Analgesic effects of non-surgical and non-interventional treatments for low back pain: a systematic review and meta-analysis of placebo-controlled randomised trials

PainSci » bibliography » Cashin et al 2025
updated Apr 14, 2025

Tags: treatment, back pain, bad news, pain problems, spine

PainSci commentary on Cashin 2025: ?This page is one of thousands in the PainScience.com bibliography. It is not a general article: it is focused on a single scientific paper, and it may provide only just enough context for the summary to make sense. Links to other papers and more general information are provided wherever possible.

This big new review of back pain treatments seems to be just about as discouraging as it could possibly be. But tilt your head like a curious doggo for a different view, and maybe it’s not as bad as it seems? Here’s some good news about the bad news:

Given the amount of garbage out there, getting some relief from 1 in 10 treatments doesn’t actually strike me as being all that bad. And the winners are: NSAIDs, exercise, spinal manipulation, taping, antidepressants, and TPRV1 antagonists (like capsaicin in spicy rubs).
There’s a lot of “garbage in, garbage out” here, and it mostly confirms that we have inadequate rather than negative evidence. They were only reviewing placebo-controlled trials, which is a high bar to clear, and most of what they found wasn’t enough for conclusions. (And yet consumers are spending billions of bucks on those not-clinically-proven treatments. 😬) But the silver lining is that there could be good treatments that simply haven’t been tested enough yet.

And now the bad news about the bad news. Unfortunately, if tilt your head the other way, the bad news looks even worse than it seemed at first. Quite a bit worse.

The lucky handful of treatments that are being touted as effective here are offering really minor relief, all very damned-with-faint-praise.
And some of those small benefits are likely illusory — evidence that registered as a thumbs up in this review, but likely won’t stand up to scrutiny/replication.
And the reems of “inconclusive” evidence here? Most of that is extremely unlikely to ever get conclusive.

The bottom line is clear: back pain is largely immune to treatment … still. The results of this review are very similar to the 2009 version from many of the same authors — they just had more data to work with this time.

~ Paul Ingraham

original abstract †Abstracts here may not perfectly match originals, for a variety of technical and practical reasons. Some abstacts are truncated for my purposes here, if they are particularly long-winded and unhelpful. I occasionally add clarifying notes. And I make some minor corrections.

OBJECTIVES: To investigate the efficacy of non-surgical and non-interventional treatments for adults with low back pain compared with placebo.

ELIGIBILITY CRITERIA: Randomised controlled trials evaluating non-surgical and non-interventional treatments compared with placebo or sham in adults (≥18 years) reporting non-specific low back pain.

INFORMATION SOURCES: MEDLINE, CINAHL, EMBASE, PsychInfo and Cochrane Central Register of Controlled Trials were searched from inception to 14 April 2023.

RISK OF BIAS: Risk of bias of included studies was assessed using the 0 to 10 PEDro Scale.

SYNTHESIS OF RESULTS: Random effects meta-analysis was used to estimate pooled effects and corresponding 95% confidence intervals on outcome pain intensity (0 to 100 scale) at first assessment post-treatment for each treatment type and by duration of low back pain-(sub)acute (<12 weeks) and chronic (≥12 weeks). Certainty of the evidence was assessed using the Grading of Recommendations Assessment (GRADE) approach.

RESULTS: A total of 301 trials (377 comparisons) provided data on 56 different treatments or treatment combinations. One treatment for acute low back pain (non-steroidal anti-inflammatory drugs (NSAIDs)), and five treatments for chronic low back pain (exercise, spinal manipulative therapy, taping, antidepressants, transient receptor potential vanilloid 1 (TRPV1) agonists) were efficacious; effect sizes were small and of moderate certainty. Three treatments for acute low back pain (exercise, glucocorticoid injections, paracetamol), and two treatments for chronic low back pain (antibiotics, anaesthetics) were not efficacious and are unlikely to be suitable treatment options; moderate certainty evidence. Evidence is inconclusive for remaining treatments due to small samples, imprecision, or low and very low certainty evidence.

CONCLUSIONS: 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. The efficacy for the majority of treatments is uncertain due to the limited number of randomised participants and poor study quality. Further high-quality, placebo-controlled trials are warranted to address the remaining uncertainty in treatment efficacy along with greater consideration for placebo-control design of non-surgical and non-interventional treatments.

original abstract †Abstracts here may not perfectly match originals, for a variety of technical and practical reasons. Some abstacts are truncated for my purposes here, if they are particularly long-winded and unhelpful. I occasionally add clarifying notes. And I make some minor corrections.

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