March 24, 2025 from Medscape
Widespread Treatments, Modest Results
A new systematic review and meta-analysis published in BMJ Evidence-Based Medicine challenges the effectiveness of most noninvasive treatments for nonspecific low back pain. Researchers analyzed 301 randomized placebo-controlled trials and found that just 10% of evaluated therapies provided even modest pain relief. The overwhelming majority failed to show better outcomes than placebo.
The review, led by Dr. Aidan G. Cashin of the Centre for Pain IMPACT at Neuroscience Research Australia, included data on 56 different treatments or treatment combinations for adult patients. Pain outcomes were assessed after the first treatment point and stratified by duration — acute (less than 12 weeks) versus chronic (12 weeks or more).
Few Effective Options for Acute and Chronic Pain
The findings revealed that for acute low back pain, only nonsteroidal anti-inflammatory drugs (NSAIDs) demonstrated efficacy compared to placebo, supported by moderate-certainty evidence. In contrast, three commonly used treatments — exercise, glucocorticoid injections, and paracetamol — showed no meaningful benefit over placebo.
For chronic low back pain, the results were slightly more encouraging. Five treatments demonstrated moderate-certainty evidence of efficacy: exercise, spinal manipulative therapy, taping, antidepressants, and transient receptor potential vanilloid 1 (TRPV1) agonists.
However, even in chronic pain management, many popular approaches fell short. Antibiotics and anesthetics, for instance, showed no efficacy, while 38 other treatments had inconclusive evidence due to low- or very low-certainty data.
Call for Better Research and Placebo Design
The authors emphasized that their analysis highlights a critical gap in evidence-based treatment for back pain. They wrote that
“most nonsurgical and non interventional treatments for low back pain were not efficacious”
and recommended better-designed trials moving forward.
They also noted that future studies should focus on improving placebo design to better isolate true treatment effects, especially for interventions that are difficult to blind effectively, such as exercise or manual therapies.
Limitations and Interpretation
Despite the comprehensive nature of the analysis, the study had several limitations. There was considerable variability in how placebos were defined across trials, and similar treatments were sometimes grouped together regardless of how they were administered. The exclusion of unpublished trials may have also introduced bias, while small sample sizes and inconsistent findings reduced the certainty of some conclusions.
Ultimately, the review provides a sobering look at just how few nonsurgical treatments for low back pain are backed by solid evidence. For both patients and clinicians, it underscores the need to rethink how chronic pain is managed — and where to invest future research efforts.
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