A Systematic Review and Meta-Analysis of Efficacy, Cost-Effectiveness, and Safety of Selected Complementary and Alternative Medicine for Neck and Low-Back Pain
Table 2
Summary of findings of acupuncture for low-back pain (only pain and functional outcomes).
Duration and cause of pain
Outcomes
GRADE*
Findings
Acupuncture versus no treatment
Acute/subacute, mixed, and unknown (specific, nonspecific)
Four trials showed a significant immediate/short-term posttreatment benefit of acupuncture [35, 48, 51, 52]. The pooled estimate was based on 3 trials (short-term posttreatment mean score difference: −1.19, 95% CI: −2.17 to −0.21) [35, 48, 52]. See Figure 3.
One trial showed greater improvement in pain disability index with acupuncture (Mean difference: −8.2, 95% CI: −12.0 to −4.4) [51].
Chronic specific
NA
Insufficient No trial
NA
Acupuncture versus placebo
Acute/subacute nonspecific
Pain intensity score (VAS)
Moderate Design: RCT ROB: Medium Consistency: yes Directness: yes
In two trials [31, 53], short-term posttreatment pain intensity score was not significantly different between acupuncture and placebo groups. Mean score difference: 10.6, 95% CI: −4.1, 25.3, Mean score: versus , ).
Roland-Morris Disability score
Low Design: RCT ROB: Medium Consistency: NA (only 1 trial) Directness: yes
In one trial, acupuncture was not significantly different from placebo at 3 months (mean score difference: 2.6, 95% CI: −0.7, 5.9) [53].
Acute/sub acute specific
NA
Insufficient No trial
NA
Chronic nonspecific
Pain intensity score (modified MPQ, VAS, von Korff Chronic Pain Grade Scale: 0–10)
Acupuncture was compared to placebo in 16 trials [32, 45, 51, 54–67]. The results of these trials were conflicting. The pooled estimates of 10 trials showed a significant benefit of acupuncture but only immediately posttreatment (mean score difference −0.59, 95% CI: −0.93, −0.25) [51, 55, 56, 58, 59, 61–65, 67]. The mean score differences at short- (−1.11, 95% CI: −2.33, 0.11) [54–56, 58], intermediate- (−0.18, 95% CI: −0.85, 0.49) [51, 54, 67], and long-term (−0.21, 95% CI: −0.64, 0.22) [51, 54, 63, 67] followups after the sessions were not statistically significant. See Figure 4
Roland-Morris Disability score
Moderate Design: RCT ROB: Medium Consistency: yes Directness: yes
The pooled estimate of two trials was not statistically significant (mean score difference: 0.81, 95% CI: −0.27, 1.9) [62, 67].
Chronic specific
NA
Insufficient No trial
NA
Mixed (specific, nonspecific)
NA
NA
NA
Unknown nonspecific
Pain intensity score (VAS)
Moderate Design: RCT ROB: Medium Consistency: yes Directness: yes
In one trial [68], there was no significant difference in the proportions of subjects with improved pain (not specified) between the acupuncture versus placebo (sham-acupuncture). Either real needling [30] or total body acupuncture [33] was superior to sham needling in reducing pain intensity immediately posttreatment. For example, in one study [30], the mean pain intensity (VAS score) was 37.3 in acupuncture group and 64.1 in the placebo group.
Unknown specific
NA
Insufficient No trial
NA
Acupuncture versus medication
Acute/subacute (specific, nonspecific)
NA
Insufficient No trial
NA
Chronic nonspecific
Pain intensity score (VAS)
Low Design: RCT ROB: High Consistency: no Directness: yes
There was no significant difference between acupuncture and medication immediately posttreatment. The pooled estimate was based on four trials (mean score difference: 0.11, 95% CI: −1.42, 1.65) [49, 69–71].
Oswestry Disability Index
Low Design: RCT ROB: High Consistency: no Directness: yes
In one trial, [69, 72] acupuncture achieved better score than medication (13 versus 24). The pooled estimate based on two trials showed no significant difference (mean score difference: −2.40, 95% CI: −12.20, 7.40) [69, 70].
Chronic specific
NA
Insufficient No trial
NA
Mixed nonspecific
NA
Insufficient No trial
NA
Mixed specific
No pain or function outcome reported
—
NR
Unknown nonspecific
No pain or function outcome reported
—
NR
Unknown specific
NA
Insufficient No trial
NA
Acupuncture versus physiotherapy
Acute/subacute (specific, nonspecific)
Insufficient No trial
Chronic nonspecific
Oswestry Disability Index
Low Design: RCT ROB: Medium Consistency: NA (only 1 trial) Directness: yes
One trial showed manual acupuncture to be significantly superior to physiotherapy (consisted of light, electricity, and/or heat therapy) [26]. Acupuncture group: (before) and (after) Physiotherapy group: (before) and (after).
Chronic specific
NA
Insufficient No trial
NA
Mixed/unknown (specific, nonspecific)
NA
Insufficient No trial
NA
Acupuncture versus manipulation
Acute/subacute (specific, nonspecific)
Insufficient No trial
Chronic nonspecific
Pain intensity score (VAS)
Low Design: RCT ROB: High Consistency: no Directness: yes Precision: yes
There were significant reductions in pain intensity in favour of manipulation (pooled mean difference in VAS score: 3.70, 95% CI: 1.5, 5.8) [69, 70]. See Figure 5.
Chronic specific
NA
Insufficient No trial
NA
Mixed/unknown (specific, nonspecific)
NA
Insufficient No trial
NA
Acupuncture versus massage
Acute/subacute (specific, nonspecific)
NA
Insufficient No trial
NA
Chronic nonspecific
Symptom bothersomeness scale score (0 to 10)
Low Design: RCT ROB: Medium Consistency: NA (only 1 trial) Directness: yes
One trial showed massage to be significantly better than manual acupuncture at long-term followup () [36]. Massage group—at baseline: 6.2 (95% CI: 5.8, 6.6) and at 1 year: 3.2 (95% CI: 2.5, 3.9). Acupuncture group—at baseline: 6.2 (95% CI: 5.8, 6.5) and 4.5 (95% CI: 3.8, 5.2).
Roland-Morris Disability score
Low Design: RCT ROB: Medium Consistency: NA (only 1 trial) Directness: yes
One trial showed massage to be significantly better than manual acupuncture at immediate- () or long-term followup () [36]. Mean values at baseline, 4 weeks and 1 year after treatment in the massage group: 11.8 (95% CI: 10.8, 12.7), 7.9 (95% CI: 6.9, 9.0), and 6.8 (95% CI: 5.5, 8.1) [36]. Mean values at baseline, 4 weeks and 1 year after treatment in the acupuncture group: 12.8 (95% CI: 11.7, 13.8), 9.1 (95% CI: 7.8, 9.9) and 8.0 (95% CI: 6.6, 9.3) [36].
Chronic specific
NA
Insufficient No trial
NA
Mixed/unknown (specific, nonspecific)
NA
Insufficient No trial
NA
Acupuncture versus usual care
Acute/subacute specific
NA
Insufficient No trial
NA
Acute/subacute nonspecific
Roland-Morris Disability score
Low Design: RCT ROB: Medium Consistency: NA (only 1 trial) Directness: yes
In one trial [41], the addition of acupuncture to usual care did not improve the degree of disability (RMDQ score) compared to usual care alone immediately, shortly, or intermediate-term posttreatment.
Chronic specific
NA
Insufficient No trial
NA
Chronic nonspecific
Roland-Morris Disability score
Moderate Design: RCT ROB: Medium Consistency: yes Directness: yes
In two trials, subjects who received acupuncture significantly improved in disability compared to subjects in usual care groups at short-term or intermediate-term followup after treatment [47, 67].
Pain intensity score (VAS)
Moderate Design: RCT ROB: Medium Consistency: yes Directness: yes
In two trials, subjects who received acupuncture significantly improved in pain intensity compared to subjects in usual care groups at short-term or intermediate-term followup after treatment [47, 67].
Mixed specific
NA
Insufficient No trial
NA
Mixed nonspecific
Disability score (Oswestry)
Low Design: RCT ROB: Medium Consistency: NA (only 1 trial) Directness: yes
In one trial [208], a long-term posttreatment disability score was not significantly different between the acupuncture and usual care groups (Oswestry score: −3.4, 95% CI: −7.8, 1.0).
Pain intensity score (MPQ)
Low Design: RCT ROB: Medium Consistency: NA (only 1 trial) Directness: yes
In one trial [208], a long-term posttreatment pain intensity was not significantly different between the acupuncture and usual care groups (mean difference in MPQ score: −0.2, 95% CI: −0.6, 0.1).
Unknown (specific, nonspecific)
NA
Insufficient No trial
NA
*Precision in formal grading was applied only to pooled results. VAS: visual analog scale; RMDQ: Roland-Morris disability scale; MPQ: McGill pain questionnaire; PDI: pain disability index; NPQ: neck pain questionnaire; NA: not applicable; ROB: risk of bias; RCT: randomized controlled trial.
