Acupuncture Versus Oral Medications for Acute/Subacute Non‑Specific Low Back Pain: A Systematic Review and Meta‑Analysis

Acute and subacute nonspecific low back pain represents one of the leading medical complaints worldwide, affecting approximately 9.4% of the global population and accounting for 90 to 95% of all back pain cases. This condition not only causes significant suffering for patients but also imposes a substantial economic burden on healthcare systems, costing billions of dollars annually in the United States alone because of reduced productivity. The term "nonspecific" indicates that there is no clearly identifiable anatomical cause for the pain, which makes treatment a major clinical challenge. Approximately 60% of acute cases can progress to chronic pain, making it crucial to seek effective treatments in the early stages.

Conventional treatment for acute low back pain generally includes oral medications such as nonsteroidal anti-inflammatory drugs, muscle relaxants, and, in some cases, more potent analgesics. Although these medications can provide relief, they are not without risks and may cause adverse effects, especially when used for prolonged periods. Given these limitations, acupuncture has emerged as a promising therapeutic alternative and is even recommended in international clinical guidelines for low back pain management. However, until this study was conducted, no systematic analysis specifically compared the efficacy and safety of acupuncture versus oral medications in the treatment of acute and subacute nonspecific low back pain.

The researchers conducted a rigorous systematic review and meta-analysis with the primary objective of evaluating whether acupuncture is more effective and safer than oral medications for treating patients with acute (0 to 4 weeks) and subacute (4 to 12 weeks) nonspecific low back pain. To do so, they performed a comprehensive search across 14 international databases, including PubMed, Cochrane Library, Embase, and other Chinese databases, covering all available literature through April 2022. Inclusion criteria were rigorous, selecting only randomized controlled trials, crossover studies, and cohort studies that directly compared traditional acupuncture (manual or electroacupuncture) with oral medications. Studies that combined acupuncture with other therapies or that used sham acupuncture as a control were excluded.

Two independent reviewers assessed the methodological quality of the studies and extracted data, with a third reviewer resolving any disagreements.

From a total of 6,784 records identified, 14 studies met the inclusion criteria, involving 1,263 participants. The meta-analysis results revealed that acupuncture demonstrated statistically significant superiority over oral medications in three primary outcomes. For pain relief, measured using validated scales such as the visual analog scale, acupuncture showed a mean reduction of 1.17 points compared with medications, representing a moderate, clinically relevant effect. In terms of functionality, assessed using questionnaires specific to low back disability, acupuncture demonstrated a substantial advantage with what is considered a large effect, although the quality of evidence was rated very low because of methodological limitations of the included studies.

The overall improvement rate was 12% higher in the acupuncture group, with improvement observed in 1,078 of 1,028 treated participants. A particularly interesting subgroup analysis showed that "acupuncture with movement" — a technique that involves stimulation of specific points while the patient performs directed lumbar movements — was superior to other acupuncture modalities, especially when applied across multiple sessions.

The clinical implications of these findings are important for both patients and healthcare professionals. For patients, the results suggest that acupuncture offers an effective and potentially safer alternative to traditional oral medications. Acupuncture proved particularly advantageous in terms of safety, with only four of the 14 studies reporting minimal adverse events such as mild dizziness or small local hematomas, in contrast to the gastrointestinal effects and other risks associated with anti-inflammatory drugs. For clinicians, this study provides scientific evidence that can guide therapeutic decisions, especially considering current guidelines that recommend caution in the prolonged use of analgesic medications.

The acupuncture-with-movement technique proved particularly promising, suggesting that combining acupoint stimulation with active mobilization may enhance therapeutic benefits through mechanisms that raise the pain threshold and modulate pain signal transmission.

However, it is essential to acknowledge important limitations of this study that influence interpretation of the results. The main methodological limitation was the inability to blind therapists and patients because of the nature of the interventions, which may have introduced performance and detection biases. Most of the included studies were of Chinese origin, which may limit the generalizability of the results to other populations. The overall methodological quality of the studies was considered low to very low according to GRADE criteria, mainly because of inadequacies in the description of randomization methods, allocation concealment, and high dropout rates in some studies.

In addition, all studies assessed only short-term effects, providing no information on the durability of acupuncture benefits. Another limitation was the exclusion of studies in other Asian languages, potentially missing relevant evidence. Despite these limitations, when minimum clinically important differences for the primary outcomes are considered, a consistent trend favoring acupuncture is observed. This pioneering study offers valuable guidance for clinicians treating acute and subacute low back pain, although caution is warranted in interpretation given the methodological limitations identified and the need for higher-quality future studies to confirm these promising findings.