Acupuncture for the Relief of Chronic Pain: A Synthesis of Systematic Reviews

Abstract

Background and Objectives: It is estimated that 28 million people in the UK live with chronic pain. A biopsychosocial approach to chronic pain is recommended which combines pharmacological interventions with behavioural and non-pharmacological treatments. Acupuncture represents one of a number of non-pharmacological interventions for pain. In the current climate of difficult commissioning decisions and constantly changing national guidance, the quest for strong supporting evidence has never been more important. Although hundreds of systematic reviews (SRs) and meta-analyses have been conducted, most have been inconclusive, and this has created uncertainty in clinical policy and practice. There is a need to bring all the evidence together for different pain conditions. The aim of this review is to synthesise SRs of RCTs evaluating the clinical efficacy of acupuncture to alleviate chronic pain and to consider the quality and adequacy of the evidence, including RCT design. Materials and Methods: Electronic databases were searched for English language SRs and meta-analyses on acupuncture for chronic pain. The SRs were scrutinised for methodology, risk of bias and judgement of efficacy. Results: A total of 177 reviews of acupuncture from 1989 to 2019 met our eligibility criteria. The majority of SRs found that RCTs of acupuncture had methodological shortcomings, including inadequate statistical power with a high risk of bias. Heterogeneity between RCTs was such that meta-analysis was often inappropriate. Conclusions: The large quantity of RCTs on acupuncture for chronic pain contained within systematic reviews provide evidence that is conflicting and inconclusive, due in part to recurring methodological shortcomings of RCTs. We suggest that an enriched enrolment with randomised withdrawal design may overcome some of these methodological shortcomings. It is essential that the quality of evidence is improved so that healthcare providers and commissioners can make informed choices on the interventions which can legitimately be provided to patients living with chronic pain.

Full text

medicina
Review
Acupuncture for the Relief of Chronic Pain:
A Synthesis of Systematic Reviews
Carole A. Paley 1, 2, * and Mark I. Johnson 2
1
Research and Development Dept, Airedale National Health Service (NHS) Foundation Trust, Skipton Road,
Steeton, Keighley BD20 6TD, UK
2Centre for Pain Research, School of Clinical and Applied Sciences, Leeds Beckett University, City Campus,
Leeds LS1 3HE, UK; M.Johnson@leedsbeckett.ac.uk
*Correspondence: carole.paley@nhs.net
Received: 24 October 2019; Accepted: 6 December 2019; Published: 24 December 2019


Abstract:
Background and Objectives: It is estimated that 28 million people in the UK live with chronic
pain. A biopsychosocial approach to chronic pain is recommended which combines pharmacological
interventions with behavioural and non-pharmacological treatments. Acupuncture represents one
of a number of non-pharmacological interventions for pain. In the current climate of difficult
commissioning decisions and constantly changing national guidance, the quest for strong supporting
evidence has never been more important. Although hundreds of systematic reviews (SRs) and
meta-analyses have been conducted, most have been inconclusive, and this has created uncertainty
in clinical policy and practice. There is a need to bring all the evidence together for different pain
conditions. The aim of this review is to synthesise SRs of RCTs evaluating the clinical efficacy of
acupuncture to alleviate chronic pain and to consider the quality and adequacy of the evidence,
including RCT design. Materials and Methods: Electronic databases were searched for English language
SRs and meta-analyses on acupuncture for chronic pain. The SRs were scrutinised for methodology,
risk of bias and judgement of efficacy. Results: A total of 177 reviews of acupuncture from 1989 to 2019
met our eligibility criteria. The majority of SRs found that RCTs of acupuncture had methodological
shortcomings, including inadequate statistical power with a high risk of bias. Heterogeneity between
RCTs was such that meta-analysis was often inappropriate. Conclusions: The large quantity of RCTs on
acupuncture for chronic pain contained within systematic reviews provide evidence that is conflicting
and inconclusive, due in part to recurring methodological shortcomings of RCTs. We suggest that an
enriched enrolment with randomised withdrawal design may overcome some of these methodological
shortcomings. It is essential that the quality of evidence is improved so that healthcare providers and
commissioners can make informed choices on the interventions which can legitimately be provided
to patients living with chronic pain.
Keywords: acupuncture; pain; systematic review; evidence synthesis
1. Introduction
The World Health Organisation (WHO) recognises chronic pain as a long-term condition in its
own right and as a secondary consequence of other long-term conditions [
1
]. It has been estimated
that 28 million adults in the UK (43%) are affected by chronic pain and that the pain of 7.9 million
of these adults is moderately or severely limiting [
2
]. The prevalence of chronic pain is higher in
older age groups, with an estimated 62% of people over 75 being affected [
2
]. Individuals living with
pain often experience a very poor quality of life, it affects their ability to work, socialise, sleep and
maintain good relationships and can lead to depressive illness, decreased motivation and a reduction
Medicina 2020,56, 6; doi:10.3390/medicina56010006 www.mdpi.com/journal/medicina

Medicina 2020,56, 6 2 of 48
in physical activity [
3
]. As such, chronic pain represents a major challenge for health service provision
and government policy.
Current guidance from the International Association for the Study of Pain (IASP) recommends a
biopsychosocial approach to pain utilising a multidisciplinary, multimodal, stepwise approach which
combines pharmacological interventions with behavioural and non-pharmacological treatments [
4
].
Non-pharmacological interventions are recommended as part of a comprehensive pain management
programme, including lifestyle adjustments, pain education, and physical, psychological and
complementary therapies.
In the UK, acupuncture has been available in some parts of the National Health Service (NHS)
for decades as a non-pharmacological intervention to manage acute or chronic pain. In the NHS,
acupuncture is administered by Allied Health Professionals, Nurses or Doctors. Outside the NHS,
acupuncture is available from a variety of sources, including ‘traditional’ acupuncturists, sports
therapists, osteopaths and chiropractors.
Acupuncture is an age-old technique which became part of modern medicine in the 1970s.
In modern medicine, traditional forms of acupuncture, based on the ancient Chinese concept of qi and
meridians, have been superseded by acupuncture based on a neurophysiological model [
5
,
6
]. The
unique identity of acupuncture lies in the process of inserting needles (‘acu’) in the skin (‘puncture’),
although a modern definition should include the need to do this at specific points in accordance with
known physiological or anatomical rationale [7].
Over the past two decades, the quantity of clinical studies on the use of acupuncture for various
types of pain has significantly increased. In 2013, it was estimated that over 3000 clinical trials had been
published [
8
] with over one hundred systematic reviews (SRs) (some with meta-analyses) attempting
to synthesise available evidence. Many SRs of randomised controlled trials (RCTs) of acupuncture have
been inconclusive and this has created uncertainty in clinical policy and practice. This uncertainty was
highlighted in 2016 when the National Institute for Health and Care Excellence (NICE) reversed its 2009
recommendation to offer acupuncture as a first line treatment for non-specific, chronic low back pain
because evidence indicated that it was no more effective than sham acupuncture [
9
–
11
]. Interestingly,
there had been no significant change in evidence provided by RCTs between 2009 and 2016. Presently,
NICE only recommends acupuncture as a prophylactic treatment for chronic tension-type headache
and migraine [12,13].
In the face of conflicting evidence and continually changing guidance, it is unsurprising that
acupuncture practitioners are finding that an intervention that, anecdotally at least, is often well
received by patients in the clinic and appears to have good results, is rejected by commissioners and
policy makers and regarded in some quarters as a ‘theatrical placebo’ [
8
,
14
]. One reason for this
uncertainty may be related to the clinical research methodologies used to determine clinical efficacy.
Policy makers give credence to the findings of RCTs because they are the ‘gold standard’
methodology for evaluating clinical efficacy. RCTs enable isolation of the effects (benefit and harm)
associated with the active ingredient of a treatment from effects associated with the act of receiving a
treatment, i.e., believing that an active ingredient of a treatment has been received. This is operationalised
by using needles to puncture the skin at defined points compared with pretending to puncture the skin
at defined points (i.e., a ‘placebo’ or ‘sham’ intervention).
Systematic reviews and meta-analyses of multiple RCTs provide an indicator of consistency of
findings between RCTs and allow for generalisability of findings [
15
]. Practitioners and policy makers
may feel overwhelmed by the volume of SRs on acupuncture, suggesting a need to bring all this
evidence together. In doing so, there is an opportunity to appraise RCT design and whether it is fit
for purpose.
The aim of this review is to synthesise evidence from previously published SRs of RCTs evaluating
the clinical efficacy of acupuncture to alleviate chronic pain from any source. We have made judgements
from a Western medical perspective. Our approach is to outline research findings through commentary
rather than a comprehensive objective appraisal of SRs. We appreciate that the non-systematic approach

Medicina 2020,56, 6 3 of 48
is vulnerable to selection and evaluation biases and opinion-orientated arguments. Nevertheless,
our approach enables consideration of issues surrounding the quality and adequacy of the evidence,
including RCT design, and provides practitioners and policy makers with a comprehensive source of
SRs published to date.
2. Materials and Methods
A search of electronic databases (MEDLINE, the Database of Abstracts of Reviews of Effects
(DARE) and the Cochrane Library) was conducted in April 2019 and updated in July 2019 using free
text search terms ‘acupuncture’, ‘chronic pain’, ‘analgesia’, ‘pain management’, ‘systematic review’
and/or ‘meta-analysis’. The search was restricted to English language databases. Systematic reviews
and meta-analyses were screened for eligibility.
2.1. Inclusion Criteria
Search results were screened by the authors, CAP and MIJ. All SRs with or without meta-analyses
of studies using manual acupuncture, electro-acupuncture, dry needling or auriculotherapy (ear
acupuncture) for any chronic pain condition were included. Reviews were included where
acupuncture was compared with sham or placebo acupuncture, no treatment, or another intervention
(pharmacological and non-pharmacological). We included Cochrane and non-Cochrane reviews
and overviews of SRs. Systematic reviews containing non-RCT studies were included in order that
information from RCTs could be extracted.
2.2. Exclusion Criteria
Reviews were excluded if they did not evaluate invasive acupuncture (e.g., reviews on acupressure
or laser acupuncture). Systematic reviews were excluded if they evaluated acute pain but not chronic
pain (e.g., specifically focusing on postoperative pain or pain in the emergency setting). Reviews
focusing on additional elements such as bee venom were also excluded. Non-English reviews were
included if they contained an English abstract. However, non-English reviews were not translated.
2.3. Evidence Synthesis
One review author (CAP) extracted information from reviews including type of pain, number of
RCTs, treatments, conclusion and quality of evidence stated by the authors of each included review
taken as a direct quote from the Conclusion, Abstract or Discussion sections of their manuscript. In
addition, we ascribed a judgement of efficacy of each review according to whether the sample size met
criteria based on the work of Moore et al. [
16
,
17
] and adopted by the Pain, Palliative and Supportive
Care group from Cochrane Collaboration in their risk of bias assessment. They suggest that trial arms
with fewer than 200 participants in RCTs or fewer than 500 participants in meta-analyses are at a high
risk of bias, which seriously undermines confidence in findings. Thus, reviews were categorized as
meeting our criteria for adequacy if they contained a pooled analysis of 500 events or at least one RCT
with >200 participants in each arm of the trial. We categorised efficacy as: Sufficient evidence and
in favour of acupuncture (+), sufficient evidence in favour of control/placebo (
−
), sufficient evidence
but conflicting/inconclusive (=) and insufficient evidence to make a judgement (?). We also noted
statements within manuscripts about RCT methodology across the following themes:
•The nature of placebo/sham interventions.
•Quality and risk of bias (including blinding).
•
Sample size in relation to treatment effect. We used criteria developed by Dechartres [
18
] when
commenting on adequacy of sample size as: adequately powered (
≥
200 patients per treatment
arm), moderately powered (100–199 patients per treatment arm) and underpowered <100 patients
per treatment arm).

Medicina 2020,56, 6 4 of 48
3. Results
A total of 177 reviews of acupuncture for pain relief published between 1989 to September
2019 were included (Table 1). There were two overviews of Cochrane reviews, ten overviews of
non-Cochrane SRs and 145 non-Cochrane SRs. The earliest systematic reviews were published in
1989 by ter Riet [
19
–
21
]. There were 20 Cochrane SRs (including updates), with the earliest published
in 2000 by Tulder et al. [
22
] and the most recent published in 2018 by Choi et al. [
23
]. Findings are
presented according to the most frequent evaluations of acupuncture for different types of pain and
described chronologically to provide a sense of the evolution of evidence over time. A statement of
current clinical guidance from NICE is provided where available.
3.1. Chronic Pain Irrespective of Aetiology or Pathophysiology
The earliest SR that evaluated the efficacy of acupuncture across chronic pain conditions irrespective
of aetiology or pathophysiology was published in 2000 and was inconclusive, although it was claimed
that six or more sessions of acupuncture were more likely to be associated with positive outcomes [
24
].
The first overview of SRs was published in 2006 and concluded that acupuncture was not shown to be
efficacious for a variety of pain conditions [25].
We found four other overviews of SRs of acupuncture for chronic pain irrespective of aetiology or
pathophysiology. In 2010, Ernst and Lee published an overview of 30 SRs of acupuncture (319 RCTs)
for ‘rheumatic conditions’ and judged there to be some evidence to support efficacy in routine care of
patients with pain associated with osteoarthritis, low back pain and lateral elbow pain [
26
]. Hopton
et al. pooled data from eight meta-analyses of acupuncture for chronic pain and concluded that
acupuncture was more effective than a placebo, despite an absence of statistical significance for
individual conditions, except osteoarthritis of the knee and headache [27]. Two overviews published
in 2011 concluded that there was tentative evidence that acupuncture might be effective for headache,
peripheral joint osteoarthritis and neck pain (overview of eight Cochrane Reviews [
28
], overview of
57 SRs [
29
]), although reviewers agreed that the quality of the primary studies was poor, with a high
risk of bias.
We found 20 SRs of acupuncture for chronic pain irrespective of aetiology or pathophysiology.
In 2014, SRs reported that evidence supported the efficacy of wrist-ankle acupuncture and auricular
acupuncture for alleviating chronic pain [
30
,
31
]. Since then, SRs were generally inconclusive because
of methodological shortcomings and small sample sizes in primary studies [
32
–
36
]. In 2018, Vickers et
al. concluded that evidence supported the efficacy of acupuncture for various chronic pain conditions
associated with musculoskeletal disorders, headache and osteoarthritis, with beneficial effects persisting
at long-term follow-up (39 RCTs, [
37
]). The long-term effects of acupuncture were consistent with
evidence from an earlier SR by MacPherson et al. [38].
Evidence from SRs suggests that there are insufficient high-quality RCTs to judge the efficacy
of acupuncture for chronic pain associated with various medical conditions. There is no specific
NICE guidance about the use of acupuncture for chronic pain conditions irrespective of aetiology or
pathophysiology, although some guidance exists for specific pain conditions (see respective sections
below). Guidance by NICE on chronic pain assessment and management is currently being developed
(GID-NG10069) with publication expected in August 2020.

Medicina 2020,56, 6 5 of 48
Table 1. Systematic reviews of Acupuncture (acup) for Chronic Pain Conditions.
Condition Reference Type of Review Treatments
Evaluated
No of RCTs in
Review
Systematic Reviewers’
Conclusion of Efficacy *
Our Judgement
of Efficacy **
Systematic Reviewers’
Conclusion of Quality of
Available Evidence ***
Our Comments
CHRONIC PAIN
IRRESPECTIVE OF
AETIOLOGY OR
PATHOPHYSIOLOGY
Vickers et al.,
2018 [37]
Non-Cochrane
Systematic
Review
Chronic Pain 39
‘We conclude that acupuncture
is effective for the treatment of
chronic pain, with treatment
effects persisting over time.’
+
‘. . . in keeping with the
original analyses,
significant heterogeneity
was found in 5 out of 7
comparisons.’
Large studies with arms
>200 participants were
included for headache,
low back pain, OA and
shoulder pain.
MacPherson
et al., 2017
[38]
Non-Cochrane
Systematic
Review
Chronic Pain
(persistence of
acupuncture effects
over time)
29
‘The effects of a course of
acupuncture treatment for
patients with chronic pain do
not appear to decrease
importantly over 12 months.’
+
‘. . . strict inclusion criteria
required evidence of
unambiguous allocation
concealment, leading to our
inclusion of only higher
quality trials.’
Dataset of almost
18,000 patients,
including some
high-quality studies
with >200 participants
per trial arm.
Gattie et al.,
2017 [36]
Non-Cochrane
Systematic
Review
Musculoskeletal
conditions 13
‘
. . .
evidence suggests that dry
needling is more effective than
no treatment, sham dry
needling, and other treatments
. . . ’
?
‘. . . overall quality of the
evidence was considered to
be very low to moderate
using the GRADE
approach.’
Included studies all had
arms of <200
participants.
Zhang et al.,
2017 [39]
Non-Cochrane
Systematic
Review
Pain conditions 23
‘Cupping therapy and
acupuncture are potentially
safe, and they have similar
effectiveness in relieving pain.’
N/A
‘. . . no study was
evaluated as low risk of
bias, studies unclear risk of
bias, and the remaining 15
studies, high risk of bias.’
This was a comparative
SR between
acupuncture and
cupping. None of
included studies had
arms of >200
participants
Cox et al.,
2016 [32]
Non-Cochrane
Systematic
Review
Musculoskeletal
Disorders of the
Extremities
15
‘Evidence for the effectiveness
of acupuncture for
musculoskeletal disorders of
the extremities was
inconsistent.’
=
‘Ten of 15 RCTs had a low
risk of bias . . . . Five of 15
RCTs had a high risk of
bias.’
Effect sizes were small.
One large study with
>200 participants per
treatment arm and low
risk of bias.
Yuan et al.,
2016 [33]
Non-Cochrane
Systematic
Review
Musculoskeletal
pain 61
‘Our review provided
low-quality evidence that
acupuncture has a moderate
effect (approximately a
12-point pain reduction on the
VAS 100 mm) on relieving pain
associated with
musculoskeletal disorders.’
=
‘The main weakness of this
study was the relative
paucity of high-quality
RCTs. About half of the
trials did not perform
intention to treat analyses
or correct allocation
concealments.’
This review included
several large studies
with pooled events of
>500

Medicina 2020,56, 6 6 of 48
Table 1. Cont.
Condition Reference Type of Review Treatments
Evaluated
No of RCTs in
Review
Systematic Reviewers’
Conclusion of Efficacy *
Our Judgement
of Efficacy **
Systematic Reviewers’
Conclusion of Quality of
Available Evidence ***
Our Comments
Wong et al.,
2015 [34]
Non-Cochrane
Systematic
Review
Chronic MSK pain 19
‘This review showed moderate
evidence of local or distant
points stimulation in reducing
pain at the end of the treatment
when compared with control
groups.’
?‘The 19 studies were of
moderate quality.’
Comparison between
local and distal acup
stimulation. No
included studies had
arms of >200
participants.
Zhao et al.,
2015 [35]
Non-Cochrane
Systematic
Review
Chronic pain 15
‘Due to the significant clinical
heterogeneity and
methodological flaws
identified in the analysed trials,
the current evidence on AT for
chronic pain management is
still limited.’
?
‘The significant
methodological flaws
identified . . . contributed
to high risk of bias of the
included studies.’
Auricular therapy
studies (not all acup).
No included studies
had arms of >200
participants.
Yeh et al.,
2014 [31]
Non-Cochrane
Systematic
Review
Pain management 22
‘. . . AA (auricular acup), was
found to be a significant
method of pain relief when
compared to the sham or
control group.’
?
‘In the studies included in
this meta-analysis, 91%
were rated as good
[quality] . . . ’
No included studies
had arms of >200
participants.
Publication bias was
detected.
Zhu et al.,
2014 [30]
Non-Cochrane
Systematic
Review
Pain symptoms
(Wrist-ankle acup
(WAA))
33
‘. . . the efficacy of WAA or
WAA adjuvants was much
better than Western medicine,
sham acupuncture, or body
acupuncture.’
?
‘. . . higher quality and
more rigorously designed
clinical trials with large
enough sample sizes are
needed . . . ’
All studies were
Chinese. No included
studies had arms of
>200 participants.
Vickers et al.,
2012 [40]
Non-Cochrane
Systematic
Review
Chronic pain 29
‘Acupuncture is effective for
the treatment of chronic pain
and is therefore a reasonable
referral option. Significant
differences between true and
sham acupuncture indicate
that acupuncture is more than
a placebo.’
+
‘Neither study quality nor
sample size appear to be a
problem for this
meta-analysis, on the
grounds that only
high-quality studies were
eligible, and the total
sample size is large.’
Authors looked at
musculoskeletal (MSK)
pain, osteoarthritis
(OA), headache and
shoulder pain. Six
studies included with
arms of >200
participants.
Ernst & Lee
2011 [29]
Systematic
review of
systematic
reviews
Multiple pain
conditions 57 SR
‘In conclusion, numerous
systematic reviews have
generated little truly
convincing evidence that
acupuncture is effective in
reducing pain. ‘
−
‘For indications where only
one systematic review was
available, definitive
conclusions were usually
prevented by the paucity or
poor quality of the primary
studies or the poor quality
of the reviews.’
Four out of 57 reviews
were of excellent
quality. Primary studies
variable in sample sizes.

Medicina 2020,56, 6 7 of 48
Table 1. Cont.
Condition Reference Type of Review Treatments
Evaluated
No of RCTs in
Review
Systematic Reviewers’
Conclusion of Efficacy *
Our Judgement
of Efficacy **
Systematic Reviewers’
Conclusion of Quality of
Available Evidence ***
Our Comments
Lee & Ernst
2011 [28]
Overview of
Cochrane
reviews
Pain 8 SR
‘All of these reviews were of
high quality. Their results
suggest that acupuncture is
effective for some but not all
types of pain.’
?
‘Many primary studies that
were included . . . had a
high risk of bias. This often
means that the current
evidence is limited,
insufficient, or
inconclusive.’
All these Cochrane
Reviews are of high
quality. Acupuncture
effective for only some
types of pain.
Asher et al.,
2010 [41]
Non-Cochrane
Systematic
Review
8 perioperative, 4
acute, and 5 chronic
pain
17
‘Auriculotherapy may be
effective for the treatment of a
variety of types of pain,
especially postoperative pain.’
?
‘. . . we believe our results
likely reflect the results of
higher quality studies and
reduced publication bias.’
Auricular therapy only.
Six studies were rated
as ‘good’ quality. Study
arms all had <200
participants.
Ernst & Lee
2010 [26]
Overview of
systematic
reviews
Rheumatic
conditions 30 SR
‘Only for OA, low back pain
and lateral elbow pain is the
evidence sufficiently sound to
warrant positive
recommendations of this
therapy . . . ’
=
‘SRs of acupuncture have
been noted to be limited by
the often poor-quality of
the primary data . . . ’
Studies of variable
quality and primary
studies of various
sample sizes.
Hopton &
MacPherson
2010 [27]
Systematic
review of
pooled data
from
meta-analyses
Chronic Pain 8 SR
‘The accumulating evidence
from recent reviews suggests
that acupuncture is more than
a placebo . . . .’
=
‘. . . the reviews we are
reporting include
small-scale trials, with
some variability in quality
. . . ’
Positive score for OA
knee and headache only.
Number of pooled
participants >1000 in 3
of SRs.
Madsen et
al., 2009 [42]
Non-Cochrane
Systematic
Review
Pain conditions 13
‘We found a small analgesic
effect of acupuncture that
seems to lack clinical relevance
and cannot be clearly
distinguished from bias.’
−
‘The review is fairly large,
includes several trials of
high methodological
quality . . . ’
One study with arms
>200 participants and
pooled events of >500.
Ernst et al.,
2009 [43]
Systematic
review of
Cochrane
reviews
Multiple conditions,
including pain. 32 SR
‘It is concluded that Cochrane
reviews of acupuncture do not
suggest that this treatment is
effective for a wide range of
conditions.’
−
‘
. . .
. acupuncture trials are
. . . often poorly designed
and badly reported.
Included 10 SRs on
chronic pain conditions,
representing 95 primary
RCTs.
Derry et al.,
2006 [25]
Systematic
review of
systematic
reviews
1996-2005
Multiple pain
conditions 35 SR
‘Systematic reviews . . .
provide no robust evidence
that acupuncture works for any
indication.’
−
‘Many reviews included
studies with designs
known to be associated
with bias and
overestimation of treatment
effects.’
Included SRs on
non-pain conditions,
e.g., nausea and
vomiting. 24 out of 35
reviews had
information on less
than 1000 patients.

Medicina 2020,56, 6 8 of 48
Table 1. Cont.
Condition Reference Type of Review Treatments
Evaluated
No of RCTs in
Review
Systematic Reviewers’
Conclusion of Efficacy *
Our Judgement
of Efficacy **
Systematic Reviewers’
Conclusion of Quality of
Available Evidence ***
Our Comments
Ezzo et al.,
2000 [24]
Non-Cochrane
Systematic
Review
Chronic pain 51
‘There is limited evidence that
acupuncture is more effective
than no treatment for chronic
pain, and inconclusive
evidence that acupuncture is
more effective than placebo,
sham acupuncture or standard
care.’
?
‘Two-thirds of the studies
. . . received a low-quality
score and low-quality trials
were significantly
associated with positive
results . . . High-quality
studies were associated
with . . . risk of false
negative (type II) errors . . .
’
Fifty-one RCTs
representing 2423
chronic pain patients.
The median sample size
per group was 18 and
the mode was 15.
HEADACHE
(a) Tension-type
Linde et al.,
2016 [44]
Cochrane
Review
Episodic or chronic
tension-type
headache
12
‘. . . acupuncture is effective
for treating frequent episodic
or chronic tension-type
headaches . . . ’
+
‘Overall, the quality of the
evidence assessed using
GRADE was moderate or
low . . . .’
Includes 2 studies with
>200 participants in
each study arm
Linde et al.,
2009 [45]
Cochrane
review
Episodic or chronic
tension-type
headache
11
‘. . . acupuncture could be a
valuable non-pharmacological
tool in patients with frequent
episodic or chronic
tension-type headaches.’
+
‘. . . sequence generation,
allocation concealment,
handling of dropouts and
withdrawals and reporting
of findings were adequate.’
Includes 2 studies with
>200 participants in
each study arm
Davis et al.,
2008 [46]
Non-Cochrane
Systematic
Review
Non-migrainous
headache 8
‘. . . limited efficacy for the
reduction of headache
frequency’
−
‘. . . all included studies to
be of high quality, with
scores of 3 or 4 . . . ’
One study with >200
participants per arm.
Pooled analysis not
significant
Vernon et al.,
1999 [47]
Non-Cochrane
Systematic
Review
Tension-type and
cervicogenic
headache
8
‘Acupuncture does not appear
to be more effective than a
course of physiotherapy.’
?
‘Two of four higher quality
studies reported negative
results . . . .’
None of included
studies has >200
participants in each arm
Sun et al.,
2008 [48]
Non-Cochrane
Systematic
Review
Chronic headache 31
‘
. . .
acupuncture is superior to
sham acupuncture and
medication therapy in
improving headache intensity,
frequency, and response rate.’
+
‘The quality of the more
recent trials is higher than
the older trials, with more
emphasis on proper
randomization, allocation
concealment, and
description of patient
dropout.’
Three studies with >200
participants in each
arm. Pooled events
>500
Ter Riet et
al., 1989 [20]
Non-Cochrane
Systematic
Review
Tension-type
headache and
migraine
10
‘It is not . . . possible to draw a
conclusion that acupuncture
works for migraine and/or
tension headache’.
?
‘. . . number of patients
and the methodological
level of the experiments are
. . . low.’
None of included
studies has >200
participants in each arm

Medicina 2020,56, 6 9 of 48
Table 1. Cont.
Condition Reference Type of Review Treatments
Evaluated
No of RCTs in
Review
Systematic Reviewers’
Conclusion of Efficacy *
Our Judgement
of Efficacy **
Systematic Reviewers’
Conclusion of Quality of
Available Evidence ***
Our Comments
(b) Migraine
Linde et al.,
2016 [49]
Cochrane
review Episodic migraine 22
‘. . . a course of acupuncture
consisting of at least six
treatment sessions can be a
valuable option . . . .’
+‘Overall the quality of the
evidence was moderate.’
Number of pooled
events >500 and 3
studies with >200
participants in each arm
Yang et al.,
2016 [50]
Non-Cochrane
Systematic
Review
Migraine 10
‘. . . verum acupuncture is
superior to sham acupuncture
in migraine’
?
‘The majority of the
included studies were
considered to be of
generally high
methodological quality
. . . .’
All study arms <200
participants and pooled
events <500
Linde et al.,
2009 [51]
Cochrane
review Migraine 22
‘. . . acupuncture is at least as
effective as, or possibly more
effective than, prophylactic
drug treatment, and has fewer
adverse effects.’
+
‘Methods for sequence
generation, allocation
concealment, handling of
dropouts and withdrawals
and reporting of findings
were adequate in most of
the recent trials.’
Number of pooled
events >500 and 3
studies with >200
participants in each arm
(c) Other headache
Melchart et
al., 2001 [52]
Cochrane
review
Idiopathic headache
26
‘. . . the existing evidence
supports the value of
acupuncture for the treatment
of idiopathic headaches.’
?
‘. . . the quality and
amount of evidence are not
fully convincing.’
None of included
studies has >200
participants in each
arm. Pooled events
<500
Manias et al.,
2000 [53]
Non-Cochrane
Systematic
Review
Primary headaches 27
‘In the majority of the trials (23
of the 27 trials), it was
concluded that acupuncture
offers benefits in the treatment
of headaches.’
?
The authors did not make a
statement of study validity.
Insufficient information
available regarding
sample sizes.
Melchart et
al., 1999 [54]
Non-Cochrane
Systematic
Review
Recurrent headache 22
‘. . . no straightforward
recommendation for clinical
practice can be made. ‘
?
‘. . . most trials were small
and were either
inadequately reported or
had identifiable
methodological flaws.’
None of included
studies has >200
participants in each
arm. Pooled events <
500
OSTEOARTHRITIS
(OA)
(a) Knee
Li et al.,
2019 [55]
Overview of
Systematic
Reviews
OA Knee 12 SRs
‘According to the high-quality
evidence, we concluded that
acupuncture may have some
advantages in treating KOA.’
+
‘. . . there are some risk of
bias and reporting
deficiencies still needed to
be improved.’
Two of the largest SRs
were deemed to have
the highest reporting
quality.

Medicina 2020,56, 6 10 of 48
Table 1. Cont.
Condition Reference Type of Review Treatments
Evaluated
No of RCTs in
Review
Systematic Reviewers’
Conclusion of Efficacy *
Our Judgement
of Efficacy **
Systematic Reviewers’
Conclusion of Quality of
Available Evidence ***
Our Comments
Sun et al.,
2019 [56]
Non-Cochrane
Systematic
Review
Symptom
management in OA
knee
8
‘The effect of acupuncture may
be associated with dose of
acupuncture, with a higher
dosage related to better
treatment outcomes . . . ’
+
‘The results of this study
rely largely on high-quality
primary RCTs. However,
they are inevitably limited
by the small number of
included trials . . . ’
One included study
with >200 participants
and one with 189–191
per trial arm.
Li et al.,
2018 [57]
Non-Cochrane
Systematic
Review
Symptom
management in OA
knee
16
‘. . . acupuncture with heat
pain or electrical stimulation
might be suggested as the
better choices . . . . . . ’
+
‘The methodological
quality evaluation was low
. . . ’
Network meta-analysis.
One study with >200
participants and two
with 189–191 per
sample arm.
Chen et al.,
2017 [58]
Non-Cochrane
Systematic
Review
Knee OA
(KOA)—Electro
acupuncture (EA)
studies only
11
‘. . . EA is a great opportunity
to remarkably alleviate the
pain . . . ’
?
‘. . . more high quality
RCTs with rigorous
methods of design,
measurement and
evaluation are needed.’
Meta-analysis with
<500 pooled events.
Lin et al.,
2016 [59]
Non-Cochrane
Systematic
Review
OA knee 10
‘
. . .
only short-term pain relief
in patients with chronic knee
pain due to osteoarthritis.’
?
‘Significant publication bias
was not detected (p>0.05),
but the heterogeneity of the
studies was substantial.’
Insufficient information
available on sample
sizes of primary
studies.
Corbett et
al., 2013 [60]
Non-Cochrane
Systematic
Review
OA knee 11
‘. . . acupuncture can be
considered as one of the more
effective physical treatments
for alleviating osteoarthritis
knee pain in the short-term.’
+
‘Around three-quarters of
the studies were classed as
being of poor quality.’
Network meta-analysis
(2794 acup patients).
Eleven “better-quality”
acupuncture studies
included.
Cao et al.,
2012 [61]
Non-Cochrane
Systematic
Review
OA knee 14
‘Acupuncture provided
significantly better relief from
knee osteoarthritis pain and a
larger improvement in function
than sham acupuncture,
standard care treatment, or
waiting for further treatment.’
+
‘According to the Cochrane
Back Review Group scale,
11 RCTs had high internal
validity and 3 RCTs had
low internal validity.’
One study with >200
participants and four
with >100 per trial arm.
Pooled events >500.
Selfe et al.,
2008 [62]
Non-Cochrane
Systematic
Review
OA knee 10
‘
. . .
acupuncture is an effective
treatment for pain and physical
dysfunction associated with
osteoarthritis of the knee.’
+Authors did not make any
assessment of quality.
Included 1 study with
>200 participants per
trial arm and 2 with
>100.
Bjordal et al.,
2007 [63]
Non-Cochrane
Systematic
Review
OA knee 7
‘. . . an intensive regimen of
2–4 weeks with TENS, EA or
low-level laser therapy (LLLT)
seems to safely induce
statistically significant and
clinically relevant short-term
pain relief.’
?
‘Trials were generally of
medium to high quality
(≥3) . . . ’ (Jadad)
Insufficient pooled
events in EA studies
(<500) which reduced
validity of conclusions.

Medicina 2020,56, 6 11 of 48
Table 1. Cont.
Condition Reference Type of Review Treatments
Evaluated
No of RCTs in
Review
Systematic Reviewers’
Conclusion of Efficacy *
Our Judgement
of Efficacy **
Systematic Reviewers’
Conclusion of Quality of
Available Evidence ***
Our Comments
Manheimer
et al., 2007
[64]
Non-Cochrane
Systematic
Review
OA knee 11
‘Waiting list-controlled trials
suggest clinically relevant
benefits, some of which may be
due to placebo or expectation
effects.’
?
‘Because of heterogeneity
and small effects, current
estimates should be
regarded as preliminary.’
One study with >200
participants and three
with >100 per trial arm.
No information on
number of pooled
events.
Ferrández
Infante et al.,
2002 [65]
Non-Cochrane
Systematic
Review
OA knee 4
‘. . . not enough evidence to
recommend acupuncture as a
treatment for knee pain.’
−‘Only one study presented
a high-quality level . . . ’
None of the included
studies had sample
sizes of >100
Ezzo et al.,
2001 [66]
Non-Cochrane
Systematic
Review
OA knee 7
‘The existing evidence suggests
that acupuncture may play a
role in the treatment of knee
OA.’
?
‘More than half of the trials
(n =4) received a
low-quality rating.’
None of included
studies had trial arms
of >200 participants
(b) Hip
Manheimer
et al., 2018
[67]
Cochrane
review Hip OA 16
‘Acupuncture probably has
little or no effect in reducing
pain or improving function
relative to sham acupuncture in
people with hip osteoarthritis.’
−
‘Overall the evidence was
limited, with only six RCTs
of five different
comparisons, with small
sample sizes, and at high
risk of bias, especially for
the criteria of blinding.’
None of included
studies had trial arms
of <200 participants.
Pooled events were
<500.
(c) Other
Manyanga
et al., 2014
[68]
Non-Cochrane
Systematic
Review
OA—Various 12
‘The use of acupuncture is
associated with significant
reductions in pain intensity,
improvement in functional
mobility and quality of life.’
+
‘. . . limited by
methodological
challenges... From the
included trials, 75% were
adjudicated to be of unclear
or high risk of bias.’
One study >200
participants. Pooled
events >500. However,
effect estimates might
be inflated due to risk
of bias in some studies.
Manheimer
et al., 2010
[69]
Cochrane
review Peripheral joint OA 16
‘Waiting list-controlled trials
. . . suggest statistically
significant and clinically
relevant benefits . . . which
may be due to expectation or
placebo effects.’
+
‘. . . we considered the five
[studies] with the highest
quality ratings on the
Cochrane Back Review
Group scale. Only two of
the five had any obvious
methodological flaws . . . ’
Pooled events were
>500
Kwon et al.,
2006 [70]
Non-Cochrane
Systematic
Review
Peripheral joint OA 18
‘. . . . acupuncture seems an
option worthy of consideration
particularly for knee OA.’
=
‘Even though the total
number of 18 RCTs is
encouraging, it is too small
considering the
heterogeneity of the overall
dataset.’
14 studies on OA knee.
One large study
including >200
participants in trial
arms. Pooled events <
500.

Medicina 2020,56, 6 12 of 48
Table 1. Cont.
Condition Reference Type of Review Treatments
Evaluated
No of RCTs in
Review
Systematic Reviewers’
Conclusion of Efficacy *
Our Judgement
of Efficacy **
Systematic Reviewers’
Conclusion of Quality of
Available Evidence ***
Our Comments
Ernst 1997
[71]
Non-Cochrane
Systematic
Review
OA 9 (13 studies)
‘. . . the notion that
acupuncture is superior to
sham-needling in pain
associated with OA is not
supported by published data
from controlled clinical trials.’
−‘Most trials suffer from
methodological flaws.’
Sample sizes for all
studies <100
participants, therefore
insufficient.
CHRONIC KNEE
PAIN
(NON-SPECIFIC)
Zhang et al.,
2017 [72]
Non-Cochrane
Systematic
Review
Chronic knee pain 17
‘. . . we are currently unable to
draw any strong conclusions
regarding the effectiveness and
safety of acupuncture for
chronic knee pain.’
−
‘. . . the overall
methodological quality of
the included trials was not
satisfactory.’
One study with trial
arms of >200
participants and one
with arms of 190/189.
White et al.,
2007 [73]
Non-Cochrane
Systematic
Review
Chronic knee pain 13
‘Acupuncture that meets
criteria for adequate treatment
is significantly superior to
sham acupuncture and to no
additional intervention . . . ’
+
‘The evidence appears to be
robust enough to
encourage wider use of
acupuncture for chronic
knee pain . . . ’
Included 3 large studies
of high quality. Two
with trial arms >200
participants and one
with >189 participants.
LOW BACK PAIN
(a) Chronic
Xiang et al.,
2019 [74]
Non-Cochrane
Systematic
Review
Non-specific low
back pain 14
‘
. . .
there is moderate evidence
of efficacy for acupuncture in
terms of pain reduction
immediately after treatment
. . .
when compared to sham or
placebo acupuncture’.
=
‘. . . trials included were
heterogeneous regarding
the needling sites, the
needling manipulation and
the duration of
acupuncture sessions, and
the type of sham . . . .’
One study with trial
arms of >200
participants.
Hu et al.,
2018 [75]
Non-Cochrane
Systematic
Review
Chronic LBP 16
‘. . . current evidence is not
robust to draw a firm
conclusion regarding the
efficacy and safety of DN for
LBP.’
−
‘. . . methodological
shortcomings . . . greatly
reduced the quality of
evidence.’
No studies with trial
arms of >200. Pooled
events <500.
Tang et al.,
2018 [76]
Non-Cochrane
Systematic
Review
Lumbar disc
herniation 30
There is tentative evidence that
acupuncture is more beneficial
at alleviating pain than lumbar
traction, drug therapy or
Chinese herbal medicine.
=
There was insufficient
robust evidence to draw
firm conclusions because of
methodological
shortcomings.
Pooled events >500
participants.
GRADE evidence
assessed by authors
was LOW or VERY
LOW for all studies.

Medicina 2020,56, 6 13 of 48
Table 1. Cont.
Condition Reference Type of Review Treatments
Evaluated
No of RCTs in
Review
Systematic Reviewers’
Conclusion of Efficacy *
Our Judgement
of Efficacy **
Systematic Reviewers’
Conclusion of Quality of
Available Evidence ***
Our Comments
Yeganeh et
al., 2017 [77]
Non-Cochrane
Systematic
Review
Low back pain (in
Iran) 3 (7 in total)
‘In conclusion, overall, the lack
of studies with a low risk of
bias precludes any strong
recommendations.’
?
‘The methodological
quality of the studies was
generally poor.’
None of the 3 acup
studies had arms of
>200 participants and
pooled events
insufficient (<500)
Liu et al.,
2015 [78]
Overview of
systematic
reviews
Chronic low back
pain 16 SR
‘. . . . consistent evidence
shows that acupuncture is
more effective for pain relief
and functional improvement at
short-term follow-ups.’
+
‘. . . three systematic
reviews were considered as
high quality, eight as
moderate quality, and five
as low quality . . . ’
Number of pooled
participants in
moderate to high
quality SRs were >500
Close et al.,
2014 [79]
Non-Cochrane
Systematic
Review
Low back and
pelvic pain in
pregnancy
6 (8 in total)
‘At present, we simply do not
have enough high-quality trials
on CAM for managing Low
back and pelvic pain in
pregnancy.’
−
‘The restricted availability
of high-quality studies,
combined with the very
low evidence strength,
makes it impossible to
make evidence-based
recommendations . . . .’
Overall strength of
evidence graded VERY
LOW. Study arms had
sample sizes of <200.
Kim et al.,
2013 [80]
Non-Cochrane
Systematic
Review
Lumbar spinal
stenosis 12 (6 RCT)
‘We found no conclusive
evidence of the effectiveness
and safety of acupuncture
. . .
.’
?
‘The current evidence
found in this review is
seriously limited by high or
uncertain risk of bias.’
All studies had arms
with <200 participants
Lam et al.,
2013 [81]
Non-Cochrane
Systematic
Review
Chronic,
non-specific low
back pain
32
‘. . . . acupuncture is effective
in providing long-term relief of
chronic low back pain, but this
effect is produced by
non-specific effects that arise
from skin manipulation.’
=
‘Given the clinical
heterogeneity of other
treatments for chronic low
back pain, it is not
surprising that a consistent
conclusion could not be
made . . . .’
Two studies had trial
arms with >200
participants, however,
the results were not
conclusive.
Xu et al.,
2013 [82]
Non-Cochrane
Systematic
Review
Chronic low back
pain 13
‘Compared with no treatment,
acupuncture achieved better
outcomes in terms of pain
relief, disability recovery and
better quality of life, but these
effects were not observed when
compared to sham
acupuncture...’
=
No specific statement on
quality included. The
authors state ‘The main
biases that affected the
results were performance
bias and detection bias.’
Two studies had trial
arms with >200
participants, however,
the results were not
conclusive.
Hutchinson
et al., 2012
[83]
Non-Cochrane
Systematic
Review
Chronic,
non-specific low
back pain
7
‘This review provides some
evidence to support
acupuncture as more effective
than no treatment . . . ’
−No specific statement on
quality of studies.
3 studies with trial arms
of >200 participants but
these studies did not
demonstrate a
significant difference
between acupuncture
and sham.

Medicina 2020,56, 6 14 of 48
Table 1. Cont.
Condition Reference Type of Review Treatments
Evaluated
No of RCTs in
Review
Systematic Reviewers’
Conclusion of Efficacy *
Our Judgement
of Efficacy **
Systematic Reviewers’
Conclusion of Quality of
Available Evidence ***
Our Comments
Standaert, et
al., 2011 [84]
Non-Cochrane
Systematic
Review
Chronic low back
pain 2
‘. . . insufficient evidence to
comment on the relative
benefit of acupuncture
compared with either
structured exercise or SMT
. . .
’
?
‘The overall strength of the
evidence . . . was
“insufficient.”
Results of only one
acup RCT included
therefore there was
insufficient evidence.
Trigkilidas
2010 [85]
Non-Cochrane
Systematic
Review
Chronic low back
pain 4
‘acupuncture can be superior
to usual care in treating chronic
low back pain, especially, when
patients have positive
expectations about
acupuncture.’
=
No specific statement on
quality was made but study
designs introduced bias.
3 out of 4 studies had
trial arms of >200
participants but results
not conclusive.
Yuan et al.,
2008 [86,87]
Non-Cochrane
Systematic
Review
Chronic low back
pain 23
‘There is moderate evidence
that acupuncture is more
effective than no treatment,
and strong evidence of no
significant difference between
acupuncture and sham
acupuncture, for short-term
pain relief.’
=
‘. . . although 16/23 of the
studies (70%) scored highly
on the Van Tulder scale,
only 8/23 had more than 40
patients per group of which
2 studies had high
dropouts leaving only 6/23
high quality studies.’
2 studies had trial arms
of >200 participants.
Both scored 8 or above
on the Van Tulder scale.
Results are conflicting.
Furlan et al.,
2005 [88]
Cochrane
review Low back pain 35
‘The data do not allow firm
conclusions about the
effectiveness of acupuncture
for acute low-back pain.’
=
‘The methodologic quality
of the included RCTs .. .
was poor. There were two
studies with fatal flaws
. . .
’
One study had trial
arms of >200
participants.
Manheimer
et al., 2005
[89]
Non-Cochrane
Systematic
Review
Chronic low back
pain 33
‘Acupuncture effectively
relieves chronic low back pain.
No evidence suggests that
acupuncture is more effective
than other active therapies.’
?
No statement on
methodological quality was
included.
All of the studies
included had trial arms
of <100 participants.
Yuan et al.,
2004 [90]
Non-Cochrane
Systematic
Review
Non-specific low
back pain 10
‘This review has provided
strong evidence that there is no
significant difference between
acupuncture and sham
acupuncture . . . ’
−
‘Ten high-quality studies,
with a mean Van Tulder
score of 6.6/11, met the
inclusion criteria . . . ’
Includes two studies of
high quality with trial
arms of >200
Henderson
2002 [91]
Non-Cochrane
Systematic
Review
Chronic low back
pain
5 (11 studies in
total)
‘Systematic examination of
these articles did not provide
definitive evidence to support
or refute the use of
acupuncture . . . .’
?No quality assessment
conducted.
One study with n =262
was inconclusive. Only
one other RCT with
positive results had n =
28.
van Tulder
et al., 1999
[92]
Cochrane
review
Non-specific low
back pain 11
‘The evidence . . . does not
indicate that acupuncture is
effective for the treatment of
back pain.’
?
‘The methodological
quality was low. Only two
trials were of high quality.’
All studies had small
sample sizes of 100 or
less.

Medicina 2020,56, 6 15 of 48
Table 1. Cont.
Condition Reference Type of Review Treatments
Evaluated
No of RCTs in
Review
Systematic Reviewers’
Conclusion of Efficacy *
Our Judgement
of Efficacy **
Systematic Reviewers’
Conclusion of Quality of
Available Evidence ***
Our Comments
Strauss et al.,
1999 [93]
Non-Cochrane
Systematic
Review
Chronic low back
pain 4
‘One cannot necessarily
conclude from this review
whether acupuncture is an
effective treatment.’
?‘. . . all the trials were of
poor quality.’
Minimal information
on primary studies
included in review
including study design
and number of patients.
Ernst &
White 1998
[94]
Non-Cochrane
Systematic
Review
Low back pain 12
‘. . . insufficient evidence to
state whether it is superior to
placebo.’
?
‘. . . Only 2 trials . . . were
of low quality. Thus, the
present meta-analysis is
based largely on rigorous
research.’
All samples sizes were
less than 100.
(b) Mixed
Cherkin et
al., 2003 [95]
Non-Cochrane
Systematic
Review
Acute and chronic
back pain 6
‘Because the quality of the
research evaluating the
effectiveness of the most
popular CAM therapies used
for low back pain is generally
poor, clear conclusions are
difficult to reach . . . ’
?
‘The trials had serious
limitations, including small
sample sizes, inadequate
acupuncture treatment, and
high dropout rates.’
The largest included
study had n =262. All
others were<100.
van Tulder
et al., 1999
[96]
Non-Cochrane
Systematic
Review
Low back pain
(acute and chronic) 11
‘. . . this systematic review did
not clearly indicate that
acupuncture is effective in the
management of back pain . . . ’
?
‘Overall, the methodologic
quality was low. Only two
studies met the pre-set
“high-quality” level for this
review.’
All included studies
had sample sizes of
<100
(c) Back and neck Pain
Griswold et
al., 2019 [97]
Non-Cochrane
Systematic
Review
Spine-related
painful conditions 12
‘Both superficial and deep
needling resulted in clinically
meaningful changes in pain
scores over time.’
?
‘The included studies
demonstrated an unclear to
high risk of bias
recommending a cautious
interpretation of the
results.’
This article has a
delayed release
(embargo) and will be
available in 2020
Yuan et al.,
2015 [98]
Non-Cochrane
Systematic
Review
Chronic neck and
low back pain (CNP
and CLBP)
30 (48 studies in
total)
‘Acupuncture, acupressure,
and cupping could be
efficacious in treating the pain
and disability associated with
CNP or CLBP in the immediate
term.’
?
‘In summary, many more
studies with higher quality
and longer-term follow-ups
are warranted.’
All trial arms had <200
participants and pooled
events <500
Smith et al.,
2000 [99]
Non-Cochrane
Systematic
Review
Chronic neck and
back pain 13
‘There is no convincing
evidence for the analgesic
efficacy of acupuncture for
back or neck pain.’
?
‘With acupuncture for
chronic back and neck pain,
we found that the most
valid trials tended to be
negative.’
Trial arms all had <200
participants.

Medicina 2020,56, 6 16 of 48
Table 1. Cont.
Condition Reference Type of Review Treatments
Evaluated
No of RCTs in
Review
Systematic Reviewers’
Conclusion of Efficacy *
Our Judgement
of Efficacy **
Systematic Reviewers’
Conclusion of Quality of
Available Evidence ***
Our Comments
Ter Riet et
al., 1989 [19]
Non-Cochrane
Systematic
Review
Neck and back pain 16 (22 studies)
‘. . . it is impossible to draw
definite conclusions.’
The authors noted the presence
of publication bias.
?
‘The quality was generally
low and low therefore no
definitive conclusions can
be drawn.’
Sample sizes
insufficient. One study
with trial arm ≥50
participants
NECK PAIN
Seo et al.,
2017 [100]
Non-Cochrane
Systematic
Review
16
‘Acupuncture and
conventional medicine for
chronic neck pain have similar
effectiveness on pain and
disability...’
?
‘. . . . a lot of the results
were evaluated to have low
level of evidence, making it
difficult to draw clear
conclusions . . . ’
Trial arms <200
participants, pooled
events <500.
Moon et al.,
2014 [101]
Non-Cochrane
Systematic
Review
Whiplash-associated
disorder 6
‘In conclusion, the evidence for
the effectiveness of
acupuncture therapy for
whiplash associated disorder is
limited.’
?
‘Most of the included RCTs
have serious
methodological flaws.’
No trials arms with
>200 participants
Wang et al.,
2011 [102]
Non-Cochrane
Systematic
Review
Cervical
spondylosis 8
‘At the present, there has been
no sufficient evidence to ensure
that . . . abdominal
acupuncture therapy is
superior . . . ’
?
‘Attention should be paid
to the randomized
controlled study of larger
samples and qualified
design.’
Paper in Chinese
therefore information
taken from abstract.
Small sample sizes.
Fu et al.,
2009 [103]
Non-Cochrane
Systematic
Review
14
‘The quantitative meta-analysis
. . . confirmed the short-term
effectiveness and efficacy of
acupuncture in the treatment
of neck pain.’
+
‘. . . evidence supporting
the main hypothesis that
acupuncture was effective
in the treatment of neck
pain was stronger than the
evidence denying this . . . ’
Only one study with
sufficient power
including >200
participants per trial
arm.
Trinh et al.,
2006 [104]
Cochrane
review Neck disorders 10
‘Individuals with chronic neck
pain who received
acupuncture reported, on
average, better pain relief
immediately after treatment
and in the short-term than
those who received sham . . . ’
?
‘. . . the overall quality of
these studies was not
considered high, with only
40% of the studies (4/10)
considered as high quality
. . . ’
None of included
studies had arms >200
White &
Ernst 1999
[105]
Non-Cochrane
Systematic
Review
Neck pain 14
‘. . . the hypothesis that
acupuncture is efficacious
. . .
is
not based on the available
evidence from sound clinical
trials.’
?
‘. . . the methodological
quality of the studies, as
assessed by the three
criteria of the modified
Jadad score for clinical
trials, was disappointing.’
Included studies all had
arms with <100
participants.

Medicina 2020,56, 6 17 of 48
Table 1. Cont.
Condition Reference Type of Review Treatments
Evaluated
No of RCTs in
Review
Systematic Reviewers’
Conclusion of Efficacy *
Our Judgement
of Efficacy **
Systematic Reviewers’
Conclusion of Quality of
Available Evidence ***
Our Comments
MYOFASCIAL
PAIN/TRIGGER
POINTS (MTPs)
Espejo-
Antúnez et
al., 2017
[106]
Non-Cochrane
Systematic
Review
MTPs 15
‘Our review suggests a
short-term positive impact of
dry needling on pain intensity
and insufficient evidence on
the long-term effectiveness, in
line with the findings of
previous systematic reviews.’
?
‘The 15 randomized
controlled trials had a
mean method quality score
of 7.53 ±1.30 out of 10,
ranging from 5 to 9 in the
PEDro scale.’
Dry needling studies.
Included studies all had
arms with <100
participants.
Li et al., 2017
[107]
Non-Cochrane
Systematic
Review
Myofascial Pain
syndrome 33
‘. . . most acupuncture
therapies, including
acupuncture combined with
other therapies, showed
superiority over the other
single physical therapies . . . ’
?
‘The quality of this analysis
is restricted by the quality
of the underlying data.’
Included studies all had
arms with <100
participants.
Wang et al.,
2017 [108]
Non-Cochrane
Systematic
Review
Myofascial pain
syndrome (MPS) 10
‘. . . we have demonstrated
favourable efficacy of MA in
terms of pain relief as well as
the reduction of muscle
irritability due to MPS when
myofascial trigger points (but
not acupuncture points) are
stimulated . . .
?
‘High RoB, variable
duration of symptoms and
differences in the severity
of initial conditions may
partly influence the validity
of the conclusions.’
Included studies all had
arms with <100
participants.
Rodríguez-
Mansilla et
al., 2016
[109]
Non-Cochrane
Systematic
Review
Myofascial pain
syndrome 10
‘. . . Dry needling was more
effective in decreasing pain
comparing to no treatment, it
was not significantly different
from placebo in decreasing
pain.’
?
Authors report that
methodological quality was
variable from good to poor.
Dry needling studies.
Included studies all had
arms with <100
participants.
Cagnie et al.,
2015 [110]
Non-Cochrane
Systematic
Review
Trigger Points the
upper trapezius in
patients with neck
pain
15
‘There is moderate evidence for
ischemic compression and
strong evidence for dry
needling to have a positive
effect on pain intensity.’
?
‘Six articles were of low
quality and were not
further included in the
analysis; 9, of moderate
quality; and 6, of good
quality.’
Dry needling and
ischaemic compression.
Included studies all had
arms with <100
participants.
Ong et al.,
2014 [111]
Non-Cochrane
Systematic
Review
MTPs in neck and
shoulders 5
‘. . . there is no significant
difference between dry
needling and lidocaine . . . .’
?
‘Four out of five RCTs were
rated as high-quality
(
≥
6/10); only one RCT rated
as low-quality evidence
(≤5/10).’
Included studies all had
arms with <100
participants. Pooled
events <500

Medicina 2020,56, 6 18 of 48
Table 1. Cont.
Condition Reference Type of Review Treatments
Evaluated
No of RCTs
in Review
Systematic Reviewers’
Conclusion of Efficacy *
Our Judgement
of Efficacy **
Systematic Reviewers’
Conclusion of Quality of
Available Evidence ***
Our Comments
Kietrys et al.,
2013 [112]
Non-Cochrane
Systematic
Review
Upper quarter
myofascial pain 12
‘. . . we recommend dry
needling, compared to sham or
placebo, for decreasing pain
immediately after treatment
and at 4 weeks . . . ’
?
‘. . . variance in
comparison groups, control
conditions, dosage of
intervention, outcomes,
outcome measurement
tools, times to outcomes,
and internal validity . . . ’
Included studies all had
arms with <200
participants.
Tough &
White 2011
[113]
Non-Cochrane
Systematic
Review
MTP pain 3
‘There is limited evidence that
direct MTrP (myofascial trigger
points) dry needling has an
overall treatment effect when
compared with standard care.’
?
‘. . . there is still a need for
large scale, adequately
powered, high-quality
placebo-controlled trials to
provide a more conclusive
result.’
Included studies all had
arms with <100
participants.
Cotchett et
al., 2010
[114]
Non-Cochrane
Systematic
Review
MTPs associated
with plantar heel
pain
3 (non-RCT)
‘There is limited evidence for
the effectiveness of dry
needling and/or injections of
MTrPs associated with plantar
heel pain.’
?
‘. . . the poor quality and
heterogeneous nature of
the included studies
precludes definitive
conclusions being made.’
Included studies all had
arms with <50
participants.
Tough et al.,
2009 [115]
Non-Cochrane
Systematic
Review
MTP pain 7
‘. . . limited evidence deriving
from one study that deep
needling directly into
myofascial trigger points has
an overall treatment effect . . . ’
?
‘
. . .
the limited sample size
and poor quality of these
studies highlights and
supports the need for large
scale, good-quality
placebo-controlled trials
. . .
’
One study with n =296.
All other studies with
small sample sizes.
Cummings
et al., 2001
[116]
Non-Cochrane
Systematic
Review
MTP pain 23
‘. . . the hypothesis that
needling therapies have
efficacy beyond placebo is
neither supported nor refuted
by the evidence from clinical
trials.’
?
‘No trials were of sufficient
quality or design to test the
efficacy of any needling
technique beyond placebo
in the treatment of
myofascial pain.’
One study with n =296.
All other studies with
small sample sizes.
CANCER PAIN
Chiu et al.,
2017 [117]
Non-Cochrane
Systematic
Review
Malignancy-related,
surgery-related or
other
treatment-related
pain.
29
‘Acupuncture is effective in
relieving cancer-related pain,
particularly
malignancy-related and
surgery-induced pain.’
?
‘. . . methodological
limitations . . . affected the
strength of evidence and
limited the internal validity
of this review.’
Included studies all had
arms with <100
participants.
Hu et al.,
2016 [118]
Non-Cochrane
Systematic
Review
Cancer-related pain 20
‘Acupuncture plus drug
therapy is more effective than
conventional drug therapy
alone for cancer-related pain.’
?
‘. . . GRADE analysis
revealed that the quality of
all outcomes about
acupuncture plus drug
therapy was very low.’
Included studies all had
arms with <100
participants.

Medicina 2020,56, 6 19 of 48
Table 1. Cont.
Condition Reference Type of Review Treatments
Evaluated
No of RCTs in
Review
Systematic Reviewers’
Conclusion of Efficacy *
Our Judgement
of Efficacy **
Systematic Reviewers’
Conclusion of Quality of
Available Evidence ***
Our Comments
Paley et al.,
2015 [119]
Cochrane
review Cancer pain 5
‘We conclude that there is
insufficient evidence to judge
whether acupuncture is
effective in relieving cancer
pain in adults.’
?
‘. . . the available evidence
is of low quality. Therefore,
a judgement on whether
acupuncture is effective
cannot be made.’
Included studies all had
arms with <100
participants.
Lian et al.,
2014 [120]
Non-Cochrane
Systematic
Review
Palliative care
symptoms
including pain
6 (33 in total)
‘The result . . . suggested that
the effectiveness of
acupuncture in palliative care
for cancer patients is
promising, especially in
reducing . . . cancer pain.’
?
‘Although the RCTs
included in this study have
relatively high quality,
nearly half of them still
rated as Jadad score 2 or
below.’
Included studies all had
arms with <50
participants.
Garcia et al.,
2013 [121]
Non-Cochrane
Systematic
Review
Cancer care (8
symptoms
including pain)
11
‘. . . appropriate adjunctive
treatment for
chemotherapy-induced
nausea/vomiting . . . For other
symptoms’ management,
efficacy remains
undetermined.’
?
‘Of the 11 trials examining
acupuncture for pain, nine
were positive, but eight had
high ROB (risk of bias).’
Included studies all had
arms with <100
participants.
Choi et al.,
2012 [122]
Non-Cochrane
Systematic
Review
Cancer pain 15
‘The total number of RCTs
included in the analysis and
their methodological quality
were too low to draw firm
conclusions.’
?
‘As suggested by previous
systematic reviews . . .
methodological flaws
suggest that caution should
be taken when interpreting
the results of these studies
. . . ’
Included studies all had
arms with <100
participants.
Paley et al.,
2011 [123]
Cochrane
review Cancer pain 3
‘There is insufficient evidence
to judge whether acupuncture
is effective in treating cancer
pain in adults.’
?
‘Acupuncture is widely
used to treat cancer-related
pain, but the available
evidence is of low quality.’
Included studies all had
arms with <100
participants.
Peng et al,
2010 [124]
Non-Cochrane
Systematic
Review
Cancer pain 7 ‘Acupuncture is effective for
pain relief.’ ?
‘. . . the poor quality of the
majority of the trials
reduces the reliability of
the conclusion.’
Article in Chinese.
Included studies all had
arms with <100
participants.
Ernst & Lee
2010 [125]
Systematic
review of
systematic
reviews
Palliative and
supportive cancer
care
7 SR
‘In conclusion,
chemotherapy-induced nausea
and vomiting is the only
indication for acupuncture that
is currently supported . . . ’
?
‘. . . SRs of acupuncture
tended to be based on
poor-quality primary
studies. Our analysis
confirms this notion.’
Short report. Only one
good-quality SR on
cancer pain including 7
primary studies of low
quality.

Medicina 2020,56, 6 20 of 48
Table 1. Cont.
Condition Reference Type of Review Treatments
Evaluated
No of RCTs in
Review
Systematic Reviewers’
Conclusion of Efficacy *
Our Judgement
of Efficacy **
Systematic Reviewers’
Conclusion of Quality of
Available Evidence ***
Our Comments
Lee et al.,
2005 [126]
Non-Cochrane
Systematic
Review
Cancer-related pain 7 (3 RCT)
‘The notion that acupuncture
may be an effective analgesic
adjunctive method for cancer
patients is not supported by
the data currently available
from the majority of rigorous
clinical trials.’
?
‘Due to a dearth of
high-quality primary
studies in this field, no
informative conclusion
could be drawn.’
Included studies all had
arms with <100
participants.
FIBROMYALGIA
Zhang et al.,
2019 [127]
Non-Cochrane
Systematic
Review
Fibromyalgia 12
‘. . . there was moderate
quality evidence showing that
real acupuncture was more
effective than sham
acupuncture in the short term.’
?
‘
. . .
most of the studies had
a relatively small sample
size . . . Second, there was
considerable heterogeneity
in our meta-analysis.’
Included studies all had
arms with <100
participants.
Kim et al.,
2019 [128]
Non-Cochrane
Systematic
Review
Fibromyalgia 10
‘. . . verum acupuncture
compared with sham
acupuncture has a short-term
efficacy on reducing pain . . . ’
?
‘. . . high heterogeneity
downgraded the level of
evidence.’
Included studies all had
arms with <100
participants.
Yang et al.,
2014 [129]
Non-Cochrane
Systematic
Review
Fibromyalgia 9
‘. . . there was not enough
evidence to prove the efficacy
of acupuncture therapy for the
treatment of fibromyalgia.’
?
‘. . . the included trials
were not of high quality or
had high bias risks.’
Included studies all had
arms with <50
participants.
Cao et al.,
2013 [130]
Non-Cochrane
Systematic
Review
Fibromyalgia 16
‘Acupoint stimulation appears
to be effective . . . compared
with medications.’
?
‘The quality of the included
studies is generally poor
. . . ’
Included studies all had
arms with <50
participants.
Deare et al.,
2013 [131]
Cochrane
review Fibromyalgia 9
‘Overall, there is a . . .
moderate level of evidence that
acupuncture is not better than
sham controls.’
?
‘The small sample size,
scarcity of studies for each
comparison, lack of an
ideal sham acupuncture
weakens the level of
evidence . . . .’
Included studies all had
arms with <100
participants. Pooled
events <500.
Cao et al.,
2010 [132]
Non-Cochrane
Systematic
Review
Fibromyalgia 12 (25 studies in
total)
‘. . . . acupuncture was
significantly better than
conventional medications for
reducing pain and number of
tender points . . . significantly
better than amitriptyline for
preventing relapse.’
?
‘Seven trials (28%) were
evaluated as having a low
risk of bias and the
remaining trials were
identified as being as
unclear or having a high
risk of bias.’
Included studies all had
arms with <100
participants.
Langhorst et
al., 2010
[133]
Non-Cochrane
Systematic
Review
Fibromyalgia 7
‘. . . small analgesic effect of
acupuncture was present . . .
not clearly distinguishable
from bias.’
?
‘. . . great variability of the
methodological quality of
studies . . . not robust
against potential
methodological biases.’
Included studies all had
arms with <50
participants.

Medicina 2020,56, 6 21 of 48
Table 1. Cont.
Condition Reference Type of Review Treatments
Evaluated
No of RCTs in
Review
Systematic Reviewers’
Conclusion of Efficacy *
Our Judgement
of Efficacy **
Systematic Reviewers’
Conclusion of Quality of
Available Evidence ***
Our Comments
Martin-
Sanchez et
al., 2009
[134]
Non-Cochrane
Systematic
Review
Fibromyalgia 6
‘This systematic review found
no evidence of benefit resulting
from acupuncture versus
placebo, as a treatment for
fibromyalgia.’
?
No specific statement on
methodological quality was
made but the authors
stated there were reporting
inconsistencies.
Included studies all had
arms with <100
participants.
Mayhew et
al., 2007
[135]
Non-Cochrane
Systematic
Review
Fibromyalgia 5
‘The notion that acupuncture is
an effective symptomatic
treatment . . . is not supported
by the results from rigorous
clinical trials.’
?
‘
. . .
methodological quality
was mixed and frequently
low.’
Included studies all had
arms with <100
participants.
Berman et
al., 1999
[136]
Non-Cochrane
Systematic
Review
Fibromyalgia (FMS)
3 (7 studies in
total)
‘. . . real acupuncture is more
effective than sham
acupuncture for improving
symptoms of patients with
FMS . . . this conclusion is
based on a single high-quality
study . . . ’
?‘. . . limited amount of
high-quality evidence . . . ’
Included studies all had
arms with <100
participants. Only one
high quality RCT.
PELVIC PAIN
Qin et al.,
2019 [137]
Non-Cochrane
Systematic
Review
Chronic
prostatitis/pelvic
pain
6 (4 RCT)
‘Acupuncture may have
clinically long-lasting benefits
. . . However, current evidence
is limited . . . ’
?
‘
. . .
insufficient quantity of
studies and small sample
size limited to conduct the
robust evidence.’
Included studies all had
arms with <100
participants.
Zhang et al.,
2019 [138]
Overview of SRs
Primary
Dysmenorrhea 5 SRs
‘. . . there are insufficient
qualified evidences to
determine the effectiveness of
acupuncture in the treatment
of PD.’
?
‘All five SRs have more
than one critical weakness
. . . their methodological
qualities were considered
as critically low.’
Ranking of all 5 SRs
was ‘critically low’. No
information on sample
sizes in primary
studies.
Woo et al.,
2018 [139]
Non-Cochrane
Systematic
Review
Primary
Dysmenorrhea 60
‘The results of this study
suggest that acupuncture
might reduce menstrual pain
. . . compared to no treatment
or NSAIDs.’
=
‘. . . the quality of the
included RCTs was low,
and methodological
restriction existed in this
study.’
One study with arms
including 344/173
patients. Pooled events
>500 for MA vs no
treatment.
Sung et al.,
2018 [140]
Non-Cochrane
Systematic
Review
Chronic pelvic pain
in women 4
‘The results of our review and
meta-analysis suggest the
effectiveness of AT
(acupuncture) . . . ’
?
‘. . . most of the included
studies had low
methodological quality in
the Cochrane ROB
assessment.’
Included studies all had
arms with <200
participants.
Chang et al.,
2017 [141]
Non-Cochrane
Systematic
Review
Chronic
prostatitis/pelvic
pain (CP/CPPS)
7
‘Acupuncture has promising
efficacy for patients with
CP/CPPS. Compared to
standard medical treatment, it
has better efficacy.’
?
‘The heterogeneous
composition . . . contribute
to the heterogeneity and
possible effect modification
or interactions.’
Included studies all had
arms with <100
participants.

Medicina 2020,56, 6 22 of 48
Table 1. Cont.
Condition Reference Type of Review Treatments
Evaluated
No of RCTs in
Review
Systematic Reviewers’
Conclusion of Efficacy *
Our Judgement
of Efficacy **
Systematic Reviewers’
Conclusion of Quality of
Available Evidence ***
Our Comments
Liu et al.,
2017 [142]
Non-Cochrane
Systematic
Review
Primary
Dysmenorrhea (PD)
23
‘The available evidence
suggests that acupuncture may
be effective for PD and justifies
future high-quality studies.’
=
‘. . . most trials had an
unclear or a high risk of
bias, which may have
caused an overestimation
or underestimation of the
true treatment effect.’
Two larger studies n =
501 and n =600 with
low risk of bias.
Xu et al.,
2017 [143]
Non-Cochrane
Systematic
Review
Endometriosis-
related pain 10
‘. . . acupuncture reduces pain
and serum CA-125 levels,
regardless of the control
intervention used.’
?
‘To confirm this finding,
additional studies with
proper controls, blinding
methods, and adequate
sample sizes are needed.’
Included studies all had
arms with <50
participants.
Xu et al.,
2017 [144]
Non-Cochrane
Systematic
Review
Primary
Dysmenorrhea 16
‘The current evidence reveals
that acupoint-stimulation in
the treatment of PD has some
obvious advantages compared
with treatment by NSAIDs.’
?
‘. . . sample sizes were
small, leading to a low
inspection efficiency . . .
inadequate reporting of
allocation concealment . . .
the results were
heterogeneous . . . ’
Included studies all had
arms with <100
participants.
Xu et al.,
2014 [145]
Non-Cochrane
Systematic
Review
Primary
Dysmenorrhea 20
‘. . . acupoint therapy can
relieve pain effectively for
individuals with PD, and these
treatments have advantages in
overall efficiency.’
=
‘Insufficient high-quality
evidence is available in the
current literature . . . .
Hence, the findings . . . are
by no means definitive.’
Study arms <200 but
pooled events >500.
However, conclusions
not definitive due to
quality issues
Chen et al.,
2013 [146]
Non-Cochrane
Systematic
Review
Primary
Dysmenorrhea 4
‘. . . insufficient high-quality
evidence available . . .
regarding the effectiveness of
acupuncture . . . .’
?
‘We were only able to
determine that one of the
acupuncture trials
identified was free of
selective reporting.’
Only studies using the
SP6 acupoint were
included. Included
studies all had arms
with <100 participants.
Chung et al.,
2012 [147]
Non-Cochrane
Systematic
Review
Primary
Dysmenorrhea 30
‘. . . acupoint stimulation,
especially non-invasive
acupoint stimulation, could
have good short-term effects
on the pain of primary
dysmenorrhea.’
?
‘. . . the poor quality of the
methodology of the studies
was indicated by a low
average Jadad score, with
84%
. . .
scoring less than 3.’
Included studies all had
arms with <200
participants. Most
studies had Jadad
scores of 1 or 2.
Cohen et al.,
2012 [148]
Non-Cochrane
Systematic
Review
Chronic
prostatitis/chronic
pelvic pain
35
‘A statistically significant
placebo effect was found for all
outcomes and time analysis
showed that efficacy of all
treatments increased over
time.’
?
‘
. . .
there was a wide range
of study quality. Several
trials had questionable
placebo groups and
inadequate blinding. This
makes interpretation of the
results difficult . . . ’
Included studies all had
arms with <200
participants. Pooled
events <500.

Medicina 2020,56, 6 23 of 48
Table 1. Cont.
Condition Reference Type of Review Treatments
Evaluated
No of RCTs in
Review
Systematic Reviewers’
Conclusion of Efficacy *
Our Judgement
of Efficacy **
Systematic Reviewers’
Conclusion of Quality of
Available Evidence ***
Our Comments
Posadzki et
al., 2012
[149]
Non-Cochrane
Systematic
Review
Chronic
nonbacterial
prostatitis +chronic
pelvic pain
syndrome
9
‘The evidence . . . syndrome is
encouraging but, because of
several caveats, not conclusive
. . . ’
?
‘. . . methodologic quality
was variable; most were
associated with major flaws.
Only one RCT had a Jadad
score of more than 3 . . . ’
Included studies all had
arms with <200
participants. Pooled
events <500
Zhu et al.,
2011 [150]
Cochrane
review Endometriosis 1
‘The evidence to support the
effectiveness of acupuncture
for pain in endometriosis is
limited . . . .’
?
‘The trial included in this
review was
methodologically weak.’
Only one low-quality
RCT with n =67
included in the review.
Cho et al.,
2010 [151]
Non-Cochrane
Systematic
Review
Primary
Dysmenorrhea 27
‘The review found promising
evidence in the form of RCTs
for the use of acupuncture
. . .
.’
?
‘. . . the results were
limited by methodological
flaws.’
Included studies all had
arms with <200
participants. Possible
publication bias.
Ee et al.,
2008 [152]
Non-Cochrane
Systematic
Review
Pelvic and back
pain in pregnancy 3
‘We conclude that limited
evidence supports acupuncture
use in treating
pregnancy-related pelvic and
back pain.’
?
‘Additional high-quality
trials are needed to test the
existing promising
evidence for this relatively
safe and popular
complementary therapy.’
Based on 3 trials with
insufficient sample
sizes. Included studies
all had arms with <200
participants.
INFLAMMATORY
ARTHRITIS
Ramos et al.,
2018 [153]
Overview of
Systematic
Reviews
Rheumatoid
arthritis 7 SR
‘The use of acupuncture
probably has minimal or no
impact on joint pain in
rheumatoid arthritis.’
−
No formal statement of
methodological quality was
made but the GRADE score
for the pain studies was
moderate.
20 primary RCTs
included. Pain data
included from only 2
primary studies.
Seca et al.,
2019 [154]
Non-Cochrane
Systematic
Review
Rheumatoid
arthritis (RA) 13
‘Evidence suggests that
acupuncture interventions may
have a positive effect in pain
relief, physical function and
HRQoL (health related quality
of life) in RA patients.’
?
‘. . . due to the
heterogeneity and
methodologic limitations of
the studies included in this
systematic review, evidence
is not strong enough to
produce a best practice
guideline.’
Ten studies were
published in China. No
information available
on sample sizes
Lu et al.,
2016 [155]
Non-Cochrane
Systematic
Review
Gouty arthritis 28
‘
. . .
we cautiously suggest that
acupuncture is an effective and
safe therapy for patients with
gouty arthritis.’
?
‘the methodological
qualities of included
studies were judged to be
poor; . . . ’
Included studies all had
arms with <100
participants. All were
Chinese and single-site
studies.
Lee et al.,
2013 [156]
Non-Cochrane
Systematic
Review
Gouty arthritis 10
‘This study demonstrates
efficacy of acupuncture
treatment in decreasing VAS
and uric acid in gout.’
?
‘
. . .
the quality of the trials
in this study is generally
weak . . . ’
Included studies all had
arms with <200
participants. All studies
were Chinese.

Medicina 2020,56, 6 24 of 48
Table 1. Cont.
Condition Reference Type of Review Treatments
Evaluated
No of RCTs in
Review
Systematic Reviewers’
Conclusion of Efficacy *
Our Judgement
of Efficacy **
Systematic Reviewers’
Conclusion of Quality of
Available Evidence ***
Our Comments
Lee et al.,
2008 [157]
Non-Cochrane
Systematic
Review
Rheumatoid
arthritis 8
‘. . . penetrating or
non-penetrating
sham-controlled RCTs failed to
show specific effects of
acupuncture for pain control
. . . ’
?
‘The number, size and
quality of the RCTs are too
low to draw firm
conclusions.’
Included studies all had
arms with <200
participants.
Possible publication
bias.
Wang et al.,
2008 [158]
Non-Cochrane
Systematic
Review
Rheumatoid
arthritis 8
‘Despite some favourable
results in active-controlled
trials, conflicting evidence
exists in placebo-controlled
trials concerning the efficacy of
acupuncture for RA.’
?
‘. . . inappropriate control
interventions
(non-comparable), no
double-blind interventions,
inadequate description of
the randomization process,
and scarce use of validated
outcome measures.’
Included studies all had
arms with <200
participants. Possible
publication bias.
Casimiro et
al., 2005
[159]
Cochrane
review
Rheumatoid
arthritis 2
‘. . . electroacupuncture may
be beneficial . . . the reviewers
concluded that the poor quality
of the trial, including the small
sample size preclude its
recommendation.’
?
‘. . . poor quality of the
trials, the high
methodological variability
. . . and the small sample
size of the included
studies.’
Only 2 studies met the
inclusion criteria.
Sample sizes n =64 and
n=20
Lautenschlager
1997 [160]
Non-Cochrane
Systematic
Review
Inflammatory
rheumatic diseases 17
‘Acupuncture cannot be
recommended for treatment of
these diseases.’
?
‘By far, the most studies
examined failed to show
sufficient quality.’
Written in German. No
information about
sample sizes.
NEUROPATHIC PAIN
AND NEURALGIA
Pei et al.,
2019 [161]
Non-Cochrane
Systematic
Review
Post-herpetic
neuralgia 8
‘. . . the quality of evidence
was low because of the lack of
blinding and the small sample
sizes of the included studies.’
?
‘
. . .
the quality of evidence
was moderate for the
assessment of pain
intensity’.
Seven out of eight
studies published in
China. Included studies
all had arms with <50
participants.
Hu et al.,
2019 [162]
Non-Cochrane
Systematic
Review
Trigeminal
neuralgia 33
‘. . . no statistically significant
differences between the two
groups for alleviating pain
intensity.’
?
‘. . . all current evidence is
very limited due to the
overall low methodological
quality of the included
RCTs.’
Only 3 small studies
included with pain as
an outcome measure.
Included studies all had
arms with <200
participants.
Oh & Kim
2018 [163]
Non-Cochrane
Systematic
Review
Chemotherapy-
induced peripheral
neuropathy
5 (22 studies)
‘. . . these results provide little
evidence of the effectiveness of
acupuncture . . . ’
−
Written in Korean.
Insufficient high-quality
data to make a judgement.
Only 5 included RCTs
Acupuncture study
arms had <200
participants.

Medicina 2020,56, 6 25 of 48
Table 1. Cont.
Condition Reference Type of Review Treatments
Evaluated
No of RCTs in
Review
Systematic Reviewers’
Conclusion of Efficacy *
Our Judgement
of Efficacy **
Systematic Reviewers’
Conclusion of Quality of
Available Evidence ***
Our Comments
Choi et al.,
2018 [23]
Cochrane
review
Carpal tunnel
syndrome 12
‘. . . there is currently
insufficient evidence to assess
the effectiveness of
acupuncture for symptoms of
CTS.’
?
‘Most studies were very
small (fewer than 100
participants) and all
estimates of effects suffered
from imprecision.’
Included studies all had
arms with <200
participants.
Wang et al.,
2018 [164]
Non-Cochrane
Systematic
Review
Diabetic peripheral
neuropathy 14
‘. . . ST36 injection appears . . .
effective in reducing pain score
and improving NCV compared
with intramuscular injection
. . . . ‘
?
‘. . . poor methodological
and reporting quality
reduced confidence in the
findings.’
Included studies all had
arms with <200
participants.
Wang 2018
[165]
Non-Cochrane
Systematic
Review
Post-herpetic
neuralgia 7
‘. . . acupuncture is safe and
might be effective in pain
relieving for patients with
PHN.’
?
‘Given the low quality of
included studies, the
results are not conclusive
. . . ’
Included studies all had
arms with <200
participants. Pooled
events <500
Dimitrova et
al., 2017
[166]
Non-Cochrane
Systematic
Review
Peripheral
neuropathy 13 (15 studies)
‘This systematic review
suggests that acupuncture is
effective in diabetic neuropathy,
Bell’s palsy, and CTS .. . ’
?
‘. . . various
methodological issues were
identified.’
Two studies reported a
sample size calculation.
Included studies all had
arms with <200
participants.
Ju et al.,
2017 [167]
Cochrane
review Neuropathic pain 6
‘. . . there is insufficient
evidence to support or refute
the use of acupuncture for
neuropathic pain . . . ’
?
‘The overall quality of
evidence is very low due to
study limitations . . . ’
Included studies all had
arms with <200
participants.
Franconi et
al., 2013
[168]
Non-Cochrane
Systematic
Review
Chemotherapy-
induced peripheral
neuropathy
3 (6 studies)
‘. . . although there are some
indications that acupuncture
may be effective
. . .
the current
evidence available is limited.’
?
‘All the clinical studies
reviewed had important
methodological
limitations.’
Only 3 studies were
RCTs and all had arms
with <200 participants.
Sim, et al.,
2011 [169]
Non-Cochrane
Systematic
Review
Carpal tunnel
syndrome 6
‘The existing evidence is not
convincing enough to suggest
that acupuncture is an effective
therapy for CTS.’
?
‘The total number of
included RCTs and their
methodological quality
were low.’
Included studies all had
arms with <200
participants.
Liu et al.,
2010 [170]
Non-Cochrane
Systematic
Review
Trigeminal
neuralgia 12
‘The evidence reviewed
previously suggests that
acupuncture is of similar
efficacy as CBZ but with fewer
adverse effects . . . ’
?
‘. . . the evidence is weak
because of low
methodological quality of
the reviewed studies.’
All studies Chinese.
Included studies all had
arms with <200
participants.
Longworth
et al., 1997
[171]
Non-Cochrane
Systematic
Review
Sciatica 7 (38 studies in
total)
‘The association between
acupuncture (AP) and pain
relief is so strong that it has
tended to obscure any other
. . .
clinical results.’
?
‘Although plentiful, the
research is variable in
quality, especially with
respect to design,
consistency, and
follow-up.’
Included studies all had
arms <200 participants.

Medicina 2020,56, 6 26 of 48
Table 1. Cont.
Condition Reference Type of Review Treatments
Evaluated
No of RCTs in
Review
Systematic Reviewers’
Conclusion of Efficacy *
Our Judgement
of Efficacy **
Systematic Reviewers’
Conclusion of Quality of
Available Evidence ***
Our Comments
OTHER PAIN
CONDITIONS
Vier et al.,
2019 [172]
Non-Cochrane
Systematic
Review
Orofacial pain
associated with
temporo-
mandibular joint
dysfunction (TMD)
7
‘To date, there is insufficient
data to draw strong
conclusions about DN for the
treatment of orofacial pain
associated with TMD.’
?
‘. . . due the low quality of
evidence and high risk of
bias of some included
studies, larger and low risk
of bias trials are needed . . .
’
Language restrictions.
Included studies all had
arms with <200
participants.
Kim et al.,
2018 [173]
Systematic
review of SRs
and network
meta-analysis
Aromatase inhibitor
induced arthralgia 2 (6 in total)
‘Acupuncture . . . is
recommended for AIA with
low overall confidence based
on the current evidence.’
?
‘. . . evidence for
acupuncture as an effective
treatment for AIA was
considered low.’
Only 2 small RCTS of
acupuncture included
in network analysis
with total samples of 20
and 22.
Pan et al.,
2018 [174]
Non-Cochrane
Systematic
Review
Osteoporosis 35
‘This present systematic review
indicated that acupuncture
could be an effective therapy
for treating osteoporosis.’
?
‘. . . nearly all Chinese
studies reported positive
results . . . and all the
studies . . . in this
meta-analysis were
Chinese trials.
Publication bias.
Included studies all had
arms with <200
participants.
Chau et al.,
2018 [175]
Non-Cochrane
Systematic
Review
Shoulder pain (PSP)
in stroke survivors 29
‘. . . . conventional
acupuncture and
electroacupuncture could be
effective treatments for
survivors with PSP, with
regard to reducing pain . . . .’
?
‘
. . .
the very high potential
for bias was prevalent in
the included trials. These
methodological flaws may
have led to biased results in
the included trials . . . ’
All trials were
conducted in China.
Included studies all had
arms with <200
participants.
Luo et al.,
2018 [176]
Non-Cochrane
Systematic
Review
Osteoporosis 9
‘WNA may have beneficial
effects on bone mineral density
and VAS scores of patients
with primary OP.’
?
‘
. . .
all included trials were
at high risk of bias and of
low quality.’
Warm needle
acupuncture (WNA).
Included studies all had
arms with <200
participants.
Hall et al.,
2018 [177]
Non-Cochrane
Systematic
Review
Upper extremity
pain & dysfunction 11
‘There is very low evidence to
support the use of TDN
(trigger point dry needling) in
the shoulder region for treating
patients with upper extremity
pain or dysfunction.’
?
‘The current evidence
supporting TDN for upper
extremity pain and
dysfunction is very low,
and future research is likely
to change treatment effect
estimates.’
Included studies all had
arms with <200
participants.
Chen et al.,
2017 [178]
Non-Cochrane
Systematic
Review
Aromatase inhibitor
induced arthralgia 5
‘. . . acupuncture treatment
significantly reduced Brief Pan
Inventory worst pain scores
and WOMAC pain scores after
6-8 weeks . . . ’
?
‘. . . certain trials recruited
a relatively small sample
size of patients per
treatment group . . .
outcomes were reported
inconsistently.’
Included studies all had
arms with <50
participants.

Medicina 2020,56, 6 27 of 48
Table 1. Cont.
Condition Reference Type of Review Treatments
Evaluated
No of RCTs in
Review
Systematic Reviewers’
Conclusion of Efficacy *
Our Judgement
of Efficacy **
Systematic Reviewers’
Conclusion of Quality of
Available Evidence ***
Our Comments
Fernandes et
al., 2017
[179]
Non-Cochrane
Systematic
Review
TMJ disorder
(TMD) 4
‘. . . acupuncture treatment
appears to relieve the signs and
symptoms of pain in
myofascial TMD.’
?
‘. . . the four included
studies revealed two
studies of good quality and
two studies of weak
quality.’
Included studies all had
arms with <50
participants.
Thiagarajah
2017 [180]
Non-Cochrane
Systematic
Review
Plantar fasciitis 4
‘. . . acupuncture may reduce
. . . pain in the short term . . .
insufficient evidence for a
definitive conclusion regarding
. . . the longer term.’
?
‘The number of participants
(range 23–53) was small in
all studies and the types of
controls employed varied.’
Included studies all had
arms with <50
participants.
Lee & Lim
2016 [181]
Non-Cochrane
Systematic
Review
Post-stroke
shoulder pain 12
‘Although there is some
evidence for an effect of
acupuncture on poststroke
shoulder pain, the results are
inconclusive.’
?
‘. . . some of the included
studies were of poor quality
and had methodological
shortcomings . . . .’
Included studies all had
arms with <100
participants.
Wang et al.,
2016 [182]
Non-Cochrane
Systematic
Review
Shoulder pain 9
‘Ashi point stimulation might
be superior to conventional
acupuncture, drug therapy and
no treatment for shoulder
pain.’
?
‘
. . .
most of the trials suffer
from many flaws
. . .
. Eight
out of 9 included studies
had severe methodological
defects.’
Included studies all had
arms with <100
participants.
Tang et al.,
2015 [183]
Non-Cochrane
Systematic
Review
Lateral
epicondylitis 4
‘For the small number of
included studies . . . no firm
conclusion can be drawn
regarding the effect of
acupuncture . . . ’
?
‘The overall quality rated
by GRADE was from very
low to low.’
Pain was not an
outcome measure.
Included studies all had
arms with <100
participants.
Chang et al.,
2014 [184]
Non-Cochrane
Systematic
Review
Lateral
epicondylitis 9
‘Manual acupuncture is
effective in short-term pain
relief . . . however, its
long-term analgesic effect is
unremarkable.’
−
The analgesic effect of
manual acupuncture on the
treatment of lateral
epicondylalgia is Level B
Included studies all had
arms with <100
participants.
Lee et al.,
2012 [185]
Non-Cochrane
Systematic
Review
Post-stroke
shoulder pain 7
‘It is concluded from this
systematic review that
acupuncture combined with
exercise is effective for
shoulder pain after stroke.’
?
‘. . . there were insufficient
quality assessments with
respect to allocation
concealment, blinding of
outcome assessors, and
long-term follow-up.’
All studies were
Chinese. Included
studies all had arms
with <100 participants.
Clark et al.,
2012 [186]
Non-Cochrane
Systematic
Review
Plantar heel pain 5 (8 in total)
‘In view of the heterogeneity of
these papers, it is not possible
to give a simple conclusion
. . . .’
?
‘Two studies provide good
reporting of high-quality
studies; six are of lesser
quality.’
The included RCTs all
had arms with <100
participants.

Medicina 2020,56, 6 28 of 48
Table 1. Cont.
Condition Reference Type of Review Treatments
Evaluated
No of RCTs in
Review
Systematic Reviewers’
Conclusion of Efficacy *
Our Judgement
of Efficacy **
Systematic Reviewers’
Conclusion of Quality of
Available Evidence ***
Our Comments
Smith, et al.,
2011 [187]
Cochrane
review Labour pain 13
‘There are insufficient data to
demonstrate whether
acupuncture and acupressure
are more effective than a
placebo control, or whether
there is additional benefit from
acupuncture when used in
combination with usual care.’
?
‘The risk of bias was high
in the majority of trials and
recommendations for
practice cannot be made
until further high-quality
research has been
undertaken.’
One large study with
>200 participants in the
acupuncture group and
>100 in the other two
groups. Other studies
had <200 participants
in each arm and
relatively high risk of
bias.
Cho et al.,
2010 [188]
Non-Cochrane
Systematic
Review
Labour pain 10
‘The evidence from RCTs does
not support the use of
acupuncture for controlling
labour pain.’
?‘The primary studies are
diverse and often flawed.’
As above—One large
study. Others had <200
participants per arm
La Touche et
a, 2010 [189]
Non-Cochrane
Systematic
Review
TMJ disorder 9
‘. . . acupuncture is a
reasonable adjunctive
treatment for producing a
short-term analgesic effect
. . .
.’
?
‘. . . the relevance of these
results was limited by the
fact that substantial bias
was present.’
Included studies all had
arms with <100
participants.
Fink et al.,
2006 [190]
Non-Cochrane
Systematic
Review
TMJ disorder 6
‘Acupuncture appears to be a
suitable complementary
treatment method in the
management . . . .’
?
‘. . . results achieved must
be interpreted with caution
because of the
methodological
shortcomings identified.’
Only 3 electronic
databases searched.
Green et al.,
2005 [191]
Cochrane
review Shoulder pain 9
‘There is little evidence to
support or refute the use of
acupuncture . . . ’
?
‘This review has
highlighted the paucity of
methodologically rigorous,
well described randomised
controlled trials with
adequate sample size . . . ’
Largest study, with
unclear risk of bias, had
150 participants. All
others had <200
participants per arm.
Trinh et al.,
2004 [192]
Non-Cochrane
Systematic
Review
Lateral epicondyle
pain 6
‘There is strong evidence
suggesting that acupuncture is
effective in the short-term relief
of lateral epicondyle pain.’
?
‘The six studies being
assessed were considered
consistent high-quality . . .
because they were all
within the 3–5 range on the
Jadad scale.’
In spite of the relatively
high Jadad score the
studies all had small
sample sizes, ranging
from 17–82.
Lee & Ernst
2004 [193]
Non-Cochrane
Systematic
Review
Labour pain
management 3
‘Overall, the evidence of
acupuncture for pain
management during labour is
encouraging . . . ’
?
‘The methodologic quality
of the primary studies is
generally good . . . ’
Conclusions based on 3
studies with trials arms
<200 participants.
Green et al.,
2002 [194]
Cochrane
review Lateral elbow pain 4
‘There is insufficient evidence
to either support or refute the
use of acupuncture . . . ’
?
‘Due to . . . problems with
methodology of the
included trials . . . the
results of this review are
inconclusive.’
Included studies all had
arms with <100
participants.

Medicina 2020,56, 6 29 of 48
Table 1. Cont.
Condition Reference Type of Review Treatments
Evaluated
No of RCTs in
Review
Systematic Reviewers’
Conclusion of Efficacy *
Our Judgement
of Efficacy **
Systematic Reviewers’
Conclusion of Quality of
Available Evidence ***
Our Comments
Rosted 2001
[195]
Non-Cochrane
Systematic
Review
TMJ disorder 3
‘Acupuncture has in three out
of three randomised controlled
trials (RCT) proved effective
for the treatment of TMD.’
?
‘. . . publications . . .
fulfilled the list of
predefined methodological
criteria with a score
between 77% and 84%.’
Trial arms included
<100 participants.
However, the purpose
of this review was to
present standard
acupuncture procedure.
Ernst &
White 1999
[196]
Non-Cochrane
Systematic
Review
TMJ dysfunction 3
‘Even though all studies are in
accordance with the notion that
acupuncture is effective for
temporomandibular joint
dysfunction, this hypothesis
requires confirmation . . . ’
?
‘None of the trials was
performed with blinded
evaluators, details of
randomization are not
given, and therefore all
studies are subject to
important bias.’
Studies as in Rosted
2001 above. All 3
studies from
Scandinavia.
Rosted 1998
[197]
Non-Cochrane
Systematic
Review
Dentistry 15
‘Acupuncture in 11 out of 15
studies proved effective . . . as
analgesia.’
?
No definitive statement on
quality but authors report
that 6 studies were of
‘excellent’ or ‘good’ quality.
Insufficient sample
sizes.
Ter Riet et
al., 1989 [21]
Non-Cochrane
Systematic
Review
Facial pain 2
‘The effectiveness of
acupuncture on facial pain may
not be accepted as proven.’
?
‘The shortcomings of the
studies are clear from the
table. The big spread in the
score of the study [by]
Lewith et al. is mainly due
to the poor reporting.’
Only two small RCTs
included.
Key: * Systematic reviewers’ conclusion about efficacy: Direct quote taken from the conclusion of the article (from either Abstract or Discussion section). ** Our judgement of efficacy
within the review: Determined by the following criteria: +means sufficient evidence and in favour of acupuncture;
−
means sufficient evidence in favour of control/placebo; =means
sufficient evidence but inconclusive; ? means insufficient evidence to make a judgement. Sufficient evidence =pooled analysis of 500 events or >200 participants in each arm of at least one
RCT. *** Systematic reviewers’ conclusion of quality of available evidence: Direct quote taken from the conclusion of the article (from either Abstract or Discussion section).

Medicina 2020,56, 6 30 of 48
3.2. Headache (Including Migraine)
We found one overview of Cochrane reviews of acupuncture for various pain conditions [
28
]
(described above) that claimed there to be evidence that acupuncture was effective for tension-type
headache (1 Cochrane review [45]) and migraine (1 Cochrane review [51]).
The earliest SR was published in 1999 and judged there to be too few RCTs of sufficient
methodological quality to determine efficacy of acupuncture for recurrent headache (22 randomised
or ‘quasi’ randomised trials, Melchart [
54
]) or tension-type and cervicogenic headache (8 RCTs [
47
]).
A similar pattern of ‘promising’ but not definitive evidence continued through the next decade
(27 RCTs [
53
]; 8 RCTs [
46
]), including a Cochrane review of 26 RCTs of acupuncture for idiopathic
headache [
52
]. Nevertheless, some reviewers have claimed that there is evidence that acupuncture is
superior to sham for chronic headache (31 RCTs, only 2 RCTs were of high quality and adequately
powered, Sun [
48
]), and a recent Cochrane review providing evidence of superiority of acupuncture
over placebo for the prevention of tension-type headache ([
44
] 12 RCTs, including two adequately
powered RCTs) and episodic migraine ([
49
], 22 RCTs, including two adequately powered RCTs). A
systematic review published in 2016 is consistent with the latter finding that acupuncture was superior
to sham acupuncture for migraine (10 RCTs [50]).
Evidence from the SRs suggests that acupuncture prevents episodic or chronic tension-type
headaches and episodic migraine, although long-term studies and studies comparing acupuncture
with other treatment options are still required. The current NICE guidance (clinical guideline CG150)
is that a course of up to 10 sessions of acupuncture over 5–8 weeks is recommended for tension-type
headache and migraine [12].
3.3. Osteoarthritis (OA)
The overview of eight Cochrane reviews of acupuncture for various pain conditions described
previously [
28
], judged there to be evidence that acupuncture produced short-term improvements
in pain based on a SR of 16 RCTs on peripheral joint osteoarthritis [
69
]). In 2019, an overview
of non-Cochrane SRs that included a meta-analysis concluded that acupuncture was beneficial
for alleviating pain associated with OAK, although RCT outcomes assessed using the Grades of
Recommendation, Assessment, Development and Evaluation (GRADE) indicated that the SR evidence
was of mixed quality (12 SRs [55]).
We found that the earliest SR on acupuncture for OA was published in 1997 and found studies
to be contradictory with no evidence that acupuncture was more effective than sham (9 RCTs [
71
]).
SRs on acupuncture for peripheral joint OA were inconclusive in 2006 (18 RCTs [
70
]), superior to
waiting list controls in 2010 ([
69
], Cochrane review of 16 RCTs) and associated with reductions in pain
intensity, improvement in functional mobility and quality of life in 2014 (12 RCTs [
68
]). In 2018, a
Cochrane review by Manheimer et al. found little evidence that acupuncture significantly reduced
pain associated with OA of the hip [
67
]. To date, the majority of SRs have evaluated the clinical efficacy
of acupuncture for OA of the knee (OAK).
We found that the earliest SR on acupuncture for OAK was published in 2001 and was inconclusive
(7 RCTs, with 4 of low methodological quality [
66
]). Chronologically, SRs in 2002 (4 RCTs, [
65
]) and 2007
(11 RCTs [
64
]) were inconclusive, whereas a SR by Bjordal et al. in 2007 found statistically significant
and clinically relevant short-term pain relief from two to four weeks of intensive electroacupuncture
(7 RCTs [
63
]). In 2008 and 2012, two further SRs (10 RCTs [
62
]; 14 RCTs, [
61
] respectively) reported
superiority over sham acupuncture. More recently, SRs in 2016 (10 RCTs [
59
]), 2017 (17 RCTs [
72
],
11 RCTs [
58
]), 2018 (16 RCTs [
57
]) and 2019 (8 RCTs [
56
]) judged there to be evidence that acupuncture
provides relief of pain associated with OAK when administered alone or in combination with
other treatments.
These positive findings are supported by a network meta-analysis published in 2013 that evaluated
22 treatments, including acupuncture (11 RCTs [
60
]), and judged there to be evidence of short-term
efficacy. This finding was confirmed in another network meta-analysis published in 2018, which found

Medicina 2020,56, 6 31 of 48
that needle or electro-acupuncture decreased pain compared with other treatments (16 RCTs [
57
]).
Nevertheless, reviewers consistently mitigate these positive findings by describing RCTs as having low
methodological quality, thus reducing confidence in judgements.
The most recent evidence from a Cochrane review of 16 RCTs suggests that acupuncture is not
superior to sham acupuncture for OA of the hip [
67
], although in contrast, evidence from non-Cochrane
reviews suggests that there is moderate-quality evidence that acupuncture may be effective in the
symptomatic relief of pain from OA of the knee. Why there should be a difference in evidence between
the knee and the hip is not known. Interestingly, guidance from NICE (CG177) states: “Do not offer
acupuncture for the management of osteoarthritis” Section 1.4.6. [198].
3.4. Chronic Low Back Pain and/or Neck Pain
The overview of eight Cochrane reviews of acupuncture for various pain conditions described
previously [
28
] included one Cochrane review on low back pain [
88
] and judged there to be evidence
that acupuncture might be an effective adjunctive intervention for low back pain. However, the quality
of the primary studies was low. An overview of 16 SRs on acupuncture for low back pain published
in 2015 judged that acupuncture either in isolation or as an adjunct to conventional treatment had
short-term benefits but again, the quality of the included reviews was variable [78].
We found that the earliest SR on acupuncture chronic low back pain was published in 1989
and evaluated the clinical efficacy of acupuncture for neck and/or back pain (22 studies including
16 RCTs [
19
]) but the findings were inconclusive. The earliest SR that evaluated the clinical efficacy of
acupuncture specifically for chronic low back pain was published in 1998 by Ernst et al. (12 RCTs [
94
]),
and found evidence that acupuncture was superior to various control interventions, but insufficient
evidence to judge whether it was superior to placebo. The included studies were mostly of high-quality,
but sample sizes were inadequate. In 2000, Smith et al. published a SR that found no evidence that
acupuncture was effective for either chronic neck or low back pain (13 RCTs [99]).
Throughout the following decade, SRs reported insufficient high-quality evidence to make any
judgement on efficacy of acupuncture in treating low back pain (4 RCTs [
93
], 11 RCTs [
22
], 5 RCTs [
91
],
6 RCTs [
95
], 33 RCTs [
89
], 35 RCTs [
88
] and 10 RCTs [
90
]). In 2010, Trigkilidas published a SR that
evaluated the clinical efficacy of acupuncture for low back pain (4 RCTs [
85
]) that judged there to be
evidence of superiority of acupuncture compared with usual care in treating chronic low back pain,
especially when patients have positive expectations about the intervention. Between 2011 and 2017,
none of the published SRs provided compelling evidence to support the efficacy of acupuncture for
chronic low back pain (2 RCTs [
84
], 7 RCTs [
83
], 13 RCTs [
82
], 32 RCTs [
81
], 8 RCTs [
79
] and 7 RCTs [
77
]),
or lumbar spinal stenosis (12 studies, 6 RCTs [80]).
In 2018, Hu et al. published a SR that evaluated the clinical efficacy of acupuncture for low
back pain (16 RCTs [
75
]) and found evidence that dry needling was more effective for low back pain
than conventional acupuncture or sham immediately post treatment, but at follow-up, was equal to
acupuncture. In 2018, Tang et al. published a SR that evaluated the clinical efficacy of acupuncture
for the relief of pain associated with lumbar disc herniation (30 RCTs [
76
]), which found insufficient
robust evidence to draw firm conclusions because of methodological shortcomings in primary RCTs.
However, there was tentative evidence that dry needling was more beneficial than lumbar traction,
drug therapy or Chinese herbal medicine. In 2019, Xiang et al. published a SR on acupuncture for
non-specific low back pain (14 RCTs [
74
]). There was moderate evidence of benefit but confidence in
the results was diminished due to heterogeneity and small sample sizes in the included studies.
Evidence suggests that there are insufficient high-quality RCTs to judge the efficacy of acupuncture
for low back pain. In 2009, NICE published guidance for the management of non-specific low back
pain that recommended a course of acupuncture as part of first line treatment [
10
]. This guidance
produced much debate. Subsequently, NICE have updated guidance for the management of low back
pain and sciatica in people over 16 (NG59) and currently recommend in Section 1.2.8 “Do not offer

Medicina 2020,56, 6 32 of 48
acupuncture for managing low back pain with or without sciatica”, even though the evidence had not
significantly changed [9].
3.5. Myofascial Pain Syndrome and Myofascial Trigger Points
We found that the earliest SR on acupuncture (dry needling) to alleviate pain associated with
myofascial trigger points (MTPs) was published in 2001 (23 RCTs [
116
]) and found no evidence to
demonstrate the efficacy of any needling technique beyond placebo. In 2009, Tough et al. published a
SR that evaluated the efficacy of dry needling acupuncture (7 RCTs [
115
]) which produced insufficient
evidence to determine efficacy. A further systematic review by Tough et al. published in 2011
(3 RCTs [
113
]) had similar conclusions. In 2013, a SR found that acupuncture was superior to sham or
placebo in reducing pain associated with upper quadrant myofascial pain immediately post-treatment
and at four weeks, although the quality of the primary studies was low (12 RCTs [
112
]). In 2014,
Ong and Claydon published a SR that evaluated the clinical efficacy of dry needling to alleviate pain
associated with MTPs in the neck and shoulders (5 RCTs [
111
]) and found that there was no significant
difference between dry needling and lidocaine.
In 2017, Espejo-Ant
ú
nez et al. published a SR that evaluated the clinical efficacy of dry needling to
alleviate pain associated with myofascial trigger points (15 RCTs [
106
]) and found a possible short-term
benefit following dry needling. In 2017, SRs have found tentative evidence that acupuncture alone
or combined with other therapies improved outcomes associated with myofascial pain syndrome
(10 RCTs [
108
]; 33 RCTs [
107
]), although substantial heterogeneity and a high risk of bias, including
inadequate sample sizes in the primary RCTs, undermined confidence in the findings.
Evidence from SRs suggests that dry needling acupuncture might be effective in alleviating pain
associated with myofascial trigger points, at least in the short-term, although there are insufficient
high-quality RCTs to judge the efficacy with any degree of certainty. There is no guidance from NICE
on the management of myofascial pain syndrome.
3.6. Cancer Pain
We found one overview of SRs of acupuncture for palliative and supportive cancer care that
included 7 SRs [
125
], but only one systematic review on cancer-related pain [
126
]. We found that
the earliest SR on acupuncture for pain associated with cancer and/or its treatment (7 studies with
3 RCTs [
126
]) concluded that there was evidence of efficacy for chemotherapy-induced nausea and
vomiting, but insufficient evidence to judge efficacy for cancer-related pain. In 2010, a SR of 7 RCTs
provided tentative evidence that that acupuncture alleviated cancer-related pain [
124
], and in 2011,
the first Cochrane review on acupuncture for cancer pain judged there to be insufficient evidence to
determine the efficacy (3 RCTs [
123
]), and this was confirmed in an update in 2015 (5 RCTs [
119
]).
Subsequently, non-Cochrane SRs in 2012 (15 RCTs [
122
]), 2013 (11 RCT [
121
]), 2014 (33 studies,
6 RCTs [
120
]) and 2016 (20 RCTs [
120
]) provide promising but inconclusive evidence of efficacy. In
2017, Chiu et al. published a Cochrane review that evaluated the clinical efficacy of acupuncture for
cancer-related pain, which included treatment-related or surgery-related pain, and judged there to be
evidence that acupuncture alleviated pain associated with malignancy (29 RCTs [
117
]), but there was a
high risk of bias due to inadequate sample sizes.
Evidence from the SRs suggests that there are insufficient high-quality RCTs to judge the
efficacy of acupuncture for cancer-related pain and more high-quality, appropriately designed and
adequately powered studies are needed. The most recent guidance from NICE (CSG4) recognises
that patients who are receiving palliative care often seek complementary therapies, but it does not
specifically recommend acupuncture. It recognises that “Many studies have a considerable number of
methodological limitations, making it difficult to draw definitive conclusions” (Section 11.27) [199].

Medicina 2020,56, 6 33 of 48
3.7. Fibromyalgia
We found that the earliest SR on acupuncture for fibromyalgia was published in 1999 (7 studies,
3 RCTs [
136
]) and concluded that there was limited evidence supporting the use of acupuncture for
fibromyalgia but this was based on only one high-quality study. Subsequently, SRs published in 2007
(5 RCTs [
135
]) and 2009 (6 RCTs [
134
]) concluded that acupuncture had no symptomatic benefit, and in
2010 were inconclusive (7 RCTs [133], and 25 studies, 12 RCTs [132] respectively).
In 2013, a Cochrane review conducted by Deare et al. (9 RCTs [
131
]) found low-quality evidence
that acupuncture might be superior to no acupuncture or medication, and moderate-quality evidence
that acupuncture was not superior to sham. Non-Cochrane SRs published in 2013 (16 RCTs [
130
]) and
2014 (9 RCTs [
129
]) were inconclusive. In 2019, two SRs have produced evidence that acupuncture was
superior to sham but the evidence status was downgraded due to high levels of heterogeneity and
inadequate sample sizes (10 RCTs [128]; 12 RCT [127]).
Evidence from SRs suggests that there are insufficient high-quality RCTs to judge the efficacy of
acupuncture for fibromyalgia pain. There is no NICE guidance on the treatment of fibromyalgia.
3.8. Pelvic Pain
We found one overview of SRs on acupuncture for primary dysmenorrhoea which was published
in 2018 and concluded that the evidence was inconclusive (5 SRs [
138
]). We found a number of SRs on
acupuncture and associated therapies for primary dysmenorrhea, although all report a high-risk of
bias leading to evidence that is inconclusive (30 RCTs [
147
]; 4 RCTs [
146
]; 16 RCTs [
144
]; 20 RCTs [
145
];
23 RCTs [
142
]; 60 RCTs [
139
]). In 2008, a SR investigating acupuncture for pelvic and back pain during
pregnancy was inconclusive (3 RCTs [
152
]), and in 2010, a SR described RCTs findings as ‘promising’
but inconclusive for primary dysmenorrhea (27 RCTs [
151
]). A Cochrane review by Zhu et al. in
2011 on acupuncture for endometriosis included one low-quality RCT and was inconclusive [
150
].
A follow-up non-Cochrane review in 2017 including 10 RCTs was still inconclusive [143].
We found five SRs on acupuncture for chronic prostatitis and/or chronic pelvic pain, and despite
promising RCT findings, all reviewers concluded that the evidence was inconclusive (9 RCTs [
149
];
35 RCTs [148]; 7 RCTs [141]; 4 RCTs [140]; 4 RCTs [137]).
Evidence from the SRs suggests that there are insufficient high-quality RCTs to judge the efficacy
of acupuncture for primary dysmenorrhea or chronic pelvic pain. There is NICE guidance on
endometriosis (NG73) [
200
] but this does not recommend any form of Chinese medicine for this type
of pelvic pain, although acupuncture is not specifically mentioned.
3.9. Inflammatory Arthritis
In 2018, an overview of SRs concluded that acupuncture has minimal or no impact on joint
pain associated with rheumatoid arthritis (7 SRs, 20 RCTs [
153
]). We found that the earliest SR on
acupuncture for pain associated with inflammatory rheumatic diseases was published in 1997 and
found insufficient high-quality evidence to make a judgement on efficacy. Subsequently, a Cochrane
review published in 2005 (2 RCTs [
159
]) and various non-Cochrane SRs published in 2008 (8 RCTs [
158
];
8 RCTs [
157
]), 2013 (10 RCTs [
156
]) and 2016 (28 RCTs [
155
]) have been inconclusive. The most recent
SR on acupuncture for rheumatoid arthritis reported that RCT findings were tentatively positive but
inconclusive (13 RCTs [154]).
Evidence from the SRs suggests that there are insufficient high-quality RCTs to judge the efficacy
of acupuncture for pain in inflammatory arthritis. There is a NICE guideline (NG100) [
201
] for the
treatment of rheumatoid arthritis but this does not recommend acupuncture.

Medicina 2020,56, 6 34 of 48
3.10. Neuropathic Pain/Neuralgia
The earliest SR on acupuncture for neurological symptoms was published in 1997 and reported that
findings were positive for alleviation of symptoms associated with lumbar disk herniation (38 studies,
7 RCTs [171]).
The majority of SRs have been conducted on peripheral neuropathy of various aetiologies, but
all had methodological shortcomings resulting in inconclusive evidence (chemotherapy-induced
peripheral neuropathy, 6 studies, 3 RCTs [
168
]; various peripheral neuropathies, 15 studies,
13 RCTs [166]; and diabetic peripheral neuropathy, 14 RCTs [164]).
There are two SRs on acupuncture for trigeminal neuralgia (12 RCTs [
170
]; 33 RCTs [
162
]), two SRs
on acupuncture for carpal tunnel syndrome (6 RCTs [
169
]; 12 RCTs [
23
]) and one SR on acupuncture for
post-herpetic neuralgia (7 RCTs [
165
]). None were able to judge efficacy with any degree of confidence
due to insufficient high-quality RCTs.
Evidence from the SRs suggests that there are insufficient high-quality RCTs to judge the efficacy
of acupuncture for neuropathic pain or neuralgia. There is NICE guidance (CG173) [
202
] on the
management of neuropathic pain, but acupuncture is not included in the list of recommended/not
recommended treatments.
3.11. Other Pain Conditions
In 2002, a Cochrane review found insufficient high-quality RCTs to determine the efficacy of
acupuncture for lateral elbow pain (4 RCTs [
194
]). In 2005, a Cochrane review found insufficient
high-quality RCTs to judge the efficacy of acupuncture for shoulder pain. In 2011, a Cochrane review
by Smith et al. found insufficient evidence to judge the efficacy of acupuncture or acupressure for
labour pain (13 RCTs [187]).
Our search found an additional 27 reviews for a variety of other pain conditions, including
dental/facial pain, osteoporosis and upper extremity pain of various aetiologies, although none of
these reviews provides sufficient high-quality evidence to make a judgement about the efficacy of
acupuncture (Table 1) [21,172–197].
Evidence from SRs suggests that there are insufficient high-quality RCTs to judge the efficacy of
acupuncture for a variety of other painful conditions, including lateral elbow pain, shoulder pain and
labour pain. There is no guidance available from NICE on the treatment of any of these conditions.
4. Discussion
Our evidence synthesis reveals long-standing and continued uncertainty about the clinical
efficacy of acupuncture to alleviate pain, despite a high volume of published research. We have
revealed a raft of SRs with inconclusive findings due to persistent methodological shortcomings in
RCTs contributing to a high risk of bias and downgrading of evidence. These shortcomings include
inadequate statistical power, uncertainty about adequacy of acupuncture technique and dose, and
inappropriate design of ‘placebo’ acupuncture controls. These contribute to methodological and
clinical heterogeneity, deterring systematic reviewers from pooling data for meta-analyses. When
meta-analyses are conducted, substantial statistical heterogeneity results, markedly reducing confidence
in findings and inferences [
18
,
203
,
204
]. The high financial cost of continuing to undertake research
that produces inconclusive evidence is of concern and demands reconsideration of the methodological
design and delivery of future RCT design. We will discuss three common challenges to the design
of RCTs of acupuncture that emerge from our evidence synthesis: adequate sample sizes, adequate
acupuncture intervention, and adequate placebo controls.
4.1. The Challenge of Inadequate Sample Sizes
RCTs with small sample sizes are associated with an overestimation of treatment effects. Dechartres
et al. [
18
] found that treatment effects were, on average, 48% larger in trials with fewer than 50 patients.

Medicina 2020,56, 6 35 of 48
Overestimation of treatment effects occurs in studies with sample sizes of 100–200 participants per
treatment arm, suggesting that at least 200 participants per treatment arm is necessary to achieve a
low risk of bias. Roberts [
205
] argued that the production of fewer but broader reviews that exclude
underpowered trials would increase the validity of review findings and create a more trustworthy
evidence base. Turner et al. [
203
] examined the distribution of statistical power within meta-analyses
published as part of Cochrane reviews and argued that the results of meta-analyses that contain at least
two adequately powered studies are not influenced to any significant degree when underpowered
studies are omitted. At present, the inclusion of underpowered studies in meta-analyses is at the
discretion of reviewers.
Funding constraints that prevent the use of larger sample sizes in RCTs is likely to continue into
the future. Thus, strategies to reduce statistical heterogeneity associated with high variance in pain
data in RCTs need consideration. Often, pain data used as the primary outcome within RCTs is a
continuous variable, such as pain intensity measured on a visual analogue scale (VAS) and expressed
as an average. Averages of pain intensity data from VAS can be misleading because averages may
obscure good and poor responders to acupuncture [
206
,
207
]. There is a likelihood that scores of pain
intensity produce U-shaped rather than bell-shaped distributions, with some participants experiencing
large reductions in pain and others not. Thus, pain intensity data from acupuncture responders may
be diluted by data from non-responders [
208
]. For this reason, the Pain and Palliative Support and
Care group of the Cochrane collaboration recommends the use of primary outcome responder rates of
participants reporting relief of 30% or greater (i.e., at least moderate pain relief) or 50% or greater (i.e.,
significant pain relief) expressed as frequency (dichotomous) data.
4.2. The Challenge of Appropriate Controls
Acupuncture RCTs can assess two aspects of the active ingredient of treatment: effects associated
with needling acupuncture points and effects associated with needles piercing the skin. Thus,
two common controls used in RCTs of acupuncture are: inserting real needles into the skin at
non-acupuncture points and using ‘sham’ needles which touch but do not penetrate the skin. It is
important that SRs and RCTs emphasise exactly which outcome is being assessed at the outset, and
ideally include this in the title and aim of the report.
Controls that involve inserting needles into the skin at non-acupuncture points can be used to
determine the influence of needling discrete points of the skin on outcome. If administering treatment
at any point on the skin produced equivalent benefits and harms when compared with needling specific
points, this would challenge the need for anatomical acupuncture charts and prescribed acupuncture
practitioner training.
Controls that use ‘sham’ needles which touch but don’t penetrate the skin are often labelled
as placebo controls. The purpose of a placebo control comparison is to isolate the effect of the act
of receiving a treatment from the active ingredient of the treatment. Placebo controls are usually
operationalised using fake or sham interventions and enable measurement of non-specific treatment
effects associated with expectations, conditioning, anxiety and social context (i.e., therapist/patient
interaction and theatrical elements of the treatment) [
209
,
210
]. It has been argued that the reason
why some RCTs fail to detect differences in treatment effects between real and sham acupuncture
is that sham needling techniques are not physiologically inert, and this may have contributed to an
underestimation of acupuncture effects in the evidence base [
211
]. This argument is valid but can be
misleading if taken at face value. The purpose of a control intervention is not to be physiologically inert
but rather to control for outcomes associated with non-specific effects of the act (theatre) of receiving
the treatment. No placebo control (including a sham needling) is ever physiologically inert because
it instigates changes in physiological (and psychological) state. The human body evolved to detect
and respond to disturbances in the internal and/or external environment (i.e., stimuli) from physical,
physiological, social and/or environmental change. This is the premise of homeostasis.

Medicina 2020,56, 6 36 of 48
Placebo controls are research tools that enable isolation of effects associated with the active
ingredient(s) of the treatment. Thus, a comparison of effects during real needling versus sham needling,
whereby needles touch but do not penetrate the skin, enable investigators to isolate the magnitude and
incidence of effects associated with needles piercing the skin per se (i.e., the ‘acu’ and ‘puncture’). If
puncturing the skin with needles produces equivalent benefits to touching without puncturing the
skin, then it may be safer not to puncture the skin in clinical practice, providing that the sham needles
do less harm. Interestingly, a system of evaluating the physiological effects of sham needling has been
proposed to assist researchers [212].
The term ‘placebo’ is used extensively in research and clinical literature, although it lacks scientific
precision and has become emotive. We would prefer precise statements of purpose and method when
describing control interventions. For example, a control group that uses fake needles that do not
puncture the skin would be used to isolate effects associated with needles puncturing the skin. We
would also encourage a shift away from assessing patient ‘blinding’ using questions such as ‘Do you
think the intervention was a placebo?’ to questions assessing the ‘credibility’ and ‘functioning’ of
interventions using questions such as ‘Do you think the intervention was credible?’ and ‘Do you think
the intervention was functioning correctly?’, as has been suggested for other non-pharmacological
interventions such as transcutaneous electrical nerve stimulation (TENS) [213].
4.3. The Challenge of Adequacy of Dose
Acupuncture practitioners argue that acupuncture is a complex intervention that should not be
standardised but instead tailored to each individual patient, based on principles of practice and the
experience of the clinician. Components of needling include type, number, and location of needles,
needling technique (e.g., thrusting, rotation, flicking, pecking), duration of needle insertion, regimen of
treatment and philosophical paradigm. Debates about optimal technique are long-standing and there
are evidence-based principles underpinning optimisation of technique for acupuncture treatment [
214
].
Delivering identical acupuncture prescription to all participants runs the risk of some participants
receiving sub-optimal dose. Often, acupuncture interventions used in RCTs are grounded in principles
of Western acupuncture with flexibility to individualise treatment at the discretion of individual
practitioners. Individualising acupuncture treatment increases between-subject variability in treatment
(e.g., needling number, location, technique, duration). At face value, this may appear to conflict with
classical RCT methodology that aims to standardise methodology and treatment intervention under
strictly controlled conditions. However, standardisation can be based on the principles of optimising
treatment per individual, as is the case when titrating drug dosage to therapeutic window. What
constitutes adequacy of acupuncture technique and dose has been a matter of much debate [
56
,
214
–
216
].
In trials of pharmacological agents, dose is crucial, and it should be no different in studies
investigating the efficacy of acupuncture. The Standards for Reporting Interventions in Controlled
Trials of Acupuncture (STRICTA) were developed from the consolidated standards for reporting trials
(CONSORT) [
217
] to encourage accurate reporting of the acupuncture intervention [
218
]. STRICTA
recommend that six items should be included: rationale, details of needling (e.g., points used,
depth, angle, needle thickness, number of needles), treatment regimen, co-intervention, practitioner
background and control interventions [
219
]. The impact of using STRICTA has been positive
with improvements in reporting quality of RCTs on acupuncture [
220
–
223
]. In 2008, White et al.
published a meta-analysis that provided evidence that better outcomes in comparisons of acupuncture
with non-acupuncture controls were achieved when noted that greater numbers of needles and
treatment sessions were used [
214
]. In 2019, Sun et al. conducted a systematic review of eight RCTs
(2106 participants) to determine whether the effect of acupuncture is dose-dependent for symptom
management in knee osteoarthritis [
56
]. Sun et al. proposed a scoring system whereby +1 score
was awarded if
≥
9 points needled, if de qi was present, if
≥
2 treatment sessions a week and if
≥
8
treatment sessions in total. A score of
−
1 was awarded to each of these parameters if they were below
these thresholds. The sum of scores was taken and high dosage categorised for total between 1 and

Medicina 2020,56, 6 37 of 48
4, medium dosage for a score of 0 and low dosage for scores from
−
4 to
−
1. Sun et al. categorised
one RCT as low dose, one RCT as medium dose and 6 RCTs as high dose and concluded that higher
dosage of acupuncture was associated with better pain relief and functional improvements. It is
becoming common for journal editors to require STRICTA in RCTs of acupuncture and this will
improve comparison and assessment of adequacy of acupuncture dose in systematic reviews. What is
less common, however, is the inclusion and reporting of ‘run-in phases’ in RCTs, whereby optimisation
of technique and dosage is titrated over a period of weeks prior to randomisation into real and
placebo acupuncture.
4.4. Design of Future Randomised Controlled Trials (RCTS)
It has been argued that enriched enrolment with randomised withdrawal (EERW) study designs
are of value for treatments influencing symptoms but not necessarily the course of the underlying
disease or pathology, as is the case for acupuncture in the management of chronic pain [
224
]. The
potential for using such designs in the assessment of pharmacological agents has been recognised [
225
],
although EERW designs are rarely used to assess non-pharmacological interventions. The EERW
trials consist of (i) an observational ‘open-label’ phase with all participants receiving active treatment
(acupuncture), during which treatment technique and dosage would be titrated and optimized,
followed by (ii) a RCT phase, whereby participants who had potential for response were enrolled
(i.e., an enriched sample) and randomised to receive either experimental (real needling) or control
interventions (sham needling). Selection of participants for the enriched sample of the RCT is based on
the findings from phase one and would exclude participants who did not wish to continue treatment or
experienced non-manageable adverse events, although their data from phase one would be analysed.
Trials with EERW designs increase sensitivity to detect treatment effects by enriching the sample of
participants enrolling into the randomised controlled phase of the trial, thus reducing the need for
large sample sizes [207].
To our knowledge, there have not been any published studies of acupuncture using the EERW
design, although it has been used to determine the efficacy of drugs for chronic pain conditions. Given
the shortcomings in classically design RCTs on acupuncture, it would be interesting to observe the
results of studies using an EERW design.
4.5. Limitations of This Review
A limitation of this synthesis is that it does not contain granular quantitative analyses. It could be
argued that there is a case for an all-encompassing SR and meta-analysis of all RCTs on acupuncture for
pain conditions, but this would be a considerable undertaking with the possibility that it not produce
any meaningful information due to the relatively poor quality of RCTs resulting in amplification
of heterogeneity.
5. Conclusions
We hope that our evidence synthesis of systematic reviews and meta-analyses of RCTs of
acupuncture for chronic pain conditions serves as a reference tool for practitioners, researchers and
commissioners. Our evidence synthesis reveals a long-standing unresolved debate about the clinical
efficacy of acupuncture to alleviate pain that is grounded in a high volume of inconclusive RCT
evidence. If healthcare providers and commissioners are to be able to make informed choices on the
role of acupuncture for chronic pain, it is essential that the quality of clinical trials of acupuncture
is improved. Our evidence synthesis has revealed three methodological challenges that have faced
investigators of RCT of acupuncture for decades. We have argued that enriched enrolment with
randomised withdrawal trial designs may provide a way forward. We hope that our review catalyses
further debate on this issue.

Medicina 2020,56, 6 38 of 48
Author Contributions:
Conceptualization, C.A.P. and M.I.J.; methodology, C.A.P.; formal analysis, C.A.P. and
M.I.J.; writing—Original draft preparation, C.A.P.; writing—Review and editing, C.A.P. and M.I.J. All authors
have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Conflicts of Interest:
C.A.P. declares no conflict of interest. M.I.J.’s institution has received research and
consultancy funding for work that he has undertaken for GlaxoSmithKline.
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