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Back Pain - What Works Largest Meta-analysis to Date

In 2017, low-back pain caused 65 million years lived with disability. That was 17.5% worse than in 2007.1

What’s more, two thirds of people with low back pain continue to experience pain at 12 months.2 Clinicians can prescribe a number of non-pharmacological interventions, but which ones work? To help sort that problem, Silvia Gianola and colleagues published the largest meta-analysis to date in January.1 Their analysis incorporated 46 trials covering 8,765 patients with non-specific, lowback pain (LBP).

The studies measured 15 different treatments including acupuncture, back school, cognitive behavioural therapy, heat wraps, education, opioids, non-steroidal anti-inflammatories (NSAIDs), steroids, muscle relaxants, etc. Many of these were effective, but which were the most effective? Which were the best use of the patient’s time? Researchers compared all nonpharmacological treatments against each other in terms of reduction in pain and disability.

The Top 6 Most Effective, Non-pharmacological LBP Treatments (from most to least effective) 1. Manual therapy 2. Exercise 3. Heat wrap 4. Acupuncture 5. Education 6. Inert treatment / placebo The authors offered several sub-analyses which compared pharmacological and nonpharmacological treatments directly. For instance, the most effective treatments for pain at one week were (from largest difference to least) exercise, heat wrap, opioids, manual therapy, and NSAIDs. The least effective was education (below placebo).

The most effective treatments for pain changed at different time frames: one month—manual therapy (then NSAIDs), six months—manual therapy, one year—cognitive behavioural therapy (then exercise). For disability, the most effective treatments at one week were (from largest to smallest difference): exercise, heat wrap, manual therapy, and education. At different timeframes, the most effective treatments for disability changed: one month—manual therapy, three to six months—manual therapy, one year—cognitive behavioural therapy (followed closely by exercise). The authors caution that their data spans 40 years, in which treatments have changed. Specific situations such as types of exercise, timing of care, etc. can influence overall outcomes.

However, for the most effective treatments across all timeframes, the available data suggests manual therapy, exercise therapy, and heat therapy. All of these, of course, are treatments within the expertise of physiotherapists. For safe, effective treatment of LBP . . .


1. Gianola S, Bargeri S, Del Castillo G, Corbetta D, Turolla A, Andreano A, Moja L, Castellini G. Effectiveness of treatments for acute and subacute mechanical non-specific low back pain: a systematic review with network meta-analysis. British Journal of Sports Medicine. 2022 Jan 1;56(1):41-50.

2. Costa LD, Maher CG, Hancock MJ, McAuley JH, Herbert RD, Costa LO. The prognosis of acute and persistent low-back pain: a meta-analysis. CMAJ. 2012 Aug 7;184(11):E613-24.

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