Low back pain is a prevalent and debilitating condition that causes pain, discomfort, reduced functionality, and financial stress. Approximately 80 to 90% of cases are categorized as non-specific, meaning they have no clear underlying cause. First-line care recommends non-interventional and non-surgical treatments, but the growing number of available options makes it hard for stakeholders to stay informed. This study aims to bridge gaps in previous research by analyzing the most recent data on treatment effectiveness compared to a placebo.
The current systematic review and meta-analysis study, published in BMJ Evidence-Based Medicine, aimed to evaluate the effectiveness of non-interventional and non-surgical therapies for adults with low back pain compared to a placebo.
This study was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. It included articles related to adults (≥18 years) with non-specific low back pain undergoing conservative, pharmacological, or non-pharmacological treatments, randomized placebo-controlled clinical trials, and published in the English language from January 1, 2005, to April 14, 2023. Studies like crossover trials, clinical trial registries, grey literature, patients with low back pain because of specific spinal pathological conditions and lumbar radicular syndrome, patients who underwent recent spinal surgery, minimally invasive procedures, and pregnant women were excluded.
The relevant studies were selected using various databases such as APA PsycInfo Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and CINAHL. Included articles were examined for risk of bias through the Physiotherapy Evidence Database (PEDro) Scale (0 to 10) and certainty of the evidence through the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system.
Pooled effects and associated 95% confidence interval (CI) on pain intensity (0-10 scale) at initial post-treatment assessment were estimated using the random effects meta-analysis. This was determined for each treatment type and by the duration of low back pain conditions like sub-acute (<12 weeks) and chronic (≥12 weeks).
Initially, 6258 studies were identified from all databases. Finally, a total of 301 studies (377 treatment comparisons) were included in this review. These studies provided information on 56 different treatments or treatment combinations. Of these studies, 27 focused on non-steroidal anti-inflammatory drugs (NSAIDs), 26 on opioids, 25 on laser and light therapy, 24 on acupuncture, and 19 on mobilization. Individuals with acute low back pain were observed in 56 trials, chronic low back pain in 228 trials, and both acute and chronic conditions in 21 clinical studies.
The median score of the PEDro scale for all included records was found to be 8 (Interquartile Range [IQR] 6 to 9). Nearly 62% (187/302) of studies were deemed to be at a greater risk of bias. The certainty of the evidence for 69 treatment comparisons was found to be moderate for 11 studies, low for 25, and very low for 33.
This study found that the five treatments for chronic pain, including spinal manipulative therapy, exercise, transient receptor potential vanilloid 1 (TRPV1) agonist, antidepressants, taping, and one treatment for acute low back pain (NSAIDs) were effective, and effect sizes were modest for moderate certainty evidence. Intermediate-certainty evidence was observed for two treatments for chronic (anesthetics and antibiotics) and three treatments for acute low back pain (glucocorticoid injections, exercise, and paracetamol), which resulted in ineffective therapies. Evidence was not concluded in the remaining therapies because of small sample sizes, low or very-low certainty evidence, and imprecision.
In conclusion, this review highlights that only one in ten commonly used non-surgical and non-interventional therapies was effective for people with low back pain, offering modest pain relief compared to placebo. To address the remaining uncertainty regarding efficacy, further high-quality placebo-controlled trials are necessary. Additionally, non-surgical and non-interventional therapeutic placebos should be more carefully designed. Â
Reference: Cashin AG, Furlong BM, Kamper SJ, et al. Analgesic effects of non-surgical and non-interventional treatments for low back pain: a systematic review and meta-analysis of placebo-controlled randomised trials. BMJ Evidence-Based Medicine. 2025. doi: 10.1136/bmjebm-2024-112974
