“It was surprising to see that so few treatments were effective, and that when effective, the benefits were mostly modest,” says lead study author Aidan Cashin, PhD, deputy director of the Center for Pain Impact at Neuroscience Research Australia in Randwick, New South Wales.
“Low back pain is a common and complex problem which can be difficult to treat due to many possible contributors that could be causing and maintaining an individual’s back pain experience,” Dr. Cashin says. “More work is needed to better understand what causes and maintains low back pain so we can develop more targeted treatments.”
Even the Best Treatments Are Only Marginally Helpful
For the analysis, Cashin and collaborators looked at back pain trials focused on medications such as muscle relaxants and nonsteroidal anti-inflammatory drugs (NSAIDs) including aspirin, ibuprofen, and naproxen. They also assessed trials on nondrug options, such as exercise, massage, and spinal manipulation.
The most common interventions under investigation were:
- NSAIDs (27 trials)
- opioids (26 trials)
- laser and light therapy (25 trials)
- acupuncture (24 trials)
- gentle manual therapy (19 trials)
A total of 52 trials involved participants with acute low back pain; 228 focused on those with chronic low back pain; and 21 included participants with both types. Acute low back pain was defined as pain lasting less than 12 weeks, while chronic pain was categorized as lasting 12 weeks or longer.
Researchers evaluated the effects of treatments on pain intensity according to scales that provided a standardized way of measuring severity based on patient descriptions.
The results, published online this week in the journal BMJ Evidence-Based Medicine, showed that compared with placebo, only NSAIDs were effective for acute (short-term) low back pain.
For chronic back pain, five therapies showed effectiveness:
- Exercise
- Spinal manipulation
- Taping the lower back
- Antidepressants
- Topical creams that cause a warming sensation
All these benefits, however, were small in comparison to placebo.
Many Back Pain Therapies Were Identified as Ineffective
Three therapies were specifically identified as being ineffective for acute low back pain: exercise, steroid injections, and acetaminophen (Tylenol).
Two treatments demonstrated no benefit for chronic low back pain: antibiotics and anesthetics such as Lidocaine.
For the remaining treatments, their effectiveness was found to be inconclusive due to small samples, imprecise studies, or low and very low quality evidence.
For acute back pain, inconclusive nondrug interventions included acupuncture, behavior and education, heat, laser and light, massage, spinal manipulative therapy, and transcutaneous (passing through the skin) electrical nerve stimulation (TENS). Inconclusive medications included cannabinoids (compounds found in cannabis), immunoglobulins (drugs that contain antibodies), muscle relaxants, opioids, and ozone injections.
For chronic back pain, inconclusive nondrug therapies included acupuncture, massage, osteopathy (hands-on therapy), and TENS, while inconclusive medications included antidepressants plus paracetamol (also known as acetaminophen), bisphosphonates (medications used for bone conditions), and muscle relaxants.
“Our review did not find reliable evidence of large effects for any of the included treatments,” concluded the study authors. “While we would like to provide more certain recommendations for where to invest and disinvest in treatments, it is not possible at this time.”
Individual Responses to Back Pain Therapies Can Vary Significantly
For Sean Mackey, MD, chief of the division of pain medicine at Stanford Health Care in Palo Alto, California, the research provides a “valuable update” of existing knowledge concerning noninvasive therapies for low back pain.
“What is notable is the relative scarcity of high-quality, larger-scale placebo-controlled research for certain commonly used treatments. This highlights an ongoing need for more rigorous and collaborative research in this area,” says Dr. Mackey, who was not involved in this study.
He stressed that the findings do not mean that 9 out of 10 will definitely not work for patients.
“This is perhaps my greatest concern about potential misinterpretation of this study,” says Mackey. “For most treatments, the evidence was inconclusive, rather than definitively negative. Meta-analyses [like this one] report average effects across populations, but individual responses vary considerably.”
“These findings don’t imply that nothing works,” he adds. “A treatment showing small or no average benefit may still significantly help specific patients based on their unique pain mechanisms, preferences, and biology. This is why personalized medicine approaches are essential in pain management.”
There Is No ‘Magic Bullet’ for Back Pain Treatment
For back pain management, multidisciplinary care is key, according to Mackey. This approach combines physical, psychological, and medication approaches, which can often yield the best real-world results.
“There is no single ‘magic bullet’ treatment for back pain, and modest expectations for any single intervention are appropriate,” he says. “If one therapy doesn’t work, you may need to explore others or a combination. Listen to professional advice and track what improves your quality of life, not just pain scores.”
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