SPINE Volume 24, Number 11, pp 1113C1123 1999, Lippincott

William ! Wil"in, Inc#

The Effectiveness of Acupuncture in the Management of
Acute and Chronic Low Back Pain
$ S%tematic &e'ie( Wit)in t)e *rame(or" o+ t)e Coc)rane Collaboration
,ac" &e'ie( -roup
Maurits W. van Tulder, PhD,* Daniel C. Cherkin, PhD, Brian Berman,
MD, Lixing Lao, PhD, L!, and Bart W. "oes, PhD*
3.eae t)at ten/ to impro'e pontaneoul% o'er time
,Study Design. s#stemati! revie$ o% randomi&ed !ontrolled
trials.
Objectives. To evaluate the e%'!a!# and e%%e!tiveness o%
a!u(un!ture %or the management o% nons(e!i'! lo$ )a!k (ain.
Summary of Background Data. !u(un!ture is one o% the
oldest %orms o% thera(#, )ut little is kno$n a)out the e%%e!tiveness
o% a!u(un!ture %or lo$ )a!k (ain.
Methods. *andomi&ed !ontrolled trials $ere done to assess
the e%%e!tiveness o% all t#(es o% a!u(un!ture treatment, $hi!h
involves needling %or su)+e!ts $ith nons(e!i'! lo$ )a!k (ain.
T$o revie$ers )linded $ith res(e!t to authors, institution, and
+ournal inde(endentl# assessed the methodologi! ,ualit# o% the
studies. Be!ause data $ere statisti!all# and !lini!all# too
heterogeneous, a ,ualitative revie$ $as (er%ormed. The
eviden!e $as !lassi'ed into %our levels- strong, moderate,
limited, or no eviden!e.
Results. .leven randomi&ed !ontrolled trials $ere in!luded.
/verall, the methodologi! ,ualit# $as lo$. /nl# t$o studies met
the (reset 01high ,ualit#02 level %or this revie$. 3o stud# !learl#
evaluated a!u(un!ture %or a!ute lo$ )a!k (ain. The results
indi!ate that there $as no eviden!e sho$ing a!u(un!ture to )e
more e%%e!tive than no treatment. There $as moderate eviden!e
indi!ating that a!u(un!ture is not more e%%e!tive than trigger4
(oint in+e!tion or trans!utaneous ele!tri!al nerve stimulation, and
there $as limited eviden!e that a!u(un!ture is not more e%%e!tive
than (la!e)o or sham a!u(un!ture %or the management o%
!hroni! lo$ )a!k (ain.
Conclusions. Be!ause this s#stemati! revie$ did not !learl#
indi!ate that a!u(un!ture is e%%e!tive in the management o% )a!k
(ain, the authors $ould not re!ommend a!u(un!ture as a regular
treatment %or (atients $ith lo$ )a!k (ain. There !learl# is a need
%or more high4,ualit# randomi&ed !ontrolled trials. 5"e# $ords-
a!u(un!ture, Co!hrane Colla)oration, e%%e!tiveness, lo$ )a!k
(ain, s#stemati! revie$6 Spine !!!"#$%&'C#&
31Lo( bac" pain 0L,P1 i a ma2or )ealt) problem in Wetern
in/utriali3e/ countrie an/ a ma2or caue o+
me/icale4pene,(or"abenteeim,an//iablement#
$lt)ou5) L,P uuall% i a el+6limitin5 an/ beni5n /i6
*rom t)e 7Intitute +or &eearc) in E4tramural 8e/icine, Vri2e 9ni'eriteit,
$mter/am, t)e Net)erlan/, :Center +or ;ealt) Stu/ie, -roup ;ealt)
Cooperati'e o+ Pu5et Soun/, Seattle, Wa)in5ton, an/ <=i'iion o+
Complementar% 8e/icine, =epartment o+ *amil% 8e/icine, 9ni'erit% o+
8ar%lan/, ,altimore, 8ar%lan/# Supporte/ b% t)e =utc) ;ealt) Inurance
,oar/, t)e Net)erlan/# $c"no(le/5ment /ate> =ecember 23, 199?#
$cceptance /ate> =ecember 23, 199?# =e'ice tatu cate5or%> 1#2.a lar5e
'ariet% o+ t)erapeutic inter'ention are a'ailable +or it
mana5ement#;o(e'er, t)e e++ecti'ene
claime/+ormoto+t)eeinter'ention)anotbeencon'incin5l%/e
montrate/an/,cone@uentl%,t)et)erapeutic mana5ement o+
L,P 'arie (i/el%# $cupuncture, one o+ t)e ol/et +orm o+
t)erap%, )a it
rootinancientC)ineep)iloop)%#Ara/itionalC)inee me/icine
i bae/ on a number o+ p)iloop)ical concept, one o+ ()ic)
potulate t)at an% mani+etation o+ /ieae i coni/ere/ a i5n
o+ imbalance bet(een t)e yin an/ yang +orce in t)e bo/%# In
claical acupuncture t)eor%, it i belie'e/ t)at all /ior/er are
reBecte/ at peciCc point eit)er on t)e "in ur+ace or 2ut
beneat) it# Vital ener5% circulate t)rou5)out t)e bo/% alon5
t)e o6calle/ meri/ian, ()ic) )a'e eit)er %in or %an5
c)aracteritic# $ correct c)oice +or nee/lin5 amon5 t)e 3.1
claical acupuncture point locate/ on t)ee meri/ian i
belie'e/ to retore t)e balance in t)e bo/%#
W)en t)e nee/le )a'e been place/ ucce+ull%, t)e patient
i uppoe/ to e4perience a enation "no(n a teh chi, /eCne/
a a ub2ecti'e +eelin5 o+ +ullne, numbne, tin5lin5, an/
(armt) (it) ome local orene an/ a +eelin5 o+ /itenion
aroun/ t)e acupuncture point# A)ere i no conenu amon5
acupuncturit about t)e neceit% o+ reac)in5 te) c)i +or
acupuncture to be e++ecti'e# In a//ition to nee/lin5,
acupuncture o+ten inclu/e tec)ni@ue uc) a mo4ibution an/
cuppin5#
1.Since acupuncture (a /ieminate/ to t)e Wet e'eral
)un/re/ %ear a5o, man% /i++erent t%le o+ acupuncture
)a'e /e'elope/ inclu/in5 Dapanee meri/ian t)erap%,
*renc) ener5etic acupuncture, Eorean contitutional
acupuncture, an/ Lemin5ton F6element acupuncture#
$lt)ou5) t)ee are imilar to tra/itional acupuncture, t)e%
eac) )a'e /itinct c)aracteritic# In recent /eca/e, ne(
+orm o+ acupuncture )a'e /e'elope/ uc) a ear
0auricular1 acupuncture, )ea/ 0calp1 acupuncture, )an/
acupuncture, an/ +oot acupuncture#
8o/ern acupuncturit ue not onl% tra/itional meri/ian
acupuncture point, but alo nonmeri/ian or e4trameri/ian
acupuncture point, ()ic) are C4e/ point not necearil%
aociate/ (it) meri/ian# $cupuncturit alo ue tri55er
point, ()ic) )a'e no C4e/ location an/ are +oun/ b%
elicitin5 ten/erne at t)e ite o+ mot pain#
111
3
1114 pine7!o"ume #4 7$um%er 1171&&&
1.$cupuncture commonl% inclu/e manual
timulation o+ t)e nee/le, but 'ariou a/2unct
o+ten are ue/ in mo/ern +orm o+ t)e t)erap%
inclu/in5 electrical acupuncture 0(it) an electrical
timulator connecte/ to t)e acupuncture nee/le1,
in2ection acupuncture 0(it) )erbal e4tract
in2ecte/ into acupuncture point1, an/ acupuncture
(it) mo4ibution 0t)e burnin5 o+ t)e mo4a )erb,
Artemisia vulgaris, at t)e en/ o+ t)e nee/le1#
4,2GIt i till not clear ()at e4act mec)anim
un/erlie t)e action o+ acupuncture# $ccor/in5 to
tra/itional C)inee me/icine, acupuncture
promote t)e Bo( o+ qi 0li+e +orce ener5%1,
t)ereb% balancin5 t)e )uman bo/% %tem#
WeterncientiCcreearc))apropoe/mec)anim
+or t)e e++ect o+ acupuncture in relie'in5 pain# It
)a been u55ete/ t)at acupuncture mi5)t act
accor/in5 to principle enunciate/ b% t)e 5ate
control t)eor% o+ pain# Hne t%pe o+ enor% input
0lo( bac" pain1 coul/ be in)ibite/ in t)e central
ner'ou %tem b% anot)er t%pe o+ input
0nee/lin51# $not)er t)eor%, /i++ue no4iou
in)ibitor% control 0=NIC1, implie t)at no4iou
timulation o+ )eterotopic bo/% area mo/ulate
t)e pain enation ori5inatin5 in area ()ere a
ub2ect +eel pain# A)ere alo i ome e'i/ence
t)at acupuncture ma% timulate t)e pro/uction o+
en/orp)in, erotonin an/, acet%lc)oline in t)e
central ner'ou %tem, en)ancin5 anal5eia#
2?$lt)ou5) t)e e++ecti'ene o+ acupuncture in t)e
mana5ement o+ c)ronic pain )a been re'ie(e/
%tematicall% be+ore,no re'ie( )a'e +ocue/
peciCcall% on t)e e++ecti'ene o+ acupuncture
+or L,P# A)e current re'ie( ummari3e t)e
a'ailable cientiCc e'i/ence on t)e e++ecti'ene
o+ acupuncture +or bot) acute an/ c)ronic L,P#
Objectives A)i %tematic re'ie( aime/ to
/etermine i+ acupunc6
ture i an e++ecti'e met)o/ o+ mana5ement +or
nonpeciCc L,P# A)e +ollo(in5 comparion (ere
in'eti5ate/>
1# $cupuncture compare/ (it) no treatment a#
$cupuncture in a//ition to baeline me/ication or
treatment compare/ (it) baeline
me/ication or treatment alone
b# $cupuncture treatment onl%, a compare/
(it) a 5roup not recei'in5 an% inter'ention
2# $cupuncture compare/ (it) placebo or )am
treatment a# $cupuncture compare/ (it) nee/le
attac)ment to
"in ur+ace 0placebo> nee/le t)at /oe not
penetrate t)e "in1
b# $cupuncture compare/ (it) nee/lin5 pric"
on "in ur+ace 0)am> nee/le place/ in an
area cloe to but not in acupuncture point1
3# $cupuncture compare/ (it) con'entional
treatment
Methods Criteria for 'nc"uding tudies in
This (eview) Types of
Studies. Hnl% ran/omi3e/ controlle/ trial 0&CA1 (ere
in6clu/e/ in t)i re'ie(# Nonran/omi3e/ controlle/
clinical trial an/ trial controlle/ be+ore an/ a+ter
tu/ie (ere e4clu/e/#
Types of Participants. &an/omi3e/ controlle/ trial
t)at in'ol'e/ ub2ect (it) nonpeciCc L,P (ere
inclu/e/, but
&CAt)atinclu/e/ub2ect(it)L,Pcaue/b%peciCcpat)
olo5ic entitie uc) a in+ection, metatatic /ieae,
neoplam, oteoporoi, r)eumatoi/ art)riti, or
+racture (ere e4clu/e/# Patient (it) ubacute L,P
012 (ee" or le1, c)ronic L,P 0more t)an 12 (ee"1,
or bot) (ere inclu/e/#
Types of Interventions. $rticle e'aluatin5
acupuncture treatment t)at in'ol'e/ nee/lin5 (ere
inclu/e/ in t)i re'ie(#
Eit)ertra/itionalacupuncturein()ic)t)enee/leareinert
e/ at claical meri/ian point or contemporar%
acupuncture in ()ic) t)e nee/le are inerte/ at
nonmeri/ian or tri55er point
(ereinclu/e/int)ere'ie(#Stu/ie(ereinclu/e/re5ar/le
o+ t)e ource o+ timulation 0e.g., manual or electrical1#
Stu/ie in ()ic) t)e acupuncture treatment /i/ not
in'ol'e nee/lin5, uc) a acupreure or laer
acupuncture, (ere e4clu/e/# A)e control inter'ention
(ere placebo acupuncture, ot)er t)erapeutic
inter'ention, or no treatment#
Types of Outcome Measures. &an/omi3e/
controlle/ trial (ere inclu/e/ t)at ue/ at leat one
o+ t)e +our primar% outcome meaure t)at t)e
current aut)or coni/ere/ to be t)e mot important>
pain intenit% 0V$S1, a 5lobal meaure 0o'erall
impro'ement, proportion o+ patient reco'ere/,
ub2ecti'e impro'ement o+ %mptom1, +unctional
tatu 0&olan/68orri =iabilit% Iuetionnaire,
H(etr% Scale1, an/ return to (or" 0return to (or"
tatu, number o+ /a% o++ (or"1# P)%iolo5ic
outcome o+ p)%ical e4amination 0e.g., ran5e o+
motion, pinal Be4ibilit%, /e5ree o+ trai5)t le5
raiin5, or mucle tren5t)1, 5eneric )ealt) tatu 0a
aee/ b% t)e 8e/ical Hutcome Stu/% S)ort
*orm63. JS*3.K, Nottin5)am ;ealt) ProCle,
Sic"ne Impact ProCle1, an/ ot)er %mptom uc)
a me/ication ue an/ i/e e++ect (ere coni/ere/
econ/ar% outcome#
earch trateg* for 'denti+cation of tudies)
&ele'ant &CA meetin5 t)e incluion criteria +or t)i
re'ie( (ere i/entiCe/ in t)e +ollo(in5 tep>
3,3L1) Computer6ai/e/ earc) o+ t)e 8E=LINE
019..C199.1, E8,$SE 019??C199.1, an/
Coc)rane Complementar% 8e/icine *iel/ /atabae
uin5 t)e earc) trate5% recommen/e/ b% t)e
E/itorial ,oar/ o+ t)e Coc)rane ,ac" &e'ie(
-roup#
#) Screenin5 o+ re+erence in rele'ant re'ie( an/
&CA i/entiCe/ in Step 1 3) Screenin5 o+ t)e
Coc)rane Librar% 199G, Iue 1 4) Citation trac"in5
o+ t)e &CA i/entiCe/ in Step 1 to 3, uin5 t)e
Science Citation In/e4#
Methods of the (eview) Study Selection. Hne
re'ie(er 08'A1 5enerate/ t)e 8E=LINE an/
E8,$SE earc) trate5ie an/ /o(nloa/e/ t)e
aut)or, title, "e%(or/, an/ abtract o+ all t)e
i/entiCe/ tu/ie into a computer Cle# A(o re'ie(er
0=Can/8'A1t)enin/epen/entl%re'ie(e/t)ein+ormati
onto i/enti+% trial t)at mi5)t potentiall% meet t)e
incluion criteria# *ull article /ecribin5 t)ee trial
(ere obtaine/, an/ t)e ame re'ie(er in/epen/entl%
applie/ t)e election criteria to t)e
tu/ie#Conenu(aue/tool'e/ia5reementconc
ernin
5
7111,Acupuncture for Low Back
Painvan Tu"der et a"
(able . Methodologic )uality Criteria *ist
Patient sele!tion a. Were the eligi)ilit# !riteria s(e!i'ed8 9es 3o Don0:t kno$ ). Treatment allo!ation
;< Was the method o% randomi&ation des!ri)ed and ade,uate8 9es 3o Don0:t kno$ =< Was the treatment
allo!ation !on!ealed8 9es 3o Don0:t kno$
!. Were the grou(s similar at )aseline regarding the most im(ortant (rognosti! indi!ators8 9es 3o Don0:t kno$
>ntervention d. Were thera(euti! and !ontrol interventions o(erationali&ed8 9es 3o Don0:t kno$ e. Was the !are
(rovider )linded8 9es 3o Don0:t kno$ %. Was !ontrolled %or !o4interventions $hi!h !ould ex(lain the results8 9es 3o
Don0:t kno$ g. Was the !om(lian!e rate ?in ea!h grou(< unlikel# to !ause )ias8 9es 3o Don0:t kno$ h. Was the
(atient )linded8 9es 3o Don0:t kno$
/ut!ome measurement i. Was the out!ome assessor )linded8 9es 3o Don0:t kno$ +. Was at least one o% the
(rimar# out!ome measures a((lied8 9es 3o Don0:t kno$ k. Was there a des!ri(tion o% adverse e%%e!ts8 9es 3o
Don0:t kno$ l. Was the $ithdra$al@dro(4out rate unlikel# to !ause )ias8 9es 3o Don0:t kno$ m. Timing o% %ollo$4u(
measurements
;< Was a short4term %ollo$4u( measurement (er%ormed8 9es 3o Don0:t kno$ =< Was a long4term %ollo$4u(
measurement (er%ormed8 9es 3o Don0:t kno$
n. Was the timing o% the out!ome assessment in )oth grou(s !om(ara)le8 9es 3o Don0:t kno$ Atatisti!s
o. Was the sam(le si&e %or ea!h grou( des!ri)ed8 9es 3o Don0:t kno$ (. Did the anal#sis in!lude an intention4to4
treat anal#sis8 9es 3o Don0:t kno$ ,. Were the (oint estimates and measures o% varia)ilit# (resented %or the (ri4
mar# out!ome measures8 9es 3o Don0:t kno
$t)e Cnal incluion o+ &CA, an/ a t)ir/ re'ie(er (a
conulte/ i+ /ia5reement perite/#
Methodologic Quality Assessment. A)e
met)o/olo5ic @ualit% o+ eac) &CA (a aee/
in/epen/entl% b% t(o re'ie(er, ()o (ere blin/e/ (it)
repect to aut)or, intitution, an/ 2ournal# A)i blin/in5
(a per+orme/ b% an in/epen/ent peron not in'ol'e/
in t)e re'ie(# Conenu (a ue/ to reol'e
/ia5reement, an/ a t)ir/ re'ie(er (a conulte/ i+
/ia5reement perite/#
3LA)e met)o/olo5ic @ualit% o+ t)e &CA (a aee/
accor/in5 to t)e criteria lit 0Aable 11 recommen/e/ in
t)e met)o/ 5ui/eline o+ t)e Coc)rane ,ac" &e'ie(
-roup +or %tematic re'ie(#Hnl% t)e 1L item
reBectin5 t)e internal 'ali/it% o+ t)e &CA 0criteria
,1, ,2, C, E, *, -, ;, I, L, N1 (ere ue/ in t)e meta6
anal%i to ae t)e met)o/olo5ic @ualit% o+ t)e
&CA# Eac) criteria (a core/ a MN%e,MO MNno,MO or
MN/onMPt "no(#MO
22,23Se'en o+ t)e ei5)t En5li) lan5ua5e tu/ie (ere
aee/ b% t)e t(o principal re'ie(er 0=C an/ 8'A1#
,ecaue one o+ t)e En5li) lan5ua5e tu/ie (a "no(n
b% t)ee re'ie(er,
34,3Ft)attu/%(aaee/b%t(oot)erre'ie(er0,Ean/
W=1to maintain t)e 5oal o+ blin/in5# *or practical
reaon, t)e
-erman0,Ean/8'A1an/*renc).2L0,Ean/W=1tu/iea
lo (ere aee/ b% one or t(o ot)er e4perience/
re'ie(er# A)e Poli) tu/%(a aee/ b% one
re'ie(er 08'A1 (it) t)e )elp o+ an in/i'i/ual ()oe
Crt lan5ua5e (a Poli)#
ata !"traction. A(o re'ie(er blin/e/ to aut)or,
intitution, an/ 2ournal in/epen/entl% e4tracte/ t)e /ata
on t)e primar% outcome meaure 0pain intenit%, a
5lobal meaure, +unctional tatu, an/ return to (or"1
an/ econ/ar% outcome meaure 0p)%ical meaure,
5eneric )ealt) tatu, an/ ot)er %mptom uc) a
me/ication ue an/ i/e e++ect1#
=ata on t)e c)aracteritic o+ t)e tu/% population
(ere e4tracte/> t%pe, location, an/ /uration o+ L,PQ a5e
an/ 5en/erQ an/ acupuncture an/ re+erence
inter'ention uc) a t%pe o+ inter'ention, +re@uenc%,
intenit%, /uration, an/ ettin5#A)e aut)or o+ t)e
ori5inal tu/ie (ere not contacte/ +or more in+ormation
becaue all but one &CA (ere publi)e/ be+ore 199L#
Analysis. A)e reult o+ eac) &CA (ere plotte/ a
point etimate 0i.e., o// ratio (it) correpon/in5
9FR conC/ence inter'al +or /icrete outcome, an/
mean an/ tan/ar/ /e'iation +or continuou outcome1#
Statitical )omo5eneit% (a +ormall% tete/#
$ccor/in5 to t)e re'ie(er, t)e tu/ie (ere
clinicall% )etero5eneou (it) repect to t)e t%pe an/
/uration o+ t)e /ior/er, t)e inter'ention 0t%pe o+
acupuncture1, an/ t)e outcome# *urt)ermore, t)e
outcome (ere poorl% preente/ in . o+ t)e 11 tu/ie
0a reBecte/ b% t)e i4 ne5ati'e core to item I o+ t)e
criteria lit1 in uc) a (a% t)at poolin5 (a not
poible# A)ere+ore, it (a /eci/e/ not to pool t)e /ata
tatiticall%, but to per+orm a @ualitati'e re'ie( 0bet
e'i/ence %nt)ei1 b% attributin5 'ariou le'el o+
e'i/ence to t)e e++ecti'ene o+ acupuncture, ta"in5
into account t)e met)o/olo5ic @ualit% an/ t)e outcome
o+ t)e ori5inal tu/ie>
Le'el 1> Stron5 e'i/enceMSpro'i/e/ b% 5enerall%
conitent Cn/in5 in multiple, rele'ant, )i5)6@ualit%
&CA
Le'el 2> 8o/erate e'i/enceCpro'i/e/ b% 5enerall%
conitent Cn/in5 in one rele'ant, )i5)6@ualit% &CA
an/ one or more rele'ant lo(6@ualit% &CA
Le'el 3> Limite/ e'i/enceCpro'i/e/ b% 5enerall%
conitent Cn/in5 in one or more rele'ant lo(6
@ualit% &CA
Le'el4>NoorconBictin5e'i/enceCi+t)ere(ereno&C
Aor i+ t)e reult (ere conBictin5#
$n &CA (a coni/ere/ to be o+ )i5)er @ualit% i+
more t)an F o+ t)e 1L 'ali/it% item core/
poiti'el%# A)e literature (a coni/ere/ to be
conBictin5 i+ le t)an one t)ir/ o+ t)e tu/ie (ere
eit)er poiti'e or ne5ati'e +or a peciCc outcome
meaure# A)e Cn/in5 o+ eac) tu/% (ere aee/ b%
t)e blin/e/ re'ie(er to be poiti'e, neutral,
ne5ati'e, or unclear 0i+ t)e reult

111- pine7!o"ume #4 7$um%er 1171&&&

(able #. +nternal ,alidity +tems
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= ; =
;I#esK =InoK 8 I don0:t kno$. . Were the
eligi)ilit# !riteria s(e!i'ed8 D. Were
thera(euti! and !ontrol interventions
8
#;I#esK =InoK 8 I don0:t kno$ /. Was the sam(le si&e
%or ea!h grou( des!ri)ed8 P. Did the anal#sis in!lude
an intention4to4treat anal#sis8 L. Were (oint estimates
and measures o% varia)ilit# (resented %or the
$(able $. Statistical +tems
*e%eren!e / P L
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Methodologic )uality Aable 2CF )o( t)e
core on t)e met)o/olo5ic criteria lit# A)ere (a
/ia5reement bet(een t)e re'ie(er concernin5
F1 o+ 19L core 02GR1# $+ter t)e conenu
meetin5, 1. o+ t)e /ia5reement (ere not
reol'e/, an/ a t)ir/ re'ie(er ma/e a Cnal
/eciion, ta"in5 into account t)e comment o+ t)e
re'ie(er ()o /ia5ree/#
.,1LH'erall, t)e number o+ 'ali/it% item (it) a
poiti'e core (a lo(# Hnl% t(o tu/iemet t)e
preet )i5)@ualit% le'el re@uirin5 a core 5reater
t)an FLR# 8ot
tu/ielac"e/in+ormationononeormore'ali/it%item
# In particular, in+ormation (a lac"in5 on item
,1, ,2, C, E, * an/ I, meanin5 t)at t)e
ran/omi3ation proce/ure (a not a/e@uatel%
/ecribe/, t)at it (a unclear i+ t)e 5roup (ere
imilar at baeline, t)at t)e care pro'i/er (a not
blin/e/, t)at co6inter'ention (ere neit)er
a'oi/e/ nor ub2ecte/ to control, an/ t)at t)e
outcome aeor (a not blin/e/#
In+ormation alo (a lac"in5 in mot tu/ie
on ome o+ t)e /ecripti'e an/ tatitical item,
particularl% item E, 82, an/ I, in/icatin5 t)at
a/'ere e++ect (ere not /ecribe/, t)at t)ere
(a no lon56term +ollo(6up meaurement, an/
t)at t)e reult (ere preente/ poorl%#
F,12,29Study Characteristics A)e tu/%
c)aracteritic are pro'i/e/ in /etail in Aable
.#A)ere(eret)reetu/iecomparin5acupunctureton
o treatment,1L,1G,1?t(o tu/ie comparin5
acupuncture to con'entional
treatment,.,G,1L,1G,1?,2LC23,34,3Fan/ ei5)t tu/ie
comparin5 acupuncture to a placebo or )am
acupuncture#.,G,12,1G,1?,2L,21,34,3FSe'en tu/ie too"
place in a econ/ar% care ettin5,F,1L,22,23,29an/ in
+our tu/ie t)e ettin5 (a not
peciCe/#F,12,1G,1?,21C23,29Si4 tu/ie inclu/e/
patient (it) c)ronic L,P#
.,2L,34,3FA)ree tu/ie inclu/e/ a mi4 o+
patient (it) acute, ubacute, an/ c)ronic
L,P,G,1Lan/ t(o tu/ie /i/ not peci+% t)e
/uration o+ t)e reporte/
con/ition#12,1G,1?,21,29,34,34*i'e tu/ie
inclu/e/ a mi4 o+ L,P patient (it) an/
(it)out ra/iation#In +our tu/ie, it (a
notG,1L,1G,1?,21,29,34,34
F,1G,1?,22,23,29
1L
MF ?C< ; = Du(lan et al==,=DM ?F< D ; Mendelson et
alFI ?F< D = .delist et al;=H ?G< = H Eunn et al=;H ?H< M
B Ma!Donald et al;F,;GH ?G< = H Lehmann et al=BD ?M<
H D Lo(a!& and Erale$ski=CD ?F< D H Thomas and
Lund)ergDH,DID ?F< D H Jon Men!ke et alID ?M< H D
Coan et al= ?=< G B
The values in (arentheses re%er to sensitivit# anal#sisK num)er
o% validit# items %ul'lled i% all 01don0:t kno$02 s!ores are
(ositive
.
111. pine7!o"ume #4 7$um%er 1171&&&
(able -. Study Characteristics
Atud# Methods Parti!i(ants >nterventions /ut!omes 3ote
sICoan et
al
Du(lan
et alM
F.delist et
al
Earve# et al;B*CTK
randomi&ation $as
!arried out )#
having (re(ared in
advan!e a small
)ox $ith IB
identi!all# si&ed
(ie!es o% (a(er,
%olded so that the#
!ould not )e read
=I had and
=I had B
$ritten on them
The )ox $as
shaken and one
o% the (ie!es o%
(a(er $as
removed %rom
the )ox )lindl#
*CTK randomi&ation
(ro!edure not
des!ri)ed
*CTK randomi&ation
(ro!edure not
des!ri)ed
*CTK !om(uter4
generated %our4tier
entr# listIB (atients
re!ruited via
ne$s(a(ers. >n!lusion
!riteria- LBP %or M
months or more, no
(revious a!u(un!ture
treatments, no histor#
o% dia)etes, in%e!tion or
!an!er, and not more
than = )a!k surgeries
Neterogeneous
(o(ulation regarding
t#(e and lo!ation o%
disorder
DB hos(ital (atients
>n!lusion !riteria- se4
vere lum)os!iati!a,
dis! origin, no
im(rovement a%ter
!onventional
medi!ine
.x!lusion !riteria-
neurologi!al
involvement, !auda
e,uina, tumor, (ost4
surgi!al re!urren!e
DB (atients >n!lusion
!riteria- no
im(rovement a%ter
!onventional
thera(# in!luding
)ed rest,
analgesi!s, heat
and (h#siothera(#
Patients $ere
%elt to have dis!
disease
MD (atients >n!lusion
!riteria- non4
radiating LBP, normal
neurologi!al
examination, a)sen!e o%
tension signs, normal x4
ra#, (ersistent (ain
des(ite initial treatment
o% H $eeks, )eing a)le
to lo!ali&e a (oint o%
maximum tenderness
?trigger
(oint<!u(un!ture tx-
a!!ording to !lassi!al
/riental meridian theor#
.le!tri!al a!u(un!ture in
some (atients
!kno$ledged
a!u(un!turists
*e%eren!e tx- $aiting list
!ontrolsK no treatment
!u(un!ture tx- C
traditional a!u(un!ture
(oints, ele!troni!all#
dete!ted, meridian,
sterile needles inserted
=OCD mm, no manual or
ele!tri!al stimulation, I
treatments o% =B minutes
Training and ex(erien!e
o% a!u(un!turists
unkno$n *e%eren!e tx-
(la!e)o a!u(un!ture, M
(oints, I treatments o%
=B minutes
!u(un!ture tx- manual
insertion o% H sterile
needles into traditional
a!u(un!ture (oints until
rea!hing MTte !hi,MP then
ele!troa!u(un!ture at
DOC;B N& %or DB minutes,
D treatments in maximum
= $eeks Training and
ex(erien!e o%
a!u(un!turists unkno$n
*e%eren!e tx- sham
a!u(un!ture, H needles
(la!ed in areas devoid o%
!lassi! a!u(un!ture
(oints, no MTte !hiMP
!u(un!ture tx- a
single dr#needle sti!k
$ith a =;gauge needle
a%ter an iso(ro(#l
al!ohol $i(e Training
and ex(erien!e o%
a!u(un!turists
unkno$n *e%eren!e tx-
;- in+e!tion $ith ;.I ml
o% ;P lido!aine using a
;.I in!h, =;4gauge
needle a%ter an
iso(ro(#l al!ohol $i(e
=- in+e!tion $ith B.FI ml
o% ;P lido!aine and
B.FI ml o% ristos(an
using a ;.I in!h, =;4
gauge needle a%ter an
iso(ro(#l al!ohol $i(e
D- ;B4se! eth#l !hloride
s(ra# %rom M in!hes
a$a#, %ollo$ed )# =B
se! a!u(ressure using
the (lasti! needle guard
a%ter an iso(ro(#l
al!ohol $i(e*esults
a%ter ;B $eeks in
a!u(un!ture and a%ter
;I $eeks in re%eren!e
grou(- redu!tion in (ain
s!ore ?;;4(oint s!ale<,
glo)al im(rovement
and DL ?H(oint s!ale<-
a!u(un!ture grou(
I;P, GDP and ;CP vs.
re%eren!e grou( =P,
D;P and BP
>nade,uate treatment in
;; o% the IB (atients
treated $ith
a!u(un!ture
*esults- mean
im(rovement in (ain at
rest and standing ?JA<
a%ter M da#s in
a!u(un!ture grou( =CP
and =;P, in re%eren!e
grou( ;P and ;DP
>n!rease on Lase,ue
test in a!u(un!ture
grou( o% ;D degrees and
in re%eren!e grou( F
degrees >m(rovement in
A!ho)er test and
'ngerti(4Qoor distan!e
B.D !m and =.I !m in
a!u(un!ture and =B.;
!m and D !m in
re%eren!e grou(
*esults- no. o% (atients
im(roved (osttreatment
on glo)al measure
?su)+e!tive< and (h#si!al
examination ?o)+e!tive<-
a!u(un!ture F ?HFP<, M
?HBP< vs. re%eren!e M
?HBP<, I ?DDP< 3ot
signi'!ant
*esults on glo)al
im(rovement
?im(roved or not
im(roved<- no. ?P<
o% (atients
im(roved a%ter =
$eeks-
a!u(un!ture ;;
?IIP<, lido!aine
in+e!tion H ?D;P<,
lido!aine ; steroid
I ?=MP<,
a!u(ressure G
?IBP<Con!lusion
o% authors
MT(ositiveMPK
!on!lusion o%
revie$ers
MTun!learMP Large
num)er o% dro(4
outs >nade,uate
treatment grou(
should have )een
in!luded in
intention4to4treat
anal#sis Di%%eren!e
in %ollo$4u( time
Con!lusion o%
authors
MT(ositiveMP,
!on!lusion o%
revie$ers
MT(ositiveMP Control
grou( seemed to
have more severe
!om(laints Most
di%%eren!es tested
$ithin grou(s not
)et$een grou(s
Con!lusion o%
authors
MTneutralMP
Con!lusion o%
revie$ers
MTneutralMP Jer#
small sam(le si&e,
no. o% (atients
randomi&ed
unkno$n
Con!lusion o%
authors
MT(ositiveMPK
!on!lusion o%
revie$ers
MTneutralMP 3ot
traditional
a!u(un!tur
e
7111&Acupuncture for Low Back
Painvan Tu"der et a"
Atud# Methods Parti!i(ants >nterventions /ut!omes 3ote
s;=Eunn et
al
Lehmann
et al;F,;G
Lo(a!& and
Erale$ski=B
=;Ma!Donald et
al*CTK randomi&ed
)lo!ks, )lo!ks
de'ned )# age and
o(eration statusK
the 'rst su)+e!t
%rom ea!h )lo!k
$as assigned to the
a!u(un!ture
treatment
*CTK )lo!k
randomi&ation,
)lo!ks de'ned )#
(rior lum)ar
surger#
*CTK randomi&ation
(ro!edure not
des!ri)ed
*CTK a strati'ed
random (ro!ess to
divide the sexes as
e,uall# as (ossi)le
)et$een the t$o
grou(sIM (atients
>n!lusion !riteria-
males $ith LBP %or at
least ;= $eeks, $ho
had had G $eeks o% a
standard !lini!
regimen
Persistent
disa)ling (ain
des(ite all traditional
medi!al or surgi!al
thera(# and re!over#
deemed a)sent
.x!lusion !riteria-
(s#!hosomati! or
(s#!hologi!al
(ro)lems
Neterogeneous
(o(ulation regarding
t#(e and lo!ation o%
disorder
IH (atients s!reened
at ortho(aedi! !lini!
>n!lusion !riteria-
!hroni! disa)ling LBP
$arranting the
ex(ense o% in(atient
treatment
.x!lusion !riteria-
!andidates %or lum)ar
surger#, (ain less
than D months,
(regnan!#,
osteom#elitis o% the
s(ine, dis!itis, tumor,
ank#losing
s(ond#litis, verte)ral
%ra!tures and
stru!tural s!oliosis
DH (atients %rom a
neurolog# de(artment
>n!lusion !riteria-
lo$ )a!k (ain %or ;
month or more
;F (atients re%erred
%rom ortho(aedi! or
rheumatologi!al
de(artments
>n!lusion !riteria- !hroni!
LBP %or at least ; #ear,
no relie% %rom
!onventional
treatments!u(un!ture
tx- standard !lini!al
regimen (lus
a!u(un!utreK
nonmeridian, mus!le
motor (oints, DOCI !m
needles, dire!tion o% the
needle (er(endi!ular to
the skin, me!hani!al
stimulation )# (e!king
and t$irling, lo$ voltage
?C J< ele!tri!al
stimulation interru(ted
dire!t !urrent or (hasi!
!urrent Training and
ex(erien!e o%
a!u(un!turists unkno$n
*e%eren!e tx- standard
!lini!al regimen
?(h#siothera(#, remedial
exer!ises, o!!u(ational
thera(#, industrial
assessment<
!u(un!ture tx-
ele!troa!u(un!ture,
)i(hasi! $ave at =OCH
N&, meridian, Noku
(oints and additional
(oints $ere stimulated
a!!ording to the
(atientMPs (attern o% (ain,
t$i!e $eekl# %or D $eeks
!erti'ed a!u(un!turist
ex(erien!ed in its
a((li!ation *e%eren!e tx-
;- T.3A, (ulse $idth o%
=IB@se! at MB N&, ;I
treatments in D $eeks
su)threshold intensit#,
(oints o% stimulation over
the !enter o% (ain,
ex(erien!ed
(h#siothera(ist =-
(la!e)o T.3A, same as
T.3A )ut dead )atter#
!u(un!ture tx- H
needles !lose to s(ine,
B.I !m ;BP 3aCl, ;B
minutes, H treatments, G
da#s, (lus
(harma!othera(#
Training and ex(erien!e
o% a!u(un!turists
unkno$n *e%eren!e tx-
(la!e)o, suggestion, ne$
A$edish method %or (ain
relie%, same H (oints
e!ho4en!e(halogra(h,
;B minutes, H treatments,
G da#s, (lus
(harma!othera(#
!u(un!ture tx-
su)!utaneous ?Hmm< DB4
gauge needle insertion
at trigger (oints ?no. o%
trigger (oints unkno$n<
IOC=B minutes,
maximum o% ;B
treatments in ;B $eeks
Training and ex(erien!e
o% a!u(un!turists
unkno$n
.le!troa!u(un!ture
?im(ulses FBB ms at =
N&< i% manual stimulation
%ailed *e%eren!e tx-
(la!e)o a!u(un!ture,
ele!trodes !onne!ted to
dumm# a((aratus,
maximum ;B treatments
in ;B $eeks*esults o%
glo)al im(rovement ?H4
(oint s!ale<- no. o%
(atients $ith good or
total im(rovement at
dis!harge and a%ter ;=
$eeks in a!u(un!ture
grou( ;G, ;F vs. H, H in
re%eren!e grou(s
Aigni'!ant t 'nal %ollo$4
u( ?;=OCM; $eeks< in
a!u(un!ture grou( ;G
?M=P< had returned to
$ork and in re%eren!e
grou( H ?;IP<
*esults- a!u(un!ture
signi'!antl# more relie%
o% average (ain
(osttreatment and a%ter M
months ?DMP, HDP< than
)oth re%eren!e grou(s
?FP, DP, and D=P, ;MP<
3o di%%eren!es )et$een
re%eren!e grou(s *eturn
to $ork a%ter M months
IDP in a!u(un!ture and
M;P in T.3A and HHP
in (la!e)o T.3A grou(
*esults o% glo)al
im(rovement ?I4(oint
s!ale<- a%ter ; treatment
and H treatments no. ?P<
im(rovement in
a!u(un!ture grou( ;D
?F=P<, ;D ?F=P< and in
re%eren!e grou( D ?;CP<,
C ?IMP<
*esults- mean
(er!entage
redu!tion
(osttreatment in
(ain s!ore ?JA<,
(ain relie% s!ore
?JA<, (h#si!al
examination
?(resen!e o%
(h#si!al signs<
and DL ?JA<-
a!u(un!ture grou(
IFP, FFP, CFP,
and I=P vs.
re%eren!e grou(
=DP, DBP, =CP,
and MP
Aigni'!antCon!lusi
on o% authors
MT(ositiveMPK
!on!lusion o%
revie$ers
MTneutralMP
Con!lusion o%
authors
MT(ositiveMP %or
(ain, MTneutralMP %or
glo)al measure and
return to $ork,
overall !on!lusion
MT(ositiveMP
Con!lusion o%
revie$ers
MTneutralMP
Con!lusion o%
authors
MTneutralMP,
!on!lusion o%
revie$ers
MTneutralMP Jer#
short term %ollo$4u(
onl# Amall sam(le
si&e Polish
language
Con!lusion
o% authors
MT(ositiveMPK
!on!lusion o%
revie$ers MTneutralMP
Jer# small sam(le
si&e, no. o% treatments
unkno$n, and %ollo$4u(
time unkno$n
?Continues
<
11#/ pine7!o"ume #4 7$um%er 1171&&&
(able -. .Continued/
Atud# Methods Parti!i(ants >nterventions /ut!omes 3ote
sMendelso
n et al==,=D
=CThomas and
Lund)erg*CTK
random num)er
method
*CTK randomi&ation
(ro!edure not
des!ri)ed;BB (atients
>n!lusion !riteria-
!hroni! lo$ )a!k (ain,
no !om(ensation or
litigation (ending, no
overt (s#!hiatri!
disease
HD (atients %rom =
!lini!s >n!lusion
!riteria- no!i4
!e(tive LBP %or M
months or more,
restri!tion o% trunk or
hi( movement due
to (ain, restri!tion o%
DL, mus!le s(asm
.x!lusion !riteria-
(revious surger#,
!laudi!ation, de(ression,
neurosis, !lini!al
examination not
no!i!e(tive!u(un!ture
tx- traditional Chinese
a!u(un!ture, meridian, G
needles, manual
stimulation until rea!hing
MTteh !hiMP, DB minutes
$ith no %urther
stimulation, t$i!e $eekl#,
H $eeks surgeon
trained at the Chinese
Traditional Medi!al
*esear!h >nstitute in
Peking *e%eren!e tx-
(la!e)o a!u(un!ture,
intradermal in+e!tion o%
=P lido!aine at
nona!u(un!ture,
nontender sites, then
a!u(un!ture needles %or
DB minutes $ithout
stimulation., t$i!e
$eekl#, H $eeks
!u(un!ture tx- manual
stimulation o% needles,
lo$ %re,uen!# ?= N&< and
high %re,uen!# ?GB N&<
ele!tri!al stimulation o%
needles, D (aras(inal
(oints and DOCH distal
(oints, insertion ;OCI
!m, rotation (rodu!ing
MTteh !hiMP, ;B sessions
o% DB minutes, =
registered
(h#siothera(ists trained
in a!u(un!ture
*e%eren!e tx- $aiting list
!ontrols, no
treatment*esults-
redu!tion in (ain s!ore
?JA< a%ter H $eeks in
a!u(un!ture grou( HBP
vs. re%eren!e grou( =MP
3ot signi'!ant. Cross4
over- redu!tion in (ain
s!ore no$ a!u(un!ture
;CP, (la!e)o HBP
Aigni'!ant /verall mean
(er!entage de!rease in
(ain s!ore =M.; %or
a!u(un!ture and =;.G %or
(la!e)o 3ot signi'!ant
*esults-
randomi&ation onl#
%or three modes o%
a!u(un!ture vs.
$aiting list !ontrols
?WLC< The
im(rovement in
(ain ?no. o% $ords
%rom !hart o% GD
$ords des!ri)ing
(ain intensit#<,
glo)al
im(rovement ?D4
(oint s!ale< and
%un!tional status
?JA on ;= DL<
$as in the
a!u(un!ture grou(
a%ter M $eeks =,
B.M and B.F and in
the WLC grou(
=B.;, =B.;, and
=B.G %ter M
months =.;, B.=
and ;.B vs. =B.=, B
and B.DCon!lusion
o% authors
MTneutralMP
Con!lusion o%
revie$ers
MTun!learMP
Con!lusion o%
authors
MT(ositiveMP %or
(ain, glo)al
measure and
(h#si!al
examination,
neutral %or
%un!tional
status, overall
!on!lusion o%
authors
MT(ositiveMP
/verall
!on!lusion o%
revie$ers
MT(ositiveMP %or
a!u(un!ture
!om(ared to
WLC
*andomi&ation
onl# %or
!om(arison
a!u(un!ture vs.
WLC, not %or
di%%erent modes
o% a!u(un!tur
t#(e, lo!ation,
and duration
o%
disorderDH,DIJ
on Men!ke et
al*CTK
randomi&ation
(ro!edure not
des!ri)edMI
(atients %rom
an ortho(edi!
!lini!!u(un!
ture tx-
manual
a!u(un!ture,
traditional
meridian
a!u(un!ture or
trigger (oints,
rotation, insertion
B.=OCD !m,
MOC;= needles
IOC=B minutes, G
treatments
Training and
ex(erien!e o%
a!u(un!turists
unkno$n
*e%eren!e tx-
sham
a!u(un!ture, no
traditional
a!u(un!ture or
trigger
(oints*esults-
a%ter short4term
%ollo$4u(,
im(rovement in
(ain intensit#
?JA< in
a!u(un!ture
grou( IIP in
re%eren!e grou(
DFP, a%ter long4
term %ollo$4u(
HHP vs. DBP
Elo)al
im(rovement in
CHP o%
a!u(un!ture and
IBP o% re%eren!e
grou( >n!rease in
A!ho)er test a%ter
short4term and
longterm %ollo$4
u( in a!u(un!ture
vs. re%eren!e
grou( M.H and
F.G vs. =.F
and =B.C, %or
LasegueMPs
test M.B and
M.F vs. =.=
and
B.M.Con!lusio
n o% authors
MT(ositiveMP
%or all
out!ome
measures
MN/onMPt "no(MO met t)e
current criteria +or a poiti'e
core, t)en 9 o+ t)e 11 tu/ie
(oul/ )a'e been o+ )i5)er
@ualit%# ;o(e'er, t)e current
aut)orMP concluion
re5ar/in5 t)e e++ecti'ene o+
acupuncture compare/ (it) no
treatment +or c)ronic L,P
(oul/ not c)an5e becau
e
t(o o+ t)e t)ree tu/ieF,12(oul/ till be o+ lo(er
met)o/olo5ic @ualit% an/ t)e reult (oul/ be
conBictin5#
A)eirconcluionre5ar/in5t)ee++ecti'eneo+acup
uncture compare/ (it) con'entional mana5ement
o+ L,P (oul/ no( point to tron5 e'i/ence
)o(in5 t)at acupuncture i not more e++ecti'e
t)an ot)er con'entional treatment 0tri55er point
in2ection or AENS1# *urt)ermore, t)eir
concluion re5ar/in5 t)e e++ecti'ene o+
acupuncture compare/ (it) placebo or )am
acupuncture+orL,P(oul/maintaint)atallei5)ttu/i
e(ereo+ )i5)er @ualit%, an/ t)at i4 )a/ an
o'erall concluion o+ neutral# A)u, t)ere (oul/
be tron5 e'i/ence t)at acupuncture i not more
e++ecti'e t)an placebo or )am acupuncture +or t)e
mana5ement o+ L,P#
Discussion Ele'en &CA (ere inclu/e/ in
t)i %tematic re'ie(#
.,1LH'erall, t)e number o+ 'ali/it% item 0ue/ to
ae t)e met)o/olo5ic @ualit%1 (it) a poiti'e
core (a lo(# Hnl% t(o tu/iemet t)e preet
)i5)er @ualit% le'el re@uirin5 a core )i5)er t)an
FLR# $ccor/in5 to t)e reult, t)ere (a no
e'i/ence to )o( t)at acupuncture
imoree++ecti'et)annotreatment,mo/eratee'i/ence
to )o( t)at acupuncture i not more e++ecti'e
t)an tri55er point in2ection or AENS, an/ limite/
e'i/ence to )o( t)at acupuncture i not more
e++ecti'e t)an placebo or )am acupuncture +or t)e
mana5ement o+ c)ronic L,P#
?,11,24Selection Bias $lt)ou5) e++ort (ere
ma/e to Cn/ all publi)e/ &CA, ome rele'ant
trial mi5)t )a'e been mie/# Ei5)t o+ t)e 11
inclu/e/ &CA (ere publi)e/ in En5li), an/ one
eac) (a publi)e/ in *renc), -erman, an/
Poli), repecti'el%# A)ere i ome empirical
e'i/ence )o(in5 t)at e4cluion o+ trial
publi)e/ in lan5ua5e ot)er t)an En5li) mi5)t
be aociate/ (it) bia#$lt)ou5) none o+ t)e
lan5ua5e (ere e4clu/e/, t)e number o+ 2ournal
publi)e/ in lan5ua5e ot)er t)an En5li) in/e4e/
in electronic /atabae uc) a 8E=LINE an/
E8,$SE i limite/# I+ a//itional trial are +oun/,
t)i re'ie( (ill be up/ate/#
Blinding Some empirical
e'i/ence142,33upport blin/e/ aement o+ t)e
met)o/olo5ic @ualit% o+ &CA 0(it) repect to
aut)or, 2ournal, an/ intitution1 to pre'ent
re'ie(er
bia,butt(orecentl%publi)e/tu/ie/i/not)o(an
% e++ect o+ blin/in5 on t)e reult o+ a meta6
anal%i#
It i o+ten /i+Ccult to ac)ie'e true blin/in5
becaue e4pert uuall% are in'ol'e/ in t)e
re'ie( proce# A)e t(o principal re'ie(er
()o con/ucte/ t)e @ualit% aement an/
/ata e4traction are e4pert in t)e Cel/ o+ L,P
in primar% care, but t)e% )a/ no peciCc
"no(le/5e or e4perience in t)e Cel/ o+
acupuncture# $lt)ou5) t)e tu/% election (a
nonblin/e/, t)e current aut)or belie'e t)at
t)e blin/e/ @ualit% aement till ma/e
ene# A)e En5li) lan5ua5e tu/%, +or ()ic)
t)ee re'ie(er coul/ not be blin/e/, (a
aee/ b% t(o ot)er e4perience/
re'ie(er#711#1Acupuncture for Low Back
Painvan Tu"der et a"
,lin/in5iepeciall%importanti+t)ere'ie(er)a
'ea
conBicto+interet#Hneremar"ableCn/in5int)ecurre
nt re'ie( (a t)e notable /i++erence bet(een t)e
o'erall concluion o+ t)e 0blin/e/1 re'ie(er an/
t)e o'erall concluion reac)e/ b% t)e aut)or o+
t)e ori5inal tu/ie# A)e aut)or o+ ei5)t tu/ie
conclu/e/ t)at acupuncture (a e++ecti'e, ()erea
t)e re'ie(er conclu/e/ t)at t)ere (a a poiti'e
e++ect o+ acupuncture in onl% t(o tu/ie# I+ a
conBict o+ interet i li"el% to e4it in a %tematic
re'ie( 0e.g., acupuncturit appraiin5 t)e @ualit%
o+ a re'ie( on acupuncture1, it i recommen/e/
t)at t)e tu/ie be blin/e/ +or reult an/
concluion#
Methodologic )uality A)e met)o/olo5ic
@ualit% o+ t)e inclu/e/ &CA (a e4tremel% poor#
A)e met)o/olo5ic @ualit% in t)e current
re'ie((a/eCne/b%t)einternal'ali/it%criteria,()i
c) re+erre/ to c)aracteritic o+ t)e tu/% t)at
mi5)t be relate/ to election, per+ormance,
attrition, an/ /etection bia# Stu/ie (it) lo(er
met)o/olo5ic @ualit%, a in t)i re'ie(, are
uppoe/ to )a'e biae/ Cn/in5# It eem
reaonable t)at in t)e aut)orMP bet6e'i/ence
%nt)ei, tron5 e'i/ence can be pro'i/e/ onl%
b% )i5)er @ualit% tu/ie, ()ic) are le li"el% to
)a'e biae/ reult#
1F,32$lt)ou5) t)e le'el o+ e'i/ence in t)i re'ie(
(ere arbitrar%, it eem unli"el% t)at a /i++erent
ratin5 %tem (oul/ )a'e reulte/ in /i++erent
concluion# A)e
eniti'it%anal%i)o(t)ate'en()enitiaume/t
)atall criteria core/ a MN/onMPt "no(MO (ere
+ulClle/, t)ere till i no tron5 e'i/ence in +a'or
o+ acupuncture# ;o(e'er, it i 'er% unli"el% t)at
in t)e Cel/ o+ L,P all t)ee uncertain criteria (ere
met becaue, in 5eneral, t)e met)o/olo5ic @ualit%
o+ &CA in t)i Cel/ i lo(#
*evels of 0vidence ,ecaue t)e aut)or
'ie(e/ t)e tu/ie in t)i re'ie( a 'er%
)etero5eneou clinicall%, t)e% con/ucte/ a
MNbete'i/ence %nt)eiMO rat)er t)an a meta6
anal%i 0i.e., tatitical poolin5 o+ t)e /ata1# A)ere
(a a lar5e 'ariet% in
t)et%pe,location,an//urationo+L,PQt)einter'entio
n
0t%peo+acupuncture1Qan/t)eoutcomemeaure/#*
urt)ermore,t)eoutcome(erepoorl%preente/in.o+
t)e 11 tu/ie to t)e e4tent t)at poolin5 (a not
poible# A)e le'el o+ e'i/ence ue/ in t)e re'ie(
(ere arbitrar% becaue t)ere till i no conenu
on )o( to ae t)e tren5t) o+ t)e e'i/ence#
Ht)er le'el o+ e'i/ence mi5)t lea/ to /i++erent
concluion# &ea/er ma% appl% t)eir o(n ratin5
%tem to ee i+ t)e concluion in/ee/
c)an5e#;o(e'er,it)oul/be"eptinmin/t)attoa'oi/
bia, a ratin5 %tem i/eall% )oul/ be pre/eCne/
an/ in/epen/ent o+ t)e reult +rom t)e tu/ie
inclu/e/ in t)e re'ie(#
,alidity of (reatment A)e e4perience an/
trainin5 o+ t)e acupuncturit ()o 5a'e t)e
treatment (ere mentione/ in a onl% +e(
tu/ie# None o+ t)e tu/ie tate/ ()at t)at
e4perience in'ol'e/ o +ar a %ear o+ practice,
+or e4ample#
*urt)ermore,inmottu/iet)enumbero+nee/le,
numberan
/
11## pine7!o"ume #4 7$um%er 1171&&&
/urationo+eion,an/t)e/urationo+t)einter'entio
n perio/ (ere not peciCe/# Some tu/ie reporte/
t)at t)e acupuncture point, t)e number o+
eion, an/ t)e /uration o+ treatment (ere
in/i'i/uali3e/ accor/in5 to t)e pattern o+ t)e
patientMP pain#
9*rom t)e carce /ecription o+ treatment inclu/e/
in mot o+ t)e tu/ie, it i /i+Ccult to e'aluate
()et)er t)e acupuncture treatment (a 'ali/ or
not# A)e 'ali/it% o+ t)e acupuncture treatment
mi5)t be relate/ to it a+et% a (ell a it
e++ecti'ene# Seriou a/'ere e'ent )a'e been
aociate/ (it) acupuncture uc) a in+ection
0)uman immuno/eCcienc% 'iru, )epatiti,
ubacute bacterial en/ocar/iti1 caue/ b%
nonterile nee/le, or complication
0pneumot)ora4, car/iac tampona/e1 caue/ b%
tiue trauma, but t)e inci/ence o+ a/'ere e'ent
i un"no(n#$ recent National Intitute o+ ;ealt)
conenureporttate/t)atonea/'anta5eo+acupunct
urei
t)att)einci/enceo+a/'eree++ectiubtantiall%lo(
er t)an t)at o+ man% ot)er accepte/ me/ical
inter'ention#
Summary $ recent National Intitute o+
;ealt) conenu panel conclu/e/ t)at t)ere i
clear cientiCc e'i/ence to )o( t)at acupuncture
i e++ecti'e +or potoperati'e /ental pain, +or
nauea an/ 'omitin5 caue/ b% c)emot)erap%, an/
+or pain a+ter ur5er% an/ probabl% /urin5
pre5nanc%# ;o(e'er, t)e panel alo conclu/e/ t)at
u+Ccient cientiCc e'i/ence o+ e++ecti'ene i
lac"in5 concernin5 e'eral ot)er in/ication +or
()ic) acupuncture +re@uentl% i ue/ 0e.g.,
c)ronic pain, at)ma, an/ nicotine a//iction1# A)e
reult o+ t)i %tematic re'ie( conCrm t)at t)ere
i no con'incin5 cientiCc e'i/ence to )o( t)at
acupuncture i e++ecti'e in t)e mana5ement o+
acute an/ c)ronic L,P# ;o(e'er, becaue t)e
tu/ie in t)i
re'ie((ereo+poor@ualit%,t)ee++ecti'eneo+acupu
ncture +or L,P remain unclear#
Conclusions
+mplications
for 1ractice
32,ecaue t)i %tematic re'ie( /i/ not clearl%
)o( t)at acupuncture i e++ecti'e in t)e
mana5ement o+ bac" pain,
an/becauet)erearee++ecti'ealternati'e,t)eaut)or
/onotrecommen/acupunctureaare5ulartreatmento
+ patient (it) L,P#
1+mplications for Research ,ecaue mot o+
t)e tu/ie (ere o+ 'er% poor
met)o/olo5ic@ualit%,notmeetin5t)ecurrenttan/ar
/+orcon/uctin5 an/ reportin5 o+ &CA,t)ere
certainl% i a +urt)er nee/ +or +uture )i5)6@ualit%
&CA# In particular,
+uturetu/ie)oul/o'ercomemoto+t)elimitation
o+
t)e&CApreente/int)ire'ie(b%uin5atu/%/ei5
n t)at enure a )i5) internal 'ali/it%# *uture
tu/ie alo )oul/ )a'e lar5er ample i3e,
)oul/ ue a 'ali/ acupuncture treatment, an/
)oul/ )a'e bot) a )ort6term an/ a lon56term
+ollo(6up#2ckno3ledgments A)e aut)or
t)an" =r# Dim Uen an/ Elau Lin/e +or
t)eir )elp+ul comment on t)e protocol an/ =r# W#
=e'ille an/ 8r# E Sto"46-ruber +or t)eir )elp
(it) t)e @ualit% aement an/ /ata e4traction#
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reportin5 o+ ran/omi3e/ controlle/ trial> A)e CHNSH&A tatement#
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c)ronic lo( bac" pain> $ ran/omi3e/ clinical trial (it) lon5term
+ollo(6up# Spine 19?LQF>2G9C91# 13# ;ac"ett -I, Se//on =,
Eamin"i =# Electroacupuncture compare/ (it) paracetamol +or
acute lo( bac" pain# Practitioner 19??Q232>1.3C4# 14# Da/a/ $&,
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ran/omi3e/ clinical trial> I blin/in5 necear%V Control Clin Arial
199.Q1G>1C 12# 1F# Eoe ,W, ,outer L8, 'an /er ;ei2/en -D8-#
8et)o/olo5ical @ualit% o+ ran/omi3e/ clinical trial on treatment
e+Ccac% in lo( bac" pain# Spine 199FQ2L> 22?C3F# 1.# Lao L#
$cupuncture tec)ni@ue an/ /e'ice# D $lternati'e Complementar%
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E+Ccac% o+ electroacupuncture an/ AENS in t)e re)abilitation o+
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nonor5anic p)%ical Cn/in5 on a controlle/ trial o+ trancutaneou
electrical ner'e timulation an/ electroacupuncture# Spine
19?3Q?>.2FC34# 19#
LiD,C)enar/D&,8arc)an/S,C)aretD,La'i5nolle,#Point/MPacupunct
ure et3one6
5ac)ette>&eM[ponealapreonetreM[itancecutaneM[ec)e3/elombal
5ie c)roni@ue# &)umatolo5ie 1994Q4.>11C19# 2L# Lopac3 S,
-rale("i Z# $ trial o+ aement o+ t)e reult o+ acupuncture or
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19G9Q?> 4LFC9# 21# 8ac=onal/ $D, 8acrae E=, 8ater ,&, &ubin
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con/uct an/ reportin5 o+ %tematic re'ie(# Lancet
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19?.Q24>1FC4L
#
2.# Spit3er WH, Le,lanc *E, =upui 8, e/# ScientiCc approac)
to t)e aement an/ mana5ement o+ acti'it%6relate/ pinal
/ior/er# Spine 19?GQG0Suppl1> 1CF9# 2G# Stu4 -, Pomeran3 ,#
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$cupuncture an/ c)ronic pain> $ criteria6bae/ meta6anal%i# D
Clin Epi/emiol 199LQ43>1191C9# 29# A)oma 8, Lun/ber5 A#
Importance o+ mo/e o+ acupuncture in t)e treatment o+ c)ronic
nocicepti'e lo( bac" pain# $cta $naet)eiol Scan/ 1994Q3?>
.3C9# 3L# 'an Aul/er 8W, $en/el+t WDD, Eoe ,W, ,outer
L8, an/ t)e E/itorial
,oar/o+t)eCoc)raneCollaboration,ac"&e'ie(-roup#8et)o/5ui/
eline+or %tematic re'ie( in t)e Coc)rane Collaboration ,ac"
&e'ie( -roup +or Spinal =ior/er# Spine 199GQ22>2323C3L# 31#
'an Aul/er 8W, Eoe ,W, ,outer L8# $ cot6o+6illne tu/% o+
bac" pain in t)e Net)erlan/# Pain 199FQ.2>233C4L# 32# 'an
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acute an/
c)ronicnonpeciCclo(bac"pain>$%tematicre'ie(o+ran/omi3e/c
ontrolle/ trial o+ t)e mot common inter'ention# Spine
199GQ22>212?CF.# 33# Ver)a5en $P, =e Vet ;CW, =e ,ie &$,
Eeel $-;, ,oer 8, Enipc)il/ P-# ,alneot)erap% an/ @ualit%
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199?QF1>33FC41#711#3Acupuncture for Low Back
Painvan Tu"der et a"
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;er5et ;*#$"upun"tur/eSc)ulter6$rm6
S%n/romun//erLumba5ie\Ic)ial5ie>Z(ei proep"ti'e =oppelblin/6
Stu/ien7 0Aeil I1# $"upun"tur 19??Q4>2L4C1F# 3F# 'on 8enc"e 8,
Wie/en AE, ;oppe 8, Porc)"e W, ;o++mann H, ;er5et
;*#$"upun"tur/eSc)ulter6$rm6
S%n/romun//erLumba5ie\Ic)ial5ie>Z(ei proep"ti'e =oppelblin/6
Stu/ien7 0Aeil II1# $"upun"tur 19?9QF>FC13# 3.# Wa//ell -# $ ne(
clinical mo/el +or t)e treatment o+ lo( bac" pain# Spine
19?GQ12>.32C44#
Address reprint requests to 8aurit 'an Aul/er,
P)=
Institute for #esearch in !"tramural
Medicine $ri%e &niversiteit
van der
'oechorststraat
( )*+) 'T
Amsterdam
the ,etherlands !-mail.
m/.van0tulder.emgo1med.vu.nl