Needling Point Location Used in Sham Acupuncture for Chronic Nonspecific Low Back Pain: A Systematic Review and Network Meta-Analysis

Chronic nonspecific low back pain, defined as pain in the back lasting more than three months without a specific identifiable cause, represents a significant health problem that affects between 15% and 37% of the general population. Although conventional treatments are available, including medications and physical therapy, not all patients respond adequately to these approaches, and prolonged use of medications can cause unwanted side effects. In this context, acupuncture has emerged as a promising alternative therapy, but its efficacy remains controversial because of methodological issues in research, particularly related to the type of placebo control used in studies.

This study aimed to investigate a fundamental question in acupuncture research: whether the location of needling points in placebo acupuncture influences treatment outcomes. The researchers conducted a systematic review and network meta-analysis, analyzing studies published through February 2023 in four major medical databases. Ten randomized controlled trials involving 4,379 participants with chronic nonspecific low back pain were included. The study classified placebo acupuncture into two types: that performed at the same points as true acupuncture (called SATV) and that performed at different points (called SATS).

The methodology included advanced statistical techniques to compare all treatments directly and indirectly, primarily evaluating improvement in pain and back function immediately after treatment.

The results revealed important findings that question the validity of certain acupuncture research methodologies. When compared with SATS, true acupuncture showed significant benefits for both pain and function. Surprisingly, there were no significant differences between true acupuncture and SATV, suggesting that performing placebo acupuncture at the same points as real acupuncture may produce therapeutic effects. Even more intriguing was the finding that SATV showed better results than SATS for both outcomes evaluated.

In the efficacy rankings, SATV took first place, followed by true acupuncture, then SATS, and finally the waitlist. All active treatments (true acupuncture, SATV, and SATS) proved superior to the waitlist, indicating that even forms of placebo acupuncture have some therapeutic effect.

These findings have profound clinical implications for both patients and health care professionals. For patients, the results suggest that acupuncture may be more effective than indicated in some prior studies, especially those that used placebo acupuncture at the same points as real acupuncture. This means that patients with chronic low back pain may benefit more from acupuncture than previously documented in the scientific literature. For health care professionals, the study clarifies why different clinical guidelines make inconsistent recommendations regarding acupuncture for chronic low back pain.

The findings also alert researchers to the importance of choosing appropriate placebo controls in future studies, since using placebo acupuncture at the same points as real acupuncture may underestimate the true benefits of treatment. This can lead to mistaken conclusions about the efficacy of acupuncture and inappropriately influence health policy and clinical recommendations.

The study presents some important limitations that should be considered in interpreting the results. Only one study used SATV, which may have affected the precision of statistical analyses. In addition, the search was limited to English-language databases, potentially excluding relevant studies published in other languages. The researchers were also unable to analyze other factors that could influence the results, such as different types of placebo acupuncture devices, due to the limited number of available studies.

Furthermore, including waitlist groups to form adequate statistical connections may not be ideal for evaluating self-reported measures of pain and function. Despite these limitations, this study represents the first systematic investigation of point specificity in acupuncture through analysis of different types of placebo acupuncture. The findings suggest that placebo acupuncture performed at the same points as true acupuncture does not constitute an adequate placebo control and may mask the true benefits of acupuncture. Future studies should consider these findings in designing more rigorous research, and it would be valuable to confirm whether similar results occur in other pain and non-pain conditions.