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Placebo Response among Different Types of Sham Acupuncture for Low Back Pain: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

  • Evidence-Based Integrative Medicine
  • Published:
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Abstract

Background

Low back pain (LBP) is a prevalent and debilitating condition that poses a significant burden on healthcare systems. Acupuncture has been proposed as a promising intervention for LBP, but the evidence supporting its specific effect is insufficient, and the use of sham acupuncture as a control in clinical trials presents challenges due to variations in sham acupuncture techniques and the magnitude of the placebo effect.

Objective

To investigate the magnitude of the placebo response of sham acupuncture in trials of acupuncture for nonspecific LBP, and to assess whether different types of sham acupuncture are associated with different responses.

Methods

Four databases including PubMed, EMBASE, MEDLINE, and the Cochrane Library were searched through April 15, 2023, and randomized controlled trials (RCTs) were included if they randomized patients with LBP to receive acupuncture or sham acupuncture intervention. The main outcomes included the placebo response in pain intensity, back-specific function and quality of life. Placebo response was defined as the change in these outcome measures from baseline to the end of treatment. Random-effects models were used to synthesize the results, standardized mean differences (SMDs, Hedges’g) were applied to estimate the effect size.

Results

A total of 18 RCTs with 3,321 patients were included. Sham acupuncture showed a noteworthy pooled placebo response in pain intensity in patients with LBP [SMD −1.43, 95% confidence interval (CI) −1.95 to −0.91, I2=89%]. A significant placebo response was also shown in back-specific functional status (SMD −0.49, 95% CI −0.70 to −0.29, I2=73%), but not in quality of life (SMD 0.34, 95% CI −0.20 to 0.88, I2=84%). Trials in which the sham acupuncture penetrated the skin or performed with regular needles had a significantly higher placebo response in pain intensity reduction, but other factors such as the location of sham acupuncture did not have a significant impact on the placebo response.

Conclusions

Sham acupuncture is associated with a large placebo response in pain intensity among patients with LBP. Researchers should also be aware that the types of sham acupuncture applied may potentially impact the evaluation of the efficacy of acupuncture. Nonetheless, considering the nature of placebo response, the effect of other contextual factors cannot be ruled out in this study. (PROSPERO registration No. CRD42022304416)

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Authors and Affiliations

  1. International Acupuncture and Moxibustion Innovation Institute, School of Acupuncture-Moxibustion and Tuina, Beijing University of Chinese Medicine, Beijing, 100029, China

    Zhi-yi Xiong, Pei-hong Ma, Chong-yang Sun, Cheng-yi Sun, Ting-lan Liu, Cun-zhi Liu & Shi-yan Yan

  2. School of Acupuncture-Moxibustion and Tuina, Tianjin University of Traditional Chinese Medicine, Tianjin, 301617, China

    Xiao-yu Liu

  3. China Academy of Chinese Medical Sciences, Beijing, 100007, China

    Bao-yan Liu

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  1. Zhi-yi Xiong
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  2. Xiao-yu Liu
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  4. Chong-yang Sun
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  7. Bao-yan Liu
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  8. Cun-zhi Liu
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Contributions

Yan SY, Xiong ZY, Liu CZ, Liu BY and Liu XY conceived and designed the review. Xiong ZY, Liu XY and Sun CY did the literature search and extracted data. Xiong ZY, Yan SY, Ma PH, Sun CY, Sun CYi and Liu TL analyzed and interpreted the result. Xiong ZY and Yan SY drafted the manuscript. All authors participated in critical revision and writing of the article, and approved the final version.

Corresponding author

Correspondence to Shi-yan Yan.

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All authors declare that they have no conflict of interests.

Additional information

Supported by the National Natural Science Foundation of China (No. 82174234) and the National Science Fund for Distinguished Young Scholars (No. 81825024)

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Xiong, Zy., Liu, Xy., Ma, Ph. et al. Placebo Response among Different Types of Sham Acupuncture for Low Back Pain: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Chin. J. Integr. Med. 29, 941–950 (2023). https://doi.org/10.1007/s11655-023-3608-1

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