*4.1. Summary of Evidence*

This systematic review attempted to estimate the comparative effectiveness of Western and Eastern manual therapies for COPD patients based on a total of 30 RCTs [18–47]. Data for five interventions, including manipulation, massage, acupressure, tuina, and foot reflexology, were obtained from the pair-wise meta-analysis results. Additional massage (FEV/FVC), acupressure (FVC, 6MWD), tuina (FEV1/FVC, 6MWD), and foot reflexology (6MWD) showed significantly improved results compared to ROC alone in one or more outcomes of lung functions and/or exercise capacity. However, manipulation did not show significantly better results (FEV1, FVC, FEV1/FVC, 6MWD) compared to sham treatment. In addition, there was evidence that additional acupressure and tuina could significantly improve the quality of life of COPD patients (CAT and SGRQ), although meta-analysis could not be carried out because there was only one study that evaluated this outcome. Additional acupressure could significantly improve some objective outcomes of COPD patients, including sputum secretion, SpO2, PaO2, PaCO2, and SaO2. There were no interventions that significantly differed in the incidence of AEs compared to the controls. The number of interventions included in the NMA for FEV1, FVC, FEV1/FVC, and 6MWD was four, three, four and five, respectively. According to the results, only additional massage for FEV1 and only additional acupressure for FVC showed significantly better results than ROC. On the other hand, additional massage for FEV1/FVC showed significantly better results than ROC, acupressure, and tuina. Only additional tuina showed significantly better results for 6MWD than ROC. However, the comparative effect of foot reflexology was not significant for any outcome. The optimal treatment for each outcome according to SUCRA was massage, acupressure, massage, and tuina for FEV1, FVC, FEV1/FVC, and 6MWD, respectively.

The methodological quality of the included studies was generally poor. Limitations of methodological quality were found throughout the evaluated domains in the Cochrane's risk of bias tool, and more than half of the studies were evaluated as having an unclear or high risk of bias in relation to random sequence generation, allocation concealment, and blinding procedures. This suggests that the study results derived from the included studies may have been influenced by the placebo effect or overestimated.
