Long-term effectiveness of non-surgical interventions for chronic low back pain: a systematic review and meta-analysis

Background: Chronic low back pain is a long-term recurrent condition. Interventions with sustained benefits are needed to reduce the associated personal and societal burden. We aimed to assess the long-term effectiveness of non-surgical interventions for reducing pain intensity and disability in adults with chronic low back pain. 

Methods: We performed a systematic review and meta-analysis. MEDLINE, EMBASE, and CINAHL were searched from inception until May 22, 2024, for randomised controlled trials assessing non-surgical interventions in adults with chronic low back pain. Studies assessing pain intensity outcomes, disability outcomes, or both at long-term (1–2 years) and very long-term (≥2 years) follow-up were included. Comparators included placebo, adjuvant intervention, no intervention, or usual care. Study characteristics and outcome measures were extracted and risk of bias assessed. Random effects meta-analysis was performed for studies with similar populations, interventions, and outcome measures. We involved people with experience living with or treating chronic low back pain in the design and interpretation of this review. The review protocol was prospectively registered in PROSPERO (CRD42023408537). 

Findings: 75 trials (15 395 participants) were included. Risk of bias was rated high for the majority of studies (51 [68%] of 75). In people with non-specific chronic low back pain at long-term follow-up, there was moderate certainty evidence that cognitive behavioural therapy and mindfulness probably result in reductions in pain intensity (mean difference –7·2 [95% CI –9·8 to –4·6]; I² =0·0 for cognitive behavioural therapy and –10·0 [–14·4 to –5·6]; I² =0·1 for mindfulness) and disability (–5·7 [–7·7 to –3·7]; I² =0·0 and –9·3 [–14·4 to –4·1]; I² =11·1). Goal setting (–8·3 [–12·8 to –3·9]; I² =4·8) and needling (–4·8 [–8·1 to –1·5]; I² =0·0) probably reduce disability at long-term follow-up. There was low certainty evidence that multidisciplinary care could reduce pain intensity (–10·1 [–16·6 to –3·7; I² =0·0) and exercise might reduce disability (–10·2 [–17·5 to –2·9]; I² =33·5) at very long-term follow-up. Heterogeneity was evident in several of the meta-analyses, and results should be interpreted with caution. 

Interpretation: Some interventions, including cognitive behavioural therapy, mindfulness, exercise, and multidisciplinary care could produce the long-term benefits required to reduce the global burden due to non-specific chronic low back pain; however, the effects are mostly small, and the strength of evidence is relatively uncertain. Greater attention is needed on developing and testing interventions with long-term effects for chronic low back pain.