to the editor: I appreciated the article by Dr. Herndon and colleagues about chronic low back pain. I was surprised, however, that acupuncture was not mentioned as a treatment for this condition. Two meta-analyses found that acupuncture provided clinically significant pain relief compared with placebo and sham acupuncture when added to conventional therapies.^1,2 Compared with the other treatment options discussed in the article, the adverse effect profile of acupuncture makes it a reasonable alternative, especially in individuals with a risk of addiction, those with chronic comorbidities, and those taking multiple pharmacologic agents.

in reply: We thank Dr. Frank for his accurate assessment that acupuncture may be a useful and important adjunct in the overall treatment of chronic low back pain.¹ We did not discuss acupuncture or dry needling because of concerns that adequate assessment and communication of the data were not feasible within our space constraints. In our experience, the variance in types of acupuncture performed, study control and blinding methods, and pain syndrome heterogeneity prevent a succinct assessment and clinical recommendation. Unfortunately, we also find that acupuncture is typically beyond the financial means of many of our patients and often not covered by third-party payers. Hopefully, as data continue to emerge examining specific forms of acupuncture and treatment durability, physicians will be able to more readily incorporate this modality into their treatment of chronic low back pain.