Green 200537. Green S, et al. Acupuncture for shoulder pain. Cochrane Database Syst Rev 2005(2):CD005319. for more details † see Green 200537. Green S, et al. Acupuncture for shoulder pain. Cochrane Database Syst Rev 2005(2):CD005319. for more details ‡ see Green 200537. Green S, et al. Acupuncture for shoulder pain. Cochrane Database Syst Rev 2005(2):CD005319. for more details A c c i d e n t C o m p e n s a t i o n C o r p o r a t i o n Page 4 The search was run on the 31st July 2011 for the period 2000 to present. Manual searching of reference lists was also carried out. A pragmatic approach was taken initially searching for randomised controlled trials (RCTs), systematic reviews and meta-analyses, as the highest levels of evidence. RCT’s are also the trial design of choice when investigating treatment efficacy. The literature was critically appraised using SIGN9 (see below) grading system for systematic reviews and RCTs. SIGN – LEVELS OF EVIDENCE 1++ High quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias 1+ Well-conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias 1- Meta-analyses, systematic reviews, or RCTs with a high risk of bias 2++ High quality systematic reviews of case control or cohort or studies High quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal 2+ Well-conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is causal 2- Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal 3 Non-analytic studies, e.g. case reports, case series 4 Expert opinion 3. Review of the Literature Neck pain and lower back pain (LBP) are two conditions that can be problematic to treat. Studies examining effective conservative treatments for (sub)acute and chronic non-specific low back pain have been largely inconclusive. This is also true of neck and thoracic spine pain. A lot of the literature focuses on chronic spinal pain; there are no high quality trials for the treatment of acute spinal pain. There is limited evidence to suggest that acupuncture is not an appropriate treatment for any spinal condition with suspected neurological involvement10 11. 3.1 Lower Back Pain Chronic spinal pain presents a diagnostic and treatment challenge ,reaching a specific diagnosis is often difficult. Effective conservative treatments for (sub)acute and chronic nonspecific LBP have been largely inconclusive12. Differing patient populations and methodologies make direct comparison of studies problematic often resulting in inconclusive findings. Studies comparing spinal manipulation, medication, and acupuncture for chronic spinal pain revealed that spinal manipulation produced the greatest benefit both in the short13 and long term 12; within these studies acupuncture produced ‘consistent’ improvement in outcomes although this did not reach statistical significance. Outcome measures addressed both pain and function (Oswestrey scale, Visual Analogue Scale (VAS), lumbar flexion in sitting and standing); overall recovery was 27% of the patients receiving spinal manipulation, 9.4% of those receiving acupuncture and only 5% of those receiving medication. It is noteworthy A c c i d e n t C o m p e n s a t i o n C o r p o r a t i o n Page 5 here that spinal manipulation is not appropriate for all LBP patients and a range of conservative treatment options must always be considered. In this study it was not possible to blind the patient and the therapist to the treatment allocation due to the ‘hands on’ nature of manipulation and acupuncture, therefore the placebo effect cannot be discounted. In a study14 comparing 3 different acupuncture approaches (individualised, standardised & sham) to standard care (inclusive of medications, primary care and physical therapy, nonstudy related), all groups treated with acupuncture demonstrated greater improvement in dysfunction than standard care14. The acupuncture groups included in this study all used different needle locations and depths, which suggests that this is unimportant in eliciting a therapeutic effect and may in-fact represent a placebo or non-specific effect. This was the only study reporting on function; the literature more frequently reports pain relieving effects. Itoh et al15 reported that a study group receiving trigger point acupuncture recorded significantly less pain (VAS) than a sham control group. This finding remained true when the groups were crossed over following a 3 week washout period. As acknowledged by the authors, the 3 week washout may have been insufficient and therefore a carry over treatment effect could not be discounted. This study does however support the notion that both sham and real acupuncture exert positive therapeutic effects on chronic LBP and that real acupuncture is more effective than sham. A systematic review of acupuncture for chronic LBP16 returned only 5 RCT’s. A metaanalysis was not performed due to the wide disparities in design, groups, needling points, control groups and how & when pain relief outcomes were measured in these studies. The trials were examined individually, and did not provide definitive evidence to support or refute acupuncture as an effective treatment for chronic LBP.