Rhe Efficacy of Non-Surgical and Non-Interventional Treatments for Low Back Pain:

Placebo-controlled randomised trials are the best method for evaluating efficacy of treatments. There is a limited but growing evidence base of placebo-controlled randomised trials investigating the analgesic effects of non-surgical and non-interventional treatments for non-specific low back pain.

A study from Australia assesses the effectiveness of non-surgical and non-interventional treatments for adults with non-specific low back pain, comparing these treatments against placebos.

The study investogated published randomized controlled trials that assessed these treatments in adults aged 18 and older, sourced from extensive databases up until April 14, 2023. The researchers employed a random effects meta-analysis to synthesize results, focusing on pain intensity measured on a 0 to 100 scale immediately after treatment. The studies were categorized based on the duration of the low back pain being either acute (less than 12 weeks) or chronic (12 weeks or more). The final review included findings from 301 trials, which included 377 comparisons and data on 56 different treatments.

Efficacious Interventions:

1. Acute Low Back Pain:
   • Pharmacological: NSAIDs are the only treatment found efficacious based on moderate certainty evidence.
2. Chronic Low Back Pain:
   • Non-Pharmacological: Exercise, spinal manipulative therapy, and taping are efficacious, supported by moderate certainty evidence.
   • Pharmacological: Antidepressants and TRPV1 agonists are efficacious, with moderate certainty evidence.

Non-Efficacious Interventions:

1. Acute Low Back Pain:
   • Non-Pharmacological: Exercise is not efficacious.
   • Pharmacological: Glucocorticoid injections and paracetamol are not efficacious; both supported by moderate certainty evidence.
2. Chronic Low Back Pain:
   • Pharmacological: Anaesthetics and antibiotics are not efficacious, supported by moderate certainty evidence.

Inconclusive Evidence:

1. Acute Low Back Pain:
   • Non-Pharmacological: Treatments like acupuncture, masage heat therapy, osteopathy, acupuncture, exercise, and TENS have a moderate effect on reduced pain intensity but inconclusive efficacy due to low to very low certainty evidence.
   • Pharmacological: Treatments such as opioids, muscle relaxants, and cannabinoids also show inconclusive efficacy with similar low certainty.
2. Chronic Low Back Pain:
   • Non-Pharmacological: A wide range of treatments including acupressure, acupuncture, exercise, and ultrasound have shown to reduce a level of pain but inconclusive evidence of efficacy due to high catiabillity.
   • Pharmacological: Treatments such as anticonvulsants, muscle relaxants, and NSAIDs are inconclusive for efficacy.
3. Additional Insights: The review included a comprehensive analysis of 301 placebo-controlled trials and applied GRADE methodology to assess evidence certainty.

The findings indicate

Only a minor fraction of non-surgical and non-interventional treatments for low back pain are demonstrably efficacious, providing minimal analgesic benefits beyond placebo effects.

Placebo or sham-controlled trials are crucial for accurately determining the effectiveness of treatments by differentiating specific effects from non-specific and contextual influences.

While manual therapy such as massage had a large effect, of over 20% pain reduction on chronic condition, the certainty of this evidence remains low due to several limitations, including small study sizes and experimental limitations.

There is no universal solution to low back pain, a condition often exacerbated by a complex mix of biological, psychological, and sociocultural factors, especially in chronic cases.

Adopting a whole-person approach offers a valuable opportunity to provide tailored care that might combine methods like exercise, acupuncture, massage therapy, and spinal manipulation with pharmacological treatments. This multi-dimensional strategy aims to effectively manage back pain, catering to the unique needs of each individual.

Impact on Research, Practice, and Policy: The results underscore the effectiveness of specific non-surgical treatments in reducing pain intensity compared to placebos, offering guidance for clinical practices and policy-making.