OBJECTIVES: To 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.
RESULTS: 14 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.
CONCLUSION: There 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.
REGISTRATION: PROSPERO registration no. CRD42017059438.
BACKGROUND: Many randomized controlled trials (RCTs) of acupuncture reveal no significant differences between acupuncture and so-called placebo acupuncture. There is a strong tendency to replace the term "placebo" by the term "sham," because any needling stimulates a certain physiological response. However, neither concept accounts for the great diversity of results in RCTs comparing verum acupuncture and sham (placebo) acupuncture. Some trials have shown little or no difference, while other studies have found statistically significant differences.
OBJECTIVE: Verum acupuncture and sham (placebo) acupuncture may achieve similar results to the extent that they share active constituents. We identified these common active constituents as dermatomes: the segmental structure of the human body. In our study, we tested the hypothesis that the more verum and sham (placebo) acupuncture share the same dermatomes, the closer the clinical outcomes will be, and vice versa.
METHODS: All major databases were searched for RCTs that tested acupuncture versus sham (placebo) acupuncture. The dermatome charts of Hansen and Schliack were used to verify verum and sham (placebo) needling locations. Reported clinical outcomes were assessed in relation to the percentage of overlap between the dermatomes stimulated by acupuncture and sham (placebo) acupuncture.
RESULTS: Our literature search yielded a total of 1738 references. Thirty-four studies met the inclusion criteria. The effects of sham (placebo) acupuncture varied according to the dermatomes stimulated: high overlap with those stimulated by verum acupuncture resulted in almost identical efficacy, while low overlap resulted in significant differences in efficacy. Clinical outcomes were similar when verum acupuncture and sham (placebo) acupuncture shared the same dermatomes (p < 0.01).
DISCUSSION: The findings of this review confirm our hypothesis. Acupuncture studies that employed verum and sham locations on overlapping dermatomes helped to create a mediocre to negative picture of acupuncture's efficacy. The segmental structure of the body with its interconnected reflex system offers an additional neurophysiological explanation for the effectiveness of acupuncture applied to structures segmentally innervated by the spinal and visceral nervous system. Further comparative acupuncture studies should be based on knowledge of segmental anatomy. In testing verum acupuncture versus sham acupuncture, the chosen sham acupuncture needling locations should be situated on non-overlapping dermatomes.
ABSTRACT Objective To 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. Results 427 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.
ABSTRACT Objective To 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. Results 427 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.
OBJECTIVES: Systematically review the literature about all available interventions to manage non-specific low back pain (NSLBP) in older adults (≥60 years).
DESIGN: We 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.
SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO (CRD42016036686).
OBJECTIVES: Many interventions are available to manage chronic pain; understanding the durability of treatment effects may assist with treatment selection. We sought to assess which noninvasive nonpharmacological treatments for selected chronic pain conditions are associated with persistent improvement in function and pain outcomes at least 1 month after the completion of treatment.
DATA SOURCES: Electronic databases (Ovid MEDLINE®, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews) through November 2017, reference lists, and ClinicalTrials.gov.
REVIEW METHODS: Using predefined criteria, we selected randomized controlled trials of noninvasive nonpharmacological treatments for five common chronic pain conditions (chronic low back pain; chronic neck pain; osteoarthritis of the knee, hip, or hand; fibromyalgia; and tension headache) that addressed efficacy or harms compared with usual care, no treatment, waitlist, placebo, or sham intervention; compared with pharmacological therapy; or compared with exercise. Study quality was assessed, data extracted, and results summarized for function and pain. Only trials reporting results for at least 1 month post-intervention were included. We focused on the persistence of effects at short term (1 to <6 months following treatment completion), intermediate term (≥6 to <12 months), and long term (≥12 months).
RESULTS: Two hundred eighteen publications (202 trials) were included. Many included trials were small. Evidence on outcomes beyond 1 year after treatment completion was sparse. Most trials enrolled patients with moderate baseline pain intensity (e.g., >5 on a 0 to 10 point numeric rating scale) and duration of symptoms ranging from 3 months to >15 years. The most common comparison was against usual care. Chronic low back pain: At short term, massage, yoga, and psychological therapies (primarily CBT) (strength of evidence [SOE]: moderate) and exercise, acupuncture, spinal manipulation, and multidisciplinary rehabilitation (SOE: low) were associated with slight improvements in function compared with usual care or inactive controls. Except for spinal manipulation, these interventions also improved pain. Effects on intermediate-term function were sustained for yoga, spinal manipulation, multidisciplinary rehabilitation (SOE: low), and psychological therapies (SOE: moderate). Improvements in pain continued into intermediate term for exercise, massage, and yoga (moderate effect, SOE: low); mindfulness-based stress reduction (small effect, SOE: low); spinal manipulation, psychological therapies, and multidisciplinary rehabilitation (small effects, SOE: moderate). For acupuncture, there was no difference in pain at intermediate term, but a slight improvement at long term (SOE: low). Psychological therapies were associated with slightly greater improvement than usual care or an attention control on both function and pain at short-term, intermediate-term, and long-term followup (SOE: moderate). At short and intermediate term, multidisciplinary rehabilitation slightly improved pain compared with exercise (SOE: moderate). High-intensity multidisciplinary rehabilitation (≥20 hours/week or >80 hours total) was not clearly better than non–high-intensity programs. Chronic neck pain: At short and intermediate terms, acupuncture and Alexander Technique were associated with slightly improved function compared with usual care (both interventions), sham acupuncture, or sham laser (SOE: low), but no improvement in pain was seen at any time (SOE: llow). Short-term low-level laser therapy was associated with moderate improvement in function and pain (SOE: moderate). Combination exercise (any 3 of the following: muscle performance, mobility, muscle re-education, aerobic) demonstrated a slight improvement in pain and function short and long term (SOE: low). Osteoarthritis: For knee osteoarthritis, exercise and ultrasound demonstrated small short-term improvements in function compared with usual care, an attention control, or sham procedure (SOE: moderate for exercise, low for ultrasound), which persisted into the intermediate term only for exercise (SOE: low). Exercise was also associated with moderate improvement in pain (SOE: low). Long term, the small improvement in function seen with exercise persisted, but there was no clear effect on pain (SOE: low). Evidence was sparse on interventions for hip and hand osteoarthritis . Exercise for hip osteoarthritis was associated with slightly greater function and pain improvement than usual care short term (SOE: low). The effect on function was sustained intermediate term (SOE: low). Fibromyalgia: In the short term, acupuncture (SOE: moderate), CBT, tai chi, qigong, and exercise (SOE: low) were associated with slight improvements in function compared with an attention control, sham, no treatment, or usual care. Exercise (SOE: moderate) and CBT improved pain slightly, and tai chi and qigong (SOE: low) improved pain moderately in the short term. At intermediate term for exercise (SOE: moderate), acupuncture, and CBT (SOE: low), slight functional improvements persisted; they were also seen for myofascial release massage and multidisciplinary rehabilitation (SOE: low); pain was improved slightly with multidisciplinary rehabilitation in the intermediate term (SOE: low). In the long term, small improvements in function continued for multidisciplinary rehabilitation but not for exercise or massage (SOE: low for all); massage (SOE: low) improved long-term pain slightly, but no clear impact on pain for exercise (SOE: moderate) or multidisciplinary rehabilitation (SOE: low) was seen. Short-term CBT was associated with a slight improvement in function but not pain compared with pregabalin. Chronic tension headache: Evidence was sparse and the majority of trials were of poor quality. Spinal manipulation slightly improved function and moderately improved pain short term versus usual care, and laser acupuncture was associated with slight pain improvement short term compared with sham (SOE: low). There was no evidence suggesting increased risk for serious treatment-related harms for any of the interventions, although data on harms were limited.
CONCLUSIONS: Exercise, multidisciplinary rehabilitation, acupuncture, CBT, and mind-body practices were most consistently associated with durable slight to moderate improvements in function and pain for specific chronic pain conditions. Our findings provided some support for clinical strategies that focused on use of nonpharmacological therapies for specific chronic pain conditions. Additional comparative research on sustainability of effects beyond the immediate post-treatment period is needed, particularly for conditions other than low back pain.
Objectives: To 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. Results: This 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; I2statistic=16%; participants=624; studies=6) for the Visual Analog Scale and −0.35 (95% CI −0.49 to −0.20; I2statistic=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. Conclusion: Compared 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.
Despite wide use in clinical practice, acupuncture remains a controversial treatment for chronic pain. Our objective was to update an individual patient data meta-analysis to determine the effect size of acupuncture for four chronic pain conditions.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 non-specific 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. 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 both sham and no acupuncture control for each pain condition (all p<0.001) with differences between groups close to 0.5 standard deviations (SD) for comparison with no acupuncture control and close to 0.2 SDs in comparison 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 one 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. While factors in addition to the specific effects of needling at correct acupuncture point locations are important contributors to the treatment effect, decreases in pain following acupuncture cannot be explained solely in terms of placebo effects. Variations in the effect size of acupuncture in different trials are driven predominately 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 musculosketal, 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.
Complementary medicine therapies are frequently used to treat pain conditions such as headaches and neck, back, and joint pain. Chronic pain, described as pain lasting longer than 3-6 months, can be a debilitating condition that has a significant socioeconomic impact. Pharmacologic approaches are often used for alleviating chronic pain, but recently there has been a reluctance to prescribe opioids for chronic noncancer pain because of concerns about tolerance, dependence, and addiction. As a result, there has been increased interest in integrative medicine strategies to help manage pain and to reduce reliance on prescription opioids to manage pain. This article offers a brief critical review of integrative medical therapies used to treat chronic pain, including nutritional supplements, yoga, relaxation, tai chi, massage, spinal manipulation, and acupuncture. The goal of this article is to identify those treatments that show evidence of efficacy and to identify gaps in the literature where additional studies and controlled trials are needed. An electronic search of the databases of PubMed, The Cochrane Library, EMBASE, PsycINFO, and Science Citation Index Expanded was conducted. Overall, weak positive evidence was found for yoga, relaxation, tai chi, massage, and manipulation. Strong evidence for acupuncture as a complementary treatment for chronic pain that has been shown to decrease the usage of opioids was found. Few studies were found in which integrative medicine approaches were used to address opioid misuse and abuse among chronic pain patients. Additional controlled trials to address the use of integrative medicine approaches in pain management are needed.
