A Systematic Review and Meta-Analysis of Efficacy, Cost-Effectiveness, and Safety of Selected Complementary and Alternative Medicine for Neck and Low-Back Pain

doi:10.1155/2012/953139

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Evid Based Complement Alternat Med. 2012; 2012: 953139.

Published online 2011 Nov 24. doi: 10.1155/2012/953139

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Table 2

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

Duration and cause of pain	Outcomes	GRADE*	Findings
Acupuncture versus no treatment

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

Chronic nonspecific	Pain 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.
Chronic nonspecific	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 specific	NA	Insufficient No trial	NA

Acupuncture versus placebo

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

Acute/sub acute specific	NA	Insufficient No trial	NA

Chronic nonspecific	Pain intensity score (modified MPQ, VAS, von Korff Chronic Pain Grade Scale: 0–10)	Moderate Design: RCT ROB: Medium Consistency: yes Directness: yes Precision: yes	Acupuncture was compared to placebo in 16 trials [32, 45, 51, 54–67]. The results of these trials were conflicting. The pooled estimates of 10 trials showed a significant benefit of acupuncture but only immediately posttreatment (mean score difference −0.59, 95% CI: −0.93, −0.25) [51, 55, 56, 58, 59, 61–65, 67]. The mean score differences at short- (−1.11, 95% CI: −2.33, 0.11) [54–56, 58], intermediate- (−0.18, 95% CI: −0.85, 0.49) [51, 54, 67], and long-term (−0.21, 95% CI: −0.64, 0.22) [51, 54, 63, 67] followups after the sessions were not statistically significant. See Figure 4
Chronic nonspecific	Roland-Morris Disability score	Moderate Design: RCT ROB: Medium Consistency: yes Directness: yes	The pooled estimate of two trials was not statistically significant (mean score difference: 0.81, 95% CI: −0.27, 1.9) [62, 67].

Chronic specific	NA	Insufficient No trial	NA

Mixed (specific, nonspecific)	NA	NA	NA

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

Unknown specific	NA	Insufficient No trial	NA

Acupuncture versus medication

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

Chronic nonspecific	Pain intensity score (VAS)	Low Design: RCT ROB: High Consistency: no Directness: yes	There was no significant difference between acupuncture and medication immediately posttreatment. The pooled estimate was based on four trials (mean score difference: 0.11, 95% CI: −1.42, 1.65) [49, 69–71].
Chronic nonspecific	Oswestry Disability Index	Low Design: RCT ROB: High Consistency: no Directness: yes	In one trial, [69, 72] acupuncture achieved better score than medication (13 versus 24). The pooled estimate based on two trials showed no significant difference (mean score difference: −2.40, 95% CI: −12.20, 7.40) [69, 70].

Chronic specific	NA	Insufficient No trial	NA

Mixed nonspecific	NA	Insufficient No trial	NA

Mixed specific	No pain or function outcome reported	—	NR

Unknown nonspecific	No pain or function outcome reported	—	NR

Unknown specific	NA	Insufficient No trial	NA

Acupuncture versus physiotherapy

Acute/subacute (specific, nonspecific)		Insufficient No trial

Chronic nonspecific	Oswestry Disability Index	Low Design: RCT ROB: Medium Consistency: NA (only 1 trial) Directness: yes	One trial showed manual acupuncture to be significantly superior to physiotherapy (consisted of light, electricity, and/or heat therapy) [26]. Acupuncture group: 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 specific	NA	Insufficient No trial	NA

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

Acupuncture versus manipulation

Acute/subacute (specific, nonspecific)		Insufficient No trial

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

Chronic specific	NA	Insufficient No trial	NA

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

Acupuncture versus massage

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

Chronic nonspecific	Symptom bothersomeness scale score (0 to 10)	Low Design: RCT ROB: Medium Consistency: NA (only 1 trial) Directness: yes	One trial showed massage to be significantly better than manual acupuncture at long-term followup (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).
Chronic nonspecific	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 specific	NA	Insufficient No trial	NA

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

Acupuncture versus usual care

Acute/subacute specific	NA	Insufficient No trial	NA

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

Chronic specific	NA	Insufficient No trial	NA

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

Mixed specific	NA	Insufficient No trial	NA

Mixed nonspecific	Disability score (Oswestry)	Low Design: RCT ROB: Medium Consistency: NA (only 1 trial) Directness: yes	In one trial [208], a long-term posttreatment disability score was not significantly different between the acupuncture and usual care groups (Oswestry score: −3.4, 95% CI: −7.8, 1.0).
Mixed nonspecific	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.