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Acupuncture that meets criteria for adequate treatment is significantly superior to sham acupuncture and to no additional intervention in improving pain and function in patients with chronic knee pain. Due to the heterogeneity in the results, however, further research is required to confirm these findings and provide more information on long-term effects.

Pain from myofascial trigger points is often treated by needling, with or without injection, although evidence is inconclusive on whether this is effective. We aimed to review the current evidence on needling without injection, by conducting a systematic literature review. We searched electronic databases to identify relevant randomised controlled trials, and included studies where at least one group were treated by needling directly into the myofascial trigger points, and where the control was either no treatment, or usual care; indirect local dry needling or some form of placebo intervention. We extracted data on pain, using VAS scores as the standard. Seven studies were included. One study concluded that direct dry needling was superior to no intervention. Two studies, comparing direct dry needling to needling elsewhere in the muscle, produced contradictory results. Four studies used a placebo control and were included in a meta-analysis. Combining these studies (n=134), needling was not found to be significantly superior to placebo (standardised mean difference, 14.9 [95%CI, -5.81 to 33.99]), however marked statistical heterogeneity was present (I(2)=88%). In conclusion, there is limited evidence deriving from one study that deep needling directly into myofascial trigger points has an overall treatment effect when compared with standardised care. Whilst the result of the meta-analysis of needling compared with placebo controls does not attain statistically significant, the overall direction could be compatible with a treatment effect of dry needling on myofascial trigger point pain. However, the limited sample size and poor quality of these studies highlights and supports the need for large scale, good quality placebo controlled trials in this area.

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Many different styles of acupuncture practice exist, and lack of agreement on the optimal acupuncture treatment for any particular condition may mean that some patients do not receive the best treatment. This uncertainty also makes the negative results of sham controlled trials difficult to interpret. Unless we can be sure that both adequate acupuncture and an inactive sham were used in a particular trial, then that trial should not be interpreted as dismissing acupuncture for that condition. Acupuncture practice clearly involves much more than needling procedures, but there is a strong argument for elucidating the role of those needling procedure first. The components of acupuncture needling procedures have been described in the STRICTA document, but it is also clear that the patient's perception of needling is relevant for the outcome of treatment. We therefore recommend the concept of ‘dose’ of acupuncture needling, which should include both the stimulus given to the patient, and certain aspects of the patient's perceptions and response that are known to be linked to the subsequent therapeutic response. We propose the following definition of dose: the physical procedures applied in each session, using one or more needles, taking account of the patient's resulting perception (sensory, affective and cognitive) and other responses (including motor). The dose may be affected by the state of the patient (eg nervous, immune and endocrine systems); different doses may be required for different conditions. The constituents of an adequate dose can be established initially by clinical opinion and subsequently by empirical evidence from experimental studies, which may be either clinical or basic research studies. Systematic reviews which do not consider the adequacy of the acupuncture treatment may have unreliable conclusions. Out of 47 recent systematic reviews, only six have applied some criteria for adequacy. Five used a rating system or conducted a subgroup analysis, and one excluded studies from the analysis altogether if they did not meet criteria for adequacy. Research into what constitutes an adequate dose of acupuncture has long been neglected and is now urgent. Clinical studies that compare the effects of different treatment protocols are probably the most reliable source of evidence, and may also demonstrate a dose-response relationship.

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