Comparative efficacy of acupuncture for chronic low back pain: A network meta-analysis

Background: Chronic non-specific low back pain (CNSLBP) is a globally prevalent condition that significantly impairs quality of life and imposes a substantial burden on healthcare systems. While acupuncture is widely recognized for its therapeutic benefits, a comprehensive comparison of its efficacy across different modalities remains lacking. This network meta-analysis (NMA) evaluates the comparative effectiveness of acupuncture interventions for CNSLBP. Methods: A systematic review and NMA were conducted following PRISMA-NMA guidelines (PROSPERO: CRD42024507870). Twelve databases, including PubMed, Cochrane Library, Web of Science, Embase, Scopus, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform, and others, were searched up to January 15, 2024. Inclusion criteria: randomized controlled trials (RCTs) comparing acupuncture with placebo, sham, or active controls in adults with CNSLBP. Sixty-three RCTs (n = 9454) were included. Pain intensity and functional improvement were analyzed using a Bayesian framework. Risk of bias was assessed via ROB 2.0; evidence certainty was evaluated using GRADE methodology and CINeMA. Results: The analysis revealed that individualized acupuncture (IA), routine acupuncture combined with traditional Chinese medicine, and lumbar-pelvic training with electroacupuncture (LP + EA) significantly reduced pain intensity compared to placebo. For example, IA showed a mean difference (MD) of −11 mm (95 % credible interval [CrI]: −15.6 to −6.4) on the Visual Analog Scale (VAS), exceeding the minimal clinically important difference (MCID) threshold of 10–15 mm. LP + EA also significantly improved functional capacity, with a mean difference of −11.7 points (95 % CrI: −15.3 to −8.1) on the Oswestry Disability Index (ODI), approaching the MCID of 10 points. Multimodal therapies were generally more effective than single modalities, showing superior results in both pain relief and functional improvement. Subgroup analyses indicated optimal results with 6–12 weeks of intervention and greater functional improvements in younger patients (<50 years). Heterogeneity was moderate (I2 = 49.6 %). Limitations include variability in acupuncture protocols (e.g., needle depth, session frequency) and follow-up durations (range: 2 weeks to 12 months). Conclusion: This study highlights the effectiveness of acupuncture, particularly when combined with complementary therapies such as traditional Chinese medicine, education, or exercise, in managing chronic non-specific low back pain. The findings demonstrate that these interventions provide clinically meaningful reductions in pain intensity and improvements in functional capacity, as evidenced by conversions to familiar units (VAS and ODI) and anchoring to MCID thresholds. These findings underscore the value of multimodal and individualized treatment strategies. Standardized protocols and long-term trials are needed to strengthen evidence.