2 Participant types
Patients with stable COPD were included, and patients with acute exacerbation of COPD were excluded. There were no limitations on age, sex, and COPD severity. Patients who did not receive the standard pharmacological therapy as specified in the GOLD guideline during the study period were also excluded.
2.1.3 Intervention types and controls
The main intervention was EATM-NPI. Herbal medicine and pharmacoacupuncture therapy were excluded. EATM-NPI was broadly categorized into qigong (unspecified qigong, Wuqinxi, Liuzijue, Yijinjing, Taichi, and Baduanjin), moxibustion, cupping, chuna (fascia chuna therapy, joint mobilization and distraction, and spine and joint manipulation), and acupuncture (traditional stimulation of acupoints without the use of thermal stimulation). The treatment for the control group was not limited, but studies that used additional drugs or an herbal regimen for the control group were excluded. The treatment of the control group was broadly divided into pharmacological treatment (pharmacological therapy specified in the GOLD guidelines), exercise therapy (aerobic exercise prescribed in PR that is not considered an EATM-NPI, e.g., pursed-lip breathing and abdominal respiration), and placebo (with blinded).
2.1.4 Outcomes measures
The outcome measures were pulmonary function and exercise capacity. Pulmonary function was assessed based on FEV1 measured through spirometry, and exercise capacity was assessed based on the 6-min walking distance (6MWD). Specifically, FEV1 was measured using 2 units: FEV1 (L), which represents the actual exhalation volume, and FEV1 (%), which indicates the percentage of the predicted value based on the normal range for healthy individuals. Adverse events (AEs) reported in the included studies that reported FEV1 and 6MWD as the primary outcomes were collected.
2.2 Literature searches
A comprehensive search strategy was formulated using a combination of search terms pertaining to disease and intervention (Supplement 2). The language was not limited. The literature search was conducted in the following electronic databases from the beginning of the database to May 22, 2022: Medline via PubMed, EMBASE via Elsevier, CENTRAL (The Cochrane Central Register of Controlled Trials), China National Knowledge Infrastructure, DBpia, Korean Studies Information Service System, Research Information Service System, and Oriental Medicine Advanced Searching Integrated System.
2.3 Data selection
The references of the included studies and systematic reviews of relevant topic were manually searched. Ongoing protocols and conference abstracts were searched in Clinicaltrials.gov and the World Health Organization International Clinical Trials Registry Platform.
2.4 Data extraction
After uploading all the search results into EndNote X9.3.3 (Clarivate Analytics), two researchers (JAR and KIK) independently screened the titles and abstracts and then reviewed the full texts to select the studies. The same two researchers exported the title, author, publication. Year, country of origin, study design, enrolled and analyzed sample sizes, population age, disease severity, diagnostic criteria of COPD, treatment modalities and details of each assigned group, total treatment duration, treatment schedule, follow-up, reported AEs, and outcome measures of the studies as a spreadsheet (Microsoft Excel; Microsoft Corp.).
Any disagreements between the two researchers were resolved upon discussion. If an agreement could not be reached, a third researcher (JL) was involved to reach a consensus.
2.5 Quality/risk of bias assessment of included studies
Two researchers (JAR and KIK) independently assessed the risk of bias of the included studies using the Cochrane Handbook 5.1.0. assessment tool (18). The following items were rated as low risk, high risk, or unclear risk: random sequence generation, allocation concealment, blinding of participants and personnel, blinding of the outcome assessment, incomplete outcome data, selective reporting, and other bias.
2.6 Data analysis
First, PMA was performed for each intervention using Cochrane’s Review Manager (RevMan 5.4). The effect sizes of EATM-NPI were calculated based on all the included studies that could be included in the NMA. The primary outcome measures FEV1 (both L and %) and 6MWD were statistically analyzed using mean differences (MDs) and 95% confidence intervals (CIs). Data at the end of treatment were used; a positive MD indicated greater improvement of pulmonary function and exercise capacity.
A network model with a random effects model (19) was setup using the R package “netmeta (20)” for of the free software R-4.2.1 for Windows and RStudio (21) to conduct NMA using the frequentist method (22, 23). FEV1 was analyzed separately for each scale, and the results were presented in a forest plot and league table. P-scores, the probability of comparative advantage in non-pharmacological therapy, were calculated using the “netrank” function (21). The Egger’s test was used, and the results were visualized in a funnel plot to assess potential publication bias and overall bias of the included studies (21). Regarding the assumptions of NMA, connectivity was assessed using a network plot, and heterogeneity was assessed using I2. Network transitivity and consistency were verified through a global approach using Q-statistics, and consistency between direct and indirect comparisons was verified through a local approach using the node-splitting method.
3 Results
3.1 Study characteristics
In total, 2,272 studies were identified, and after removing duplicate results and ineligible studies per PICOS, 142 studies were included (Figure 1) (24–165). With the exception of one cross-over RCT (133), all studies were RCTs. The number of participants assigned to each group was 9–139. Participants’ mean age was 49–76 years, and COPD severity varied. Most studies (87.7%) were conducted in China. No studies used cupping therapy as the intervention. The qigong group included qigong, health qigong integrated for lung health, Wuqinxi, Liujizue, Yijinjing, Taichi, and Baduanjin (24–110). The moxibustion group included unspecified moxibustion, ginger moxibustion, heat-sensitive point’s moxibustion, Yi Fei moxibustion, and fire-dragon moxibustion (111–130). The chuna group included osteopathic manipulative therapy, specialized physiotherapy, and chuna (131–136). The acupuncture group included filiform acupuncture, Acu-TENS, warm needle acupuncture, auricular acupressure, electroacupuncture, pressing needle acupuncture, and acupressure (137–165). Treatment duration ranged from once to 1 year (Table 1). If FVC was also reported in the included study, the data were presented in the table to aid in qualitative interpretation (Supplementary Table S1). Outcome variables presented as medians, mean differences, or points were excluded from the meta-analysis (33, 47, 64, 70, 71, 91, 105, 133, 142). Of 142 studies, 27 studies (27, 58, 64, 66–71, 86, 93, 132, 133, 137, 140, 141, 147, 150–156, 159, 163, 164) reported AEs (18.5%), and AEs requiring treatment were not reported (Table 1).
Figure 1
Figure 1. Flowchart of identification and screening for the eligible studies. COPD, chronic obstructive pulmonary disease; CNKI, China National Knowledge Infrastructure; KISS, Korean Studies Information Service System; RISS, Research Information Service System; OASIS, Oriental Medicine Advanced Searching Integrated System.
Table 1
Table 1. Characteristics of the included studies.
3.2 Quality/risk of bias of included studies
The studies had a low risk of bias in terms of random sequence generation (61.3%) (24–26, 31, 32, 34, 37, 38, 40–44, 46–48, 50, 52–54, 56–58, 60–64, 66–, 68–72, 78, 80–82, 85, 86, 88, 89, 92–100, 110, 117–119, 121, 125, 127, 128, 130–133, 135, 139–142, 145–147, 149–153, 155, 156, 158, 160, 161, 163–165) and incomplete outcome data (83.8%) (24, 25, 28, 30–38, 40–44, 46–52, 54–72, 74, 75, 78–81, 83–85, 87, 93, 95–139, 141–153, 156, 158, 159, 161, 162, 164, 165), but there was unclear risk of bias in terms of allocation concealment (80.9%) (26–33, 35, 36, 38–40, 42–45, 47, 49, 51–57, 59–67, 70, 73–85, 87, 88, 90–93, 96–117, 119–130, 132–134, 136–141, 143–149, 154–159, 161, 162, 164, 165) and blinding of the outcome assessment (78.2%) (27–33, 35, 39–45, 47–49, 51–57, 59–63, 65, 67, 69, 73–88, 90–94, 96–130, 133–136, 138, 143–149, 154–159, 161, 162, 164, 165). Because of the nature of non-pharmacological treatment, there were no studies with a low risk of bias in terms of blinding of participants and personnel, and 14.8% of the studies (25–27, 34, 36–38, 46, 66, 68, 89, 131, 133, 140–142, 150–153, 160) had a high risk of bias in this aspect. One study published the protocol (64), and the remaining studies had an unclear risk of bias in terms of selective reporting, as shown in Supplementary Table S2.
3.3 Intervention effects
PMA of 133 RCTs (24–32, 34–46, 48–63, 65–69, 72–75, 77–104, 106–132, 134–141, 143–165) revealed that qigong, moxibustion, and acupuncture adjunctive therapies improved pulmonary function and exercise capacity, whereas chuna adjunctive therapy only improved exercise capacity (Supplement 4). In NMA, there were no issues with network connectivity and inconsistency in each of the three outcome measures (Figures 2A–C and Supplementary Figures S1–S3). NMA of the same 133 RCTs included in the PMA (24–32, 34–46, 48–63, 65–69, 72–75, 77–104, 106–132, 134–141, 143–165) showed that all types of EATM-NPI added to standard pharmacological treatment led to improvements in exercise capacity compared to standard pharmacological treatment alone, and qigong and moxibustion adjunctive therapies led to improvements in pulmonary functions.
Figure 2
Figure 2. Network evidence map of eligible comparisons: (A) FEV1(L); (B) FEV1(%); (C) 6MWD(m). FEV1: forced expiratory volume in a 1 s; 6MWD, 6-min walking distance; Tx, treatment.
NMA results were as follows. FEV1 (L) was most improved by moxibustion (113, 114, 121–125, 128, 129), followed by qigong (25, 30–32, 35, 37, 39, 41, 43, 49, 50, 53, 56, 59, 60, 62, 63, 66–69, 72, 74, 77–82, 84, 85, 88, 91, 92, 94–96, 101–103, 107, 108, 110), acupuncture (137, 140, 141, 145, 148, 149, 152, 153, 156–159), placebo, chuna (132, 134, 136), exercise therapy, and standard pharmacological treatment (Table 2A). P-scores were as follows: moxibustion, B: 0.7752; qigong, A: 0.7537; acupuncture, D: 0.5603; placebo, 3: 0.5510; chuna, C: 0.3894; exercise therapy, 2: 0.3490; and standard pharmacological treatment 1: 0.1213. Compared to the reference (standard pharmacological treatment), chuna and acupuncture adjunctive therapies had overlapping CIs, and qigong (A: MD 0.228, 95% CI 0.122–0.334) and moxibustion adjunctive therapies (B: MD 0.252, 95% CI 0.046–0.458) were statistically significant (Figure 3A and Supplementary Table S3).
Table 2
Table 2. Ranking test results.
Figure 3
Figure 3. Network forest plots. All non-pharmacological interventions of East Asian Traditional Medicine (EATM-NPIs) were compared with pharmacological Tx (“1”) using a random-effects model: (A) FEV1(L); (B) FEV1(%); (C) 6MWD(m). FEV1: forced expiratory volume in a 1 s; 6MWD, 6-min walking distance; Tx, treatment; MD, mean difference; CI, confidence interval.
FEV1 (%) was most improved by moxibustion (111–113, 115–122, 124–130), followed by chuna (132, 134–136), qigong (25–31, 34, 35, 37–41, 43–45, 49, 51, 53–55, 57, 59–63, 65, 66, 68, 69, 73, 75, 78, 80, 82, 84, 85, 88, 91, 93–99, 101–107, 110), acupuncture (137–141, 143–145, 151, 154–163, 165), placebo, exercise therapy, and standard pharmacological treatment (Table 2B). P-scores were as follows: moxibustion, B: 0.8094; chuna, C: 0.6825; qigong, A: 0.6753; acupuncture, D: 0.6181; placebo, 3: 0.2677; exercise therapy, 2: 0.2472; and standard pharmacological treatment, 1: 0.1998. Compared to the reference, chuna and acupuncture adjunctive therapies had overlapping CIs, and moxibustion (B: MD 6.064, 95% CI 1.844–10.285) and qigong adjunctive therapies (A: MD 4.441, 95% CI 1.724–7.158) were statistically significant (Figure 3B and Supplementary Table S3).
6MWD (m) was most improved by chuna (131, 134–136), followed by qigong (24–27, 29–31, 34, 36, 38, 40, 42, 43, 46, 48, 49, 52, 55, 58–63, 65–69, 72–74, 78, 80–84, 86–90, 94–100, 103, 107–109), acupuncture (137, 138, 141, 144, 146–148, 150, 151, 156, 160, 161, 164, 165), moxibustion (112, 117, 122, 123, 125), placebo, exercise therapy, and standard pharmacological treatment (Table 2C). P-scores were as follows: chuna, C: 0.8539; qigong, A: 0.6599; acupuncture, D: 0.6229; moxibustion, B: 0.5954; placebo, 3: 0.5408; exercise therapy, 2: 0.2157; and standard pharmacological treatment, 1: 0.0113. Compared to the reference, qigong adjunctive therapy (A: MD 44.941, 95% CI 34.448–55.434), moxibustion adjunctive therapy (B: MD 41.654, 95% CI 10.890–72.419), chuna adjunctive therapy (C: MD 62.599, 95% CI 18.277–106.921), and acupuncture adjunctive therapy (D: MD 43.167, 95% CI 23.081–63.252) were statistically significant (Figure 3C and Supplementary Table S3).
Regarding publication bias, the distribution was symmetrical overall, but studies with a large sample size had a greater impact on the results. Further, the Egger’s test result suggested a possibility of publication bias in FEV1; thus, caution is needed when interpreting the findings (p < 0.01) (Supplementary Figure S4).
4 Discussion
4.1 Summary of evidence
The present NMA sheds light on the comparative effects of EATM-NPI adjunctive therapy on pulmonary function and exercise capacity in patients with stable COPD. Compared to standard pharmacological treatment alone, qigong and moxibustion add-on therapies were more effective in improving FEV1, whereas qigong, moxibustion, chuna, and acupuncture add-on therapies were more effective in improving 6MWD. Hence, moxibustion may be considered over other adjunctive therapies when attempting to improve pulmonary function, whereas chuna may be considered first when the goal is to improve exercise capacity. AEs reported across the 27 studies (27, 58, 64, 66–71, 86, 93, 132, 133, 137, 140, 141, 147, 150–156, 159, 163, 164) were mostly mild. Some studies showed methodological issues related to random sequence generation, allocation concealment, and blinding of personnel.
4.2 Agreements and disagreements with other reviews
Dyspnea and decline in physical activities among patients with COPD are linked to secondary musculoskeletal problems (166). Therefore, it is possible that controlling these musculoskeletal problems could improve respiratory symptoms even without directly improving pulmonary function. Additionally, exacerbation of pulmonary functions (e.g., ventilatory limitation, gas exchange limitation, and cardiac limitation) can limit exercise capacity, and if musculoskeletal limitations, particularly limitation due to lower limb muscle dysfunction becomes chronic (167, 168), respiratory functions may weaken due to muscle dysfunction (169).
There is extensive research on the treatment of musculoskeletal disorders with the following modalities: chuna that is performed using hands, (12, 170, 171), qigong that trains the mind for meditation and places emphasis on smooth respiration and motions (172–174), acupuncture that stimulates soft tissues at acupoints using acupuncture needle (175, 176), and moxibustion that uses mugwort instead of needles (177). Our study is significant in that it sheds light on the potential of treating respiratory disorders by improving reversible and modifiable musculoskeletal issues.
Moxibustion has positive effects on respiratory diseases, such as lung cancer (178), pulmonary fibrosis (179), asthma (180), allergic rhinitis (181), and joint and spinal disorders (182, 183) through the regulation of inflammatory responses. Moxibustion regulates the body’s immune system (184) by improving the CD4+/CD8+ ratio, tumor necrosis factor-α levels, interleukin (IL)-10 levels, and IL-10/IL-6 ratio (185–187), thus effectively reducing inflammation (188). Our finding that moxibustion more effectively improved FEV1 than 6MWD did might have been attributable its use in treating chronic inflammation of the lungs.
Acupuncture may be effective in patients with COPD, as it reduces the chronic inflammatory state and concurrently improves chest wall stiffness. Acupuncture provides anti-inflammatory effects by regulating vascular responses and cytokines (142, 189–191) and clinically reduces inflammatory conditions, e.g., asthma (192), allergic rhinitis (193), and inflammatory bowel disease (194). Additionally, acupuncture mechanically stimulates connective tissues (195–198) and improves musculoskeletal flexibility (199), exhibiting effectiveness in various musculoskeletal disorders, e.g., low back pain (200, 201), neck pain (202), and frozen shoulder (203). However, in our NMA, acupuncture was effective in improving only 6MWD. Improving the mobility of the thorax and back may be a more beneficial pathway for patients with COPD, and further research on this is required.
Qigong involves following a step-by-step movement while regulating breathing, which promotes a sense of self-confidence, enhances flexibility and overall body balance, and activates bodily functions (59, 173, 174, 204–206). Although the exact mechanism underlying Qigong’s effects remains unclear, it has been reported to improve the 6MWD in patients with ischemic heart failure (207) and chronic heart failure (208), enhance FEV1 (%) in patients with non-small cell lung cancer (209), and manage pain in patients with chronic pain (210, 211). Qigong has demonstrated benefits in regulating the movement of the respiratory muscles and the overall musculoskeletal system. Meta-analyses conducted in 2014 (212) and 2019 (213) on the use of qigong in COPD reported statistically significant improvements in 6MWD, FEV1 (L), and FEV1 (%). Consistent with these previous meta-analyses, our study confirmed that qigong improves both FEV1 and 6MWD.
Chuna therapy may help improve exercise capacity in patients with COPD by alleviating chest stiffness through manual manipulation. Although the exact mechanism remains unclear, previous studies (10, 214) have suggested that Chuna therapy can improve both pulmonary function and exercise capacity. However, in this study’s NMA, while Chuna therapy demonstrated the most prominent improvement in 6MWD, significant effects were observed only in exercise capacity. Given the limited number of studies on Chuna therapy, large-scale follow-up studies are warranted.
4.3 Strengths and limitations of review
This is the first study to conduct the latest meta-analysis to compare the effectiveness of various EATM-NPIs in patients with COPD. We provided decisive evidence for the clinical prescription of EATM-NPI through NMA, and in addition to prior research, we also showed that EATM-NPI is a promising treatment approach for COPD.
A previous NMA on qigong (10) used FEV1/FVC (%) as the index for pulmonary function, but we used FEV1 instead. For COPD patients, the impairment of FEV1 is distinct and more crucial compared to FVC. Moreover, the GOLD guidelines categorize the severity of COPD based on FEV1, emphasizing the significance of FEV1 variability in COPD. In this study, we employed raw values of FEV1 rather than the FEV1/FVC ratio, distinguishing between absolute FEV1 in liters and the FEV1%. We conducted separate meta-analyses to examine the respective effects of each. There was no closed loop in the network diagram of Li et al.’s study, but we used a closed loop for a mixed comparison (10). Li et al. reported that Wuqinxi is the most effective traditional exercise modality for improving FEV1/FVC (%) and 6MWD (10). Herein, we examined broad categories of traditional interventions and showed that qigong is significantly more effective than other EATM-NPIs in improving FEV1 and 6MWD. Previous studies on acupuncture as an adjunctive therapy (11, 12) conducted PMA for acupuncture, Acu-TENS, moxibustion, acupressure, auricular acupuncture, and cupping, but we included acupuncture, Acu-TENS, warm needle acupuncture, auricular acupressure, electroacupuncture, pressing needle acupuncture, and acupressure in the acupuncture group and conducted NMA to compare it with other EATM-NPIs. One benefit of this analysis is that it provides the therapeutic efficacy estimates of each EATM-NPI as add-on treatment options to clinicians to improve motor and respiratory functions in patients with COPD who are refractory to standard treatment.
This study has several limitations. The scope of the included studies was broad, so it was not possible to control for all sources of heterogeneity. To conduct macroscopic analysis, we had to include heterogeneous treatments in each EATM-NPI, and the treatment schedules and severity of COPD varied across individual studies. Future studies should narrow the research question to focus on specific severities of COPD or capacities of intervention. Furthermore, our study was affected by the essential limitation of research on EATM-NPI; because of the intrinsic nature of non-pharmacological therapies, therapists could not be blinded, which led to low overall quality of the included studies and a lack of robustness in the NMA results. Moreover, we conducted a mixed comparison in macroscopic analysis, but the number of studies on each type of EATM-NPI varied, and few studies directly compared different EATM-NPIs. Finally, this study was limited by the lack of an evaluation of GRADE. Consequently, a constraint affects clearly determining the recommendation level. However, when RCTs conducted in China were assessed using GRADE, the recommendation levels were generally low, with little variation among different interventions. Considering these circumstances, the primary significance of this meta-analysis lies in its identification of information that can assist Traditional Chinese Medicine practitioners in clinical decision-making when faced with the challenge of selecting interventions under conditions of low research quality and evidence levels, i.e., in situations where information is limited. However, our evaluation of the evidence level for individual interventions was incomplete. Therefore, future research should involve subsequent studies applying the GRADE methodology to individual interventions through PMA rather than NMA.
4.4 Clinical and research implications
For patients with COPD, pharmacological treatment alone has limitations in terms of adverse drug reactions, compliance, and satisfaction. Non-pharmacological treatments for patients with COPD have been established since the mid-2000s, and evidence has been accumulating for treatment modalities such as qigong, moxibustion, chuna, and acupuncture. This study provides clinical practitioners with additional therapeutic options for managing stable COPD that does not respond to standard therapy. Particularly, various types of exercises are recommended for patients who still have diminished exercise capacity even with improved parameters on respiratory function tests. Subsequent studies should investigate various exercise therapies and indications for qigong, an EATM intervention, to establish evidence-based personalized treatment for patient symptoms. Future studies should also comply with Standards for Reporting Interventions in Clinical Trials of Acupuncture (215) and Consolidated Standards of Reporting Trials extension for non-pharmacologic treatment (216) to improve methodological quality. Moreover, the severity of COPD is an important consideration in the treatment selection and subsequent studies should further analyze this.
We did not investigate pharmacological treatments, such as herbal medicine, pharmacopuncture, and aromatherapy. In the future, studies should also investigate EATM-pharmacological interventions and conduct NMA of the synergistic effects with herbal medicine. Since head-to-head trials are difficult for EATM interventions because of a lack of resources, the findings of such studies would help present the optimal EATM intervention for each symptom and present implications for clinical practice and clinical practice guidelines. The search in this study was conducted until May 2022, so caution should be exercised when interpreting its results. If further research is conducted, a GRADE assessment should be incorporated for a more comprehensive evaluation.
5 Conclusion
Our study confirmed that the addition of EATM-NPI to standard therapy can aid symptom management in patients with COPD. We confirmed that moxibustion or qigong therapies as adjunctive therapies to standard treatment improve pulmonary function and exercise capacity, whereas chuna and acupuncture adjunctive therapies improve exercise capacity in patients with stable COPD. Clinically, we provide evidence supporting the use of moxibustion add-on therapy to improve FEV1 and chuna add-on therapy to improve 6MWD in patients who do not respond well to standard treatment. We look forward to future research efforts aimed at identifying responders to each NPI among patients with COPD, thereby optimizing NPI methods for this population.
Data availability statement
The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.
Author contributions
J-AR: Formal analysis, Investigation, Methodology, Writing – original draft, Writing – review & editing. JL: Data curation, Formal analysis, Methodology, Writing – review & editing. B-JL: Data curation, Writing – review & editing. K-IK: Conceptualization, Funding acquisition, Investigation, Methodology, Writing – original draft, Writing – review & editing. H-JJ: Conceptualization, Funding acquisition, Writing – review & editing.
Funding
The author(s) declare that financial support was received for the research, authorship, and/or publication of this article. This work was supported by the Korea Health Technology R&D Project through the Korea Health Industry Development Institute (KHIDI), funded by the Ministry of Health & Welfare, Republic of Korea (grant numbers: RS-2020-KH087748 and RS-2023-KH139413).
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Publisher’s note
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Supplementary material
The Supplementary material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpubh.2025.1410342/full#supplementary-material
Abbreviations
AE, Adverse events; CAT, COPD-acupuncture trial; CI, Confidence interval; COPD, Chronic obstructive pulmonary disease; EATM, East Asian traditional medicine; FEV1, Forced expiratory volume in 1 s; FVC, Forced vital capacity; GOLD, Global Initiative for Chronic Obstructive Lung Disease; MD, Mean differences; NMA, Network meta-analysis; NTI, Non-pharmacological intervention; OASIS, Oriental Medicine Advanced Searching Integrated System; OMT, Osteopathic manipulative treatment; QOL, Quality of life; PICOS, Participant intervention comparison outcome and study; PMA, Pairwise meta-analysis; RCT, Randomized controlled trials; STRICTA, Standards for Reporting Interventions in Clinical Trials of Acupuncture; YLD, Years lived with disability.
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Keywords: chronic obstructive pulmonary disease, non-pharmacological treatment, AddOn, systematic review, network meta-analysis
Citation: Roh J-A, Leem J, Lee B-J, Kim K-I and Jung H-J (2025) Comparative efficacy of traditional non-pharmacological add-on treatments in patients with stable chronic obstructive pulmonary disease: a systematic review and network meta-analysis. Front. Public Health. 13:1410342. doi: 10.3389/fpubh.2025.1410342
Edited by:
Manuel Zeitelhofer, Karolinska Institutet (KI), SwedenReviewed by:
Marcos Edgar Herkenhoff, University of São Paulo, BrazilYi Sub Kwak, Dong-Eui University, Republic of Korea
Fedor Malykhin, Stavropol State Medical University, Russia
Abhitinder Kumar, GD Goenka University, India
Copyright © 2025 Roh, Leem, Lee, Kim and Jung. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Kwan-Il Kim, bXloYXBweTc4QG5hdmVyLmNvbQ==; S3dhbmlsa2ltQGtodS5hYy5rcg==; Hee-Jae Jung, aGFuZmlzaEBraG1jLm9yLmty