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Table 2

Summary of findings of acupuncture for low-back pain (only pain and functional outcomes).

Duration and cause of painOutcomesGRADE*Findings
Acupuncture versus no treatment

Acute/subacute, mixed, and unknown (specific, nonspecific)NA Insufficient
No trial
NA

Chronic nonspecificPain intensity score (VAS) Moderate
Design: RCT
ROB: Medium
Consistency: yes
Directness: yes
Precision: yes
Four trials showed a significant immediate/short-term posttreatment benefit of acupuncture [35, 48, 51, 52]. The pooled estimate was based on 3 trials (short-term posttreatment mean score difference: −1.19, 95% CI: −2.17 to −0.21) [35, 48, 52]. See Figure 3.
Pain Disability Index Moderate
Design: RCT
ROB: Low
Consistency: NA (only 1 trial)
Directness: yes
One trial showed greater improvement in pain disability index with acupuncture (Mean difference: −8.2, 95% CI: −12.0 to −4.4) [51].

Chronic specificNA Insufficient
No trial
NA

Acupuncture versus placebo

Acute/subacute nonspecificPain intensity score (VAS) Moderate
Design: RCT
ROB: Medium
Consistency: yes
Directness: yes
In two trials [31, 53], short-term posttreatment pain intensity score was not significantly different between acupuncture and placebo groups.
Mean score difference: 10.6, 95% CI: −4.1, 25.3,Mean score: 49.9 ± 22.2 versus 51.8 ± 26.1, P > 0.05).
Roland-Morris Disability score Low
Design: RCT
ROB: Medium
Consistency: NA (only 1 trial)
Directness: yes
In one trial, acupuncture was not significantly different from placebo at 3 months (mean score difference: 2.6, 95% CI: −0.7, 5.9) [53].

Acute/sub acute specificNA Insufficient
No trial
NA

Chronic nonspecificPain intensity score (modified MPQ, VAS, von Korff Chronic Pain Grade Scale: 0–10) Moderate
Design: RCT
ROB: Medium
Consistency: yes
Directness: yes
Precision: yes
Acupuncture was compared to placebo in 16 trials [32, 45, 51, 5467]. The results of these trials were conflicting.
The pooled estimates of 10 trials showed a significant benefit of acupuncture but only immediately posttreatment (mean score difference −0.59, 95% CI: −0.93, −0.25) [51, 55, 56, 58, 59, 6165, 67]. The mean score differences at short- (−1.11, 95% CI: −2.33, 0.11) [5456, 58], intermediate- (−0.18, 95% CI: −0.85, 0.49) [51, 54, 67], and long-term (−0.21, 95% CI: −0.64, 0.22) [51, 54, 63, 67] followups after the sessions were not statistically significant.
See Figure 4
Roland-Morris Disability score Moderate
Design: RCT
ROB: Medium
Consistency: yes
Directness: yes
The pooled estimate of two trials was not statistically significant (mean score difference: 0.81, 95% CI: −0.27, 1.9) [62, 67].

Chronic specificNA Insufficient
No trial
NA

Mixed (specific, nonspecific)NANANA

Unknown nonspecificPain intensity score (VAS) Moderate
Design: RCT
ROB: Medium
Consistency: yes
Directness: yes
In one trial [68], there was no significant difference in the proportions of subjects with improved pain (not specified) between the acupuncture versus placebo (sham-acupuncture).
Either real needling [30] or total body acupuncture [33] was superior to sham needling in reducing pain intensity immediately posttreatment. For example, in one study [30], the mean pain intensity (VAS score) was 37.3 in acupuncture group and 64.1 in the placebo group.

Unknown specificNA Insufficient
No trial
NA

Acupuncture versus medication

Acute/subacute (specific, nonspecific)NA Insufficient
No trial
NA

Chronic nonspecificPain intensity score (VAS) Low
Design: RCT
ROB: High
Consistency: no
Directness: yes
There was no significant difference between acupuncture and medication immediately posttreatment. The pooled estimate was based on four trials (mean score difference: 0.11, 95% CI: −1.42, 1.65) [49, 6971].
Oswestry Disability Index Low
Design: RCT
ROB: High
Consistency: no
Directness: yes
In one trial, [69, 72] acupuncture achieved better score than medication (13 versus 24). The pooled estimate based on two trials showed no significant difference (mean score difference: −2.40, 95% CI: −12.20, 7.40) [69, 70].

Chronic specificNA Insufficient
No trial
NA

Mixed nonspecificNA Insufficient
No trial
NA

Mixed specificNo pain or function outcome reportedNR

Unknown nonspecificNo pain or function outcome reportedNR

Unknown specificNA Insufficient
No trial
NA

Acupuncture versus physiotherapy

Acute/subacute (specific, nonspecific) Insufficient
No trial

Chronic nonspecificOswestry Disability Index Low
Design: RCT
ROB: Medium
Consistency: NA (only 1 trial)
Directness: yes
One trial showed manual acupuncture to be significantly superior to physiotherapy (consisted of light, electricity, and/or heat therapy) [26].
Acupuncture group: 38.58 ± 5.0 (before) and 11.55 ± 3.24 (after)
Physiotherapy group: 40.24 ± 5.8 (before) and 18.83 ± 5.24 (after).

Chronic specificNA Insufficient
No trial
NA

Mixed/unknown (specific, nonspecific)NA Insufficient
No trial
NA

Acupuncture versus manipulation

Acute/subacute (specific, nonspecific) Insufficient
No trial

Chronic nonspecificPain intensity score (VAS) Low
Design: RCT
ROB: High
Consistency: no
Directness: yes
Precision: yes
There were significant reductions in pain intensity in favour of manipulation (pooled mean difference in VAS score: 3.70, 95% CI: 1.5, 5.8) [69, 70]. See Figure 5.

Chronic specificNA Insufficient
No trial
NA

Mixed/unknown (specific, nonspecific)NA Insufficient
No trial
NA

Acupuncture versus massage

Acute/subacute (specific, nonspecific)NA Insufficient
No trial
NA

Chronic nonspecificSymptom bothersomeness scale score (0 to 10) Low
Design: RCT
ROB: Medium
Consistency: NA (only 1 trial)
Directness: yes
One trial showed massage to be significantly better than manual acupuncture at long-term followup (P = 0.002) [36].
Massage group—at baseline: 6.2 (95% CI: 5.8, 6.6) and at 1 year: 3.2 (95% CI: 2.5, 3.9).
Acupuncture group—at baseline: 6.2 (95% CI: 5.8, 6.5) and 4.5 (95% CI: 3.8, 5.2).
Roland-Morris Disability score Low
Design: RCT
ROB: Medium
Consistency: NA (only 1 trial)
Directness: yes
One trial showed massage to be significantly better than manual acupuncture at immediate- (P = 0.01) or long-term followup (P = 0.05) [36].
Mean values at baseline, 4 weeks and 1 year after treatment in the massage group: 11.8 (95% CI: 10.8, 12.7), 7.9 (95% CI: 6.9, 9.0), and 6.8 (95% CI: 5.5, 8.1) [36].
Mean values at baseline, 4 weeks and 1 year after treatment in the acupuncture group: 12.8 (95% CI: 11.7, 13.8), 9.1 (95% CI: 7.8, 9.9) and 8.0 (95% CI: 6.6, 9.3) [36].

Chronic specificNA Insufficient
No trial
NA

Mixed/unknown (specific, nonspecific)NA Insufficient
No trial
NA

Acupuncture versus usual care

Acute/subacute specificNA Insufficient
No trial
NA

Acute/subacute nonspecificRoland-Morris Disability score Low
Design: RCT
ROB: Medium
Consistency: NA (only 1 trial)
Directness: yes
In one trial [41], the addition of acupuncture to usual care did not improve the degree of disability (RMDQ score) compared to usual care alone immediately, shortly, or intermediate-term posttreatment.

Chronic specificNA Insufficient
No trial
NA

Chronic nonspecificRoland-Morris Disability score Moderate
Design: RCT
ROB: Medium
Consistency: yes
Directness: yes
In two trials, subjects who received acupuncture significantly improved in disability compared to subjects in usual care groups at short-term or intermediate-term followup after treatment [47, 67].
Pain intensity score (VAS) Moderate
Design: RCT
ROB: Medium
Consistency: yes
Directness: yes
In two trials, subjects who received acupuncture significantly improved in pain intensity compared to subjects in usual care groups at short-term or intermediate-term followup after treatment [47, 67].

Mixed specificNA Insufficient
No trial
NA

Mixed nonspecificDisability score (Oswestry) Low
Design: RCT
ROB: Medium
Consistency: NA (only 1 trial)
Directness: yes
In one trial [208], a long-term posttreatment disability score was not significantly different between the acupuncture and usual care groups (Oswestry score: 3.4, 95% CI: 7.8, 1.0).
Pain intensity score (MPQ) Low
Design: RCT
ROB: Medium
Consistency: NA (only 1 trial)
Directness: yes
In one trial [208], a long-term posttreatment pain intensity was not significantly different between the acupuncture and usual care groups (mean difference in MPQ score: 0.2, 95% CI: 0.6, 0.1).

Unknown (specific, nonspecific)NA Insufficient
No trial
NA

*Precision in formal grading was applied only to pooled results.

VAS: visual analog scale; RMDQ: Roland-Morris disability scale; MPQ: McGill pain questionnaire; PDI: pain disability index; NPQ: neck pain questionnaire; NA: not applicable; ROB: risk of bias; RCT: randomized controlled trial.

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