Sommaire

low back pain

Lombalgies et lombalgies chroniques : évaluation de l'acupuncture

Articles connexes : - conduites thérapeutiques - traitements de référence - lombalgie aigue -

1. Systematic Reviews and Meta-Analysis

1.1. Generic Acupuncture

1.1.1. Feise 2023

Feise RJ, Mathieson S, Kessler RS, Witenko C, Zaina F, Brown BT. Benefits and harms of treatments for chronic nonspecific low back pain without radiculopathy: systematic review and meta-analysis. Spine J. 2023 May;23(5):629-641. https://doi.org/10.1016/j.spinee.2022.11.003

Background contextCurrently, there are no published studies that compare nonpharmacological, pharmacological and invasive treatments for chronic low back pain in adults and provide summary statistics for benefits and harms.
PurposeThe aim of this review was to compare the benefits and harms of treatments for the management of chronic low back pain without radiculopathy and to report the findings in a format that facilitates direct comparison (Benefit-Harm Scale: level 1 to 7).
Methods Design: Systematic review and meta-analysis of randomized controlled trials, including trial registries, from electronic databases up to 23rd May 2022. Patient sample: Adults with chronic nonspecific low back pain, excluding radicular pain, in any clinical setting. Outcome measures: Comparison of pain at immediate-term (≤2 weeks) and short-term (>2 weeks to ≤12 weeks) and serious adverse events using the Benefit-Harm Scale (level 1 to 7).
Methods This was a registered systematic review and meta-analysis of randomized controlled trials. Interventions included nonpharmacological (acupuncture, spinal manipulation), pharmacological and invasive treatments compared to placebo. Best evidence criteria was used. Two independent reviewers conducted eligibility assessment, data extraction and quality appraisal.
Results The search retrieved 17,362 records. Three studies provided data on the benefits of interventions, and 30 provided data on harms. Studies included interventions of acupuncture (n=8); manipulation (n=2); pharmacological therapies (n=9), including NSAIDs and opioid analgesics; surgery (n=8); and epidural corticosteroid injections (n=3). Acupuncture (standardized mean difference (SMD) -0.51, 95%CI -0.88 to -0.14, n=1 trial, moderate quality of evidence, benefit rating of 3) and manipulation (SMD -0.39, 95%CI -0.56 to -0.21, n=2 trials, moderate quality of evidence, benefit rating of 5) were effective in reducing pain intensity compared to sham. The benefit of the other interventions was scored as uncertain due to not being effective, statistical heterogeneity preventing pooling of effect sizes, or the absence of relevant trials. The harms level warnings were at the lowest (eg, indicating rarer risk of events) for acupuncture, spinal manipulation, NSAIDs, combination ingredient opioids, and steroid injections, while they were higher for single ingredient opioid analgesics (level 4) and surgery (level 6).
Conclusions There is uncertainty about the benefits and harms of all the interventions reviewed due to the lack of trials conducted in patients with chronic nonspecific low back pain without radiculopathy. From the limited trials conducted, nonpharmacological interventions of acupuncture and spinal manipulation provide safer benefits than pharmacological or invasive interventions. However, more research is needed. There were high harms ratings for opioids and surgery.

1.1.2. Giovanardi 2023

Giovanardi CM, Gonzalez-Lorenzo M, Poini A, Marchi E, Culcasi A, Ursini F, Faldini C, Martino AD, Mazzanti U, Campesato E, Matrà A, Cevoli S, Benedetti MG. Acupuncture as an alternative or in addition to conventional treatment for chronic non-specific low back pain: Systematic review and meta-analysis. Integr Med Res. 2023 Sep;12(3):100972. https://doi.org/10.1016/j.imr.2023.100972. Epub 2023 Jul 7. PMID: 37637183; PMCID: PMC10448023.

Background Conventional therapies (CTs), pharmacological (PH) and non-pharmacological (NPH), do not always achieve benefits in the treatment of chronic low back pain (CLBP). We assessed efficacy and safety of acupuncture for CLBP as alternative or addition to CT.
Methods We included randomised controlled trials (RCTs) comparing acupuncture alone or in combination with CT to CT. We searched Medline, Cochrane Library, Embase up to May 2022. We assessed risk of bias with the original Cochrane tool and GRADE certainty of evidence. Results were pooled through meta-analysis.
Results Ten RCTs (2122 participants) were included comparing acupuncture versus CT and 6 (374 participants) comparing acupuncture plus CT to CT alone. Comparing acupuncture with NPH or PH, no differences were found for pain and disability. Comparing with combined PH and NPH, pain and disability were reduced (SMD=-0.50, 95%CI-0.62 to -0.37; SMD=-0.71, 95%CI-1.17 to -0.24). Comparing acupuncture plus NPH with NPH alone, pain and disability were reduced (SMD=-0.70, 95%CI-0.94 to -0.46; SMD=-0.95, 95%CI-1.36 to -0.54). Comparing acupuncture plus PH with PH alone, pain and disability were reduced (MD=-0.21,8 95%CI-433.28 to -10.42; MD=-3.1, 95%CI-4.87 to -1.83). Comparing acupuncture plus combined treatment versus combined treatment alone, no differences were found in pain, while disability was reduced (MD=-3.40 95%CI-5.17 to -1.63). No studies assessed adverse event. Certainty of evidence ranged from moderate to very low.
Conclusion We are uncertain whether acupuncture is more effective and safer than CT. In the comparisons without estimates' imprecision, acupuncture showed promising results. Acupuncture could be an option based on patients' preferences.

1.1.3. Asano 2022 (adjunct to standard therapy) ☆☆

Asano H, Plonka D, Weeger J. Effectiveness of Acupuncture for Nonspecific Chronic Low Back Pain: A Systematic Review and Meta-Analysis. Med Acupunct. 2022 Apr 1;34(2):96-106. https://doi.org/10.1089/acu.2021.0057

ObjectiveThis systematic review and meta-analysis assess the effectiveness of acupuncture as an adjunct to standard therapy in the management of nonspecific chronic low back pain (NScLBP), compared with standard therapy alone.
Methods A systematic literature search of full-text articles of randomized controlled trials in the date range of 2000-2020, utilizing PubMed and EBSCO databases, was performed to evaluate the efficacy of acupuncture treatment for nonspecific chronic lower back pain. The outcomes of interest were pain intensity and disability. The methodological quality of each study was evaluated using Cochrane risk-of-bias criteria. The studies were combined using meta-analysis when statistical pooling of data was possible.
Results This systematic review included 5 studies of which 4 were included in the meta-analysis. Acupuncture as an adjunct to standard therapy had clinically meaningful reduction in self-reported pain at post-treatment (mean difference = -1.04 [95% confidence interval (CI), -1.59 to -0.49], P < 0.001, I 2 = 46.1%) and at intermediate term (mean difference = -0.82 [95% CI, -1.13 to -0.50], P < 0.001, I 2 = 0%), compared with standard care. Levels of disability showed similar clinically meaningful reduction at post-treatment and intermediate term.
Conclusion Both the systematic review and meta-analysis demonstrate that acupuncture as an adjunct to standard therapy is a safe and effective method in reducing pain and disability among adults with NScLBP.

1.1.4. Baroncini 2022 ☆☆☆

Baroncini A, Maffulli N, Eschweiler J, Molsberger F, Klimuch A, Migliorini F. Acupuncture in chronic aspecific low back pain: a Bayesian network meta-analysis. J Orthop Surg Res. 2022 Jun 20;17(1):319. https://doi.org/10.1186/s13018-022-03212-3

Background This Bayesian network meta-analysis investigated the available randomized control trials (RCTs) to point out which acupuncture protocol is the most effective for chronic aspecific low back pain (LBP). Efficacy was measured in terms of pain (Visual Analogic Scale, VAS) and disability (Roland Morris Disability Questionnaire, RMQ), Transcutaneous Electrical Nerve Stimulation (TENS).
Methods PubMed, Google scholar, Embase, and Scopus were accessed in March 2022. All the RCTs comparing two or more acupuncture modalities for aspecific chronic LBP were accessed. Only studies which investigated the efficacy of acupuncture on patients with symptoms lasting a minimum of 1.5 months, or with at least three episodes in the previous 12 months, were considered eligible. The Review Manager Software (The Nordic Cochrane Collaboration, Copenhagen) was used for the methodological quality assessment. The STATA Software/MP, Version 14.1 (StataCorporation, College Station, Texas, USA), was used for the statistical analyses. The NMA was performed through the STATA routine for Bayesian hierarchical random-effects model analysis.
Results Data from 44 RCTs (8338 procedures) were retrieved. 56% of patients were women. The mean age of the patients was 48 ± 10.6 years. The mean BMI was 26.3 ± 2.2 kg/m2. The individual group (95% confidence interval (CI) 2.02, 7.98) and the standard combined with TENS (95% CI 2.03, 7.97) demonstrated the highest improvement of the RMQ. The VAS score was lower in the standard combined with TENS group (95% CI 3.28, 4.56). Considering the standard acupuncture group, different studies used similar protocols and acupuncture points and the results could thus be compared. The equation for global linearity did not find any statistically significant inconsistency in any of the network comparison.
ConclusionVerum acupuncture is more effective than sham treatment for the non-pharmacological management of LBP. Among the verum protocols, individualized acupuncture and standard acupuncture with TENS were the protocols that resulted in the highest improvement in pain and quality of life.

1.1.5. Kolber 2021

Kolber MR, Ton J, Thomas B, Kirkwood J, Moe S, Dugré N, Chan K, Lindblad AJ, McCormack J, Garrison S, Allan GM, Korownyk CS, Craig R, Sept L, Rouble AN, Perry D. PEER systematic review of randomized controlled trials: Management of chronic low back pain in primary care. Can Fam Physician. 2021;67(1). [217060]. doi

ObjectiveTo determine the proportion of chronic low back pain patients who achieve a clinically meaningful response from different pharmacologic and nonpharmacologic treatments. Data sources: MEDLINE, EMBASE, Cochrane Library, and gray literature search. Study selection: Published randomized controlled trials (RCTs) that reported a responder analysis of adults with chronic low back pain treated with any of the following 15 interventions: oral or topical nonsteroidal anti-inflammatory drugs (NSAIDs), exercise, acupuncture, spinal manipulation therapy, corticosteroid injections, acetaminophen, oral opioids, anticonvulsants, tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors (SNRIs), selective serotonin reuptake inhibitors, cannabinoids, oral muscle relaxants, or topical rubefacients.
Synthesis A total of 63 RCTs were included. There was moderate certainty that exercise (risk ratio [RR] of 1.71; 95% CI 1.37 to 2.15; number needed to treat [NNT] of 7), oral NSAIDs (RR = 1.44; 95% CI 1.17 to 1.78; NNT = 6), and SNRIs (duloxetine; RR = 1.25; 95% CI 1.13 to 1.38; NNT = 10) provide clinically meaningful benefits to patients with chronic low back pain. Exercise was the only intervention with sustained benefit (up to 48 weeks). There was low certainty that spinal manipulation therapy and topical rubefacients benefit patients. The benefit of acupuncture disappeared in higher-quality, longer (> 4 weeks) trials. Very low-quality evidence demonstrated that corticosteroid injections are ineffective. Patients treated with opioids had a greater likelihood of discontinuing treatment owing to an adverse event (number needed to harm of 5) than continuing treatment to derive any clinically meaningful benefit (NNT = 16), while those treated with SNRIs (duloxetine) had a similar likelihood of continuing treatment to attain benefit (NNT = 10) as those discontinuing the medication owing to an adverse event (number need to harm of 11). One trial each of anticonvulsants and topical NSAIDs found similar benefit to that of placebo. No RCTs of acetaminophen, cannabinoids, muscle relaxants, selective serotonin reuptake inhibitors, or tricyclic antidepressants met the inclusion criteria.
Conclusion Exercise, oral NSAIDs, and SNRIs (duloxetine) provide a clinically meaningful reduction in pain, with exercise being the only intervention that demonstrated sustained benefit after the intervention ended. Future high-quality trials that report responder analyses are required to provide a better understanding of the benefits and harms of interventions for patients with chronic low back pain.

1.1.6. Li 2020

Li YX, Yuan SE, Jiang JQ, Li H, Wang YJ. Systematic review and meta-analysis of effects of acupuncture on pain and function in non-specific low back pain. Acupuncture in Medicine. 2020. [205629]. doi

ObjectiveTo assess the effectiveness of acupuncture for non-specific low back pain (NSLBP) through systematic review of published randomised controlled trials (RCTs).
MethodsStudies were identified in electronic databases from their inception to February 2018, and were grouped according to the control interventions. The outcomes of interest were pain intensity and disability. Methodological quality was evaluated using the Cochrane risk-of-bias criteria and the Standards for Reporting Interventions in Controlled Trials of Acupuncture (STRICTA) checklist. The review was reported according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines.
Results25 trials (n=7587 participants) were identified and included in a meta-analysis. The results showed that acupuncture was more effective at inducing pain relief than: no treatment (standardised mean difference (SMD) -0.69, 95% CI -0.99 to -0.38); sham acupuncture in the immediate term (SMD -0.33, 95% CI -0.49 to -0.18), short term (SMD -0.47, 95% CI -0.77 to -0.17), and intermediate term (SMD -0.17, 95% CI -0.28 to -0.05); and usual care in the short term (SMD -1.07, 95% CI -1.81 to -0.33) and intermediate term (SMD -0.43, 95% CI -0.77 to -0.10). Also, adjunctive acupuncture with usual care was more effective than usual care alone at all time points studied. With regard to functional improvement, the analysis showed a significant difference between acupuncture and no treatment (SMD -0.94, 95% CI -1.57 to -0.30), whereas the other control therapies could not be assessed.
ConclusionWe draw a cautious conclusion that acupuncture appears to be effective for NSLBP and that acupuncture may be an important supplement to usual care in the management of NSLBP.

1.1.7. Mu 2020 ☆

Mu J, Furlan AD, Lam WY, Hsu MY, Ning Z, Lao L. Acupuncture for chronic nonspecific low back pain. Cochrane Database Syst Rev. 2020:CD013814. [167953].doi

BackgroundChronic nonspecific low back pain (LBP) is very common; it is defined as pain without a recognizable etiology that lasts for more than three months. Some clinical practice guidelines suggest that acupuncture can offer an effective alternative therapy. This review is a split from an earlier Cochrane review and it focuses on chronic LBP.
ObjectivesTo assess the effects of acupuncture compared to sham intervention, no treatment, or usual care for chronic nonspecific LBP.
Methods Search methods: We searched CENTRAL, MEDLINE, Embase, CINAHL, two Chinese databases, and two trial registers to 29 August 2019 without restrictions on language or publication status. We also screened reference lists and LBP guidelines to identify potentially relevant studies. Selection criteria: We included only randomized controlled trials (RCTs) of acupuncture for chronic nonspecific LBP in adults. We excluded RCTs that investigated LBP with a specific etiology. We included trials comparing acupuncture with sham intervention, no treatment, and usual care. The primary outcomes were pain, back-specific functional status, and quality of life; the secondary outcomes were pain-related disability, global assessment, or adverse events. Data collection and analysis: Two review authors independently screened the studies, assessed the risk of bias and extracted the data. We meta-analyzed data that were clinically homogeneous using a random-effects model in Review Manager 5.3. Otherwise, we reported the data qualitatively. We used the GRADE approach to assess the certainty of the evidence.
Main results We included 33 studies (37 articles) with 8270 participants. The majority of studies were carried out in Europe, Asia, North and South America. Seven studies (5572 participants) conducted in Germany accounted for 67% of the participants. Sixteen trials compared acupuncture with sham intervention, usual care, or no treatment. Most studies had high risk of performance bias due to lack of blinding of the acupuncturist. A few studies were found to have high risk of detection, attrition, reporting or selection bias. We found low-certainty evidence (seven trials, 1403 participants) that acupuncture may relieve pain in the immediate term (up to seven days) compared to sham intervention (mean difference (MD) -9.22, 95% confidence interval (CI) -13.82 to -4.61, visual analogue scale (VAS) 0-100). The difference did not meet the clinically important threshold of 15 points or 30% relative change. Very low-certainty evidence from five trials (1481 participants) showed that acupuncture was not more effective than sham in improving back-specific function in the immediate term (standardized mean difference (SMD) -0.16, 95% CI -0.38 to 0.06; corresponding to the Hannover Function Ability Questionnaire (HFAQ, 0 to 100, higher values better) change (MD 3.33 points; 95% CI -1.25 to 7.90)). Three trials (1068 participants) yielded low-certainty evidence that acupuncture seemed not to be more effective clinically in the short term for quality of life (SMD 0.24, 95% CI 0.03 to 0.45; corresponding to the physical 12-item Short Form Health Survey (SF-12, 0-100, higher values better) change (MD 2.33 points; 95% CI 0.29 to 4.37)). The reasons for downgrading the certainty of the evidence to either low to very low were risk of bias, inconsistency, and imprecision. We found moderate-certainty evidence that acupuncture produced greater and clinically important pain relief (MD -20.32, 95% CI -24.50 to -16.14; four trials, 366 participants; (VAS, 0 to 100), and improved back function (SMD -0.53, 95% CI -0.73 to -0.34; five trials, 2960 participants; corresponding to the HFAQ change (MD 11.50 points; 95% CI 7.38 to 15.84)) in the immediate term compared to no treatment. The evidence was downgraded to moderate certainty due to risk of bias. No studies reported on quality of life in the short term or adverse events. Low-certainty evidence (five trials, 1054 participants) suggested that acupuncture may reduce pain (MD -10.26, 95% CI -17.11 to -3.40; not clinically important on 0 to 100 VAS), and improve back-specific function immediately after treatment (SMD: -0.47; 95% CI: -0.77 to -0.17; five trials, 1381 participants; corresponding to the HFAQ change (MD 9.78 points, 95% CI 3.54 to 16.02)) compared to usual care. Moderate-certainty evidence from one trial (731 participants) found that acupuncture was more effective in improving physical quality of life (MD 4.20, 95% CI 2.82 to 5.58) but not mental quality of life in the short term (MD 1.90, 95% CI 0.25 to 3.55). The certainty of evidence was downgraded to moderate to low because of risk of bias, inconsistency, and imprecision. Low-certainty evidence suggested a similar incidence of adverse events immediately after treatment in the acupuncture and sham intervention groups (four trials, 465 participants) (RR 0.68 95% CI 0.46 to 1.01), and the acupuncture and usual care groups (one trial, 74 participants) (RR 3.34, 95% CI 0.36 to 30.68). The certainty of the evidence was downgraded due to risk of bias and imprecision. No trial reported adverse events for acupuncture when compared to no treatment. The most commonly reported adverse events in the acupuncture groups were insertion point pain, bruising, hematoma, bleeding, worsening of LBP, and pain other than LBP (pain in leg and shoulder).
Authors' conclusionsWe found that acupuncture may not play a more clinically meaningful role than sham in relieving pain immediately after treatment or in improving quality of life in the short term, and acupuncture possibly did not improve back function compared to sham in the immediate term. However, acupuncture was more effective than no treatment in improving pain and function in the immediate term. Trials with usual care as the control showed acupuncture may not reduce pain clinically, but the therapy may improve function immediately after sessions as well as physical but not mental quality of life in the short term. The evidence was downgraded to moderate to very low-certainty considering most of studies had high risk of bias, inconsistency, and small sample size introducing imprecision. The decision to use acupuncture to treat chronic low back pain might depend on the availability, cost and patient's preference

1.1.8. Xiang 2020 ★★★

Xiang Y, He JY, Tian HH, Cao BY, Li R. Evidence of efficacy of acupuncture in the management of low back pain: a systematic review and meta-analysis of randomised placebo- or sham-controlled trials. Acupuncture in Medicine. 2020;38(1):15-24. [203366]. DOI

ObjectivesTo assess the evidence for the efficacy of acupuncture for non-specific low back pain (NSLBP), compared with sham or placebo therapies. Methods: We searched Cochrane CENTRAL to December 2016, and conducted searches from 1980 to December 2016 in PubMed, MEDLINE and Embase. There were no regional restrictions applied. We included only randomised controlled trials of adults with NSLBP. Placebo/sham procedures were required of the control interventions. The trials were combined using meta-analysis when the data reported allowed for statistical pooling.
Results14 trials (2110 participants) were included in the review, and 9 were included in the meta-analysis. Immediately after the acupuncture treatment we found statistically significant differences in pain reduction between acupuncture and sham or placebo therapy (standardised mean difference (SMD) -0.40, 95% CI -0.54 to -0.25; I2 7%; 753 participants; 9 studies), but there were no differences in function (weighted mean difference (WMD) -1.05, 95% CI -3.61 to 1.52; I2 79%; 462 participants; 4 studies). At follow-up, there were significant differences in pain reduction (SMD -0.46, 95% CI -0.82 to -0.09; I2 67%), but not in function (WMD -0.98, 95%CI -3.36 to 1.40; I2 87%). We conducted subgroup analyses both immediately after treatment and at follow-up.
ConclusionThere is moderate evidence of efficacy for acupuncture in terms of pain reduction immediately after treatment for NSLBP ((sub)acute and chronic) when compared to sham or placebo acupuncture.

1.1.9. Vickers 2018 ★★★

Vickers AJ, Vertosick EA, Lewith G et al, Acupuncture Trialists' Collaboration. Acupuncture for Chronic Pain: Update of an Individual Patient Data Meta-Analysis. J Pain. 2018 May;19(5):455-474. [168043]

Comporte une analyse en sous-groupe des lombalgies
Purpose Our objective was to update an individual patient data meta-analysis to determine the effect size of acupuncture for 4 chronic pain conditionss.
Methods We searched MEDLINE and the Cochrane Central Registry of Controlled Trials randomized trials published up until December 31, 2015. We included randomized trials of acupuncture needling versus either sham acupuncture or no acupuncture control for nonspecific musculoskeletal pain, osteoarthritis, chronic headache, or shoulder pain. Trials were only included if allocation concealment was unambiguously determined to be adequate. Raw data were obtained from study authors and entered into an individual patient data meta-analysis.
Results The main outcome measures were pain and function. An additional 13 trials were identified, with data received for a total of 20,827 patients from 39 trials. Acupuncture was superior to sham as well as no acupuncture control for each pain condition (all P < .001) with differences between groups close to .5 SDs compared with no acupuncture control and close to .2 SDs compared with sham. We also found clear evidence that the effects of acupuncture persist over time with only a small decrease, approximately 15%, in treatment effect at 1 year. In secondary analyses, we found no obvious association between trial outcome and characteristics of acupuncture treatment, but effect sizes of acupuncture were associated with the type of control group, with smaller effects sizes for sham controlled trials that used a penetrating needle for sham, and for trials that had high intensity of intervention in the control arm. We conclude that acupuncture is effective for the treatment of chronic pain, with treatment effects persisting over time.Although factors in addition to the specific effects of needling at correct acupuncture point locations are important contributors to the treatment effect, decreases in pain after acupuncture cannot be explained solely in terms of placebo effects. Variations in the effect size of acupuncture in different trials are driven predominantly by differences in treatments received by the control group rather than by differences in the characteristics of acupuncture treatment.
Perspective Acupuncture is effective for the treatment of chronic musculoskeletal, headache, and osteoarthritis pain. Treatment effects of acupuncture persist over time and cannot be explained solely in terms of placebo effects. Referral for a course of acupuncture treatment is a reasonable option for a patient with chronic pain..

1.1.10. Chou 2017 ★★

Chou R, Deyo R, Friedly J, Skelly A1, Hashimoto R, Weimer M, Fu R, Dana T, Kraegel P, Griffin J, Grusing S, Brodt ED. Nonpharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline. Ann Intern Med. 2017. [191864].

Objectives A 2007 American College of Physicians guideline addressed nonpharmacologic treatment options for low back pain. New evidence is now available. Purpose: To systematically review the current evidence on nonpharmacologic therapies for acute or chronic nonradicular or radicular low back pain.
Methods Data Sources: Ovid MEDLINE (January 2008 through February 2016), Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and reference lists. Study Selection: Randomized trials of 9 nonpharmacologic options versus sham treatment, wait list, or usual care, or of 1 nonpharmacologic option versus another. Data Extraction: One investigator abstracted data, and a second checked abstractions for accuracy; 2 investigators independently assessed study quality.
Results Data Synthesis: The number of trials evaluating nonpharmacologic therapies ranged from 2 (tai chi) to 121 (exercise). New evidence indicates that tai chi (strength of evidence [SOE], low) and mindfulness-based stress reduction (SOE, moderate) are effective for chronic low back pain and strengthens previous findings regarding the effectiveness of yoga (SOE, moderate). Evidence continues to support the effectiveness of exercise, psychological therapies, multidisciplinary rehabilitation, spinal manipulation, massage, and acupuncture for chronic low back pain (SOE, low to moderate). Limited evidence shows that acupuncture is modestly effective for acute low back pain (SOE, low). The magnitude of pain benefits was small to moderate and generally short term; effects on function generally were smaller than effects on pain.Limitation: Qualitatively synthesized new trials with prior meta-analyses, restricted to English-language studies; heterogeneity in treatment techniques; and inability to exclude placebo effects.
Conclusions Several nonpharmacologic therapies for primarily chronic low back pain are associated with small to moderate, usually short-term effects on pain; findings include new evidence on mind-body interventions.

1.1.11. Yeganeh 2017 ★

Yeganeh M, Baradaran HR, Qorbani M, Moradi Y, Dastgiri S. The effectiveness of acupuncture, acupressure and chiropractic interventions on treatment of chronic nonspecific low back pain in Iran: A systematic review and meta-analysis. Complement Ther Clin Pract. 2017:11-18. [195110]. doi

BackgroundLow back pain (LBP) is one of the most common health problems in adults. The impact of LBP on the individual can cause loss of health status and function related to pain in the back. To reduce the impact of LBP on adults, drug therapy is the most frequently recommended intervention. But over the last decade, a substantial number of randomized clinical trials of non-pharmacological intervention for LBP have been published.
ObjectiveTo determine the effectiveness of acupuncture, acupressure and chiropractic (non-pharmacological) interventions on the treatment of chronic nonspecific low back pain in Iran. STUDY DESIGN: Systematic review and meta-analysis.
Methods A systematic literature search was completed without date restrictions up to May 2013 in five major databases (Medline, CINAHL, Science Direct, CAJ Full-text Database, and Cochrane databases). Only randomized controlled trials published in Persian (Farsi) or English languages were included. Two independent reviewers extracted the data. The quality of the papers was assessed using the Cochrane Back Review Risk of Bias criteria.
ResultsInitial searches revealed 415 papers, 382 of which were excluded on the basis of abstract alone. After excluding 23 papers due to duplication, the remaining 10 trial papers were subjected to a more detailed analysis of the full text, which resulted in three being excluded. The seven remaining trials had a lack of methodological and clinical homogeneity, precluding a meta-analysis. The trials used different comparators with regards to the primary outcomes, the number of treatments, the duration of treatment and the duration of follow-up.
Conclusion This systematic review demonstrates that acupuncture, acupressure and chiropractic may have a favorable effect on self-reported pain and functional limitations on NSCLBP. However, the results should be interpreted in the context of the limitations identified, particularly in relation to the heterogeneity in the study characteristics and the low methodological quality in many of the included studies.

1.1.12. Liang 2016 ★★

Liang Fei-Fan, Chen Wei-Ye, Chen Bo, Wang Hui-Hao, Xu Qin-Guang, Zhan Hong-Sheng. [Effect of acupuncture therapy on patients with low back pain: a meta-analysis]. China Journal of Orthopaedics and Traumatology. 2016;5:449-455. [186910].

ObjectiveTo systematically review the clinical efficacy of acupuncture on the patients with low back pain (LBP).
MethodsRandomized controlled trials (RCTs) about pure acupuncture therapy versus other treatments in treating LBP were electronically searched in Pub Med, CBM, Embase, The Cochrane Library, CNKI, VIP and Wanfang Data from January 2004 to May 2014. The observed index on the results were the changed scores of VAS, ODI, JOA and RMDQ. Two reviewers independently screened the literatures according to the inclusion and exclusion criteria, as well as the extracted data, and assessed the methodological quality. The results of Meta-analysis was conducted by Rev Man 5. 2 software.
ResultsTen RCTs involved 751 patients were finally included. The results of Meta-analysis indicated that the role of pure acupuncture group in improving the VAS score was better than that of the control group, and the combined effect size was RR=-1. 32, 95%CI (-1. 41, -1. 22); Z=27. 28, P<0. 000 01;the role of pure acupuncture group in improving the ODI score was better than that of the control group, and the combined effect size was RR=-5. 07, 95%CI (-7. 50, -2. 65);Z=4. 10, P<0. 000 1;the role of pure acupuncture group on improved JOA score was better than that of the control group and the combined effect size was RR=2. 83, 95%CI (2. 02, 3. 63), Z=6. 90, P<0. 000 01. The role of pure acupuncture group in improving the RMDQ score was better than that of the control group, and the combined effect size was RR=-2. 80, 95%CI (-3. 49, -2. 11), Z=7. 95, P<0. 000 01.
ConclusionThe result of meta-analysis demonstrates that pure acupuncture may have a favorable effect on self reported pain and functional limitations in LBP patients.

1.1.13. Yuan 2016 ★

Yuan QL, Wang P, Liu L, Sun F, Cai YS, Wu WT, Ye ML, Ma JT, Xu BB, Zhang YG. Acupuncture for musculoskeletal pain: A meta-analysis and meta-regression of sham-controlled randomized clinical trials. Sci Rep. 2016. [164489].

Comporte une analyse en sous-groupe des lombalgies
Aims The aims of this systematic review were to study the analgesic effect of real acupuncture and to explore whether sham acupuncture (SA) type is related to the estimated effect of real acupuncture for musculoskeletal pain.
Methods Five databases were searched. The outcome was pain or disability immediately (≤1 week) following an intervention. Standardized mean differences (SMDs) with 95% confidence intervals were calculated. Meta-regression was used to explore possible sources of heterogeneity.
Results Sixty-three studies (6382 individuals) were included. Eight condition types were included. The pooled effect size was moderate for pain relief (59 trials, 4980 individuals, SMD -0.61, 95% CI -0.76 to -0.47; P < 0.001) and large for disability improvement (31 trials, 4876 individuals, -0.77, -1.05 to -0.49; P < 0.001). In a univariate meta-regression model, sham needle location and/or depth could explain most or all heterogeneities for some conditions (e.g., shoulder pain, low back pain, osteoarthritis, myofascial pain, and fibromyalgia); however, the interactions between subgroups via these covariates were not significant (P < 0.05).
Conclusions Our review provided low-quality evidence that real acupuncture has a moderate effect (approximate 12-point reduction on the 100-mm visual analogue scale) on musculoskeletal pain. SA type did not appear to be related to the estimated effect of real acupuncture.

1.1.14. Yuan 2015 ★★★

Yuan QL, Guo TM, Liu L, Sun F, Zhang YG. Traditional Chinese Medicine for Neck Pain and Low Back Pain: A Systematic Review and Meta-Analysis. 2015;PLoS One. 2015 Feb 24;10(2):e0117146. doi: 10.1371/journal.pone.0117146. eCollection 2015.[141558]

Purpose Neck pain (NP) and low back pain (LBP) are common symptoms bothering people in daily life. Traditional Chinese medicine (TCM) has been used to treat various symptoms and diseases in China and has been demonstrated to be effective. The objective of the present study was to review and analyze the existing data about pain and disability in TCM treatments for NP and LBP.
Methods Studies were identified by a comprehensive search of databases, such as MEDLINE, EMBASE, and Cochrane Library, up to September 1, 2013. A meta-analysis was performed to evaluate the efficacy and safety of TCM in managing NP and LBP.
Results Seventy five randomized controlled trials (n = 11077) were included. Almost all of the studies investigated individuals experiencing chronic NP (CNP) or chronic LBP (CLBP). We found moderate evidence that acupuncture was more effective than sham-acupuncture in reducing pain immediately post-treatment for CNP (visual analogue scale (VAS) 10 cm, mean difference (MD) = -0.58 (-0.94, -0.22), 95%confidence interval, p = 0.01), CLBP (standardized mean difference = -0.47 (-0.77, -0.17), p = 0.003), and acute LBP (VAS 10 cm, MD = -0.99(-1.24, -0.73), p< 0.001). Cupping could bemore effective than waitlist in VAS (100mm)(MD = -19.10 (-27.61, -10.58), p < 0. 001) for CNP or medications (e.g. NSAID) for CLBP (MD = -5.4 (-8.9, -0.19), p = 0.003). No serious or life-threatening adverse effects were found.
Conclusion Acupuncture, acupressure, and cupping could be efficacious in treating the pain and disability associated with CNP or CLBP in the immediate term. Gua sha, tai chi, qigong, and Chinese manipulation showed fair effects, but we were unable to draw any definite conclusions, and further research is still needed. The efficacy of tuina and moxibustion is unknown because no direct evidence was obtained. These TCM modalities are relatively safe.

1.1.15. Xu 2013 ★★

Xu M, Yan S, Yin X, Li X, Gao S, Han R, Wei L, Luo W, Lei G. Acupuncture for chronic low back pain in long-term follow-up: a meta-analysis of 13 randomized controlled trials. Am J Chin Med. 2013;41(1):1-19.[159282]

Purpose To determine the effectiveness of acupuncture therapy.
Methods A meta-analysis was performed to compare acupuncture with sham acupuncture and other treatments. Overall, 2678 patients were identified from thirteen randomized controlled trials. The meta-analysis was performed by a random model (Cohen’s test), using the I-square test for heterogeneity and Begg’s test to assess for publication bias. Clinical outcomes were evaluated by pain intensity, disability, spinal flexion, and quality of life.
Results Compared with no treatment, acupuncture achieved better outcomes in terms of pain relief, disability recovery and better quality of life, but these effects were not observed when compared to sham acupuncture.
Conclusion Acupuncture achieved better outcomes when compared with other treatments. No publication bias was detected.
AMSTAR 5 [Liu 2015]

Lam M, Galvin R, Curry P. Effectiveness of acupuncture for nonspecific chronic low back pain: a systematic review and meta-analysis Spine (Phila Pa 1976). 2013;38(24):2124-38.[170367]

Purpose To evaluate the totality of evidence in relation to the effectiveness of acupuncture for nonspecific chronic low back pain (NSCLBP).
Methods A systematic literature search was completed without date or language restrictions up to May 2012. Studies included in the review were RCTs that examined all forms of acupuncture that adhered to the Traditional Acupuncture Theory for treating NSCLBP. Outcome measures included impairment, activity limitation, and participation restriction. The methodological quality of the studies was examined using the Cochrane risk of bias tool.
Results Thirty-two studies were included in the systematic review, of which 25 studies presented relevant data for the meta-analysis. Acupuncture had a clinically meaningful reduction in levels of self-reported pain (mean difference =-16.76 [95% confidence interval, -33.33 to -0.19], P = 0.05, I = 90%) when compared with sham, and improved function (standard mean difference =-0.94 [95% confidence interval, -1.41 to -0.47], P < 0.00, I = 78%) when compared with no treatment immediately postintervention. Levels of function also clinically improved when acupuncture in addition to usual care, or electroacupuncture was compared with usual care alone. When acupuncture was compared with medications (NSAIDs, muscle relaxants, and analgesics) and usual care, there were statistically significant differences between the control and the intervention groups but these differences were too small to be of any clinical significance. There was no evidence in support of acupuncture over transcutaneous electrical nerve stimulation.
Conclusion This systematic review demonstrates that acupuncture may have a favorable effect on self-reported pain and functional limitations on NSCLBP. However, the results should be interpreted in the context of the limitations identified, particularly in relation to the heterogeneity in the study characteristics and the low methodological quality .
AMSTAR 6 [Liu 2015]

1.1.17. Hutchinson 2012 ★

Hutchinson AJ, Ball S, Andrews JC, Jones GG. The effectiveness of acupuncture in treating chronic non-specific low back pain: a systematic review of the literature. J Orthop Surg Res. 2012;30;7:36.[159283]

Purpose Recently published guidelines support the use of acupuncture for treating non-specific low back pain and it has become a popular alternative treatment modality for patients with low back pain.
Methods A comprehensive systematic literature search was conducted through Medline using Ovid and Medical Subject Headings for randomized controlled trials published in the last 10 years. The outcomes scored were subjective pain scores and functional outcome scores.
Results Eighty two randomized studies were identified, of which 7 met our inclusion criteria (13874 patients). Three studies found a significant difference in pain scores when comparing acupuncture, or sham acupuncture, with conventional therapy or no care. Two studies demonstrated a significant difference between acupuncture treatment and no treatment or routine care at 8 weeks and 3 months. Three studies demonstrated no significant difference between acupuncture and minimal/sham acupuncture with no difference in pain relief or function over 6 to 12 months.
Conclusion This review provides some evidence to support acupuncture as more effective than no treatment, but no conclusions can be drawn about its effectiveness over other treatment modalities as the evidence is conflicting.

1.1.18. Chou 2010 ★

Chou R. Low back pain (chronic). BMJ Clin Evid. 2010. pii: 1116 [167410].

Introduction Over 70% of people in developed countries develop low back pain (LBP) at some time. But recovery is not always favourable: 82% of non recent-onset patients still experience pain 1 year later. Many patients with chronic LBP who were initially told that their natural history was good spend months or years seeking relief.
Methods We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of oral drug treatments? What are the effects of injection therapy? What are the effects of non-drug treatments? What are the effects of non-surgical and surgical treatments? We searched: Medline, Embase, The Cochrane Library, and other important databases up to April 2009 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
Results We found 64 systematic reviews or RCTs that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
Conclusions In this systematic review, we present information relating to the effectiveness and safety of the following interventions: acupuncture, analgesics, antidepressants, back schools, behavioural therapy, electromyographic biofeedback, exercise, injections (epidural corticosteroid injections, facet joint injections, local injections), intensive multidisciplinary treatment programmes, lumbar supports, massage, muscle relaxants, non-steroidal anti-inflammatory drugs (NSAIDs), non-surgical interventional therapies (intradiscal electrothermal therapy, radiofrequency denervation), spinal manipulative therapy, surgery, traction, and transcutaneous electrical nerve stimulation (TENS).
Acupuncture Likely to be beneficial

1.1.19. Furlan 2010 ☆

Furlan AD, Yazdi F, Tsertsvadze A, Gross A, Van Tulder M, Santaguida L et al. Complementary and alternative therapies for back pain II. Evid Rep Technol Assess (Full Rep). 2010;194:1-764. [75543].

Background Back and neck pain are important health problems with serious societal and economic implications. Conventional treatments have been shown to have limited benefit in improving patient outcomes. Complementary and Alternative Medicine (CAM) therapies offer additional options in the management of low back and neck pain. Many trials evaluating CAM therapies have poor quality and inconsistent results.
Objectives To systematically review the efficacy, effectiveness, cost-effectiveness, and harms of acupuncture, spinal manipulation, mobilization, and massage techniques in management of back, neck, and/or thoracic pain.
Methods Data Sources: MEDLINE, Cochrane Central, Cochrane Database of Systematic Reviews, CINAHL, and EMBASE were searched up to 2010; unpublished literature and reference lists of relevant articles were also searched. Study selection: All records were screened by two independent reviewers. Primary reports of comparative efficacy, effectiveness, harms, and/or economic evaluations from randomized controlled trials (RCTs) of the CAM therapies in adults (age ≥ 18 years) with back, neck, or thoracic pain were eligible. Non-randomized controlled trials and observational studies (case-control, cohort, cross-sectional) comparing harms were also included. Reviews, case reports, editorials, commentaries or letters were excluded. Data Extraction: Two independent reviewers using a predefined form extracted data on study, participants, treatments, and outcome characteristics.
RESULTS 265 RCTs and 5 non-RCTs were included [acupuncture N= 105]. Acupuncture for chronic nonspecific low back pain was associated with significantly lower pain intensity than placebo but only immediately post-treatment (VAS: -0.59, 95 percent CI: -0.93, -0.25). However, acupuncture was not different from placebo in post-treatment disability, pain medication intake, or global improvement in chronic nonspecific low back pain. Acupuncture did not differ from sham-acupuncture in reducing chronic non-specific neck pain immediately after treatment (VAS: 0.24, 95 percent CI: -1.20, 0.73). Acupuncture was superior to no treatment in improving pain intensity (VAS: -1.19, 95 percent CI: 95 percent CI: -2.17, -0.21), disability (PDI), functioning (HFAQ), well-being (SF-36), and range of mobility (extension, flexion), immediately after the treatment. In general, trials that applied sham-acupuncture tended to produce negative results (i.e., statistically non-significant) compared to trials that applied other types of placebo (e.g., TENS, medication, laser). Results regarding comparisons with other active treatments (pain medication, mobilization, laser therapy) were less consistent Acupuncture was more cost-effective compared to usual care or no treatment for patients with chronic back pain. For both low back and neck pain, manipulation was significantly better than placebo or no treatment in reducing pain immediately or short-term after the end of treatment. Manipulation was also better than acupuncture in improving pain and function in chronic nonspecific low back pain. Results from studies comparing manipulation to massage, medication, or physiotherapy were inconsistent, either in favor of manipulation or indicating no significant difference between the two treatments. Findings of studies regarding costs of manipulation relative to other therapies were inconsistent. Mobilization was superior to no treatment but not different from placebo in reducing low back pain or spinal flexibility after the treatment. Mobilization was better than physiotherapy in reducing low back pain (VAS: -0.50, 95 percent CI: -0.70, -0.30) and disability (Oswestry: -4.93, 95 percent CI: -5.91, -3.96). In subjects with acute or subacute neck pain, mobilization compared to placebo significantly reduced neck pain. Mobilization and placebo did not differ in subjects with chronic neck pain. Massage was superior to placebo or no treatment in reducing pain and disability only amongst subjects with acute/sub-acute low back pain. Massage was also significantly better than physical therapy in improving back pain (VAS: -2.11, 95 percent CI: -3.15, -1.07) or disability. For subjects with neck pain, massage was better than no treatment, placebo, or exercise in improving pain or disability, but not neck flexibility. Some evidence indicated higher costs for massage use compared to general practitioner care for low back pain. Reporting of harms in RCTs was poor and inconsistent. Subjects receiving CAM therapies reported soreness or bleeding on the site of application after acupuncture and worsening of pain after manipulation or massage. In two case-control studies cervical manipulation was shown to be significantly associated with vertebral artery dissection or vertebrobasilar vascular accident.
Conclusions Evidence was of poor to moderate grade and most of it pertained to chronic nonspecific pain, making it difficult to draw more definitive conclusions regarding benefits and harms of CAM therapies in subjects with acute/subacute, mixed, or unknown duration of pain. The benefit of CAM treatments was mostly evident immediately or shortly after the end of the treatment and then faded with time. Very few studies reported long-term outcomes. There was insufficient data to explore subgroup effects. The trial results were inconsistent due probably to methodological and clinical diversity, thereby limiting the extent of quantitative synthesis and complicating interpretation of trial results. Strong efforts are warranted to improve the conduct methodology and reporting quality of primary studies of CAM therapies. Future well powered head to head comparisons of CAM treatments and trials comparing CAM to widely used active treatments that report on all clinically relevant outcomes are needed to draw better conclusions

1.1.20. Rubinstein 2010 ★★

Rubinstein Sm, Van Middelkoop M, Kuijpers T, Ostelo R, Verhagen Ap, De Boer Mr, Koes Bw, Van Tulder Mw. A systematic review on the effectiveness of complementary and alternative medicine for chronic non-specific low-back pain. Eur Spine J. 2010;19(8):1213-28. [155288]

ObjectifsThe purpose of this systematic review was to assess the effects of spinal manipulative therapy (SMT), acupuncture and herbal medicine for chronic non-specific LBP.
MethodsA comprehensive search was conducted by an experienced librarian from the Cochrane Back Review Group (CBRG) in multiple databases up to December 22, 2008. Randomised controlled trials (RCTs) of adults with chronic non-specific LBP, which evaluated at least one clinically relevant, patient-centred outcome measure were included. Two authors working independently from one another assessed the risk of bias using the criteria recommended by the CBRG and extracted the data. The data were pooled when clinically homogeneous and statistically possible or were otherwise qualitatively described. GRADE was used to determine the quality of the evidence
ResultsIn total, 35 RCTs (8 SMT, 20 acupuncture, 7 herbal medicine), which examined 8,298 patients, fulfilled the inclusion criteria. Approximately half of these (2 SMT, 8 acupuncture, 7 herbal medicine) were thought to have a low risk of bias. In general, the pooled effects for the studied interventions demonstrated short-term relief or improvement only. The lack of studies with a low-risk of bias, especially in regard to SMT precludes any strong conclusions; however, the principal findings, which are based upon low- to very-low-quality evidence, suggest that SMT does not provide a more clinically beneficial effect compared with sham, passive modalities or any other intervention for treatment of chronic low-back pain. There is evidence, however, that acupuncture provides a short-term clinically relevant effect when compared with a waiting list control or when acupuncture is added to another intervention. Although there are some good results for individual herbal medicines in short-term individual trials, the lack of homogeneity across studies did not allow for a pooled estimate of the effect.
Conclusions. In general, these results are in agreement with other recent systematic reviews on SMT, but in contrast with others. These results are also in agreement with recent reviews on acupuncture and herbal medicine. Randomized trials with a low risk of bias and adequate sample sizes are direly needed.
AMSTAR 5 [Liu 2015]

1.1.21. Trigkilidas 2010 ★★

Trigkilidas D. Acupuncture Therapy for chronic lower back pain: a systematic review. Ann R Coll Surg Engl. 2010;92(7):595-8.[155569].

Introduction Chronic low back pain is a common condition affecting a significant proportion of the population and has large economic implications on the society. Acupuncture has grown in popularity as an alternative therapy for chronic low back pain. Recent National Institute for Health and Clinical Excellence (NICE) guidelines on low back pain offer a course of acupunctureas a baseline treatment option according to patient preference. The aim of this systematic review was to evaluate if this treatment option is justified in view of recent evidence available on the efficacy of acupuncture.
Materials And Methods Studies included were identified by a PubMed search for relevant, randomised, controlled trials on the 23 July 2009. A systematic review was performed.
Results Fifteen randomised controlled trials were identified. Of these, four met the eligibility criteria .These trials suggest acupuncture can be superior to usual care in treating chronic low back pain, especially, when patients have positive expectations about acupuncture.
Conclusions NICE guidelines of a course of acupuncture, offered according to patient preference as a treatment option for chronic low back pain, are justified.

1.1.22. Machado 2009

Machado LAC, Kamper SJ, Herbert RD, Maher CG, and Mcauley JH. Analgesic effects of treatments for non-specific low back pain: a meta-analysis of placebo-controlled randomized trials. Rheumatology. 2009;48(5):520-7. [200359].

OBJECTIVE: Estimates of treatment effects reported in placebo-controlled randomized trials are less subject to bias than those estimates provided by other study designs. The objective of this meta-analysis was to estimate the analgesic effects of treatments for non-specific low back pain reported in placebo-controlled randomized trials. METHODS: Medline, Embase, Cinahl, PsychInfo and Cochrane Central Register of Controlled Trials databases were searched for eligible trials from earliest records to November 2006. Continuous pain outcomes were converted to a common 0-100 scale and pooled using a random effects model. RESULTS: A total of 76 trials reporting on 34 treatments were included. Fifty percent of the investigated treatments had statistically significant effects, but for most the effects were small or moderate: 47% had point estimates of effects of <10 points on the 100-point scale, 38% had point estimates from 10 to 20 points and 15% had point estimates of >20 points. Treatments reported to have large effects (>20 points) had been investigated only in a single trial. CONCLUSIONS: This meta-analysis revealed that the analgesic effects of many treatments for non-specific low back pain are small and that they do not differ in populations with acute or chronic symptoms.

AMSTAR 3 [Liu 2015]

1.1.23. Ammendola 2008 ★★

Ammendolia C, Furlan AD, Imamura M, Irvin E, Van Tulder M. Evidence-informed management of chronic low back pain with needle acupuncture. Spine J. 2008;8(1):160-172. [147464]

In this review, there appears to be some evidence for the use of acupuncture for the treatment of CLBP. When compared with no treatment, there is evidence that acupuncture is effective in pain relief and functional improvement immediately after a series of treatment sessions and in the short-term follow-up. Compared with other treatments, evidence suggests that acupuncture is not more effective for pain relief or functional improvement. The most consistent evidence appears to be for the addition of acupuncture to other therapies, which demonstrated more effective benefit in pain relief and functional improvement than the same therapies without acupuncture. However, given the inconclusive evidence for the effectiveness of acupuncture when compared with sham acupuncture, more studies are needed to determine whether the positive demonstrated benefits extend beyond placebo. Among the eligible studies in this review, 50% were considered to be of low quality or had fatal flaws. Even among the most recent published RCTs, half were of lower quality. Therefore, there is a need for high-quality studies evaluating the effectiveness of acupuncture for CLBP. This is especially the case for the evaluation of acupuncture to no treatment, for which there is currently only one highquality trial. This is also the case for comparing acupuncture with sham/placebo therapy where the current evidence is conflicting. More research is also needed to assess the validity of sham acupuncture. It is unknown, for example, whether applying needle acupuncture to nonacupuncture points is associated with a therapeutic benefit beyond placebo. There is also a need for better reporting of RCTs for acupuncture. Given the variation in the practice of acupuncture, details regarding specific techniques, use of adjunct treatments, number of needles and/or acupuncture points used, duration of treatment, and experience of the acupuncturists should be reported. Future studies should also report clinically important differences among study groups rather than only statistically significant differences. There is also the need for more studies evaluating the costs associated with acupuncture in comparison with other.

AMSTAR 4 [Liu 2015]

1.1.24. Hall 2008 ∅

Hall H, McIntosh G. Low back pain (chronic). BMJ Clin Evid. 2008. pii: 1116 [167666]

Introduction Over 70% of people in resource-rich countries develop low back pain (LBP) at some time. But recovery is not always favourable: 82% of non-recent-onset patients still experience pain one year later. Many chronic patients who were initially told that their natural history was good spend months or years seeking relief.
Methods And Outcomes We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of oral drug treatments? What are the effects of injection therapy? What are the effects of non-drug treatments? We searched: Medline, Embase, The Cochrane Library, and other important databases up to May 2007 (BMJ Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
Results We found 74 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
Conclusions In this systematic review, we present information relating to the effectiveness and safety of the following interventions: acupuncture, analgesics, antidepressants, back schools, behavioural therapy, electromyographic biofeedback, exercise, injections (epidural steroid injections, facet joint injections, local injections), intensive multidisciplinary treatment programmes, lumbar supports, massage, muscle relaxants, non-steroidal anti-inflammatory drugs (NSAIDs), spinal manipulative therapy, traction, and transcutaneous electrical nerve stimulation (TENS).
Acupuncture Unknown effectiveness

1.1.25. Yuan 2008 ★★

Yuan J, Purepong N, Kerr DP, Park J, Bradbury I, McDonough S. Effectiveness of Acupuncture for Low Back Pain. A Systematic Review. Spine. 2008;33(23):E887–E900. [152529]

Purpose To explore the evidence for the effectiveness of acupuncture for nonspecific low back pain (LBP).
Methods Searches were completed for RCTs on all types of acupuncture for patients with nonspecific LBP published in English. Methodologic quality was scored using the Van Tulder scale. Trials were deemed to be high quality if they scored more than 6/11 on the Van Tulder scale, carried out appropriate statistical analysis, with at least 40 patients per group, and did not exceed 20% and 30% dropouts at short/intermediate and long-term follow-up, respectively. High quality trials were given more weight when conducting the best evidence synthesis. Studies were grouped according to the control interventions, i.e., no treatment, sham intervention, conventional therapy, acupuncture in addition to conventional therapy. Treatment effect size and clinical significance were also determined. The adequacy of acupuncture treatment was judged by comparison of recommendations made in textbooks, surveys, and reviews.
Results Twenty-three trials (n = 6359) were included and classified into 5 types of comparisons, 6 of which were of high quality. There is moderate evidence that acupuncture is more effective than no treatment, and strong evidence of no significant difference between acupuncture and sham acupuncture, for short-term pain relief. There is strong evidence that acupuncture can be a useful supplement to other forms of conventional therapy for nonspecific LBP, but the effectiveness of acupuncture compared with other forms of conventional therapies still requires further investigationes.
Conclusion Acupuncture versus no treatment, and as an adjunct to conventional care, should be advocated in the European Guidelines for the treatment of chronic LBP.

1.1.26. Keller 2007

Keller A, Hayden J, Bombardier C, Van Tulder M. Effect sizes of non-surgical treatments of non-specific low-back pain. Eur Spine J. 2007;16(11):1776-88. [146413].

Numerous randomized trials have been published investigating the effectiveness of treatments for non-specific low-back pain (LBP) either by trials comparing interventions with a no-treatment group or comparing different interventions. In trials comparing two interventions, often no differences are found and it raises questions about the basic benefit of each treatment. To estimate the effect sizes of treatments for non-specific LBP compared to no-treatment comparison groups, we searched for randomized controlled trials from systematic reviews of treatment of non-specific LBP in the latest issue of the Cochrane Library, issue 2, 2005 and available databases until December 2005. Extracted data were effect sizes estimated as Standardized Mean Differences (SMD) and Relative Risk (RR) or data enabling calculation of effect sizes. For acute LBP, the effect size of non-steroidal anti-inflammatory drugs (NSAIDs) and manipulation were only modest (ES: 0.51 and 0.40, respectively) and there was no effect of exercise (ES: 0.07). For chronic LBP, acupuncture, behavioral therapy, exercise therapy, and NSAIDs had the largest effect sizes (SMD: 0.61, 0.57, and 0.52, and RR: 0.61, respectively), all with only a modest effect. Transcutaneous electric nerve stimulation and manipulation had small effect sizes (SMD: 0.22 and 0.35, respectively). As a conclusion, the effect of treatments for LBP is only small to moderate. Therefore, there is a dire need for developing more effective interventions.

AMSTAR 2 [Liu 2015]

1.1.27. Furlan 2005 ★★★

Furlan Ad, Van Tulder Mw, Cherkin Dc, Tsukayama H, Lao L, Koes Bw, Berman Bm.. Acupuncture and dry-needling for low back pain. Cochrane Database Syst Rev. 2005;001351. [135606]. . Update of Cochrane Database Syst Rev. 2000:CD001351. Reproduit dans : Furlan AD, van Tulder M, Cherkin D, Tsukayama H, Lao L, Koes B, Berman B. Acupuncture and dry-needling for low back pain: an updated systematic review within the Framework of the Cochrane Collaboration. Spine. 2005;30(8):944-63. [140619]

Background Although low-back pain is usually a self-limiting and benign disease that tends to improve spontaneously over time, a large variety of therapeutic interventions are available for its treatment.
ObjectivesTo assess the effects of acupuncture for the treatment of non-specific low-back pain and dry-needling for myofascial pain syndrome in the low-back region. Search Strategy: We updated the searches from 1996 to February 2003 in CENTRAL, MEDLINE, and EMBASE. We also searched the Chinese Cochrane Centre database of clinical trials and Japanese databases to February 2003. Selection Criteria: Randomized trials of acupuncture (that involves needling) for adults with non-specific (sub)acute or chronic low-back pain, or dry-needling for myofascial pain syndrome in the low-back region. Data Collection And Analysis: Two reviewers independently assessed methodological quality (using the criteria recommended by the Cochrane Back Review Group) and extracted data. The trials were combined using meta-analyses methods or levels of evidence when the data reported did not allow statistical pooling.
Main ResultsThirty-five RCTs were included; 20 were published in English, seven in Japanese, five in Chinese and one each in Norwegian, Polish and German. There were only three trials of acupuncture for acute low-back pain. They did not justify firm conclusions, because of small sample sizes and low methodological quality of the studies. For chronic low-back pain there is evidence of pain relief and functional improvement for acupuncture, compared to no treatment or sham therapy. These effects were only observed immediately after the end of the sessions and at short-term follow-up. There is evidence that acupuncture, added to other conventional therapies, relieves pain and improves function better than the conventional therapies alone. However, effects are only small. Dry-needling appears to be a useful adjunct to other therapies for chronic low-back pain. No clear recommendations could be made about the most effective acupuncture technique.
Authors' ConclusionsThe data do not allow firm conclusions about the effectiveness of acupuncture for acute low-back pain. For chronic low-back pain, acupuncture is more effective for pain relief and functional improvement than no treatment or sham treatment immediately after treatment and in the short-term only. Acupuncture is not more effective than other conventional and “alternative” treatments. The data suggest that acupuncture and dry-needling may be useful adjuncts to other therapies for chronic low-back pain. Because most of the studies were of lower methodological quality, there certainly is a further need for higher quality trials in this area.
AMSTAR 9 [Liu 2015]

1.1.28. Manheimer 2005 ★★★

Manheimer E, White A, Berman B et al. Méta-analysis: acupuncture for low back pain. Ann Intern Med 2005;142:651-63.[136186]

Purpose To assess acupuncture's effectiveness for treating law back pain. Data Sources: Randomized, controlled trials were identified through searches of MEDLINE, Cochrane Central, EMBASE, AMED, CINAHL, CISCOM, and GERA databases through August 2004. Additional data sources included previous reviews and personal contacts with colleagues.
Methods Randomized, controlled trials were identified through searches of MEDLINE, Cochrane Central, EMBASE, AMED, CINAHL, CISCOM, and GERA databases through August 2004. Additional data sources included previous reviews and personal contacts with colleagues. Randomized, controlled trials comparing needie acupuncture with sham acupuncture, other sham treatments, no additional treatment, or another active treatment for patients with low back pain. Data were dually extracted for the outcomes of pain, functional status, overall improvement, return to work, and analgesic consumption. ln addition, study quality was assessed.
Results The 33 randomized, controlled trials that met inclusion criteria were subgrouped according to acute or chronic pain, style of acupuncture, and type of control group used. For the primary outcome of short-term relief of chronic pain, the meta-analyses (22 RCTs) showed that acupuncture is significantly more effective than sham treatment (standardized mean difference, 0.54 [95% Cl, 0.35 to 0.73]; 7 trials) and no additional treatment (standardized mean difference, 0.69 [Cl, 0.40 to 0.98]; 8 trials).
Conclusion Acupuncture effectively relieves chronic low back pain. No evidence suggests that acupuncture is more effective than other active therapies.
AMSTAR 8 [Liu 2015]

1.1.29. Cherkin 2003 Ø

Cherkin DC et al. A review of the evidence for the effectiveness, safety, and cost acupuncture, massage therapy, and spinal manipulation for pain. Ann Intern Med. 2003;138(11):898-906.[27277].

BackgroundFew treatments for back pain are supported by strong scientific evidence. Conventional treatments, although widely used, have had limited success. Dissatisfied patients have, therefore, turned to complementary and alternative medical therapies and providers for care for back pain.
ObjectifsTo provide a rigorous and balanced summary of the best available evidence about the effectiveness, safety, and costs of the most popular complementary and alternative medical therapies used to treat back pain.
MéthodsData Sources: MEDLINE, EMBASE, and the Cochrane Controlled Trials Register. Study Selection: Systematic reviews of randomized, controlled trials (RCTs) that were published since 1995 and that evaluated acupuncture, massage therapy, or spinal manipulation for nonspecific back pain and RCTs published since the reviews were conducted. Data Extraction: two authors independently extracted data from the reviews (including number of RCTs, type of back pain, quality assessment, and conclusions) and original articles (including type of pain, comparison treatments, sample size, outcomes, follow-up intervals, loss to follow-up, and authors' conclusions). Data Synthesis: because the quality of the 20 RCTs that evaluated acupuncture was generally poor, the effectiveness of acupuncture for treating acute or chronic back pain is unclear. The three RCTs that evaluated massage reported that this therapy is effective for subacute and chronic back pain. A meta-regression analysis of the results of 26 RCTs evaluating spinal manipulation for acute and chronic back pain reported that spinal manipulation was superior to sham therapies and therapies judged to have no evidence of a benefit but was not superior to effective conventional treatments.
ConclusionsInitial studies have found massage to be effective for persistent back pain. Spinal manipulation has small clinical benefits that are equivalent to those of other commonly used therapies. The effectiveness of acupuncture remains unclear. All of these treatments seem to be relatively safe. Preliminary evidence suggests that massage, but not acupuncture or spinal manipulation, may reduce the costs of care after an initial course of therapy.

1.1.30. Ernst 2002 ★★

Ernst E et al. Acupuncture for back pain meta-analysis of randomised controlled trials and an update with data from the most recent studies. Schmerz. 2002;16(2):129-39.[101134]

Purpose To compare our meta-analysis of trials of acupuncture for the treatment of back pain with a qualitative review and the most recent studies on the subject.
Methods A systematic literature search was conducted to retrieve all randomised controlled trials of any form of acupuncture for any type of back pain in humans. The adequacy of the acupuncture was assessed by consulting six experienced acupuncturists. The main outcome measure for the meta-analysis was numbers of subjects who where improved at the end of treatment. These data are discussed in relation to the qualitative review and the most recent studies.
Results Twelve studies were included of which nine presented data suitable for meta-analysis.The odds ratio of improvement with acupuncture compared with control intervention was 2.30 (95% confidence interval 1.28 to 4.13). For sham-controlled, evaluator-blinded studies, the odds ratio was 1.37 (95% confidence interval, 0.84-2.25). The results from the majority of the most recent studies also support the effectiveness of acupuncture in the treatment of back pain.
Conclusion Collectively, these data imply that acupuncture is superior to various control interventions,although there is insufficient evidence to state whether it is superior to placebo.

1.1.31. Henderson 2002 ★

Henderson H. Acupuncture: evidence for its use in chronic low back pain. Br J Nurs. 2002;11:1395-140.[178346].

Back pain is a major economic burden in the UK, with increasing numbers of patients seeking complementary therapies, such as acupuncture, as a means to supplement traditional medical treatments. Studies to date have produced conflicting results relating to the efficacy of acupuncture and thus this systematic review will provide a concise summary of the clinical scenario in Western countries. A search of various electronic databases identified 11 articles consisting of three case studies, five randomized controlled trials, and two cross-over trials. Systematic examination of these articles did not provide definitive evidence to support or refute the use of acupuncture in the treatment of low back pain. In an era of increasing demands for evidence-based practice and professional accountability, the absence of irrefutable scientific evidence places nurses and medics in a vulnerable position.

1.1.32. Zhu 2002

Zhu Y, Origasa H, and Wang Q. [Meta-analysis of acupuncture therapy for relieving low back pain on the visual analog scale], Japanese Pharmacology and Therapeutics. 2002;30(12):997-1002. [200361].

BackgroundAcupuncture has been applied to medical practices within the Chinese traditional medicine for a long time. It was supposed to alleviate the low back pain through low frequency electricity.
ObjectiveThe purpose of this study is to assess the overall efficacy of acupuncture on low back pain using a meta-analytic method.
MethodsWe used the VAS （visual analog scale）as a measure of the effect on pain relief in a scale of 10cm. From nine controlled clinical trials selected by Medline or Japanese database on medical articles, Giles study was excluded since it included a therapy of spinal manipulation.
Results Therefore, a total of 8 studies including 394 patients were utilized for the meta－analysis. The efficacy was consistent across studies, favoring acupuncture. The overall efficacy representing the difference between acupuncture and control was 0.33cm（95％CI ：0.11－0.54cm, p＝0.003. Subset analyses by Japanese and English articles showed similar results that indicated the validity of meta-analytic finding.
ConclusionsThe meta-analysis has shown that acupuncture might be effective to lower the low back pain. Since the total sample size was relatively small, a larger controlled trial is further necessary to conduct.
AMSTAR 26 [Liu 2015]

1.1.33. Van Tulder 2000 Ø

Tulder MW VA, Cherkin DC, Berman B, Lao L, Koes BW. Acupuncture for low back pain. Cochrane Database Syst Rev. 2000;2:001351. [95316].

Background Although low back pain is usually a self-limiting and benign disease that tends to improve spontaneously over time, a large variety of therapeutic interventions are available for the treatment of low back pain.
ObjectivesThe objective of this review was to assess the effects of acupuncture for the treatment of non-specific low back pain. Search Strategy: We searched the Cochrane Complementary Medicine Field trials register, the Cochrane Controlled Trials Register (1997, issue 1), Medline (1966 - 1996), Embase (1988 - 1996), Science Citation Index and reference lists of articles. Selection Criteria: Randomised trials of all types of acupuncture treatment that involves needling for subjects with non-specific low back pain. Data Collection And Analysis: Two reviewers blinded with respect to authors, institution and journal independently assessed trial quality and extracted data.
Main ResultsEleven trials were included. The methodological quality was low. Only two trials were of high quality. Three trials compared acupuncture to no treatment, which were of low methodological quality and provide conflicting evidence. There was moderate evidence from two trials that acupuncture is not more effective than trigger point injection or transcutaneous electrical nerve stimulation (TENS). There was limited evidence from eight trials that acupuncture is not more effective than placebo or sham acupuncture for the treatment of chronic low back pain.
Reviewer's ConclusionsThe evidence summarised in this systematic review does not indicate that acupuncture is effective for the treatment of back pain.

1.1.34. Strauss 1999 Ø

Strauss AJ. Acupuncture and the treatment of chronic low back pain: a review of the literature. Chiropractic Journal of Australia 1999;29(3):112-8.[111357]

Purpose To systematically review clinical trials assessing the efficacy of acupuncture treatment of chronic low-back pain. The goals of this critical review of the literature include: 1) to determine how strong the research evidence is for acupuncture as a treatment for chronic low-back pain; 2) to evaluate if the research is of an acceptable standard; and 3) to propose a research design to evaluate acupuncture management in the treatment of chronic low-back pain.
Methods Chronic low-back pain is a very common condition for which no universally accepted treatment exists. Acupuncture is a commonly used therapy to treat chronic pain. Data Sources: A computer-aided search of medical indexes for papers published between 1978 and 1998 was conducted. The indices included MEDLINE, CINAHL, MANTIS, AMED,AMI, and the Internet using the terms: acupuncture, low back pain, and Chinese Medicine. Study Selection: Four peer-reviewed literature articles were identified. Data Extraction: Scores were given for quality based on the following categories: study population, quality of intervention, effect measurement, and data presentation and analysis.
Results The methods scored in the trials ranged from 20 to 46 points (out of a possible total of 100), indicating that all the trials were of poor quality. Three studies showed a favourable result for acupuncture.
Conclusion There are flaws in the design of all four studies. The efficacy of acupuncture for patients with chronic low-back pain has not been demonstrated with sound randomised controlled clinical trials. One cannot necessarily conclude from this review whether acupuncture is an effective treatment due to the poor design and/or methodology of the trials. This paper suggests an alternate design and methodology to evaluate the efficacy of acupuncture in the management of chronic low-back pain.

1.1.35. Van Tulder 1999 ★

Van Tulder MW, Cherkin DC, Berman B, Lao L, Koes BW. The effectiveness of the acupuncture in the managment of acute and chronic law back pain. A systematic review within the framework of the Cochrane Collaboration Back Review Group. Spine. 1999;24(11):1113-1123.[59016]

Purpose To evaluate the efficacy and effectiveness of acupuncture for the management of nonspecific low back pain.
Methods Randomized controlled trials were done to assess the effectiveness of all types of acupuncture treatment, which involves needling for subjects with nonspecific low back pain. Two reviewers blinded with respect to authors, institution, and journal independently assessed the methodologic quality of the studies. Because data were statistically and clinically too heterogeneous, a qualitative review was performed. The evidence was classified into four levels: strong, moderate, limited, or no evidence.
Results Eleven randomized controlled trials were included. Overall, the methodologic quality was low. Only two studies met the preset “high quality” level for this review. No study clearly evaluated acupuncture for acute low back pain. The results indicate that there was no evidence showing acupuncture to be more effective than no treatment. There was moderate evidence indicating that acupuncture is not more effective than trigger-point injection or transcutaneous electrical nerve stimulation, and there was limited evidence that acupuncture is not more effective than placebo or sham acupuncture for the management of chronic low back pain.
Conclusion Because this systematic review did not clearly indicate that acupuncture is effective in the management of back pain, the authors would not recommend acupuncture as a regular treatment for patients with low back pain. There clearly is a need for more high-quality randomized controlled trials.

1.1.36. Ernst 1998 ★

Ernst E, White AR. Acupuncture for back pain: a metaanalysis of randomized controlled trials. Arch Intern Med 1998;158(20):2235-41.[58723]

Purpose To perform a meta-analysis of trials of acupuncture for the treatment of back pain.
Methods A systematic literature search was conducted to retrieve all randomized controlled trials of any form of acupuncture for any type of back pain in humans. The adequacy of the acupuncture treatment was assessed by consulting 6 experienced acupuncturists. The main outcome measure for the meta-analysis was numbers of patients whose symptoms were improved at the end of treatment.
Results Twelve studies were included, of which 9 presented data suitable for meta-analysis. The odds ratio of improvement with acupuncture compared with control intervention was 2.30 (95% confidence interval, 1.28-4.13). For sham-controlled, evaluator-blinded studies, the odds ratio was 1.37 (95% confidence interval, 0.84-2.25).
Conclusion Acupuncture was shown to be superior to various control interventions, although there is insufficient evidence to state whether it is superior to placebo.
AMSTAR 8 [Liu 2015]

1.1.37. Van Tulder 1997 ∅

Van Tulder Mw et al. Conservative Treatment of acute and chronic nonspecific low back pain: a systematic review of randomized controlled trials of the most common interventions. Spine. 1997;22:2128-56.[70881].

Objectifs. A systematic review of randomized controlled trials. Objectives. To assess the effectiveness of the most common conservative types of treatment for patients with acute and chronic nonspecific low back pain.
BackgroundMany treatment options for acute and chronic low back pain are available, but little is known about the optimal treatment strategy.
MethodsA rating system was used to assess the strength of the evidence, based on the methodologic quality of the randomized controlled trials, the relevance of the outcome measures, and the consistency of the results.
ResultsThe number of randomized controlled trials identified varied widely with regard to the interventions involved. The scores ranged from 20 to 79 points for acute low back pain and from 19 to 79 points for chronic low back pain on a 100-point scale, indicating the overall poor quality of the trials. Overall, only 28 (35%) randomized controlled trials on acute low back pain and 20 (25%) on chronic low back pain had a methodologic score of 50 or more points, and were considered to be of high quality. Various methodologic flaws were identified. Strong evidence was found for the effectiveness of muscle relaxants and nonsteroidal anti-inflammatory drugs and the ineffectiveness of exercise therapy for acute low back pain; strong evidence also was found for the effectiveness of manipulation, back schools, and exercise therapy for chronic low back pain, especially for short-term effects.
ConclusionsThe quality of the design, execution, and reporting of randomized controlled trials should be improved, to establish strong evidence for the effectiveness of the various therapeutic interventions for acute and chronic low back pain. The available evidence suggests that NSAIDs might be effective for this purpose, but not physical modalities such as TENS, electromyographic, biofeedback, acupuncture, and orthoses.

1.2. Special Acupuncture Techniques

1.2.1. Comparison of acupuncture techniques

1.2.2. Zhang 2024 (network meta-analysis)

Zhang K, Lin X, Liu Z, Fu Y, Wang L, Zhang D, Zhang Q, Zhang F, Wang X, Dong B. Therapeutic effects of different acupuncture methods on chronic nonspecific low back pain: A network meta-analysis. J Orthop Surg Res. 2024 Sep 30;19(1):615. https://doi.org/10.1186/s13018-024-05118-8. PMID: 39350218; PMCID: PMC11440812.

Backgound Low back pain has become a globally challenging health problem, and about 90% of cases are nonspecific. Due to the risks associated with opioid use and the limited effectiveness of drug treatment, acupuncture and other non-drug methods have become the first-line treatment for this disease. However, the best acupuncture method has not yet been determined. In this study, the effects of different acupuncture methods on chronic nonspecific low back pain (CNLBP) were compared by network meta-analysis, aiming at identifying the best option and providing a basis for precise treatment of CNLBP.
Methods Clinical randomized controlled trials (RCTs) on acupuncture in the treatment of NSLBP were searched in eight databases including PubMed, Embase, Cochrane Library, Web of Science, Sinomed, CNKI, Wanfang Data and VIP from the inception of databases to January 21, 2024. The Cochrane risk-of-bias tool 2.0 (RoB 2.0) and Stata 15.0 (Stata Corp, College Station, Texas, USA) were used to evaluate the literature quality and meta-analysis, and the evidence quality was assessed based on GRADE guidelines. This systematic review was registered at the International Prospective Register of Systematic Reviews.
Results A total of 27 articles were included, involving 2579 patients. The results of the network meta-analysis showed that the top three treatment schemes were warm needle acupuncture, intensive silver needle therapy and meridian-sinew theory-based treatment. In terms of relieving pain, the top three treatments were electrical warm needling, intensive silver needle therapy and warm needle acupuncture. In improving mobility, the top three were meridian-sinew theory-based treatment, routine acupuncture and electroacupuncture.
Conclusion For CNLBP patients, warm needle acupuncture, electrical warm needling and meridian-sinew theory-based treatment are mainly recommended. If patients have significant pain, electroacupuncture is strongly suggested. On the contrary, for patients with decreased joint mobility, meridian-sinew theory-based treatment is advocated.
1.2.2.1. Wang 2021 (Network Meta-Analysis)

Wang L, Yin Z, Zhang Y, Sun M, Yu Y, Lin Y, Zhao L. Optimal Acupuncture Methods for Nonspecific Low Back Pain: A Systematic Review and Bayesian Network Meta-Analysis of Randomized Controlled Trials. J Pain Res. 2021. [218262]. doi

Background Nonspecific low back pain (NLBP) is a common disabling disease that cannot be attributed to a specific, recognizable pathology. The use of acupuncture for NLBP is supported by several guidelines and systematic reviews. However, the efficacy of different acupuncture methods for NLBP management is still debated.
ObjectiveThis study ranked the effectiveness of acupuncture methods using network meta-analysis to screen out the optimal acupuncture methods and expound the current controversies for their effective application in health policies as well as guiding clinical operations.
Methods The following databases were searched for relevant randomized controlled trials (RCTs) from inception to December 20, 2020: China National Knowledge Infrastructure, VIP Database for Chinese Technical Periodicals, WANFANG Database, Chinese biomedical literature service system, PubMed, Web of Science, Embase, and Cochrane Library. Relevant registration platforms, including the International Standard Randomised Controlled Trial Number Register (ISRCTN) and Chinese Clinical Trial Registry (ChiCTR), were also searched. Manual retrieval and tracking of references was also performed. Pairwise meta-analysis and Bayesian network meta-analysis using Revman and ADDIS, respectively, were performed and standardized mean differences examined. The primary outcome was visual analog scale (VAS) score and the secondary outcome was Oswestry Disability Index (ODI) score. Safety was defined as the incidence of adverse events.
Results A total of 30 trials with 3196 participants were analyzed; 16.67% of which showed a high risk of bias. The results indicated that fire acupuncture plus manual acupuncture, auricular needling, and electroacupuncture plus warm acupuncture were most effective in reducing VAS score. The most effective interventions for reducing ODI score were manual acupuncture plus conventional medicines, followed by moxibustion and manual acupuncture plus moxibustion. Manual acupuncture plus moxibustion was dominant in the cluster ranking. Acupuncture showed a lower incidence of adverse events (7.70%) than other interventions (conventional medicines, routine care, and placebo; 12.24%).
Conclusion We found that manual acupuncture plus moxibustion is the most effective way to reduce NLBP pain and disability. Acupuncture is safer than other interventions. However, more direct comparative evidence from high-quality, large-sample, multicenter RCTs is needed to validate these findings.

1.2.3. Combined with core muscle exercises

1.2.3.1. Li 2024

Li X, Zhai G, Zhang H, Li X, Wu M, Zhang S, Cui J, Tang Z, Hu Z. Clinical efficacy of acupuncture therapy combined with core muscle exercises in treating patients with chronic nonspecific low back pain: a systematic review and meta-analysis of randomized controlled trials. Front Med (Lausanne). 2024 Apr 4;11:1372748. https://doi.org/10.3389/fmed.2024.1372748

IntroductionThis meta-analysis aimed to determine the clinical efficacy of acupuncture combined with core muscle exercises on pain and functional status in patients with chronic nonspecific low back pain.
Methods This study followed the Preferred Reporting Items for Systematic Reviews and meta-analysis criteria for systematic reviews and meta-analyses. Randomized controlled trials published till November 2023 were searched in PubMed, Web of Science, Cochrane, Embase, China National Knowledge Infrastructure, Chinese Biomedical Literature, and Wanfang databases. The search strategy was related to disease type, intervention, and control measures and was structured around the search terms “low back pain,” “acupuncture therapy,” and “exercise.” Two reviewers applied inclusion and exclusion criteria. Sensitivity and fixed effects analyses were performed to determine the primary outcomes.
Results We included 11 randomized controlled trials (n = 727) on acupuncture combined with core muscle exercises in patients with chronic nonspecific low back pain. Compared with controls, clinical efficacy was significant, with improvements in pain scores (visual analog pain scale and numerical rating scale) and Oswestry Disability Index in the intervention group.
Discussion Acupuncture therapy combined with core muscle exercises improved pain and functional status in patients with chronic nonspecific low back pain, with favorable clinical outcomes compared with single-core muscle training. Multicenter large-sample trials are required to obtain more reliable conclusions.

1.2.4. Moxibustion

1.2.4.1. Yao 2022

Yao Y, Zhou L, Chen FQ, Zhang R, Pang XT, Leng YF, Xu X, Sun ZL. The Effect and Safety of Thunder-Fire Moxibustion for Low Back Pain: A Meta-Analysis of Randomized Controlled Trials. Evid Based Complement Alternat Med. 2022 May 18;2022:6114417. https://doi.org/10.1155/2022/6114417

Background Low back pain (LBP) is considered the leading cause of people living with years of disability worldwide. Notably, thunder-fire moxibustion (TFM) is a new type of moxibustion, which has been widely applied to treat pain syndromes for thousands of years. This study aims to provide evidence to evaluate the effect and safety of TFM in treating LBP.
Methods A systematic search of PubMed, Web of Science, the Cochrane Library, Embase, EBSCO, CNKI, Wanfang Data, CBM, and VIP (until April 2021) was used to identify studies reporting pain intensity, disability, Japanese Orthopedic Association (JOA) score, and quality of life in patients with LBP. Randomized controlled trials (RCTs), which compared TFM and other therapies in LBP, were included. Meanwhile, methodological quality was evaluated using the Cochrane criteria for risk of bias, and the level of evidence was rated utilizing the GRADE approach.
Results Twenty-one RCTs, including 2198 patients, satisfied the inclusion criteria. Compared with other therapies, the effect of TFM was statistically significant, pain intensity decreased (SMD = 0.94; 95% CI (0.74, 1.14); p < 0.00001), disability improved (SMD = 1.39; 95% CI (0.19, 2.59); p=0.02), and the JOA score increased (SMD = -1.34; 95% CI (-1.88, -0.80); p < 0.00001). It was also reported that the patient's quality of life improved after treatment for a period of 4 weeks (SMD = -0.29; 95% CI (-0.42, -0.16); p < 0.0001) and after a follow-up of 1 month (SMD = -0.20; 95% CI (-0.34, -0.07); p=0.003). The evidence level of the results was determined to be very low to low.
ConclusionsBased on the existing evidence, it can be concluded that TFM may have a better effect than other treatments on LBP. However, it is not yet possible to assess the safety level of TFM therapy. Due to the universal low quality of the eligible trials and low evidence level, rigorously designed large-scale RCTs must be conducted in order to further confirm the results in this review.
1.2.4.2. Chen 2020

Chen FQ, Ge JF, Leng YF, Li C, Chen B, Sun ZL. Efficacy and safety of moxibustion for chronic low back pain: A systematic review and meta-analysis of randomized controlled trials. Complement Ther Clin Pract. 2020. [208848]. doi

IntroductionTo systematically review and meta-analyze the efficacy of moxibustion in treating patients with chronic low back pain (CLBP).
MethodsA systematic search of the Cochrane Library, Web of Science, PubMed, Embase, EBSCO, CBM, Wanfang, CNKI and VIP (until November, 2019) was used to identify studies reporting pain intensity (VAS or NRS), disability (ODI or RMDQ), JOA score, and quality of life (SF-36) in patients with CLBP. Study selection, data extraction was performed critically and independently by two reviewers. Cochrane criteria for risk of bias was used to assess the methodological quality of the trials. The Grading of Recommendations Assessment, Development, and Evaluation Methodology (GRADE) was applied to test the quality of evidence from the quantitative analysis.
ResultsTen RCTs, including 987 patients, met the inclusion criteria. Moxibustion had a superior effect on VAS score when compared with western medicine [RR = -1.69, 95%CI(-2.40, -0.98), p < 0.00001] and acupuncture [RR = -0.47, 95%CI(-0.92, -0.02), p=0.04], but it failed to do so when compared with core stability training [RR = -0.41, 95%CI(-0.87, 0.05), p=0.08]. The result showed that moxibustion plus other active treatments (including western medicine, massage, acupuncture and core stability training) had better effects on low back pain relief compared with active treatments alone. Moxibustion showed favourable effects on disability [SMD = -3.80, 95%CI (-5.49, -2.11), p < 0.0001], JOA score [MD = 4.10, 95%CI(2.30, 5.90), p < 0.00001], and SF-36 score [MD = 13.41, 95%CI(9.68, 17.14), p < 0.00001]. The evidence level of the results from the ten studies was determined to be very low to low.
ConclusionsIt is difficult to draw firm conclusions that moxibustion is an effective intervention for treating CLBP due to the small sample size of eligible trails and the high risk of bias among the available articles. Rigorously designed large-scale RCTs are required to further confirm the results in this review.

1.2.5. Warm Needle

1.2.5.1. Zhong 2020

Zhong Min. [Meta-analysis of Effectiveness and Safety of Heated Needle Therapy in Treating Lumbar Intervertebral Disc Herniation]. Journal of Guangzhou University of Traditional Chinese Medicine. 2020. [213518].

Objectives & MethodsThe clinical randomized controlled trials of heated needle therapy (trial group) vs conventional acupuncture or electroacupuncture (control group)in the main domestic and oversea databases of CNKI, VIP, CBM, Wanfang Data, PubMed, Embase, Cochrane Library were searched. And then the efficacy and safety of the heated needle therapy for the treatment of lumbar intervertebral disc herniation were evaluated systematically, so as to provide evidence-based reference for clinical practice.
Results A total of 14 randomized controlled trials which met the included and excluded criteria were obtained, and the trials involved 1 138 cases. The trial group had higher total effective rate than the control group [RR = 1. 17, 95%CI (1. 06, 1. 30), P = 0. 003], and showed better efficacy on improving Fairback J C scores for lumbago[WMD =-4. 28, 95%CI (-6. 49, -2. 06), P = 0. 000], visual analogue scale (VAS)pain scores [WMD =-1. 35, 95%CI (-1. 60, -1. 10), P = 0. 000], present pain intensity (PPI)scors [WMD=-0. 66, 95%CI (-0. 84, -0. 49), P = 0. 000], McGill scale pain scores [WMD =-0. 87, 95%CI (-1. 11, -0. 63), P = 0. 000], and Japanese Orthopedic Association (JOA)lumbago scores [WMD = 2. 59, 95%CI (2. 19, 2. 98), P = 0. 000] than the control group.
ConclusionsThe results indicated that heated needle therapy exerts certain effects and with good safety for the treatment of lumbar intervertebral disc herniation, but for the inferior methodological quality and less amount of the included research, the conclusion still needs further verification with multi-center, large-sample, and high-quality randomized controlled trials.

1.2.6. Electroacupuncture

1.2.6.1. Hsieh 2024

Hsieh D, Chen YC, Chang HC, Wei CC, Lee TH. Efficacy of Electroacupuncture Compared to Standard and Manual Needling Therapy for Nonspecific Low Back Pain: A Systematic Review and Meta-Analysis. Cureus. 2024 Oct 28;16(10):e72577. https://doi.org/10.7759/cureus.72577

BackgroundNonspecific low back pain is prevalent, and electroacupuncture is one potential treatment option. However, a focused evaluation of previous experimental studies is lacking. This systematic review and meta-analysis aimed to assess the efficacy of electroacupuncture for nonspecific low back pain in comparison to standard therapy and manual needling therapy.
MethodsWe systematically searched PubMed, Cochrane Library, and Embase up to December 1, 2023, for randomized controlled trials on electroacupuncture for nonspecific low back pain. Outcomes measured included the Visual Analog Scale and Numerical Rating Scale. The risk of bias was assessed using the Cochrane Risk of Bias 2.0 tool. 10 reports were included in the meta-analysis.
ResultsSix studies used electroacpuncture with standard therapy compared to standard therapy alone. Four studies compared electroacupuncture with manual needling therapies. Compared to control groups, electroacupuncture with standard therapy resulted in a statistically significant large effect in reduction in pain (standardized mean difference (SMD) -0.83, 95% CI -1.22; -0.43, P < 0.0001) Electroacupuncture did not produce a statistically significant result compared to manual needling therapies (SMD 0, 95% CI -0.71; 0.71, P = 1.0) In terms of long-term analgesic effects, electroacupuncture with standard therapy versus standard therapy yielded a statistically significant large effect in reduction in pain at one month (SMD -0.84, 95% CI -1.30 to -0.37, P = 0.0004) and small effect at two months (SMD -0.40, 95% CI -0.65 to -0.16, P = 0.001) after treatment completion.
ConclusionsLimitations, including small numbers of included studies and participants, the difficulty of blinding, and clinical heterogeneity among studies, were found. The certainty of evidence for these comparisons remained very low, which highlights the need for more robust studies. Compared to standard therapy alone, electroacupuncture used with standard therapy produced greater pain reduction for nonspecific low back pain in immediate effects and one month and two months after treatment completion. The findings suggest that electroacpuncture may provide sustained pain relief for nonspecific low back pain when combined with standard therapy.

1.2.7. Laser acupuncture

1.2.7.1. Mao 2024

Mao X, He H, Ding J. Efficacy of Laser Acupuncture for Treatment of Chronic Low Back Pain: A Systematic Review and Meta-Analysis. Pain Manag Nurs. 2024 Oct;25(5):529-537. https://doi.org/10.1016/j.pmn.2024.05.001

Objective To summarize and systematically analyze the efficacy of laser acupuncture (LA) interventions in reducing pain scores in patients suffering from chronic low back pain (LBP).
Methods PubMed, EMBASE, and Scopus databases were searched for randomized controlled trials, published in peer-reviewed journals, and reporting LA interventions in patients with chronic LBP. All included studies had a comparison group of patients, receiving placebo treatment, sham intervention, conventional therapy, or no treatment. The outcome of interest was the pain intensity score. Pooled effect estimates were calculated using random-effects models and reported as weighted mean difference (WMD) with 95% confidence intervals (CI).
Results A total of 20 studies were included. Compared to the control group, patients who underwent LA experienced a significant reduction in reported pain scores immediately after completing the treatment (WMD -1.14, 95% CI: -1.68 to -0.61). High dose of LA was associated with a more significant decrease in the pain scores (WMD -1.40, 95% CI: -1.94 to -0.85; N = 15, I2 = 81.0%). However, reported pain scores of patients who received LA were statistically similar to those of the control group at short-term (4-8 weeks after the treatment) and long-term (12 months) follow-ups.
Conclusions In patients with chronic LBP, LA may help in alleviating pain immediately after the treatment. However, this effect does not appear to be sustained on later follow-up assessments. Consequently, patients should be informed about the potential limitations of the treatment in providing lasting pain relief.
1.2.7.2. Yeum 2020

Hyewon Yeum, Yejin Hong, Dongwoo Nam. Low-Level Laser Therapy including Laser Acupuncture for Non-Specific Chronic Low Back Pain: Systematic Review and Meta-Analysis. J Acupunct Res. 2021;38(1):8-19. [219976]. doi
Hyewon Yeum, Yejin Hong, Dongwoo Nam. Effective Low-Level Laser Therapy Including Laser Acupuncture Treatment Conditions for Non-Specific Chronic Low Back Pain: Systematic Review and Meta-Analysis. J Acupunct Res. 2021;38(2):85-95. [219984]. doi

Objective Low-level laser therapy including laser acupuncture (LLLT/LA) has been widely used for non-specific chronic low back pain (NCLBP). However, there is no critically appraised evidence of its potential benefits. This study aimed to evaluate the effectiveness of LLLT/LA for NCLBP.
MethodsThere were 12 databases (MEDLINE, CENTRAL, EMBASE, KoreaMed, KMBASE, KISS, NDSL, KISTI, OASIS, CNKI, CiNII, J-stage) searched for randomized controlled trials using LLLT/LA for NCLBP up until June 2019. The primary outcome was pain intensity and functional status/disability due to NCLBP.
Results and conclusions A random-effects meta-analysis was conducted on 20 studies involving 1,323 participants. LLLT/LA showed a significant positive effect on pain relief scores compared with sham treatments (SMD −0.51, 95% CI: −0.88 to −0.13; χ2 = 31.12, I2 = 74%). Alone, the therapy showed a significant positive effect on function/disability scores (30 participants, MD −11.90, 95% CI: −17.37 to −6.43). As an add-on treatment, it showed a significant positive effect on pain relief (80 participants, MD −5.10, 95% CI: −9.31 to −0.88; χ2 = 28.99, I2 = 97%) and improved function/disability scores (120 participants, MD 5.44, 95% CI: 2.19 to 8.68; χ2 = 4.07, I2 = 75%). Among 20 studies, 9 studies reported no adverse events and 1 study reported mild adverse events. LLLT/LA may be an alternative or add-on treatment for NCLBP.
1.2.7.3. Glazov 2016 ★★

Glazov G, Yelland M, Emery J. Low-level laser therapy for chronic non-specific low back pain: a meta-analysis of randomised controlled trials. Acupunct Med. 2016. [186242].

ObjectiveThe efficacy of low-level laser treatment (LLLT) for chronic back pain remains controversial due to insufficient trial data. We aimed to conduct an updated review to determine if LLLT (including laser acupuncture) has specific benefits in chronic non-specific low back pain (CNLBP).
MethodsElectronic databases were searched for randomised trials using sham controls and blinded assessment examining the intervention of LLLT in adults with CNLBP. Primary outcomes were pain and global assessment of improvement with up to short-term follow-up. Secondary outcomes were disability, range of back movement, and adverse effects. A random effects meta-analysis was conducted. Subgroup analyses were based on laser dose, duration of baseline pain, and whether or not laser therapy used an acupuncture approach.
Results15 studies were selected involving 1039 participants. At immediate and short-term follow-up there was significant pain reduction of up to WMD (weighted mean difference) -1.40 cm (95% CI -1.91 to -0.88 cm) in favour of laser treatment, occurring in trials using at least 3 Joules (J) per point, with baseline pain <30 months and in non-acupuncture LLLT trials. Global assessment showed a risk ratio of 2.16 (95% CI 1.61 to 2.90) in favour of laser treatment in the same groups only at immediate follow-up.
ConclusionsWe demonstrated moderate quality of evidence (GRADE) to support a clinically important benefit in LLLT for CNLBP in the short term, which was only seen following higher laser dose interventions and in participants with a shorter duration of back pain. Rigorously blinded trials using appropriate laser dosage would provide greater certainty around this conclusion.

1.2.8. Dry needling

1.2.8.1. Dach 2023

Dach F, Ferreira KS. Treating myofascial pain with dry needling: a systematic review for the best evidence-based practices in low back pain. Arq Neuropsiquiatr. 2023 Dec;81(12):1169-1178. https://doi.org/10.1055/s-0043-1777731. Epub 2023 Dec 29. PMID: 38157883; PMCID: PMC10756779.

Backgound Myofascial pain syndrome (MPS) is a common source of pain in primary care or pain clinics. There are many different ways to manage and treat MPS, such as physical exercise, trigger points massage, and dry needling.
Objective The objective of this overview is to highlight and discuss the evidence-based treatment of myofascial pain by dry needling in patients with low back pain.
Methods A systematic review was made based on meta-analysis (MA) and randomized controlled trials (RCTs) related to dry needling treatment for myofascial pain in patients with lumbar pain, published from 2000 to 2023.
Results A total of 509 records were identified at first. Seventy were published before 2000, so they were excluded. From the remaining 439 studies, ninety-two were RCTs or MA, of which 86 additional studies were excluded for the following reasons: not related to dry needling treatment (n = 79), not published in English (n = 4), duplicated (n = 1), project protocol (n = 1), and not related to myofascial pain (n = 1). So, this review was based on 4 RCTs and two MA. These studies compared dry needling efficacy to other treatments, such as acupuncture, sham dry needling, laser therapy, physical therapy, local anesthetic injection, ischemic compression, and neuroscience education. Despite outcomes and follow-up period varied between them, they showed that dry needling can decrease post-intervention pain intensity and pain disability.
Conclusion
1.2.8.2. Hu 2018 ☆

Hu HT, Gao H, Ma RJ, Zhao XF, Tian HF, Li L. Is dry needling effective for low back pain? A systematic review and PRISMA-compliant meta-analysis. Medicine (Baltimore). 2018;97(26). [166682].

BackgroundTo evaluate the efficacy and safety of dry needling (DN) for treating low back pain (LBP).
Methods Nine databases were searched from inception to October 2017. Eligible randomized controlled trials (RCTs) involving DN for treating LBP were retrieved. Two reviewers independently screened the articles, extracted data, and evaluated the risk of bias among the included studies using the risk of bias assessment tool by Cochrane Collaboration.
Results Sixteen RCTs were included and the risk of bias assessment of them was “high” or “unclear” for most domains. Meta-analysis results suggested that DN was more effective than acupuncture in alleviating pain intensity and functional disability at postintervention, while its efficacy on pain and disability at follow-up was only equal to acupuncture. Besides, DN was superior to sham needling for alleviating pain intensity at postintervention/follow-up and functional disability at postintervention. Additionally, qualitative review revealed that DN combined with acupuncture had more significant effect on alleviating pain intensity at postintervention and achieved higher response rate than DN alone. However, compared with other treatments (laser, physical therapy, other combined treatments, etc.), it remained uncertain whether the efficacy of DN was superior or equal because the results of included studies were mixed.
Conclusions Compared with acupuncture and sham needling, DN is more effective for alleviating pain and disability at postintervention in LBP, while its effectiveness on pain and disability at follow-up was equal to acupuncture. Besides, it remains uncertain whether the efficacy of DN is superior to other treatments. Nevertheless, considering the overall “high” or “unclear” risk of bias of studies, all current evidence is not robust to draw a firm conclusion regarding the efficacy and safety of DN for LBP. Future RCTs with rigorous methodologies are required to confirm our findings.

1.2.9. Acupressure

1.2.9.1. Li 2021

Li T, Li X, Huang F, Tian Q, Fan ZY, Wu S. Clinical Efficacy and Safety of Acupressure on Low Back Pain: A Systematic Review and Meta-Analysis. Evid Based Complement Alternat Med. 2021. [217555].doi

Objectives To evaluate the effectiveness and safety of acupressure on low back pain (LBP).
Methods We searched 7 electronic databases and 2 trial registries through December 28, 2020. Randomized controlled trials (RCTs) of acupressure on LBP were considered for meta-analysis with Revman 5.3 and Stata 15.0 software. Methodological quality was evaluated using the Cochrane Collaboration's tool. Trial sequential analysis (TSA) was used to quantify the statistical reliability. HETRED analysis and GRADE were used to determine the heterogeneity and quality of the results, respectively.
Results Twenty-three RCTs representing 2400 participants were included. Acupressure was superior to tuina massage on response rate (RR 1.25; 95% CI, 1.16 to 1.35; P < 0.00001) and in the standardized mean difference (SMD) for pain reduction [SMD -1.92; 95% CI, -3.09 to -0.76; P=0.001]. Likewise, acupressure was superior to physical therapy [SMD, -0.88; 95% CI, -1.10 to -0.65; P < 0.00001] and to usual care [SMD, -0.32; 95% CI, -0.61 to -0.02; P=0.04] in pain reduction. The Oswestry Disability Index was significantly improved by acupressure compared with usual care [SMD, -0.55; 95% CI, -0.84 to -0.25; P=0.0003]. The combination of acupressure with either manual acupuncture or electro-acupuncture showed significant improvements over the adjuvant therapies alone in response rate [RR 1.19; 95% CI, 1.13 to 1.26; P < 0.00001], pain reduction, and the Japanese Orthopedic Association score (JOA). However, each study displayed substantial heterogeneity. Through subgroup sensitivity analysis and -HETRED analysis, the heterogeneity of acupressure compared with manual acupuncture decreased while the results maintained significance with respect to pain reduction [SMD -0.9; 95% CI, -1.21 to -0.6; P < 0.00001] and JOA [SMD, 0.66; 95% CI, 0.33 to 0.98; P < 0.00001]. Similar results were obtained comparing acupressure with electro-acupuncture with respect to pain [SMD, -1.07; 95% CI, -1.33 to -0.81; P < 0.00001] and JOA [SMD, 0.89; 95% CI, 0.51 to 1.27, P < 0.00001]. TSA demonstrated the effectiveness of acupressure as a standalone or as a combinative treatment (with manual acupuncture or electro-acupuncture) for LBP.
Conclusion Acupressure is an effective treatment for LBP. However, GRADE assessments downgraded the evidence in the trials, indicating that additional investigations are needed to confirm these observations.

1.2.10. Integrated Treatment

1.2.10.1. Hu 2015 ☆

Hu XY, Chen NN, Chai QY, Yang GY, Trevelyan E, Lorenc A, Liu JP, Robinson N. Integrative treatment for low back pain: an exploratory systematic review and meta-analysis of randomized controlled trials. Chin J Integr Med. 2015.doi:10.1007/s11655-015-2125-2 [184500].
Hu Xiaoyang, Chen Nini, Yang Guoyan, Chai Qianyun et al. Integrated treatment for low back pain: A systematic review (abstract). European Journal of Integrative Medicine. 2013;5(6):572. [206804]. doi

ObjectiveLow back pain (LBP) is a common musculoskeletal condition often treated using integrative medicine (IM). Most reviews have focused on a single complementary and alternative medicine (CAM) therapy for LBP rather than evaluating wider integrative approaches. This exploratory systematic review aimed to identify randomized controlled trials (RCTs) and provide evidence on the effectiveness, cost effectiveness and adverse effects of integrative treatment for LBP.
MethodsA literature search was conducted in 12 English and Chinese databases. RCTs evaluating an integrative treatment for musculoskeletal related LBP were included. Reporting, methodological quality and relevant clinical characteristics were assessed and appraised. Metaanalyses were performed for outcomes where trials were sufficiently homogenous.
Results Fifty-six RCTs were identified evaluating integrative treatment for LBP. Although reporting and methodological qualities were poor, meta-analysis showed a favourable effect for integrative treatment over conventional and CAM treatment for back pain and function at 3 months or less follow-up. Two trials investigated costs, reporting £ 5332 per quality adjusted life years with 6 Alexander technique lessons plus exercise at 12 months follow-up; and an increased total costs of $244 when giving an additional up to 15 sessions of CAM package of care at 12 weeks. Sixteen trials mentioned safety; no severe adverse effects were reported.
ConclusionIntegrative treatment that combines CAM with conventional therapies appeared to have beneficial effects on pain and function. However, evidence is limited due to heterogeneity, the relatively small numbers available for subgroup analyses and the low methodological quality of the included trials. Identification of studies of true IM was not possible due to lack of reporting of the intervention details.
1.2.10.2. Hu 2014 ★★

Hu X, Chen N, Chai Q, Yang G, Trevelyn E, Lorenc A, Liu J, Robinson N. Acupuncture related integrative treatment for low back pain: a systematic review and meta-analysis of randomized controlled trials. Journal of Alternative and Complementary Medicine. 2014;20(5):A9-10.[160612]

Purpose This systematic review was carried out to identify clinical evidence from RCTs to evaluate the effectiveness and report any adverse effects of integrative treatment for low back pain (LBP). This review also aimed to inform the method of conducting systematic reviews in integrative medicine.
Methods A literature search of 8 English and 4 Chinese databases for RCTs evaluating the effectiveness of integrative treatments for musculoskeletal related LBP was conducted. Reporting/methodological quality and relevant clinical characteristics were assessed, extracted by two researchers, with consensus by a third reviewer and meta-analyses conducted.
Results Initially 1470 English and 3358 Chinese studies were identified. Screening titles/abstracts gave 218 English and 739 Chinese articles. After inclusion and exclusion criteria, 13 English, 46 Chinese articles remained (22 acupuncture). Acupuncture combined with traction was the most popular treatment in China (8/17); for other countries acupuncture plus usual care (4/5) was the most popular combination. Favourable improvements were shown in integrative treatments (acupuncture combined with traction/medication/epidural injection/usual care) over conventional medicine (CM) alone – with traction: 5 studies: n = 450, visual analogue scale (VAS), standardized mean difference (SMD) - 1.43, 95% CI [ - 1.69, - 1.18], p = 0.18, I2 = 34%; 2 studies: Japanese Orthopaedic Association (JOA) score, SMD 0.52, 95% CI [0.02, 1.01]; modified JOA, [SMD 2.50, 95% CI [1.82, 3.19]; with medication: 3 studies: n = 234, VAS, SMD - 0.89, 95% CI [ - 1.17, - 0.62], p = 0.38, I2 = 2%; 2 studies: n = 142, Oswestry pain disability index score, SMD - 1.04, 95% CI [ - 1.40, - 0.69],p = 0.72, I2 = 0%); with EI: 1 study: VAS, SMD - 1.67 [ - 2.36,- 0.97]; 1 study: JOA score, SMD - 1.93 [ - 2.44, - 1.41] and positive results comparing acupuncture plus usual care. Minimal safety data was generated. Chinese studies had poorer reporting/ methodological quality.
Conclusion Previously effectiveness of IM has been inadequately evaluated. Variations in terminology/policy/registration A9 system/education/clinical practice/definition/inter-country différences are problematic. Future studies should focus on the most effective combinations of IM treatment.
1.2.10.3. Kizhakkeveettil 2014 ★★

Kizhakkeveettil A, Rose K, Kadar GE. Integrative therapies for low back pain that include complementary and alternative medicine care: a systematic review. Glob Adv Health Med. 2014. 3(5):49-64. [177812].

Study DesignSystematic review of the literature.
ObjectiveTo evaluate whether an integrated approach that includes different Complementary and Alternative Medicine (CAM) therapies combined or CAM therapies combined with conventional medical care is more effective for the management of low back pain (LBP) than single modalities alone.
MethodsThe PRISMA Statement guidelines were followed. The Cochrane Back Review Group scale was used to rate the quality of the studies found.
ResultsTwenty-one studies were found that met the inclusion criteria. The CAM modalities used in the studies included spinal manipulative therapy, acupuncture, exercise therapy, physiotherapy, massage therapy, and a topical ointment. Twenty studies included acupuncture and/or spinal manipulative therapy. Nine high quality studies showed that integrative care was clinically effective for the management of LBP. Spinal manipulative therapy combined with exercise therapy and acupuncture combined with conventional medical care or with exercise therapy appears to be promising approaches to the management of chronic cases of LBP.
ConclusionsThere is support in the literature for integrated CAM and conventional medical therapy for the management of chronic LBP. Further research into the integrated management of LBP is clearly needed to provide better guidance for patients and clinicians.

1.2.11. TENS

1.2.11.1. Khadilkar 2008 Ø

Khadilkar A, Odebiyi DO, Brosseau L, Wells GA. transcutaneous electrical nerve stimulation (tens) versus placebo for chronic low-back pain. Cochrane Database Syst Rev. 2008;8(4):cd003008. [151008].

BackgroundTranscutaneous electrical nerve stimulation (TENS) was introduced more than 30 years ago as a therapeutic adjunct to the pharmacological management of pain. However, despite widespread use, its effectiveness in chronic low-back pain (LBP) is still controversial.
ObjectivesTo determine whether TENS is more effective than placebo for the management of chronic LBP. Search Strategy: The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, PEDro and CINAHL were searched up to July 19, 2007.
MéthodsSelection Criteria: only randomized controlled clinical trials (RCTs) comparing TENS to placebo in patients with chronic LBP were included. Data Collection And Analysis: two review authors independently selected the trials, assessed their methodological quality and extracted relevant data. If quantitative meta-analysis was not possible, a qualitative synthesis was performed, taking into consideration 5 levels of evidence as recommended by the Cochrane Collaboration Back Review Group.
Main ResultsFour high-quality RCTs (585 patients) met the selection criteria. Clinical heterogeneity prevented the use of meta-analysis. Therefore, a qualitative synthesis was completed. There was conflicting evidence about whether TENS was beneficial in reducing back pain intensity and consistent evidence in two trials (410 patients) that it did not improve back-specific functional status. There was moderate evidence that work status and the use of medical services did not change with treatment. Conflicting results were obtained from two studies regarding generic health status, with one study showing no improvement on the modified Sickness Impact Profile and another study showing significant improvements on several, but not all subsections of the SF-36 questionnaire. Multiple physical outcome measures lacked statistically significant improvement relative to placebo. In general, patients treated with acupuncture-like TENS responded similarly to those treated with conventional TENS. However, in two of the trials, an inadequate stimulation intensity was used for acupuncture-like TENS, given that muscle twitching was not induced. Optimal treatment schedules could not be reliably determined based on the available data. Adverse effects included minor skin irritation at the site of electrode placement.
Authors' ConclusionsAt this time, the evidence from the small number of placebo-controlled trials does not support the use of TENS in the routine management of chronic LBP. Further research is encouraged.
1.2.11.2. Brosseau 2002 ∅

Brosseau I et al. Efficacy of the transcutaneous electrical nerve stimulation for the treatment of chronic low back pain: a meta-analysis. Spine. 2002;27(6):596-603. [101183]

BackgroundLow back pain affects a large proportion of the population. Transcutaneous electrical nerve stimulation (TENS) was introduced more than 30 years ago as an alternative therapy to pharmacologic treatments for chronic pain. However, despite its widespread use, the efficacy of TENS is still controversial.
PurposeThe aim of this meta-analysis was to determine the efficacy of TENS in the treatment of chronic low back pain.
MethodsThe authors searched MEDLINE, EMBASE, PEDro, and the Cochrane Controlled Trials Register up to June 1, 2000. Only randomized controlled clinical trials of TENS for the treatment of patients with a clinical diagnosis of chronic low back pain were included. Abstracts were excluded unless further data could be obtained from the authors. Two reviewers independently selected trials and extracted data using predetermined forms. Data Analysis: Heterogeneity was tested with Cochrane's Q test. A fixed effects model was used throughout for continuous variables, except where heterogeneity existed, in which case, a random effects model was used. Results are presented as weighted mean differences with 95% confidence intervals, where the difference between the treated and control groups was weighted by the inverse of the variance. Standardized mean differences were calculated by dividing the difference between the treated and control by the baseline variance. Standardized mean differences were used when different scales were integrated to measure the same concept. Dichotomous outcomes were analyzed with odds ratios.
Main ResultsFive trials were included, with 170 subjects randomized to the placebo group receiving sham TENS and 251 subjects receiving active TENS (153 for conventional mode, 98 for acupuncture-like TENS). The schedule of treatments varied greatly between studies ranging from one treatment/day for 2 consecutive days, to three treatments/day for 4 weeks. There were no statistically significant differences between the active TENS group compared with the placebo TENS group for any outcome measures. Subgroup analysis performed on TENS application and methodologic quality did not demonstrate a significant statistical difference (P > 0.05). Remaining preplanned subgroup analysis was not conducted because of the small number of included trials and the variety of outcome measures reported.
ConclusionThe results of the meta-analysis present no evidence to support the use or nonuse of TENS alone in the treatment of chronic low back pain. Considering the small number of studies responding to the criteria to be included in this meta-analysis, it is clear that more appropriately designed studies are needed before a final conclusion. Clinicians and researchers should consistently report the characteristics of the TENS device and the application techniques used. New trials on TENS should make use of standardized outcome measures. This meta-analysis lacked data on how TENS efficacy is affected by four important factors: type of applications, site of application, treatment duration of TENS, and optimal frequencies and intensities.
1.2.11.3. Milne 2001 ∅

Milne S et al. Transcutaneous electrical nerve stimulation (tens) for chronic low back pain (cochrane review). Cochrane Database Syst Rev. 2001;2:CD003008. [94810]

BackgroundLow back pain (LBP) affects a large proportion of the population. Trancutaneous electrical nerve stimulation (TENS) was introduced more than 30 years ago as an alternative therapy to pharmacological treatments for chronic pain. However, despite its widespread use, the effectiveness of TENS is still controversial.
ObjectivesThe aim of this systematic review was to determine the efficacy of TENS in the treatment of chronic LBP. Search Strategy: We searched MEDLINE, EMBASE, PEDro and the Cochrane Controlled Trials Register up to June 1, 2000. Selection Criteria: Only randomized controlled clinical trials of TENS for the treatment of patients with a clinical diagnosis of chronic LBP were included. Abstracts were excluded unless further data could be obtained from the authors. Data Collection And Analysis: Two reviewers independently selected trials and extracted data using predetermined forms. Heterogeneity was tested with Cochran's Q test. A fixed effects model was used throughout for continuous variables, except where heterogeneity existed, in which case, a random effects model was used. Results are presented as weighted mean differences (WMD) with 95% confidence intervals (95% CI), where the difference between the treated and control groups was weighted by the inverse of the variance. Standardized mean differences (SMD) were calculated by dividing the difference between the treated and control by the baseline variance. SMD were used when different scales were used to measure the same concept. Dichotomous outcomes were analyzed with odds ratios.
Main ResultsFive trials were included, with 170 subjects randomized to the placebo group receiving sham-TENS and 251 subjects receiving active TENS (153 for conventional mode, 98 for acupuncture-like TENS). The schedule of treatments varied greatly between studies ranging from one treatment/day for two consecutive days, to three treatments/day for four weeks. There were no statistically significant differences between the active TENS group when compared to the placebo TENS group for any outcome measures. Subgroup analysis performed on TENS application and methodological quality did not demonstrate a significant statistical difference. Remaining pre-planned subgroup analysis was not conducted due to the small number of included trials and the variety of outcome measures reported.
Reviewer's ConclusionsThe results of the meta-analysis present no evidence to support the use of TENS in the treatment of chronic low back pain. Clinicians and researchers should consistently report the characteristics of the TENS device and the application techniques used. New trials on TENS should make use of standardized outcome measures. This meta-analysis lacked data on how TENS effectiveness is affected by four important factors: type of applications, site of application, treatment duration of TENS, optimal frequencies and intensities.
1.2.11.4. Gadsby 2000 ★★

Gadsby JG, Flowerdew MW. Transcutaneous electrical nerve stimulation and acupuncture-like transcutaneous electrical nerve stimulation for chronic low back pain. Cochrane Database Syst Rev. 2000. CD000210. [166704]

Purpose To determine the effectiveness of transcutaneous electrical nerve stimulation in reducing pain and improving range of movement in patients with chronic low back pain.
Methods Electronic searches of EMBASE, MEDLINE, CISCOM, AMED for all studies of TENS in the English language, identifying those treating chronic low back pain and hand searching their references. SELECTION CRITERIA: The inclusion criterion for studies included in this review, 6 of 68 identified, was comparisons of TENS/ALTENS versus placebo in patients with chronic low back pain. DATA COLLECTION AND ANALYSIS: Outcome data on pain reduction, range of movement, functional status and work was extracted by two independent reviewers together with trial design qualities to construct a Quality Index.
Results The ratio of odds of improvement in pain for each comparison was calculated: TENS vs. placebo at 1.62 (95% CI 0.90, 2.68); ALTENS vs. placebo at 7.22 (95% CI 2.60, 20.01) and TENS/ALTENS vs. placebo at 2.11 (95% CI 1.32, 3.38) times that of placebo. An improvement in pain reduction was seen in 45.80% (CI 37.00%, 55.00%) of TENS; 86.70% (CI 80.00%, 93.00%) of ALTENS; 54.00% (CI 46.20%, 61.80%) of TENS/ ALTENS and 36.40% (95%CI 28.40%, 44.40%) of placebo subjects. The odds of improvement in range of movement on ALTENS vs. placebo was 6.61 times (95% CI 2.36, 18.55) that of placebo.
Conclusion Transcutaneous electrical nerve stimulation appears to reduce pain and improve the range of movement in chronic low back pain subjects.

1.2.12. Cupping

1.2.12.1. Li 2025

Li J, Jia Y, Sun T, Bai Z, Dong X, Hou X. Interventions Used in Control Group against Cupping Therapy for Chronic Nonspecific Low Back Pain: A Systematic Review and Network Meta-Analysis. Complement Ther Med. 2025 Mar 22:103167. https://doi.org/10.1016/j.ctim.2025.103167

IntroductionThe evidence for the effect of cupping therapy on chronic nonspecific low back pain (CLBP) remains controversial, and existing researches didn't consider outcomes influenced by factor of selection of interventions in control group. This review and network meta-analysis is to compare the effects of diverse interventions in cupping therapy control groups for CLBP, with the objective of identifying the suitable control intervention against cupping therapy for CLBP.
Methods Studies were identified by a comprehensive search of databases, such as PubMed, Embase, Cochrane Library, Web of Science and China National Knowledge Infrastructure (CNKI), up to June, 2024. A total of 10 randomized control trials (RCT) were included in this network meta-analysis (NMA).
Results The results showed that compared with cupping therapy, minimum negative pressure cupping therapy (MNPCT) (SMD = -0.01; 95%CI: -0.92 to 0.89), air circulating cupping therapy (ACCT) (SMD = -0.05; 95%CI: -0.63 to 0.54) and diclofenac (SMD = -0.13; 95%CI: -1.13 to -0.87) was no significantly different from improvement of pain intensity. But there was significant difference between cupping therapy and D-ibuprofen (SMD = -1.11; 95%CI: -2.08 to -0.13), paracetamol (SMD = -1.12; 95%CI: -1.80 to -0.43) or usual care (SMD = -1.18; 95%CI: -2.56 to -1.06). The order of intervention effect by SUCRA diagram was as follows: cupping therapy (77.7%) > MNPCT (75.2%) > ACCT (73.8%) > diclofenac (68.8%) > D-ibuprofen (26.3%) > paracetamol (24.5%) > usual care (3.8%). The quality of evidence for network estimates was moderate to very low due to the risk of bias and imprecision.
Conclusions The results of this study suggest that usual care was the least effective in alleviating the pain intensity of CLBP, which might serve as the most appropriate intervention in the control group in cupping-related RCTs. MNPCT and ACCT have similar effects with cupping therapy for CLBP. Future research may be based on some objective clinical outcomes and control interventions with physiological inertia to isolate the true effect of cupping therapy or SCT from psychological biases.
1.2.12.2. Zhang 2024

Zhang Z, Pasapula M, Wang Z, Edwards K, Norrish A. The effectiveness of cupping therapy on low back pain: A systematic review and meta-analysis of randomized control trials. Complement Ther Med. 2024 Mar;80:103013. https://doi.org/10.1016/j.ctim.2024.103013

Objectives This study aims to investigate the effectiveness of cupping therapy on low back pain (LBP).
Methods Medline, Embase, Scopus and WANFANG databases were searched for relevant cupping RCTs on low back pain articles up to 2023. A complementary search was manually made on 27 September for update screening. Full-text English and Chinese articles on all ethnic adults with LBP of cupping management were included in this study. Studies looking at acute low back pain only were excluded. Two independent reviewers screened and extracted data, with any disagreement resolved through consensus by a third reviewer. The methodological quality of the included studies was evaluated independently by two reviewers using an adapted tool. Change-from-baseline outcomes were treated as continuous variables and calculated according to the Cochrane Handbook. Data were extracted and pooled into the meta-analysis by Review Manager software (version 5.4, Nordic Cochrane Centre).
Results Eleven trials involving 921 participants were included. Five studies were assessed as being at low risk of bias, and six studies were of acceptable quality. High-quality evidence demonstrated cupping significantly improves pain at 2-8 weeks endpoint intervention (d=1.09, 95% CI: [0.35-1.83], p = 0.004). There was no continuous pain improvement observed at one month (d=0.11, 95% CI: [-1.02-1.23], p = 0.85) and 3-6 months (d=0.39, 95% CI: [-0.09-0.87], p = 0.11). Dry cupping did not improve pain (d=1.06, 95% CI: [-0.34, 2.45], p = 0.14) compared with wet cupping (d=1.5, 95% CI: [0.39-2.6], p = 0.008) at the endpoint intervention. There was no evidence indicating the association between pain reduction and different types of cupping (p = 0.2). Moderate- to low-quality evidence showed that cupping did not reduce chronic low back pain (d=0.74, 95% CI: [-0.67-2.15], p = 0.30) and non-specific chronic low back pain (d=0.27, 95% CI: [-1.69-2.24], p = 0.78) at the endpoint intervention. Cupping on acupoints showed a significant improvement in pain (d=1.29, 95% CI: [0.63-1.94], p < 0.01) compared with the lower back area (d=0.35, 95% CI: [-0.29-0.99], p = 0.29). A potential association between pain reduction and different cupping locations (p = 0.05) was found. Meta-analysis showed a significant effect on pain improvement compared to medication therapy (n = 8; d=1.8 [95% CI: 1.22 - 2.39], p < 0.001) and usual care (n = 5; d=1.07 [95% CI: 0.21- 1.93], p = 0.01). Two studies demonstrated that cupping significantly mediated sensory and emotional pain immediately, after 24 h, and 2 weeks post-intervention (d= 5.49, 95% CI [4.13-6.84], p < 0.001). Moderate evidence suggested that cupping improved disability at the 1-6 months follow-up (d=0.67, 95% CI: [0.06-1.28], p = 0.03). There was no immediate effect observed at the 2-8 weeks endpoint (d=0.40, 95% CI: [-0.51-1.30], p = 0.39). A high degree of heterogeneity was noted in the subgroup analysis (I2 >50%).
Conclusion High- to moderate-quality evidence indicates that cupping significantly improves pain and disability. The effectiveness of cupping for LBP varies based on treatment durations, cupping types, treatment locations, and LBP classifications. Cupping demonstrated a superior and sustained effect on pain reduction compared with medication and usual care. The notable heterogeneity among studies raises concerns about the certainty of these findings. Further research should be designed with a standardized cupping manipulation that specifies treatment sessions, frequency, cupping types, and treatment locations. The actual therapeutic effects of cupping could be confirmed by using objective pain assessments. Studies with at least six- to twelve-month follow-ups are needed to investigate the long-term efficacy of cupping in managing LBP.
1.2.12.3. Chaoju 2022 (blood pricking and cupping)

Chaoju X, Zhangyin S, Changchun JI, Jinsheng Y. Efficacy and safety of blood pricking and cupping for treating nonspecific low back pain: a systematic review and Meta-analysis. J Tradit Chin Med. 2022 Dec;42(6):869-876. https://doi.org/10.19852/j.cnki.jtcm.20220922.003. PMID: 36378043; PMCID: PMC9924687.|

Objective To systematically evaluate the efficacy and safety of blood pricking and cupping in the treatment of nonspecific low back pain (NLBP).
Methods The China National Knowledge Infrastructure Database (CNKI), Wanfang Med Online Database (Wanfang), China Science and Technology Journal Database (VIP), PubMed, Web of Science, EMBase, and Cochrane Library databases were searched from inception to October 31, 2021, for randomized controlled trials (RCTs) of the treatment of NLBP by blood pricking and cupping. The quality of each included study was evaluated according to the Cochrane Systematic Assessor's Manual evaluation criteria, while the Meta-analysis was performed using RevMan 5.4 software.
Results A total of 13 thirteen RCTs included a total of 1088 subjects. The visual analogue scale scores indicated that blood pricking and cupping was superior to the other treatments at relieving NLBP pain [mean difference () = -1.43; 95% confidence interval (): -2.31 to 0.54; = 3.15; = 0.002). The Oswestry Disability Index score of blood pricking and cupping was superior to that of the control group in terms of improving NLBP dysfunction ( = -6.25; 95%: -8.37 to -4.31); = 5.77; < 0.000 01). 7 RCTs mentioned no adverse reactions, while one study reported mild syncope [7% (3), all in the 17-30 years group] that was gradually relieved after rest.
Conclusions Blood pricking and cupping therapy can safely and effectively reduce pain and improve functional impairment in patients with NLBP. However, this study included limited high-grade studies with a small overall sample size; therefore, further high-quality large-sample RCTs are needed to improve clinical evidence.
1.2.12.4. Shen 2022

Shen WC, Jan YK, Liau BY, Lin Q, Wang S, Tai CC, Lung CW. Effectiveness of self-management of dry and wet cupping therapy for low back pain: A systematic review and meta-analysis. Medicine (Baltimore). 2022 Dec 23;101(51):e32325. https://doi.org/10.1097/MD.0000000000032325

Backgound Low back pain (LBP) can significantly affect a person's quality of life. Cupping has been used to treat LBP. However, various cupping methods are typically included in evaluating the efficacy of cupping therapy. Therefore, the objectives of this study were to evaluate the evidence from the literature regarding the effects of dry and wet cupping therapy on LBP in adults. Dry and wet cupping therapy are analyzed categorically in this study.
Methods We searched for randomized clinical trials with cupping in LBP published between 2008 and 2022. In dry or wet cupping clinical studies, pain intensity was assessed using the Visual Analogue Scale and present pain intensity, and the quality of life intensity was measured using the Oswestry disability index.
Results The 656 studies were identified, of which 10 studies for 690 patients with LBP were included in the meta-analysis. There was a significant reduction in the pain intensity score with present pain intensity using wet cupping therapy (P < .01). In addition, both cupping therapy groups displayed significant Oswestry disability index score reduction compared to the control group (both P < .01). The patients with LBP have a substantial reduction by using wet cupping but have not shown a considerable decrease by using dry cupping (P = .19). In addition, only wet cupping therapy groups displayed a significantly improved quality of life compared to the control group. The study had a very high heterogeneity (I2 > 50%). It means there is no standardization in the treatment protocol in randomized clinical trials. In the meta-regression, there was statistically significant evidence that the number of treatment times and intercepts were related (P < .01).
Conclusion The present meta-analysis shows that wet cupping therapy effectively reduces the pain intensity of LBP. Furthermore, both dry wet cupping therapy improved patients with LBP quality of life.
1.2.12.5. Huang 2013 ★

Huang CY, Choong MY, Li TS. Effectiveness of cupping therapy for low back pain: a systematic review. Acupunct Med. 2013; 31(3):336-7. [165328]

Since there is no consensus on the role of cupping therapy in the treatment of low back pain, we reviewed the medical literature in an attempt to test its effectiveness in low back pain and to further examine this method.Three reviewers took part in the study. One reviewer selected the titles and abstracts for inclusion, one extracted data from the full-text articles and the third reviewer confirmed the reference lists of potentially eligible studies. Identified studies were assigned a level of evidence according to the Oxford Centre for Evidence-Based Médicine 2011 levels of evidenceThrough our electronic and reference search we identified 29 citations (table 1): one randomised controlled trial (RCT, level I evidence), 4 six non-RCTs (level II evidence), 5–10 20 case reports (level IV evidence) and two mechanismbased reasoning studies (level V evidence).In this article, the research results show that cupping therapy is promising for pain control and improvement of quality of life, and minimises the potential risks of treatment. Therefore, further studies are needed to determine the potential role of cupping therapy in the treatment of low back pain.

1.2.13. Scraping Therapy

1.2.13.1. Wang 2021

Wang XQ, Duan PB, Zheng M, Yang LH, Wang AQ, Zhang M. Effect of Scraping Therapy on Chronic Low Back Pain: A Systematic Review and Meta-analysis of Randomized Controlled Trials. J Manipulative Physiol Ther. 2021;44(3):255-270. [220465].doi

Objective The purpose of this study was to review the literature on the effect of scraping therapy on chronic low back pain (LBP) from randomized controlled trials (RCTs).
MethodsThree English medical electronic databases (PubMed, Embase, and the Cochrane Library) and 2 Chinese databases (China National Knowledge Infrastructure and Wanfang) were searched. Only randomized controlled trials related to the effects of scraping therapy on chronic LBP were included in this systematic review. Study selection, data extraction, and validation were conducted independently by 2 reviewers. The methodological quality of the studies was evaluated by the Cochrane risk-of-bias tool. RevMan 5.3 software was applied to perform meta-analysis of the data.
ResultsTen studies comprising 627 participants were included. Overall, the quality of evidence was moderate owing to a lack of blinding and allocation concealment in some studies and unclear risk of selective reporting. Meta-analysis of 9 RCTs indicated that scraping therapy had a statistically significant effect on pain reduction (standard mean difference = -0.66, 95% confidence interval [CI], -0.83 to -0.49, P < .001). However, if only a single scrape treatment was carried out, the results did not show that scraping was superior to the control group regarding pain relief (mean difference = -0.35, 95% CI, -1.23 to 0.53, P = .44). Moreover, the results of 6 RCTs involving 468 participants showed significantly greater improvement in lumbar dysfunction (mean difference = -10.05, 95% CI, -13.52 to -2.32, P < .001). In addition, the results of 5 RCTs involving 393 participants showed a favorably significant effect on the overall efficacy (odds ratio = 4.74, 95% CI, 2.34-9.62, P < .001). As for follow-up effects, meta-analysis of 3 RCTs involving 241 participants showed a promising effect on pain reduction and lumbar function improvement at 1 month and 3 months after the end of treatment, respectively. Only 1 study reported adverse effects, and none were serious.
Conclusion Scraping therapy may have a therapeutic effect for some individuals with chronic LBP. However, due to the limited amount of research and the low methodological quality of the included studies, additional large-scale, multicenter, high-quality RCTs on relieving pain intensity and improving lumbar dysfunction are still necessary.

1.2.14. Acupotomy

1.2.14.1. Xiang 2015 (syndrome du piriforme) ★★

Xiang J, Xue ZH ,Chen G et al. [Meta Analysis of Curative Effect of Needle Knife in the Treatment of Piriformis Syndrome] Journal of Clinical Acupuncture and Moxibustion. 2015;31(7):67-70,71. [188103]

ObjectiveTo evaluate the effect of small needle knife treatment on piriformis syndrome.
MethodsThrough comprehensive searching in vIP, Wan-fang and CNKI database, the relevant literatures with clinical randomized controlled trials which had been published about needle knife therapy for piriformis synclrome were collected. Then we manually looked up books and periodicals on piriformis syndrome, using Cochorane system evaluation method, according to the standard screening of literatures into the exclusion, sorting data, and use the RevMan5. 2 software to make quality evaluation and meta analysis.
ResultsThere were totally 10 Chinese literatures, including 977 patients. Meta analysis results: Comprehensively curative effect was well〔RR= 1. 16 ,95 % CI (1. 10, 1. 22) , Z = 5. 64 , P .c 0. 00001] , also with an instantly analgesic effect [ OR = 2. 68 ,95% C1 ( 1. 64 ,4. 36) , Z = 3. 95 , P < O. 0001].
ConclusionSmall needle knife in the treatment of piriformis syndrorne has a good curative effect, and has a instantly analgesic effect, but it also needs randomized clinical trials with more standardization and high quality to provide a reliable basis for clinical application.

1.2.15. Auricular Acupuncture

1.2.15.1. Moura 2019

Moura CC, Chaves ECL, Cardoso ACLR, Nogueira DA, Azevedo C, Chianca TCM. Auricular acupuncture for chronic back pain in adults: a systematic review and metanalysis. Rev Esc Enferm USP. 2019. [200455].

ObjectiveTo investigate randomized clinical trials on the action of auricular acupuncture for chronic back pain in adults, and to identify the most commonly used outcomes for assessing this condition, the protocol used for applying the intervention, and the efficacy of the therapy on pain intensity.
Method A systematic review and a metanalysis were carried out between June 2017 and May 2018, based on the PubMed, CINAHL, PEDro, Embase, Scopus, and the Virtual Health Library databases. Reference lists of systematic reviews were also explored.
Results427 studies were located, 15 included in the qualitative analysis, and seven in the quantitative analysis. Auricular acupuncture led to positive results in 80% of the studies. The most commonly used outcomes were pain intensity and quality, medication consumption, physical disability, and quality of life. There is a lack of protocol standardization for auricular acupuncture for chronic back pain. The metanalysis results showed that auricular acupuncture was effective in reducing pain intensity scores (p=0.038). CONCLUSION: Auricular acupuncture is a promising practice for the treatment of chronic back pain in adults.

1.2.16. Sham acupuncture versus routine treatments or waiting list

Xiang Y, He J, Li R. Appropriateness of sham or placebo acupuncture for randomized controlled trials of acupuncture for nonspecific low back pain: a systematic review and meta-analysis. J Pain Res. 2017:83-94. [52523].

ObjectivesTo establish whether sham acupuncture (SA) or placebo acupuncture (PA) is more efficacious for reducing low back pain (LBP) than other routine treatments and to discuss whether SA or PA is appropriate for randomized controlled trials of acupuncture for LBP.
Methods Six databases were searched on 31 May 2017. We included only randomized controlled trials of adults with LBP and lower back myofascial pain syndrome. The studies had at least two control arms: a sham-controlled acupuncture arm and a routine care or waiting list arm (people who did not receive acupuncture until the end of treatment). Trials were combined using meta-analysis methods when the data allowed statistical pooling. Pooled effect sizes were calculated by random effects models.
ResultsThis review identified 7 trials (1768 participants); all were included in the meta-analysis. We found statistically significant differences in pain reduction post-intervention between SA or PA and routine care or a waiting list, with a standardized mean difference of -0.36 (95% CI -0.54 to -0.18; I2 statistic=16%; participants=624; studies=6) for the Visual Analog Scale and -0.35 (95% CI -0.49 to -0.20; I2 statistic=0%; participants=736; studies=1) for the Chronic Pain Grade Scale; however, no significant difference was observed between SA or PA and routine care or no treatment for post-intervention function.
ConclusionCompared with routine care or a waiting list, SA or PA was more efficacious for pain relief post-intervention. Concluding that SA or PA is appropriate for acupuncture research would be premature. Guidelines evaluating SA or PA control methods are needed to determine the specific effect of acupuncture over placebo.

1.3. Specific outcome

1.3.1. Standaert 2011 (versus exercises or spinal manipulation) ★

Standaert CJ, Friedly J, Erwin MW, Lee MJ, Rechtine G, Henrikson NB, Norvell DC. Comparative effectiveness of exercise, acupuncture, and spinal manipulation for low back pain. Spine (Phila Pa 1976). 2011;36(21 Suppl):S120-30. [156609].

Objectifs We sought to answer the following clinical questions: (1) Is structured exercise more effective in the treatment of chronic low back pain (LBP) than spinal manipulative therapy (SMT)? (2) Is structured exercise more effective in the treatment of chronic LBP than acupuncture? (3) Is SMT more effective in the treatment of chronic LBP than acupuncture? (4) Do certain subgroups respond more favorably to specific treatments? (5) Are any of these treatments more cost-effective than the others?
Méthodes Summary of Background Data: Exercise, SMT, and acupuncture are widely used interventions in the treatment of chronic LBP. There is evidence that all of these approaches may offer some benefit for patients with chronic LBP when compared with usual care or no treatment. The relative benefits or cost-effectiveness of any one of these treatments when compared with the others are less well-defined, and it is difficult to identify specific subgroups of those with chronic LBP who may preferentially respond to a particular treatment modality. Methods:A systematic review of the literature was performed to identify randomized controlled trials comparing a structured exercise program, SMT, or acupuncture with one another in patients with chronic LBP.
Résultats Two studies were identified comparing the use of structured exercise with SMT that met our inclusion criteria. Although these studies utilized different approaches for the exercise and SMT treatment groups, patients in both groups improved in terms of pain and function in both studies. Using random-effects modeling, there was no difference between the exercise and SMT groups when the data from these studies were pooled. We identified no studies meeting our inclusion criteria that compared acupuncture with either structured exercise or SMT or that addressed the relative cost-effectiveness of these approaches in the treatment of patients with chronic LBP.
Conclusions The studies identified indicate that structured exercise and SMT appear to offer equivalent benefits in terms of pain and functional improvement for those with chronic LBP with clinical benefits evident within 8 weeks of care. However, the level of evidence is low. There is insufficient evidence to comment on the relative benefit of acupuncture compared with either structured exercise or SMT or to address the differential effects of structured exercise, SMT, or acupuncture for specific subgroups of individuals with chronic LBP. There is also insufficient evidence regarding the relative cost-effectiveness of structured exercise, SMT, or acupuncture in the treatment of chronic LBP. Clinical Recommendations: Structured exercise and SMT appear to offer equivalent benefits in the management of pain and function for patients with nonspecific chronic LBP. If no clinical benefit is appreciated after using one of these approaches for 8 weeks, then the treatment plan should be reevaluated and consideration should be given to modifying the treatment approach or using alternate forms of care. Strength of recommendation: Weak.There is insufficient evidence regarding the relative benefits of the acupuncture compared with either structured exercise or SMT in the treatment of chronic LBP.There is insufficient evidence to address differential effects of structured exercise, SMT, or acupuncture for specific subgroups of individuals with chronic LBP. There is insufficient evidence regarding the relative cost-effectiveness of structured exercise, SMT, or acupuncture in the treatment of chronic LBP.

1.3.2. Keller 2007 (Effect sizes) ★★

Keller A, Hayden J, Bombardier C, Van Tulder M. Effect sizes of non-surgical treatments of non-specific low-back pain. Eur Spine J. 2007;16(11):1776-88. [146413]

Numerous randomized trials have been published investigating the effectiveness of treatments for non-specific low-back pain (LBP) either by trials comparing interventions with a no-treatment group or comparing different interventions. In trials comparing two interventions, often no differences are found and it raises questions about the basic benefit of each treatment. To estimate the effect sizes of treatments for non-specific LBP compared to no-treatment comparison groups, we searched for randomized controlled trials from systematic reviews of treatment of non-specific LBP in the latest issue of the Cochrane Library, issue 2, 2005 and available databases until December 2005. Extracted data were effect sizes estimated as Standardized Mean Differences (SMD) and Relative Risk (RR) or data enabling calculation of effect sizes. For acute LBP, the effect size of non-steroidal anti-inflammatory drugs (NSAIDs) and manipulation were only modest (ES: 0.51 and 0.40, respectively) and there was no effect of exercise (ES: 0.07). For chronic LBP, acupuncture, behavioral therapy, exercise therapy, and NSAIDs had the largest effect sizes (SMD: 0.61, 0.57, and 0.52, and RR: 0.61, respectively), all with only a modest effect. Transcutaneous electric nerve stimulation and manipulation had small effect sizes (SMD: 0.22 and 0.35, respectively). As a conclusion, the effect of treatments for LBP is only small to moderate. Therefore, there is a dire need for developing more effective interventions.

1.3.3. Zhu 2002 (visual analog scale) ★★

Zhu Yb, Origasa H, Wang Q. Meta-analysis of acupuncture therapy for relieving low back pain on the visual analog scale. Jpn Pharmacol Ther. 2002;30(12):997-1002. [146717].

Acupuncture has been applied to medical practices within the Chinese traditional medicine for a long time. It was supposed to alleviate the low back pain through low frequency electricity. The purpose of this study is to assess the overall efficacy of acupuncture on low back pain using a meta－analytic method. We used the VAS (visual analog scale）as a measure of the effect on pain relief in a scale of 10cm. From nine controlled clinical trials selected by Medline or Japanese database on medical articles, Giles study was excluded since it included a therapy of spinal manipulation. Therefore, a total of 8 studies including 394 patients were utilized for the meta－analysis. The efficacy was consistent across studies, favoring acupuncture. The overall efficacy representing the difference between acupuncture and control was 0.33cm (95％CI ：0.11－0.54cm, p=0.003). Subset analyses by Japanese and English articles showed similar results that indicated the validity of meta－analytic finding. The meta－analysis has shown that acupuncture might be effective to lower the low back pain. Since the total sample size was relatively small, a larger controlled trial is further necessary to conduct.

 

1.3.4. Zhao 2023 (Inflammatory Cytokines)

Zhao Z, Li J, Wen J, He Y, Sun Z. Effect of Moxibustion on Inflammatory Cytokines for Low Back Pain: A Systematic Review, Meta-Analysis and Meta-Regression. Ther Clin Risk Manag. 2023 Oct 18;19:811-827. https://doi.org/10.2147/TCRM.S429469. PMID: 37873037; PMCID: PMC10590597.

Background and objective Moxibustion is effective for low back pain (LBP), and inflammatory cytokines may play an important role in the mechanism of moxibustion treatment. The purpose of this meta-analysis was to explore the mechanism of moxibustion in LBP in terms of inflammatory cytokines.
Methods We searched China National Knowledge Infrastructure, Wanfang database, Cochrane Central Register of Controlled Trials, Ovid MEDLINE, Embase, PubMed, and Web of Science to identify eligible randomized controlled trials (RCTs). There was no restriction on the publication date.
Results Thirty RCTs measuring interleukin (IL-) 1, IL-1β, IL-6, IL-12, IL-17, IL-23, and tumor necrosis factor (TNF-) α were included in this meta-analysis. Compared to controls: single moxibustion could effectively decrease levels IL-6 and IL-23 (SMD, -0.71, 95% CI: -1.25 to -0.17, p = 0.01; SMD, -1.61, 95% CI: -2.20 to -1.03, p < 0.01, respectively); combined moxibustion had significant effects on IL-1, IL-1β, IL-6, IL-12, IL-17, and TNF-α (p < 0.05). Overall, for LBP, single or combined moxibustion could effectively down-regulate levels of pro-inflammatory cytokines (p = 0.007 and p < 0.00001, respectively). For safety of moxibustion, the incidence rate of side effects was similar to that of controls (RD, -0.01, 95% CI: -0.02 to 0.01, p = 0.59). Sensitivity analysis showed that the pooled estimates were robust, and publication bias analysis showed there was a significant small study effect (Egger's test p = 0.0000). High statistical heterogeneity existed between included RCTs, meta-regression showed there was no potential factor explaining the source of heterogeneity.
Conclusion For LBP, moxibustion can effectively decrease levels of IL-1, IL-1β, IL-6, IL-12, IL-17, IL-23, and TNF-α to achieve analgesia. Because the side effects of moxibustion are transient, it is relatively safe for clinical use. However, based on high heterogeneity in this meta-analysis, rigorously designed RCTs are required to further confirm the results in this review.

1.4. Special Clinical Forms

1.4.1. low back pain in the elderly

1.4.1.1. Nascimento 2019

Nascimento PRCD, Costa LOP, Araujo AC, Poitras S, Bilodeau M. Effectiveness of interventions for non-specific low back pain in older adults. A systematic review and meta-analysis. Physiotherapy. 2019;105(2):147-162. [115114].

Objectives Systematically review the literature about all available interventions to manage non-specific low back pain (NSLBP) in older adults (≥60 years).
DesignWe searched the Medline, EMBASE, CINAHL, LILACS, PEDro, and Cochrane CENTRAL databases reference lists for randomized controlled trials (RCTs) testing interventions for NSLBP. Two independent reviewers extracted data, assessed the risk of bias and completeness of the description of interventions.
Results Eighteen (RCTs) fulfilled the eligibility criteria. Evidence about interventions to manage NSLBP in older adults is weak. Very low to moderate quality evidence showed that complementary health approach (i.e., manual therapy, acupuncture, mindfulness, yoga), percutaneous electrical nerve stimulation (PENS), education, exercise or pharmacological agents were not effective to produce a clinically significant reduction in pain and disability at short-term and intermediate-term compared to sham, usual care or minimal intervention. Interventions were moderately well-described according to the template for intervention description and replication (TIDieR) and the risk of bias was moderate 6.4 points on the 10-point PEDro Scale (SD=1.44).
Conclusion Evidence about interventions for NSLP in older adults is limited and new studies are highly likely to change these results. This result may impact healthcare providers due to the lack of effective evidence-based interventions, patients, and policy makers that will expend financial resources with interventions that provide in the best scenario a not significant improvement of the clinical symptoms. Researchers need to consider the importance of designing clinical trials targeting older adults and examine possible outcome modifiers present in this population allowing the recommendation of more efficacious evidence-based interventions.

1.4.2. Pyriformis Syndrome

1.4.2.1. Fu 2020

Fu Sisi. [Meta-analysis of Acupuncture and Massage Therapy in Treatment of Pyriformis Syndrome]. Clinical Journal of TCM. 2020. [212940].

Objective The clinical efficacy of acupuncture and massage in the treatment of piriformis syndrome was systematically evaluated by meta-analysis.
Methods Through searching PubMed, CKNI, Wanfang Database, VIP and CBM, find out the randomized controlled trial of acupuncture and massage in the treatment of piriformis syndrome, and select RevMan5. 3 software to conduct quality evaluation and meta-analysis of the final included literature.
Results A total of 729 patients were included in 11 studies. The results of meta-analysis showed that the total effective rate of acupuncture and massage in the treatment of piriformis syndrome was high [OR=4. 43, Z=5. 31 (P<0. 00001), 95%CI= (2. 56, 7. 67)].
Conclusion Acupuncture and massage has a good effect on piriformis syndrome. However, the literature quality is low, and more high-quality RCT studies are needed for comprehensive efficacy analysis.

1.4.3. Lumbar spondylolysis

1.4.3.1. Tanveer 2021

Tanveer F, Arslan SA, Darain H, Ahmad A, Gilani SA, Hanif A. Prevailing treatment methods for lumbar spondylolysis: A systematic review. Medicine (Baltimore). 2021 Dec 23;100(51):e28319. doi: 10.1097/MD.0000000000028319. PMID: 34941130; PMCID: PMC8702222.

Background Aim of this study was to systematically review the prevailing treatment methods for lumbar spondylolysis.
MethodsManuscripts published between 1951 and 2020 were searched by using PubMed, Medline, Scopus, Springer, Web of Science databases. The study protocol was registered with PROSPERO (CRD42020218651). The inclusion criteria for all articles of prevailing treatment methods for spondylolysis were: 1. English language; 2. at least 1 relevant treatment method for spondylolysis; 3. Randomized controlled trial (RCT), systematic review, comparative study, cross-sectional, cohort, and/or case control study 4. pre-diagnosed cases of spondylolysis whereas article was excluded if 5. any spinal deformity 6. any neurological condition. Standards have been independently applied by using 2 reviewers and another author resolved disagreements.
ResultsData extraction screened 12 full-length articles. Description, treatment, outcome, and findings were individually extracted and cross-referenced.
Discussion Current review has suggested that the noninvasive treatment method specifically low intensity pulsed ultrasound, electro acupuncture and pulsed electromagnetic filed is effective for bone union while operative treatment specifically pedicle screw fixation +/- interbody fusion depending the extent of disk degeneration and craniocaudal foraminal stenosis is effective for minimizing pain and functional disability in patients with spondylolysis. This review concluded that the noninvasive treatment method specifically low intensity pulsed ultrasound is effective for bone union.

1.4.4. Low Back Fasciitis

1.4.4.1. Geng 2023

Geng T, Lin D, Fu B, Wang H, Wan J. Meta-analysis of the efficacy of acupuncture in the treatment of low back fasciitis. Am J Transl Res. 2023 Aug 15;15(8):5486-5494. https://pubmed.ncbi.nlm.nih.gov/37692963

Background Acupuncture has unique advantages in the treatment of low back fasciitis and has been paid increasing attention. At present, many studies have summarized the efficacy of acupuncture and moxibustion in the treatment of low back fasciitis, but few have been summarized from the perspective of acupuncture alone.
AimTo evaluate the clinical efficacy of acupuncture in the treatment of lumbodorsal fasciitis by meta-analysis.
Methods The randomized controlled trials (RCT) of acupuncture in the treatment of low back fasciitis were searched in Pubmed, Embase, and Cochrane Library from the data of establishment to July 2023. Two authors independently conducted document screening, data abstraction, and qualitative assessment. RevMan 5.3 software and Stata 17.0 software were used for data analysis. The quantitative data were represented by mean difference (MD). The qualitative data were represented by odds ratio (OR).
Results Finally, a total of 12 RCTs with a total sample size of 930 cases were included, of which 461 patients received simple acupuncture treatment (Group A) and 469 patients received non-simple acupuncture treatment (Group B). The results of the meta-analysis showed that: (1) Clinical total effective rate: The results of subgroup analysis showed that the clinical total effective rate of acupuncture was significantly higher than that of Western medicine [OR = 12.72, 95% CI (2.26, 71.78), P = 0.004]; the total effective rate of the traditional Chinese medicine therapy was significantly higher than that of acupuncture [OR = 0.35, 95% CI (0.19, 0.65), P < 0.001]. (2) Score of the visual analog scale (VAS) after treatment: There was no significant difference in VAS score between Group A and Group B after treatment [MD = -0.22, 95% CI (-1.56, 1.12), P = 0.75]. (3) Oswestry disability index after treatment: The results of subgroup analysis showed that the Oswestry disability index after treatment of acupuncture was significantly lower than that of Western medicine therapy [MD = -0.05, 95% CI (-0.10, -0.00), P = 0.04]; the Oswestry disability index of Chinese medicine therapy was significantly lower than that of acupuncture alone [WD = 0.10, 95% CI (0.05, 0.15), P < 0.001].
Conclusion In the treatment of low back fasciitis, simple acupuncture therapy is superior to Western medicine therapy in improving treatment efficiency and low back muscle dysfunction, but slightly inferior to other traditional Chinese medicine therapies. Due to the limited efficacy of acupuncture, it is recommended to combine other therapies to improve the efficacy. Due to the small number of RTCs included and the unclear evaluation of many bias risks, high-quality, large sample randomized controlled studies are still needed to prove it.
1.4.4.2. Zhang 2023

Zhang R, Wen SY, Zhan HS, Lin X, Zhang M, Pang J, Cao YL, Chen B. Acupuncture for lumbar myofascial pain syndrome: systematic review and Meta-analysis. Zhongguo Zhen Jiu. 2023 Sep 8;43(11):1324-1332. English, Chinese. https://doi.org/10.13703/j.0255-2930.20221120-0002

Aim This study systematically reviewed the clinical efficacy of acupuncture for lumbar myofascial pain syndrome.
Methods The randomized controlled trials (RCTs) regarding acupuncture for lumbar myofascial pain syndrome were searched in PubMed, Cochrane Library, Web of Science, EMbase, Scopus, China national knowledge infrastructure (CNKI), Wanfang database, VIP database, and China biomedical literature service system (SinoMed) from database inception until August 1st, 2022. The Cochrane's risk of bias assessment tool was used to assess the risk of bias in all included studies, and Review Manager 5.3 software was used for statistical analysis of the extracted data.
Result As a result, 12 RCTs, involving 1 087 patients with lumbar myofascial pain syndrome, were ultimately included. The Meta-analysis results showed that the visual analog scale (VAS) score of pain in the observation group was lower than those in the oral non-steroidal anti-inflammatory medication control [SMD=-1.67, 95%CI (-2.44, -0.90), Z=4.26, P<0.000 1] and other treatment control [low-frequency electrical stimulation, tuina, electromagnetic wave irradiation combined with piroxicam gel, SMD=-1.98, 95%CI (-2.48, -1.48), Z=7.74, P<0.000 01]. The pain rating index (PRI) score in the observation group was lower than those in the lidocaine injection control [MD=-2.17, 95%CI (-3.41, -0.93), Z=3.44, P=0.000 6] and other treatment control [low-frequency electrical stimulation, tuina, MD=-5.75, 95%CI (-9.97, -1.53), Z=2.67, P=0.008]. The present pain intensity (PPI) score in the observation group was lower than that in other treatment control [low-frequency electrical stimulation, tuina, MD=-1.04, 95%CI (-1.55, -0.53), Z=4.01, P<0.000 1].
Conclusion In conclusion, compared with oral non-steroidal anti-inflammatory medication, low-frequency electrical stimulation, tuina, and electromagnetic wave irradiation combined with piroxicam gel, acupuncture is more effective in reducing pain in patients with lumbar myofascial pain syndrome; acupuncture also exhibites advantage over lidocaine injection in improving PRI score and showed better outcomes over tuina and low-frequency electrical stimulation in improving PRI and PPI scores.

2. Overviews of Systematic Reviews

2.1. Wu 2024

Wu M, Fan C, Liu H, Chen X, Gao Z, Zhao X, Zhou J, Jiang Z. The Effectiveness of Acupuncture for Low Back Pain: An Umbrella Review and Meta-Analysis. Am J Chin Med. 2024;52(4):905-923. https://doi.org/10.1142/S0192415X2450037X

Background Recommendations on the use of acupuncture in managing low back pain (LBP) vary across different guidelines. The methodological quality of existing systematic reviews and meta-analyses on this topic also demonstrates considerable diversity, potentially leading to biased conclusions.
Methods Therefore, we comprehensively searched PubMed, EMBASE, Web of Science, Cochrane Database of Systematic Reviews, and Chinese National Knowledge Infrastructure (CNKI) databases and conducted an umbrella review. Scrutiny was performed to ascertain whether primary studies within the systematic reviews and meta-analyses adhered to our inclusion criteria, followed by a meticulous reanalysis of pertinent data. Participant numbers, heterogeneity, publication bias, and excessive significance were taken into account when assessing the credibility of the evidence. For robustness, sensitivity analysis was performed using the leave-one-out method.
ResultsThe results of the umbrella review yielded highly suggestive evidence in favor of the immediate and short-term analgesic effects of acupuncture, with suggestive evidence supporting intermediate-term analgesic effects. However, the effectiveness of acupuncture on disability improvement has demonstrated weak to suggestive evidence. Evidence supporting the enhancement of quality of life by acupuncture is limited. The leave-one-out analysis corroborated the robustness of the meta-analysis, further confirming the credibility of the findings. This umbrella review indicated that the most significant advantage of acupuncture for LBP is its capacity to reduce pain.

2.2. Yan 2023

Yan WX, Lin HZ, Wang X, Zhang W, Liu LP, Yu JN, Yang T. Acupuncture for Low Back Pain: Reevaluation of Systematic Reviews and Meta-analyses. Curr Pain Headache Rep. 2023 Sep;27(9):351-369. https://doi.org/10.1007/s11916-023-01139-w

Purpose of reviewThis overview aims to reevaluate the methodological quality, report quality, and evidence quality of systematic reviews (SRs)/meta-analyses (MAs) of acupuncture for low back pain to determine whether acupuncture effectively treats low back pain (LBP).
Recent findingsTwenty-three SRs/Mas were deemed eligible for the present overview. The AMSTAR 2 score showed that the methodological quality of one SR/MA was of medium quality, one was of low quality, and 21 were of critically low quality. Based on the results of the PRISMA evaluation, there are certain areas for improvement in the quality of reporting of SRs/MAs. There were some reporting flaws in the topic of search strategy (8/23, 34.78%), certainty assessment (4/23, 17.39%), the certainty of evidence (4/23, 17.39%), registration and protocol (3/23, 13.04%), and availability of data, code, and other material (1/23, 4.35%). Results from the GRADE evaluation indicated that 13 of 255 outcomes were rated as moderate, 88 were low, and 154 were very low. Acupuncture effectively treated LBP in the SRs/MAs included in the reevaluation. However, the methodological, report, and evidence-based quality of the SRs/MAs on acupuncture for LBP was low. Therefore, further rigorous and comprehensive studies are warranted to improve the quality of SRs/MAs in this field.

2.3. Liu 2015

Liu LZ, Skinner M, Mcdonough S, Mabire L, Baxter GD. Acupuncture for low back pain: an overview of systematic reviews. Evidence-based Complementary and Alternative Medicine,. 2015. [177632].

Purpose As evidence of the effectiveness of acupuncture for low back pain (LBP) is inconsistent, we aimed to critically appraise the evidence from relevant systematic reviews.
Methods Systematic reviews of randomized controlled trials (RCTs) concerning acupuncture and LBP were searched in seven databases. Internal validity and external validity of systematic reviews were assessed. Systematic reviews were categorized and high quality reviews assigned greater weightings. Conclusions were generated from a narrative synthesis of the outcomes of subgroup comparisons.
Results Sixteen systematic reviews were appraised. Overall, the methodological quality was low and external validity weak. For acute LBP, evidence that acupuncture has a more favorable effect than sham acupuncture in relieving pain was inconsistent; it had a similar effect on improving function. For chronic LBP, evidence consistently demonstrated that acupuncture provides short-term clinically relevant benefits for pain relief and functional improvement compared with no treatment or acupuncture plus another conventional intervention.
Conclusion Systematic reviews of variable quality showed that acupuncture, either used in isolation or as an adjunct to conventional therapy, provides short-term improvements in pain and function for chronic LBP. More efforts are needed to improve both internal and external validity of systematic reviews and RCTs in this area.

2.4. Zeng 2015

Zeng Yingchun, Chung J Wai-yee. Acupuncture for chronic nonspecific low back pain: An overview of systematic reviews. European Journal of Integrative Medicine. 2015;7(2):94-107. [207036].

Introduction Chronic nonspecific low back pain (cnLBP), which cannot be attributed to a specific pathology is very common. As a result acupuncture is frequently used by patients as a treatment option. This overview aimed to summarize and evaluate the available systematic reviews on the clinical effectiveness and cost-effectiveness of acupuncture for the management of cnLBP, and to identify the safety of acupuncture for the management of cnLBP.
Methods Systematic reviews of acupuncture and cnLBP were sourced from five databases. Publications between January 2003 and May 2014 were included for analysis. Quality appraisal of included systematic reviews was assessed by the Overview Quality Assessment Questionnaire.
Results Seventeen systematic reviews were included. Five found that acupuncture was more effective when compared with a no treatment/waiting list control, as there were eight systematic reviews and meta-analysis providing positive and consistent findings. Seven systematic reviews providing positive findings of the comparison of acupuncture to sham acupuncture/passive modality treatment. Three systematic reviews of multiple RCTs also indicated positive and consistent findings of the comparison of acupuncture plus an intervention vs an intervention alone. Overall, findings on the effectiveness of acupuncture for cnLBP were consistent.
Conclusions As there is a range of diverse acupuncture styles used for patients with cnLBP, future trials are needed to establish the standardization of acupuncture in terms of the length of treatment sessions, frequency of sessions, number of needles needed per treatment, placement of needle insertion, depth of needle insertion, and whether needle stimulation achieves De Qi.

3. Cost-Effectiveness Analysis

See corresponding item

4. Clinical Practice Guidelines

⊕ positive recommendation (regardless of the level of evidence reported)
Ø negative recommendation (or lack of evidence)

4.1. American Psychological Association (APA, USA) 2024 ⊕

American Psychological Association (2024). Guideline for Psychological and Other Nonpharmacological Treatment of Chronic Musculoskeletal Pain in Adults. Retrieved from https://www.apa.org/practice/guidelines/nonpharmacological-treatment-chronic-musculoskeletal-pain.pdf

For patients with chronic LBP, the panel suggests offering patients the following interventions over usual care, attention control, or another intervention (Strength/Direction: Conditional For) : Acupuncture for short-term pain management.

4.2. World Health Organization (WHO) 2023 ⊕

WHO guideline for non-surgical management of chronic primary low back pain in adults in primary and community care settings [Internet]. Geneva: World Health Organization; 2023. Available from: https://www.ncbi.nlm.nih.gov/books/NBK599212/

Recommendation: Needling therapies such as acupuncture may be offered as part of care to adults, including older people, with CPLBP (conditional recommendation in favour of use, low certainty evidence)

4.3. Centers for Disease Control and Prevention (CDC, USA) 2022 ⊕

Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC Clinical Practice Guideline for Prescribing Opioids for Pain - United States, 2022. MMWR Recomm Rep. 2022 Nov 4;71(3):1-95. https://doi.org/10.15585/mmwr.rr7103a1

Clinicians should recommend appropriate noninvasive nonpharmacologic approaches to help manage chronic pain, such as […] psychological therapy, spinal manipulation, low-level laser therapy, massage, mindfulness-based stress reduction, yoga, acupuncture, and multidisciplinary rehabilitation for low back pain.

4.4. Department of Veterans Affairs Department of Defense (VA/DoD, USA) 2022 ⊕

VA/DoD Clinical Practice Guideline for the Diagnosis and Treatment of Low Back Pain. Department of Veterans Affairs Department of Defense. 2022:141P. https://www.healthquality.va.gov/guidelines/Pain/lbp/VADoDLBPCPGFinal508.pdf

For patients with chronic low back pain, we suggest acupuncture. Weak for.
For patients with chronic low back pain, there is insufficient evidence to recommend for or against auricular acupressure.

4.5. Istituto Superiore di Sanità (ISS, Italy) 2022 ⊕

Agopuntura per la terapia del dolore. Linea guida pubblicata nel Sistema Nazionale Linee Guida Roma, 25 luglio 2022. https://snlg.iss.it/wp-content/uploads/2022/07/LG-412_FISA_Agopuntura-per-terapia-dolore.pdf

Quesito 2: Dovrebbe essere utilizzata l’agopuntura in pazienti affetti da lombalgia cronica aspecifica rispetto al trattamento non farmacologico?
Raccomandazione clinica: In pazienti adulti affetti da lombalgia cronica aspecifica è possibile utilizzare sia l'agopuntura che il trattamento non farmacologico. Certezza nelle prove: molto bassa. Forza della raccomandazione: Condizionata a favore di agopuntura o trattamento non farmacologico.
Quesito 3: Dovrebbe essere utilizzata l’agopuntura in pazienti affetti da lombalgia cronica aspecifica rispetto al trattamento farmacologico?
Raccomandazione clinica: In pazienti adulti affetti da lombalgia cronica aspecifica è possibile utilizzare l'agopuntura rispetto al trattamento farmacologico. Certezza nelle prove: molto bassa. Forza della raccomandazione: condizionata a favore di agopuntura.
Quesito 4: Dovrebbe essere utilizzata l’agopuntura in pazienti affetti da lombalgia cronica aspecifica rispetto al trattamento combinato farmacologico e non farmacologico?
Raccomandazione clinica: In pazienti adulti affetti da lombalgia cronica aspecifica è possibile utilizzare l'agopuntura rispetto al trattamento combinato farmacologico e non farmacologico. Certezza nelle prove: moderata. Forza della raccomandazione: condizionata a favore di agopuntura.
Quesito 5: Dovrebbe essere utilizzata l’agopuntura in aggiunta al trattamento non farmacologico in pazienti affetti da lombalgia cronica aspecifica rispetto al trattamento non farmacologico?
Raccomandazione clinica: In pazienti adulti affetti da lombalgia cronica aspecifica è possibile utilizzare l'agopuntura in aggiunta al trattamento non farmacologico rispetto al trattamento non farmacologico. Certezza nelle prove: molto bassa. Forza della raccomandazione: condizionata a favore di agopuntura. .
Quesito 6: Dovrebbe essere utilizzata l’agopuntura in aggiunta al trattamento combinato farmacologico e non farmacologico in pazienti affetti da lombalgia cronica aspecifica rispetto al trattamento combinato farmacologico e non farmacologico?
Raccomandazione clinica: In pazienti adulti affetti da lombalgia cronica aspecifica l'aggiunta dell'agopuntura al trattamento combinato farmacologico e non farmacologico migliora gli esiti clinici, rispetto al solo trattamento combinato farmacologico e non farmacologico. Certezza nelle prove: molto bassa. Forza della raccomandazione: condizionata a favore di agopuntura

4.6. American Academy of Family Physicians (AAFP, USA) 2021 ⊕

AAFP Chronic Pain Toolkit. American Academy of Family Physicians. 2021. [188191]. URL

Chronic pain : Non-opioid analgesics, physical therapy, cognitive behavioral therapy, rehabilitation, exercise, integrative medical therapies (e.g., yoga, relaxation, tai chi, massage, and acupuncture), opioids on a case-by-case basis.
Acupuncture : indications Low back pain, fibromyalgia, chronic headache, neck pain. Magnitude to benefit pain and function: small to moderate.

4.7. College of Family Physicians of Canada (CFPC, Canada) 2021 ∅

Korownyk CS, Montgomery L, Young J, Moore S, Singer AG, MacDougall P, Darling S, Ellis K, Myers J, Rochford C, Taillefer MC, Allan GM, Perry D, Moe SS, Ton J, Kolber MR, Kirkwood J, Thomas B, Garrison S, McCormack JP, Falk J, Dugré N, Sept L, Turgeon RD, Paige A, Potter J, Nickonchuk T, Train AD, Weresch J, Chan K, Lindblad AJ. PEER simplified chronic pain guideline: Management of chronic low back, osteoarthritic, and neuropathic pain in primary care. Can Fam Physician. 2022 Mar;68(3):179-190. https://doi.org/10.46747/cfp.6803179

Chronic low back pain. Unclear: acupuncture, rubefacients

4.8. Agency for Care Effectiveness, Ministry of Health (ACE, Singapore) 2020 ⊕

Technology Guidance from the MOH Medical Technology Advisory Committee. Acupuncture for adults with low back pain and neck pain. Agency for Care Effectiveness, Ministry of Health, Republic of Singapore. 2020. [196853]. URL.

Guidance Recommendations. The Ministry of Health’s Medical Technology Advisory Committee has recommended: Needled acupuncture (with or without electro stimulation) performed in public healthcare institutions (PHIs) for pain reduction or functional improvement in adults aged 18 years and above as clinically appropriate for:
- Low back pain,
- Neck pain, including pain radiating to the neck, or from neck to shoulders.
It can be administered for up to 12 sessions within 3 months from treatment initiation following formal diagnosis and recommendation by a referring medical specialist in a PHI. Subsequent treatment up to 12 more sessions within the next 3 months is subject to the reviewing medical specialist’s assessment of sustained pain reduction or functional improvement for the patient. It shall be performed by acupuncturists registered with the Traditional Chinese Medicine Practitioners Board (TCMPB) in accordance with minimum practice standards defined by the TCM Branch of MOH.
Subsidy status. Subsidy for needled acupuncture (with or without electro stimulation) for the above mentioned criteria is applicable only for treatments performed in public healthcare institutions.

4.9. Agency for Healthcare Research and Quality (ARQ, USA) 2020 ⊕

Skelly AC, Chou R, Dettori JR, Turner JA, Friedly JL, Rundell SD, Fu R, Brodt ED, Wasson N, Kantner S, Ferguson AJR. Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review Update [Internet]. . 2020;:607p. [208656]. doi

Interventions that improved function and/or pain for ≥1 month: Exercise, psychological therapy, spinal manipulation, low-level laser therapy, massage, mindfulness-based stress reduction, yoga, acupuncture, multidisciplinary rehabilitation (MDR).
Acupuncture: Acupuncture was associated with a small improvement in short-term function compared with sham acupuncture or usual care (4 trials); there was no difference between acupuncture and controls in intermediate-term (3 trials) or long-term (1 trial) function (SOE: low). Acupuncture was associated with small improvements in short-term (5 trials) and long-term (1 trial) pain compared with sham acupuncture, usual care, an attention control, or a placebo intervention but there was no difference in intermediate-term pain (5 trials) (SOE: moderate for short term, low for intermediate term and long term).

4.10. American College of Occupational and Environmental Medicine (ACOEM, USA) 2020 ⊕

Hegmann KT, Travis R, Andersson GBJ, Belcourt RM, Carragee EJ, Donelson R, Eskay-Auerbach M, Galper J, Goertz M, Haldeman S, Hooper PD, Lessenger JE, Mayer T, Mueller KL, Murphy DR, Tellin WG, Thiese MS, Weiss MS, Harris JS. Non-Invasive and Minimally Invasive Management of Low Back Disorders. J Occup Environ Med. 2020 Mar;62(3):e111-e138. https://doi.org/10.1097/JOM.0000000000001812

LBP : Acupuncture is Recommended (C), For treatment of acute, subacute, radicular, or postoperative LBP, there are no quality studies, there are other effective treatments for those patients, and thus, acupuncture is Not Recommended (I), Moderate Confidence.

4.11. Centers for Medicare & Medicaid Services (CMS, USA) 2020 ⊕

NCA - Acupuncture for Chronic Low Back Pain (CAG-00452N) - Decision Memo. Centers for Medicare & Medicaid Services (CMS). 2020. 41P. [219397]. URL

Medicare Part B (Medical Insurance) covers up to 12 acupuncture visits in 90 days for chronic low back pain.
Medicare covers an additional 8 sessions if you show improvement. If your doctor decides your chronic low back pain isn’t improving or is getting worse, then Medicare won't cover your treatments. No more than 20 acupuncture treatments can be given yearly.

4.12. Ministry of Public Health of Qatar (MOPH, Qatar) 2020 ∼

The management of low back pain in adults. National Clinical Guidelines. Ministry of Public Health of Qatar (MOPH). 2020:34P. [219473]. URL

Acupuncture is not recommended for the management of LBP due to insufficient evidence of benefit [L1, RGB], but may be considered in refractory cases. Dry Needling (of muscular trigger points may also be beneficial in certain patients .

4.13. North American Spine Society (NASS, USA) 2020 ⊕

Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care: Diagnosis & Treatment of Low Back Pain. North American Spine Society. 2020:217P. [219367]. URL

In patients with low back pain, there is conflicting evidence that acupuncture provides improvements in pain and function as compared to sham acupuncture.
In patients with chronic low back pain, addition of acupuncture to usual care is recommended for short-term improvement of pain and function compared to usual care alone.
There is insufficient evidence to draw conclusions regarding the comparative effectiveness of acupuncture techniques.

4.14. AIM Specialty Health (USA) 2019 ⊕

Spine Surgery. Musculoskeletal Program Clinical Appropriateness Guidelines. AIM Specialty Health. 2019;:42P. [198043].

Cervical Decompression With or Without Fusion/ Cervical Disc Arthroplasty/ Lumbar Disc Arthroplasty/ Lumbar Discectomy, Foraminotomy, and Laminotomy/ Lumbar Fusion and Treatment of Spinal Deformity (including Scoliosis and Kyphosis)/ Lumbar Laminectomy. Conservative management should include a combination of strategies to reduce inflammation, alleviate pain, and improve function, including but not limited to the following: [Alternative therapies such as acupuncture]. The requirement for a period of conservative treatment as a prerequisite to a surgical procedure is waived when there is evidence of progressive nerve or spinal cord compression resulting in a significant neurologic deficit, or when myelopathy, weakness, or bladder disturbance is present.

4.15. American Chronic Pain Association (ACPA, USA) 2019 ⊕

American Chronic Pain Association Resource Guide to Chronic Pain management, An Integrated Guide to Medical, Interventional, Behavioral Pharmacologic and Rehabilitation Therapies. Feinberg S (ed.) American Chronic Pain Association Inc., Rocklin, California. 2019:156p. [219425]. URL

Acupuncture has been gaining popularity in the United States since the 1970s, and, in wake of increasing acceptance by both the public and medical professionals, it is now covered by many insurance policies. In the field of chronic pain medicine, there is a strong body of research supporting the efficacy of acupuncture for headache, osteoarthritis, and musculoskeletal conditions, such as neck and lower back pain

4.16. Chinese Association for the Study of Pain (CASP, China) 2019 ⊕

Ma K, Zhuang ZG, Wang L, Liu XG, Lu LJ, Yang XQ, Lu Y, Fu ZJ, Song T, Huang D, Liu H, Huang YQ, Peng BG, Liu YQ. The Chinese Association for the Study of Pain (CASP): Consensus on the Assessment and Management of Chronic Nonspecific Low Back Pain. Pain Res Manag. 2019;:8957847. [199422].

13.10. Acupotomy. Acupotomy is indicated for soft tissue originated pain. It was reported that acupotomy can effectively treat the third lumbar transverse process syndrome, iliolumbar ligament injury, and lumbar gluteal myofasciitis [108, 109]. In contrast to silver needle thermoconduction therapy, acupotomy is especially applicable to localized soft tissue originated pain.
14.2. Acupuncture. Acupuncture can relieve pain immediately, and its effect can be maintained for up to 12 weeks. However, its long-term efficacy is unknown [114].

4.17. Haute Autorité de Santé (HAS, France) 2019 ∅

  • Prise en charge du patient présentant une lombalgie commune. Haute Autorité de Santé. 2019. Rapport d'élaboration [195589]. Arbre décisionnel de prise en charge [195568]. Fiche mémo [195919].
  • Bailly F, Trouvin AP, Bercier S, Dadoun S, Deneuville JP, Faguer R, Fassier JB, Koleck ML, Lassalle L, Le Vraux T, Brigitte L, Petitprez K, Ramond-Roquin A, Renard JO, Roren A, Rozenberg S, Sebire C, Vuides G, Rannou FO, Audrey P. Clinical guidelines and care pathway for management of low back pain with or without radicular pain. Joint Bone Spine. 2021 Dec;88(6):105227. doi: 10.1016/j.jbspin.2021.105227
L’acupuncture, l’acupression et le dry needling n’ont pas démontré d’efficacité sur l’évolution de la lombalgie (NP2, niveau de preuve 2)

.

4.18. Japanese Orthopaedic Association (JOA, Japan) 2019 Ø

Shirado O, Arai Y, Iguchi T, Imagama S, Kawakami M, Nikaido T, Ogata T, Orita S, Sakai D, Sato K, Takahata M, Takeshita K, Tsuji T; Structured abstract preparation team. Formulation of Japanese Orthopaedic Association (JOA) clinical practice guideline for the management of low back pain- the revised 2019 edition. J Orthop Sci. 2022 Jan;27(1):3-30. https://doi.org/10.1016/j.jos.2021.06.024

Low back pain. There is no established evidence of complementary and alternative medicine (CAM) therapies [acupuncture] in Japan. Therefore, it is basically impossible to state their usefulness or recommendation in this guideline.

Cited by Okawa Y, Yamashita H, Masuyama S, Fukazawa Y, Wakayama I. Quality assessment of Japanese clinical practice guidelines including recommendations for acupuncture. Integr Med Res. 2022 Sep;11(3):100838. https://doi.org/10.1016/j.imr.2022.100838. Note : Underestimated

4.19. Russian Society for the Study of Pain (RSSP, Russia) 2019 ⊕

Parfenov V, Yakhno N, Davydov O, Kukushkin M, Churyukanov M, Golovacheva V, et al. [Chronic nonspecific (musculoskeletal) low back pain. Guidelines of the Russian Society for the Study of Pain (RSSP)]. Neurol Neuropsychiatry Psychosom. 2019;11(2S):7–16. https://doi.org/10.14412%2F2074-2711-2019-2S-7-16

Additional Treatment (low level of evidence) : Back muscle massage, acupuncture; botulinum toxin injections

4.20. Scottish Intercollegiate Guidelines Network (SIGN) 2019 ⊕

Scottish Intercollegiate Guidelines Network (SIGN). Management of chronic pain. Edinburgh: SIGN. 2019. https://www.sign.ac.uk/media/1108/sign136_2019.pdf

Acupuncture should be considered for short-term relief of pain in patients with chronic low back pain or osteoarthritis grade of recommendation A/

4.21. Aetna (insurance provider, USA) 2018 ⊕

Acupuncture. Aetna (insurance provider, USA). 2018. 73P. [188029].

Aetna considers needle acupuncture (manual or electroacupuncture) medically necessary for any of the following indications: Low Back Pain.

4.22. Agency for Healthcare Research and Quality (ARQ, USA) 2018 ⊕

Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review. Agency for Healthcare Research and Quality (ARQ, USA). 2018. 1398P. [192680].

Interventions that improved function and/or pain for at least 1 month when used for: - Chronic low back pain: Exercise, psychological therapies (primarily cognitive behavioral therapy [CBT]), spinal manipulation, low-level laser therapy, massage, mindfulness-based stress reduction, yoga, acupuncture, multidisciplinary rehabilitation (MDR).

4.23. Institute for Clinical Systems Improvement (ICSI, USA) 2018 ⊕

Institute for Clinical Systems Improvement. Adult acute and subacute low back pain. Sixteenth edition. Bloomington: ICSI. 2018;:49p. [195619].

Acupuncture should be considered for subacute low back pain. Quality of Evidence: Low. Weak Recommendation.

4.24. The Global Spine Care Initiative (GSCI, USA) 2018 ⊕

Chou R, Côté P, Randhawa K, Torres P, Yu H, Nordin M, Hurwitz EL, Haldeman S, Cedraschi C. The Global Spine Care Initiative: applying evidence-based guidelines on the non-invasive management of back and neck pain to low- and middle-income communities. Eur Spine J. 2018:851-860. [115666]. doi

For patients with chronic low back and neck pain without serious pathology, primary treatment options are exercise, yoga, cognitive behavioral therapies, acupuncture, biofeedback, progressive relaxation, massage, manual therapy, interdisciplinary rehabilitation, NSAIDs, acetaminophen, and antidepressants.

4.25. Bundesärztekammer [German Medical Association] et al (BÄK, Germany) 2017 ⊕

Nationale VersorgungsLeitlinie Nicht‐spezifischer Kreuzschmerz – Langfassung, 2. Auflage. Version 1 Bundesärztekammer (BÄK), Kassenärztliche Bundesvereinigung (KBV), & Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften (AWMF). 2017. [213521]. URL

5-2. Acupuncture can be used to treat chronic non-specific low back pain.

4.26. Canadian Medical Association (CMA, Canada) 2017 ⊕

Lignes directrices canadiennes relatives à l’utilisation des opioïdes pour le traitement de la douleur chronique non cancéreuse, Canadian Medical Association. 2017:110P. [196698].

Recommandation 1: Lorsqu’on envisage le traitement d'un patient atteint de douleur chronique non cancéreuse nous recommandons l’optimisation de la pharmacothérapie non opioïde et du traitement non pharmacologique plutôt qu’un essai d’opioïdes (Recommandation Forte).
Le tableau 2 énumère certains des traitements spécifiques disponibles pour la prise en charge de la douleur chronique non cancéreuse ainsi que les données probantes appuyant chacun de ces traitements .
Lombalgie chronique. Qualité des données probantes : Faible à modérée Données probantes soutenant des bienfaits légers à modérés à court terme avec les stratégies suivantes : Tai-chi, méthode de réduction de stress fondée sur la pleine conscience, exercice, rééducation multidisciplinaire, manipulation rachidienne, massothérapie et acupuncture. Les effets sur la capacité fonctionnelle étaient en général moins importants que les effets sur la douleur.

4.27. Centre Fédéral d'Expertise des Soins de Santé (KCE, Belgium) 2017 ∅

van Wambeke P, Desomer A, Ailliet L, Berquin A, Demoulin C, Depreitere B, Dewachter J, Dolphens M et al. Low back pain and radicular pain: assessment and management. Bruxelle: Centre Fédéral d'Expertise des Soins de Santé (KCE). 2017;:167P. [199094]. URL

No recommendation on acupuncture has been formulated.

4.28. Colorado Division of Workers' Compensation (USA) 2017 ⊕

Chronic pain disorder medical treatment guideline. Colorado Division of Workers' Compensation. 2017:178p. [198058].

Based on the multiple studies with good and some evidence listed above, there is strong evidence that true or sham acupuncture may be useful for chronic low back pain in patients with high expectations, and it should be used accordingly.

4.29. Department of Veterans Affairs, Department of Defense (VA/DOD, USA) 2017 ⊕

Diagnosis and Treatment of Low Back Pain Work Group. VA/DoD clinical practice guideline for diagnosis and management of low back pain. Version 2.0. Washington (DC): Department of Veterans Affairs, Department of Defense. 2017:110P. [198140].

For patients with acute low back pain, there is insufficient evidence to support the use of acupuncture. (Strength: Not Applicable; Category: Reviewed, New-replaced),
For patients with chronic low back pain we suggest offering acupuncture. (Strength:Weak For; Category: Reviewed, New-replaced)

4.30. Finnish Medical Association and the Finnish Physical Society (Finland) 2017 ⊕

[Lower back pain]. Duodecim of the Finnish Medical Association and the Finnish Physical Society. 2017:20p. [219471]. URL

Acupuncture in chronic low back pain apparently slightly relieves pain and cures short-term performance [117-119] C

4.31. Institute for Clinical and Economic Review (ICER, USA) 2017 ⊕

Tice JA, Kumar V, Otuonye I, et al. Cognitive and Mind-Body Therapies for Chronic Low Back and Neck Pain: Effectiveness and Value, Final Evidence Report. The Institute for Clinical and Economic Review (ICER). 2017;:171p. [219448]. URL

Chronic Low Back. Acupuncture. Net Health Benefit: Small. Level of Certainty: Moderate. ICER Evidence Rating: C+: Comparable or better.

4.32. Kaiser Foundation Health 2017 (USA) ⊕

Non-specific Back Pain Guideline. Kaiser Permanente Clinical Guidelines. 2017:17p. [198162].

Acupuncture: Evidence suggests that acupuncture may improve chronic back pain in the short term. Long-term improvement is unknown. Most patients may self-refer for acupuncture; advise patients to check with Member Services to determine their individual coverage and benefits.
Acute low back pain There is insufficient evidence to determine whether acupuncture is effective for acute low back pain.
Chronic low back pain One systematic review (Liu 2015) and one meta-analysis (Yuan 2016) found that acupuncture may reduce pain in the short term. However, the effect is not clinically important. The main limitations included high heterogeneity and short follow-up periods. In addition, harms were poorly assessed. Overall, the quality of evidence is low and results should be interpreted with caution.

4.33. Philippine Academy of Rehabilitation Medicine (PARM) 2017 ⊕

Low back pain management guideline. Philippine Academy of Rehabilitation Medicine (PARM). 2017:294P. [198246].

Acute non-specific low back pain.: There is some evidence that acupuncture is useful in patients with acute non-specific low back pain. PARM recommends use of acupuncture acute non-specific low back pain.
Acute low back pain with radiculopathy: There is some evidence to use acupuncture in acute low back pain with radiculopathy. PARM Endorses use of acupuncture as treatment for low back pain with radiculopathy,
Subacute non-specific low back pain: There is some evidence that acupuncture is useful in patients with subacute non-specific low back pain. PARM recommends acupuncture in patients as treatment for subacute non-specific low back pain.
Chronic non-specific low back pain : There is evidence in the use of therapeutic acupuncture as treatment for chronic nonspecific low back pain. PARM endorses the use of therapeutic acupuncture as treatment for chronic non-specific low back pain.

4.34. Alberta Health Services (AHS, Canada) 2017 ⊕

Low Back Pain, Adult – Emergency. Clinical Practice Guideline. Alberta Health Services. 2017. 16P. [178726].

Acupuncture: Role in acute low back pain is unclear. May be a useful adjunct to other therapies in chronic low back pain (low quality evidence).

4.35. Ontario Protocol for Traffic Injury Management (OPTIMa, Canada) (Revue de recommandations) 2017 ⊕

Wong JJ, Côté P, Sutton DA, Randhawa K, Yu H, Varatharajan S, et al. Clinical practice guidelines for the noninvasive management of low back pain: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Eur J Pain. 2017;21(2):201-216. [188699].

According to high-quality guidelines: the management of chronic LBP may include exercise, paracetamol or NSAIDs, manual therapy, acupuncture, and multimodal rehabilitation (combined physical and psychological treatment).

4.36. American College of Physicians (ACP, USA) 2017 ⊕

Qaseem A, Wilt TJ, McLean RM, Forciea MA. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017. 166(7):514-530 [191863].

Recommendation 2: for patients with chronic low back pain,clinicians and patients should initially select nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (moderate-quality evidence). [Grade: strong recommendation].

4.37. German Association for Quality Assurance in Medicine (Ärztliches Zentrum für Qualität in der Medizin, ÄZQ, Germany) 2017 ⊕

Chenot JF, Greitemann B, Kladny B, Petzke F, Pfingsten M, Schorr SG. Non-Specific Low Back Pain. Dtsch Arztebl Int. 2017;114(51-52):883-89. [195651].

Acupuncture can be used to treat chronic low back pain as part of an overall concept in combination with activating therapeutic measures.

4.38. Centre Fédéral d'Expertise des Soins de Santé (CFESS, Belgique) 2017 Ø

CFESS. Guide de pratique clinique pour les douleurs lombaires et radiculaires. Centre Fédéral d'Expertise des Soins de Santé. 2017;:41P. [16938].

Les recommandations présentées ici proviennent en grande partie du guideline « Low back pain and sciatica in over 16s: assessment and management », publié par NICE le 30 novembre 2016. Chacune des recommandations cliniques a été adaptée au contexte belge selon la méthode ADAPTE (www.adapte.org). Cette démarche a nécessité l’implication active d’un groupe multidisciplinaire de professionnels de la santé, appelé ci-après le Guideline Development Group (GDG). Les différences entre la version belge et la version originale de NICE sont clairement soulignées dans le rapport scientifique.

Interventions sans recommandation claire. L’acupuncture n’a pas clairement démontré sa supériorité sur un traitement placebo dans les douleurs lombaires, mais il n’existe pas non plus de preuves d’éventuels effets indésirables. Il est possible que cette technique soit davantage indiquée dans les douleurs neuropathiques que dans les douleurs mécaniques, mais la revue de la littérature n’a pas permis de distinguer ces deux types de douleur. Il n’est donc pas possible de formuler une recommandation univoque.

4.39. Société Scientifique de Médecine Générale (Belgique) 2017 ⊕

Henrard G, Cordyn S, Chaspierre A, Kessels T, Mingels S, Vanhalewyn M. Guide de Pratique Clinique - Prise en charge de la douleur chronique en première ligne de soins. Société Scientifique de Médecine Générale (Groupe de Travail Développement Recommandations de Bonne Pratique Première Ligne) Belgique. 2017; : 59p. [194983].

L’acupuncture doit être envisagée pour soulager à court terme pendant une certaine période les patients souffrant de douleur chronique dans le bas du dos ou d’arthrose. (GRADE 2B)

4.40. Emblemhealth (insurance provider, USA) 2017 ⊕

Acupuncture — Medicare Dual-Eligible Members Emblemhealth. 2017. [111547].

Members with the Medicare Dual-Eligible benefit are eligible for acupuncture when performed by an individual licensed by New York State to perform acupuncture and when performed for the following diagnoses: 1. Adult postoperative nausea and vomiting 2. Chemotherapy related nausea and vomiting 3. Pregnancy related nausea and vomiting 4. Carpal tunnel syndrome 5. Epicondylitis (tennis elbow) 6. Headache 7. Low back pain 8. Menstrual pain 9. Myofascial pain 10. Osteoarthritis

4.41. Agency for Healthcare Research and Quality (ARQ, USA) 2016 ⊕

Noninvasive Treatments for Low Back Pain: Current State of the Evidence. Agency for Healthcare Research and Quality (ARQ, USA). 2016. 808p. [192682].

For chronic low back pain, effective therapies versus placebo, sham, no treatment, usual care, or wait list are NSAIDs, opioids, tramadol, duloxetine, multidisciplinary rehabilitation, acupuncture, and exercise (SOE: moderate). For chronic low back pain, effective therapies versus placebo, sham, no treatment, usual care, or wait list are NSAIDs, opioids, tramadol, duloxetine, multidisciplinary rehabilitation, acupuncture, and exercise (SOE: moderate).

4.42. Danish Health and Medicines Authority (DHMA, Danemark) 2016 ⊕

[NKR: Treatment of new-onset low back pain]. Danish Health and Medicines Authority (DHMA, Danemark). 2016. [219385]. URL

[Only offer acupuncture techniques in addition to regular treatment to patients with new-onset low back pain after careful consideration as the beneficial effect is uncertain. Update of the recommendation is not deemed necessary in 2019.]

4.43. National Institute for Health and Clinical Excellence (NICE, UK) 2016 Ø

National Institute for Health and Clinical Excellence. Low back pain and sciatica in over 16s: assessment and management (NG59). Evidence-based recommendations on assessing and managing low back pain and sciatica in people aged 16 and over London (UK): National Institute for Health and Clinical Excellence (NICE). 2016. [158090]. Données relatives à l'acupuncture : [158090-b].

1.2.8, Do not offer acupuncture for managing low back pain with or without sciatica.

4.44. NHS Lothian (Scotland) 2015 ⊕

NHS Lothian Integrated Back Pain Service. RefHELP NHS Lothian Referral Guidelines. 2015:78P. [197935].

Patients are managed within physiotherapy services based on their complexity and “risk category”. Examples of physiotherapy management include [ …] Individualised physiotherapy including in addition to advice and education, manual therapy (mobilisation/ manipulation), group based exercise, acupuncture, individualised home exercise (typically the “medium risk” group).

4.45. Toward Optimized Practice (TOP, Canada) 2015 ⊕

Toward Optimized Practice. Evidence-informed primary care management of low back pain Edmonton (AB): Toward Optimized Practice. 2015. 49p. [169847].

Chronic low back pain, Acupuncture : Recommend acupuncture as a short-term therapy or as an adjunct to a broader active rehabilitation program. No serious adverse events were reported in the clinical trials. The incidence of minor adverse events was 5%.

4.46. National Health Committee (NHC, New-Zealand) 2015 ⊕

National Health Committee. Low Back Pain: A Pathway to Prioritisation. Wellington: National Health Committee. 2015;:98p. [200342].

Analgesia is provided through a stepped approach (First-line: paracetamol, Second-line: NSAIDs, Third-line: Tricyclic antidepressants and/or weak opioids), and combined with treatment programmes including exercise, spinal manipulation and/or acupuncture.

4.47. Oregon Health Autority (OHA, USA) 2014 ⊕

Health Evidence Review Commission (HERC). Coverage guidance: lower back pain: nonpharmacological/non-invasive interventions. Oregon Health Autority (OHA). 2014. 8P . [189900].

For pain > 4 weeks duration, the following treatments are recommended for coverage: Acupuncture, Cognitive-behavioral therapy, Exercise therapy, Intensive interdisciplinary rehabilitation, Massage therapy, Progressive relaxation, Spinal manipulation, Yoga (viniyoga).

4.48. State of Colorado Department of Labor and Employment (USA) 2014 ⊕

Low Back Pain Medical Treatment Guidelines. State of Colorado Department of Labor and Employment. 2014. 117p. [180921].

Acupuncture is recommended for subacute or chronic pain patients who are trying to increase function and/or decrease medication usage and have an expressed interest in this modality. It is also recommended for subacute or acute low back pain for patients who cannot tolerate nonsteroidal anti-inflammatory drugs (NSAIDs) or other medications.

4.49. Scottish Intercollegiate Guidelines Network (SIGN, Ecosse) 2013 ⊕

Scottish Intercollegiate Guidelines Network (SIGN). Management of chronic pain. A national clinical guideline. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network (SIGN). 2013; 64P. [167517].
Smith BH, Hardman JD, Stein A, Colvin L; SIGN Chronic Pain Guideline Development Group.. Managing chronic pain in the non-specialist setting: a new SIGN guideline. Br J Gen Pract. 2014;64(624):e462-4. [193376].

Acupuncture should be considered for short term relief of pain in patients with chronic low back pain or osteoarthritis.

Acupuncture. U.S. Navy Bureau of Medicine and Surgery. 2013.17p. [180539].

Category A (fair to high quality evidence): Authorized and recommended for routine use. Low back pain (LBP).

4.51. Associação Brasileira de Medicina Física e Reabilitação (Bresil) 2013 ⊕

Associação Brasileira de Medicina Física e Reabilitação. Chronic nonspecific low back pain: rehabilitation. Rev Assoc Med Bras. 2013;59(6):536-53. [159530].

7. What is the role of electrical stimulation in non-specific chronic low-back pain? Both TENS and PENS (electroacupuncture) are recommended, albeit with some restrictions derived from their contraindications and side effects.[…] For PENS, it is recommended to bilaterally place the needles at the levels corresponding to T12, L3, L5, S2, and at the piriformis muscle motor point; stimulation must be applied for 30 minutes at T12 and for 15 minutes at the other sites twice weekly for eight weeks. Additionally, a 60-minute exercise programme should be indicated with the intent to promote strength and flexibility, along with an aerobic component. It is worth observing that the use of TENS and PENS without a specific exercise programme does not suffice to maintain analgesia over a long period of time because those therapies merely facilitate the performance of specific rehabilitation exercises (A)(B). 9. What is the benefit of acupuncture in the treatment of non-specific chronic low-back pain? Not enough studies of satisfactory quality have been found to enable a sound evidence-based recommendation regarding the use of acupuncture for the treatment of non-specific chronic mechanical low-back pain. The combined use of acupuncture and conservative treatment modalities such as physical therapy, NSAIDs, analgesia, heat, self-care, and postural education was more beneficial than those same therapies alone for the treatment of non-specific chronic mechanical low-back pain (B). There is a continued controversy regarding the efficacy of true acupuncture (deep needle insertion in the acupoints) versus that of sham acupuncture (superficial needle insertion in sites distant from acupoints) for the treatment of non-specific low-back pain. While some studies reported benefits with true acupuncture (A), others found both techniques to be equivalent (B). That controversy notwithstanding, sham acupuncture (superficial needle insertion) has been shown not to be an inert procedure. Additionally, one study found no benefit with the use of true acupuncture in individuals with chronic low-back pain compared to the use of simulated acupuncture (no actual needle insertion, but mere skin stimulation) (A). Acupuncture proved more efficacious than a placebo (TENS)in 1 high-quality study (A), although this finding was not confirmed by another study (B); this discrepancy might be due to the differences in quality between the studies. Acupuncture was found inferior to massage with respect to pain and disability after 10 weekly sessions for the treatment of non-specific chronic low-back pain. That difference was maintained at a 1-year follow-up (B). Acupuncture proved to be more beneficial than local anaesthetic injection when both applied at the most painful palpation points for the treatment of chronic low-back pain (B). 12. What is the cost-effectiveness of acupuncture for chronic low-back pain? Although acupuncture for the treatment of non-specific low-back pain is associated with a cost increase, 10 sessions at a twice-weekly frequency are recommended, as these improve the patients’ quality of life and reduce work absenteeism and thus reduce the individuals’ social costs (B). Acupuncture in addition to routine care induced relevant clinical benefits and was found to be cost-effective in patients with chronic low-back pain who were assisted at German primary care centres. Therefore, acupuncture should be considered as a feasible option for the management of patients with chronic low-back pain (B).

4.52. American College of Occupational and Environmental Medicine (ACOEM, USA) 2011 ⊕

American College of Occupational and Environmental Medicine (ACOEM). Low back disorders. Elk Grove Village (IL): American College of Occupational and Environmental Medicine (ACOEM). 2011; 333-796. [166563].

Acute Low Back Pain. Not Recommended: Routine use of acupuncture (I)
Subacute Low Back Pain. Not Recommended: Routine use of acupuncture (I)
Chronic Low Back Pain. Recommended: Acupuncture for select use in chronic moderate to severe low back pain as an adjunct to more efficacious treatments (C)

4.53. Accident Compensation Corporation (ACC, New-Zealand) 2011 ⊕

Hardaker N, Ayson M. Pragmatic Evidence Based Review. The efficacy of acupuncture in the management of musculoskeletal pain. Accident Compensation Corporation (ACC, New-Zealand). 2011. [182414].

The evidence for the effectiveness of acupuncture is most convincing for the treatment of chronic neck and shoulder pain. In terms of other injuries, the evidence is either inconclusive or insufficient. The state of the evidence on the effectiveness of acupuncture is not dissimilar to other physical therapies such as physiotherapy, chiropractic and osteopathy.
General
- There is insufficient evidence to make a recommendation for the use of acupuncture in the management of acute neck, back or shoulder pain
- There is emerging evidence that acupuncture may enhance/facilitate other conventional therapies (including physiotherapy & exercise-based therapies)
- There is a paucity of research for the optimal dosage of acupuncture treatment for treating shoulder, knee, neck and lower back pain
- Studies comparing effective conservative treatments (including simple analgesics, physical therapy, exercise, heat & cold therapy) for (sub) acute and chronic non-specific low back pain (LBP) have been largely inconclusive.
Lower back
- The evidence for the use of acupuncture in (sub)acute LBP is inconclusive
- There is limited evidence to support the use of acupuncture for pain relief in chronic LBP in the short term (up to 3 months)
- The evidence is inconclusive for the use of acupuncture for long term (beyond 3 months) pain relief in chronic LBP
- There is no evidence to recommend the use of acupuncture for lumbar disc herniation related radiculopathy (LDHR)

4.54. Philippine Academy of Rehabilitation Medicine (PARM, Philippine) 2011 ⊕

Clinical Practice Guidelines on the Diagnosis and Management of Low Back Pain. Philippine Academy of Rehabilitation Medicine (PARM). 2011. [199237]. Voir rappel des recommandations 2011 dans : Low back pain management guideline. Philippine Academy of Rehabilitation Medicine (PARM). 2017:294P. [198246].

There is conflicting evidence that acupuncture is useful in patients with acute non-specific low back pain (Inconsistent level of evidence – Moderate volume – Non-current – Variable thought).
There is some evidence to use acupuncture in acute low back pain with radiculopathy (Low Volume – Current)
There is conflicting evidence that acupuncture is useful in patients with subacute non-specific low back pain (Inconsistent level of evidence – High volume – Non-current – Variable thought).
There is evidence that therapeutic acupuncture is beneficial in managing chronic non-specific low back pain (Inconsistent level of evidence – High volume – Non-current – Uniform thought (PARM recommends).

4.55. Toward Optimized Practice 2011 (TOP, Canada) 2011 ⊕

Toward Optimized Practice. Evidence-informed primary care management of low back pain Edmonton (AB): Toward Optimized Practice. 2011:37p. [197355].

There is insufficient evidence to recommend for or against the following interventions for acute or subacute low back pain: [Acupuncture].
Chronic low back pain, Acupuncture is recommended as a stand-alone therapy or as an adjunct to an overall active treatment program. No serious adverse events were reported in the trials. The incidence of minor adverse events was 5% in the acupuncture group.

4.56. Agency for Healthcare Research and Quality (ARQ, USA) 2010 ⊕

Complementary and Alternative Therapies for Back Pain II, Agency for Healthcare Research and Quality (ARQ, USA). 2010;:764P. [195622].

The results suggest that acupuncture might be an option for the treatment of acute, subacute, and chronic LBP (specific or nonspecific cause). For chronic nonspecific back pain there is evidence that real acupuncture is no better than sham acupuncture, but better than no treatment or usual care. The benefit of acupuncture was mostly evident immediately or shortly after the end of the treatment and then faded with time. The evidence base for acute, subacute, and mixed duration specific LBP was very sparse and less conclusive

4.57. American Society of Anesthesiologists / American Society of Regional Anesthesia and Pain Medicine (USA) 2010 ⊕

Practice guidelines for chronic pain management: an updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology. 2010;112(4):810-33. [155473].

Recommendations for acupuncture. Acupuncture may be considered as an adjuvant to conventional therapy (e.g., drugs, physical therapy, and exercise) in the treatment of nonspecific, noninflammatory low back pain.

4.58. National Collaborating Centre for Primary Care and Royal College of General Practitioners (NCCPC, RCGP, UK) 2009 ⊕

Savigny P, Kuntze S, Watson P, Underwood M, Ritchie G , Cotterell M, Hill D, Browne N, Buchanan E, Coffey P, Dixon P, Drummond C, Flanagan M, Greenough,C, Griffiths M, Halliday-Bell J, Hettinga D, Vogel S, Walsh D. Low Back Pain: Early Management of Persistent Non-specific Low Back Pain (NICE Clinical Guidelines, No. 88). London: Royal College of General Practitioners. 2009:240P. [199157].

Offer one of the following treatment options, taking into account patient preference an exercise programme, a course of manual therapy or a course of acupuncture. Consider offering another of these options further if the chosen treatment does not result in satisfactory improvement.

4.59. The Clinic on Low-back pain in Interdisciplinary Practice (CLIP, Canada) 2008 ⊕

Poitras S, Rossignol M, Dionne C, Tousignant M, Truchon M, Arsenault B, Allard P, Coté M, Neveu A. An interdisciplinary clinical practice model for the management of low-back pain in primary care: the CLIP project. BMC Musculoskelet Disord. 2008;9:54. [199150].

Acute low-back pain (0–4 weeks). Can be recommended: Acupuncture (Grade of scientific evidence : poor).
Subacute subacute low-back pain (4–12 weeks). Can be recommended : Acupuncture (Grade of scientific evidence : poor).
Persistent low-back pain (12 weeks +). Can be recommended : Acupuncture (Grade of scientific evidence : poor).

4.60. American College of Physicians, American Pain Society (USA) 2007 ⊕

Chou R, Qaseem A, Snow V, Casey D, Cross JT Jr, Shekelle P, Owens DK. Clinical efficacy assessment subcommittee of the American College of Physicians. Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Ann Intern Med. 2007;147(7):478-91. [146893].

Recommendation 7: For patients who do not improve with self-care options, clinicians should consider the addition of nonpharmacologic therapy with proven benefits—for acute low back pain, spinal manipulation; for chronic or subacute low back pain, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation (weak recommendation, moderate-quality evidence).

4.61. European evidence-based Guidelines (Europe, COST ACTION B13) 2006 Ø

Airaksinen O, Brox JI, Cedraschi C, Hildebrandt J, Klaber-Moffett J, Kovacs F, Mannion AF, Reis S, Staal JB, Ursin H, Zanoli G; COST B13 Working Group on Guidelines for Chronic Low Back Pain. Chapter 4. European guidelines for the management of chronic nonspecific low back pain. Eur Spine J. 2006;15 Suppl 2:S192-300. [70488] .

Acupuncture : Summary of evidence. There is conflicting evidence that acupuncture is better than a sham procedure in the treatment of chronic low back pain (level C). There is moderate evidence that acupuncture is not more effective than trigger point injection and TENS (level B). There is limited evidence that acupuncture is less effective than massage and spinal manipulation (level C). There is limited evidence in each case that acupuncture is similar to self-care education, and better than training of proper posture and motion in accordance with Bruegger concepts (level C). There is limited evidence that the addition of acupuncture improves the results of standard GP treatment (defined as exercise, NSAIDs, aspirin and/or non-narcotic analgesics) or conventional treatment (defined as physiotherapy, exercise, back school, mud packs, infrared heat therapy and diclofenac) (level C). Recommendation. We cannot recommend acupuncture for the treatment of chronic low back pain.

4.62. Instituto di Recovero e Cura a Caraterre Scientifico (IRCCS, Italia) 2006 Ø

Negrini S, Giovannoni S, Minozzi S, Barneschi G, Bonaiuti D, Bussotti A, D'Arienzo M, Di Lorenzo N, Mannoni A, Mattioli S, Modena V, Padua L, Serafini F, Violante FS. Diagnostic therapeutic flow-charts for low back pain patients: the Italian clinical guidelines. Eura Medicophys. 2006;42(2):151-70. [199104].

Treatment of Low back pain patient. Physical therapies: acupuncture is not effective (strenght of evidence : A).
Treatment of sciatica patient. Physical therapies: acupuncture is not effective (strenght of evidence : A).

4.63. The Swedish Council on Technology Assessment in Health Care, Statens beredning för medicinsk utvärdering (SBU, Sweden) 2006 ⊕

Axelsson S, Boivie J, Eckerlund I, Gerdle B, Johansson E, Kristiansson M, List T, Lundberg B, Mannheimer C et al. Metoder för behandling av långvarig smärta [Methods of treating chronic pain]. SBU. Statens beredning för medicinsk utvärdering. The Swedish Council on Technology Assessment in Health Care; Stockholm. 2006:508p. [199760].

Chronic Back Pain . Acupuncture. Evidence Force 1 - Strong scientific evidence

4.64. Agence Nationale d’Accréditation et d’Évaluation en Santé (ANAES, France) 2000 Ø

Diagnostic, prise en charge et suivi des malades atteints de lombalgie chronique. Paris: Agence Nationale d’Accréditation et d’Évaluation en Santé (ANAES). 2000; 95P. [166354].

L’efficacité de l’acupuncture n’est pas démontrée dans la lombalgie chronique. Il semble que la stimulation des zones gâchettes (neuro-réflexothérapie) ait un effet antalgique à court terme dans la lombalgie chronique (grade C), mais son intérêt éventuel reste à définir dans la prise en charge du lombalgique chronique (accord professionnel). La place de l’électro-acupuncture reste à définir car elle aurait un effet antalgique à court terme sans qu'il soit possible de recommander une technique particulière (grade C).

5. Overviews of Clinical Practice Guidelines

5.1. Yang 2019

Yang XY , Zhao H , Liu J , He LY , Liu BY. [Current status of application of acupuncture in low back pain guidelines]. Chinese Acupuncture and Moxibustion. 2019;39(8):908-12. [200765].

ObjectiveTo systematically review the current status of application of acupuncture in low back pain guidelines.
MethodsThe computer retrieval was conducted in PubMed, Cochrane Library, Embase, China Journal Full Text Database (CNKI), China Biomedical Literature Database (CBM), VIP, Wanfang, guidelines databases, and the official websites of WHO and academic organizations (American Pain Society, American College of Physicians, etc.). After screening, the basic information and acupuncture-related issues in the guidelines that met the inclusion criteria were extracted and compared by using Excel software.
ResultsA total of 35 low back pain guidelines were included. ① One guideline was published before 2000, 16 guidelines were published from 2000 to 2010, and 18 guidelines were published from 2011 to 2017; 17 guidelines were published by the United States, 4 by Canada and China, 2 by New Zealand, the United Kingdom, and Europe, and 1 by Netherlands, Philippines, Denmark and Italy. ② Twenty-three guidelines were evidence-based guidelines, which was developed mainly by system review, meta-analysis and expert consultation, involving diagnosis, treatment, primary care of low back pain. ③ Acupuncture was mentioned in 23 guidelines, of them, 7 guidelines recommended acupuncture, 6 guidelines indicated that acupuncture might be considered under certain conditions such as combined with other therapies or patients were interested in acupuncture, however, 10 guidelines did not recommended acupuncture for low back pain.
Conclusion The guidelines of low back pain are mainly developed by Europe countries and the United States, and the majority is published in the last 20 years. Among them, 20% of the guidelines have recommend acupuncture for low back pain.

5.2. Oliveira 2018

Oliveira CB, Maher CG, Pinto RZ, Traeger AC, Lin CC, Chenot JF, van Tulder M, Koes BW.. Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview. Eur Spine J. 2018;27(11):2791-2803. [198203].

Similarly, the recommendations for acupuncture were inconsistent. Four guidelines [1, 7, 10, 28] recommend the use of acupuncture. Of these, three guidelines recommend acupuncture for patients with acute and chronic LBP [1, 28]. One guideline [7, 10] recommends acupuncture as an adjunct of an active rehabilitation program for patients with chronic LBP. Four out of eight guidelines do not recommend acupuncture [9, 24, 30] (37%) or state that acupuncture should be avoided [25] (13%).

5.3. Wong 2017

Wong JJ, Côté P, Sutton DA, Randhawa K, Yu H, Varatharajan S, et al. Clinical practice guidelines for the noninvasive management of low back pain: A systematic review by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Eur J Pain. 2017;21(2):201-216. [188699].

According to high-quality guidelines: the management of chronic LBP may include exercise, paracetamol or NSAIDs, manual therapy, acupuncture, and multimodal rehabilitation (combined physical and psychological treatment).

6. Randomized Controlled Trials

6.1. Sources

  1. Li 2020:Li YX, Yuan SE, Jiang JQ, Li H, Wang YJ. Systematic review and meta-analysis of effects of acupuncture on pain and function in non-specific low back pain. Acupuncture in Medicine. 2020. [205629].
  2. Mu 2020: Mu J, Furlan AD, Lam WY, Hsu MY, Ning Z, Lao L. Acupuncture for chronic nonspecific low back pain. Cochrane Database Syst Rev. 2020:CD013814. [167953].doi
  3. Xiang 2020: Xiang Y, He JY, Tian HH, Cao BY, Li R. Evidence of efficacy of acupuncture in the management of low back pain: a systematic review and meta-analysis of randomised placebo- or sham-controlled trials. Acupuncture in Medicine. 2020;38(1):15-24. [203366].
  4. Vickers 2018: Vickers AJ, Vertosick EA, Lewith G et al, Acupuncture Trialists' Collaboration. Acupuncture for Chronic Pain: Update of an Individual Patient Data Meta-Analysis. J Pain. 2018 May;19(5):455-474. [168043]Yuan 2016 [46]
  5. NICE 2016: National Institute for Health and Clinical Excellence. Low back pain and sciatica in over 16s: assessment and management (NG59). Evidence-based recommendations on assessing and managing low back pain and sciatica in people aged 16 and over London (UK): National Institute for Health and Clinical Excellence (NICE). 2016. [158090].
  6. Yuan 2016: Yuan QL, Wang P, Liu L, Sun F, Cai YS, Wu WT, Ye ML, Ma JT, Xu BB, Zhang YG. Acupuncture for musculoskeletal pain: A meta-analysis and meta-regression of sham-controlled randomized clinical trials. Sci Rep. 2016. [164489].
  7. Yuan 2015: Yuan QL, Guo TM, Liu L, Sun F, Zhang YG. Traditional Chinese Medicine for Neck Pain and Low Back Pain: A Systematic Review and Meta-Analysis. 2015;PLoS One. 2015 Feb 24;10(2):e0117146. doi: 10.1371/journal.pone.0117146. eCollection 2015.[141558]
  8. Lam 2013: Lam M, Galvin R, Curry P. Effectiveness of acupuncture for nonspecific chronic low back pain: a systematic review and meta-analysis Spine (Phila Pa 1976). 2013;38(24):2124-38.[170367]
  9. Xu 2013: Xu M, Yan S, Yin X, Li X, Gao S, Han R, Wei L, Luo W, Lei G. Acupuncture for chronic low back pain in long-term follow-up: a meta-analysis of 13 randomized controlled trials. Am J Chin Med. 2013;41(1):1-19.[159282]
  10. Hutchinson 2012: Hutchinson AJ, Ball S, Andrews JC, Jones GG. The effectiveness of acupuncture in treating chronic non-specific low back pain: a systematic review of the literature. J Orthop Surg Res. 2012;30;7:36.[159283]
  11. Vickers 2012: Vickers AJ, Cronin AM, Maschino AC, et al; Acupuncture Trialists’Collaboration. Acupuncture for chronic pain: individual patient data meta-analysis. Arch Intern Med 2012;172:1444-53. 157530

6.2. List

RCT Comparator Sources
2020 Kong JT, Puetz C, Tian L, Haynes I, Lee E, Stafford RS, Manber R, Mackey S. Effect of Electroacupuncture vs Sham Treatment on Change in Pain Severity Among Adults With Chronic Low Back Pain: A Randomized Clinical Trial. JAMA Netw Open. 2020;3(10):. [213196]. Acudoc2
2017 Kizhakkeveettil A, Rose KA, Kadar GE, et al. Integrative Acupuncture and Spinal Manipulative Therapy Versus Either Alone for Low Back Pain: A Randomized Controlled Trial Feasibility Study. J Manipulative Physiol Ther 2017; 40: 201–213 Li 2020
2016 Yuan QL, Liu L, Ma JT, Wu WT, Ye ML, Zhang YG. A clinical study of acupuncture for low back pain. The Journal of Traditional Chinese Orthopedics and Traumatolog 2016;28(6):12-7. Sham Mu 2020
Ushinohama A, Cunha BP, Costa LO, Barela AM, Freitas PB. Effect of a single session of ear acupuncture on pain intensity and postural control in individuals with chronic low back pain: a randomized controlled trial. Braz J Phys Ther. 2016;20(4):328-35. [188319]. Sham Mu 2020
2014 Hasegawa TM, Baptista AS, de Souza MC, Yoshizumi AM, Natour J. Acupuncture for acute non-specific low back pain: a randomised, controlled, double-blind, placebo trial. Acupuncture in Medicine. 2014; 32(2):109-115 Sham Li 2020, Xiang 2020, NICE 2016 [202], Yuan 2016 [41]
Marignan M. Auriculotherapy treatment protocol for low-back pain: A randomized trial. Medical Acupuncture. 2014; 26(3):154-160 NICE 2016 [327]
2013 Cho YJ, Song YK, Cha YY, Shin BC, Shin IH, Park HJ et al. Acupuncture for chronic low back pain: a multicenter, randomized, patient-assessor blind, sham-controlled clinical trial. Spine. 2013; 38(7):549-557 Sham Li 2020, Mu 2020, Xiang 2020, NICE 2016 [83]
Peng DQ, Yang T, Chen YC, et al. The 53 cases’ observation of three tong method of He’s acupuncture to treat intervertebral lumbar disc herniation syndrome. Zhong Yi Za Zhi 2013; 54: 1127–1130. Li 2020
Shin JS, Ha IH, Lee J, Choi Y, Kim MR, Park BY et al. Effects of motion style acupuncture treatment in acute low back pain patients with severe disability: a multicenter, randomized, controlled, comparative effectiveness trial. Pain. 2013; 154(7):1030-1037 NICE 2016 [450]
Weiss J, Quante S, Xue F, Muche R, Reuss-Borst M. Effectiveness and acceptance of acupuncture in patients with chronic low back pain: results of a prospective, randomized, controlled trial. Journal of Alternative and Complementary Medicine. 2013; 19(12):935-941. [193230]. Vickers 2018 [102], NICE 2016 [537]
Zhang SG, Wang XH and Xiong CM. Chinese acupuncture to treat low back pain patients in Africa. Zhonghua Zhong Yi Yao Xue Kan 2013; 31: 1188–1190. Li 2020
2012 Hunter RF, McDonough SM, Bradbury I, Liddle SD, Walsh DM, Dhamija S et al. Exercise and Auricular Acupuncture for Chronic Low-back Pain: A Feasibility Randomized-controlled Trial. Clinical Journal of Pain. 2012; 28(3):259-267. [166206] Vickers 2018 [40], Cité mais non inclu NICE 2016 [234]
Vas J, Aranda JM, Modesto M, Benitez-Parejo N, Herrera A, Martinez-Barquin DM et al. Acupuncture in patients with acute low back pain: a multicentre randomised controlled clinical trial. Pain. 2012; 153(9):1883-1889 Sham Xiang 2020, NICE 2016 [515]
Yun M, Shao Y, Zhang Y, He S, Xiong N, Zhang J et al. Hegu acupuncture for chronic low-back pain: a randomized controlled trial. Journal of Alternative and Complementary Medicine. 2012; 18(2):130-136. [172965] Li 2020, NICE 2016 [558]
Yun M, Xiong N, Guo M, Zhang J, Liu D, Luo Y et al. Acupuncture at the back-pain-acupoints for chronic low back pain of Peacekeepers in Lebanon: A randomized controlled trial. Journal of Musculoskeletal Pain. 2012; 20(2):107-115 NICE 2016 [557]
Zeng MG. The compared analysis of acupuncture and medicine to treat the root pain due to intervertebral lumbar disc herniation syn¬drome. Zhongguo Wei Sheng Chan Ye 2012:174 Li 2020
2010 Liu J, Li N. Clinical observation of a combination of acupuncture and drug administration for non-specific acute lumbar sprain. Journal of Acupuncture and Tuina Science. 2010; 8(1):47-49 NICE 2016 [312]
Zaringhalam J, Manaheji H, Rastqar A, Zaringhalam M. Reduction of chronic non-specific low back pain: a randomised controlled clinical trial on acupuncture and baclofen. Chinese Medicine. 2010;5(1):15 [155426]. NICE 2016 [559], Hutchinson 2012
2009 Cherkin DC, Sherman KJ, Avins AL, Erro JH, Ichikawa L, Barlow WE et al. A randomized trial comparing acupuncture, simulated acupuncture, and usual care for chronic low back pain. Archives of Internal Medicine. 2009; 169(9):858-866. [152825]. Sham Li 2020, Xiang 2020, Vickers 2018 [19], NICE 2016 [75], Vickers 2012 [94], Hutchinson 2012
Fan Y, Xue LF and Meng XF. Analysis of efficacy of warm acupuncture to treat intervertebral lumbar disc herniation syndrome. Zhongguo Zhong Yi Yao Xian Dai Yuan Cheng Jiao Yu 2009; 7: 144–145. Li 2020
Itoh K, Itoh S, Katsumi Y, Kitakoji H. A pilot study on using acupuncture and transcutaneous electrical nerve stimulation to treat chronic non-specific low back pain. Complementary Therapies in Clinical Practice. 2009; 15(1):22-25 NICE 2016 [243]
Kazunori I, Itoh S, Katsumi Y and Kitakoji H. A pilot study on using acupuncture and transcutaneous electrical nerve stimulation to treat chronic non-specific low back pain. Complement. Ther. Clin. Pract. 2009;15:22–25 Hutchinson 2012
Miyazaki, S., Hagihara, A., Kanda, R., Mukaino, Y. & Nobutomo, K. Applicability of press needles to a double-blind trial: a randomized, double-blind, placebo-controlled trial. Clin J Pain. 2009;25:438–444. Sham Xiang 2020, Yuan 2016 [43], excluded Mu 2020 : Patients with a mixed pain duration were enrolled and investigated
2008 Kennedy S, Baxter GD, Kerr DP, Bradbury I, Park J, McDonough SM. Acupuncture for acute non-specific low back pain: a pilot randomised non-penetrating sham controlled trial. Complementary Therapies in Medicine. 2008; 16(3):139-146 Sham Xiang 2020, Vickers 2018 [48], NICE 2016 [269], Yuan 2016 [45], Vickers 2012 [34]
2007 Haake M, Muller HH, Schade-Brittinger C, Basler HD, Schafer H, Maier C et al. German Acupuncture Trials (GERAC) for chronic low back pain: randomized, multicenter, blinded, parallel-group trial with 3 groups. Archives of Internal Medicine. 2007; 167(17):1892-1898 Sham Lu 2020, Mu 2020, Xiang 2020, Vickers 2018 [36], NICE 2016 [184], Yuan 2016 [46], Xu 2013, Vickers 2012 [12], Hutchinson 2012
Kwon Y, Lee S, Lee C, Jung S, Kim D, Choi S. The short-term efficacy of acupuncture for chronic low back pain: randomised sham controlled trial. Journal of Oriental Rehabilitation Medicine. 2007; 17(2):123-132 NICE 2016 [287]
Szczurko O, Cooley K, Busse JW, Seely D, Bernhardt B, Guyatt GH, Zhou Q and Mills EJ. Naturopathic care for chronic low back pain: a randomized trial. PloS. One. 2007;2(9):e919. [146847]. Hutchinson 2012
Thomas KJ, MacPherson H, Thorpe L, Brazier J, Fitter M, Campbell MJ et al. Randomized controlled trial of a short course of traditional acupuncture compared with usual care for persistent non-specific low back pain. Journal of the Acupuncture Association of Chartered Physiotherapists. 2007;(3):47-56 NICE 2016 [486]
2006 Brinkhaus B, Witt CM, Jena S, Linde K, Streng A, Wagenpfeil S et al. Acupuncture in patients with chronic low back pain: a randomized controlled trial. Archives of Internal Medicine. 2006; 166(4):450-457 Sham Li 2020, Mu 2020, Xiang 2020, Vickers 2018 [11], NICE 2016 [51], Yuan 2016 [49], Xu 2013, Vickers 2012 [15], Hutchinson 2012
Inoue M, Kitakoji H, Ishizaki N, Tawa M, Yano T, Katsumi Y et al. Relief of low back pain immediately after acupuncture treatment–a randomised, placebo controlled trial. Acupuncture in Medicine. 2006; 24(3):103-108 Sham Xiang 2020, NICE 2016 [241], Yuan 2016 [48], Excluded Mu 2020 : The study assessed specific LBP caused by lumbar vertebral arthritis diagnosed by physicians
Itoh, K., Katsumi, Y., Hirota, S. & Kitakoji, H. Effects of trigger point acupuncture on chronic low back pain in elderly patients–a sham-controlled randomised trial. Acupunct Med. . 2006; 24: 5–12 Yuan 2016 [47], Xu 2013
Thomas KJ, MacPherson H, Thorpe L, Brazier J, Fitter M, Campbell MJ et al. Randomised controlled trial of a short course of traditional acupuncture compared with usual care for persistent non-specific low back pain. BMJ. 2006; 333(7569):623 Li 2020, Vickers 2018 [87], NICE 2016 [485], Xu 2013, Vickers 2012 [23], Hutchinson 2012
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