Optimal Acupuncture Methods for Nonspecific Low Back Pain: A Systematic Review and Bayesian Network Meta-Analysis of Randomized Controlled Trials

Background: Nonspecific low back pain (NLBP) is a common disabling disease that cannot be attributed to a specific, recognizable pathology. The use of acupuncture for NLBP is supported by several guidelines and systematic reviews. However, the efficacy of different acupuncture methods for NLBP management is still debated. This study ranked the effectiveness of acupuncture methods using network meta-analysis to screen out the optimal acupuncture methods and expound the current controversies for their effective application in health policies as well as guiding clinical operations. Methods: The following databases were searched for relevant randomized controlled trials (RCTs) from inception to December 20, 2020: China National Knowledge Infrastructure, VIP Database for Chinese Technical Periodicals, WANFANG Database, Chinese biomedical literature service system, PubMed, Web of Science, Embase, and Cochrane Library. Relevant registration platforms, including the International Standard Randomised Controlled Trial Number Register (ISRCTN) and Chinese Clinical Trial Registry (ChiCTR), were also searched. Manual retrieval and tracking of references was also performed. Pairwise meta-analysis and Bayesian network meta-analysis using Revman and ADDIS, respectively, were performed and standardized mean differences examined. The primary outcome was visual analog scale (VAS) score and the secondary outcome was Oswestry Disability Index (ODI) score. Safety was defined as the incidence of adverse events. Results: A total of 30 trials with 3196 participants were analyzed; 16.67% of which showed a high risk of bias. The results indicated that fire acupuncture plus manual acupuncture, auricular needling, and electroacupuncture plus warm acupuncture were most effective in reducing VAS score. The most effective interventions for reducing ODI score were manual acupuncture plus conventional medicines, followed by moxibustion and manual acupuncture plus moxibustion. Manual acupuncture plus moxibustion was dominant in the cluster ranking. Acupuncture showed a lower incidence of adverse events (7.70%) than other interventions (conventional medicines, routine care, and placebo; 12.24%). Conclusion: We found that manual acupuncture plus moxibustion is the most effective way to reduce NLBP pain and disability. Acupuncture is safer than other interventions. However, more direct comparative evidence from high-quality, large-sample, multicenter RCTs is needed to validate these findings.