Guideline-Recommended Back Pain Treatments Mostly Offer Good Value for Money

Low back pain is the leading cause of disability worldwide, yet health systems have had surprisingly little evidence on which guideline-endorsed treatments actually deliver value for money.

The research team, led by Stephanie Mathieson and Manuela L. Ferreira, searched ten electronic databases, including MEDLINE, EMBASE and PsycINFO, from their inception up to 9 February 2026. They looked for cost-effectiveness studies of guideline-recommended treatments for non-specific low back pain. The primary outcome was the cost per quality-adjusted life year, or QALY, which the researchers converted into 2024 Great British Pound values and summarised qualitatively.

Secondary outcomes covered direct costs, including total costs, intervention costs, health service use, community services and out-of-pocket payments, as well as indirect costs such as lost wages, lost productivity and absenteeism. Methodological quality was assessed using the Consensus Health Economics Criteria checklist for within-trial economic evaluations and the Philips checklist for modelling studies.

The review included 20 studies published between 2005 and 2026: 17 within-trial economic evaluations and three modelling studies. Half of the studies focused on chronic low back pain, defined as pain lasting more than three months, and eight included mixed populations spanning acute, subacute and chronic presentations. Notably, all of the included studies examined non-pharmacological, non-surgical interventions, ranging from single-modality treatments to multimodal programmes such as exercise combined with spinal manipulation or diet combined with physical activity.

The headline finding is encouraging: most of the evaluated interventions are cost-effective at a willingness-to-pay threshold of £20,000 per QALY gained. In other words, when judged against the conventional benchmark that health systems use to decide whether a treatment justifies its price, the majority of guideline-recommended, non-drug, non-surgical approaches pass the test.

Some interventions went further and appeared potentially cost-saving. Treatments aiming to reduce fear and stress or to support self-management in people with chronic low back pain, along with clinician-delivered interventions including yoga, acupuncture, cognitive therapy and self-management support, were both more effective and less costly than usual care, which typically consists of first contact management including advice and medication. That pattern held across the healthcare, societal and payer perspectives reported in the underlying studies.

The authors caution, however, that the entire evidence base comes from high-income countries and represents a considerably heterogeneous body of literature. Evidence on cost-effective treatments in low- and middle-income countries remains limited, meaning the findings cannot simply be transferred to health systems with very different resource levels and care pathways.

The review’s conclusions are straightforward: non-pharmacological, non-surgical interventions that include education, psychological support, acupuncture and exercise appear to be cost-effective for managing low back pain compared with usual care.

Subject of Research: Cost-effectiveness of guideline-recommended non-pharmacological interventions for managing low back pain

Article Title: Cost-effectiveness of recommended interventions for managing low back pain: A systematic review

Article References: Mathieson, S., Underwood, M., Ibrahim, M., Hua, Z., Zhu, Z., Ferreira, P. H., Mistry, H., Atkins, E. R., Bowden, J. L., Eyles, J. P., Briggs, A. M., Hunter, D. J., & Ferreira, M. L. (2026). Cost-effectiveness of recommended interventions for managing low back pain: A systematic review. PLOS Medicine, 23(10), e1005273. https://doi.org/10.1371/journal.pmed.1005273

Image Credits: AI Generated

DOI: 10.1371/journal.pmed.1005273

Keywords: low back pain, cost-effectiveness, systematic review, QALY, guidelines, non-pharmacological interventions, acupuncture, yoga, self-management, health economics, PLOS Medicine, recommended