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Panel findings and recommendations: 
 -   Invasive needle acupuncture and other dry needling techniques are not recommended for treating patients with low back problems.  (Strength of Evidence = D.)  
  Acupuncture is defined here to include all types of "dry needling" procedures (where no medication is injected) into cutaneous and subcutaneous tissues, muscles, or ligaments.  Traditional acupuncture, based on Chinese philosophy, requires that needles be inserted into specific areas of the body (the prescribed Chinese meridians) and that these needles be rotated to produce a noxious stimulus.  Other types of dry needling involve needle insertion without regard for the Chinese meridians into tender spots or other areas and may or may not involve the rotation of the needles.  Some dry needling techniques also add electrical stimulation to the needles.  The therapeutic objective of acupuncture and other dry needling techniques is to reduce pain. 
Literature Reviewed     Evidence on Efficacy   Potential Harms and Costs      Summary of Findings     Author's Example 
  Literature Reviewed.  Of 24 articles screened for this topic, 8 reporting on 6 RCTs met criteria for review. 
161, 162, 210, 211, 212, 213, 214, 215  The panel also examined a meta-analysis.216  Other articles contained information used by the panel, but did not meet article selection criteria.217, 218, 219, 220 
  Evidence on Efficacy.    All six RCTs evaluated patients with chronic back problems (with or without leg symptoms) of greater than 6 months' duration. Four of the articles reporting on three RCTs compared groups that received needling with groups that received no needling. 161, 162, 210, 213  Needling received was either acupuncture in traditional Chinese meridians161, 162, 210 or needle insertion into tender muscle points.213  In these studies, the groups that received some type of needling intervention had significantly better outcomes (in pain reduction and increased activity levels) than did the groups receiving no needling. 
  The remaining four articles reporting on three RCTs compared groups receiving acupuncture in the traditional Chinese meridians to groups receiving various types of needle insertion in other parts of the back. 
211, 212, 213, 214, 215  None of these studies found any significant differences between groups in any outcomes measured. 
  A meta-analysis, based on 51 clinical studies on acupuncture used for various types of chronic pain (including back pain), found that the quality of even the better studies was mediocre and their results highly contradictory.216  Specifically noted was that most of these studies did not provide an appropriate control group or were not adequately blinded. None of the studies demonstrated an advantage of needling in the appropriate Chinese meridians over "misplaced" needling.  In this meta-analysis, the authors concluded that the efficacy of acupuncture for treatment of chronic pain remains doubtful. 
  Potential Harms and Costs.  Reported complications of acupuncture include hematomas, infections (hepatitis B and Staphylococcus aureus), pneumothorax, and spinal nerve and spinal cord injuries due to buried needles migrating to the spinal cord.217, 218, 219, 220  In addition, the panel offered the opinion that needle insertion treatments involve some discomfort.  Costs of acupuncture and other dry needling treatments vary depending on the number of treatment visits. 
  Summary of Findings.  No studies were found evaluating efficacy of acupuncture in patients with acute low back problems.  In three of the six RCTs evaluating efficacy for chronic low back problems, outcomes were better for the acupuncture group than for nontreatment control groups.  All studies had methodologic flaws.  Acupuncture was also found to have risks of significant complications. 
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