Only 10% of non-interventional treatments for back pain relief are effective

There are figures that leave no room for doubt, and this is one of them: over 600 million people worldwide suffer from low back pain. And the situation is only going to worsen. It is estimated that by 2030, the prevalence of lower back problems will surpass 800 million people, or 10% of the global population. Treatments aimed at addressing this pain — the leading cause of disability worldwide — are numerous. Typically, they follow a progression from less to more invasive options, with medication being the first step and surgery being the last, more drastic measure. However, a new review published on Tuesday in BMJ Evidence Based Medicine reports that only one in 10 non-interventional treatments is effective in treating back pain. These treatments only “provided small analgesic effects beyond placebo,” the analysis states.

Aidan Cashin, a researcher at the University of New South Wales Pain Centre in Australia, is the lead author of the review. He explains that there are many non-surgical and non-invasive treatment options for the initial management of lower back pain, but it’s not always clear which ones are effective. “We were interested in identifying which of these treatments demonstrated concrete effects,” he says. To do so, the team of researchers reviewed placebo-controlled trials that measured the effectiveness of treatments for people with non-specific back pain (chronic and acute) with the goal of pooling the results.

The approaches included in the data pool included pharmacological approaches, such as anti-inflammatories, analgesics, and muscle relaxants; and non-pharmacological approaches, such as exercise, massage, and spinal manipulation. The analysis showed that, compared with placebo, only anti-inflammatories were effective for acute low back pain. Exercise, manipulation, and spinal taping were effective for chronic pain. However, the effects were small compared with placebo.

Cashin acknowledges that the article has its limitations. Many of the 301 trials analyzed — which examined 56 treatments or treatment combinations — had small sample sizes and yielded inconsistent results, making their findings uncertain.

Alfonso Vidal Marcos, director of the Pain Unit at the Hospital Sur in Alcorcón in Madrid, was not involved in the study, but notes that while the data provided are reliable, the methodology used to collect it is “questionable.” “They mix apples with oranges and tomatoes,” he says, adding that “pain often has many causes, and conducting studies on the subject, especially if placebos are involved, ends up generating certain biases.”

Miguel Ángel Plasencia, a traumatologist and head of the spine unit at the Cemtro clinic in Madrid, agrees with his colleague: “The review methodology is somewhat inconsistent because it mixes acute and chronic low back pain, pathologies that have nothing to do with each other.”

He adds: “For acute pain, which sometimes arises from excessive exertion or a fall, evidence shows that the best options continue to be anti-inflammatories, analgesics, and muscle relaxants. For chronic low back pain, physical exercise or rehabilitation treatments are much more effective.”

A study published in 2019 supports this, showing that physical exercise reduces lower back pain by 20% with the effect being sustained over time.

For Luis Miguel Torres, president of the Spanish Multidisciplinary Pain Society, “the new article has a potentially malicious message.” The risk, he explains, is that some patients may become discouraged and end up abandoning less aggressive treatments, such as acupuncture or medications, which have proven to be useful in clinical settings. “If they didn’t work, at least a little, patients would stop doing them or taking them, and that doesn’t happen,” he comments.

The best treatment is prevention

Between 80% and 90% of low back pain cases have no concrete explanation, and only 40% can be prevented. But this prevention, according to all the experts consulted for this article, can make a key difference in a patient’s quality of life.

Vidal Marcos is categorical: “Although the doctor does a thousand things to try to alleviate the problem, the most important thing is what the patient does.” In this regard, the specialist emphasizes the importance of teaching proper posture and movement from childhood. “Think of the impossibly heavy backpacks the little ones carry every day to school. In addition to sleeping and sitting any which way.”

Torres adds to the list of prevention measures preventing obesity and avoiding a sedentary lifestyle with exercises such as swimming and Pilates; and Plasencia recommends the use of appropriate mattresses — not too hard or too high — and ergonomic chairs in offices to maintain proper posture during long work days in front of the computer.

The review published Tuesday leaves out one of the most promising new treatments for back pain: regenerative medicine, which focuses on cartilage, tendons, joints, and muscles. “There are good prospects for treatments with, for example, stem cells or platelet-rich plasma. This could generate a paradigm shift in pain treatment,” Torres notes.

Cashin, the author of the analysis, insists that “the results of the review help clarify which treatments have a specific effect and are worth considering.” He also emphasizes that more research is needed to shed light on a disease whose economic cost, beyond its social cost, ranges between 1.7% and 2.1% of a European country’s GDP.

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