Acupuncture as an alternative or in addition to conventional treatment for chronic non-specific low back pain: A systematic review and meta-analysis

Chronic non-specific low back pain is one of the most prevalent and impactful health problems in the modern world, affecting millions of people in developed countries and generating socioeconomic costs estimated between $1.93 billion and $81.24 billion per person. This condition is defined as pain, discomfort, or stiffness in the lumbar region that persists for more than three months, without being associated with an identifiable specific pathology such as infection, tumor, or structural spine problems. Prevalence varies significantly across studies, reaching up to 31.5% of the population in some regions of Italy, representing a substantial challenge for patients and healthcare professionals.

Currently available conventional treatments include both pharmacological and non-pharmacological options, but they often fail to provide satisfactory relief. Traditional medications, such as acetaminophen, nonsteroidal anti-inflammatory drugs, opioids, and muscle relaxants, may have limited efficacy and be associated with significant side effects, including gastrointestinal, hepatic, and cardiovascular issues, and the risk of dependence. Non-pharmacological therapies such as physical therapy, exercise, and cognitive-behavioral therapy, while beneficial, do not always achieve the expected results. Given these limitations, acupuncture emerges as a promising alternative, with well-established mechanisms of action that involve activation of pain control systems, release of endogenous opioids, and modulation of neurotransmitters such as adenosine.

This study performed a systematic review and meta-analysis to assess the efficacy and safety of acupuncture in the treatment of chronic non-specific low back pain, either as an alternative or as a complement to conventional treatments. Researchers conducted a comprehensive search of major medical databases, including Medline, Cochrane Library, and Embase, through May 2022, with no language restrictions. Only randomized clinical trials comparing acupuncture alone or in combination with conventional treatment versus conventional treatment alone were included. Studies were rigorously selected, excluding those that evaluated specific forms of acupuncture such as auricular acupuncture or techniques that did not involve needle insertion.

Researchers categorized the studies into two main groups: acupuncture as an alternative to conventional treatment and acupuncture as an additional therapy alongside conventional treatment.

The final analysis included 14 randomized clinical trials involving 2,496 participants, with ages ranging from 33 to 81 years. Ten studies evaluated acupuncture as an alternative to conventional treatment, while four studies examined acupuncture as a complementary therapy. Results revealed a complex and nuanced picture of acupuncture efficacy. When compared in isolation with non-pharmacological or pharmacological treatments, acupuncture did not show significant differences in pain or disability reduction.

However, when compared with the combination of pharmacological and non-pharmacological treatments, acupuncture showed statistically significant benefits, reducing both pain and functional disability. In studies that evaluated acupuncture as add-on therapy to conventional treatments, results were more encouraging, especially when combined with non-pharmacological therapies, demonstrating significant reductions in pain and disability.

The clinical implications of these findings are relevant for both patients and healthcare professionals. For patients with chronic low back pain who have not obtained adequate relief from conventional treatments, acupuncture represents an additional therapeutic option that can be considered, especially as a complement to already established treatments. Results suggest that acupuncture may be particularly useful when combined with other therapies, enhancing the benefits of multimodal treatment. For healthcare professionals, these data provide scientific evidence that can guide more informed clinical decisions, allowing a more personalized approach based on individual patient characteristics, resource availability, and personal preferences.

Acupuncture may be especially valuable for patients with contraindications or intolerance to conventional medications, offering an alternative with a generally favorable safety profile.

It is important to acknowledge the significant limitations of this study, which influence interpretation of the results. The methodological quality of the included studies was variable, with most having a high risk of bias due to the inability to blind participants and practitioners — an inherent limitation in acupuncture studies. Certainty of evidence ranged from moderate to very low for most outcomes, reflecting not only methodological issues but also imprecision due to the relatively small number of studies in each comparison and limited sample sizes. In addition, none of the included studies adequately assessed adverse events, preventing a full analysis of acupuncture's safety profile.

Heterogeneity across studies in terms of treatment protocols, populations, and outcome measures also limited the ability to draw definitive conclusions.

In conclusion, although the current evidence does not allow categorical claims of acupuncture's superiority over conventional treatments for chronic non-specific low back pain, results suggest that it may play a clinically meaningful role, especially in specific treatment combinations. The most promising findings emerged in comparisons with larger samples and lower statistical imprecision, indicating that acupuncture may be a valuable option based on individual patient preferences and characteristics. Future clinical trials with larger samples, more rigorous methodology, and detailed description of control interventions are needed to more definitively establish acupuncture's role in chronic low back pain management. In the meantime, acupuncture remains a reasonable therapeutic option for patients seeking alternatives or complements to conventional treatments, particularly when these have not provided adequate relief.