Chronic nonspecific low back pain is the leading cause of years lived with disability worldwide, according to the Global Burden of Disease study, and represents a huge economic and social burden across all age groups. Conventional treatment — which may include anti-inflammatories, simple analgesics, isolated physical therapy, or postural guidance — frequently offers modest and temporary relief, with cumulative risks of gastrointestinal and renal adverse effects from prolonged NSAID use.
A new systematic review and meta-analysis published in SICOT-J (Volume 12, 2026, Article 7), the official journal of the International Society of Orthopaedic Surgery and Traumatology, conducted by Sotiropoulos and colleagues, evaluated specifically whether acupuncture is superior to usual care as a reference — instead of comparisons with sham acupuncture. With data from 8 randomized clinical trials and 1,123 patients from six countries (Germany, Iran, India, Brazil, China, and Spain), the results confirm significant clinical benefits of acupuncture both at short and medium term.
MAIN RESULTS: ACUPUNCTURE VS. USUAL CARE
Why compare with usual care — and not with sham?
Most meta-analyses of acupuncture for low back pain compare real acupuncture with sham acupuncture (false needle or superficial insertion at non-acupoints). Although this comparison is methodologically rigorous for isolating specific effects of the needle, it underestimates the real clinical benefit: in practice, the patient does not choose between real acupuncture and sham acupuncture — the patient chooses between acupuncture and the treatment that would otherwise be received.
By directly comparing acupuncture versus usual care (medication, conventional physical therapy, guidance), the meta-analysis by Sotiropoulos and colleagues answers the clinically more relevant question: is it worth offering acupuncture to this patient instead of what we are already doing? The answer, based on 1,123 patients, is consistently positive.
The effect grows with time: relevance of the medium term
A particularly relevant datum from this meta-analysis is that the effect size for pain increased from short term (SMD −0.73) to medium term (SMD −1.13) — a pattern suggesting that acupuncture benefits consolidate and expand in the weeks following treatment. This finding is consistent with current understanding of the mechanisms of action of acupuncture: descending pain modulation, reduction of central sensitization, and cortical reorganization are neuroplastic processes that establish themselves progressively over time.
For disability, the pattern was similar: the SMD went from −0.49 in the short term to −0.79 in the medium term. This indicates that functional improvement accompanies — and may even amplify — pain reduction, reflecting progressive recovery of daily activities as analgesic control consolidates.
Control-group comparators: what “usual care” is
The usual care in the included studies covered a spectrum of interventions commonly offered in clinical practice for chronic low back pain: pharmacologic management with NSAIDs, physical therapy modalities (TENS, therapeutic ultrasound), therapeutic exercises, and health education. This diversity of comparators reflects the real heterogeneity of conventional treatment and strengthens the external validity of the results — acupuncture proved superior not to a specific comparator, but to the spectrum of care that patients actually receive in the day-to-day of health services.
Frequently Asked Questions
The meta-analysis demonstrates that acupuncture produces significantly larger reductions in pain and disability compared with usual care (which includes medications, physical therapy, and guidance). The effect sizes are moderate to large and grow over the medium term. However, the certainty of evidence is low to very low by GRADE, indicating the need for more high-quality RCTs to confirm the exact magnitude of benefits.
Subgroup analyses suggest that electroacupuncture may have slightly superior effects (SMD −0.82 vs. −0.73 for immediate pain; −1.36 vs. −1.13 in the medium term). However, 6 of the 8 studies used electroacupuncture, só the evidence for manual acupuncture alone is more limited. Electroacupuncture combines mechanical needle stimulation with low-frequency electrical stimulation, which may potentiate the release of endorphins and enkephalins.
The protocols in the 8 RCTs varied from 5 days to 6 weeks of treatment. The effect is significant by the first 2 weeks (SMD −0.73 for pain) and broadens between 2 weeks and 6 months (SMD −1.13). This suggests that a minimum 2-week protocol is necessary for an initial effect, with growing benefits in the subsequent weeks.
Across the 1,123 patients evaluated, only one study reported adverse events — mild bruising in the electroacupuncture group. No serious adverse events were recorded. The safety profile of acupuncture compares favorably with the risks of prolonged use of NSAIDs (gastric injury, nephrotoxicity) and opioids (dependence, sedation).
The SMD is a statistical measure that allows comparison of effects across studies that used different scales (VAS, NRS, ODI, RMDQ). SMD values around 0.2 are considered small effects, 0.5 moderate, and 0.8 or greater are large. In this meta-analysis, the effects ranged from moderate (−0.49) to large (−1.13), indicating clinically relevant benefits.
Founded in 1989 by physicians trained at the University of São Paulo (USP) and specialized in China, CEIMEC is a Brazilian national reference in the teaching and practice of medical acupuncture. With more than 3,000 physicians trained over 35 years, it collaborates with HC-FMUSP and is recognized by the Brazilian Medical College of Acupuncture (CMBA/AMB).
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