(Photo by Funkcines Terapijos Centras)
Key takeaways
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University of Sydney researchers found one treatment (NSAIDs) to be effective at moderate-level certainty for acute low back pain
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Five treatments (exercise, spinal manipulation, taping, antidepressants, TRPV1 agonists) with statistically significant but small effects for chronic low back pain. All were compared to placebo.
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Some common treatments—like paracetamol, glucocorticoids, anaesthetics, and antibiotics—showed no benefits, while massage, acupuncture, and cognitive behavioral therapy had inconclusive evidence due to low-quality or limited studies.
- Dr. Steve Kamper said in an interview that there few treatments for chronic low back pain that are both statistically reliable and clinically meaningful.
These treatments are:
- Nonsteroid anti-inflammatory drugs (NSAIDS) for acute low back pain
- Exercise, spinal manipulative therapy, taping, antidepressants, and TRPV1 agonists (substances that activate a receptor that regulates pain sensation and inflammation) for chronic low back pain.
While “moderate certainty” means that the results are likely not gotten by chance , they reported that the effect sizes of these five treatments were small when compared to a placebo.
Led by Dr. Aiden Cashin, the researchers found that exercise, glucocorticoids, and paracetamol for acute low back pain had “no effect” based on research with at least moderate quality of evidence. The same is said for anaesthetics and antibiotics for chronic low back pain.
For other types of treatments—such as massage therapy, acupuncture, cognitive behavioral therapy, and ultrasound—the evidence is “inconclusive” because of “few participants, imprecision, or being of low or very low certainty.”
Regarding massage therapy, their conclusion is similar to a 2024 systematic review that found the certainty level of evidence of massage is “low” for low back pain.
The study reviewed 301 trials that compared a treatment with a placebo. It also added 21 treatments or treatment combinations compared to a previous 2009 review. The researchers analyzed non-drug and drug interventions and back pain duration separately.
Dr. Steve Kamper, who co-authored the 2025 study with Cashin, said that they included trials that used a sham intervention because they did not see the distinction between placebo and sham as “meaningful.”
“Given that any sort of intervention could be labelled by researchers as ‘control,’ we did not include those [randomized-controlled trials] because they could estimate the difference in effect between two interventions of widely varying types,” Kamper told Massage & Fitness. “This inclusion criterion was based on the authors’ label in their study. By posing a specific research question, we reduce the clinical heterogeneity among the included studies which supports the aim to synthesise the evidence.”
The study excluded trials that compared a treatment to a waitlist, no treatment, and usual care. Studies where it was not possible to isolate the effectiveness of the target intervention were also excluded.
Kamper said the certainty of evidence has become “more developed” since 2009 because they used the GRADE tool as a guide rather than using a “simple assessment” to evaluate a study’s quality. The GRADE tool (Grading of Recommendations Assessment, Development and Evaluation) is a widely used system in research to assess the quality or certainty of evidence and the strength of recommendations in healthcare.
It helps researchers and clinicians answer two key questions:
- How confident are we that the evidence reflects the true effect?
- How strong should a recommendation based on this evidence be?
“In the 2009 study, we found a few interventions that had effect sizes on pain of more than two points on a 10-point scale,” Kamper said. “In the updated [systematic review], we did not find moderate quality evidence of clinically meaningful effects for any of those interventions.
“Had [the GRADE tool] been available at the time, we probably would have concluded that the treatments that showed larger effects were probably not very reliable estimates,” Kamper added. “Overall though, the finding that few treatments appear to be much more effective than placebos and those that have small effects is more or less the same.”
The authors acknowledged several limitations in their review, such as:
- They only included trials that clearly labeled the comparison group as a placebo or sham, but definitions of these terms varied across studies.
- They grouped similar treatments—like different types of NSAIDs—together, even if they were given in different ways because the researchers wanted to simplify the analysis and support policy decision-making.
- They also included studies where both groups received the same additional treatment, which likely did not affect the results.
- They did not include unpublished studies due to practical reasons, and the impact of leaving them out is unclear.
Kamper mentioned that a caveat in their study is that the volume of research for “complex and behavioural interventions” represented in the systematic review is “quite small because those interventions do not lend themselves to testing against placebos.”
“Not to say it is impossible, but it hasn’t been done very often. That means we don’t know much about whether these are effective versus placebo,” he said. “People with back pain can use these estimates as part of a conversation with their clinician as to whether the different treatment options are right for them.”
Nick Ng is the editor of Massage & Fitness Magazine and the managing editor for My Neighborhood News Network.
An alumni from San Diego State University with a bachelor’s degree in graphic communications, Nick had completed his massage therapy training at International Professional School of Bodywork in San Diego in 2014. In 2021, he earned an associate’s degree in journalism at Palomar College.
When he gets a chance, he enjoys weightlifting at the gym, salsa dancing, and exploring new areas in the Puget Sound area in Washington state.
