Acupuncture and dry-needling for low back pain: Cochrane systematic review

Abstract

Assessed as up to date: 2003/06/01

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.

Objectives

To 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 authors 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 results

Thirty-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' conclusions

The 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.

Author(s)

Furlan Andrea D, van Tulder Maurits W, Cherkin Dan, Tsukayama Hiroshi, Lao Lixing, Koes Bart W, Berman Brian M

Summary

Acupuncture and dry-needling for low back pain

Thirty-five RCTs covering 2861 patients were included in this systematic review. There is insufficient evidence to make any recommendations about acupuncture or dry-needling for acute low-back pain. For chronic low-back pain, results show that acupuncture is more effective for pain relief than no treatment or sham treatment, in measurements taken up to three months. The results also show that for chronic low-back pain, acupuncture is more effective for improving function than no treatment, in the short-term. Acupuncture is not more effective than other conventional and "alternative" treatments. When acupuncture is added to other conventional therapies, it 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.

Reviewer's Conclusions

Implications for practice

There were only three heterogeneous trials of acupuncture for acute low-back pain. Therefore we could not reach convincing conclusion and there is a need for future studies to make recommendation in this area.

There is some evidence of the effects of acupuncture for chronic low-back pain. Compared to no treatment, there is evidence for pain relief and functional improvement for acupuncture at shorter-term follow-ups. Compared to sham therapies, there is evidence for pain relief at shorter-term follow-up, but these effects were not maintained at the longer-term follow-ups, nor were they observed for functional outcomes. Compared to other conventional or "alternative" treatments, acupuncture is no better for measures of pain and function. There is evidence that acupuncture, added to other conventional therapies, relieves pain and improves function better than conventional therapies alone. According to these results, acupuncture may be useful as either a unique therapy for chronic low-back pain or as an adjunct therapy to other conventional therapies. Although the conclusions show some positive results of acupuncture, the magnitude of the effects were generally small.

Although dry-needling appears to be a useful adjunct to other therapies for chronic low-back pain, no clear recommendations can be made because of small sample sizes and low methodological quality of the studies.

With respect to the different techniques of acupuncture, most studies were either small, of lower methodological quality, or both, therefore, no clear recommendation could be made.

Implications for research

Because most of the studies were of poor methodological quality, there certainly is a need for future higher-quality RCTs. Also, because many trials were poorly reported, we recommend that authors use the CONSORT statement as a model for reporting RCTs (www.consort-statement.org) and use the STRICTA criteria to report the interventions. Many trials could not be included in the meta-analyses because of the way the authors reported the results, therefore we suggest that publications of future trials report means with standard deviations for continuous measures, or number of events and total patients analysed for dichotomous measures. Future research should focus on areas where there are few or no trials, for example, acupuncture compared to no treatment, placebo or sham for acute low-back pain. Future studies should also have larger sample sizes, use a valid acupuncture treatment, and have both a short-term and a long-term follow-up (for chronic pain). From the available high quality trials included in this review, deep stimulation seems to be the most promising acupuncture treatment. Future studies are needed that evaluate superior features of acupuncture. We suggest that publications of future trials report the proportion of subjects who obtain a clinically important improvement in the groups being compared to facilitate a judgment about clinically important differences between the groups. Although an evaluation of costs was not the objective of this review, we suggest that future research assesses cost-effectiveness of acupuncture compared to other treatments.

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