Cost-effectiveness of non-invasive and non-pharmacological interventions for low back pain: a systematic literature review

This systematic review examined the available evidence on the cost-effectiveness of noninvasive and nonpharmacological interventions for low back pain, analyzing 33 studies conducted between 2000 and 2015 in developed countries. Low back pain represents a major public health problem, being the leading cause of years lived with disability globally and generating substantial economic costs, estimated at more than £12 billion in the United Kingdom in 1998. The investigators categorized the interventions into four main groups: combined treatments of physical exercise and psychological therapy, physical exercise therapy alone, manual therapy, and information and education interventions. The methodology included systematic searches across six bibliographic databases, with independent screening by three reviewers and quality assessment using the CHEC checklist.

Most studies (29 of 33) were based on randomized controlled trials, with a time horizon typically of 12 months. The results showed that combined treatments of physical exercise and psychological therapy were consistently cost-effective, with incremental cost-effectiveness ratios ranging from dominance to £5,000 per QALY. Acupuncture proved cost-effective in all four studies evaluated, with ICERs below the commonly accepted threshold of £20,000 per QALY. Specifically, acupuncture had an ICER of £4,241 per QALY in the main British study.

Medical yoga proved particularly promising, being dominant (lower cost and greater effectiveness) compared with other interventions. Spinal manipulation also demonstrated cost-effectiveness, although with greater variability in results. Information and education programs showed benefits primarily through reduced work absenteeism. The evidence on physical exercise alone was inconclusive, with the exception of medical yoga.

The clinical implications suggest that health care professionals can consider these interventions as economically viable alternatives for the management of low back pain. Acupuncture, in particular, offers a therapeutic option with a good cost-benefit ratio. However, the review identified important limitations, including methodological diversity across studies, different economic perspectives adopted, relatively short time horizons, and variability in the inclusion of productivity costs. Generalization of the results is also limited by the concentration of studies in developed countries with specific health systems.