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Most treatments for back pain do not work and even the few that do bring little relief, a global review of the evidence on one of the world’s commonest health problems has found.
Six in 10 adults in the UK live with lower back pain at some point. Symptoms can include excruciating pain, restricted movement, inability to work and reluctance to mix socially. Some people feel better within weeks but others can find their life dominated by chronic pain for years.
The wide range of treatment available includes painkillers, acupuncture, stretching, massage, anti-inflammatory drugs, laser and light therapy, and manipulation of the spine.
However, the bad news for the many who endure back pain is that only 10% of these non-surgical treatments usually deployed actually have any effect – and the rest provide little or no benefit.
Only six out of the 56 treatments analysed are effective and even those yield only “small” relief. The other 50 treatments either do not work, only modestly reduce pain or may even worsen it.
That is the conclusion of the most comprehensive review yet of the worldwide evidence surrounding what non-surgical treatments have analgesic – pain-killing – effects on back pain.
Australian researchers led by Dr Aidan Cashin at the pain impact centre at Neuroscience Research Australia examined 301 previously published randomised controlled trials that investigated the 56 treatments or combinations of treatments, such as anti-inflammatories and muscle relaxants. The trials were carried out in 44 countries worldwide, including in Europe, North America and Asia.
“The current evidence shows that one in 10 non-surgical and non-interventional treatments for low-back pain are efficacious, providing only small analgesic effects beyond placebo,” conclude the authors, whose findings are published in the medical journal BMJ Evidence-Based Medicine.
“The efficacy for the majority of treatments is uncertain. Our review did not find reliable evidence of large effects for any of the included treatments.”
The one treatment that does help those with acute low-back pain is non-steroidal anti-inflammatory drugs (NSAIDs), they found. In addition, five treatments also bring some relief for chronic low-back pain: exercise, spinal manipulative therapy, taping, antidepressants and what are known as transient receptor potential vanilloid 1 (TPRV1) drugs.
But three treatments for acute back pain do not work – exercise, glucocortisoid injections and taking paracetamol. And two for chronic back pain are also ineffective – antibiotics and anaesthetics.
However, the evidence for the other 45 treatments is “inconclusive”. The researchers assessed and offered a judgement on the extent to which they all relieved pain. Despite some of them being very popular, most “may provide modest reductions in pain”, they said.
Interventions that “probably provide little to no difference in pain” include exercise, paracetamol, glucocortisoid injections, anaesthetics and antibiotics or antimicrobial drugs.
However, having a massage, taking painkillers and wearing foot orthotics “may provide” large reductions in pain.
Heat, acupuncture, spinal manipulation and transcutaneous electrical nerve stimulation (TENS) may produce a “moderate” reduction in pain. Osteopathic treatment and using muscle relaxants and NSAIDs together may produce a small lessening of pain.
However, two treatments may increase someone’s pain, including extracorporeal shockwaves and the anti-inflammatory drug colchicine.
Prof Kamila Hawthorne, the chair of the Royal College of General Practitioners, said that family doctors often refer patients with back pain for physiotherapy as a first-line treatment, to be assessed and given exercises to perform, or to link workers, who suggest non-medical interventions.
“Many patients do report feeling some relief from the interventions – medical or not – that we suggest,” Hawthorne said.
Tim Button, the president of the British Chiropractic Association, welcomed the study’s endorsement of spinal manipulation and taping as effective treatments.
“Our members are increasingly seeing patients come to them with back pain, worried that they can’t work and stuck on NHS waiting lists,” he said.
“While this may not always be a ‘miracle cure’ to chronic musculoskeletal conditions, it is as effective as other non-invasive treatments and makes a real difference to how quickly people can get back to work and normal life.”
A Chartered Society of Physiotherapy spokesperson said: “Physiotherapists carry out an in-depth assessment to identify the root causes of back pain, which will be different for everyone and can range widely from stress, fear of movement and poor sleep to smoking, obesity, job-related strain, and insufficient physical activity.
“Exercise has been shown to be the most helpful treatment for back pain. Hands-on treatments have been shown to have a small benefit to back pain, but only when used as part of a whole treatment programme, which includes exercise.
“Similarly, injections may be beneficial as part of a treatment programme, but not on their own.”
