Acupuncturecombinedtherapyforthetreatmentofnapedorsalmyofascialpainsyndrome:meta-analysis,systematicevaluation,andGRADEevaluation

Myofascial pain syndrome (MPS) is a common source of chronic neck and upper back pain, often caused by overuse, injury, or strain. It is characterized by myofascial trigger points—sensitive knots in muscles that cause local and referred pain, stiffness, and movement problems. The muscles most often affected in the neck and upper back include the upper trapezius and levator scapulae. Studies suggest MPS is highly prevalent, affecting a large portion of people with chronic non-specific neck pain.

While medications such as non-steroidal anti-inflammatory drugs and muscle relaxants are commonly used, they carry risks like stomach upset, drowsiness, and allergic reactions. Traditional Chinese medicine approaches, particularly acupuncture and related techniques, offer a non-pharmacological alternative. Acupuncture combined therapy—meaning needle insertion at specific points plus adjuncts such as moxibustion, cupping, or massage—is widely practiced and theorized to create synergistic effects that relieve pain and restore function. However, the overall strength and reliability of evidence supporting this combined approach for nape dorsal MPS remained unclear.

This study aimed to fill that gap by systematically evaluating all available randomized controlled trials.

The research team conducted a systematic review and meta-analysis registered with PROSPERO and reported according to PRISMA 2020 guidelines. They comprehensively searched eight electronic databases—including CNKI, VIP, Wanfang, SinoMed, Web of Science, PubMed, Embase, and Scopus—for randomized controlled trials published from inception through 26 February 2025. Studies were included if they compared acupuncture combined therapy (needle insertion plus at least one adjunct like moxibustion or cupping) against control interventions such as simple acupuncture, drug therapy, or exercise therapy in adults diagnosed with nape dorsal MPS. Two researchers independently screened literature, extracted data, assessed risk of bias using Cochrane RoB 2.0, and rated evidence certainty with GRADE Profiler 3.6.

Statistical analyses included random-effects or fixed-effects meta-analysis, heterogeneity assessment, meta-regression, subgroup analysis, sensitivity analysis, and trim-and-fill methods to evaluate publication bias. Outcomes of interest included pain measured on the Visual Analogue Scale (VAS), clinical effective rate, Neck Disability Index (NDI), cervical range of motion (ROM), Pain Rating Index (PRI), Present Pain Intensity (PPI), quality of life (SF-36), pressure pain threshold (PPT), and Oswestry disability score.

The review identified 21 randomized controlled trials involving a total of 1,630 patients. Compared with control groups, acupuncture combined therapy produced statistically significant improvements in several key outcomes. Pooled analysis of 17 studies showed a large reduction in VAS pain scores (SMD = −1.51, 95% CI: −2.12 to −0.90, p < 0.00001), though heterogeneity was extremely high (I2 = 96%). Twelve studies demonstrated a higher clinical effective rate with combined therapy (RR = 1.15, 95% CI: 1.1 to 1.2, p < 0.00001), with low heterogeneity (I2 = 25%).

For cervical function, only ROM flexion showed a significant benefit (MD = 7.76, 95% CI: 0.64 to 14.88, p = 0.03), while other movement directions did not differ significantly. The Pain Rating Index score improved (MD = −0.45, 95% CI: −0.52 to −0.38, p < 0.00001), and the Oswestry score showed a small but significant reduction (MD = −0.30, 95% CI: −0.59 to −0.01, p = 0.05). The NDI, SF-36, and overall PPT scores did not show statistically significant differences under random-effects models. Notably, subgroup analyses suggested that patients with a mean age greater than 35 years experienced significantly greater pain reduction and neck disability improvement than younger patients.

Publication bias analyses indicated potential bias for VAS scores and clinical effective rate. Trim-and-fill adjustment for VAS scores imputed missing studies and nullified the statistical significance, suggesting this particular finding may be less robust. In contrast, the clinical effective rate remained significant after adjustment. Regarding safety, only 5 of the 21 trials explicitly reported adverse events monitoring; one reported a single allergic reaction, four reported no adverse events, and the remaining 16 studies provided no safety data.

GRADE assessments rated evidence for VAS, NDI, SF-36, and PPT as very low certainty, while clinical effective rate and PRI score were rated as moderate certainty.

For patients suffering from nape dorsal myofascial pain syndrome, this review suggests that acupuncture combined with adjunctive therapies such as moxibustion, cupping, or massage may offer meaningful short-term pain relief and a higher chance of overall clinical improvement compared with routine care, simple acupuncture, or exercise alone. However, clinicians and patients should interpret these findings with caution. The very high heterogeneity and potential publication bias weaken confidence in the pain score improvements, even though the direction of benefit is consistent. The more robust finding is the improved clinical effective rate, supported by moderate-certainty evidence.

The observation that older patients (mean age over 35) appear to respond better could help guide treatment decisions, though more research is needed to confirm this. Safety seems acceptable based on limited reporting, but the lack of systematic adverse event monitoring across most studies means the true risk profile remains unknown. Clinicians should consider combined acupuncture therapy as a potentially effective option for short-term management while advocating for standardized protocols, better study designs with adequate blinding and allocation concealment, longer follow-up periods, and rigorous safety reporting in future trials. Patients should discuss these benefits and uncertainties with their providers, especially if they have not responded well to conventional treatments.