Key messages
For acute low back pain (pain lasting less than 6 weeks)
• Advice to stay active probably reduces pain and improves function compared to advice to rest in bed.
For subacute low back pain (pain lasting from 6 to 12 weeks)
• Multidisciplinary therapies probably reduce pain compared to usual care.
• Spinal manipulation probably does not improve function compared to placebo (a 'sham' or 'dummy' treatment designed to resemble the actual treatment but lacking active ingredients or the intended therapeutic effect).
For chronic low back pain (pain lasting longer than 12 weeks)
• Acupuncture probably reduces pain and improves function compared to placebo and no treatment/usual care.
• Exercise therapies probably reduce pain and improve function compared to placebo and no treatment/usual care.
• Traction probably does not reduce pain compared to sham traction.
• Multidisciplinary therapy probably reduces pain and improves function compared to usual care.
• Psychological therapies probably reduce pain but make no difference to function compared to usual care.
What is low back pain, and how is it treated?
Low back pain is a common health condition that can be associated with disability and poor quality of life. For most cases of low back pain, the cause of pain is unknown and is described as ‘non-specific’ low back pain. Many types of non-medicine and non-surgical treatments are available for people with low back pain of different durations: acute (pain lasting less than 6 weeks), subacute (pain lasting from 6 to 12 weeks) and chronic (pain lasting longer than 12 weeks). There is a need to provide accessible, high-quality information on the benefits and safety of non-drug and non-surgical treatments for healthcare professionals and patients to better manage low back pain.
What did we want to find out?
We wanted to summarise the evidence from Cochrane reviews on the effectiveness and safety of non-medicine and non-surgical treatments for adults with non-specific low back pain.
What did we do?
We found 31 reviews that included 644 studies with 97,183 participants. The studies investigated the effects of 27 different types of treatment for low back pain.
What did we find?
For people with acute/subacute low back pain, we found that advice to stay active probably reduces pain in the short term (i.e. up to 3 months) compared to advice to rest in bed. We found that multidisciplinary therapies probably reduce pain in the long term (i.e. at 12 months or longer). Spinal manipulation probably does not improve function in the short term.
For people with chronic low back pain, we found that acupuncture, exercise, and psychological therapies probably reduce pain in the short and medium term (i.e. from 3 to 12 months). Acupuncture and exercise probably also improve function in the short and medium term. Multidisciplinary therapies probably reduce pain and improve function in the short and medium term. Traction probably does not reduce pain in the short term.
We have less confidence in the effects of other non-medicine and non-surgical interventions for low back pain.
Non-medicine and non-surgical interventions may not be associated with serious adverse (i.e. unwanted, harmful) events.
What are the limitations of the evidence?
We have reduced confidence in the evidence because we judged that 38% of the reviews did not employ the most rigorous methods available. Almost three-quarters of the reviews were published before 2020, meaning that the evidence they contain may be relatively dated. There is a need to update some Cochrane reviews following recommended guidance.
Because of the quality of the evidence, we are still uncertain about the benefits or risks of many non-medicine and non-surgical treatments commonly used in clinical practice for low back pain. We encourage healthcare professionals, patients, and organisations that fund research on low back pain to use this overview to make informed decisions for low back pain treatment.
How current is this evidence?
This overview is current to April 2023. However, one-third (10 of 31) of the reviews are more than 15 years old, meaning the evidence they contain is even more dated.
Spinal manipulation probably makes no difference to function compared to placebo for people with acute/subacute LBP. Acupuncture probably improves function slightly for people with chronic LBP, compared to sham acupuncture. There is probably no difference between traction and sham traction for pain intensity in people with chronic LBP. Compared to advice to rest, advice to stay active probably reduces pain intensity slightly and improves function slightly for people with acute LBP.
Acupuncture probably reduces pain intensity, and improves function slightly for people with chronic LBP, compared to no treatment. Acupuncture probably improves function slightly for people with chronic LBP, compared to usual care. Exercise therapies probably reduce pain intensity, and improve function slightly for people with chronic LBP, compared to no treatment/usual care. Multidisciplinary therapies probably reduce pain intensity, and improve function slightly for people with chronic LBP, compared to usual care. Compared to usual care, psychological therapies probably reduce pain intensity slightly, but probably make no difference to function for people with chronic LBP.
Low back pain (LBP) is a significant public health issue due to its high prevalence and associated disability burden. Clinical practice guidelines recommend non-pharmacological/non-surgical interventions for managing pain and function in people with LBP.
To provide accessible, high-quality evidence on the effects of non-pharmacological and non-surgical interventions for people with LBP and to highlight areas of remaining uncertainty and gaps in the evidence regarding the effects of these interventions for people with LBP.
We searched the Cochrane Database of Systematic Reviews from inception to 15 April 2023, to identify Cochrane reviews of randomised controlled trials testing the effect of non-pharmacological/non-surgical interventions, unrestricted by language. Major outcomes were pain intensity, function and safety.
Two authors independently assessed eligibility, extracted data and assessed the quality of the reviews using AMSTAR 2 (A MeaSurement Tool to Assess Systematic Reviews) and the certainty of the evidence using GRADE. The primary comparison was placebo/sham.
We included 31 Cochrane reviews of 644 trials that randomised 97,183 adults with LBP. We have high confidence in the findings of 19 reviews, moderate confidence in the findings of two reviews, and low confidence in the findings of 10 reviews. We present results for non-pharmacological/non-surgical interventions compared to placebo/sham or no treatment/usual care at short-term (≤ three months) follow-up.
Placebo/sham comparisons
Acute/subacute LBP
Compared to placebo, there is probably no difference in function (at one-week follow-up) for spinal manipulation (standardised mean difference (SMD) -0.08, 95% confidence interval (CI) -0.37 to 0.21; 2 trials, 205 participants; moderate-certainty evidence).
Data for safety were reported only for heated back wrap. Compared to placebo, heated back wrap may result in skin pinkness (6/128 participants versus 1/130; 2 trials; low-certainty evidence).
Chronic LBP
Compared to sham acupuncture, acupuncture probably provides a small improvement in function (SMD -0.38, 95% CI -0.69 to -0.07; 3 trials, 957 participants; moderate-certainty evidence).
Compared to sham traction, there is probably no difference in pain intensity for traction (0 to 100 scale, mean difference (MD) -4, 95% CI -17.7 to 9.7; 1 trial, 60 participants; moderate-certainty evidence).
Data for safety were reported only for acupuncture. There may be no difference between acupuncture and sham acupuncture for safety outcomes (risk ratio (RR) 0.68, 95% CI 0.42 to 1.10; I2 = 0%; 4 trials, 465 participants; low-certainty evidence).
No treatment/usual care comparisons
Acute/subacute LBP
Compared to advice to rest, advice to stay active probably provides a small reduction in pain intensity (SMD -0.22, 95% CI -0.02 to -0.41; 2 trials, 401 participants; moderate-certainty evidence).
Compared to advice to rest, advice to stay active probably provides a small improvement in function (SMD -0.29, 95% CI -0.09 to -0.49; 2 trials, 400 participants; moderate-certainty evidence).
Data for safety were reported only for massage. There may be no difference between massage and usual care for safety (risk difference 0, 95% CI -0.07 to 0.07; 1 trial, 51 participants; low-certainty evidence).
Chronic LBP
Compared to no treatment, acupuncture probably provides a medium reduction in pain intensity (0 to 100 scale, mean difference (MD) -10.1, 95% CI -16.8 to -3.4; 3 trials, 144 participants; moderate-certainty evidence), and a small improvement in function (SMD -0.39, 95% CI -0.72 to -0.06; 3 trials, 144 participants; moderate-certainty evidence).
Compared to usual care, acupuncture probably provides a small improvement in function (MD 9.4, 95% CI 6.15 to 12.65; 1 trial, 734 participants; moderate-certainty evidence).
Compared to no treatment/usual care, exercise therapies probably provide a small to medium reduction in pain intensity (0 to 100 scale, MD -15.2, 95% CI -18.3 to -12.2; 35 trials, 2746 participants; moderate-certainty evidence), and probably provide a small improvement in function (0 to 100 scale, MD -6.8, 95% CI -8.3 to -5.3; 38 trials, 2942 participants; moderate-certainty evidence).
Compared to usual care, multidisciplinary therapies probably provide a medium reduction in pain intensity (SMD -0.55, 95% CI -0.83 to -0.28; 9 trials, 879 participants; moderate-certainty evidence), and probably provide a small improvement in function (SMD -0.41, 95% CI -0.62 to -0.19; 9 trials, 939 participants; moderate-certainty evidence).
Compared to no treatment, psychological therapies using operant approaches probably provide a small reduction in pain intensity (SMD -0.43, 95% CI -0.75 to -0.11; 3 trials, 153 participants; moderate-certainty evidence).
Compared to usual care, psychological therapies (including progressive muscle relaxation and behavioural approaches) probably provide a small reduction in pain intensity (0 to 100 scale, MD -5.18, 95% CI -9.79 to -0.57; 2 trials, 330 participants; moderate-certainty evidence), but there is probably no difference in function (SMD -0.2, 95% CI -0.41 to 0.02; 2 trials, 330 participants; moderate-certainty evidence).
It is uncertain whether there is a difference between non-pharmacological/non-surgical interventions and no treatment/usual care for safety (very low-certainty evidence).