Systematic Review to Inform a World Health Organization (WHO) Clinical Practice Guideline: Benefits and Harms of Needling Therapies for Chronic Primary Low Back Pain in Adults

Abstract

Purpose Evaluate benefits and harms of needling therapies (NT) for chronic primary low back pain (CPLBP) in adults to inform a World Health Organization (WHO) standard clinical guideline. Methods Electronic databases were searched for randomized controlled trials (RCTs) assessing NT compared with placebo/sham, usual care, or no intervention (comparing interventions where the attributable effect could be isolated). We conducted meta-analyses where indicated and graded the certainty of evidence. Results We screened 1831 citations and 109 full text RCTs, yeilding 37 RCTs. The certainty of evidence was low or very low across all included outcomes. There was little or no difference between NT and comparisons across most outcomes; there may be some benefits for certain outcomes. Compared with sham, NT improved health-related quality of life (HRQoL) (physical) (2 RCTs; SMD = 0.20, 95%CI 0.07; 0.32) at 6 months. Compared with no intervention, NT reduced pain at 2 weeks (21 RCTs; MD = − 1.21, 95%CI − 1.50; − 0.92) and 3 months (9 RCTs; MD = − 1.56, 95%CI − 2.80; − 0.95); and reduced functional limitations at 2 weeks (19 RCTs; SMD = − 1.39, 95%CI − 2.00; − 0.77) and 3 months (8 RCTs; SMD = − 0.57, 95%CI − 0.92; − 0.22). In older adults, NT reduced functional limitations at 2 weeks (SMD = − 1.10, 95%CI − 1.71; − 0.48) and 3 months (SMD = − 1.04, 95%CI − 1.66; − 0.43). Compared with usual care, NT reduced pain (MD = − 1.35, 95%CI − 1.86; − 0.84) and functional limitations (MD = − 2.55, 95%CI − 3.70; − 1.40) at 3 months. Conclusion Based on low to very low certainty evidence, adults with CPLBP experienced some benefits in pain, functioning, or HRQoL with NT; however, evidence showed little to no differences for other outcomes.

Improving Rehabilitation Research to Optimize Care and Outcomes for People with Chronic Primary Low Back Pain: Methodological and Reporting Recommendations from a WHO Systematic Review Series

“…It is unclear if knowledge user perspectives were considered from study inception in the included RCTs of our four systematic reviews [ 4 – 7 ].…”

“…We only included RCTs of unimodal interventions directed at the patient in our systematic reviews [ 4 – 7 ]; however, this does not reflect clinical practice and how pain is managed in a contemporary model underpinned by the biopsychosocial approach. We excluded RCTs of multimodal interventions if the specific attributable effect of the single intervention could not be isolated (e.g., exercise + treatment B vs. treatment B alone).…”

“…Our systematic reviews included comparisons of no interventions, placebo/sham interventions, and usual care. Across three of our four reviews (on standardized and structured education/advice, TENS, needling therapies) [ 4 , 6 , 7 ], 13 of 69 included RCTs (19%) compared the active intervention with no intervention (i.e., no therapeutic component, for example, waitlist control). In our review on structured exercise programs [ 5 ], RCTs rated as overall high risk of bias were not included in our primary analysis and notably, all the RCTs that used a ‘no intervention’ comparison were rated as high risk of bias.…”

“…Researchers are dedicated to advancing the understanding of CPLBP and rehabilitation interventions to provide patients, practitioners, and policymakers with the best available evidence for guiding treatment decisions and improving outcomes. In line with this objective, our aim is to share valuable insights gained from conducting four systematic reviews on the management of CPLBP (published in this series) [ 4 – 7 ]. These reviews focused on examining the benefits and harms of structured and standardized education/advice, structured exercise programs, transcutaneous electrical nerve stimulation (TENS), and needling therapies for adults with CPLBP.…”