Trinh Et Al-2016-The Cochrane Library - Sup-2

Cochrane Database of Systematic Reviews
Acupuncture for neck disorders (Review)

Trinh K, Graham N, Irnich D, Cameron ID, Forget M
Trinh K, Graham N, Irnich D, Cameron ID, Forget M.

Acupuncture for neck disorders.
Cochrane Database of Systematic Reviews 2016, Issue 5. Art. No.: CD004870.
DOI: 10.1002/14651858.CD004870.pub4.
www.cochranelibrary.com

Copyright 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
SUMMARY OF FINDINGS FOR THE MAIN COMPARISON . . . . . . . . . . . . . . . . . . .
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Figure 1.
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Figure 2.
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ADDITIONAL SUMMARY OF FINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . .
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
AUTHORS CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ACKNOWLEDGEMENTS
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REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 1.1. Comparison 1 Acupuncture versus sham treatment, Outcome 1 Pain intensity (VAS) immediate post
treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 1.2. Comparison 1 Acupuncture versus sham treatment, Outcome 2 Pain intensity (VAS) short term. . . .
Analysis 1.3. Comparison 1 Acupuncture versus sham treatment, Outcome 3 Pain intensity (VAS) intermediate term.
Analysis 1.4. Comparison 1 Acupuncture versus sham treatment, Outcome 4 Pain intensity (VAS) long term. . . .
Analysis 1.5. Comparison 1 Acupuncture versus sham treatment, Outcome 5 Disability (NDI) immediate post
treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 1.6. Comparison 1 Acupuncture versus sham treatment, Outcome 6 Disability (NPQ) immediate post
treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 1.7. Comparison 1 Acupuncture versus sham treatment, Outcome 7 Disability (NPQ) short term. . . . .
Analysis 1.8. Comparison 1 Acupuncture versus sham treatment, Outcome 8 Disability (NDI) short term. . . . .
Analysis 1.9. Comparison 1 Acupuncture versus sham treatment, Outcome 9 Disability (NDI) intermediate term. .
Analysis 1.10. Comparison 1 Acupuncture versus sham treatment, Outcome 10 Quality of life (SF-36) immediate post
treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 1.11. Comparison 1 Acupuncture versus sham treatment, Outcome 11 Quality of life (SF-36) short term. .
Analysis 2.1. Comparison 2 Acupuncture versus inactive control, Outcome 1 Pain intensity (VAS) immediate post
treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 2.2. Comparison 2 Acupuncture versus inactive control, Outcome 2 Pain intensity (VAS) short term. . . .
Analysis 2.3. Comparison 2 Acupuncture versus inactive control, Outcome 3 Pain intensity (VAS) intermediate term.
Analysis 2.4. Comparison 2 Acupuncture versus inactive control, Outcome 4 Pain intensity (VAS) long term. . . .
Analysis 2.5. Comparison 2 Acupuncture versus inactive control, Outcome 5 Pain pressure threshold immediate post
treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 2.6. Comparison 2 Acupuncture versus inactive control, Outcome 6 Pain pressure threshold short term. . .
Analysis 2.7. Comparison 2 Acupuncture versus inactive control, Outcome 7 Pain intensity (proportion pain relief )
immediate post treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 2.8. Comparison 2 Acupuncture versus inactive control, Outcome 8 Disability (NDI) short term. . . . .
Analysis 2.9. Comparison 2 Acupuncture versus inactive control, Outcome 9 Disability (NDI) intermediate term. .
Analysis 2.10. Comparison 2 Acupuncture versus inactive control, Outcome 10 Disability (NDI) long term. . . .
Analysis 2.11. Comparison 2 Acupuncture versus inactive control, Outcome 11 Function (NHP) immediate post
treatment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 2.12. Comparison 2 Acupuncture versus inactive control, Outcome 12 Function (NHP) intermediate term.
Analysis 2.13. Comparison 2 Acupuncture versus inactive control, Outcome 13 Function (NPQ) short term. . . .
Analysis 2.14. Comparison 2 Acupuncture versus inactive control, Outcome 14 Quality of life (SF-36, Functional
Component) short term. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Analysis 3.1. Comparison 3 Acupuncture versus wait-list, Outcome 1 Pain intensity (VAS) short term. . . . . .
Analysis 3.2. Comparison 3 Acupuncture versus wait-list, Outcome 2 Disability (neck and pain disability scale) short
term. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 3.3. Comparison 3 Acupuncture versus wait-list, Outcome 3 Disability (neck and pain disability scale) intermediate
term. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 3.4. Comparison 3 Acupuncture versus wait-list, Outcome 4 Quality of life (SF-36 mental score) short term.
Analysis 3.5. Comparison 3 Acupuncture versus wait-list, Outcome 5 Quality of life (SF-36 mental score) intermediate
term. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 3.6. Comparison 3 Acupuncture versus wait-list, Outcome 6 Quality of life (SF-36 physical score) intermediate
term. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
WHATS NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DIFFERENCES BETWEEN PROTOCOL AND REVIEW . . . . . . . . . . . . . . . . . . . . .
INDEX TERMS
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[Intervention Review]
Acupuncture for neck disorders

Kien Trinh1 , Nadine Graham2 , Dominik Irnich3 , Ian D Cameron4 , Mario Forget5
1 DeGroote School of Medicine, Office of MD Admissions, McMaster University, Hamilton, Canada. 2 School of Rehabilitation Science,
McMaster University, Hamilton, Canada. 3 Department of Anesthesiology, University of Munich, Munich, Germany. 4 John Walsh
Centre for Rehabilitation Research, Kolling Institute, Northern Sydney Local Health District, St Leonards, Australia. 5 Canadian Forces
Health Services Group/Groupe de Services de Sant des Forces Canadiennes, National Defence/Dfense Nationale, Government of
Canada/Gouvernement du Canada, Kingston, Canada
Contact address: Kien Trinh, DeGroote School of Medicine, Office of MD Admissions, McMaster University, 1200 Main Street West,
MDCL-3112, Hamilton, ON, L8N 3Z5, Canada. trinhk@mcmaster.ca.
Editorial group: Cochrane Back and Neck Group.
Publication status and date: New search for studies and content updated (conclusions changed), published in Issue 5, 2016.
Review content assessed as up-to-date: 25 August 2015.
Citation: Trinh K, Graham N, Irnich D, Cameron ID, Forget M. Acupuncture for neck disorders. Cochrane Database of Systematic
Reviews 2016, Issue 5. Art. No.: CD004870. DOI: 10.1002/14651858.CD004870.pub4.
ABSTRACT
Background
Neck pain is one of the three most frequently reported complaints of the musculoskeletal system. Treatments for neck pain are varied,
as are perceptions of benefit. Acupuncture has been used as an alternative to more conventional treatment for musculoskeletal pain.
This review summarises the most current scientific evidence on the effectiveness of acupuncture for acute, subacute and chronic neck
pain. This update replaces our 2006 Cochrane review update on this topic.
Objectives
To determine the effects of acupuncture for adults with neck pain, with focus on pain relief, disability or functional measures, patient
satisfaction and global perceived effect.
Search methods
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, the Manual, Alternative and
Natural Therapy Index System (MANTIS), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and the Index to
Chiropractic Literature (ICL) from their beginning to August 2015. We searched reference lists, two trial registers and the acupuncture
database Traditional Chinese Medical Literature Analysis and Retrieval System (TCMLARS) in China to 2005.
Selection criteria
We included published trials that used random assignment to intervention groups, in full text or abstract form. We excluded quasirandomised controlled trials (RCTs).
Data collection and analysis
Two review authors made independent decisions for each step of the review: article inclusion, data abstraction and assessment of quality
of trial methods. We assessed study quality by using the Cochrane Back Review Group Risk of bias tool. We used consensus to resolve
disagreements, and when clinical heterogeneity was absent, we combined studies by using random-effects meta-analysis models.
Main results
Of the 27 included studies, three represented individuals with whiplash-associated disorders (WADs) ranging from acute to chronic (205
participants), five explored chronic myofascial neck pain (186 participants), five chronic pain due to arthritic changes (542 participants),
six chronic non-specific neck pain (4011 participants), two neck pain with radicular signs (43 participants) and six subacute or chronic
mechanical neck pain (5111 participants).
For mechanical neck pain, we found that acupuncture is beneficial at immediate-term follow-up compared with sham acupuncture for
pain intensity; at short-term follow-up compared with sham or inactive treatment for pain intensity; at short-term follow-up compared
with sham treatment for disability; and at short-term follow-up compared with wait-list control for pain intensity and neck disability
improvement. Statistical pooling was appropriate for acupuncture compared with sham for short-term outcomes due to statistical
homogeneity (P value = 0.83; I2 = 20%). Results of the meta-analysis favoured acupuncture (standardised mean difference (SMD) 0.23, 95% confidence interval (CI) -0.20 to -0.07; P value = 0.0006). This effect does not seem sustainable over the long term. Whether
subsequent repeated sessions would be successful was not examined by investigators in our primary studies.
Acupuncture appears to be a safe treatment modality, as adverse effects are minor. Reported adverse effects include increased pain,
bruising, fainting, worsening of symptoms, local swelling and dizziness. These studies reported no life-threatening adverse effects and
found that acupuncture treatments were cost-effective.
Since the time of our previous review, the quality of RCTs has improved, and we have assessed many of them as having low risk of bias.
However, few large trials have provided high-quality evidence.
Authors conclusions
Moderate-quality evidence suggests that acupuncture relieves pain better than sham acupuncture, as measured at completion of treatment
and at short-term follow-up, and that those who received acupuncture report less pain and disability at short-term follow-up than those
on a wait-list. Moderate-quality evidence also indicates that acupuncture is more effective than inactive treatment for relieving pain at
short-term follow-up.
PLAIN LANGUAGE SUMMARY

Review question
We reviewed the evidence on effects of acupuncture on function, disability, patient satisfaction and global perceived effect among
individuals with neck pain.
Background
Neck pain is one of the three most frequently reported complaints of the musculoskeletal system. Treatments for neck pain are varied,
as are perceptions of benefit. Acupuncture is sometimes used as an alternative to more conventional treatment for musculoskeletal pain.
In this review, acupuncture was defined as stimulation of one or more specific points on the body by insertion of needles to achieve
a therapeutic effect. Acupuncture typically includes manual stimulation of needles, but variations are common, such as electrical or
heat stimulation of the needles, which is called moxibustion (moxa herb, Artemisia vulgaris, is burned at the handle end of the needle).
Injection acupuncture, in which herbal extracts are injected into acupuncture points, is occasionally used as well.
Study characteristics
We included in this review 27 trials (5462 participants) that examined effects of acupuncture for acute to chronic neck pain (lasting a
few days to at least three months). Acupuncture was compared with sham acupuncture, wait-list or inactive treatment (e.g. sham laser).
The evidence is current to August 2015.
Key results
Researchers described variability in populations studied, acupuncture techniques used and outcomes measured, so we could not combine
the results of these trials to get an overall picture of the effectiveness of acupuncture. Therefore, we could draw only limited conclusions.
Individuals with chronic neck pain who received acupuncture reported better pain relief immediately after treatment and in the short
term compared to those who received sham treatments. Individuals with chronic neck pain who received acupuncture reported better
pain relief and improvement in disability in the short term than those who were on a wait-list.
Acupuncture treatments appear to be safe, and investigators have reported only minor and short-lasting side effects.
Quality of the evidence
The quality of the evidence used to determine whether acupuncture is helpful remains low or moderate. Limitations in the evidence
include few study participants, the tendency of researchers to not keep track of who dropped out of the study and they did not make
sure that patients who entered the study were randomly assigned to a group. These types of flaws introduce bias into the studies and
therefore affect how strongly we believe the results.


S U M M A R Y O F F I N D I N G S F O R T H E M A I N C O M P A R I S O N [Explanation]
Acupuncture compared with sham for chronic neck pain

Patient or population: patients with chronic m echanical neck pain (pain f or m ore than 90 days)
Settings: varied, m ostly at university or hospital clinics
Intervention: acupuncture
Comparison: sham
Outcomes
Illustrative comparative risks* (95% CI)
Assumed risk
Corresponding risk
Sham
Acupuncture
Relative effect
(95% CI)
Number of participants Quality of the evidence Comments

(studies)
(GRADE)
Pain intensity (VAS) M ean pain intensity

short term
ranged across sham
groups f rom
3 points on a 0 to 10
scale to 47 points on a
0 to 100 scale
M ean pain intensity -0.23 (-0.20 to -0.07)

in intervention groups
was
0.23 standard deviations lower (0.20 to 0.
07 higher)
560
(8 studies)

M oderate
Lim itations: -1
Inconsistency: 0
Indirectness: 0
Im precision: 0
Other: 0
Statistical pooling was

appropriate in this instance because of
statistical hom ogeneity. Results of the
m eta-analysis f avoured
acupuncture
Disability (NPQ) short M ean disability ranged

term
across control groups
f rom
0 to 100 scale
M ean disability in inter- -0.38 (-0.62 to -0.15)

vention groups was
0.38 standard deviations lower (0.62 to 0.
15 higher)
290
(2 studies)

Low
Lim itations: -1
Inconsistency: 0
Indirectness: 0
Im precision: -1
Other: 0
Two sm all trials were

in f avour of acupuncture. On the basis of
the GRADE scale, quality level of evidence
was downgraded to low
because only 1 of the
2 studies (50%) was at
low risk with sm all sam ple size

Disability (NDI) short M ean disability ranged

term
f rom
0 to 100 scale
M ean disability in inter- -vention groups ranged

f rom
0 to 100 scale
173
(3 studies)
N/ A
All 3 studies, 2 with

low risk of bias, did not
show a statistically signif icant result in f avour
of acupuncture
Quality of life (SF- 36) M ean quality of lif e

short term
ranged f rom
0 to 100 scale
M ean quality of lif e -in intervention groups

ranged f rom
0 to 100 scale
178
(1 study)

Low
Lim itations: 0
Inconsistency: 0
Indirectness: -1
Im precision: -1
Other: 0
One study with low

risk of bias f avoured
acupuncture
* The basis f or the assumed risk (e.g. m edian control group risk across studies) is provided in f ootnotes. The corresponding risk (and its 95% conf idence interval) is based on
the assum ed risk in the com parison group and the relative effect of the intervention (and its 95% CI)
CI: conf idence interval; RR: risk ratio
Adverse ef f ects were reported in 14 studies and included increased pain, bruising, f ainting, worsening of sym ptom s, local swelling and dizziness. No lif e-threatening adverse
ef f ects were noted by these studies
GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our conf idence in the estim ate of ef f ect
M oderate quality: Further research is likely to have an im portant im pact on our conf idence in the estim ate of ef f ect and m ay change the estim ate
Low quality: Further research is very likely to have an im portant im pact on our conf idence in the estim ate of ef f ect and is likely to change the estim ate
Very low quality: We are very uncertain about the estim ate
BACKGROUND
Description of the condition

Neck pain is a common health impairment among individuals of all ages in the general population (Cote 2004; Haldeman
2008; Hogg-Johnson 2008; Miller 2010). In fact, according to
Haldeman 2008, most people can expect to experience some degree of neck pain in their lifetime. The prevalence of neck pain in
adults over a 12-month period ranges from 30% to 50% (Carroll
2008; Hogg-Johnson 2008). Furthermore, neck pain is a commonly recurring condition. Neck pain appears to be episodic in
nature and therefore frequently recurs in 50% to 80% of people one to five years after a prior incident (Carroll 2008; Cote
2004). Symptoms of neck pain range from mildly discomforting
to severely disabling and can interfere with daily activities and
quality of life. Moreover, incidents of neck pain can be associated
with headache, arm pain or even neurological or sensory deficits
(Haldeman 2008). Neck pain has a substantial impact on healthcare costs; the economic burden of neck pain is widespread because
it affects patients, insurers, governments and employers through
sick leave, disability, visits to healthcare providers and loss of productivity (Haldeman 2008; Haraldsson 2006; Miller 2010).
Description of the intervention

A variety of conventional treatments are used to address neck pain,
including massage, physiotherapy, exercise, muscle relaxants and
steroid injections (Fu 2009SR; Haraldsson 2006; Irnich 2001).
Acupuncture has been used increasingly as an alternative to more
conventional treatment for musculoskeletal pain. It is defined as
stimulation of a certain point or points on the body by insertion
of needles to achieve a therapeutic effect. Acupuncture typically
includes manual stimulation of needles, but variations are commonly used, such as electrical and heat stimulation of needles,
which is called moxibustion (the moxa herb Artemisia vulgaris is
burned at the handle end of the needle).
How the intervention might work

Research evidence indicates that acupuncture involves the release
of neurotransmitters and hormones such as endorphins (Han
2004), serotonin (Zhang 2012) and adenosine triphosphate (ATP)
(Goldman 2010).
Best evidence suggests that the release of -endorphin triggered
by acupuncture acts both as a neurotransmitter involved in central
descending pain inhibitory pathways and as a hormone released
into the blood flow. In addition, evidence indicates that central
release of dynorphines and the expression level of the opioid antagonist cholecystokinin octapeptide (CCK-8) (Tang 1997) may
play a role in central mechanisms of acupuncture-induced analgesia. In the peripheral nervous system, -endorphin seems to be
released from keratinocytes when activated by increased extracellular endocannabinoid concentrations after acupuncture in an inflammatory pain model (Chen 2009).
Likewise, serotonin is known to be involved in the analgesic effect
of acupuncture by affecting transmission of pain signals at central
and peripheral levels. Similar to oestrogen, serotonin seems to be
indirectly involved in the antinociceptive effect of acupuncture by
sensitising peripheral afferents and thereby activating endogenous
pain control. In contrast, an increase in extracellular ATP concentration may act directly on afferent neurons expressing purinergic
receptors, leading to nerve fibre activation, which in turn causes
antinociceptive spinal or supraspinal reactions.
Such mechanisms of endogenous pain control triggered by Aand C-fiber activation are generally distinguished according to the
respective neural structures and neurotransmitters involved and
are termed diffuse noxious inhibitory control (DNIC), segmental
inhibition and descending pain control pathways (Zhao 2008).
Effects of acupuncture on muscles and fascia have also been described (Langevin 2006). When effects of acupuncture are approached from the perspective of mechanical tissue manipulation, it can be concluded that existing evidence shows effects of
acupuncture on structure and alignment of connective tissue or
fasciae (Langevin 2006). Conversely, a reduction in muscle tone
through acupuncture has been proposed, but this proposal is based
mainly on observations of clinical improvement after acupuncture, such as increased cervical range of motion in patients with
neck pain (Irnich 2001). Moreover, recent brain imaging studies
have revealed that acupuncture alters brain activation patterns in
areas associated with pain processing (Huang 2012SR).
Why it is important to do this review

According to several existing reviews, including our own (Trinh
2006), moderate-quality evidence indicates that acupuncture is
effective in the short term for relieving neck pain (Fu 2009; Furlan
2012; Graham 2013; Gross 2007; Vernon 2009). Randomised
controlled trials (RCTs) included in these reviews were based on
small population samples (Irnich 2011; Linde 2007), and more
recent studies are likely to have used improved methods.
Given the heavy public health and economic burden caused by
neck pain and the fact that many sufferers consult complementary and alternative medicine practitioners for relief of their symptoms, a systematic review with new and updated evidence of these
practices was justified. The purpose of this review was to include
more recent studies in an effort to reveal updated evidence for the
use of acupuncture to relieve neck pain and to examine long-term
effects that were absent from previous studies. This review summarises the most current scientific evidence on the effectiveness of
acupuncture for acute, subacute and chronic neck pain.

OBJECTIVES
To determine the effects of acupuncture for adults with neck pain,
with focus on pain relief, disability or functional measures, patient
satisfaction and global perceived effect.
Types of interventions
Studies must have used acupuncture techniques involving insertion of needles. Stimulation of needles may involve manual, electrical, heat, laser or other forms of stimulation. Control groups
were treated with sham acupuncture (some form of mock or pretend), wait-list control or inactive treatment control (e.g. sham
transcutaneous electrical nerve stimulation (TENS)).
METHODS
Types of outcome measures
Criteria for considering studies for this review
Types of studies
We included published randomised controlled trials (RCTs) in full
text or abstract form. We included abstracts if sufficient information for analyses could be obtained from study authors. We excluded quasi-RCTs and clinical controlled trials (CCTs) because
we found numerous RCTs for this update. This is different from
the approach presented in the protocol.
Types of participants
Participants were adults (18 years or older) with the following neck
disorders.
Mechanical neck disorders (MNDs), including whiplashassociated disorders (WADs) categories 1 and 2 (Spitzer 1987;
Spitzer 1995), myofascial pain syndrome (MPS) and
degenerative changes (DCs) (Schumacher 1993).
Neck disorder with headache (Olesen 1988; Olesen 1997;
Sjaastad 1990).
Neck disorders with radicular symptoms (NDRs),
including WAD category 3 (Spitzer 1987; Spitzer 1995).
For the purposes of this review, we defined symptom duration as
acute (< 30 days), subacute (30 days to 90 days) or chronic ( 90
days).
We excluded studies if they investigated neck disorders with:
definite or possible long tract signs (e.g. myelopathies);
neck pain caused by other pathological entities
(Schumacher 1993);
neck pain related to neurological disease (e.g. spasmodic
torticollis);
neck pain related to fracture and dislocation;
headache not of cervical origin;
co-existing headache when neck pain was not dominant or
when headache was not provoked by neck movement or
sustained neck posture; or
mixed headache.
Primary outcomes
Pain relief (e.g. visual analogue scale (VAS), numerical rating scale
(NRS)), disability or functional measures (e.g. Neck Disability
Index (NDI), quality of life (e.g. Short Form (SF)-36), activities of
daily living (ADLs)), patient satisfaction questionnaires and global
perceived effect were the outcomes of interest.
Secondary outcomes
When available, we examined adverse effects and costs of treatment.

The duration of the follow-up period was defined as:
immediately post treatment: up to one day;
short-term follow-up: between one day and three months;
intermediate-term follow-up: longer than three months to
less than one year; or
long-term follow-up: one year and longer.
Search methods for identification of studies

Electronic searches
We searched the following databases from their inception to August 2015.
Cochrane Central Register of Controlled Trials
(CENTRAL, which includes the Cochrane Back Review Group
(CBRG) Trials Register; Ovid, August 2015).
MEDLINE (Ovid, 1950 to August 2015 week 4).
EMBASE (Ovid, 1980 to August 2015).
Manual, Alternative and Natural Therapy Indexing System
(MANTIS; Ovid, 1980 to November 2013 last available access
date).
Cumulative Index to Nursing and Allied Health Literature
(CINAHL; EBSCO, 1982 to August 2015).
Index to Chiropractic Literature (ICL; August 2015).
ClinicalTrials.gov (August 2015).
World Health Organization (WHO) International Clinical
Trials Registry Platform (ICTRP) (August 2015).
The Chinese Cochrane Centre searched the Traditional Chinese
Medical Literature Analysis and Retrieval System (TCMLARS) in

China in September 2005. We did not further update the TCMLARS search, as this search yielded no RCTs previously.
See Appendix 1 for the search strategies used for CENTRAL,
MEDLINE, EMBASE, MANTIS, CINAHL and ICL. Subject
headings (MeSHs) and keywords included anatomical terms, disorder or syndrome terms, treatment terms and methodological
terms consistent with those advised by the CBRG (Furlan 2009).
Searching other resources
We also screened references, communicated with the Trials Search
Co-ordinator of the CBRG, contacted identified content experts
and reviewed our own personal files.
Data collection and analysis

We used standard methodological procedures as expected by The
Cochrane Collaboration and the CBRG.
Selection of studies
At least two review authors independently identified citations,
selected studies and abstracted data. We resolved disagreements
through consensus.
If additional information was required to assess the appropriateness of a study for selection, we contacted study authors for clarification. If this was not forthcoming, we allowed a consensus process to determine selection status. If the article or citation posting was written in a non-English language, one investigator and
a translator with a health sciences background conducted study
selection in an unblinded manner.
Data extraction and management
Two review authors independently extracted raw data for demographics, descriptions of treatment and all outcomes from full
manuscripts onto pre-designed forms.
Using the Chi2 test, we calculated agreement between investigators for study identification, selection and validity processes before reaching consensus (Graham 2012). We used the quadratic
weighted kappa statistic (Kw ) (Cicchetti 1976) to measure agreement.
Assessment of risk of bias in included studies
At least two review authors independently assessed each selected
study for methodological quality using pre-piloted forms based on
the CBRG risk of bias (RoB) assessment tool (12 criteria) (Furlan
2009). See Appendix 2 for operationalisation of the RoB tool. We
rated each item as having high, low or unclear risk and entered
ratings into the RoB table. A consensus team met to reach a final assessment based on an overview of RoB items; we used no
pre-defined cutoff score for the RoB assessment. We deemed an
RCT acceptable for inclusion if we found no fatal methodological

flaws (e.g. randomisation, allocation concealment, drop-outs, intention-to-treat (ITT) analyses were done appropriately and were
well reported).
Measures of treatment effect
We used descriptive statistics to provide a summary description of
groups, interventions, outcomes, adverse effects of treatment and
costs of care. We reported results on the basis of the sample size
analysed.
We calculated standardised mean differences (SMDs) and 95%
confidence intervals (95% CIs) for outcomes reported in a continuous data format. We used the SMD because different measures
were frequently used to address the same clinical outcome. Effect
size (SMD) is a unitless measure reported in standard deviation
units. Generally, effect size can be interpreted as small (-0.20),
medium (-0.50) or large (-0.80), as defined by Cohen (Cohen
1988).
For dichotomous outcomes, we calculated risk ratios (RRs) and
95% CIs for outcome rates in the treatment versus control group.
For undesirable outcomes, RR less than one represents a beneficial
treatment.
When neither continuous nor dichotomous data were available,
we extracted findings and statistical significance as reported by
authors of the original study and noted them in the Characteristics
of included studies tables.
Unit of analysis issues
For clinical trials using a simple parallel-group design, we collected
from each participant and analysed a single measurement for each
outcome. For clinical trials using a cross-over design, we collected
from each participant and analysed measurements of each outcome
for each participant from each of the interventions. We analysed
only the first phase of the cross-over study and included no clusterrandomised trials in this review.
Dealing with missing data
When data were not extractable, we contacted the primary authors.
When neither continuous nor dichotomous data were available, we
extracted findings and presented statistical significance as reported
by study authors.
Assessment of heterogeneity
We considered the following possible sources of heterogeneity:
symptom duration (acute vs chronic); subtype of neck pain (e.g.
WAD); intervention type (traditional acupuncture vs trigger point
needling); characteristics of treatment (e.g. dosage, technique);
and outcomes (pain relief, measures of function and disability,
patient satisfaction, quality of life).

A P value for the Chi2 test (test of heterogeneity) less than 0.05 or
an I2 value greater than 25% would indicate significant statistical
heterogeneity. However, because an acupuncture review includes
few studies, the test of heterogeneity might not have the power to
detect a difference even when one exists; therefore, we determined
that subgroups were statistically heterogeneous if I2 values were
greater than 25% despite failure to reject the null hypothesis with
the Chi2 test.
Assessment of reporting biases
When a published protocol was available, we compared outcomes
reported a priori with outcomes of interest in the RCT.
Data synthesis
Before calculating a pooled effect measure, we assessed the appropriateness of pooling on clinical grounds. We planned to combine
outcome measures from individual trials by performing a metaanalysis when possible (clinical comparability of populations, interventions and outcomes between trials). We planned to use a
random-effects model for these meta-analyses.
We considered each subgroup (e.g. 1.1) to be clinically homogeneous. We meta-analysed each subgroup unless we noted statistical heterogeneity. When a meta-analysis was not possible, we described qualitatively in the text the results of clinically comparable
trials.
Regardless of whether available data were sufficient for use in
quantitative analyses to summarise the data, we assessed the overall quality of the evidence for each outcome. To accomplish this,
we used the GRADE (Grades of Recommendation, Assessment,
Development and Evaluation Working Group) approach, as recommended in the Cochrane Handbook for Systematic Reviews of
Interventions (Higgins 2011) and adapted in the updated CBRG
method guidelines (Furlan 2009). We considered that the following factors may decrease the quality of the evidence, study design
and risk of bias, inconsistency of results, indirectness (not generalisable), imprecision (sparse data) and other factors (e.g. reporting
bias). We reduced our rating of the quality of the evidence for
a specific outcome by one level according to the performance of

studies against these five factors.
High-quality evidence: Findings are consistent among at
least 75% of RCTs with low risk of bias; consistent, direct and
precise data; and no known or suspected publication bias.
Further research is unlikely to change the estimate or our
confidence in the results.
Moderate-quality evidence: One of the domains is not
met. Further research is likely to have an important impact on
our confidence in the estimate of effect and may change the
estimate.
Low-quality evidence: Two domains are not met. Further
research is very likely to have an important impact on our
confidence in the estimate of effect and is likely to change the
estimate.
Very low-quality evidence: Three domains are not met.
We are very uncertain about the results.
No evidence: We identified no RCTs that addressed this
outcome.
Subgroup analysis and investigation of heterogeneity
We did not plan to perform a subgroup analysis.
Sensitivity analysis
We planned to conduct a sensitivity analysis on risks of bias or
meta-regression by type of neck pain and duration of symptoms.
However, we did not find sufficient data for any of these categories.
RESULTS
Description of studies
We selected 27 trials (N = 5462) for inclusion in this review (Figure
1). Duration of the disorder and disorder subtypes were as follow.

Figure 1. Study flow diagram.

10
Acute and subacute WAD (n = 1) (Tough 2010).

Subacute and chronic WAD (n = 2) (Cameron 2011; Kwak
2012).
pain with radicular signs (43 participants) and six subacute or

chronic mechanical neck pain (511 participants).
Chronic myofascial neck pain (n = 5) (Birch 1998; Chou

2009; Ilbuldu 2004; Sun 2010; Tsai 2010).
Chronic pain due to osteoarthritic cervical degenerative
changes (n = 5) (Fu 2009; Liang 2009; Thomas 1991; White
2000; White 2004).
Chronic non-specific neck pain (n = 6) (He 2004; He
2005; Itoh 2007; Nabeta 2002; Vas 2006; Witt 2006).
Neck pain with radicular findings (n = 2) (Coan 1982;
Petrie 1983).
Subacute or chronic mechanical neck pain (n = 6) (Irnich
2001; Irnich 2002; Liang 2011; Petrie 1986; Sahin 2010; Seidel
2002).
Results of the search

We identified and screened 1562 citation postings and retrieved
154 studies for more detailed evaluation. We included 27 RCTs
in this review (Figure 1). We identified no RCTs through the
Chinese language search. Additionally, five studies were protocols (Calamita 2015; Kim 2014; Liang 2012; Que 2013; Sun
2014) and two were conference proceeding abstracts (Amos 2012;
Liguori 2012) that are awaiting assessment. One study is awaiting
translation (Simma-Kletscha 2009), and four further studies are
awaiting completion (Bar-Haim 2012; Cerezo-Tellez 2014; Choi
2011; Guo 2014). We found three studies that provided additional
analyses for the primary study (see Witt 2006). We found four
studies after analysis was complete; these are also awaiting assessment (Mejuto-Vzquez 2014; Sterling 2015; Wilke 2014; Zhang
SP 2013).
See Characteristics of included studies tables for additional details
on study design, numbers randomised/analysed, treatments selected, co-interventions provided, absolute benefits noted, results
reported, SMDs, RRs, ITT analyses, side effects and costs of care.
Agreement between pairs of independent review authors from diverse professional backgrounds regarding inclusion of studies was
excellent, with an estimated Kw = 0.9425 (standard error 0.020).
Included studies
Of the 27 included studies, three represented individuals with
WAD (205 participants), five chronic myofascial neck pain (186
participants), five chronic pain due to arthritic changes (n = 506),
six chronic non-specific neck pain (4011 participants), two neck
Excluded studies
We excluded 103 trials after reviewing the full report. Of these, we
excluded 13 studies on the basis of participant characteristics: Two
RCTs included participants with a neck disorder excluded from
this review (i.e. ankylosing spondylitis) (Emery 1986) and spinal
cord stenosis (Li 2006); three included headaches not of cervical
origin (Coeytaux 2005; Venancio 2008; Venancio 2009); seven included participants with pain from other areas as well (head, shoulder or back) (Gallacchi 1981; Gallacchi 1983; Gaw 1975; Giles
2003; Kisiel 1996; Lundeburg 1988; Muller 2005); and one included participants who did not have neck pain (Sato 2014). Furthermore, we excluded two abstracts (Johnson 2000; Teng 1973)
because they did not appear to describe RCTs. We excluded 64
studies on the basis of the comparison performed: Six studies included acupuncture as the control (Fernandez-Carnero 2014; Guo
2013; Harvey 2015; Li 2013; Wang G 2014; Zhang J 2013); 31
compared acupuncture types (Ceccherelli 2006; Ceccherilli 2014;
Dong 2012; Fu 2007; Gil 2015; Huang 2008; Jia 2007; Jin 2012;
Kai 2008; Li 2004; Liu 2008; Lixing 2000; Lu 2006; Myburgh
2012; Nakajima 2015; Pecos-Martin 2015; Sator-Katzenschlager
2003; Shang 2002; Shuangquan 2003; Sun 2013; Wan 2013;
Wang 2007; Wang 2008; Xu 2012; Yang 2009; Yoon 2009; Yu
2003; Zeng 2005; Zhao 2004; Zhu 2006; Zhuang 2004); 27 compared acupuncture versus active treatment (Bahadir 2009; Cho
2014; David 1998; Edwards 2003; Eroglu 2013; Falkenberg 2007;
Franca 2008; Fu 2005; Fu 2014; Ga 2007b; Giles 1999; Hu 2014;
Huang 2012; Hudson 2010; Li 2006; Liu 2013; MacPherson
2013; McLean 2013; Rayegani 2014; Salter 2006; Tobbackx 2013;
Yang 2013; Yoshimizu 2012; Zhang 2003; Zhang J 2008; Zhou
2014; Ziaeifar 2014). In addition, we excluded 15 RCTs on the
basis of the intervention provided: eight by type (i.e. EMG needle,
mini-scalpel, injection needle) (Calvo-Trujillo 2013; Chu 1997;
Lin 2004; Ma 2010; Seo 2014; Zhang X-Z 2013; Zheng 2014; Zhi
2008) and seven additional studies that used acupuncture as part
of a multi-modal approach (Cohen 2014; Gallego Sendarrubias
2015; Guanygue 2001; Hayek 2014; Hudson 2010; Lundeburg
1991; Soderlund 2001) and could not isolate the acupuncture effect. We excluded eight studies because they were not randomised
or were quasi-randomised (Ga 2007a; Hua 2009; Loy 1983; Luo
2010; Pan 2008; Peng 1987; Xue 2007; Zhang 1996). We excluded one study because investigators did not perform betweengroup comparisons (Zhu 2002). (See Characteristics of excluded
studies tables.)

11
Risk of bias in included studies

We assessed methodological quality using CBRG guidelines
(Furlan 2009). Please see Figure 2 for these results. We assessed 12
of the 27 included studies (44%) as having fatal flaws, including
selection, performance, attrition (related to lack of ITT principles) and reporting biases. Other potential sources of bias included
inadequate reporting of co-interventions and participant compliance.

12
Figure 2. Risk of bias summary: review authors judgements about each risk of bias item for each included
study.

13
Allocation
We found that six of the 27 included studies had low risk of bias
on the basis of allocation; 19 had uncertain risk of bias; and two
had high risk of bias. We discussed effects of risks of bias on review
results for each subgroup separately under Effects of interventions.
Blinding
We found that 12 of the 27 included studies had low risk of bias
on blinding of participants; 12 studies had uncertain risk of bias,
and three had high risk of bias. We discussed effects of risks of
bias on review results for each subgroup separately under Effects
of interventions.
Incomplete outcome data
We found that two of the 27 included studies had low risk of bias
on drop-out rate; four studies had uncertain risk of bias, and one
had high risk of bias. We discussed effects of risks of bias on review
results for each subgroup separately under Effects of interventions.
Selective reporting
We found that three of the 27 included studies had low risk of
bias; 24 studies had uncertain risk of bias, and no study had high
risk of bias. We discussed effects of risks of bias on review results
for each subgroup separately under Effects of interventions.
Other potential sources of bias

We assessed 12 of the 27 included studies (44%) as having fatal
flaws, including selection, performance, attrition (related to lack
of ITT principles) and reporting biases. Other potential sources
of bias included inadequate reporting of co-interventions and participant compliance.
Effects of interventions
See: Summary of findings for the main comparison; Summary
of findings 2; Summary of findings 3
Acupuncture versus sham acupuncture
a fatal methodological flaw involving randomisation issues and the

small number of participants recruited compared with the number
of participants needed for its sample size calculation. This study
was terminated early and is considered to have high risk of bias.
Itoh 2007 studied two methods of acupuncture compared with
sham acupuncture. The trigger point treatment was significantly
different from sham, and the standard acupuncture treatment was
not significantly different from sham. We considered this study to
have high risk of bias. Thomas 1991, a study with high risk of bias,
also did not favour acupuncture for individuals with osteoarthritis.
These studies involved various methods of sham acupuncture or
pretend acupuncture treatments. In some studies, sham group needles did not penetrate the skin (Chou 2009; Itoh 2007). Some
studies defined their sham treatments as superficial needle insertions (Fu 2009; Sun 2010; Thomas 1991; Tsai 2010); three studies
use a sham control group for whom needles were placed at some
distance (1 to 2 cm) from the acupuncture points (He 2004; Liang
2011; Sahin 2010) or in a remote dermatome (White 2000). Birch
1998 used predetermined irrelevant points in his control group.
We considered five of these 11 studies to have low risk of bias
(Birch 1998; Chou 2009; He 2004; Liang 2011; Tsai 2010) and
six studies to have high risk of bias (Fu 2009; Itoh 2007; Sahin
2010; Sun 2010; Thomas 1991; White 2000).
Statistical pooling was inappropriate in this instance because of
statistical heterogeneity (P value = 0.00001; I2 = 83%). Moderatequality evidence suggests that acupuncture is beneficial for individuals with chronic mechanical neck pain for pain intensity immediately following treatment. (Please see Analysis 1.1.) On the
basis of the GRADE scale, we downgraded the quality level of
evidence to moderate because only five of the 11 studies (46%)
presented low risk.
Pain intensity (VAS) short term
We assigned eight studies (n = 560) (Cameron 2011; Fu 2009;

Liang 2011; Nabeta 2002; Sahin 2010; Sun 2010; Tough 2010;
Itoh 2007) to this category. (Please see Analysis 1.2.) Statistical
pooling was appropriate in this instance because of statistical homogeneity (P value = 0.83; I2 = 0%). Results of the meta-analysis favoured acupuncture (P value = 0.006). We considered four
studies (Fu 2009; Itoh 2007; Sahin 2010; Sun 2010) to have high
risk of bias. On the basis of the GRADE scale, we downgraded
the quality level to moderate because only four of the eight studies
(50%) presented low risk.
Pain intensity (VAS) post treatment
Eleven studies (n = 712) included participants with mechanical

neck disorders or myofascial pain syndrome. Eight of these eleven
studies favoured acupuncture over sham acupuncture. One study
(Sahin 2010) did not favour acupuncture. However, this study had
Pain intensity (VAS) intermediate term
Two studies (n = 158) presented low risk of bias: one involving

participants with whiplash (Cameron 2011) and the other involving participants with mechanical neck disorders (He 2004). Both

14
studies favoured acupuncture. (Please see Analysis 1.3.) Statistical

pooling was inappropriate in this instance because of statistical
heterogeneity (P value = 0.06; I2 = 71%). On the basis of the
GRADE scale, we downgraded the quality level of evidence to
moderate as the result of imprecision.
Pain intensity (VAS) long term
One study (n = 24) with low risk of bias involved participants

with mechanical neck disorders (He 2004). This study favoured
acupuncture. (Please see Analysis 1.4.)
Disability and quality of life
No convincing evidence favoured acupuncture in all other measures such as disability (NDI) or quality of life over the short
term, the intermediate term or the long term. (Please see Analysis
1.5, Analysis 1.6, Analysis 1.7, Analysis 1.8, Analysis 1.9, Analysis
1.10, and Analysis 1.11.) Statistical pooling for Analysis 1.6 and
Analysis 1.8 were inappropriate in this instance because of heterogeneity.
Some evidence suggests that acupuncture may be more beneficial
than sham acupuncture for disability (Northwick Park Pain Questionnaire (NPQ)). Two studies (n = 290) involved participants
with mechanical neck disorders, one with low risk of bias (Liang
2011) and the other with high risk of bias (Fu 2009). Meta-analysis favoured acupuncture (P value = 0.001). (Please see Analysis
1.7.) Statistical pooling was appropriate in this instance because
of statistical homogeneity (P value = 0.88; I2 = 0%). On the basis
of the GRADE scale, we downgraded the quality level of evidence
to moderate because only one of the two studies (50%) presented
low risk.
Acupuncture versus inactive treatment
Pain intensity (VAS) immediate post treatment
We assigned five studies (n = 245) to this category (Ilbuldu 2004;

Irnich 2002; Petrie 1986; Seidel 2002; Thomas 1991). We considered two of these studies (Irnich 2002; Seidel 2002) to have
low risk of bias and three to have high risk of bias (Ilbuldu 2004;
Petrie 1986; Thomas 1991). Statistical pooling was inappropriate
in this instance because of statistical heterogeneity (P value = 0.20;
I2 = 33%). Most of these studies - four of the five - did not favour
acupuncture (Ilbuldu 2004; Petrie 1986; Seidel 2002; Thomas
1991). (Please see Analysis 2.1.)
(Petrie 1986). Another study compared acupuncture versus sham

laser and reported no differences (Irnich 2001). However, Vickers
2004 used regression analysis and adjusted for baseline pain in
re-analysing this study (Vickers 2004) and showed that acupuncture resulted in a 9.4-point greater reduction in pain over sham
laser (0.9 to 18.0 points; P value = 0.031). Another study compared acupuncture versus sham laser (Seidel 2002) and showed
statistically significant results favouring acupuncture at four-week
follow-up. One study compared acupuncture versus sham electroacupuncture stimulator and yielded positive results at one-week
follow-up, but these results were not sustained at eight-week follow-up (White 2004). Vas and colleagues also favoured acupuncture over inactive treatment (Vas 2006).
Statistical pooling was inappropriate in this instance because of
statistical heterogeneity (P value = 0.0001; I2 = 83%). We considered four of these studies (Irnich 2001; Seidel 2002; Vas 2006;
White 2004) to have low risk of bias and one study (Petrie 1986)
(n = 26) to have high risk of bias.
On the basis of the GRADE scale, we determined that evidence
should be rated as high quality because criteria such as design,
limitations, inconsistency of results, indirectness, imprecision and
other factors were met. However, because of the small sample
size of these studies, it is highly possible that future research may
change the estimate or our confidence in the results. Therefore,
we downgraded the quality level of evidence to moderate. Moderate-quality evidence suggests that acupuncture is beneficial for
individuals with chronic mechanical neck pain for pain intensity
at short-term follow-up. (Please see Analysis 2.2.)
Pain intensity (VAS) intermediate term
Three studies (n = 318) assessed participants with mechanical neck

disorders (Vas 2006; White 2004) or myofascial pain syndrome
(Ilbuldu 2004). One of these studies favoured acupuncture over
inactive treatment (Vas 2006). We considered two of these studies
(Vas 2006; White 2004) to have low risk of bias. Statistical pooling was inappropriate in this instance because of statistical heterogeneity (P value = 0.21; I2 = 36%).
Low-quality evidence suggests that acupuncture is beneficial for
individuals with chronic mechanical neck pain for pain intensity
at intermediate-term follow-up. We downgraded the quality of
evidence because of risk of bias (< 75% of the studies presented
low risk) and inconsistency of results. (Please see Analysis 2.3.)
Pain intensity (VAS) long term

Pain intensity (VAS) short term
Five studies (n = 404) (Irnich 2001; Petrie 1986; Seidel 2002;

Vas 2006; White 2004) assessed participants with mechanical
neck disorders. Petrie 1986 found no differences between groups
We considered White 2004 (n = 124) to have low risk of bias; this

study did not favour acupuncture treatment. No evidence suggests
that acupuncture is effective for long-term pain relief. (Please see
Analysis 2.4.)

15
No convincing evidence favoured acupuncture in all other measures such as disability (NDI) and quality of life over the short
term, the intermediate term or the long term. (Please see Analysis
2.5, Analysis 2.6, Analysis 2.7, Analysis 2.8, Analysis 2.9, Analysis
2.10, Analysis 2.11, Analysis 2.12, Analysis 2.13 and Analysis
2.14.) Statistical pooling for Analysis 2.5, Analysis 2.6 and Analysis
2.14 were inappropriate in this instance because of heterogeneity.
Acupuncture versus wait-list control
Pain intensity (VAS) at short-term follow-up
One study (n = 30) involving participants with mechanical

neck disorders with radicular symptoms (Coan 1982) favoured
acupuncture for short-term pain relief. This study had low risk of
bias. However, no evidence suggests that this improvement was
sustained to intermediate follow-up. (Please see Analysis 3.1.)
One study (n = 3766) involving participants with mechanical neck

disorders (Witt 2006) favoured acupuncture for short-term NDI
improvement. This study had low risk of bias, but no evidence
suggests that this improvement was sustained to intermediate follow-up. (Please see Analysis 3.2.)
No convincing evidence favoured acupuncture in all other measures such as quality of life over the short term or the intermediate
term regarding physical or mental scores (SF-36). In fact, some
evidence suggests that results favoured control on the basis of a
single study in each category. (Please see Analysis 3.3, Analysis 3.4,
Analysis 3.5 and Analysis 3.6.)
Fourteen studies reported adverse effects (Cameron 2011; Fu
2009; Irnich 2001; Irnich 2002; Itoh 2007; Kwak 2012; Liang
2011; Nabeta 2002; Seidel 2002; Sun 2010; Tough 2010; Vas
2006; White 2004; Witt 2006), which included increased pain,
bruising, fainting, worsening of symptoms, local swelling and
dizziness. (See Characteristics of included studies table for full details.) These studies noted no life-threatening adverse effects.
One large multi-centre trial reported costs of care (Witt 2006) and
indicated that acupuncture is cost-effective.
For a summary of results, please see Summary of findings for
the main comparison, Summary of findings 2 and Summary of
findings 3.

16

A D D I T I O N A L S U M M A R Y O F F I N D I N G S [Explanation]
Acupuncture compared with inactive treatments for chronic neck pain

Patient or population: patients with chronic neck pain (pain f or m ore than 90 days)
Settings: prim ary care, general practitioners clinics to secondary care, outpatient pain clinics or speciality clinics
Comparison: inactive treatm ents
Outcomes
Assumed risk
Corresponding risk
Inactive treatment
Acupuncture
Relative effect
(95% CI)

(studies)
(GRADE)

short term
ranged across control
groups f rom
0 to 100 scale
M ean pain intensity -in intervention groups

was
scale to 9 points on a 0
to 10 scale
404
(5 studies)

M oderate
Lim itations: 0
Inconsistency: 0
Indirectness: 0
Im precision: -1
Other: 0
Five studies (n = 461)

assessed participants
with m echanical neck
disorders. Four were at
low risk of bias. Statistical pooling was inappropriate in this instance because of statistical heterogeneity.
Four of these studies
f avoured acupuncture
Pain pressure thresh- M ean

old short term
pain pressure threshold
ranged across control
groups f rom
to 10 scale
M ean pain pressure -threshold in intervention groups ranged

f rom
0.2 points on a 0 to 10
to 10 scale
132
(2 studies)
N/ A
Two studies with low

risk of bias did not
f avour acupuncture
17

Disability (NDI) short M ean disability ranged

term
Function (NPQ) short f rom
term
0 to 100 scale
M ean f unction across
control groups was
scale
M ean disability in inter- -vention groups ranged

f rom
0 to 100 scale
M ean f unction in intervention groups was
scale
118
(1 study)
123
(1 study)
N/ A

Low
Lim itations: 0
Inconsistency: 0
Indirectness: -1
Im precision: -1
Other: 0
One study with low risk

of bias did not f avour
acupuncture
One study with low
risk of bias f avoured
acupuncture
Quality of life (SF- M ean f unction ranged

36, Functional Compo- across control groups
nent) short term
f rom
0.7 points on a 0 to 10
to 10 scale
M ean f unction in inter- -vention groups ranged

f rom
to 10 scale
143
(2 studies)
N/ A
Two studies with low

risk of bias did not
f avour acupuncture
ef f ects were noted by these studies
18

Acupuncture compared with wait- list control for chronic neck pain
Patient or population: patients with chronic neck pain (pain f or m ore than 90 days)
Settings: prim ary care newspaper advertisem ent or recruited through participating physicians
Comparison: wait-list control
Outcomes
Assumed risk
Corresponding risk
Wait- list control
Acupuncture
Relative effect
(95% CI)

(studies)
(GRADE)

short term
was
scale
M ean pain intensity -in intervention groups

was
scale
30
(1 study)

M oderate
Lim itations: 0
Inconsistency: 0
Indirectness: -1
Im precision: 0
Other: 0
One trial with low risk

of bias showed a sm all
reduction in pain. M oderate evidence supporting acupuncture is helpf ul
Disability (neck and M ean disability across

pain disability scale) control groups was
short term
scale
M ean disability in inter- -vention groups was

scale
3451
(1 study)

M oderate
Lim itations: 0
Inconsistency: 0
Indirectness: -1
Im precision: 0
Other: 0
One large study with

low risk of bias
f avoured acupuncture
Quality of life (SF- M ean quality of lif e

36 mental score) short score across control
term
groups was
1 point on a 0 to 10
scale
M ean quality of lif e -score in intervention

groups was
scale
3451
(1 study)
N/ A
One large study showed

no statistically signif icant f indings in f avour
of acupuncture
19

ef f ects were noted by these studies Cost of care was calculated in 1 study, which f ound that acupuncture treatm ent was cost-ef f ective
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20
DISCUSSION
Summary of main results

For mechanical neck pain, we found that acupuncture is more beneficial at immediate-term follow-up compared with sham treatments for pain intensity; at short-term follow-up compared with
sham treatments and inactive treatments for pain intensity; at
short term follow-up compared with sham treatments for disability (Northwick Park Pain Questionnaire (NPQ)) and at shortterm follow-up compared with wait-list control for pain intensity
and Neck Disability Index (NDI) improvement. Effects do not
seem sustainable over the long term. Our primary studies did not
examine whether subsequent repeated sessions will be successful.
Overall completeness and applicability of

evidence
In this review, we limited our trials to include acupuncture interventions in the experimental arm and no acupuncture interventions in the control arm. Control arms could be given sham
acupuncture, an inactive treatment or no treatment. In this way,
we could better study the effects of acupuncture. Our challenge
remains determining what constitutes acupuncture treatments.
In other Cochrane reviews such as acupuncture for back pain,
acupuncture is defined as treatment that uses some type of standardised acupuncture points, whereas dry needling is treatment
that uses acupuncture needles over trigger points. We found insufficient studies on dry needling alone to justify separating this
needling treatment method for examination in a separate review.
We found that the number of acupuncture treatment sessions was
associated with outcomes (Ezzo 2000). Ideally, treatment should
consist of six or more acupuncture sessions. One study (Irnich
2002) intentionally studied the effects of a single treatment. Five
studies provided underdosing with fewer than six treatment sessions (Chou 2009; Ilbuldu 2004; Nabeta 2002; Tsai 2010; Vas
2006). All remaining studies were adequately dosed on the basis
of this variable alone.
Quality of the evidence

The most difficult challenge faced in this review was clinical heterogeneity, which appeared at many levels, as in sample group included, acupuncture interventions provided and outcomes measured. Acupuncture interventions and sham therapies were quite
varied. Among sham therapies, treatment varied from a non-insertion type of inactivated transcutaneous electrical nerve stimulation (TENS) or laser to insertion of needles at different locations
or at different depths. The qualitative method of synthesising evidence has its limitations. We determined consistency of evidence
by group consensus, but this method is sensitive to how studies
are categorised because meeting the criteria for a certain level of

evidence depends on the number of studies included within a category.
Fortunately, the quality of acupuncture studies for neck pain seems
to have improved over time. We classified many studies identified
in the latest update of our search as having low risk of bias.
Potential biases in the review process

Weaknesses of this review rest with limitations in the primary
studies. Furthermore, many studies did not report details of dropouts. We avoided language bias by including all languages during
study selection; however, we did not search non-English language
databases, and we did not search Chinese databases beyond 2005.
Our approach to summarising the literature has several strengths.
We used a comprehensive, librarian-assisted search of multiple
databases. We relied on teams of healthcare professionals to decide
on article relevance and to assess study quality. At least two review
authors extracted data, and the principal investigator verified data
entry. We used a group consensus approach, coupled with the
Cochrane Back Review Group risk of bias assessment tool. We
avoided professional bias inherent in having members of a single
profession evaluate the literature for that profession.
Agreements and disagreements with other

studies or reviews
Our findings are similar to those of our past review in 2006 (Trinh
2006) and to those of Fu et al in 2009 (Fu 2009). This is consistent
with other reviews on acupuncture for migraine headache prophylaxis (Linde 2009), elbow pain (Trinh 2004), tension headache
(Linde 2009a) and back pain (Furlan 2005). The result is not surprising. The findings of our review of other therapies for neck disorders were disappointing. It appears that the effect size of treatments for neck disorders is small even for therapies (such as injections) believed to have a large clinical effect. It is likely that in a
clinical setting, both specific and non-specific effects of treatments
are evident, whereas in a randomised controlled trial (RCT), investigators observe non-specific effects of treatments in both experimental and control groups. Therefore, the difference is seen in
the specific effects of treatment, and these effects may be smaller
than those observed clinically.
AUTHORS CONCLUSIONS
Implications for practice
For mechanical neck pain, we found that acupuncture is beneficial immediately following treatment and at short-term follow-up

21
compared with sham treatments for pain intensity; at short-term

follow-up compared with sham treatments for disability (NPQ);
at short-term follow-up compared with inactive treatments for
pain intensity; and at short-term follow-up compared with waitlist control for pain intensity and neck disability improvement.
Effects do not seem sustainable over the long term. Acupuncture
treatments appear to be relatively safe.
Implications for research

Acupuncture trials with adequate sample size are needed to exam-
ine the long-term efficacy or effectiveness of acupuncture compared with sham acupuncture.
ACKNOWLEDGEMENTS
Thank you to the primary authors who responded to requests for
information. We also thank our volunteers, our translators and the
Cochrane Back Review Group editors.
REFERENCES
References to studies included in this review

Birch 1998 {published data only}
Birch S, Jamison R. Controlled trial of Japanese

acupuncture for chronic myofascial neck pain: assessment
of specific and nonspecific effects of treatment. Clinical
Journal of Pain 1998;14:24855. [CO2002:2756]
Cameron 2011 {published data only}
Cameron ID, Wang E. World Congress on Neck Pain
Conference Proceedings. Los Angeles, 2008.
Cameron ID, Wang E, Sindhusake D. A randomized

trial comparing acupuncture and simulated acupuncture
for subacute and chronic whiplash. Spine 2011;36(26):
E165965.
Chou 2009 {published data only}
Chou L-W, Hsieh Y-L, Kao M-J, Hong C-Z. Remote
influences of acupuncture on the pain intensity and the
amplitude changes of endplate noise in the myofascial
trigger point of the upper trapezius muscle. Archives of
Physical Medicine and Rehabilitation 2009;90:90512.
Coan 1982 {published data only}
Coan RM, Wong G, Coan PL. The acupuncture treatment
of neck pain: a randomized controlled study. American
Journal of Chinese Medicine 1982;9(4):32632.
Fu 2009 {published data only}
Fu W-B, Liang Z-H, Zhu X-P, Yu P, Zhang J-F. Analysis on
the effect of acupuncture in treating cervical spondylosis
with different syndrome types. Chinese Journal of Integrative
Medicine 2009;15(6):42630.
He 2004 {published data only}
He D, Veiersted KB, Hostmark AT, Medbo JI. Effect of
acupuncture treatment on chronic neck pain and shoulder
pain in sedentary female workers: a 6-month and 3-year
follow-up study. Pain 2004;109(3):299307. [CO2006]
He 2005 {published data only}
He D, Hostmark AT, Veiersted KB, Medbo JI. Effect
of intensive acupuncture on pain-related social and
psychological variables for women with chronic neck and
shoulder pain - an RCT with six month and three year
follow up. Acupuncture in Medicine 2005;23(2):5261.
[C)2007]
Ilbuldu 2004 {published data only}

Ilbuldu E, Cakmak A, Disci R, Aydin R. Comparison
of laser, dry needling, and placebo laser treatments in
myofascial pain syndrome. Photomedicine and Laser Surgery
2004;22(4):30611. [CO2006]
Irnich 2001 {published data only}
Irnich D, Behrens N, Molzen H, Konig A, Gleditsch J,

Krauss M, et al. Randomized trial of acupuncture compared
with conventional massage and sham laser acupuncture
for treatment of chronic neck pain. BMJ 2001;322:15748.
Knig A, Radke S, Molzen H, Haase M, Mller C, Drexler
D, et al. Randomised trial of acupuncture compared with
conventional massage and sham laser acupuncture for
treatment of chronic neck pain - range of motion analysis
[Randomisierte studie zur akupunktur in vergleich mit
konventioneller massage und scheinlaserakupunktur
in der behandlung chronischer HWSBeschwerden
Bewegungsanalyse]. Zeitschrift fr Orthopdie und ihre
Grenzgebiete 2003;141(4):395-400 [Other: CO2004].
Irnich 2002 {published data only}
Irnich D, Behrens N, Gleditsch JM, Stor W, Schreiber,

MA, Schopd P, et al. Immediate effects of dry needling and
acupuncture at distant points in chronic neck pain: results
of a randomized, double-blind, sham-controlled crossover
trial. Pain 2002;99:839. [CO2004;]
Itoh 2007 {published data only}
Itoh K, Katsumi Y, Hirota S, Kitakoji H. Randomised trial of
trigger point acupuncture compared with other acupuncture
for treatment of chronic neck pain. Complementary
Therapies in Medicine 2007;15:1729. [CO2007]
Kwak 2012 {published data only}
Kwak HY, Kim JI, Park JM, Lee SH, Yu HS, Lee JD,
et al. Acupuncture for whiplash-associated disorder: a
randomized, waiting-list controlled, pilot trial. European
Journal of Integrative Medicine 2012;4(2):1518.
Liang 2009 {published data only}
Liang ZH, Yang YH, Yu P, Zhu XP, Wu ZL, Zhang JF,
et al. Logistic regression analysis on therapeutic effect of
acupuncture on neck pain caused by cervical spondylosis
and factors influencing therapeutic effect [in Chinese].

22
Chinese Acupuncture & Moxibustion 2009;29(3):1736.

[CO2010]
chronic uncomplicated neck pain: a randomised controlled

study. Pain 2006;126(1):24555. [CO2007]

Liang Z, Zhu X, Yang X, Fu W, Lu A. Assessment of a
traditional acupuncture therapy for chronic neck pain: a
pilot randomised controlled study. Complementary Therapies
in Medicine 2011;195:52632.
White 2000 {published data only}
White PF, Craig WF, Vakharia AS, Ghoname EA, Ahmed

HE, Hamza MA. Percutaneous neuromodulation therapy:
does the location of electrical stimulation effect the acute
analgesic response?. Anesthesia Analgesic 2000;91:94954.
Nabeta 2002 {published data only}

Nabeta T, Kawakita K. Relief of chronic neck and shoulder
pain by manual acupuncture to tender points - a shamcontrolled randomized trial. Complementary Therapies in
Medicine 2002;10:21722. [CO2006]
White 2004 {published data only}
White P, Lewith G, Prescott P, Conway J. Acupuncture

versus placebo for the treatment of chronic mechanical
neck pain. Annals of Internal Medicine 2004;141:9208.
[co2004:]
Petrie 1983 {published data only}
Petrie JP, Langley GB. Acupuncture in the treatment

of chronic cervical pain. A pilot study. Clinical and
Experimental Rheumatology 1983;1:3335.
Witt 2006 {published data only}

Willich SN, Reinhold T, Selim D, Jena S, Brinkhaus B,
Witt CM. Cost-effectiveness of acupuncture treatment in
patients with chronic neck pain. Pain 2006;125:10713.
Witt CM, Brinkhaus B, Reinhold T, Willich SN. Efficacy,
effectiveness, safety and costs of acupuncture for chronic
pain - results of a large research initiative. Acupuncture in
Medicine 2006;24(Suppl):S339.
Witt CM, Jena S, Brinkhaus B, Liecker B, Wegscheider

K, Willich SN. Acupuncture for patients with chronic neck
pain. Pain 2006;125:98106. [CO2007]
Witt CM, Ludtke R, Wegscheider K, Willich SN. Physician
characteristics and variation in treatment outcomes: are
better qualified and experienced physicians more successful
in treating patients with chronic pain with acupuncture?.
The Journal of Pain 2010;11(5):4315.
Witt CM, Schutzler L, Ludtke R, Wegscheider K, Willich
SN. Patient characteristics and variation in treatment
outcomes. Which patients benefit most from acupuncture
for chronic pain?. Clinical Journal of Pain 2011;27:5505.
Petrie 1986 {published data only}
Petrie JP, Hazleman BL. A controlled study of acupuncture

in neck pain. British Journal of Rheumatology 1986;25:
2715. [CO97: 180]
Sahin 2010 {published data only}
Sahin N, Ozcan E, Sezen K, Karatas O, Issever H. Efficacy
of acupuncture in patients with chronic neck pain - a
randomised, sham controlled trial. Acupuncture and ElectroTherapeutics Research International Journal 2010;35:1727.
Seidel 2002 {published data only}
Seidel U, Uhlemann C. A randomised controlled doubleblind trial comparing dosed laser therapy on acupuncture
points and acupuncture for chronic cervical syndrome [in
German]. Deutsche Zeitschrift fur Akupunkture 2002;45:
25869. [CO2003]
Sun 2010 {published data only}
Sun M-Y, Hsieh C-L, Cheng Y-Y, Hung H-C, Li T-C,
Yen S-M, et al. The therapeutic effects of acupuncture
on patients with chronic neck myofascial pain syndrome:
a single-blind randomized controlled trial. The American
Journal of Chinese Medicine 2010;38(5):84959.
Thomas 1991 {published data only}
Thomas M, Eriksson SV, Lundeberg T. A comparative study
of diazepam and acupuncture in patients with osteoarthritis
pain: a placebo controlled study. American Journal of
Chinese Medicine 1991;19:95100.
Tough 2010 {published data only}
Tough EA, White AR, Richards SH, Campbell JL.
Myofascial trigger point needling for whiplash associated
pain - a feasibility study. Manual Therapy 2010;15:52935.
Tsai 2010 {published data only}
Tsai C-T, Hsieh L-F, Kuan T-S, Kao MJ, Chou L-W, Hong
C-Z. Remote effects of dry needling on the irritability of
the myofascial trigger point in the upper trapezius muscle.
American Journal of Physical Medicine and Rehabilitation
2010;89(2):13340.
Vas 2006 {published data only}
Vas J, Perea-Milla E, Mndez C, Snchez Navarro C, Len
Rubio JM, Brioso M. Efficacy and safety of acupuncture for
References to studies excluded from this review

Bahadir 2009 {published data only}
Bahadir C, Majlesi J, Unalan H. The effect of highpower pain threshold ultrasound therapy on the electrical
activity of trigger points and local twitch response on
electromyography: a preliminary study. Journal of
Musculoskeletal Pain 2009;17(2):16272. [CO2007]
Calvo-Trujillo 2013 {unpublished data only}
Calvo-Trujillo S. Effectiveness of the Auto-acupressure for
Diminishing Neck Pain of Benign Origin, 2013. http://
ClinicalTrials.gov/show/NCT01855893.
Ceccherelli 2006 {published data only}
Ceccherelli F, Tortora P, Nassimbeni C, Casale R, Gagliardi
G, Giron G. The therapeutic efficacy of somatic acupuncture
is not increased by auriculotherapy: a randomised, blind
control study in cervical myofascial pain. Complementary
Ceccherilli 2014 {published data only}
Ceccherelli F, Marino E, Caliendo A, Dezzoni R, Roveri
A, Gagliardi G. 3, 5, 11 needles: looking for the perfect
number of needles - a randomized and controlled study.
Acupuncture & Electro-Therapeutics Research International
Journal 2014;39:24158.

23
Cho 2014 {published data only}

Cho J-H, Nam D-H, Kim K-T, Lee J-H. Acupuncture with
non-steroidal anti-inflammatory drugs (NSAIDs) versus
acupuncture or NSAIDs alone for the treatment of chronic
neck pain: an assessor-blinded randomised controlled pilot
study. Acupuncture Medicine 2014;32:1723.
Chu 1997 {published data only}
Chu J. Does EMG (dry needling) reduce myofascial
pain symptoms due to cervical nerve root irritation?.
Electromyography and Clinical Neurophysiology 1997;37:
25972. [CO2006]
Coeytaux 2005 {published data only}
Coeytaux RR, Kaufman JS, Kaptchuk TJ, Chen W, Miller
W, Callahan LF, et al. A randomized, controlled trial of
acupuncture for chronic daily headache. Headache 2005;
45:111323.
Cohen 2014 {unpublished data only}
Cohen SP. Conservative Therapy Versus Epidual Steroids for
Cervical Radiculopathy. clinicaltrials.gov NCT01144923.
David 1998 {published data only}
David J, Modi S, ALuko AA, Robertshaw C, Farebrother J.
Chronic neck pain: a comparison of acupuncture treatment
and physiotherapy. British Journal of Rheumatology 1998;
37:111822. [CO97:3489]
Dong 2012 {published data only}
Dong W, Lin X. Clinical observation on cervical spondylosis
of neck type treated with acupuncture at original and
terminal points of trapezius. Chinese Acupuncture &
Moxibustion 2012;32(3):2114.
Edwards 2003 {published data only}
Edwards J, Knowles N. Superficial dry needling and
active stretching in the treatment of myofascial pain - a
randomized controlled trial. Acupuncture in Medicine 2003;
21(3):806. [CO2010]
Emery 1986 {published data only}
Emery P, Lythgoe S. The effect of acupuncture on
ankylosing spondylitis. British Journal of Rheumatology
1986;25:1323. [CO97]
Eroglu 2013 {published data only}
Eroglu PK, Yilmaz O, Bodur H, Ates C. A comparison of
the efficacy of dry needling, lidocaine injection, and oral
flurbiprofen treatments in patients with myofascial pain
syndrome: a double-blind (for injection, groups only),
randomized clinical trial. Turkish Journal of Rheumatology
2013;28(1):3846.
Falkenberg 2007 {unpublished data only}
Falkenberg T. Integrative Medicine for Back and Neck Pain
- A Pragmatic Randomized Clinical Pilot Trial. http://
ClinicalTrials.gov/show/NCT00565942.
Fernandez-Carnero 2014 {unpublished data only}
Fernandez-Carnero J. Immediate Effects of Dry Needling
and TENS in Chronic Neck Pain. http://ClinicalTrials.gov/
show/NCT02230709.
Franca 2008 {published data only}
Frana DL, Senna-Fernandes V, Cortez CM, Jackson MN,
Bernardo-Filho M, Guimares MA. Tension neck syndrome
treated by acupuncture combined with physiotherapy: a

comparative clinical trial (pilot study). Complementary
Fu WB, Zhang HL, Fan L. Treatment of cervical
spondylopathy by needle pricking: a clinical observation of
56 cases [in Chinese]. New Journal of Traditional Chinese
Medicine 2005;37(4):656. [CO2009]
Fu ZH, Wang JH, Sun JH, Chen XY, Xu JG. Fus
subcutaneous needling: possible clinical evidence of the
subcutaneous connective tissue in acupuncture. The Journal
of Alternative and Complementary Medicine 2007;13(1):
4751. [CO2007]
Fu 2014 {unpublished data only}
Fu Q. Clinical Study on Electroacupuncture Therapy for
Chronic Neck Pain. clinicaltrials.gov NCT01674387.
Ga 2007a {published data only}
Ga H, Koh HJ, Choi JH, Kim CH. Intramuscular and nerve
root stimulation vs lidocaine injection to trigger points
in myofascial pain syndrome. Journal of Rehabilitation
Medicine 2007;39(5):3748. [CO2010]
Ga 2007b {published data only}
Ga H, Choi JH, Park CH, Yoon HJ. Dry needling of
trigger points with and without paraspinal needling in
myofascial pain syndromes in elderly patients. The Journal
of Alternative and Complementary Medicine 2007;13(6):
61723. [CO2010]
Gallacchi 1981 {published data only}
Gallacchi G, Mueller W, Plattner GR, Schnorrenberger CC.
Acupuncture and laser treatment in cervical and lumbar
syndrome [Akupunktur und Laserstrahlbehandlung beim
Zervikal und Lumbalsyndrom]. Schweizische Medizinische
Wochenschrift 1981;111(37):13606. [CO97]
Gallacchi 1983 {published data only}
Gallacchi G, Mller W. Acupuncture - a yielding therapy
in rheumatology? [Akupunktur bringt sie etwas?].
Schweizerische Rundschau fur Medizin Praxis 1983;72:
77982. [CO2010]
Gallego Sendarrubias 2015 {unpublished data only}
Gallego Sendarrubias G. Dry Needling in Patients with
Chronic Neck Pain. clinicaltrials.gov NCT02435966.
Gaw 1975 {published data only}
Gaw AC, Chang LW, Shaw L-C. Efficacy of acupuncture on
osteoarthritic pain. New England Journal of Medicine 1975;
293:3758. [CO97]
Gil 2015 {unpublished data only}
Gil EN. Acupuncture Approaches for Chronic Pain
(AADDOPT-2). clinicaltrials.gov NCT02456727.
Giles 1999 {published data only}
Giles LG, Meller R. Chronic spinal pain syndromes: a
clinical pilot trial comparing acupuncture, a nonsteroidal
anti-inflammatory drug and spinal manipulation. Journal
of Manipulative and Physiological Therapeutics 1999;22(6):
37681. [CO2002]

24
Giles 2003 {published data only}

Giles LG, Muller R. Chronic spinal pain: a randomized
clinical trial comparing medication, acupuncture, and spinal
manipulation. Spine 2003;28(14):1490503. [CO2007]
Guanygue 2001 {published data only}
Guangyue W, Fenglin Q. Treatment of 482 cases of cervical
spondylopathy by combining point-injection and needlewarming via moxibustion. Journal of Traditional Chinese
Medicine 2001;21(1):313. [CO2002:2979]
Guo 2013 {published data only}
Guo J, Wang C, Congcong Y. Clinical study of acupuncture
combined with massage method of Tongdu in treating neck
strain. International Journal of Clinical Acupuncture 2013;
22(2):668.
Harvey 2015 {unpublished data only}
Harvey D. Lidocaine Injection Versus Sham Needling
in Treating Whiplash Associated Disorder, 2015. http://
clinicalTrials.gov/show/NCT02060734.
Hayek 2014 {unpublished data only}
Hayek S, Fisher R. Randomized, Comparative-Effectiveness
Study Comparing Epidural Steroid Injections to
Conservative Management With Medications and Physical
Therapy in Patients With Cervical Radiculopathy, 2014.
http://clinicalTrials.gov/show/NCT01144923.
Hu 2014 {published data only}
Hu A, Yang H. Comparison of efficacy between
electroacupuncture and the combination of collateral
bloodletting, cupping, and acupoint application for
cervical spondylosis radiculopathy (CRS). World Journal of
Acupuncture - Moxibustion 2014;24(3):259.
Hua 2009 {published data only}
Hua Y. Clinical observation on treatment of
cervical spondylotic radiculopathy with combined
electroacupuncture tuina and traction. Journal of
Acupuncture and Tuina Science 2009;7:1568.
Huang 2008 {published data only}
Huang YF, Wang TF, Liu Y, Zhang SX. Clinical observation
on Jiquan (HT 1) for treatment of cervical spondylosis
of nerve root type [in Chinese]. Chinese Acupuncture &
Moxibustion 2008;28(6):4278. [CO2009]
Huang 2012 {published data only}
Huang LJ, Luo WJ, Zhang KB, Geng JH. Efficacy
observation on cervical spondylosis of vertebral artery type
treated with warm needling and rehabilitation physiotherapy
therapy. World Journal of Acupuncture - Moxibustion 2012;
22(2):126.
Hudson 2010 {published data only}
Hudson JS, Ryan CG. Multimodal group rehabilitation
compared to usual care for patients with chronic neck pain:
a pilot study. Manual Therapy 2010;15:5526.
Jia 2007 {published data only}
Jia CS, Shi J, Ma XS, Li XF, Wang Y, Wang JL. Comparison
of the analgesic effect of acupuncture between otopointpenetrative needling and otopoint-straight needling for
cervical type and nerve-root type cervicospondylopathy
[in Chinese]. Acupuncture Research 2007;32(3):1869.

[CO2009]
Jin 2012 {published data only}
Jin C, Lun X, Jin S, Xia D, Huang Y, Xiao H, et al. A clinical
observation on treating stiff neck by the combination
of superficial needling at Bos abdominal acupoints and
Luozhen point. International Journal of Clincal Acupuncture
2012;21(3):8790.
Johnson 2000 {published data only}
Johnson R, Prasad K, Wong L, Varley G. Use of acupuncture
following whiplash type injuries to the neck. Journal of
Bone and Joint Surgery (British) 2000;82-B(Suppl III):1.
[CO2003]
Kai 2008 {published data only}
Kai L, Dan WEI, Jia-kang LI. Acupuncture plus
Acupoint-injection for treatment of cervical spondylosis of
vertebroarterial type. Journal of Traditional Chinese Medicine
2008;28(4):2434.
Kisiel 1996 {published data only}
Kisiel AC, Lind C. Pain relief with physical therapy and
manual acupuncture in myofascial neck and shoulder
pain [Smartlindring med fysikalisk terapi och manuell
akupunktur vid myofaciella nack och skuldersmrtor].
Sjukgymnasten 1996;12:2431. [CO97]
Li 2004 {published data only}
Li XH, Li DJ. Therapeutic effect of centro-square needling
Dazhui (GV 14) on cervical spondylosis [in Chinese].
[CO2009]
Li 2006 {published data only}
Li DJ, Wang J, Gao Q, Hou JS. Interventional effects of
cervical local-point traction manipulation plus silver needle
heat conductive treatment for cervical spinal canal stenosis
[in Chinese]. Chinese Journal of Clinical Rehabilitation
2006;10(43):710. [CO2009]
Li 2013 {published and unpublished data}
Li Y, Fu R. Therapeutic effect and blood rheology of
patients with cervical spondylosis treated with acupuncture
combined with massage. International Journal of Clinical
Acupuncture 2013;22(2):613.
Lin 2004 {published data only}
Lin MN, Liu XX, Liu JH, Zhang AP, Xu SL, Guo JH.
Needle scalpel combined with massage therapy and simple
massage therapy for nerve-root type cervical spondylopathy:
a randomized controlled analysis on 100 patients. Chinese
Journal of Clinical Rehabilitation 2004;8(23):49201.
[CO2010]
Liu 2008 {published data only}
Liu MY, Nie RR, Zhou RG, Liao WZ. Observation on
therapeutic effect of acupuncture at cervical three points
combined with cake-separated moxibustion on cervical
hyperosteogeny [in Chinese]. Chinese Acupuncture &
Moxibustion 2008;28(12):8779. [CO2010]
Liu 2013 {published data only}
Liu M, Mu J, Zheng S, Ren C. Efficacy observation on
cervical spondylosis of nerve root type treated by the warm

25
needling at Jiajl EX-B 2 and tapping with plum-blossom

needle. World Journal of Acupuncture - Moxibustion 2014;23
(4):610.
Lixing 2000 {published data only}
Lixing Z. Twenty one cases of vertebral-artery-type cervical
spondylosis treated with acupuncture and moxibustion.
Journal of Traditional Chinese Medicine 2000;20(4):2801.
[CO2006]
Llamas-Ramas 2014 {published data only}
Llamas-Ramos R, Pecos-Martin D, Gallego-Izquierdo T,
Llamas-Ramos I, Plaza-Manzano G, Ortega-Santiago R,
et al. Comparison of the short-term outcomes between
trigger point dry needling and trigger point manual therapy
for the management of chronic mechanical neck pain: a
randomized clinical trial. Journal of Orthopaedic & Sports
Physical Therapy 2014;44(11):85261.
Loy 1983 {published data only}
Loy T. Treatment of cervical spondylosis: electroacupuncture
versus physiotherapy. The Medical Journal of Australia 1983;
2:324.
Lu 2006 {published data only}
L YX, Shan QH. Clinical observation on treatment
of cervicogenic headache with turtle-probing needle at
Tianzhu (BL 10) [in Chinese]. Chinese Acupuncture &
Moxibustion 2006;26(11):7968. [CO2009]
Lundeburg 1988 {published data only}
Lundeburg T, Hurtig T, Lundeburg S, Thomas M. Longterm results of acupuncture in chronic head and neck pain.
The Pain Clinic 1988;2(1):1531. [CO02;2947]
Lundeburg 1991 {published data only}
Lundeburg T, Eriksson SV, Lundeberg S, Thomas M. Effect
of acupuncture and naloxone in patients with osteoarthritis
pain. A sham acupuncture controlled study. The Pain Clinic
1991;4(3):15561.
Luo 2010 {published data only}
Luo B, Han J. Cervical spondylosis treated by acupuncture
at Ligou (LR 5) combined with movement therapy. Journal
of Traditional Chinese Medicine 2010;30(2):1137.
Ma 2010 {published data only}
Ma C, Wu S, Li G, Xiao X, Mai M, Yan T. Comparison
of miniscalpel-needle release, acupuncture needling, and
stretching exercise to trigger point in myofascial pain
syndrome. The Clinical Journal of Pain 2010;26(3):2517.
MacPherson 2013 {published data only}
Macpherson H, Tilbrook, HE, Richmond SJ, Atkin K,
Ballard K, Bland M, et al. Alexander technique lessons,
acupuncture sessions or usual care for patients with chronic
neck pain (ATLAS): study protocol for a randomised
controlled trial. Trials 2013;14:209.
McLean 2013 {published data only}
McLean SM, Klaber Moffett JA, Sharp DM, Gardiner E.
A randomised controlled trial comparing graded exercise
treatment and usual physiotherapy for patients with nonspecific neck pain (the GET UP neck pain trial). Manual
Therapy 2013;18:199205.
Muller 2005 {published data only}

Muller R, Giles LG. Long-term follow-up of a randomized
clinical trial assessing the efficacy of medication,
acupuncture, and spinal manipulation for chronic
mechanical spinal pain syndromes. Journal of Manipulative
and Physiological Therapeutics 2005;28(1):311. [CO2009]
Myburgh 2012 {published data only}
Myburgh C, Hartvigsen J, Aagaard P, Holsgaard-Larsen
A. Skeletal muscle contractility, self-reported pain and
tissue sensitivity in females with neck/shoulder pain and
upper trapezius myofascial trigger points- a randomized
intervention study. Chiropractic & Manual Therapies 2012;
20:36.
Nakajima 2015 {published data only}
Nakajima M, Inoue M, Itoi M, Kitakoji H. Difference in
clinical effect between deep and superficial acupuncture
needle insertion for neck-shoulder pain: a randomized
controlled clinical trial pilot study. Journal of the Japanese
Society of Balneology, Climatology and Physical Medicine
2015;78(3):21627.
Pan 2008 {published data only}
Pan C, Tan G. Forty-two cases of greater occipital neuralgia
treated by acupuncture plus acupoint-injection. Journal of
Traditional Chinese Medicine 2008;28(3):1757.
Pecos-Martin 2015 {published data only}
Pecos-Mart n D, Montanez-Aguilera F, Gallego-Izquierdo
T, Urraca-Gesto A, Gomez-Conesa A, Romero-Franco
N, et al. Effectiveness of dry needling on the lower
trapezius in patients with mechanical neck pain: a
randomized controlled trial. Archives of Physical Medicine
and Rehabilitation 2015;96:77581.
Peng 1987 {published data only}
Peng A, Behar S, Shyh-Jong Y. Long-term therapeutic effects
of electro-acupuncture for chronic neck and shoulder pain
- a double blind study. Acupuncture & Electrotherapeutics
Research 1987;12(1):3744. [CO2010]
Rayegani 2014 {published data only}
Rayegani SM, Bayat M, Hasan Bahrami M, Raeissadat SA,
Kargozar E. Comparison of dry needling and physiotherapy
in treatment of myofascial pain syndrome. Clinical
Rheumatology 2014;33:85964.
Salter 2006 {published data only}
Salter GC, Roman M, Bland MJ, MacPherson H.
Acupuncture for chronic neck pain: a pilot for a randomised
controlled trial. BMC Musculoskeletal Disorders 2006;7:99.
[CO2010]
Sato 2014 {published data only}
Sato K, Oliveira A, Lima A. Effectiveness of dry needling
reduction myofascial trigger point pain in the trapezius
muscle. The Journal of Pain 2014;S1:S117.
Sator-Katzenschlager 2003 {published data only}
Sator-Katzenschlager SM, Szeles JC, Scharbert G, MichalekSauberer A, Kober A, Heinze G, et al. Electrical stimulation
of auricular acupuncture points is more effective than
conventional manual auricular acupuncture in chronic

26
cervical pain: a pilot study. Anesthesia & Analgesia 2003;97:

146973. [CO2010]
Seo 2014 {published data only}
Seo B-K, Lee J-H, Kim P-K, Baek Y-H, Jo D-J, Lee S.
Bee venom acupuncture, NSAIDs or combined treatment
for chronic neck pain: study protocol for a randomized,
assessor-blind trial. Trials 2014;15:132.
Shang 2002 {published data only}
Shang XK, Meng XW, Dong HY, Liu GW. Clinical
observations on the treatment of nerve-root cervical
spondylopathy by the combination of adjacent and remote
acupoints [in Chinese]. Shanghai Journal of Acupuncture
and Moxibustion 2002;21(6):123. [CO2009]
Shuangquan 2003 {published data only}
Shuangquan Y. The therapeutic effects of triple puncture
and routine body needling for cervical spondylosis. Journal
of Traditional Chinese Medicine 2003;23(4):2823.
Soderlund 2001 {published data only}
Sderlund A, Lindberg P. Cognitive behavioural
components in physiotherapy management of chronic
whiplash associated disorders (WAD) - a randomised group
study. Physiotherapy Theory and Practice 2001;17:22938.
[CO2003]
Sun Z, Yue J, Zhang Q. Electroacupuncture at Jing-jiaji
points for neck pain caused by cervical spondylosis: a study
protocol for a randomized controlled pilot trial. Trials 2013;
14:360.
Takakura 2014 {published data only}
Takakura N, Takayama M, Kawase T, Kaptchuk T, Kong
J, Yajima H. Design of a randomised acupuncture trial
on functional neck/shoulder stiffness with two placebo
controls. BMC Complementary and Alternative Medicine
2014;14:246.
Teng 1973 {published data only}
Teng C. Effect of acupuncture and physical therapy. Archive
of Physical Medicine and Rehabilitation 1973;53:601.
[CO97]
Tobbackx 2013 {published data only}
Tobbackx Y, Meeus M, Wauters L, DeVilder P, Roose J,
Verhaeghe T, et al. Does acupuncture activate endogenous
analgesia in chronic whiplash-associated disorders? A
randomized crossover trial. European Journal of Pain 2013;
17:27989.
Venancio 2008 {published data only}
Venncio Rde A, Alencar FG, Zamperini C. Different
substances and dry-needling injections in patients
with myofascial pain and headaches. The Journal of
Craniomandibular Practice 2008;26(2):96103. [CO2010]
Venancio 2009 {published data only}
Venancio Rde A, Alencar FG, Zamperini C. Botulinum
toxin, lidocaine, and dry-needling injections in patients
with myofascial pain and headaches. The Journal of
Craniomandibular Practice 2009;27(1):4653. [CO2010]
Wan 2013 {published data only}

Wan B, Huang W, Zhang Y, Zhang H. Influence of
electroacupuncture with penetration needling method on
comprehensive pain in patients with cervical spondylotic
radiculopathy. Chinese Acupuncture & Moxibustion 2013;33
(5):40710.
Wang 2007 {published data only}
Wang XL, Huang HY. Observation on therapeutic effect
of long-time needle retention at Baihui (GV 20) on
vertebroarterial cervical spondylopathy [Article in Chinese].
[CO2010]
Wang 2008 {published data only}
Wang XL. Observation on therapeutic effect of Shuneedling therapy as main on cervical spondylosis of nerve
root type [in Chinese]. Chinese Acupuncture & Moxibustion
2008;28(7):4978. [CO2009]
Wang G 2014 {published data only}
Wang G, Gao Q, Hou J, Li J. Effects of temperature
on chronic trapezius myofascial pain syndrome during
dry needling therapy. Evidence-Based Complementary and
Alternative Medicine 2014;638268:19.
Xu 2012 {published data only}
Xu S, Liang Z, Fu W. Chronic neck pain of cervical
spondylosis treated with acupuncture and moxibustion
in terms of the heart and kidney theory: a randomized
controlled trial. Chinese Acupuncture & Moxibustion 2012;
32(9):76975.
Xue 2007 {published data only}
Xue B, Fan L, Hu L. Clinical observation on cervical
spondylopathy vertebroarterial type treated by electroacupuncture. Journal of Traditional Chinese Medicine 2007;
27(1):3942. [CO2010]
Yang 2009 {published data only}
Yang T, Sun F, Zhou YL. Clinical observation on acupoint
sticking therapy for treatment of chronic pain of cervical
intervertebral disc [in Chinese]. Chinese Acupuncture &
Moxibustion 2009;29(3):1979. [CO2010]
Yang 2013 {published data only}
Yang J, Zhang J, Yu J, Han J. Treatment of cervical
spondylosis by spinal balancing combined with intervention
of pathway of qi: a randomized controlled study. Chinese
Acpuncture & Moxibustion 2013;33(7):5826.
Yoon 2009 {published data only}
Yoon S-H, Rah UW, Sheen SS, Cho KH. Comparison
of 3 needle sizes for trigger point injection in myofascial
pain syndrome of upper and middle trapezius muscle: a
Rrandomized controlled trial. Archives of Physical Medicine
and Rehabilitation 2009;90:13329.
Yoshimizu 2012 {published data only}
Yoshimizu M, Teo AR, Masahiko A, Kiyohara K,
Kawamur T. Relief of chronic shoulder and neck pain
by electro-acupuncture and transcutaneous electrical
nervous stimulation: a randomized crossover trial. Medical
Acupuncture 2012;24(2):97103.

27
Yu 2003 {published data only}

Yu SQ. The therapeutic effects of triple puncture and
routine body needling for cervical spondylosis. Journal of
Traditional Chinese Medicine 2003;23(4):2823. [CO2006]
Zhu 2002 {published data only}

Zhu XM, Polus B. A controlled trial on acupuncture for
chronic neck pain. American Journal of Chinese Medicine
2002;30(1):1328.
Zeng 2005 {published data only}

Zeng L. Treatment of cervical spondylopathy by pointthrough-point acupuncture [in Chinese]. Shanghai
Journal of Acupuncture and Moxibustion 2005;24(7):910.
[CO2009]
Zhu 2006 {published data only}

Zhu HZ, Quan WC, Zhang XF, Qiao JL, Liu ZJ, Fu P, et
al. Evaluation on clinical therapeutic effect of needle-knife
therapy on cervical spondylosis. Chinese Acupuncture &
Moxibustion 2006;26(5):3168. [CO2009]
Zhang 1996 {published data only}

Zhang H. A study of cervical spondylosis treated with
the chrysanthemum pillow with median hole and
electroacupuncture. Journal of Chinese Medicine 1996;51:
1820. [CO1997]
Zhuang 2004 {published data only}

Zhuang LX, Zhu FP. Effect of pressed acupuncture at baihui
acupoint on thromboxane A2 and prostacyclin in treating
vertebral artery type of cervical spondylosis. Chinese Journal
of Clinical Rehabilitation 2004;8(30):66723. [CO2009]
Zhang 2003 {published data only}

Zhang HL, Jin R. A randomized controlled trial of
electroacupuncture and traction for treatment of nerve-root
type cervical spondylosis [in Chinese]. Chinese Acupuncture
& Moxibustion 2003;23(11):6379. [CO2010]
Ziaeifar 2014 {published data only}

Ziaeifar M, Arab AM, Karimi N, Nourbakhsh MR. The
effect of dry needling on pain, pressure pain threshold and
disability in patients with a myofascial trigger point in the
upper trapezius muscle. Journal of Bodywork & Movement
Therapies 2014;18:298305.
Zhang J 2008 {unpublished data only}

Zhang J. Electroacupuncture and Laser Therapy on Neck
Pain. https://clinicaltrials.gov/ct2/show/NCT00618878
NCT00618878.
Zhang J 2013 {published and unpublished data}
Zhang J. Ashi point massage combined with warming
needle acupuncture in treating 40 cases of cervicogenic
headache. International Journal of Clinical Acupuncture
2013;22(3):1179.
Zhang X-Z 2013 {published data only}
Zhange X-Z, Wang L-L, Liu Y-Q. Clinical observation
on cervical headache treated with acupuncture and fire
needling technique. Chinese Acupuncture & Moxibustion
2013;33(11):98992.
Zhao 2004 {published data only}
Zhao ZY, Cai DJ, Liang FR. Observation on therapeutic
effect of Shencongding moxibustion on cervical headache
[in Chinese]. Chinese Acupuncture & Moxibustion 2004;24
(6):38991. [CO2009]
Zheng 2014 {published data only}
Zheng Y, Shi D, Wu X, Gu M, Ai Z, Tang K, et al.
Ultrasound-guided miniscalpel-needle release versus dry
needling for chronic neck pain: a randomized controlled
trial. Evidence-Based Complementary and Alternative
Medicine 2014;235817:18.
Zhi 2008 {published data only}
Zhi L, Feng C, Tu C. Controlled randomized trial on
therapeutic effects of acupotomy-injection combined with
Fengs spinal manipulation (FSM) for treating cervical
spondylotic radiculopathy. China Journal of Orthopaedics
and Traumatology 2008;21(6):4214. [CO2009]
Zhou 2014 {published data only}
Zhou J, Li X, Zhao J, Wang L-S, Wang L, Yang Y. Treatment
of 30 patients with cervical spondylotic radiculopathy
by acupuncture plus warming-needle moxibustion: a
randomized controlled trial. World Journal of Acupuncture Moxibustion 2014;24(4):248.
References to studies awaiting assessment

Amos 2012 {published data only}
Amos Z, Yoav M, Guy A, Adi F, Yigal M, Shmuel BH.
A randomised controlled trial of an integrative approach
utilising acupuncture for back and neck pain in an
emergency department setting. European Journal of
Integrative Medicine 2012;4S:234.
Bar-Haim 2012 {published data only}
Bar-Haim S. Acupuncture for Back and Neck Pain
in an Emergency Room Setting. clinicaltrials.gov
NCT00859365.
Cerezo-Tellez 2014 {unpublished data only}
Cerezo-Tellez E. Dry Needling of the Trapezius Muscle
in Office Workers With Neck Pain. Randomised, Single
Blinded Clinical Trial, 2014. http://ClinicalTrials.gov/
show/NCT02219386.
Choi 2011 {unpublished data only}
Choi DY. Acupuncture for Whiplash Associated Disorder.
http://ClinicalTrials.gov/show/NCT01395511.
Guo 2014 {unpublished data only}
Guo Y. Efficacy of Abdominal Acupuncture for Neck Pain:
A Randomized Controlled Trial. http://apps.who.int/
trialsearch/AdvSearch.aspx ChiCTRTRC14004932.
Liguori 2012 {published data only}
Liguori S, Liguori A, Petti F. Abdominal acupuncture and
cervicobrachialgia: is it a real possibility for setting a doubleblind trial in acupuncture research?. European Journal of
Integrative Medicine 2012;4S:31.
Mejuto-Vzquez 2014 {published data only}
Mejuto-Vzquez MJ, Salom-Marino J, Ortega-Santiago
R, Truyols-Domnguez S, Fernndez-de-las-Peas C.
Short-term changes in neck pain, widespread pressure
pain sensitivity, and cervical range of motion after the
application of trigger point dry needling in patients with

28
acute mechanical neck pain: a randomized clinical trial.

Journal of Orthopaedic & Sports Physical Therapy 2014;44
(4):25260.
Simma-Kletscha 2009 {published data only}
Simma-Kletschka I, Gleditsch J, Simma L, Piehslinger
E. Microsystems acupuncture in craniomandibular pain
syndromes - a randomised controlled trial. Deutsche
Zeitschrift fur Akupunktur 2009;52:711.
Sterling 2015 {published data only}
Sterling M, Valentin S, Vincenzino B, Souvlis T, Connelly
LB. Dry needling and exercise for chronic whiplash - a
randomised controlled trial. BMC Musculoskeletal Disorders
2009;10:160.
Sterling M, Vincenzino B, Souvlis T, Connelly LB. Dryneedling and exercise for chronic whiplash-associated
disorders: a randomized single-blind placebo-controlled
trial. Pain 2015;156(4):63543.
Wilke 2014 {published data only}
Wilke J, Vogt L, Niederera D, Hbscher M, Rothmayra J,
Ivkovic D, et al. Short-term effects of acupuncture and
stretching on myofascial trigger point pain of the neck: a
blinded, placebo-controlled RCT. Complementary Therapies
in Medicine 2014;22:83541.
Zhang SP 2013 {published data only}
Zhang SP. Electrotherapy for Chronic Neck Pain.
clinicaltrials.gov NCT00826215.
Zhang SP, Chiu TTW, Chiu A. Long-term efficacy of
electroacupuncture for chronic neck pain: a randomised
controlled trial. Hong Kong Medical Journal 2013;19(Suppl
9):S369.
References to ongoing studies

Calamita 2015 {published data only}
Calamita S, Biasotto-Gonzalez D, De Melo N, Meira dos
Santos D, de Lassa R, de Mendona F, et al. Evaluation of
the immediate effect of acupuncture on pain, cervical range
of motion and electromyographic activity of the upper
trapezius muscle in patients with nonspecific neck pain:
study protocol for a randomized controlled trial. Trials
2015;16:1.
Kim 2014 {published data only}
Kim K-H, Ryu-J-H, Park MR, Kim YI, Min MK, Park YM,
et al. Acupuncture as analgesia for non-emergent acute nonspecific neck pain, ankle sprain and primary headache in
an emergency department setting: a protocol for a parallel
group, randomised, controlled pilot trial. BMJ Open 2014;
4:18.
Liang Z-H, Di Z, Jiang S, Xu S-J, Zhu X-P, Fu W-B. The
optimized acupuncture treatment for neck pain caused by
cervical spondylosis: a study protocol of a multi-centre
randomized controlled trial. Trials 2012;13:107.
Que 2013 {published data only}
Que Q, Ye X, Su Q, Weng Y, Chu J, Mei L, et al.
Effectiveness of acupuncture intervention for neck pain
caused by cervical spondylosis: study protocol for a

randomized controlled trial. Trials 2013;14:186.
Sun Z, Yue J, Tian H, Zhang Q. Acupuncture at Houxi (SI
3) acupoint for acute neck pain caused by stiff neck: study
protocol for a pilot randomised controlled trial. BMJ Open
2014;4:1.
Additional references
Boutron 2005
Boutron I, Moher D, Tugwell P, Giraudeau B, Poiraudeau
S, Nizard R, et al. A checklist to evaluate a report of a
non pharmacological trial (CLEAR NPT) was developed
using consensus. Journal of Clinical Epidemiology 2005;58:
123340.
Carroll 2008
Carroll LJ, Hogg-Johnson S, van der Velde G, Haldeman S,
Holm LW, Carragee EJ, et al. Course and prognostic factors
for neck pain in the general population - results of the bone
and joint decade 2000-2010 task force on neck pain and its
associated disorders. Spine 2008;33(4S): S7582.
Chen 2009
Chen LI, Zhang J, Li F, Qiu Y, Wang L, Li YH, et al.
Endogenous anandamide and cannabinoid receptor-2
contribute to electroacupuncture analgesia in rats. Journal
of Pain 2009;10(7):7329.
Cicchetti 1976
Cicchetti DV. Assessing inter-rater reliability for rating
scales: resolving some basic issues. British Journal of
Psychiatry 1976;129:4526.
Cohen 1988
Cohen J. Statistical Power Analysis for the Behavioural
Sciences. 2nd Edition. Hilldale, NJ: Lawrence Erlbaum
Associates, 1988:Lawance Erlbaum.
Cote 2004
Cote P, Cassidy J, Carroll L, Kristman V. The annual
incidence and course of neck pain in the general population:
a population-based cohort study. Pain 2004;112(3):
26773.
Ezzo 2000
Ezzo J, Berman B, Hadhazy VA, Jadad AR, Lao L, Singh
BB. Is acupuncture effective for the treatment of chronic
pain? A systematic review. Pain 2000;86:21725.
Fu 2009SR
Fu L-M, Li J-T, Wu W-S. Randomized controlled trials of
acupuncture for neck pain: systematic review and metaanalysis. Journal of Alternative and Complementary Medicine
2009;15(2):13345.
Furlan 2005
Furlan AD, van Tulder MW, Cherkin DC, Tsukayama H,
Lao L, Koes BW, et al. Acupuncture and dry needling for
low back pain: an updated systematic review within the
framework of The Cochrane Collaboration. Spine 2005;30:
94463.

29
Furlan 2009
Furlan A, Pennick V, Bombardier C, van Tulder M. Updated
method guidelines for systematic reviews in The Cochrane
Collaboration Back Review Group. Spine 2009;34(18):
192941.
Huang 2012SR
Huang W, Pach D, Napadow V, Park K, Long X, Neumann
J, et al. Characterizing acupuncture stimuli using brain
imaging with FMRI - a systematic review and meta-analysis
of the literature. PLoS One 2012;7(4):e32960.
Furlan 2012
Furlan AD, Yazdi F, Tsertsvadze A, Gross A, Van Tulder
M, Santaguida L, et al. A systematic review and metaanalysis of efficacy, cost-effectiveness, and safety of selected
complementary and alternative medicine for neck and lowback pain. Evidence-Based Complementary and Alternative
Medicine 2012;2012:161.
Irnich 2011
Irnich D, Salih N, Offenbcher M, Fleckenstein J. Is
sham laser a valid control for acupuncture trials?. Journal
of Evidence-Based Complementary & Alternative Medicine
2011;2011(485945):8.
Goldman 2010
Goldman N, Chen M, Fujita T, Xu Q, Peng W, Liu W, et
al. Adenosine A1 receptors mediate local anti-nociceptive
effects of acupuncture. Nature Neuroscience 2010;13(7):
8838.
Graham 2012
Graham N, Haines T, Goldsmith CH, Gross A, Burnie S,
Shahzad U, et al. Reliability of 3 assessment tools used to
evaluate randomized controlled trials for treatment of neck
pain. Spine 2012;37(6):51522.
Jadad 1996
Jadad AR, Moore RA, Corroll D, Jenkinson C, Reynolds
DJ, Gavagha DJ, et al. Assessing the quality of reports
of randomized controlled trials: is blinding necessary?.
Controlled Clinical Trials 1996;17(1):112.
Langevin 2006
Langevin HM, Bouffard NA, Badger GJ, Churchill DL,
Howe AK. Subcutaneous tissue fibroblast cytoskeletal
remodeling induced by acupuncture: evidence for a
mechanotransduction-based mechanism. Journal of Cell
Physiology 2006;207:76774.
Graham 2013
Graham N, Gross AR, Carlesso LC, Santaguida PL,
MacDermid JC, Walton D, et al. An ICON overview on
physical modalities for neck pain and associated disorders.
Open Orthopaedics Journal 2013;7(Suppl 4 M6):44060.
Linde 2007
Linde K, Witt CM, Streng A, Weidenhammer W,
Wagenpfeil S, Brinkhaus B, et al. The impact of patient
expectations on outcomes in four randomized controlled
trials of acupuncture in patients with chronic pain. Pain
2007;128(3):26471.
Gross 2007
Gross AR, Goldsmith C, Hoving JL, Haines T, Peloso P,
Aker P, et al. Conservative management of mechanical neck
disorders: a systematic review. The Journal of Rheumatology
2007;34(3):1083102.
Linde 2009
Linde K, Allais G, Brinkhaus B, Manheimer E, Vicker A,
White A. Acupuncture for migraine prophylaxis. Cochrane
Database of Systematic Reviews 2009;1(1):1.
Haldeman 2008
Haldeman S, Carroll LJ, Cassidy JD. The empowerment of
people with neck pain: Introduction - The bone and joint
decade 2000-2010 task force on neck pain and its associated
disorders. Spine 2008;33(4S):S813.
Han 2004
Han JS. Acupuncture and endorphins. Neuroscience Letters
2004;361(1-3):25861.
Haraldsson 2006
Haraldsson B, Gross A, Myers CD, Ezzo J, Morien A,
Goldsmith CH, et al. Massage for mechanical neck
disorders. Cochrane Database of Systematic Reviews 2006;3
(CD004871):1.
Higgins 2011
Higgins JPT, Green S (editors). Cochrane Handbook for
Systematic Reviews of Interventions Version 5.1.0 [updated
March 2011]. www.cochrane-handbook.org 2011;5.1.0:1.
Hogg-Johnson 2008
Hogg-Johnson S, van der Velde G, Carroll LJ, Holm LW,
Cassidy JD, Guzman J, et al. The burden and determinants
of neck pain in the general population - results of the bone
and joint decade 2000-2010 task force on neck pain and its
associated disorders. Spine 2008;33(4S):S3951.
Linde 2009a
Linde K, Allais G, Brinkhaus B, Manheimer E, Vicker A,
White A. Acupuncture for tension-type headache. Cochrane
Database of Systematic Reviews 2009;1(1):1.
Miller 2010
Miller J, Gross A, DSylva J, Burnie SJ, Goldsmith CH,
Graham N, et al. Manual therapy and exercise for neck pain:
a systematic review. Manual Therapy 2010;15:33454.
Olesen 1988
Olesen J. Classification and diagnostic criteria for headache
disorders, cranial neuralgias and facial pain. Cephalalgia
1988;8(7):612.
Olesen 1997
Olesen J, Gobel H. ICD-10 Guide for Headaches. Guide
to the classification, diagnosis and assessment of headaches
in accordance with the Tenth Revision of the International
Classification of Diseases and Related Health Problems and
Its Application to Neurology. Cephalagia 1997;17(Suppl
19):2930.
Schumacher 1993
Schumacher HR, Klippel JH, Koopman WJ (eds). Primer
on the Rheumatic Diseases. 10th Edition. Atlanta: Arthritis
Foundation, 1993.

30
Sjaastad 1990
Sjaastad O, Fredriksen TA, Pfaffenrath V. Cervicogenic
headache: diagnostic criteria. Headache 1990;30:7256.
disorders. Cochrane Database of Systematic Reviews 2006;3

(CD004870):1.
Spitzer 1987
Spitzer WO, Leblanc FE, Dupuis M. Scientific approach to
the assessment and management of activity related spinal
disorders. Spine 1987;Suppl 7:S159.
van Tulder 2003

van Tulder M, Furlan A, Bombardier C, Bouter L, Editorial
Board of the Cochrane Collaboration Back Review Group.
Updated method guidelines for systematic reviews in The
Cochrane Collaboration Back Review Group. Spine 2003;
28(12):12909.
Spitzer 1995
Spitzer WO, Skovron ML, Salmi LR, Cassidy JD,
Duranceau J, Suissa S, et al. Scientific monograph of the
Quebec Task Force on Whiplash-Associated Disorders:
redefining whiplash and its management. Spine 1995;
Suppl:1S73S.
Vernon 2009
Vernon H, Schneider M. Chiropractic management of
myofascial trigger points and myofascial pain syndrome: a
systematic review of the literature. Journal of Manipulative
and Physiological Therapeutics 2009;32(1):1424.
Tang 1997
Tang NM, Dong HW, Wang XM, Tsui ZC, Han JS.
Cholecystokinin antisense RNA increases the analgesic
effect induced by electroacupuncture or low dose morphine:
conversion of low responder rats into high responders. Pain
1997;71(1):7180.
Trinh 2004
Trinh KV, Phillips S, Ho E, Damsma K. Acupuncture in
alleviation of lateral epicondyle pain. Rheumatology 2004;
43:108590.
Trinh 2006
Trinh KV, Graham N, Gross AR, Goldsmith CH,
Wang E, Cameron ID, et al. Acupuncture for neck
Vickers 2004
Vickers AJ. Statistical re-analysis of four recent randomized
trials of acupuncture for pain using analysis of covariance.
Clinical Journal of Pain 2004;20(5):31923.
Zhang 2012
Zhang Y, Zhang RX, Zhang M, Shen XY, Xin J, Ren K,
et al. Electroacupuncture inhibition of hyperalgesia in an
inflammatory pain rat model: involvement of distinct spinal
serotonin and norepinephrine receptor subtypes. British
Journal of Anaesthesia 2012;109(2):24552.
Zhao 2008
Zhao ZQ. Neural mechanism underlying acupuncture
analgesia. Progress in Neurobiology 2008;85(4):35575.
Indicates the major publication for the study

31
CHARACTERISTICS OF STUDIES
Characteristics of included studies [ordered by study ID]

Birch 1998
Methods
RCT
Number analysed/randomised: 36/46
Intention-to-treat: NR
Power analysis: NR
Funding source: intramural grant from the Anesthesia Department of Brigham and
Womens Hospital, Boston, MA
Participants
Myofascial neck pain lasting 6 months

Participant recruitment: hospital-based pain management centre, neurology clinic, public announcement
Interventions
INDEX TREATMENT
Group 1 - relevant acupuncture (believed to be effective for the condition treated)
Pre-determined relevant points; shallow needling (2 to 3 mm) used with copper wire
containing silicone diode applied for stage 1 of session (10 minutes); infrared lamp also
used over points during stage 2 of treatment (10 minutes). Treatment done without Deqi
by a licensed acupuncturist with 13 years of experience
COMPARISON TREATMENT 1
Group 2 - irrelevant acupuncture
Same treatment dosage and duration as Group 1, using pre-determined irrelevant points
with copper wire attached but connections severed (stage 1) and placebo light (no heat
during stage 2)
Group 3 - medical control
NSAID 500 mg OD Trilisate, no acupuncture
CO-INTERVENTION
Avoided
Treatment schedule: 14 sessions over 12 weeks, with each session averaging 30 minutes
in duration
Duration of follow-up: immediate post treatment
Outcomes
PAIN INTENSITY (VAS 0 to 10 scale)

Baseline mean: relevant 4.8, irrelevant 4.7, control 4.9
End of study mean: relevant 1.87, irrelevant 3.37, control 4.73
Absolute benefit: relevant 2.93, irrelevant 1.33, control 0.17
Reported results: Relevant acupuncture group had significantly lower pain scores, including hourly ratings
SMD -2.52 (95% CI random -3.49 to -1.54) immediate post treatment
Reasons for drop-out: 2 moved, 6 not specified, 2 lost to contact
Adverse effects: NR
Costs of care: NR
Notes
--

32
Birch 1998
(Continued)
Risk of bias
Bias
Authors judgement
Support for judgement
Random sequence generation (selection Unclear risk

bias)
Not reported
Allocation concealment (selection bias)
Not reported
Unclear risk
Blinding (performance bias and detection Low risk

bias)
All outcomes - patient?
Adequately described
Blinding (performance bias and detection High risk

bias)
All outcomes - care provider?
Not possible

bias)
All outcomes - outcome assessor?
Participant blinded as outcome assessor of

self reports
Incomplete outcome data (attrition bias)

All outcomes - Drop out rate acceptable?
Described and acceptable
Low risk

High risk
All outcomes - Analyzed in the group to
which they were allocated?
Did not analyse; all randomised
Selective reporting (reporting bias)
Unclear risk
No protocol
Similarity of baseline characteristics
Low risk
Reported to be similar
Co-interventions avoided or similar?
Unclear risk
Not reported
Compliance acceptable?
Low risk
Each participant attended 14 sessions,

twice weekly
Similar timing of outcome assessment?
Low risk
All assessed at 12 weeks
Fatal Flaw
Low risk
Acceptable

33
Cameron 2011
Methods
RCT
Intention-to-treat: reported but not done
Power analysis: calculated
Funding source: government organisational funds
Participants
Subacute and chronic WAD

Participant recruitment: newspaper advertisement
University Clinic, Sydney, Australia
Interventions
INDEX TREATMENT
Group 1 - real electroacupuncture (EAP)
Acupuncture points = GB39, GB20, L114, SI6 bilaterally 1 to 1.5 cm depth; electrodes
attached to needles at 2 acupuncture points in the cervical area, plus 1 in each wrist and
ankle 2 to 5 Hz 1.5 v; unable to feel the current
COMPARISON TREATMENT
Group 2 - simulated EAP
Same treatment dosage and duration as Group 1, points 20 to 30 mm from selected
points; same attachment of electrodes but machine not turned on
CO-INTERVENTION
Comparable between groups; included medication, physiotherapy and chiropractic therapy
Treatment schedule: 2 sessions/wk over 6 weeks, with each session averaging 30 minutes
in duration
Duration of follow-up: 3 and 6 months
Outcomes
PAIN INTENSITY (VAS 10 cm scale)

Baseline mean: real EAP 5.3, simulated 5.8
End of study mean: real EAP 4.1, simulated 5.5
Absolute benefit: real EAP 1.2, simulated 0.3
Reported results: significant favouring real EAP group
SMD -0.38 (95% CI random -0.73 to -0.02) at 3 months
FUNCTION (NDI 50 point scale)
Reported results: not significant
SMD -0.22 (95% CI random -0.57 to 0.13) at 3 months
Quality of life (SF-36, Physical Component)
Reasons for drop-out: 8 in control group, no reasons given
Adverse effects: similar in both groups, including slight pain, sweating and decreased
blood pressure
Costs of care: NR

34
Cameron 2011
(Continued)
Notes
--
Risk of bias
Bias
Authors judgement
Random sequence generation (selection Low risk

bias)
Sequence generated by random numbers

table
Numbered opaque envelopes
Low risk

bias)
Adequately blinded

bias)
Not possible

bias)
Adequately blinded participant as outcome

assessor of self reports

Described and adequate
Low risk

High risk
Not all in control group analysed (52/60)
Low risk
Protocol provided by study author (grey literature)
Low risk
Unclear risk
Reported as no evidence of imbalance but

no results provided
Low risk
Reported and acceptable
Low risk
Baseline, 3 and 6 months
Fatal Flaw
Low risk
Acceptable

35
Chou 2009
Methods
RCT
Number Analysed/randomised: 10/10
Intention-to-treat: calculated
Power analysis: NR
Funding source: none
Participants
Chronic myofascial neck pain

Participant recruitment: pain control clinic, Taiwan
Interventions
INDEX TREATMENT
Remote acupuncture group (RA)
Acupuncture points - TE5, LI11; the needle was manipulated for the Deqi. First, TE5
was inserted and manipulated for 15 seconds; after 5 minutes, LI11 was treated in the
same way. Five minutes later, both needles were manipulated for 15 seconds at the same
time; manipulation stopped and needles remained inserted for 3 minutes
Sham acupuncture
Sham acupuncture needle inserted into rubber connector taped onto skin at TE5 and
LI11; needle contacted skin but did not penetrate. No manipulation of needle
CO-INTERVENTION
Avoided
Treatment schedule: 1 session
Outcomes
PAIN INTENSITY (0 to 10 VAS scale)

Baseline mean: RA 7.4, sham 7.4
End of study mean: RA 3.3, sham 7.1
Absolute benefit: RA 4.1, sham 0.3
Reported results: significant favouring acupuncture
Drop-outs: none
Adverse effects: NR
Costs of care: NR
Notes
--
Risk of bias
Bias
Authors judgement

bias)
Sequence was generated from a computerised randomisation programme
Not reported
Unclear risk

bias)

Described in the report
36
Chou 2009
(Continued)

bias)
Not possible

bias)
Described in the report

No drop-outs
Low risk

Low risk
All randomised participants were analysed
Unclear risk
No protocol
Low risk
Low risk
Avoided by design (pre/post)
Low risk
Acceptable by design (pre/post)
Low risk
Immediate post
Fatal Flaw
High risk
Main problem involves reporting errors

and statistical analyses. No estimate of
differences between groups, only percent
changes between groups; only evidence of
improvement in abstract results was noted
within groups, not between groups; Table
1 P values are incorrect for pain duration
and initial pain; no P values should be provided for % change data
Coan 1982
Methods
RCT
Power analysis: NR
Funding source: NR
Participants
Chronic mechanical neck disorder with radicular symptoms or signs

Participant recruitment: newspaper advertisement

37
Coan 1982
(Continued)
Interventions
INDEX TREATMENT
Acupuncture (treatment group)
Technique according to classical oriental meridian theory healing by stimulating energy
flow in the body; acupuncture points varied between participants and varied from day
to day; electroacupuncture and moxibustion were used in some participants; other treatment parameters were not specified
COMPARISON
Wait-list (control group)
Treatment schedule: 3 to 4 sessions/wk over 4 weeks
Duration of follow-up: 8 weeks
CO-INTERVENTION
Comparable between index and control groups for medication use only
Outcomes
PAIN (VAS scale 0 to 10)

Baseline mean: acupuncture 6.0, control 5.3
End of study mean: acupuncture 3.6, control 5.4
Absolute benefit: acupuncture 2.4, control -0.1
Reported results: significant improvement favouring acupuncture
SMD -0.74 (95% random CI -1.49 to 0.00) at 8 weeks
Reasons for drop-out: NA
Adverse effects: NR
Costs of care: NR
Notes
--
Risk of bias
Bias
Authors judgement

bias)
Equally sized and folded papers in a box,

half marked A, the other half B
Papers not concealed
High risk

bias)
Not blinded

bias)
Not possible

bias)
Participant as outcome assessor not blinded

No drop-outs
Low risk

38
Coan 1982
(Continued)

Low risk
No missing data
Unclear risk
No protocol
Low risk
High risk
Only medications reported, no other interventions mentioned
High risk
Not reported
Low risk
8 weeks after treatment
Fatal Flaw
Low risk
Acceptable
Fu 2009
Methods
RCT
Power analysis: NR
Funding source: State Ministry of Science and Technology
Participants
Chronic cervical spondylosis

Participant recruitment: Acupuncture Department of Guangdong Provincial Traditional
Chinese Medicine Hospital, China
Interventions
INDEX TREATMENT
Acupuncture group
Acupuncture points - Du14, ExHN15, SI15 needles inserted to muscle layer manipulated
for Deqi, then remained inserted for 20 minutes; infrared radiation
Sham
Superficial insertion 1 cm apart laterally from acupuncture points. Remained for 20
minutes, no manipulation; infrared radiation
CO-INTERVENTION
NR
Treatment schedule: once every other day for 9 sessions over 18 days
Duration of follow-up: immediate post treatment, 4 weeks, 3 months
Outcomes

Baseline mean: acupuncture 5.14, sham 5.58
End of study mean: acupuncture 2.89, sham 3.28 at 3 month follow-up
Absolute benefit: acupuncture 2.25, sham 2.30
Reported results: significant immediate post treatment favouring acupuncture but not
over long term

39
Fu 2009
(Continued)

SMD -0.59 (95% CI random -0.97 to -0.21) at 4 weeks
Northwick Park Pain Questionnaire (NPQ) (0 to 100)
End of study mean: acupuncture 20.55, sham 25.77
Reported results: significant immediate post treatment favouring acupuncture but not
over long term
Reasons for drop-out: 2 fainted, 3 inconvenient (rate 4.27%)
Adverse effects: 1 in each group fainted
Costs of care: NR
Notes
--
Risk of bias
Bias
Authors judgement

bias)
Computerised sequence number and

grouping address on a randomising card
Use of sealed opaque envelopes
Low risk

bias)
Described adequately in the report

bias)
Not possible

bias)
Participant as outcome assessor

Described and acceptable 4.27%
Low risk

High risk
Not all randomised participants were analysed
Unclear risk
No protocol
Low risk

40
Fu 2009
(Continued)
Unclear risk
Not reported
Unclear risk
Not reported
Low risk
Post, 4 weeks, 12 weeks
Fatal Flaw
High risk
No sample size justifications; multiple

comparisons should have been done; analysis should have been stratified by syndrome
type; time lines between points on graph
are distorted
He 2004
Methods
RCT
Power analysis: NR
Funding source: NR
Participants
Chronic neck pain

Participant recruitment: selected from 5 large companies in Oslo by the companys
occupational physician, Norway
Interventions
INDEX TREATMENT
Acupuncture
16 body points, 6 ear points, electrostimulation
Placebo
10 to 14 mm distal to real points or 4 to 6 mm for ear points; electrostimulation set up
but no voltage
CO-INTERVENTION
Reported, see Risk of bias
Treatment schedule: 3 times per week, over 3 to 4 weeks, for a total of 10 treatments,
with each session averaging 45 minutes in duration
Duration of follow-up: immediate post treatment, 6 months, 3 years
Outcomes

Baseline mean: acupuncture 57, placebo 48
End of study mean: acupuncture 15, placebo 36 immediate post treatment
Absolute benefit: acupuncture 42, placebo 12
Reported results: statistically significant favouring acupuncture at immediate post and 6
month follow-up
SMD -2.72 (95% CI random -3.89 to -1.56) at 3 years
Drop-outs: none
Adverse effects: NR

41
He 2004
(Continued)
Costs of care: NR
Notes
--
Risk of bias
Bias
Authors judgement

bias)
Randomisation by draw with replacement
Not reported
Unclear risk

bias)
Described in report

bias)
Not possible

bias)
Described in report

No drop-outs
Low risk

Low risk
All participants randomised were analysed,

described in report
Unclear risk
No protocol
High risk
Not similar with respect to PPT and duration of symptoms; also headache baseline
information not provided
High risk
21% of the intervention group and 50% of

the control group received other treatment
Low risk
All participants completed all 10 treatments
Low risk
All assessed immediate post, 6 months, 3

years
Fatal Flaw
Low risk
Acceptable

42
He 2005
Methods
RCT
Power analysis: NR
Funding source: NR
Participants
Chronic neck pain

Participant recruitment: selected from 5 large companies in Oslo by the companys
occupational physician, Norway
Interventions
INDEX TREATMENT
Acupuncture
16 body points, 6 ear points, electrostimulation
Placebo
10 to 14 mm distal to real points or 4 to 6 mm for ear points; electrostimulation but no
voltage
CO-INTERVENTION
Reported, see Risk of bias
Treatment schedule: 3 times/wk over 3 to 4 weeks for a total of 10 treatments, with each
session averaging 45 minutes in duration
Duration of follow-up: immediate post treatment, 6 months, 3 years
Outcomes

Baseline mean: acupuncture 57, placebo 48
End of study mean: acupuncture 15, placebo 36 at immediate post
Absolute benefit: acupuncture 42, placebo 12
Reported results: statistically significant favouring acupuncture at immediate post and 3
year follow-up
SMD -3.33 (95% CI random -4.78 to -1.88) at 3 years
Drop-outs: none
Adverse effects: NR
Costs of care: NR
Notes
--
Risk of bias
Bias
Authors judgement

bias)
Not reported adequately
Not reported
Unclear risk

bias)
Interventions perceivably different
43
He 2005
(Continued)

bias)
Not possible

bias)

No drop-outs
Low risk

Unclear risk
Not reported
Unclear risk
No protocol
Low risk
Low risk
Low risk
Each participant received 3 treatments/wk

to a total of 10
Low risk
All assessed at 6 months and 3 years
Fatal Flaw
Low risk
Acceptable
Ilbuldu 2004
Methods
RCT
Power analysis: NR
Funding source: NR
Participants
Chronic myofascial pain syndrome
Interventions
INDEX TREATMENT
Dry needling (dn) upper trapezius
Placebo laser
CO-INTERVENTION
Paracetamol as needed
Treatment schedule: dn once/wk over 4 weeks, placebo laser 3 sessions/wk over 4 weeks
Duration of follow-up: immediate post treatment and 6 months

44
Ilbuldu 2004
(Continued)
Outcomes
PAIN INTENSITY (VAS activity 10 cm scale)

Baseline mean: dn 7.62, placebo 7.65
End of study mean: dn 4.24, placebo 4.22
Absolute benefit: dn 3.38, placebo 3.43
Reported results: significant differences favouring laser compared with dn and placebo
post treatment only
SMD -0.02 (95% CI random -0.64 to 0.60) immediate post treatment
SMD 0.01 (95% CI random -0.61 to 0.63 at 6 months
FUNCTION: Nottingham Health Profile Physical Activity Component (0 to 100)
Baseline mean: dn 32.80, placebo 25.59
End of study mean: dn 13.68, placebo 16.08
Absolute benefit: dn 19.12, placebo 9.51
Reported results: significant differences favouring laser compared with dn and placebo
SMD 0.22 (95% CI random -0.40 to 0.84) immediate post treatment
Adverse effects: NR
Costs of care: NR
Notes
--
Risk of bias
Bias
Authors judgement

bias)
Not reported
Not reported
Unclear risk

bias)

bias)
Not possible

bias)

Not described, no ns in tables
High risk

Unclear risk

Not reported
45
Ilbuldu 2004
(Continued)
Unclear risk
No protocol
Low risk
Unclear risk
Followed medication use only
Unclear risk
Not reported
Low risk
All assessed immediately post treatment

and at 6 months
Fatal Flaw
High risk
Unclear randomisation, allocation concealment; drops-outs not described; unclear

whether ITT done
Irnich 2001
Methods
RCT
Intention-to-treat: reported
Power analysis: NR
Funding source: German Ministry for Education and Research. Manuscript preparation
supported by German Medical Acupuncture Association
Participants
Chronic mechanical neck disorder

Participant recruitment: outpatient departments at the University of Munich
Interventions
INDEX TREATMENT
Acupuncture
TCM plus ear acupuncture and dry needling of myofascial points. Local points - UB10,
active myofascial trigger points were located predominantly in the trapezius (nearby
GB20) and levator scapulae (nearby SI14). Distal points - SI3, UB60, Liv3, GB34,
TW5, ear point (cervical spine)
Sham laser acupuncture (control)
Laser pen inactivated - each point treated for 2 minutes
CO-INTERVENTION
Not reported
Treatment schedule: 5 sessions over 3 weeks, each session 30 minutes in duration
Outcomes
PAIN INTENSITY (VAS 100-point scale) for motion-related pain

Baseline mean: acupuncture 54.15, sham laser acupuncture 57.15
End of study mean: acupuncture 28.27, sham laser acupuncture 40.82
Absolute benefit: acupuncture 25.88, sham laser acupuncture 16.33
Reported results: no significant differences between groups
SMD -0.25 (95% CI random -0.62 to 0.13) at 1 week

46
Irnich 2001
(Continued)
PAIN PRESSURE THRESHOLD (PPT kg/cm2 )

Baseline mean: acupuncture 1.07, sham laser acupuncture 1.05
End of study mean: acupuncture 0.19, sham laser acupuncture 0.03
Absolute benefit: acupuncture 0.88, sham laser acupuncture 1.02
SMD 0.16 (95% CI random -0.21 to 0.54) immediate post treatment
SMD 0.23 (95% CI random -0.15 to 0.61) at 3 months
Reasons for drop-out: withdrew, refused treatment, accident, diagnosed with other medical condition, lost to follow-up
Adverse effects: For acupuncture, complaints of slight pain and low blood pressure. For
sham laser acupuncture, complaints of slight pain, low blood pressure and sweating
Costs of care: NR
Notes
--
Risk of bias
Bias
Authors judgement

bias)
Block randomisation stratified for 2 centres
Not reported
Unclear risk

bias)

bias)
Not possible

bias)
Participant not blinded, then participant

as outcome assessor would not be blinded
either

Described and adequate
Low risk

Low risk
Reported in text
Unclear risk
No protocol
Low risk
Unclear risk
Not reported

47
Irnich 2001
(Continued)
Unclear risk
Not reported
Low risk
Assessed immediate post treatment, 3 days

after first treatment, 1 week and 3 months
Fatal Flaw
Low risk
Acceptable
Irnich 2002
Methods
RCT, cross-over
Intention-to-treat: NA
Power analysis: NR
Funding source: German Ministry for Education and Research
Participants
Chronic neck disorder without radicular symptoms

Participant recruitment: out-patients from the Department of Physical Medicine and
Rehabilitation and the Interdisciplinary Pain Unit at the University of Munich
Interventions
INDEX TREATMENT 1
Non-local needle acupuncture (NLA) at distant points according to the theory of channels of TCM and varied individually by therapist
INDEX TREATMENT 2
Dry needling (dn) of local myofascial trigger points with strong manual stimulation of
ah shi points
Sham laser acupuncture (SHAM)
CO-INTERVENTION
Not reported
Treatment schedule: each participant treated once with all interventions with a 1-week
wash-out period and each session averaging 30 minutes in duration
Duration of follow-up: immediately following completion of each treatment
Outcomes
PAIN INTENSITY (VAS 100 mm scale) for motion-related pain

Baseline mean: acupuncture (NLA) 35.0, (dn) 33.4, sham laser acupuncture 30.4
End of study mean: acupuncture (NLA) 19.1, (dn) 29.2, sham laser acupuncture 28.0
Absolute benefit: acupuncture (NLA) 15.9, (dn) 4.2, sham laser acupuncture 2.4
Reported results: NLA effective, dn not effective when compared with the sham
SMD 0.49 (95% CI random -0.98 to -0.01) NLA group immediate post treatment
SMD 0.06 (95% CI random -0.42 to 0.54) dn group immediate post treatment
Adverse effects: no serious adverse effects; however, 3 participants had mild hypotonia
and sweating (1 from NLA and 2 from dn groups)
Costs of care: NR
Notes
--
Risk of bias
48
Irnich 2002
(Continued)
Bias
Authors judgement

bias)
Cross-over design, 6 possible sequences assigned to a number from 1 to 6, random

list for 36 participants was then prepared
by rolling dice
Fully concealed
Low risk

bias)
Participant reported as blinded

bias)
Not possible for acupuncture group, only

sham laser acupuncture had caregiver
blinded

bias)
Participant blinded as outcome assessor

Low risk

High risk
Unclear risk
No protocol
Low risk
Unclear risk
Not reported
Low risk
Each participant received 1 treatment with

each intervention with 1-week wash-out
period between
Low risk
Assessed immediate post treatment
Fatal Flaw
Low risk
Acceptable

49
Itoh 2007
Methods
RCT
Intention-to-treat: not calculated
Power analysis: not calculated
Location: Japan
Funding source: Japan Society of Acupuncture and Moxibustion
Participants
Chronic neck pain, no radicular signs

Participant recruitment: Participants were recruited from the Meiji University of Oriental
Medicine Hospital
Interventions
INDEX TREATMENT 1
Standard acupuncture (SA)
Acupuncture points local: GB20, GB21, BL10, BL11, SI12, SI13; distal TE5, LI4, SI3
Inserted needles into the muscle (depth of 20 mm) using sparrow pecking technique;
manipulation stopped when participants reached Deqi, and needles were left in place
for an additional 10 minutes
INDEX TREATMENT 2
Trigger point acupuncture (TrP)
Local needling of myofascial trigger points (mean number of insertions 2.3)
Needles were inserted 20 mm into the skin over the trigger point by the sparrow pecking
technique. Manipulation was stopped when the local twitch response was elicited, and
the needle was left in place for an additional 10 minutes
INDEX TREATMENT 3:
Non-trigger point acupuncture (non-TrP)
Non-TrP group received the same treatment as above but at non-tender points (mean
number of insertions 2.4). The non-tender point chosen had no tenderness nor taut
muscle band. However, the point was selected in the same muscle but away from the
trigger point by 50 mm
Sham acupuncture (SH)
SH groups received treatment at trigger points. Similar stainless steel needles were used,
but the tips had been cut off and smoothed to prevent penetration of the skin by the needle
with the sparrow pecking technique. Simulation of needle extraction was performed
after 10 minutes (mean number of insertions 2.6)
CO-INTERVENTION
Not specified
Treatment schedule:
6 treatments within 10 weeks; applied in 2 phases of 3 treatments:
3 treatments within first 3 weeks, no treatment from week 4 to 7 and 3 treatments from
week 7 to 10
Outcomes
Groups
PAIN INTENSITY (VAS 0 to 100 mm)
Baseline mean: SA 69.5, TrP 67.0, non-TrP 70.9, SH 64.1
End of study mean: SA 51.6, TrP 11.0, non-TrP 57.6, SH 53.9
Absolute benefit: SA 17.9, TrP 56.0, non-TrP 13.3, SH 10.2
Reported results: statistically significant improvement in the TrP group only
SA vs SH: SMD -0.24 (95% CI random -1.26 to 0.78) immediate post treatment

50
Itoh 2007
(Continued)
SA vs SH: SMD -0.10 (95% CI random -1.11 to 0.92) at 3 weeks

TrP vs SH: SMD -2.77 (95% CI random -4.31 to -1.24) immediate post treatment
TrP vs SH: SMD -2.37 (95% CI random -3.78 to -0.95) at 3 weeks
Non-TrP vs SH: SMD 0.23 (95% CI random -0.79 to 1.25) immediate post treatment
Non-TrP vs SH: SMD -0.01 (95% CI random -1.03 to 1.00) at 3 weeks
DISABILITY: NECK DISABILITY INDEX (NDI 0 to 50 point scale)
Baseline mean: SA 12.6, TrP 13.0, non-TrP 15.1, SH 12.0
End of study mean: SA 10.9, TrP 3.1, non-TrP 12.0, SH 11.1
Absolute benefit: SA 1.7, TrP 9.9, non-TrP 3.1, SH 0.9
Reported results: TrP group demonstrated greatest improvement
SA vs SH: SMD -0.19 (95% CI random -1.21 to 0.83) immediate post treatment
SA vs SH: SMD -0.03 (95% CI random -1.05 to 0.98) at 3 weeks
TrP vs SH: SMD -2.81 (95% CI random -4.36 to -1.26) immediate post treatment
TPA vs SH: SMD -1.82 (95% CI random -3.09 to -0.56) at 3 weeks
Non-TrP vs SH: SMD 0.38 (95% CI random -0.65 to 1.41) immediate post treatment
Non-TrP vs SH: SMD 0.18 (95% CI random -0.84 to 1.20) at 3 weeks
Drop-outs due to no response to treatment: SA 1, TPA 1, NTPA 1, SH 1
Drop-outs due to adverse effects: deterioration of symptoms, not specified SA 1, TPA
1, NTPA 0, SH 1
Costs of care: NR
Notes
--
Risk of bias
Bias
Authors judgement

bias)
Computer-generated randomisation
Not reported
Unclear risk

bias)
Participants not adequately blinded

bias)
Not possible

bias)

adequately

Discrepancy between Table 2, Figure 3 and

text
High risk

51
Itoh 2007
(Continued)

High risk
ns in Figure 3 do not add up
Unclear risk
No protocol
Unclear risk
Table 2 gives only baseline info on those

who completed the trial, not those randomised
Unclear risk
Not reported
Unclear risk
Not reported
Low risk
Assessed immediately post treatment
Fatal Flaw
High risk
Numbers in flow charts and tables do not

add up
Kwak 2012
Methods
RCT
Intention-to-treat: reported
Power analysis: NR
Funding source: University of Tsukuba, Japan
Participants
WAD symptoms 3 months or longer

Participant recruitment: through advertisements in local newspapers and on the homepage of the Kyung Hee Medical Center
Interventions
INDEX TREATMENT
Acupuncture
Acupuncture points from the gallbladder (GB), small intestine (SI), bladder (BL), triple
energiser (TE) and large intestine (LI) meridian systems located on shoulder, neck, head
and upper limbs. Needles (length 40 mm; diameter 0.16 mm, SEIRIN Co. Ltd) were
inserted perpendicularly to a depth of 1.0 to 2.0 cm in place for 15 minutes
COMPARISON
Wait-list
CO-INTERVENTION
Both groups maintained their usual care, including physiotherapy, exercise and sufficient
rest
Treatment schedule: Treatment consisted of 6 sessions, 3/wk for 2 weeks
No follow-up
Outcomes

Baseline mean: acupuncture 4.59, wait-list 4.88
End of study mean: acupuncture 2.74, wait-list 4.47 immediate post treatment

52
Kwak 2012
(Continued)
Absolute benefit: acupuncture 1.85, wait-list 0.41

Reported results: statistically significant favouring acupuncture
Drop-outs: none
Adverse effects: 3 acupuncture participants reported mild adverse events (2 with bruising,
1 with fatigue)
No serious side effects reported
Costs of care: NR
Notes
Unable to reach study author to obtain necessary data for abstraction
Risk of bias
Bias
Authors judgement

bias)
Computerised number table generated random sequences
Envelopes sealed but not sequentially numbered (numbers inside)
Unclear risk

bias)
Not possible because of design

bias)
Blinding (performance bias and detection Unclear risk

bias)
Participant was the outcome assessor with

self reports

No drop-outs
Low risk

Low risk
Acceptable
Low risk
See registration
Low risk
Reported as similar in Tables 2, 3, 5
Unclear risk
Not reported
Unclear risk
Not reported
Low risk
Baseline and 2 weeks

53
Kwak 2012
Fatal Flaw
(Continued)
High risk
Flawed; wrong analysis was used; Figure 2

should use independent t-test, not paired ttest
Liang 2009
Methods
RCT
Power analysis: NR
Funding source: NR
Participants
Chronic neck disorder associated with degenerative changes - cervical spondylosis

Participant recruitment: Guangdong Provincial Hospital of TCM
Interventions
INDEX TREATMENT
Routine acupuncture
Treated with routine acupuncture at GV 14, Ex-HN 15 and SI 15 with 40 mm long
needles (diameter of 0.30 mm). Needles were retained for 20 minutes after Deqi was
achieved
Sham acupuncture
Sham acupuncture. Needled at 1 cm lateral to Ex-HN 15 and SI 15 (needles were 40
mm long with a diameter of 0.22 mm). Needles were retained for 20 minutes
CO-INTERVENTION
Infrared radiation as adjuvant treatment, comparable between index and control groups
Treatment schedule: Treatment consisted of 9 sessions, applied 3 times a week (every
other day) over a period of 3 weeks
No follow-up
Outcomes
QUALITY OF LIFE: Northwick Park Neck Pain Questionnaire (up to 100, low score
= better)
Baseline mean: routine acupuncture 35.32, sham acupuncture 31.96
End of study mean: routine acupuncture 19.16, sham acupuncture 23.76
Absolute benefit: routine acupuncture 16.16, sham acupuncture 8.2
Reported results: Both groups showed improvement
Adverse effects: NR
Costs of care: NR
Notes
--
Risk of bias
Bias
Authors judgement

bias)

Not described
54
Liang 2009
(Continued)
Unclear risk
Not described

bias)
Not described

bias)
Not described

bias)
Not described

No drop-outs
Low risk

Low risk
As described
Low risk
None reported
Unclear risk
Not described
Unclear risk
Not described
Unclear risk
Not described
Low risk
Similar at baseline and 3 weeks
Fatal Flaw
High risk
Reporting flaws
Liang 2011
Methods
RCT, pilot
Intention-to-treat: Not all randomised participants were analysed
Power analysis: calculated 90%
Funding source: NR
Participants

Participant recruitment: outpatient clinic of Guangdong Provincial Hospital of Chinese
Medicine in Guangzhou, China

55
Liang 2011
(Continued)
Interventions
INDEX TREATMENT
Acupuncture group
Acupuncture points - Du14, SI15 and Ex-HN15 bilaterally manually stimulated on
insertion for Deqi. Needles were inserted into the muscle (to a depth of 20 mm), left
in place for 20 minutes. During treatment, participants received infrared irradiation on
the cervical region
Sham
Participants in the control group received placebo acupuncture on the sham points,
which were 1 cm lateral to the standard acupuncture points selected in the study group.
Needles were inserted into the skin to a depth of approximately 3 mm and remained in
the subcutaneous tissues with no manual stimulation. During treatment, participants in
the control group also received infrared irradiation on the cervical region
CO-INTERVENTION
NR
Treatment schedule: 3 weeks, total 9 sessions, with each session averaging 20 minutes in
duration
Duration of follow-up: immediate post, 4 weeks, 3 months
Outcomes
PAIN INTENSITY (VAS 10 cm scale)

NECK DISABILITY: NPQ
Absolute benefit: acupuncture 13/64, sham 9.51
QUALITY OF LIFE: SF-36 (Physical Component - higher = better)
Absolute benefit: 3.47, sham 6.66
SMD 0.38 (95% CI random 0.08 to 0.68) immediate post treatment
SMD -0.05 (95% CI random -0.35 to 0.24) at 4 weeks
Reasons for drop-out: 5 drop-outs in treatment group: 3 due to fear of pain and 2
for inconvenience. 7 drop-outs in sham group: 4 due to fear of pain and 3 due to
inconvenience
Adverse effects: local bleeding, fainting: 3 participants in treatment and 4 in control; local
numbness, aching or bleeding at points: 4 participants in treatment and 2 in control. All

56
Liang 2011
(Continued)
adverse events transient and resolved, although those who fainted decided to withdraw
from the study
Costs of care: NR
Notes
--
Risk of bias
Bias
Authors judgement

bias)
Random numbers were generated by computer software
Sealed opaque envelopes
Low risk

bias)
Reported as blinded

bias)
Not possible

bias)

Reported in text and acceptable
Low risk

High risk
Unclear risk
No protocol
Low risk
Unclear risk
Not reported
Unclear risk
Not reported
Low risk
Assessed immediate post treatment, 4

weeks, 3 months
Fatal Flaw
Low risk
Acceptable

57
Nabeta 2002
Methods
RCT
Power analysis: NR
Funding source: NR
Participants
Chronic neck pain, no radicular signs

Participant recruitment: students from an acupuncture school in Japan
Interventions
Treatment was provided to tender points on the posterior aspect of the neck and upper
back
All tender points were carefully detected where the subjects felt dull pain and stiffness
(neck, shoulder, and back) and were used for the acupuncture treatment. All tender
points were treated in each group
INDEX TREATMENT
Sparrow pecking acupuncture
Disposable stainless needles (0.2 mm 40 mm) were inserted into the muscle to a depth
of about 20 mm, and the sparrow pecking technique was applied. When the participant
felt Deqi, the manipulation was stopped and the needle was retained for 5 more minutes
Simulated sparrow pecking acupuncture with no needle insertion
For sham acupuncture, similar stainless needles (0.2 mm 40 mm) were used, but the
tips had previously been cut off to prevent the needle from penetrating the skin. The cut
ends were smoothed with sandpaper manually under clean conditions. The acupuncturist
pretended to insert the needle and to use the sparrow pecking technique, then removed
the needles. Simulation of needle extraction was performed after 5 minutes
CO-INTERVENTION
Not specified
Duration of treatment: once/wk for 3 weeks
Duration of follow-up: 9 days
Outcomes
PAIN INTENSITY: VAS

SMD -0.15 (95% CI random -0.82 to 0.52) at 9 days
Reasons for drop-out: NR
Adverse effects: none
Costs of care: NR
Notes
--
Risk of bias
Bias
Authors judgement

bias)

Computerised randomisation programme
58
Nabeta 2002
(Continued)
Unclear risk
Not reported

bias)
Reported as blinded

bias)
Not possible

bias)
Participant as outcome assessor was blinded

Low risk
No drop-outs

Low risk
No drop-outs
Unclear risk
No protocol
Low risk
Reported to be similar but baseline VAS

different by 11.7
Unclear risk
Not reported
High risk
Some participants did not receive all treatment
Low risk
9 days
Fatal Flaw
Low risk
Acceptable
Petrie 1983
Methods
RCT
Power analysis: NR
Funding source: NR
Participants
Chronic mechanical neck disorder with radicular signs or symptoms

Participant recruitment: out-patients from Addenbrookes Hospital, Cambridge, UK

59
Petrie 1983
(Continued)
Interventions
INDEX TREATMENT
Acupuncture group
5 standard points used - Du14, GB20 bilateral, GB21 bilateral; 28 g needle used to
achieve sensation of Teh Chi (Deqi); needles manipulated after insertion and on removal
COMPARISON
Placebo TNS group
Sham electrical stimulation with lead electrode applied to each side of the neck, 5 cm
lateral to C7
CO-INTERVENTION
Comparable between index and control groups
Treatment schedule: 4 weeks (2 times/wk), with each session averaging 20 minutes
Duration of follow-up: none
Outcomes
PAIN INTENSITY: pain relief score (5 point scale)

Baseline mean: NR
End of study mean: NR
Reported results: significant improvement favouring acupuncture
Adverse effects: NR
Costs of care: NR
Notes
--
Risk of bias
Bias
Authors judgement

bias)
Reported only as randomly assigned
Not reported
Unclear risk

bias)

bias)
Not possible

bias)

No drop-outs
Low risk

60
Petrie 1983
(Continued)

Low risk
All randomised participants analysed
Unclear risk
No protocol
Low risk
Appears similar
Unclear risk
Not reported
Low risk
All participants treated twice weekly for 4

weeks
Low risk
Assessed immediately post treatment
Fatal Flaw
High risk
Randomisation and allocation concealment details not reported
Petrie 1986
Methods
RCT
Power analysis: reported
Funding source: NR
Participants

Participant recruitment: hospitalised patients from Queen Elizabeth Hospital, Palmersion North, New Zealand
Interventions
INDEX TREATMENT
Acupuncture group
5 predetermined acupuncture points - Du14, GB20 and GB21 bilaterally manually
stimulated on insertion to Teh Chi (Deqi) and at 5-minute intervals
Sham TNS
TNS electrodes placed at the base of the neck connected to an oscilloscope display
without a currentExaminer re-entered the room at 5 minute intervals to check display
CO-INTERVENTION
Analgesics comparable between groups
Treatment schedule: 2 sessions/wk for 4 weeks, with each session averaging 20 minutes
in duration
Outcomes
PAIN INTENSITY (4 item VAS scale)

Baseline mean: acupuncture 47.08, sham TNS 31.67
End of study mean: acupuncture 31.77, sham TNS 24.72
Absolute benefit: acupuncture 15.31, sham TNS 6.95

61
Petrie 1986
(Continued)

Reasons for drop-out: unrelated surgery, loss to follow-up
Adverse effects: NR
Costs of care: NR
Notes
--
Risk of bias
Bias
Authors judgement

bias)
Not adequately described
Not reported
Unclear risk

bias)

bias)
Not possible

bias)

Drop-outs described and acceptable
Low risk

High risk
All randomised participants were not analysed
Unclear risk
No protocol
High risk
Acupuncture group had more daily use of

NSAIDs and pain scores with statistically
significant differences
High risk
Not reported
High risk
Not all participants received the scheduled

8 treatments
Low risk
Assessed immediate post treatment

62
Petrie 1986
Fatal Flaw
(Continued)
High risk
Due to inadequate reporting
Sahin 2010
Methods
RCT
Power analysis: NR
Funding source: NR
Participants

Participant recruitment: patients recruited from the clinic of the Department of Physical
Medicine and Rehabilitation in Turkey
Interventions
INDEX TREATMENT
Electroacupuncture group (EAP)
7 acupuncture points - Du14 and GB20, GB21, LI4, UB10, UB60, TE5 all bilaterally
and manually stimulated on insertion to Teh Chi (Deqi), EAP added after 1 to 4 Hz,
200 s
Sham EAP
Same points as the treatment group; needles inserted 1 to 2 cm away from the meridian
points. No Deqi. EAP stimulated, then turned off
CO-INTERVENTION
NR
Treatment schedule: 10 sessions over 3 weeks, with each session averaging 30 minutes
in duration
Duration of follow-up: immediate post treatment, 3 months
Outcomes
PAIN INTENSITY (10 point VAS (movement) scale)

Baseline mean: EAP 7.38, sham EAP 6.19
End of study mean: EAP 4.50, sham EAP 4.50
Absolute benefit: EAP 2.88, sham EAP 1.69
Reported results: not significant, including pain at rest
Reasons for drop-out: 2 participants in the EAP group: 1 unable to obtain permission
from work to attend; 1 planning a pregnancy
Adverse effects: NR
Costs of care: NR
Notes
--
Risk of bias
Bias
Authors judgement

63
Sahin 2010
(Continued)
Random sequence generation (selection High risk

bias)
Not described
Names sealed in opaque envelopes. Envelopes were then allocated randomly into
2 groups. After the doctor examined participants, she gave the names of those who
were included in the study to someone else,
who prepared the envelopes
High risk

bias)
Reported as blinded

bias)
Not possible

bias)

Described and acceptable
Low risk

High risk
All randomised participants not analysed
Unclear risk
No protocol
High risk
VAS pain scores > 10% difference
Unclear risk
Not reported
Unclear risk
Not reported
Low risk
Assessed immediate post treatment and 3

months
Fatal Flaw
High risk
Randomisation not performed properly;

planned to recruit 80 participants but enrolled only 31

64
Seidel 2002
Methods
RCT
Power analysis: NR
Funding source: NR
Participants
Chronic mechanical neck disorder: cervical tendomyosis

Participant recruitment: NR
Interventions
INDEX TREATMENT
Conventional meridian acupuncture (Acu)
15 minutes per session; maximum 15 needles per session. Option of 15 acupuncture
points was available. Seirin needles 7, 0.3 30 mm and 0.2 15 mm. Insertion until
the Deqi response was achieved
Placebo LASER (LLLT0)
Outcome power: 0 mV, Meridian acupuncture points same as acupuncture group
CO-INTERVENTION
Avoided in trial design
Treatment schedule: 4 weeks, 2 sessions per week - total 8 sessions
Outcomes
PAIN INTENSITY: VAS (mm)

Baseline mean: Acu 39.3, LLLT0 34.1
End of study mean: Acu 7.0, LLLT0 25.2
Absolute benefit: Acu 32.3, LLLT0 8.9
SMD -0.86 (95% CI random -1.70 to -0.02) at immediate post
SMD -0.46 (95% CI random -1.27 to 0.35) at 4 week follow-up
Reported results: statistically significant favouring acupuncture immediate post treatment and at 4 week follow-up
TENDERNESS (pressure pain threshold - PPT)
Baseline mean: Acu 4.13, LLLT0 5.05
End of study mean: Acu 5.75, LLLT0 6.12
Absolute benefit: Acu 1.62, LLLT0 1.07
SMD -0.14 (95% CI random -0.95 to 0.66) at immediate post
SMD -0.22 (95% CI random -1.02 to 0.58) at 4 week follow-up
Reasons for drop-out: NR
Adverse effects: reported for control and for index treatment; not specified
Costs of care: NR
Notes
--
Risk of bias
Bias
Authors judgement

bias)

Reported randomised double-blinded
65
Seidel 2002
(Continued)
Unclear risk
Possibly adequate

bias)
Reported as blinded

bias)
Not possible

bias)
Paticipant blinded as outcome assessor

Low risk

High risk
Unclear risk
No protocol
Low risk
Low risk
Avoided
High risk
Not acceptable
Low risk
Assessed at 4 weeks
Fatal Flaw
Low risk
Acceptable
Sun 2010
Methods
RCT
Power analysis: calculated 90%
Funding source: NR
Participants
Myofascial neck pain syndrome (MPS)

Participant recruitment: Department of Neurology at Nantou Hospital, Department of
Health
Interventions
INDEX TREATMENT
Acupuncture group
5 predetermined acupuncture points - TE14, GB20, SI3 bilaterally manually stimulated

66
Sun 2010
(Continued)
on insertion to Qi
Sham acupuncture
Same points as treatment group. Inserted into subcutaneous tissue at 2 mm depth. No
manual stimulation
CO-INTERVENTION
NR
Treatment schedule: 2 sessions/wk for 3 consecutive weeks, with each session averaging
20 minutes in duration
Duration of follow-up: immediate post, 4 weeks, 12 weeks
Outcomes
PAIN INTENSITY (100 point VAS (movement) scale)

Baseline mean: acupuncture 50, sham acupuncture 50
End of study mean: acupuncture 30, sham acupuncture 30
Absolute benefit: acupuncture 20, sham acupuncture 20
Reported results: no significance differences between groups
SMD 0.00 (95% CI random -0.67 to 0.67) at 12 weeks
Reasons for drop-out: discontinued because of Chinese herb use
Adverse effects: 1 participant in treatment group experienced ecchymosis, 1 in control
group experienced slight dizziness; both were transient and resolved
Costs of care: NR
Notes
--
Risk of bias
Bias
Authors judgement

bias)
Not clear if adequately done
Not reported
Unclear risk

bias)
Some participant were not naive to

acupuncture

bias)
Not possible

bias)
Unclear whether participant was blinded

and was also the outcome assessor

Low risk

67
Sun 2010
(Continued)

Unclear risk
Appears 1 randomised participant may not

have been analysed
Unclear risk
No protocol
Low risk
Unclear risk
Not reported
Unclear risk
Not specifically and clearly reported
Low risk
Assessed after 6 treatments, 4 weeks, 12

weeks
Fatal Flaw
High risk
Randomisation not clearly done properly;

participants do not appear to have been
blinded; ITT not done; missing data handled by last observation carried forward; all
P values in Table 2 within-group changes;
scores in Table 3 do not look credible
Thomas 1991
Methods
RCT cross-over
Power analysis: Post hoc analysis suggested 70 participants per group were needed
Intention-to-treat analysis: NA
Funding source: NR
Participants
Chronic mechanical neck disorder, cervical osteoarthritis

Participant recruitment: Sweden
Interventions
INDEX TREATMENT
Acupuncture (Acu): LI3 and GB20 bilaterally, DU14, DU16, DU20 with manual stimulation for 10s for Deqi every 5 minutes, 40 minute session
Sham acupuncture: needles inserted superficially, not manually stimulated
CO-INTERVENTION
Instructed to take no pain medication 24 hours before trials
Duration of treatment: 1 session
Duration of follow-up: 2 hours
Outcomes
PAIN INTENSITY (VAS 0 to 10)

Baseline: acupuncture 2.5, placebo acupuncture 2.0, placebo diazepam 1.9
End of study mean: acupuncture 1.8, placebo 1.6, placebo diazepam 1.7
Absolute benefit: acupuncture 0.7, placebo 0.4, placebo diazepam 0.2
Reported results: not significant when acupuncture was compared with placebo acupunc-

68
Thomas 1991
(Continued)
ture but statistically significant when acupuncture was compared with placebo diazepam
vs placebo acupuncture: SMD 0.17 (95% CI random -0.25 to 0.59) immediate post
treatment
vs placebo diazepam: SMD 0.09 (95% CI random -0.33 to 0.51) immediate post treatment
Adverse effects: NR
Costs of care: NR
Notes
--
Risk of bias
Bias
Authors judgement

bias)
Only described as randomised to order
Not reported
Unclear risk

bias)

bias)
Not possible

bias)
Participant not blinded as outcome assessor

No drop-outs
Low risk

Low risk
Unclear risk
No protocol
Low risk
Each participant received all treatments
Low risk
Avoided
Low risk
All participants received all treatments
Low risk
Immediate post treatment

69
Thomas 1991
Fatal Flaw
(Continued)
High risk
Improper error terms for analysis (SD

should not be used for within-patient analysis); randomisation and concealment not
described; no adjustments made for order;
balancing not apparent
Tough 2010
Methods
RCT pilot/feasibility study

Intention-to-treat: calculated but not reported
Power analysis: reported
Funding source: NR
Participants
WAD myofascial pain (injury of 2 to 16 week duration)

Participant recruitment: Derriford Hospital Physiotherapy Department, UK
Interventions
INDEX TREATMENT
Acupuncture group
Trigger point needling using 0.25 mm 30 to 40 mm length, 6 to 7 sparrow pecking
into each MTrP (muscles treated not described)
COMPARISON
Sham acupuncture
Same procedure as treatment group; however, a sham needle 0.30 mm 50 mm cut,
and blunted end was tapped against the skin, with sparrow pecking motion
CO-INTERVENTION
Participant education, heat, analgesics and exercise (home therapy)
Treatment schedule: 1 session/wk, total 2 to 6 treatments depending on participant
response
Outcomes
PAIN INTENSITY (SF-McGill Pain Questionnaire, VAS component 10 cm scale)

Baseline mean: acupuncture 4.9, sham acupuncture 5.0
End of study mean: acupuncture 1.7, sham acupuncture 3.2
Absolute benefit: acupuncture 3.2, sham acupuncture 1.8
DISABILITY: NECK DISABILITY INDEX (NDI 0 to 50 point scale)
Reasons for drop-out: increased pain (stopped attending: 3 acupuncture, 4 sham)
Adverse effects: increased pain (16/20 acupuncture, 9/20 sham)
Costs of care: NR
Notes
--

70
Tough 2010
(Continued)
Risk of bias
Bias
Authors judgement

bias)
Reported as random allocation sequence,

computer-generated using block size of 4
Held centrally by the pharmacy department at the research site; allocation concealed from the investigator until after participant enrolment
Low risk

bias)
Unclear whether sham was indistinguishable

bias)

bias)
Participant was the outcome assessor with

self reports

Acceptable at 17%
Low risk

High risk
Only participants who completed the study

were included; ITT done only for P value
Unclear risk
No protocol available
Low risk
Reported as similar Tables 1 and 2
Unclear risk
Not reported
Unclear risk
Exercise booklet given; unsure whether participants received all acupuncture treatment prescribed
Low risk
Baseline, 3 and 6 weeks
Fatal Flaw
Low risk
Acceptable

71
Tsai 2010
Methods
RCT
Power analysis: NR
Funding source: NR
Participants

Participant recruitment: teaching hospital, Taiwan
Interventions
INDEX TREATMENT
Acupuncture group
Dry needling, used a 25-hypodermic needle (0.5 mm in diameter). Manual stimulation
of the needle to the MTrP region of the extensor carpi radialis longus muscle to elicit a
local twitch response. 1 to 2 minutes
COMPARISON
Sham acupuncture
Same procedure as treatment group; however, needle was maintained in the subcutaneous
tissue
CO-INTERVENTION
Avoided
Treatment schedule: 1 session
Outcomes

PRESSURE PAIN THRESHOLD (PPT, kg/cm2 )
Reasons for drop-out: none
Adverse effects: NR
Costs of care: NR
Notes
--
Risk of bias
Bias
Authors judgement

bias)
Computerised randomisation programme
Not reported
Unclear risk

72
Tsai 2010
(Continued)

bias)
Reported in text

bias)
Not possible

bias)

No drop-outs
Low risk

Low risk
Unclear risk
No protocol
Low risk
Low risk
Avoided by pre/post design
Low risk
Acceptable by design
Low risk
Fatal Flaw
Low risk
Acceptable
Vas 2006
Methods
RCT
Intention-to-treat: calculated (although ITT stated, not all analysed at T2, only T1)
Power analysis: calculated (90% power, alpha = 5%, 49 participants needed for experimental group and 46 for control group)
Funding source: NR
Participants
Non-specific cervical disorder, uncomplicated

Participant recruitment: Participants were referred to the Pain Treatment Unit at a Primary Attention Healthcare Centre in Spain by general practitioners in the municipality
Interventions
INDEX TREATMENT
Acupuncture
Points were selected according to pain characteristics and accompanying symptoms on

73
Vas 2006
(Continued)
the basis of traditional Chinese treatment methods. Puncture was bilateral, with sterile,
single-use needles (25 mm 0.25 mm or 40 mm 0.25 mm). Puncture was effected
by determining the Deqi. Needles were kept in place for 30 minutes and were manually
stimulated every 10 minutes. After the needles were removed, Vaccaria seeds were applied
in the ear auricle and were taped there until the following treatment session. Participants
were told to apply pressure to each ear point for a series of 10 repeats 3 times per day
TENS placebo
Applied using TRANSMED 911 transcutaneous nerve stimulation units that had been
adjusted beforehand to prevent current through the electrodes. Electrodes were placed
at Jianjing (GB 21) bilateral acupuncture point for 30 minutes. Participants state was
checked every 10 minutes, and the TENS-placebo potentiometer adjusted
CO-INTERVENTION
Not avoided but comparable; both groups were provided with analgesic rescue medications once weekly
Duration of treatment: 3 weeks
Treatment consisted of 5 sessions over 3 weeks (2 in each of first 2 weeks and once in
the third week)
Duration of follow-up: 6 months
Outcomes
PAIN INTENSITY (VAS 100 mm scale related to motion)

Baseline mean: acupuncture 68.7, placebo TENS 72.3
End of study mean: acupuncture 27.6, placebo TENS 45.5
Absolute benefit: acupuncture 41.1, placebo TENS 26.8
SMD -1.50 (95% CI random -1.91 to -1.10) at 1 week
FUNCTION (DISCAPACITY): Northwick Park Pain Questionnaire (NPQ 0 to 100
scale)
Reported results: significant at 1 week after final treatment
6 month follow-up for this outcome: NR
QUALITY OF LIFE: SF-36 (Physical Component - higher = better)
Results: significant difference at 1 week favouring acupuncture but not at 6 months
Reasons for drop-out: personal reasons, pregnancy, fear
Adverse effects: mild for both groups (4 in treatment group, 2 in control group)
Reported for control: increase in symptoms
Reported for index treatment: swelling or bruising of the hand
Costs of care: NR
Notes
--

74
Vas 2006
(Continued)
Risk of bias
Bias
Authors judgement

bias)
Computerised generated randomisation
Opaque envelopes not reported as sequentially numbered
Unclear risk

bias)
Reported in text as participant blinded

bias)
Not possible

bias)
Blinded participant as outcome assessor

Drop-out approximately 35% at long term
High risk

High risk
Not reported for long term
Unclear risk
No protocol
Low risk
High risk
Reported only on medication use
Unclear risk
Unsure whether ear seed protocol was followed by each participant
Low risk
Assessed at 1 week and 6 months
Fatal Flaw
Low risk
Acceptable

75
White 2000
Methods
RCT/cross-over
Power analysis: NR
Funding source: Forest Park Institute, Ambulatory Anesthesia Research Foundation,
White Mountain Institute
Participants
Chronic mechanical neck disorder, degenerative changes

Participant recruitment: Eugene McDermott Centre for Pain Management, Department
of Anesthesiology and Pain Management, University of Texas Southwestern Medical
Centre, Dallas, Texas
Interventions
INDEX TREATMENT 1
Local dermatomal stimulation
10 acupuncture-like needle probes inserted 2 to 4 cm into soft tissue/paraspinous muscles
in the cervical region, alternating frequency of 15 Hz to 30 Hz to produce gentle tapping
sensation without muscle contraction
Remote dermatomal stimulation
10 acupuncture-like needle probes inserted into soft tissue/paraspinous muscle in the
lower back region with identical electrical therapy characteristics of the local dermatomal
stimulation group
Control needles only
Needles inserted into the cervical region without electrical stimulation
CO-INTERVENTION
Analgesics comparable between groups
Treatment schedule: 3 times/wk for 3 consecutive weeks, with 1 week off between modalities and each session averaging 30 minutes in duration
Duration of follow-up: 24 hours after completion of each 3 week treatment period
Outcomes
PAIN INTENSITY (10 cm VAS scale)

Baseline mean: NR
End of study mean: NR
Reported results: significant differences between groups favouring local dermatomal
stimulation
Adverse effects: NR
Costs of care: NR
Notes
--
Risk of bias
Bias
Authors judgement

bias)
Not reported
Not reported
Unclear risk

76
White 2000
(Continued)

bias)

bias)
Not possible

bias)

Inadequate description
Unclear risk

Unclear risk
Unclear whether all analysed
Unclear risk
No protocol
High risk
Means given as 1 group in total
High risk
Medication use not similar
Low risk
Acceptable
Low risk
Fatal Flaw
High risk
Inadequate reporting
White 2004
Methods
RCT
Funding source: Henry Smiths Charity, Hospital Savings Association, Laing Foundation
Participants

Participant recruitment: out-patient departments of Southampton General Hospital and
Salisbury District Hospital, United Kingdom
Interventions
INDEX TREATMENT
Acupuncture with single-use needles, points based on individualised western acupuncture
techniques previously reported as effective in neck pain, 6 points on average, with each
session averaging 20 minutes in duration. Manual stimulation to Deqi. 8 treatments

77
White 2004
(Continued)
over 4 weeks provided by physiotherapists with 7 years of experience

Mock TENS electroacupuncture stimulator; up to 8 points could be stimulated at 1
time; session time not reported
CO-INTERVENTION
Comparable between index and control groups
Treatment schedule: Both groups received 8 sessions over 4 weeks
Duration of follow-up: 1 and 8 weeks, 6 and 12 months
Outcomes
PAIN INTENSITY (100 mm VAS scale)

Baseline mean: acupuncture 49.6, mock TENS 54.1
End of study mean: acupuncture 20.91, mock TENS 24.36
Absolute benefit: acupuncture 28.69, mock TENS 29.74
Reported results: Acupuncture reduced pain, with no clinically effective difference between groups
SMD -0.07 (95% CI random-0.45 to 0.30) at 6 months
SMD -0.13 (95% CI random -0.51 to 0.25) at 1 year
DISABILITY (NDI 0 to 50 point scale)
SMD -0.08 (95% CI random -0.43 to 0.27) at 1 week
SMD -0.23 (95% CI random -0.61 to 0.15) at 1 year
QUALITY OF LIFE (SF-36, Physical Component)
SMD 0.07 (95% CI random -0.28 to 0.42) at 1 week
Time points at 6 months and 1 year not reported for this outcome
Reported results: significant improvement in both treatment groups
Adverse effects: Acupuncture group reported increase in the following symptoms: faintness, slight swelling of hand, bruise, mild headache, euphoria and enhanced vision, dizziness; placebo group reported discomfort during treatment, mild headache, tiredness,
faintness, nausea, tingling in the thumb, dizziness, uncomfortable cold feeling of electrodes
Costs of care: NR
Notes
--
Risk of bias
Bias
Authors judgement

bias)
Adequate
Sealed envelopes; unclear whether opaque

and sequentially numbered
Unclear risk

78
White 2004
(Continued)

bias)

bias)
Not possible

bias)

Acceptable
Low risk

High risk
Unclear risk
No protocol
Low risk
High risk
Medication use not similar
Unclear risk
Not described
Low risk
6 months and 1 year
Fatal Flaw
Low risk
Acceptable
Witt 2006
Methods
RCT
Funding source: NR
Participants
Chronic neck pain

Participant recruitment: Participants with neck pain asked a participating physician for
acupuncture, or physician considered acupuncture to be adequate treatment
Interventions
INDEX TREATMENT
Immediate acupuncture treatment plus additional conventional treatment as needed
Participants could be treated individually, and numbers of needles and acupuncture
points used were chosen at the discretion of physicians. Only needle acupuncture (with

79
Witt 2006
(Continued)
disposable 1-time needles) and manual stimulation were allowed, whereas other forms
of acupuncture treatment were not allowed
Conventional treatment; delayed acupuncture treatment 3 months after study onset
Control group was not allowed to use any kind of acupuncture during first 3 months
CO-INTERVENTION
Comparable between index and control groups. Participants were free to use conventional
routine medical care as offered by German social health insurance funds
Treatment schedule: Each participant in the randomised acupuncture group received up
to 15 acupuncture sessions during first 3 months and no acupuncture sessions between
3 and 6 months
Duration of treatment: 3 months
Duration of follow-up: 3 months after treatment
Outcomes
HEALTH AND WELL-BEING

Neck and pain disability assessed by validated neck and pain disability scale developed
by Wheeler
Baseline mean: 55.0 immediate acupuncture (randomised), 56.0 (immediate acupuncture non-randomised), 53.9 delayed acupuncture
% reduction in neck pain and disability
Time 1 (3 months): 28.9 immediate acupuncture (randomised), 31.7 immediate
acupuncture (non-randomised), 5.8 delayed acupuncture
Time 2 (6 months): 28.0 immediate acupuncture (randomised), 30.6 immediate
acupuncture (non-randomised), 25.1 delayed acupuncture
Reported results: significant at time 1
SMD -35.53 (95% CI random -36.37 to -34.69) at 3 month follow-up
SMD 4.14 (95% CI random 4.02 to 4.26) at 6 month follow-up
SF-36 PHYSICAL COMPONENT SCORE
Baseline mean: 37.6 immediate acupuncture (randomised), 36.7 immediate acupuncture
(non-randomised), 38.1 delayed acupuncture
Time 1 (3 months): 5.8 immediate acupuncture (randomised), 6.8 immediate acupuncture (non-randomised), 4.7 delayed acupuncture
SF-36 MENTAL COMPONENT SCORE
Baseline mean: 43.1 immediate acupuncture (randomised), 42.8 immediate acupuncture
(non-randomised), 43.8 delayed acupuncture
Reasons for drop-out: 315 participants could not be included in the ITT analysis because
the study office did not receive the consent form
Adverse effects: 8.9% of cases (n = 1005); 1216 side effects were reported: 57% minor
local bleeding or hematoma, 10% pain (e.g. needling pain), 4% vegetative symptoms,

80
Witt 2006
(Continued)
29% other
Costs of care: acupuncture treatment associated with higher costs (EURO925.53
1551.06 vs EURO648.06 1459.13); however according to assumed threshold values
beyond 3 month follow-up, acupuncture appears cost-effective. Also, over-the-counter
medications were not included in the cost of routine care
Notes
--
Risk of bias
Bias
Authors judgement

bias)
Randomised using a central telephone randomisation procedure
Study office included participants into the

study
Low risk

bias)
Not possible

bias)
Not possible

bias)

Drop-outs not adequately described
High risk

Unclear risk
Unclear whether ITT was done correctly
Unclear risk
No protocol
Low risk
Unclear risk
Not reported
Low risk
Most participants (77.3%) received 5 to

10 sessions, whereas 17.7% received more
than 10 sessions and 5% fewer than 5 sessions
Low risk
Assessed at 3 and 6 months

81
Witt 2006
Fatal Flaw
(Continued)
Low risk
Acceptable
Abbreviations:
BL = bladder
CI = confidence interval
cm = centimetre
dn = dry needling
EAP = electroacupuncture
g = gauge
GB = gallbladderITT = intention-to-treat
LI = large intestine
LLLT0 = placebo intestine
mg = milligram
mm = millimetreMPS = myofascial neck pain syndrome
MTrP = muscles treated not described
NA = not applicable
NDI = Neck Disability Index
NLA = non-local needle electroacupuncture
NPQ = Northwick Park Pain Questionnaire
NR = not reported
NSAID = non-steroidal anti-inflammatory drug
NTPA = non-trigger point acupuncture
OD = daily
PPT = pain pressure threshold
RA = remote acupuncture
RCT = randomised controlled trial
SA = standard acupuncture
SD = standard deviation
SF-36 = Short Form-36
SH = sham treatment
SI = small intestine
SMD = standardised mean difference
TCM = Traditional Chinese Medicine
TE = triple energiser
TENS = transcutaneous electrical nerve stimulation
TNS = transcutaneous nerve stimulation
TPA = trigger point acupuncture
TrP = trigger point acupuncture
VAS = visual analogue scale
WAD = whiplash-associated disorder

82
Characteristics of excluded studies [ordered by study ID]
Study
Reason for exclusion
Bahadir 2009
Comparison: acupuncture vs active treatment (ultrasound)
Calvo-Trujillo 2013
Intervention: auto-acupressure, not acupuncture

Comparison: active treatment (paracetamol and/or ibuprofen and tetrazepam)
Ceccherelli 2006
Comparison: 1 acupuncture type vs another
Ceccherilli 2014
Comparison: 3 acupuncture doses compared
Cho 2014
Comparison: acupuncture vs active treatment (NSAID)
Chu 1997
Intervention (EMG needle)
Coeytaux 2005
Population: migraine and tension-type headaches, others not specified as cervicogenic

Comparison: acupuncture vs active treatment (medical management)
Cohen 2014
Intervention: acupuncture portion of multi-modal treatment
David 1998
Comparison: acupuncture vs active treatment (mobilisation)
Dong 2012
Edwards 2003
Comparison: multi-modal treatment acupuncture vs active treatment (stretching)
Emery 1986
Population: ankylosing spondylitis
Eroglu 2013
Comparison: acupuncture vs active treatment (lidocaine injection or oral flurbiprofen)
Falkenberg 2007
Comparison: acupuncture portion of multi-modal treatment vs active treatment (usual care)
Fernandez-Carnero 2014
Comparison: acupuncture received in both groups as control
Franca 2008
Comparison: acupuncture vs active treatment (exercise)
Fu 2005
Comparison: acupuncture vs active treatment (lidocaine)
Fu 2007
Comparison: 1 acupuncture insertion direction vs another
Fu 2014
Comparison: electroacupuncture vs active treatment (traction and low-frequency therapy)
Ga 2007a
Design: quasi-RCT
Ga 2007b

83
(Continued)
Gallacchi 1981
Population: tendomyotonic cervical and lumbar syndrome; unable to separate data
Gallacchi 1983
Population: rheumatoid arthritis
Gallego Sendarrubias 2015
Intervention: acupuncture combined with manual therapy; not a stand-alone treatment
Gaw 1975
Population: pain in many areas; unable to separate data
Gil 2015
Intervention: individual vs group acupuncture
Giles 1999
Comparison: acupuncture vs active treatment (medication)
Giles 2003
Population: neck and low back; unable to split data
Guanygue 2001
Comparison: included other treatments with acupuncture; the effect of acupuncture could not be
isolated
Guo 2013
Comparison: acupuncture portion of the control
Harvey 2015
Comparison: sham acupuncture vs lidocaine injection (no real acupuncture compared)
Hayek 2014
Comparison: acupuncture may be part of multi-modal treatment vs epidural steroid injections (ESI)
with depo-methylprednisolone
Hu 2014
Comparison: electroacupuncture vs active treatment

(bloodletting and cupping - CAM intervention)
Hua 2009
Design: quasi-RCT
Comparison: electroacupuncture portion of control
Huang 2008
Huang 2012
Comparison: acupuncture vs active treatment (traction, magnetic therapy)

Outcome: blood flow; no participant-specific outcomes
Hudson 2010
Comparison: acupuncture portion of multi-modal usual care active treatment (2 participants)
Jia 2007
Jin 2012
Johnson 2000
Abstract; did not appear to be RCT; unable to contact study author
Kai 2008
Kisiel 1996
Population: neck and shoulder pain; cannot split data

84
(Continued)
Li 2004
Li 2006
Population: spinal cord stenosis

Comparison: acupuncture vs active treatment (manipulation/traction)
Li 2013
Lin 2004
Intervention: scalpel technique
Liu 2008
Liu 2013
Comparison: acupuncture vs active treatment (intravenous drip with 5% glucose 250 mL and compound Salvia miltiorrhiza injection and mechanical traction)
Lixing 2000
Comparison: acupuncture vs acupuncture with moxibustion
Llamas-Ramas 2014
Comparison: acupuncture vs active treatment (trigger point manual therapy)
Loy 1983
Design: quasi-RCT
Comparison: acupuncture vs active treatment (traction and shortwave diathermy)
Lu 2006
Lundeburg 1988
Population: head and neck pain included; unable to obtain split data
Lundeburg 1991
Comparison: multi-modal; effects of acupuncture unknown
Luo 2010
Design: non-RCT
Ma 2010
Intervention: mini-scalpel
MacPherson 2013
Comparison: acupuncture vs active treatment (Alexander lessons, postural awareness, usual care)
McLean 2013
Comparison: acupuncture portion of multi-modal usual care active treatment (4 participants)
Muller 2005
Comparison: see excluded Giles 2003; this is LT follow-up
Myburgh 2012
Nakajima 2015
Comparison: 1 type of acupuncture vs another
Pan 2008
Design: quasi-RCT
Population: occipital neuralgia
Pecos-Martin 2015
Peng 1987
Design: non-RCT

85
(Continued)
Rayegani 2014
Comparison: acupuncture vs active treatment (physiotherapy including heat, TENS, ultrasound, passive
and self stretching)
Salter 2006
Comparison: acupuncture vs active treatment (GP care in both groups)
Sato 2014
Population: individuals with latent trigger points in upper trapezius, no neck pain
Sator-Katzenschlager 2003
Seo 2014
Intervention: bee venom acupuncture (BVA) injected with syringe

Comparison: acupuncture vs active treatment (NSAID)
Shang 2002
Shuangquan 2003
Soderlund 2001
Comparison: multi-modal; effects of acupuncture unknown
Sun 2013
Comparison: acupuncture vs electroacupuncture (protocol)
Takakura 2014
Population: individuals with functional neck stiffness without pain
Teng 1973
Abstract; did not appear to be RCT; unable to obtain further information
Tobbackx 2013
Comparison: active treatment (relaxation therapy)
Venancio 2008
Population: tension-type and/or migraine headaches

Venancio 2009
Population: tension-type and/or migraine headaches

Comparison: active treatment (lidocaine or Botox)
Wan 2013
Comparison: 1 acupuncture type vs another vs active treatment (oral Jing fukang granule)
Wang 2007
Wang 2008
Wang G 2014
Comparison: acupuncture in both groups as control
Xu 2012
Xue 2007
Design: quasi-RCT
Yang 2009

86
(Continued)
Yang 2013
Comparison: acupuncture vs active treatment (Chinese manipulation)
Yoon 2009
Comparison: 3 types of acupuncture needles compared
Yoshimizu 2012
Comparison: acupuncture vs active treatment (TENS)
Yu 2003
Zeng 2005
Zhang 1996
Design: appeared to be before/after study or case series report

Population: included myelopathy
Zhang 2003
Comparison: acupuncture vs active treatment (traction)
Zhang J 2008
Comparison: electroacupuncture vs active treatment (laser)
Zhang J 2013
Zhang X-Z 2013
Intervention: 1 acupuncture type vs another
Zhao 2004
Comparison: acupuncture with moxibustion
Zheng 2014
Intervention: mini-scalpel acupuncture

Zhi 2008
Intervention: injection-type needle
Zhou 2014
Comparison; acupuncture vs active treatment (moxibustion)
Zhu 2002
Outcome: no between-group comparison analysed
Zhu 2006
Comparison: acupuncture vs needle-knife therapy
Zhuang 2004
Ziaeifar 2014
Comparison: acupuncture vs active treatment (massage)

87
Characteristics of studies awaiting assessment [ordered by study ID]

Amos 2012
Methods
Abstract for RCT
Participants
67 acute neck and back pain
Interventions
Acupuncture vs sham acupuncture plus standard ER care (medication not described)
Outcomes
Numeric Rating Scale (NRS), ROM, Symptom Checklist (SCL) questionnaire and overall satisfaction
Notes
Await full study, contact study author
Bar-Haim 2012
Methods
RCT
Participants
65 patients with acute or subacute/chronic simple back or neck pain
Interventions
Acupuncture vs placebo acupuncture vs no treatment
Outcomes
Pain (NPS)
Notes
clinicaltrials.gov
Cerezo-Tellez 2014
Methods
RCT
Participants
44 patients with myofascial neck pain
Interventions
Acupuncture + stretching vs same stretching
Outcomes
Pain (VAS), pressure pain threshold
Notes
clinicaltrials.gov
Choi 2011
Methods
RCT
Participants
40 patients with whiplash-associated disorder
Interventions
Acupuncture vs wait-list
Outcomes
Pain (VAS), post-needling pain, pressure pain threshold, range of motion, quality of life (SF-36), Depression Scale,
Cornell Medical Index (CMI)

88
Choi 2011
Notes
(Continued)
clinicaltrials.gov
Guo 2014
Methods
Guo Y
Participants
154 with unspecific duration of neck pain
Interventions
Acupuncture vs sham acupuncture
Outcomes
Pain (NPQ, VAS), quality of life (SF-36), participant satisfaction
Notes
http://apps.who.int/trialsearch/AdvSearch.aspx
Liguori 2012
Methods
Abstract for RCT
Participants
60 patients with unilateral cervicobrachialgia
Interventions
Abdominal acupuncture vs sham abdominal acupuncture
Outcomes
VAS for pain and hypomobility (ROM)
Notes
Await full study, contact study author
Mejuto-Vzquez 2014
Methods
RCT
Participants
17 patients with acute mechanical idiopathic unilateral neck pain
Interventions
Dry needling of trigger points vs no treatment control
Outcomes
Numeric Pain Rating Scale (NPRS), pressure pain threshold (PPT) for pain, range of motion
Notes
--
Simma-Kletscha 2009
Methods
RCT
Participants
23 patients with acute symptoms of craniomandibular disorder
Interventions
Acupuncture vs sham laser

89
Simma-Kletscha 2009
(Continued)
Outcomes
Pain intensity (VAS), functional muscle test, ability to open the mouth, axiographic evaluation
Notes
German; awaiting translation
Sterling 2015
Methods
Protocol for double-blind RCT
Participants
120 participants with chronic whiplash, grade II
Interventions
Dry needling, advice and exercise vs sham dry needling, advice and exercise
Outcomes
Neck Disability Index (NDI), participant-perceived recovery
Notes
--
Wilke 2014
Methods
RCT, cross-over design
Participants
19 patients with myofascial neck pain
Interventions
Acupuncture, acupuncture plus stretching vs placebo laser acupuncture
Outcomes
Mechanical pain threshold, motion-related pain (visual analogue scale - VAS) and cervical range of motion, range of
motion
Notes
--
Zhang SP 2013
Methods
RCT
Participants
206 patients with chronic neck pain
Interventions
Electroacupuncture vs sham laser acupuncture
Outcomes
Neck Pain Disability Northwick Park Neck Pain Questionnaire (NPQ), Quality of Life SF-36 health survey, use of
medication for neck pain, sick leave
Notes
--

90
Characteristics of ongoing studies [ordered by study ID]

Calamita 2015
Trial name or title
Evaluation of immediate effect of acupuncture on pain, cervical range of motion and electromyographic
activity of the upper trapezius muscle in patients with non-specific neck pain: study protocol for a randomised
controlled trial
Methods
Protocol for RCT cross-over design, 1 week wash-out period
Participants
12 participants with neck pain, 12 healthy participants
Interventions
Acupuncture vs placebo acupuncture
Outcomes
EMG activity of upper trapezius, NPRS for neck pain and cervical range of motion (CROM)
Starting date
--
Contact information
--
Notes
--
Kim 2014
Trial name or title
Acupuncture as analgesia for non-emergent acute non-specific neck pain, ankle sprain and primary headache
in an emergency department setting: a protocol for a parallel-group, randomised, controlled pilot trial
Methods
Protocol for RCT
Participants
40 patients with non-emergent acute neck pain, ankle sprain or primary headache
Interventions
Acupuncture + standard emergency department care vs same
Outcomes
Numeric Rating Scale for pain (NRS), Neck Disability Index (NDI), participant-reported overall improvement
Starting date
--
Contact information
--
Notes
To be determined if number of participants with neck pain is sufficient and extractable data are available and/
or if primary headaches are of cervical origin

91
Liang 2012
Trial name or title
Optimised acupuncture treatment for neck pain caused by cervical spondylosis: a study protocol of a multicentre randomised controlled trial
Methods
Protocol for RCT
Participants
945 patients with cervical spondylosis
Interventions
Acupuncture vs sham acupuncture vs shallow acupuncture
Outcomes
Northwick Park Pain Questionnaire (NPQ), McGill Pain Questionnaire (MPQ) and SF-36 for pain and
disability
Starting date
--
Contact information
--
Notes
--
Que 2013
Trial name or title
Effectiveness of acupuncture intervention for neck pain caused by cervical spondylosis: study protocol for a
randomised controlled trial
Methods
Protocol for RCT
Participants
456 patients with neck pain caused by cervical spondylosis
Interventions
Acupuncture vs sham acupuncture
Outcomes
NPQ, MPQ and SF-36 for pain and disability
Starting date
--
Contact information
--
Notes
--
Sun 2014
Trial name or title
Acupuncture at Houxi (SI 3) acupoint for acute neck pain caused by stiff neck: study protocol for a pilot
randomised controlled trial
Methods
Protocol for pilot RCT
Participants
36 patients with acute neck pain and stiffness
Interventions
Acupuncture + massage vs massage

92
Sun 2014
(Continued)
Outcomes
NPQ, SF-MPQ
Starting date
--
Contact information
--
Notes
--

93
DATA AND ANALYSES
Comparison 1. Acupuncture versus sham treatment
Outcome or subgroup title

1 Pain intensity (VAS) immediate
post treatment
1.1 Chronic MPS 1 treatment
session
1.2 Chronic MND 3 to 4 wk
treatment
1.3 Chronic MPS 12 wk
treatment
1.4 Chronic MND SA group
10 wk treatment
1.5 Cervical osteoarthritis 1
treatment session
treatment, pain with movement
scale
2 Pain intensity (VAS) short term
treatment, 3 mo follow-up,
pain with movement scale
treatment, 1 to 4 wk follow-up
treatment, 3 mo follow-up
2.4 Subacute/chronic WAD 6
wk treatment, 3 mo follow-up
2.5 WAD myofascial 2 to 6
sessions, 6 wk follow-up
2.6 Chronic MND SA
group 10 wk treatment, 3 wk
follow-up
3 Pain intensity (VAS)
intermediate term
3.1 Chronic MPS ESNS
3 to 4 wk treatment, 6 mo
follow-up
3.2 Chronic WAD 6 wk
4 Pain intensity (VAS) long term
4.1 Chronic MPS ESNNS
3 to 4 wk treatment, 3 year
follow-up
No. of
studies
No. of
participants
Statistical method
Effect size
11
Std. Mean Difference (IV, Random, 95% CI)
Totals not selected
0.0 [0.0, 0.0]
0.0 [0.0, 0.0]
0.0 [0.0, 0.0]
0.0 [0.0, 0.0]
0.0 [0.0, 0.0]
0.0 [0.0, 0.0]
8
1
560
34

-0.23 [-0.40, -0.07]

0.0 [-0.67, 0.67]
34
-0.15 [-0.82, 0.52]
319
-0.18 [-0.40, 0.04]
124
-0.38 [-0.73, -0.02]
34
-0.60 [-1.29, 0.09]
15
-0.10 [-1.11, 0.92]
Totals not selected
0.0 [0.0, 0.0]
0.0 [0.0, 0.0]
1
1

Totals not selected

0.0 [0.0, 0.0]

94
5 Disability (NDI) immediate

post treatment
5.1 Chronic MND SA group
10 wk treatment
6 Disability (NPQ) immediate
post treatment
6.1 Chronic MND, 3 wk
treatment
7 Disability (NPQ) short term
8 Disability (NDI) short term
8.1 Chronic MND SA
group 10 wk treatment, 3 wk
follow-up
8.3 WAD II myofascial 2 to 6
treatment, 6 wk follow-up
8.4 Chronic MPS 1 treatment
9 Disability (NDI) intermediate
term
10 Quality of life (SF-36)
immediate post treatment
treatment
11 Quality of life (SF-36) short
term
Totals not selected
0.0 [0.0, 0.0]
Totals not selected
0.0 [0.0, 0.0]

-0.38 [-0.62, -0.15]

-0.38 [-0.62, -0.15]
4
1

Totals not selected

0.0 [0.0, 0.0]
0.0 [0.0, 0.0]
0.0 [0.0, 0.0]
1
1

0.0 [0.0, 0.0]

Totals not selected
0.0 [0.0, 0.0]
Std. Mean Difference (IV, Fixed, 95% CI)
Totals not selected
Std. Mean Difference (IV, Fixed, 95% CI)
0.0 [0.0, 0.0]
Totals not selected
0.0 [0.0, 0.0]
2
2
290
290
Comparison 2. Acupuncture versus inactive control

1 Pain intensity (VAS) immediate
post treatment
treatment
1.2 Chronic MND NLA
group 1 treatment session,
movement scale
treatment
1.4 Cervical osteoarthritis 1
treatment session
No. of
studies
No. of
participants
Statistical method
Effect size
Totals not selected
0.0 [0.0, 0.0]
0.0 [0.0, 0.0]
0.0 [0.0, 0.0]
0.0 [0.0, 0.0]

95

treatment, 1 to 4 wk follow-up
3 Pain intensity (VAS)
intermediate term
4 Pain intensity (VAS) long term
5 Pain pressure threshold
immediate post treatment
treatment
6 Pain pressure threshold short
term
6.1 Chronic MND 3 to 4
wk treatment, 1 to 3 month
follow-up
7 Pain intensity (proportion
pain relief ) immediate post
treatment
7.1 Chronic MND 4 wk
treatment
8 Disability (NDI) short term
9 Disability (NDI) intermediate
term
10 Disability (NDI) long term
11 Function (NHP) immediate
post treatment
treatment
12 Function (NHP) intermediate
term
treatment 6 mo follow-up
13 Function (NPQ) short term
follow-up
14 Quality of life (SF-36,
Functional Component) short
term
5
5

Totals not selected

0.0 [0.0, 0.0]
Totals not selected
0.0 [0.0, 0.0]
0.0 [0.0, 0.0]
1
1

Totals not selected

0.0 [0.0, 0.0]
Totals not selected
0.0 [0.0, 0.0]
Totals not selected
0.0 [0.0, 0.0]
Risk Ratio (M-H, Random, 95% CI)
Totals not selected
Risk Ratio (M-H, Random, 95% CI)
0.0 [0.0, 0.0]
1
1

Totals not selected

Totals not selected
0.0 [0.0, 0.0]
1
1

Totals not selected

0.0 [0.0, 0.0]
Totals not selected
0.0 [0.0, 0.0]
Totals not selected
0.0 [0.0, 0.0]
1
1

Totals not selected

0.0 [0.0, 0.0]
Totals not selected
0.0 [0.0, 0.0]

96
Comparison 3. Acupuncture versus wait-list

1.1 Chronic NDR 4 wk
2 Disability (neck and pain
disability scale) short term
2.1 Chronic MND 3 mo
3 Disability (neck and pain
disability scale) intermediate
term
4 Quality of life (SF-36 mental
score) short term
5 Quality of life (SF-36 mental
score) intermediate term
6 Quality of life (SF-36 physical
score) intermediate term
No. of
studies
No. of
participants
Statistical method
Effect size
1
1

Totals not selected

0.0 [0.0, 0.0]
Totals not selected
0.0 [0.0, 0.0]
Totals not selected
0.0 [0.0, 0.0]
Totals not selected
0.0 [0.0, 0.0]
Totals not selected
0.0 [0.0, 0.0]
Totals not selected
0.0 [0.0, 0.0]

97
Analysis 1.1. Comparison 1 Acupuncture versus sham treatment, Outcome 1 Pain intensity (VAS)
immediate post treatment.
Review:
Comparison: 1 Acupuncture versus sham treatment

Outcome: 1 Pain intensity (VAS) immediate post treatment
Study or subgroup
Treatment
N
Std.
Mean
Difference
Control
Mean(SD)
Mean(SD)
Std.
Mean
Difference
IV,Random,95% CI
IV,Random,95% CI
1 Chronic MPS 1 treatment session

Chou 2009 (1)
10
3.3 (1.1)
10
7.1 (0.9)
-3.62 [ -5.15, -2.09 ]
Tsai 2010
17
5.2 (1.6)
18
6.4 (1)
-0.88 [ -1.58, -0.19 ]
2 Chronic MND 3 to 4 wk treatment

He 2004
14
15 (5)
10
36 (8)
-3.17 [ -4.44, -1.90 ]
White 2000
23
-38 (17)
23
-9 (16)
-1.73 [ -2.41, -1.04 ]
Fu 2009
57
3.19 (1.92)
55
4.14 (1.59)
-0.53 [ -0.91, -0.16 ]
Liang 2011
88
3.48 (2.04)
90
4.01 (1.45)
-0.30 [ -0.59, 0.00 ]
15
1.87 (1.9)
16
3.37 (2.14)
-0.72 [ -1.45, 0.01 ]
46.1 (19)
51.4 (23.3)
-0.24 [ -1.26, 0.78 ]
1.8 (1.2)
44
1.6 (1.1)
0.17 [ -0.25, 0.59 ]
3 Chronic MPS 12 wk treatment

Birch 1998
4 Chronic MND SA group 10 wk treatment

Itoh 2007
5 Cervical osteoarthritis 1 treatment session

Thomas 1991
44
6 Chronic MPS 3 wk treatment, pain with movement scale

Sahin 2010
13
4.31 (1.61)
16
5.46 (2.26)
-0.56 [ -1.31, 0.19 ]
Sun 2010
17
30 (25.4)
17
40 (20.4)
-0.42 [ -1.10, 0.26 ]
-10
-5
[Acupuncture]
10
[Sham Treatment]
(1) eg. Rendant 2011: Exercise therapy vs Wait list control; duration: 18 sessions over 6 months; follow-up: none; instrument: VAS:

98
Analysis 1.2. Comparison 1 Acupuncture versus sham treatment, Outcome 2 Pain intensity (VAS) short
term.
Review:

Outcome: 2 Pain intensity (VAS) short term
Study or subgroup
Treatment
N
Std.
Mean
Difference
Control
Mean(SD)
Mean(SD)
Weight
IV,Random,95% CI
Std.
Mean
Difference
IV,Random,95% CI
1 Chronic MPS 3 wk treatment, 3 mo follow-up, pain with movement scale

Sun 2010
Subtotal (95% CI)
17
30 (15.5)
17
17
30 (20.55)
17
6.1 %
0.0 [ -0.67, 0.67 ]
6.1 %
0.0 [ -0.67, 0.67 ]
6.1 %
-0.15 [ -0.82, 0.52 ]
6.1 %
-0.15 [ -0.82, 0.52 ]
Heterogeneity: not applicable

Test for overall effect: Z = 0.0 (P = 1.0)
2 Chronic MND 3 to 4 wk treatment, 1 to 4 wk follow-up
Nabeta 2002
Subtotal (95% CI)
17
43.3 (19.7)
17
17
46.8 (25.4)
17

3 Chronic MND 3 to 4 wk treatment, 3 mo follow-up
Fu 2009
57
2.89 (1.81)
55
3.28 (1.48)
20.1 %
-0.23 [ -0.61, 0.14 ]
Liang 2011
88
2.88 (1.72)
90
3.19 (1.31)
32.0 %
-0.20 [ -0.50, 0.09 ]
Sahin 2010
13
4 (2.97)
16
3.54 (3.13)
5.2 %
0.15 [ -0.59, 0.88 ]
57.2 %
-0.18 [ -0.40, 0.04 ]
22.0 %
-0.38 [ -0.73, -0.02 ]
22.0 %
-0.38 [ -0.73, -0.02 ]
5.8 %
-0.60 [ -1.29, 0.09 ]
5.8 %
-0.60 [ -1.29, 0.09 ]
2.7 %
-0.10 [ -1.11, 0.92 ]
2.7 %
-0.10 [ -1.11, 0.92 ]
Subtotal (95% CI)
158
161
Heterogeneity: Tau2 = 0.0; Chi2 = 0.86, df = 2 (P = 0.65); I2 =0.0%

4 Subacute/chronic WAD 6 wk treatment, 3 mo follow-up
Cameron 2011
Subtotal (95% CI)
64
3.7 (2.4)
64
60
4.6 (2.32)
60

5 WAD myofascial 2 to 6 sessions, 6 wk follow-up
Tough 2010
Subtotal (95% CI)
17
1.7 (2)
17
17
3.2 (2.8)
17

6 Chronic MND SA group 10 wk treatment, 3 wk follow-up
Itoh 2007
Subtotal (95% CI)
51.6 (22)
53.9 (23)
-2
-1
[Acupuncture]
[Sham Treatment]
(Continued . . . )

99
(. . .
Study or subgroup
Treatment
N
Std.
Mean
Difference
Control
Mean(SD)
Mean(SD)
Continued)
Std.
Mean
Difference
Weight
IV,Random,95% CI
IV,Random,95% CI
Total (95% CI)
281
279
100.0 %
-0.23 [ -0.40, -0.07 ]

Test for subgroup differences: Chi2 = 2.54, df = 5 (P = 0.77), I2 =0.0%
-2
-1
[Acupuncture]
[Sham Treatment]
Analysis 1.3. Comparison 1 Acupuncture versus sham treatment, Outcome 3 Pain intensity (VAS)
intermediate term.
Review:

Outcome: 3 Pain intensity (VAS) intermediate term
Study or subgroup
Treatment
N
Std.
Mean
Difference
Control
Mean(SD)
Std.
Mean
Difference
Mean(SD)
IV,Random,95% CI
IV,Random,95% CI
24 (7)
12
36 (8)
-1.54 [ -2.47, -0.61 ]
4.1 (2.4)
60
5.5 (2.32)
-0.59 [ -0.95, -0.23 ]
1 Chronic MPS ESNS 3 to 4 wk treatment, 6 mo follow-up

He 2004
12
2 Chronic WAD 6 wk treatment, 6 mo follow-up

Cameron 2011
64
-20
-10
[Acupuncture]

10
20
[Sham Treatment]
100
Analysis 1.4. Comparison 1 Acupuncture versus sham treatment, Outcome 4 Pain intensity (VAS) long
term.
Review:

Outcome: 4 Pain intensity (VAS) long term
Study or subgroup
Treatment
N
Std.
Mean
Difference
Control
Mean(SD)
Mean(SD)
12
44 (11)
Std.
Mean
Difference
IV,Random,95% CI
IV,Random,95% CI
1 Chronic MPS ESNNS 3 to 4 wk treatment, 3 year follow-up

He 2004
12
19 (6)
-2.72 [ -3.89, -1.56 ]
-100
-50
[Acupuncture]
50
100
[Sham Treatment]
Analysis 1.5. Comparison 1 Acupuncture versus sham treatment, Outcome 5 Disability (NDI) immediate
post treatment.
Review:

Outcome: 5 Disability (NDI) immediate post treatment
Study or subgroup
Treatment
N
Std.
Mean
Difference
Control
Mean(SD)
Mean(SD)
9.4 (5.8)
10.4 (3.7)
Std.
Mean
Difference
IV,Random,95% CI
IV,Random,95% CI
1 Chronic MND SA group 10 wk treatment

Itoh 2007
-0.19 [ -1.21, 0.83 ]
-4
-2
[Acupuncture]

[Sham Treatment]
101
Analysis 1.6. Comparison 1 Acupuncture versus sham treatment, Outcome 6 Disability (NPQ) immediate
post treatment.
Review:

Outcome: 6 Disability (NPQ) immediate post treatment
Study or subgroup
Treatment
Std.
Mean
Difference
Control
Std.
Mean
Difference
Mean(SD)
Mean(SD)
IV,Random,95% CI
IV,Random,95% CI
Fu 2009
57
19.98 (11.3)
55
25.02 (13.03)
-0.41 [ -0.79, -0.04 ]
Liang 2009
53
19.16 (11.49)
53
23.76 (12.15)
-0.39 [ -0.77, 0.00 ]
Liang 2011
88
20.71 (11.91)
90
24.04 (11.83)
-0.28 [ -0.57, 0.02 ]
1 Chronic MND, 3 wk treatment
-2
-1
[Acupuncture]
[Sham Treatment]
Analysis 1.7. Comparison 1 Acupuncture versus sham treatment, Outcome 7 Disability (NPQ) short term.
Review:

Outcome: 7 Disability (NPQ) short term
Study or subgroup
Treatment
N
Std.
Mean
Difference
Control
Mean(SD)
Mean(SD)
Weight
IV,Random,95% CI
Std.
Mean
Difference
IV,Random,95% CI
1 Chronic MND, 3 wk treatment, 3 mo follow-up

Fu 2009
57
20.55 (10.2)
55
25.77 (15.05)
38.5 %
-0.40 [ -0.78, -0.03 ]
Liang 2011
88
19.09 (9.94)
90
23.53 (13.67)
61.5 %
-0.37 [ -0.67, -0.07 ]
100.0 %
-0.38 [ -0.62, -0.15 ]
Total (95% CI)
145
145

Test for subgroup differences: Not applicable
-1
-0.5
[Acupuncture]

0.5
[Sham Treatment]
102
Analysis 1.8. Comparison 1 Acupuncture versus sham treatment, Outcome 8 Disability (NDI) short term.
Review:

Outcome: 8 Disability (NDI) short term
Study or subgroup
Treatment
N
Std.
Mean
Difference
Control
Mean(SD)
Std.
Mean
Difference
Mean(SD)
IV,Random,95% CI
IV,Random,95% CI
11.1 (5)
-0.03 [ -1.05, 0.98 ]
60
14.7 (6.2)
-0.22 [ -0.57, 0.13 ]
1 Chronic MND SA group 10 wk treatment, 3 wk follow-up

Itoh 2007
10.9 (6.6)

Cameron 2011
64
13.3 (6.4)
3 WAD II myofascial 2 to 6 treatment, 6 wk follow-up

Tough 2010
17
8.4 (7.8)
17
11.9 (8.8)
-0.41 [ -1.09, 0.27 ]
17
-3.8 (0.8)
18
-2.9 (0.6)
-1.25 [ -1.98, -0.52 ]
4 Chronic MPS 1 treatment

Tsai 2010
-2
-1
[Acupuncture]

[Sham Treatment]
103
Analysis 1.9. Comparison 1 Acupuncture versus sham treatment, Outcome 9 Disability (NDI) intermediate
term.
Review:

Outcome: 9 Disability (NDI) intermediate term
Study or subgroup
Treatment
N
Std.
Mean
Difference
Control
Mean(SD)
Mean(SD)
60
16.8 (7.75)
Std.
Mean
Difference
IV,Random,95% CI
IV,Random,95% CI

Cameron 2011
64
14.5 (7.2)
-0.31 [ -0.66, 0.05 ]
-100
-50
50
[Acupuncture]
100
[Sham Treatment]
Analysis 1.10. Comparison 1 Acupuncture versus sham treatment, Outcome 10 Quality of life (SF-36)
Review:

Outcome: 10 Quality of life (SF-36) immediate post treatment
Study or subgroup
Treatment
Std.
Mean
Difference
Control
Mean(SD)
Mean(SD)
88
86.02 (13.19)
90
78.94 (22.66)
Std.
Mean
Difference
IV,Fixed,95% CI
IV,Fixed,95% CI
1 Chronic MND, 3 wk treatment

Liang 2011
0.38 [ 0.08, 0.68 ]
-1
-0.5
[Acupuncture]

0.5
[Sham Treatment]
104
Analysis 1.11. Comparison 1 Acupuncture versus sham treatment, Outcome 11 Quality of life (SF-36) short
term.
Review:

Outcome: 11 Quality of life (SF-36) short term
Study or subgroup
Treatment
N
Std.
Mean
Difference
Control
Mean(SD)
Mean(SD)
90
85.88 (14.01)
Std.
Mean
Difference
IV,Random,95% CI
IV,Random,95% CI
1 Chronic MND, 3 wk treatment, 3 mo follow-up

Liang 2011
88
84.26 (15.24)
-0.11 [ -0.40, 0.18 ]
-2
-1
[Acupuncture]
[Sham Treatment]
Analysis 2.1. Comparison 2 Acupuncture versus inactive control, Outcome 1 Pain intensity (VAS)
Review:
Comparison: 2 Acupuncture versus inactive control

Outcome: 1 Pain intensity (VAS) immediate post treatment
Study or subgroup
Treatment
Std.
Mean
Difference
Control
Std.
Mean
Difference
Mean(SD)
Mean(SD)
IV,Random,95% CI
IV,Random,95% CI
20
7.62 (1.5)
20
7.65 (1.57)
-0.02 [ -0.64, 0.60 ]
19.1 (16.11)
34
28 (19.36)
-0.49 [ -0.98, -0.01 ]

Ilbuldu 2004
2 Chronic MND NLA group 1 treatment session, movement scale

Irnich 2002
34

Petrie 1986
13
-36.59 (22.95)
12
-32.88 (18.55)
-0.17 [ -0.96, 0.62 ]
Seidel 2002
12
7 (11.4)
12
25.2 (26.6)
-0.86 [ -1.70, -0.02 ]
1.8 (1.2)
44
1.7 (1)
0.09 [ -0.33, 0.51 ]
4 Cervical osteoarthritis 1 treatment session

Thomas 1991
44
-10
-5
Favours treatment

10
Favours control
105
Analysis 2.2. Comparison 2 Acupuncture versus inactive control, Outcome 2 Pain intensity (VAS) short
term.
Review:

Study or subgroup
Treatment
N
Std.
Mean
Difference
Control
Mean(SD)
Mean(SD)
Std.
Mean
Difference
IV,Random,95% CI
IV,Random,95% CI
1 Chronic MND 3 to 4 wk treatment, 1 to 4 wk follow-up

Irnich 2001
51
-24.22 (27.98)
57
-17.28 (28.1)
-0.25 [ -0.62, 0.13 ]
Petrie 1986
13
-31.77 (24.1)
12
-24.72 (20.6)
-0.30 [ -1.09, 0.49 ]
Seidel 2002
12
9.4 (17.8)
12
19.6 (24.57)
-0.46 [ -1.27, 0.35 ]
Vas 2006
61
-42.1 (21.1)
62
-14 (15.7)
-1.50 [ -1.91, -1.10 ]
White 2004
63
20.39 (20.26)
61
30.69 (22)
-0.48 [ -0.84, -0.13 ]
-10
-5
Favours acupuncture

10
Favours sham
106
Analysis 2.3. Comparison 2 Acupuncture versus inactive control, Outcome 3 Pain intensity (VAS)
intermediate term.
Review:

Outcome: 3 Pain intensity (VAS) intermediate term
Study or subgroup
Treatment
Std.
Mean
Difference
Control
Std.
Mean
Difference
Mean(SD)
Mean(SD)
IV,Random,95% CI
IV,Random,95% CI
4.24 (2.93)
20
4.22 (3.06)
0.01 [ -0.61, 0.63 ]
1 Chronic MPS 4 wk treatment, 6 mo follow-up

Ilbuldu 2004
20

Vas 2006
45
-41.1 (26.9)
40
-26.8 (25.9)
-0.54 [ -0.97, -0.10 ]
White 2004
57
19.21 (24.22)
54
21.02 (24.38)
-0.07 [ -0.45, 0.30 ]
-10
-5
Favours treatment
10
Favours control
Analysis 2.4. Comparison 2 Acupuncture versus inactive control, Outcome 4 Pain intensity (VAS) long term.
Review:

Outcome: 4 Pain intensity (VAS) long term
Study or subgroup
Treatment
N
Std.
Mean
Difference
Control
Mean(SD)
Mean(SD)
53
24.36 (26.68)
Std.
Mean
Difference
IV,Random,95% CI
IV,Random,95% CI

White 2004
54
20.91 (25.69)
-0.13 [ -0.51, 0.25 ]
-4
-2
Favours experimental

Favours control
107
Analysis 2.5. Comparison 2 Acupuncture versus inactive control, Outcome 5 Pain pressure threshold
Review:

Outcome: 5 Pain pressure threshold immediate post treatment
Study or subgroup
Treatment
N
Std.
Mean
Difference
Control
Mean(SD)
Mean(SD)
Std.
Mean
Difference
IV,Random,95% CI
IV,Random,95% CI

Irnich 2001
51
0.06 (0.58)
57
-0.03 (0.51)
0.16 [ -0.21, 0.54 ]
Seidel 2002
12
5.75 (1.59)
12
6.12 (3.11)
-0.14 [ -0.95, 0.66 ]
-2
-1
Favours control
Analysis 2.6. Comparison 2 Acupuncture versus inactive control, Outcome 6 Pain pressure threshold short
term.
Review:

Outcome: 6 Pain pressure threshold short term
Study or subgroup
Treatment
N
Std.
Mean
Difference
Control
Mean(SD)
Mean(SD)
Std.
Mean
Difference
IV,Random,95% CI
IV,Random,95% CI
1 Chronic MND 3 to 4 wk treatment, 1 to 3 month follow-up

Irnich 2001
51
0.19 (0.77)
57
0.03 (0.62)
0.23 [ -0.15, 0.61 ]
Seidel 2002
12
6.68 (2.18)
12
7.32 (3.32)
-0.22 [ -1.02, 0.58 ]
-2
-1

Favours control
108
Analysis 2.7. Comparison 2 Acupuncture versus inactive control, Outcome 7 Pain intensity (proportion
pain relief) immediate post treatment.
Review:

Outcome: 7 Pain intensity (proportion pain relief) immediate post treatment
Study or subgroup
Treatment
Control
n/N
n/N
1/7
6/6
Risk Ratio
MH,Random,95%
CI
Risk Ratio
MH,Random,95%
CI
1 Chronic MND 4 wk treatment

Petrie 1983
0.20 [ 0.05, 0.87 ]
0.02
0.1
Favours treatment
10
50
Favours control
Analysis 2.8. Comparison 2 Acupuncture versus inactive control, Outcome 8 Disability (NDI) short term.
Review:

Outcome: 8 Disability (NDI) short term
Study or subgroup
White 2004
Treatment
Std.
Mean
Difference
Control
Mean(SD)
Mean(SD)
59
10.98 (6.27)
59
12.68 (7.79)
IV,Random,95% CI
IV,Random,95% CI
-0.24 [ -0.60, 0.12 ]
-1
-0.5
Favours treatment

Std.
Mean
Difference
0.5
Favours control
109
Analysis 2.9. Comparison 2 Acupuncture versus inactive control, Outcome 9 Disability (NDI) intermediate
term.
Review:

Outcome: 9 Disability (NDI) intermediate term
Study or subgroup
Treatment
N
Std.
Mean
Difference
Control
Mean(SD)
Mean(SD)
53
10.64 (8.3)
Std.
Mean
Difference
IV,Random,95% CI
IV,Random,95% CI
1 Chronic MND 4 wk treatment, 6 mo follow-up

White 2004
56
9.91 (6.96)
-0.09 [ -0.47, 0.28 ]
-1
-0.5
Favours treatment
0.5
Favours control
Analysis 2.10. Comparison 2 Acupuncture versus inactive control, Outcome 10 Disability (NDI) long term.
Review:

Outcome: 10 Disability (NDI) long term
Study or subgroup
Treatment
N
Std.
Mean
Difference
Control
Mean(SD)
Mean(SD)
53
10.72 (9.11)
Std.
Mean
Difference
IV,Random,95% CI
IV,Random,95% CI
1 Chronic MND 4 wk treatment, 12 mo follow-up

White 2004
53
8.89 (6.57)
-0.23 [ -0.61, 0.15 ]
-100
-50

50
100
Favours control
110
Analysis 2.11. Comparison 2 Acupuncture versus inactive control, Outcome 11 Function (NHP) immediate
post treatment.
Review:

Outcome: 11 Function (NHP) immediate post treatment
Study or subgroup
Treatment
Std.
Mean
Difference
Control
Mean(SD)
Mean(SD)
20
23.07 (19.09)
20
19.35 (14.14)
Std.
Mean
Difference
IV,Random,95% CI
IV,Random,95% CI

Ilbuldu 2004
0.22 [ -0.40, 0.84 ]
-2
-1
Favours acupuncture
Favours inactive control
Analysis 2.12. Comparison 2 Acupuncture versus inactive control, Outcome 12 Function (NHP)
intermediate term.
Review:

Outcome: 12 Function (NHP) intermediate term
Study or subgroup
Treatment
Std.
Mean
Difference
Control
Mean(SD)
Mean(SD)
13.68 (16.62)
20
16.08 (17.43)
Std.
Mean
Difference
IV,Random,95% CI
IV,Random,95% CI
1 Chronic MPS 4 wk treatment 6 mo follow-up

Ilbuldu 2004
20
-0.14 [ -0.76, 0.48 ]
-4
-2
Favours acupuncture

111
Analysis 2.13. Comparison 2 Acupuncture versus inactive control, Outcome 13 Function (NPQ) short term.
Review:

Outcome: 13 Function (NPQ) short term
Study or subgroup
Treatment
Std.
Mean
Difference
Control
Mean(SD)
Mean(SD)
61
-30.2 (13.6)
62
-12.7 (14.9)
Std.
Mean
Difference
IV,Random,95% CI
IV,Random,95% CI
1 Chronic MND 1 wk follow-up

Vas 2006
-1.22 [ -1.60, -0.83 ]
-2
-1
Favours acupuncture
Analysis 2.14. Comparison 2 Acupuncture versus inactive control, Outcome 14 Quality of life (SF-36,
Functional Component) short term.
Review:

Outcome: 14 Quality of life (SF-36, Functional Component) short term
Study or subgroup
Treatment
N
Std.
Mean
Difference
Control
Mean(SD)
Mean(SD)
Std.
Mean
Difference
IV,Random,95% CI
IV,Random,95% CI
1 Chronic MND 3 to 4 wk treatment, 8 wk follow-up

Vas 2006
45
9.3 (11)
40
5.3 (8)
0.41 [ -0.02, 0.84 ]
White 2004
59
42.49 (9.75)
59
43.75 (10.04)
-0.13 [ -0.49, 0.23 ]
-2
-1
Favours acupuncture

112
Analysis 3.1. Comparison 3 Acupuncture versus wait-list, Outcome 1 Pain intensity (VAS) short term.
Review:
Comparison: 3 Acupuncture versus wait-list

Study or subgroup
Treatment
Std.
Mean
Difference
Control
Mean(SD)
Mean(SD)
3.63 (2.21)
15
5.36 (2.32)
Std.
Mean
Difference
IV,Random,95% CI
IV,Random,95% CI
1 Chronic NDR 4 wk treatment, 8 wk follow-up

Coan 1982
15
-0.74 [ -1.49, 0.00 ]
-2
-1
Favours control
Analysis 3.2. Comparison 3 Acupuncture versus wait-list, Outcome 2 Disability (neck and pain disability
scale) short term.
Review:

Outcome: 2 Disability (neck and pain disability scale) short term
Study or subgroup
Treatment
N
Std.
Mean
Difference
Control
Mean(SD)
Mean(SD)
1698
-5.8 (0.65)
Std.
Mean
Difference
IV,Random,95% CI
IV,Random,95% CI
1 Chronic MND 3 mo treatment, 3 mo follow-up

Witt 2006
1753
-28.9 (0.65)
-35.53 [ -36.37, -34.69 ]
-2
-1
Favours treatment

Favours control
113
Analysis 3.3. Comparison 3 Acupuncture versus wait-list, Outcome 3 Disability (neck and pain disability
scale) intermediate term.
Review:

Outcome: 3 Disability (neck and pain disability scale) intermediate term
Study or subgroup
Treatment
N
Std.
Mean
Difference
Control
Mean(SD)
Mean(SD)
1698
25.1 (0.7)
Std.
Mean
Difference
IV,Random,95% CI
IV,Random,95% CI

Witt 2006
1753
28 (0.7)
4.14 [ 4.02, 4.26 ]
-100
-50
50
100
Favours control
Analysis 3.4. Comparison 3 Acupuncture versus wait-list, Outcome 4 Quality of life (SF-36 mental score)
short term.
Review:

Outcome: 4 Quality of life (SF-36 mental score) short term
Study or subgroup
Treatment
N
Std.
Mean
Difference
Control
Mean(SD)
Mean(SD)
1698
1 (0.25)
Std.
Mean
Difference
IV,Random,95% CI
IV,Random,95% CI

Witt 2006
1753
4.2 (0.25)
12.80 [ 12.49, 13.11 ]
-100
-50

50
100
Favours control
114
Analysis 3.5. Comparison 3 Acupuncture versus wait-list, Outcome 5 Quality of life (SF-36 mental score)
intermediate term.
Review:

Outcome: 5 Quality of life (SF-36 mental score) intermediate term
Study or subgroup
Treatment
N
Std.
Mean
Difference
Control
Mean(SD)
Mean(SD)
1698
3.1 (0.3)
Std.
Mean
Difference
IV,Random,95% CI
IV,Random,95% CI

Witt 2006
1753
4 (0.3)
3.00 [ 2.90, 3.10 ]
-100
-50
50
100
Favours control
Analysis 3.6. Comparison 3 Acupuncture versus wait-list, Outcome 6 Quality of life (SF-36 physical score)
intermediate term.
Review:

Outcome: 6 Quality of life (SF-36 physical score) intermediate term
Study or subgroup
Treatment
N
Std.
Mean
Difference
Control
Mean(SD)
Mean(SD)
1698
5 (0.2)
Std.
Mean
Difference
IV,Random,95% CI
IV,Random,95% CI

Witt 2006
1753
5.6 (0.2)
3.00 [ 2.90, 3.10 ]
-100
-50

50
100
Favours control
115
APPENDICES
Appendix 1. Computerised search strategy
CENTRAL-OVID
August 25, 2015
1. Neck Pain/
2. exp Brachial Plexus Neuropathies/
3. exp neck injuries/ or exp whiplash injuries/
4. cervical pain.mp.
5. neckache.mp.
6. whiplash.mp.
7. cervicodynia.mp.
8. cervicalgia.mp.
9. brachialgia.mp.
10. brachial neuritis.mp.
11. brachial neuralgia.mp.
12. neck pain.mp.
13. neck injur*.mp.
14. brachial plexus neuropath*.mp.
15. brachial plexus neuritis.mp.
16. thoracic outlet syndrome/ or cervical rib syndrome/
17. Torticollis/
18. exp brachial plexus neuropathies/ or exp brachial plexus neuritis/
19. cervico brachial neuralgia.ti,ab.
20. cervicobrachial neuralgia.ti,ab.
21. (monoradicul* or monoradicl*).tw.
22. or/1-21
23. exp headache/ and cervic*.tw.
24. exp genital diseases, female/
25. genital disease*.mp.
26. or/24-25
27. 23 not 26
28. 22 or 27
29. neck/
30. neck muscles/
31. exp cervical plexus/
32. exp cervical vertebrae/
33. atlanto-axial joint/
34. atlanto-occipital joint/
35. Cervical Atlas/
36. spinal nerve roots/
37. exp brachial plexus/
38. (odontoid* or cervical or occip* or atlant*).tw.
39. axis/ or odontoid process/
40. Thoracic Vertebrae/
41. cervical vertebrae.mp.
42. cervical plexus.mp.
43. cervical spine.mp.
44. (neck adj3 muscles).mp.
45. (brachial adj3 plexus).mp.
116
46. (thoracic adj3 vertebrae).mp.

47. neck.mp.
48. (thoracic adj3 spine).mp.
49. (thoracic adj3 outlet).mp.
50. trapezius.mp.
51. cervical.mp.
52. cervico*.mp.
53. 51 or 52
56. exp *Uterus/
57. 54 or 55 or 56
58. 53 not 57
59. 29 or 30 or 31 or 32 or 33 or 34 or 35 or 36 or 37 or 38 or 39 or 40 or 41 or 42 or 43 or 44 or 45 or 46 or 47 or 48 or 49 or 50
or 58
60. exp pain/
61. exp injuries/
62. pain.mp.
63. ache.mp.
64. sore.mp.
65. stiff.mp.
66. discomfort.mp.
67. injur*.mp.
68. neuropath*.mp.
69. or/60-68
70. 59 and 69
71. Radiculopathy/
72. exp temporomandibular joint disorders/ or exp temporomandibular joint dysfunction syndrome/
73. myofascial pain syndromes/
74. exp Sprains and Strains/
75. exp Spinal Osteophytosis/
76. exp Neuritis/
77. Polyradiculopathy/
78. exp Arthritis/
79. Fibromyalgia/
80. spondylitis/ or discitis/
81. spondylosis/ or spondylolysis/ or spondylolisthesis/
82. radiculopathy.mp.
83. radiculitis.mp.
84. temporomandibular.mp.
85. myofascial pain syndrome*.mp.
86. thoracic outlet syndrome*.mp.
87. spinal osteophytosis.mp.
88. neuritis.mp.
89. spondylosis.mp.
90. spondylitis.mp.
91. spondylolisthesis.mp.
92. or/71-91
93. 59 and 92
94. exp neck/
97. neck.mp.
117

99. cervical.mp.
100. cervico*.mp.
101. 99 or 100
104. exp *Uterus/
105. or/102-104
106. 101 not 105
109. 94 or 95 or 96 or 97 or 98 or 106 or 107 or 108
110. Intervertebral Disk/
111. (disc or discs).mp.
112. (disk or disks).mp.
113. 110 or 111 or 112
114. 109 and 113
115. herniat*.mp.
116. slipped.mp.
117. prolapse*.mp.
118. displace*.mp.
119. degenerat*.mp.
120. (bulge or bulged or bulging).mp.
121. 115 or 116 or 117 or 118 or 119 or 120
122. 114 and 121
123. intervertebral disk degeneration/ or intervertebral disk displacement/
124. intervertebral disk displacement.mp.
125. intervertebral disc displacement.mp.
126. intervertebral disk degeneration.mp.
127. intervertebral disc degeneration.mp.
128. 123 or 124 or 125 or 126 or 127
129. 109 and 128
130. 28 or 70 or 93 or 122 or 129
131. animals/ not (animals/ and humans/)
132. 130 not 131
133. exp *neoplasms/
134. exp *wounds, penetrating/
135. 133 or 134
136. 132 not 135
137. Neck Pain/rh, th [Rehabilitation, Therapy]
138. exp Brachial Plexus Neuropathies/rh, th
139. exp neck injuries/rh, th or exp whiplash injuries/rh, th
140. thoracic outlet syndrome/rh, th or cervical rib syndrome/rh, th
141. Torticollis/rh, th
142. exp brachial plexus neuropathies/rh, th or exp brachial plexus neuritis/rh, th
143. or/137-142
144. Radiculopathy/rh, th
145. exp temporomandibular joint disorders/rh, th or exp temporomandibular joint dysfunction syndrome/rh, th
146. myofascial pain syndromes/rh, th
147. exp Sprains and Strains/rh, th
148. exp Spinal Osteophytosis/rh, th
149. exp Neuritis/rh, th
150. Polyradiculopathy/rh, th
118
151. exp Arthritis/rh, th

152. Fibromyalgia/rh, th
153. spondylitis/rh, th or discitis/rh, th
154. spondylosis/rh, th or spondylolysis/rh, th or spondylolisthesis/rh, th
155. or/144-154
156. 59 and 155
157. acupuncture/ or chiropractic/
158. exp Musculoskeletal Manipulations/
159. massage.tw.
160. mobili?ation.tw.
161. Acupuncture Therapy/
162. (acupuncture or acu-puncture or needling or acupressure or mox?bustion).tw.
163. ((neck or spine or spinal or cervical or chiropractic* or musculoskeletal* or musculo-skeletal*) adj3 (adjust* or manipulat* or
mobiliz* or mobilis*)).tw.
164. (manual adj therap*).tw.
165. (manipulati* adj (therap* or medicine)).tw.
166. (massag* or reflexolog* or rolfing or zone therap*).tw.
167. Nimmo.mp.
168. exp Vibration/tu [Therapeutic Use]
169. (vibration adj5 (therap* or treatment*)).tw.
170. (Chih Ya or Shiatsu or Shiatzu or Zhi Ya).tw.
171. (flexion adj2 distraction*).tw.
172. (myofascial adj3 (release or therap*)).tw.
173. muscle energy technique*.tw.
174. trigger point.tw.
175. proprioceptive Neuromuscular Facilitation*.tw.
176. cyriax friction.tw.
177. (lomilomi or lomi-lomi or trager).tw.
178. aston patterning.tw.
179. (strain adj counterstrain).tw.
180. (craniosacral therap* or cranio-sacral therap*).tw.
181. (amma or ammo or effleuurage or petrissage or hacking or tapotment).tw.
182. Complementary Therapies/
183. ((complement* or alternat* or osteopthic*) adj (therap* or medicine)).tw.
184. (Tui Na or Tuina).tw.
185. or/157-184
186. 136 and 185
187. 143 or 156 or 186
189. 187 not 188
MEDLINE-OVID
August 25, 2015
1. Neck Pain/
2. exp Brachial Plexus Neuropathies/
3. exp neck injuries/ or exp whiplash injuries/
5. neckache.mp.
6. whiplash.mp.
7. cervicodynia.mp.
8. cervicalgia.mp.
9. brachialgia.mp.
119

12. neck pain.mp.
13. neck injur*.mp.
16. thoracic outlet syndrome/ or cervical rib syndrome/
17. Torticollis/
18. exp brachial plexus neuropathies/ or exp brachial plexus neuritis/
22. or/1-21
26. or/24-25
27. 23 not 26
28. 22 or 27
29. neck/
30. neck muscles/
31. exp cervical plexus/
33. atlanto-axial joint/
34. atlanto-occipital joint/
35. Cervical Atlas/
36. spinal nerve roots/
37. exp brachial plexus/
39. axis/ or odontoid process/
47. neck.mp.
50. trapezius.mp.
51. cervical.mp.
52. cervico*.mp.
53. 51 or 52
56. exp *Uterus/
57. 54 or 55 or 56
58. 53 not 57
or 58
60. exp pain/
61. exp injuries/
120
62. pain.mp.
63. ache.mp.
64. sore.mp.
65. stiff.mp.
66. discomfort.mp.
67. injur*.mp.
68. neuropath*.mp.
69. or/60-68
70. 59 and 69
71. Radiculopathy/
72. exp temporomandibular joint disorders/ or exp temporomandibular joint dysfunction syndrome/
73. myofascial pain syndromes/
74. exp Sprains and Strains/
75. exp Spinal Osteophytosis/
76. exp Neuritis/
77. Polyradiculopathy/
78. exp Arthritis/
79. Fibromyalgia/
80. spondylitis/ or discitis/
81. spondylosis/ or spondylolysis/ or spondylolisthesis/
83. radiculitis.mp.
86. thoracic outlet syndrome*.mp.
88. neuritis.mp.
89. spondylosis.mp.
90. spondylitis.mp.
92. or/71-91
93. 59 and 92
94. exp neck/
97. neck.mp.
99. cervical.mp.
100. cervico*.mp.
101. 99 or 100
104. exp *Uterus/
105. or/102-104
106. 101 not 105
109. 94 or 95 or 96 or 97 or 98 or 106 or 107 or 108
110. Intervertebral Disk/
113. 110 or 111 or 112
114. 109 and 113
121
115. herniat*.mp.
116. slipped.mp.
117. prolapse*.mp.
118. displace*.mp.
119. degenerat*.mp.
121. 115 or 116 or 117 or 118 or 119 or 120
122. 114 and 121
123. intervertebral disk degeneration/ or intervertebral disk displacement/
128. 123 or 124 or 125 or 126 or 127
129. 109 and 128
130. 28 or 70 or 93 or 122 or 129
132. 130 not 131
133. exp *neoplasms/
134. exp *wounds, penetrating/
135. 133 or 134
136. 132 not 135
137. Neck Pain/rh, th [Rehabilitation, Therapy]
138. exp Brachial Plexus Neuropathies/rh, th
139. exp neck injuries/rh, th or exp whiplash injuries/rh, th
140. thoracic outlet syndrome/rh, th or cervical rib syndrome/rh, th
142. exp brachial plexus neuropathies/rh, th or exp brachial plexus neuritis/rh, th
143. or/137-142
145. exp temporomandibular joint disorders/rh, th or exp temporomandibular joint dysfunction syndrome/rh, th
146. myofascial pain syndromes/rh, th
147. exp Sprains and Strains/rh, th
148. exp Spinal Osteophytosis/rh, th
149. exp Neuritis/rh, th
150. Polyradiculopathy/rh, th
151. exp Arthritis/rh, th
153. spondylitis/rh, th or discitis/rh, th
154. spondylosis/rh, th or spondylolysis/rh, th or spondylolisthesis/rh, th
155. or/144-154
156. 59 and 155
157. acupuncture/ or chiropractic/
158. exp Musculoskeletal Manipulations/
159. massage.tw.
161. Acupuncture Therapy/
122
167. Nimmo.mp.
168. exp Vibration/tu [Therapeutic Use]
182. Complementary Therapies/
185. or/157-184
186. 136 and 185
187. 143 or 156 or 186
189. 187 not 188
190. exp randomized controlled trials as topic/
191. randomized controlled trial.pt.
192. controlled clinical trial.pt.
193. (random* or sham or placebo*).tw.
194. placebos/
195. random allocation/
196. single blind method/
197. double blind method/
198. ((singl* or doubl* or trebl* or tripl*) adj25 (blind* or dumm* or mask*)).ti,ab.
199. (rct or rcts).tw.
200. (control* adj2 (study or studies or trial*)).tw.
201. or/190-200
202. 189 and 201
EMBASE-OVID
August 25, 2015
1. neck pain/
2. brachial plexus neuropathy/
3. neck injury/ or whiplash injury/
5. neckache.mp.
6. whiplash.mp.
7. cervicodynia.mp.
8. cervicalgia.mp.
9. brachialgia/
10. brachialgia.mp.
13. neck pain.mp.
123
14. neck injur*.mp.

17. thorax outlet syndrome/
18. torticollis/
22. or/1-21
24. exp gynecologic disease/
26. exp *uterine cervix/
27. or/24-26
28. 23 not 27
29. 22 or 28
30. neck/ or neck muscle/
31. cervical plexus/
32. cervical spine/
33. atlantoaxial joint/
34. atlantooccipital joint/
35. atlas/
36. spinal root/
37. brachial plexus/
39. odontoid process/
40. cervical vertebra.mp.
46. (thoracic adj3 vertebra?).mp.
47. neck.mp.
50. trapezius.mp.
51. cervical.mp.
52. cervico*.mp.
53. 51 or 52
57. 54 or 55 or 56
58. 53 not 57
60. exp pain/
61. exp injury/
62. pain.mp.
63. ache.mp.
64. sore.mp.
65. stiff.mp.
66. discomfort.mp.
124
67. injur*.mp.
68. neuropath*.mp.
69. or/60-68
70. radiculopathy/
71. temporomandibular joint disorder/
72. myofascial pain/
73. spondylosis/ or cervical spondylosis/
74. neuritis/
75. exp arthritis/
76. fibromyalgia/
77. exp spondylitis/
78. diskitis/
79. spondylolisthesis/
81. radiculitis.mp.
85. neuritis.mp.
86. spondylosis.mp.
87. spondylitis.mp.
89. or/70-88
90. 59 and 89
91. neck/
92. cervical spine/
93. neck.mp.
94. (thoracic adj3 vertebra?).mp.
95. cervical.mp.
96. cervico*.mp.
100. or/97-99
101. 95 or 96
102. 101 not 100
105. 91 or 92 or 93 or 94 or 102 or 103 or 104
106. intervertebral disk/
109. 106 or 107 or 108
110. 105 and 109
111. herniat*.mp.
112. slipped.mp.
113. prolapse*.mp.
114. displace*.mp.
115. degenerat*.mp.
117. 110 or 111 or 112 or 113 or 114 or 115 or 116
118. 110 and 117
119. intervertebral disk hernia/
125
120. intervertebral disk degeneration/

125. 119 or 120 or 121 or 122 or 123 or 124
126. 105 and 125
127. 59 and 69
128. 29 or 90 or 118 or 126 or 127
129. exp *neoplasm/
130. exp *penetrating trauma/
131. 129 or 130
132. 128 not 131
133. neck pain/rh, th
134. brachial plexus neuropathy/rh, th
135. neck injury/ or whiplash injury/rh, th
136. brachialgia/rh, th
137. thorax outlet syndrome/rh, th
140. temporomandibular joint disorder/rh, th
141. myofascial pain/rh, th
142. spondylosis/rh, th or cervical spondylosis/rh, th
143. neuritis/rh, th
144. exp arthritis/rh, th
146. exp spondylitis/rh, th
147. diskitis/rh, th
148. spondylolisthesis/rh, th
149. acupuncture/ or acupressure/ or acupuncture analgesia/
150. exp manipulative medicine/
151. massage.tw.
158. Nimmo.tw.
126
172. alternative medicine/

175. (swedish massage or rolfing).tw.
176. therapeutic touch.mp.
177. massotherapy.tw.
178. effleurage.mp.
179. or/149-178
180. 132 and 179
181. 133 or 134 or 135 or 136 or 137 or 138
182. or/139-148
183. 59 and 182
184. 180 or 181 or 183
185. randomized controlled trial/
186. controlled clinical trial/
187. (random* or sham or placebo*).tw.
188. placebo/
189. randomization/
190. single blind procedure/
191. double blind procedure/
192. ((singl* or doubl* or trebl* or tripl*) adj5 (blind* or dumm*or mask*)).ti,ab.
193. (rct or rcts).tw.
194. (control* adj2 (study or studies or tiral*)).tw.
195. or/185-194
196. human/
197. nonhuman/
198. animal/
199. animal experiment/
200. or/197-199
201. 200 not (200 and 196)
202. 195 not 201
203. 184 and 202
MANTIS-OVID
November 2013 (last available access)
1 neck pain.mp. [mp=title, abstract, descriptors]
2 brachial plexus neuropathies.mp. [mp=title, abstract, descriptors]
3 neck injuries.mp. [mp=title, abstract, descriptors]
4 cervical pain.mp. [mp=title, abstract, descriptors]
5 neckache.mp. [mp=title, abstract, descriptors]
6 whiplash.mp. [mp=title, abstract, descriptors]
7 cervicodynia.mp. [mp=title, abstract, descriptors]
8 cervicalgia.mp. [mp=title, abstract, descriptors]
9 brachialgia.mp. [mp=title, abstract, descriptors]
10 brachial neuritis.mp. [mp=title, abstract, descriptors]
11 brachial neuralgia.mp. [mp=title, abstract, descriptors]
12 brachial plexus neuropath*.mp. [mp=title, abstract, descriptors]
13 brachial plexus neuritis.mp. [mp=title, abstract, descriptors]
14 (thoracic outlet syndrome or cervical rib syndrome).mp. [mp=title, abstract, descriptors]
15 torticollis.mp. [mp=title, abstract, descriptors]
16 cervico brachial neuralgia.mp. [mp=title, abstract, descriptors]
17 (monoradicul* or monoradicl*).tw.
127
18 or/1-17
19 headache.mp. and cervic*.tw. [mp=title, abstract, descriptors]
20 genital diseases, female.mp. [mp=title, abstract, descriptors]
21 genital disease*.mp. [mp=title, abstract, descriptors]
22 or/20-21
23 19 not 22
24 18 or 23
25 neck.mp. [mp=title, abstract, descriptors]
26 neck muscles.mp. [mp=title, abstract, descriptors]
27 cervical plexus.mp. [mp=title, abstract, descriptors]
28 cervical vertebrae.mp. [mp=title, abstract, descriptors]
29 atlanto-axial joint.mp. [mp=title, abstract, descriptors]
30 atlanto-occipital joint.mp. [mp=title, abstract, descriptors]
31 cervical atlas.mp. [mp=title, abstract, descriptors]
32 spinal nerve roots.mp. [mp=title, abstract, descriptors]
33 brachial plexus.mp. [mp=title, abstract, descriptors]
34 (odontoid* or cervical or occip* or atlant*).tw.
35 (axis or odontoid process).mp. [mp=title, abstract, descriptors]
36 thoracic vertebrae.mp. [mp=title, abstract, descriptors]
38 cervical plexus.mp. [mp=title, abstract, descriptors]
39 cervical spine.mp. [mp=title, abstract, descriptors]
40 (neck adj3 muscles).mp. [mp=title, abstract, descriptors]
41 (brachial adj3 plexus).mp. [mp=title, abstract, descriptors]
42 (thoracic adj3 vertebrae).mp. [mp=title, abstract, descriptors]
43 (thoracic adj3 spine).mp. [mp=title, abstract, descriptors]
44 (thoracic adj3 outlet).mp. [mp=title, abstract, descriptors]
45 trapezius.mp. [mp=title, abstract, descriptors]
46 cervical.mp. [mp=title, abstract, descriptors]
47 cervico*.mp. [mp=title, abstract, descriptors]
48 46 or 47
51 uterus.mp. [mp=title, abstract, descriptors]
52 49 or 50 or 51
53 48 not 52
54 25 or 26 or 27 or 28 or 29 or 30 or 31 or 32 or 33 or 34 or 35 or 36
or 37 or 38 or 39 or 40 or 41 or 42 or 43 or 44 or 45 or 53
55 pain.mp. [mp=title, abstract, descriptors]
56 injuries.mp. [mp=title, abstract, descriptors]
57 ache.mp. [mp=title, abstract, descriptors]
58 sore.mp. [mp=title, abstract, descriptors]
59 stiff.mp. [mp=title, abstract, descriptors]
60 discomfort.mp. [mp=title, abstract, descriptors]
61 injur*.mp. [mp=title, abstract, descriptors]
62 neuropath*.mp. [mp=title, abstract, descriptors]
63 or/55-62
64 54 and 63
65 radiculopathy.mp. [mp=title, abstract, descriptors]
66 (temporomandibular joint disorders or temporomandibular joint dysfunction syndrome).mp. [mp=title, abstract, descriptors]
67 myofascial pain syndromes.mp. [mp=title, abstract, descriptors]
68 sprains and strains.mp. [mp=title, abstract, descriptors]
69 spinal osteophytosis.mp. [mp=title, abstract, descriptors]
128
70 neuritis.mp. [mp=title, abstract, descriptors]

71 polyradiculopathy.mp. [mp=title, abstract, descriptors]
72 arthritis.mp. [mp=title, abstract, descriptors]
73 fibromyalgia.mp. [mp=title, abstract, descriptors]
74 (spondylitis or discitis).mp. [mp=title, abstract, descriptors]
75 (spondylosis or spondylolysis or spondylolisthesis).mp. [mp=title, abstract, descriptors]
76 radiculitis.mp. [mp=title, abstract, descriptors]
77 tempomandibular.mp. [mp=title, abstract, descriptors]
78 myofascial pain syndrome*.mp. [mp=title, abstract, descriptors]
79 thoracic outlet syndrome*.mp. [mp=title, abstract, descriptors]
80 spinal osteophytosis.mp. [mp=title, abstract, descriptors]
81 neuritis.mp. [mp=title, abstract, descriptors]
82 spondylosis.mp. [mp=title, abstract, descriptors]
83 spondylitis.mp. [mp=title, abstract, descriptors]
84 spondylolisthesis.mp. [mp=title, abstract, descriptors]
85 or/65-84
86 54 and 85
87 neck.mp. [mp=title, abstract, descriptors]
89 thoracic vertebrae.mp. [mp=title, abstract, descriptors]
90 (thoracic adj3 vertebrae).mp. [mp=title, abstract, descriptors]
91 cervical.mp. [mp=title, abstract, descriptors]
92 cervico*.mp. [mp=title, abstract, descriptors]
93 91 or 92
96 uterus.mp. [mp=title, abstract, descriptors]
97 or/94-96
98 93 not 97
99 (thoracic adj3 spine).mp. [mp=title, abstract, descriptors]
100 cervical spine.mp. [mp=title, abstract, descriptors]
101 87 or 88 or 89 or 90 or 98 or 99 or 100
102 intervertebral disk.mp. [mp=title, abstract, descriptors]
103 (disc or discs).mp. [mp=title, abstract, descriptors]
104 (disk or disks).mp. [mp=title, abstract, descriptors]
105 102 or 103 or 104
106 101 and 105
107 herniat*.mp. [mp=title, abstract, descriptors]
108 slipped.mp. [mp=title, abstract, descriptors]
109 prolapse*.mp. [mp=title, abstract, descriptors]
110 displace*.mp. [mp=title, abstract, descriptors]
111 degenerat*.mp. [mp=title, abstract, descriptors]
112 (bulge or bulged or bulging).mp. [mp=title, abstract, descriptors]
113 107 or 108 or 109 or 110 or 111 or 112
114 106 and 113
115 intervertebral disk displacement.mp. [mp=title, abstract, descriptors]
116 intervertebral disc displacement.mp. [mp=title, abstract, descriptors]
117 intervertebral disk degeneration.mp. [mp=title, abstract, descriptors]
118 intervertebral disc degeneration.mp. [mp=title, abstract, descriptors]
119 115 or 116 or 117 or 118
120 101 and 119
121 24 or 64 or 86 or 106 or 114 or 120
122 (animals not (animals and humans)).mp. [mp=title, abstract, descriptors]
129
123 121 not 122

124 neoplasms.mp. [mp=title, abstract, descriptors]
125 wounds, penetrating.mp. [mp=title, abstract, descriptors]
126 124 or 125
127 123 not 126
128 rehabilitation.mp. [mp=title, abstract, descriptors]
129 therapy.mp. [mp=title, abstract, descriptors]
130 128 or 129
131 (neck pain or brachial plexus neuropathies or neck injuries or whiplash or thoracic outlet syndrome or cervical rib syndrome or
torticollis or brachial plexus neuritis).mp. [mp=title, abstract, descriptors]
132 (temporomandibular joint disorder or temporomandibular joint dysfunction syndrome).mp. [mp=title, abstract, descriptors]
133 (myofascial pain syndromes or sprains and strains).mp. [mp=title, abstract, descriptors]
134 (radiculopathy or osteophytosis or neuritis or polyradiculopathy or arthritis or fibromyalgia or spondylitis or spondylosis or
spondylolysis or spondylolisthesis).mp. [mp=title, abstract, descriptors]
135 131 or 132 or 133 or 134
136 130 and 135
137 54 and 136
138 (acupuncture or chiropractic).mp. [mp=title, abstract, descriptors]
139 musculoskeletal manipulation*.mp. [mp=title, abstract, descriptors]
140 massage.mp. [mp=title, abstract, descriptors]
141 mobili?ation.mp. [mp=title, abstract, descriptors]
142 acupuncture therapy.mp. [mp=title, abstract, descriptors]
143 (acupuncture or acu-puncture or needling or acupressure or mox?bustion).mp. [mp=title, abstract, descriptors]
144 ((neck or spine or spinal or cervical or chiropractic* or musculoskeletal*) adj3 (adjust* or manipulat* or mobiliz* or mobilis*)).mp.
[mp=title, abstract, descriptors]
145 (manual adj therap*).mp. [mp=title, abstract, descriptors]
146 (manipulati* adj (therap* or medicine)).mp. [mp=title, abstract, descriptors]
147 (massag* or reflexolog* or rolfing or zone therap*).mp. [mp=title, abstract, descriptors]
148 Nimmo.mp. [mp=title, abstract, descriptors]
149 vibration therapy.mp. [mp=title, abstract, descriptors]
150 (vibration adj5 (therap* or treatment*)).mp. [mp=title, abstract, descriptors]
151 (ChihYa or Shiatsu or Shiatzu or ZhiYa).mp. [mp=title, abstract, descriptors]
152 (flexion adj2 distraction*).mp. [mp=title, abstract, descriptors]
153 (myofascial adj3 (release or therap*)).mp. [mp=title, abstract, descriptors]
154 muscle energy technique*.mp. [mp=title, abstract, descriptors]
155 trigger point.mp. [mp=title, abstract, descriptors]
156 proprioceptive neuromuscular facilitation*.mp. [mp=title, abstract, descriptors]
157 cyriax friction.mp. [mp=title, abstract, descriptors]
158 (lomilomi or lomi-lomi or trager).mp. [mp=title, abstract, descriptors]
159 aston patterning.mp. [mp=title, abstract, descriptors]
160 (strain adj counterstrain).mp. [mp=title, abstract, descriptors]
161 (craniosacraltherap* or cranio-sacral therap* or craniosacral therap*).mp. [mp=title, abstract, descriptors]
162 (amma or ammo or effleuurage or effleurage or petrissage or hacking or tapotment).mp. [mp=title, abstract, descriptors]
163 complementary therapies.mp. [mp=title, abstract, descriptors]
164 ((complement* or alternat* or osteopathic*) adj (therap* or medicine)).mp. [mp=title, abstract, descriptors]
165 (Tui Na or Tuina).mp. [mp=title, abstract, descriptors]
166 or/138-165
167 127 and 166
168 136 or 137 or 167
169 (animals not (animals and humans)).mp. [mp=title, abstract, descriptors]
170 168 not 169
171 randomized controlled trial*.mp. [mp=title, abstract, descriptors]
172 controlled clinical trial*.mp. [mp=title, abstract, descriptors]
130
173 (random* or sham or placebo*).mp. [mp=title, abstract, descriptors]

174 placebos.mp. [mp=title, abstract, descriptors]
175 random allocation.mp. [mp=title, abstract, descriptors]
176 single blind method.mp. [mp=title, abstract, descriptors]
177 double blind method.mp. [mp=title, abstract, descriptors]
178 ((singl* or doubl* or trebl* or tripl*) adj25 (blind* or dumm*or mask*)).mp. [mp=title, abstract, descriptors]
179 (rct or rcts).mp. [mp=title, abstract, descriptors]
180 (control* adj2 (study or studies or trial*)).mp. [mp=title, abstract, descriptors]
181 or/171-180
182 170 and 181
183 (guideline* or practice guideline*).mp. [mp=title, abstract, descriptors]
184 (guideline* or guidance* or recommendation*).ti.
185 consensus.ti.
186 183 or 184 or 185
187 170 and 186
188 meta-analysis.mp. [mp=title, abstract, descriptors]
189 (metaanaly* or meta analy* or met analy* or metanaly*).mp. [mp=title, abstract, descriptors]
190 (collaborative research or collaborative review* or collaborative overview*).mp. [mp=title, abstract, descriptors]
191 (integrative research or integrative review* or integrative overview*).mp. [mp=title, abstract, descriptors]
192 (quantitative adj3 (research or review* or overview*)).mp. [mp=title, abstract, descriptors]
193 (research integration or research overview*).mp. [mp=title, abstract, descriptors]
194 (systematic* adj3 (review* or overview*)).mp. [mp=title, abstract, descriptors]
195 (methodologic* adj3 (review* or overview*)).mp. [mp=title, abstract, descriptors]
196 technology assessment biomedical.mp. [mp=title, abstract, descriptors]
197 (hta or thas or technology assessment*).mp. [mp=title, abstract, descriptors]
198 ((hand adj2 search*) or (manual* adj search*)).mp. [mp=title, abstract, descriptors]
199 ((electronic adj database*) or (bibliographic* adj database*)).mp. [mp=title, abstract, descriptors]
200 ((data adj2 abstract*) or (data adj2 extract*)).mp. [mp=title, abstract, descriptors]
201 (analys* adj3 (pool or pooled or pooling)).mp. [mp=title, abstract, descriptors]
202 mantel haenszel.mp. [mp=title, abstract, descriptors]
203 (cochrane or pubmed or pub med or medline or embase or psycinfo or psyclit or psychinfo or psychlit or cinahl or science citation
index).ab.
204 or/188-203
205 170 and 204
206 182 or 187 or 205
207 limit 206 to yr=2006 -Current
CINAHL-EBSCO
August 2015
S151 S90 or S104 or S150
S150 S82 and S149
S149 S105 or S106 or S107 or S108 or S109 or S110 or S111 or S112 or S113 or S114 or S115 or S116 or S117 or S118 or S119 or
S120 or S121 or S122 or S123 or S124 or S125 or S126 or S127 or S128 or S129 or S130 or S131 or S132 or S133 or S134 or S135
or S136 or S137 or S138 or S139 or S140 or S141 or S142 or S143 or S144 or S145 or S146 or S147 or S148
S148 TX faradic
S147 MH biofeedback
S146 TX Relaxation Therapy
S145 MH Relaxation Therapy
S144 TX alexander N3 technique OR TX alexander N3 method
S143 TX Feldenkrais
S142 TX postur* correction
S141 MH ice
131
S140 TX Cryoanesthesia
S139 MH Cryoanesthesia
S138 TX vapocoolant spray
S137 (MH Hyperthermia, Induced)
S136 MH Hydrotherapy
S135 MH cryotherapy
S134 TX repetitive magnetic stimulation
S133 (MH Physical Therapy+)
S132 (MH Physical Therapy Modalities+)
S131 MH lasers
S130 (MH Phototherapy+)
S129 MH Ultrasonic Therapy
S128 (MH Rehabilitation+)
S127 TX Laser Therapy
S126 (MH Laser Therapy)
S125 TX traction
S124 MH traction
S123 TX pillow* OR TX collar*
S122 Occlusal Splints
S121 TX oral splints
S120 (MH Periodontal Splints)
S119 TX taping
S118 TX kinesiotaping
S117 (MH Orthoses)
S116 (MH Electric Stimulation)
S115 (MH Magnet Therapy)
S114 MH electromagnetics
S113 (MH Electromagnetic Fields)
S112 pulsed electromagnetic field
S111 TX pulsed electro magnetic field
S110 (MH Electrical Stimulation, Functional) OR (MH Electrical Stimulation, Neuromuscular)
S109 (MH Therapeutic Exercise+)
S108 (MH Exertion)
S107 (MH Exercise+)
S106 (MH Exercise+)
S105 (MH Combined Modality Therapy+)
S104 S34 and S103
S103 S91 or S92 or S93 or S94 or S95 or S96 or S97 or S98 or S99 or S100 or S101 or S102
S102 (MH Spondylolisthesis/RH)
S101 (MH Spondylolysis/RH) OR (MH Spondylosis/RH)
S100 (MH Spondylitis, Ankylosing/RH)
S99 (MH Fibromyalgia/RH)
S98 (MH Arthritis+/RH)
S97 (MH Polyradiculopathy/RH)
S96 (MH Neuritis/RH)
S95 (MH Spinal Osteophytosis/RH)
S94 (MH Sprains and Strains/RH)
S93 (MH Myofascial Pain Syndromes/RH)
S92 (MH Temporomandibular Joint Syndrome/RH) OR (MH Temporomandibular Joint Diseases/RH)
S91 (MH Radiculopathy/RH)
S90 S83 or S84 or S85 or S86 or S87 or S88 or S89
S89 (MH Brachial Plexus Neuritis/RH)
S88 (MH Torticollis/RH)
132
S87 (MH Thoracic Outlet Syndrome/RH)

S86 (MH Whiplash Injuries/RH)
S85 (MH Neck Injuries/RH)
S84 (MH Brachial Plexus Neuropathies/RH)
S83 (MH Neck Pain/RH)
S82 S78 NOT S81
S81 S79 or S80
S80 (MM Pregnancy+)
S79 (MM Abortion, Induced+)
S78 S74 NOT S77
S77 S75 or S76
S76 (MM Wounds, Penetrating+)
S75 (MM Neoplasms+)
S74 S16 or S41 or S56 or S69 or S73
S73 S63 and S72
S72 S70 or S71
S71 TX intervertebral disk displacement or TX intervertebral disc displacement or TX intervertebral disk degeneration or TX intervertebral disc degeneration
S70 (MH Intervertebral Disk Displacement)
S69 S67 and S68
S68 TX herniat* or TX slipped or TX prolapse* or TX displace* or TX degenerat* or TX ( bulged OR bulge OR bulging )
S67 S63 and S66
S66 S64 or S65
S65 TX disc or TX discs or TX disk or TX disks
S64 (MH Intervertebral Disk)
S63 S61 NOT S62
S62 (MM Genital Diseases, Female+) or ( (MM Cervix) or (MM Cervix Diseases) )
S61 S57 or S58 or S59 or S60
S60 TX thoracic N3 spine or TX cervical spine or TX cervico*
S59 TX neck or TX thoracic N3 vertebr*
S58 (MH Thoracic Vertebrae)
S57 (MH Neck)
S56 S34 and S55
S55 S42 or S43 or S44 or S45 or S46 or S47 or S48 or S49 or S50 or S51 or S52 or S53 or S54
S54 TX neuritis or TX spondylosis or TX spondylitis or TX spondylolisthesis
S53 TX myofascial pain syndome* or TX thoracic outlet syndrome* or TX spinalosteophytosis
S52 TX radiculopathy or TX radiculitis or TX temporomandibular
S51 (MH Spondylolysis) or (MH Spondylolisthesis+)
S50 (MH Fibromyalgia)
S49 (MH Arthritis+)
S48 (MH Polyradiculopathy)
S47 (MH Neuritis+)
S46 (MH Spinal Osteophytosis)
S45 (MH Sprains and Strains+)
S44 (MH Myofascial Pain Syndromes+)
S43 (MH Temporomandibular Joint Diseases+) or (MH Temporomandibular Joint Syndrome)
S42 (MH Radiculopathy)
S41 S34 and S40
S40 S35 or S36 or S37 or S38 or S39
S39 (MH Neuralgia)
S38 TX stiff or TX discomfort or TX injur* or TX neuropath*
S37 TX pain or TX ache* or TX sore
S36 (MH Wounds and Injuries+)
133
S35 (MH Pain+)

S34 S33 NOT S32
S33 S17 or S18 or S19 or S20 or S21 or S22 or S23 or S24 or S25 or S26 or S27 or S28 or S29 or S30 or S31
S32 (MM Genital Diseases, Female+) or ( (MM Cervix) or (MM Cervix Diseases) )
S31 TX trapezius or TX cervico*
S30 TX thoracic N3 spine or TX thoracic N3 outlet
S29 TX neck
S28 TX thoracic N3 verteb*
S27 TX brachial N3 plexus
S26 TX neck n3 muscles
S25 (MH Thoracic Vertebrae)
S24 TX ondontoid* or TX cervical or TX occip* or TX atlant*
S23 (MH Brachial Plexus+)
S22 (MH Spinal Nerve Roots+)
S21 (MH Atlanto-Axial Joint) or (MH Atlanto-Occipital Joint)
S20 (MH Cervical Vertebrae+) or (MH Cervical Atlas)
S19 (MH Cervical Plexus+)
S18 (MH Neck)
S17 (MH Neck Muscles+)
S16 S10 or S15
S15 S11 NOT S14
S14 S12 or S13
S13 (MM Cervix) or (MM Cervix Diseases)
S12 (MM Genital Diseases, Female+)
S11 (MH Headache+) and TX cervic*
S10 S1 or S2 or S3 or S4 or S5 or S6 or S7 or S8 or S9
S9 (MH Brachial Plexus Neuritis)
S8 TX cervical brachial neuralgia
S7 TX cervical rib sydrome* or TX cervico brachial neuralgia or TX cervicobrachial neuralgia or TX monoradicul* or TX monoradicl*
S6 (MH Thoracic Outlet Syndrome) or (MH Torticollis)
S5 TX brachial neuralgia or TX neck pain or TX neck injur* or TX brachial plexus neuropath* or TX brachial plexus neuralgia or TX
brachial plexus neuritis
S4 TX cervicalgia or TX brachialgia or TX brachial neuritis
S3 TX cervical pain or TX neckache or TX neck ache or TX whiplash or TX cervicodynia
S2 (MH Neck Injuries+)
S1 (MH Neck Pain) or (MH Brachial Plexus Neuropathies) or (MH Brachial Plexus Neuritis)
ICL
August 2015
S1 Subject:Neck Pain OR Subject:Brachial Plexus Neuritis OR All Fields:brachial plexus neuropathies
S2 All Fields:brachial plexus neuropathy
S4 Subject:Neck Injuries OR Subject:Whiplash Injuries OR Subject:Cervical Vertebrae / abnormalities
S5 All Fields:cervical pain OR All Fields:neckache OR All Fields:whiplash
S6 All Fields:cervicodynia OR All Fields:cervicalgia OR All Fields:brachialgia
S7 All Fields:brachial neuritis OR All Fields:brachial neuralgia OR All Fields:neck pain
S8 Subject:Thoracic Outlet Syndrome OR Subject:Torticollis OR All Fields:cervical rib syndrom*
S11 All Fields:cerv* AND All Fields:headache*
S12 All Fields:monoradicul* OR All Fields:monoradicl*
S13 S1 OR S2 OR S4 OR S5 OR S6 OR S7 OR S8 OR S11 OR S12
S14 Subject:Neck OR Subject:Neck Muscles OR Subject:Cervical Vertebrae
S16 Subject:Cervical Atlas OR Subject:Atlanto-Axial Joint OR Subject:Atlanto-Occipital Joint
S17 Subject:Atlas OR Subject:Spinal Nerve Roots OR All Fields:brachial plexus
134
S18 All Fields:ondontoid* OR All Fields:occip* OR All Fields:atlant*

S20 Subject:Odontoid Process OR Subject:Thoracic Vertebrae OR All Fields:cervical vertebrae
S21 All Fields:cervical spine OR All Fields:trapezius OR All Fields:cervico*
S22 S14 OR S16 OR S17 OR S18 OR S20 OR S21
S23 Subject:Pain OR All Fields:sore OR All Fields:stiff
S24 All Fields:ache OR All Fields:pain OR All Fields:discomfort
S25 All Fields:injur* OR All Fields:neuropath*
S26 S23 OR S24 OR S25
S27 S22 AND S26
S28 Subject:Radiculopathy OR Subject:Temporomandibular Joint Disorders OR Subject:Temporomandibular Joint Dysfunction
Syndrome
S30 Subject:Myofascial Pain Syndromes OR Subject:Sprains and Strains OR Subject:Spinal Osteophytosis
S31 Subject:Neuritis OR Subject:Polyradiculoneuritis OR Subject:Arthritis
S32 Subject:Fibromyalgia OR Subject:Discitis OR Subject:Spondylitis
S33 Subject:Spondylolisthesis OR Subject:Spondylolysis OR Subject:Spondylosis
S34 S28 OR S30 OR S31 OR S32 OR S33
S35 S22 AND S34
S36 Subject:Neck OR Subject:Cervical Vertebrae OR Subject:Thoracic Vertebrae
S37 All Fields:thoracic spine OR All Fields:cervical spine OR All Fields:cervico*
S38 S36 OR S37
S39 All Fields:herniat* OR All Fields:slipped OR All Fields:prolapse*
S40 All Fields:displace* OR All Fields:degenerat*
S41 All Fields:bulge OR All Fields:bulged OR All Fields:bulging
S42 S39 OR S40 OR S41
S43 S38 AND S42
S44 Subject:Intervertebral Disk Displacement OR All Fields:intervertebral disk degeneration OR All Fields:intervertebral disc
degeneration
S45 All Fields:Intervertebral Disk Displacement OR All Fields:intervertebral disc displacement
S46 S44 OR S45
S47 S38 AND S46
S48 S13 OR S27 OR S35 OR S43 OR S47
S49 Year: from 2014 to 2015
S50 S48 AND S49
S51 Subject:Randomized Controlled Trials as Topic OR Subject:Controlled Clinical Trials OR Subject:Placebos
S52 All Fields:random* OR All Fields:sham OR All Fields:placebo*
S53 All Fields:clinical trial* OR All Fields:controlled study OR All Fields:controlled studies
S54 All Fields:RCT OR All Fields:RCTs
S55 S51 OR S52 OR S53 OR S54
S56 S50 AND S55
Appendix 2. Criteria for assessing risk of bias for internal validity
Random sequence generation (selection bias)
Selection bias (biased allocation to interventions) due to inadequate generation of a randomised sequence
Risk of selection bias is low if investigators describe a random component in the sequence generation process such as referring to a
random number table, using a computer random number generator, tossing a coin, shuffling cards or envelopes, throwing dice, drawing
lots and minimising (minimisation may be implemented without a random element, and this is considered to be equivalent to being
random).
135
Risk of selection bias is high if investigators describe a non-random component in the sequence generation process such as sequence
generated by odd or even date of birth, date (or day) of admission, hospital or clinic record number; or allocation by judgement of the
clinician, preference of the participant, results of a laboratory test or series of tests, or availability of the intervention.
Selection bias (biased allocation to interventions) due to inadequate concealment of allocations before assignment
Risk of selection bias is low if participants and investigators enrolling participants could not foresee assignment because one of the
following, or an equivalent method, was used to conceal allocation: central allocation (including telephone, web-based and pharmacycontrolled randomisation); sequentially numbered drug containers of identical appearance; or sequentially numbered, opaque, sealed
envelopes.
Risk of bias is high if participants or investigators enrolling participants could possibly foresee assignments and thus introduce selection
bias, such as allocation based on using an open random allocation schedule (e.g. list of random numbers); assignment envelopes were
used without appropriate safeguards (e.g. if envelopes were unsealed or non-opaque or not sequentially numbered); alternation or
rotation; date of birth; case record number; or other explicitly unconcealed procedures.
Blinding of participants
Performance bias due to knowledge of allocated interventions by participants during the study
Risk of performance bias is low if blinding of participants was ensured and it was unlikely that blinding could have been broken; or if
no blinding or incomplete blinding was provided but the review authors judged that the outcome is not likely to be influenced by lack
of blinding.
Blinding of personnel/care providers (performance bias)
Performance bias due to knowledge of allocated interventions by personnel/care providers during the study
Risk of performance bias is low if blinding of personnel was ensured and it was unlikely that blinding could have been broken; or if no
blinding or incomplete blinding was provided but the review authors judged that the outcome is not likely to be influenced by lack of
blinding.
Blinding of outcome assessor (detection bias)
Detection bias due to knowledge of allocated interventions by outcome assessors
Risk of detection bias is low if blinding of the outcome assessment was ensured and it was unlikely that blinding could have been
broken; or if no blinding or incomplete blinding was provided but the review authors judged that the outcome is not likely to be
influenced by lack of blinding, or:
for patient-reported outcomes in which the participant was the outcome assessor (e.g. pain, disability): Risk of bias for outcome
assessors is low if risk of bias for participant blinding is low (Boutron 2005);
for outcome criteria that are clinical or therapeutic events that will be determined by the interaction between participants and
care providers (e.g. co-interventions, length of hospitalisation, treatment failure), in which the care provider is the outcome assessor:
Risk of bias for outcome assessors is low if risk of bias for care providers is low (Boutron 2005); and
for outcome criteria that are assessed from data from medical forms: Risk of bias is low if the treatment or adverse effects of the
treatment could not be noticed in the extracted data (Boutron 2005).

136
Attrition bias due to amount, nature or handling of incomplete outcome data
Risk of attrition bias is low if no outcome data were missing; reasons for missing outcome data were unlikely to be related to the
true outcome (for survival data, censoring is unlikely to be introducing bias); missing outcome data were balanced in numbers, with
similar reasons for missing data across groups; for dichotomous outcome data, the proportion of missing outcomes compared with the
observed event risk was not enough to have a clinically relevant impact on the intervention effect estimate; for continuous outcome
data, the plausible effect size (difference in means or standardised difference in means) among missing outcomes was not enough to have
a clinically relevant impact on observed effect size, or missing data were imputed using appropriate methods (if drop-outs were very
large, imputation using even acceptable methods may still suggest high risk of bias) (van Tulder 2003). The percentage of withdrawals
and drop-outs should not exceed 20% for short-term follow-up and 30% for long-term follow-up and should not lead to substantial
bias (these percentages are commonly used but arbitrary and are not supported by the literature) (van Tulder 2003).
Reporting bias due to selective outcome reporting
Risk of reporting bias is low if the study protocol is available and all of the studys pre-specified (primary and secondary) outcomes of
interest in the review have been reported in the pre-specified way, or if the study protocol is not available but it is clear that published
reports include all expected outcomes, including those that were pre-specified (convincing text of this nature may be uncommon).
Risk of reporting bias is high if not all of the studys pre-specified primary outcomes have been reported; one or more primary outcomes
were reported using measurements, analysis methods or subsets of the data (e.g. subscales) that were not pre-specified; one or more
reported primary outcomes were not pre-specified (unless clear justification for their reporting is provided, such as an unexpected
adverse effect); one or more outcomes of interest in the review were reported incompletely so that they cannot be entered into a metaanalysis; or the study report fails to include results for a key outcome that would be expected to have been reported for such a study.
Group similarity at baseline (selection bias)

Bias due to dissimilarity at baseline for the most important prognostic indicators.
Risk of bias is low if groups were similar at baseline for demographic factors, value of main outcome measure(s) and important prognostic
factors (examples in the field of back and neck pain are duration and severity of complaints, vocational status and percentage of
participants with neurological symptoms) (van Tulder 2003).
Co-interventions (performance bias)
Bias because co-interventions were different across groups
Risk of bias is low if no co-interventions were provided, or if they were similar between index and control groups (van Tulder 2003).
Compliance (performance bias)
Bias due to inappropriate compliance with interventions across groups
Risk of bias is low if compliance with the interventions was acceptable and was based on reported intensity/dosage, duration, number
and frequency for both index and control intervention(s). For single-session interventions (e.g. surgery), this item is irrelevant (van
Tulder 2003).

137
Intention-to-treat analysis
Risk of bias is low if all randomised participants were reported/analysed in the group to which they were allocated by randomisation.
Timing of outcome assessments (detection bias)
Bias because important outcomes were not measured at the same time across groups
Risk of bias is low if all important outcome assessments for all intervention groups were measured at the same time (van Tulder 2003).
Other bias
Bias due to problems not covered elsewhere in the table
Risk of bias is low if the study appears to be free of other sources of bias not addressed elsewhere (e.g. study funding).
Appendix 3. Questions for clinical relevance

Are patients described in sufficient detail that you can decide whether they are comparable with those whom you see in your
practice?
Are interventions and treatment settings described well enough that you can provide the same for your patients?
Were all clinically relevant outcomes measured and reported?
Is the size of the effect clinically important?
Are likely treatment benefits worth potential harms?
WHATS NEW
Last assessed as up-to-date: 25 August 2015.
Date
Event
Description
31 December 2015
New citation required and conclusions have changed
The previous version of this review included 10 studies that focused on chronic neck pain. In this review,
we included 27 studies representing acupuncture for a
variety of acute and chronic neck disorders
31 December 2015
New search has been performed
The Risk of bias assessment tool (Furlan 2009) was

utilised for this update. Previously, according to our
protocol, Jadad 1996 and van Tulder 2003 assessment
tools were used
Methods: inclusion criteria different from protocol;
now only RCTs included

138
HISTORY
Protocol first published: Issue 3, 2004
Review first published: Issue 3, 2006
Date
Event
Description
22 May 2014
Amended
Contact details updated
19 June 2008
Amended
Converted to new review format
CONTRIBUTIONS OF AUTHORS
Primary reviewers for this review - Trinh K, Graham N, Irnich D, Cameron ID, Forget M.
Statistician - Trinh K, Goldsmith CH (Cervical Overview Group - COG).
Methodological quality assessment - COG Validity Team; Burnie S, Empey B, Forget M, Goldsmith CH, Graham N, LeBlanc F, Szeto
G.
Study identification and selection - Brunarski D, Graham N, Gross A, Haines T (COG).
Research librarian - Rice M.
Data abstraction, synthesis, manuscript preparation, public responsibility, grants, administration - primary review authors.
Final synthesis - primary review authors.
DECLARATIONS OF INTEREST
D Irnich is an author of two included studies. He did not take part in data extraction.
Use of raters from diverse professional backgrounds (sports medicine physician, rheumatologist, occupational health physician, physiatrist, statistician, physiotherapist, manual therapist, chiropractor, massage therapist) should serve to limit any conflicts of interest that
might have been present during the review process.
SOURCES OF SUPPORT
Internal sources
No sources of support supplied

139
External sources
Candian Institute of Health Research, Canada.
Knowledge Synthesis Grant Synthesizing Research Evidence into Clinical Recommendations for Managing Neck Pain
DIFFERENCES BETWEEN PROTOCOL AND REVIEW

We included only randomised controlled trials (RCTs) in this update. In the original review, we included RCTs and quasi-RCTs, as per
protocol.
We used the risk of bias assessment tool of the Cochrane Back Review Group (Furlan 2009) for this update. We previously used the
assessment tools used in Jadad 1996 and van Tulder 2003.
INDEX TERMS
Medical Subject Headings (MeSH)
Acupuncture
Therapy; Chronic Disease; Neck Pain [ therapy]; Randomized Controlled Trials as Topic; Treatment Outcome
MeSH check words

Humans

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Cochrane Database of Systematic Reviews

Acupuncture for neck disorders (Review)

Trinh K, Graham N, Irnich D, Cameron ID, Forget M.

Acupuncture for neck disorders (Review)

Acupuncture for neck disorders (Review)

Acupuncture for neck disorders

PLAIN LANGUAGE SUMMARY

Acupuncture for neck disorders (Review)

Acupuncture for neck disorders (Review)

Acupuncture compared with sham for chronic neck pain

Illustrative comparative risks* (95% CI)

Number of participants Quality of the evidence Comments

Pain intensity (VAS) M ean pain intensity

M ean pain intensity -0.23 (-0.20 to -0.07)

Statistical pooling was

Disability (NPQ) short M ean disability ranged

M ean disability in inter- -0.38 (-0.62 to -0.15)

Two sm all trials were

Acupuncture for neck disorders (Review)

Disability (NDI) short M ean disability ranged

M ean disability in inter- -vention groups ranged

All 3 studies, 2 with

Quality of life (SF- 36) M ean quality of lif e

M ean quality of lif e -in intervention groups

One study with low

Description of the condition

Description of the intervention

How the intervention might work

Why it is important to do this review

Acupuncture for neck disorders (Review)

Criteria for considering studies for this review

When available, we examined adverse effects and costs of treatment.

Search methods for identification of studies

Acupuncture for neck disorders (Review)

Data collection and analysis

RCT acceptable for inclusion if we found no fatal methodological

Acupuncture for neck disorders (Review)

a specific outcome by one level according to the performance of

Acupuncture for neck disorders (Review)

Figure 1. Study flow diagram.

Acupuncture for neck disorders (Review)

Acute and subacute WAD (n = 1) (Tough 2010).

pain with radicular signs (43 participants) and six subacute or

Chronic myofascial neck pain (n = 5) (Birch 1998; Chou

Results of the search

Acupuncture for neck disorders (Review)

Risk of bias in included studies

Acupuncture for neck disorders (Review)

Acupuncture for neck disorders (Review)

Other potential sources of bias

Acupuncture versus sham acupuncture

a fatal methodological flaw involving randomisation issues and the

We assigned eight studies (n = 560) (Cameron 2011; Fu 2009;

Pain intensity (VAS) post treatment

Eleven studies (n = 712) included participants with mechanical

Pain intensity (VAS) intermediate term

Two studies (n = 158) presented low risk of bias: one involving

Acupuncture for neck disorders (Review)

studies favoured acupuncture. (Please see Analysis 1.3.) Statistical

Pain intensity (VAS) long term

One study (n = 24) with low risk of bias involved participants

Disability and quality of life

Pain intensity (VAS) immediate post treatment