Treatments.
What works and what doesn't.
An overview of 16 treatments for back pain, rated on scientific evidence and sorted from most to least effective. From exercise therapy to surgery: not everything that is offered actually works.
First, what does “works” mean?
In 2025 a review pooled 301 placebo-controlled trials covering 56 non-surgical treatments for back pain. The result is sobering: roughly one in ten works better than a placebo, and those that do produce small effects (Cashin et al., BMJ Evidence-Based Medicine 2025). For acute back pain only NSAIDs came out ahead. For chronic back pain: exercise, spinal manipulation, taping, antidepressants and capsaicin-type agents.
That does not make the rest useless. A treatment can be worth doing because it is safe, keeps you moving, or is what a guideline advises, even when the pain-relieving effect is hard to prove. But it does mean you should be suspicious of anyone promising a lot. On this page, a high score means the evidence is strong, not that the effect is large.
Category
Movement & therapy
Movement is the best-proven treatment. This is the foundation.
Exercise therapy
How do we rate this?
We look at whether the pain decreases and whether people can move and function better again, not at how satisfied patients were with the treatment, because that says little about whether it really works. Strong comparative research is scarce for back pain, so some ratings are based on limited evidence.
A structured exercise programme is what the guidelines put first: the WHO (2023), NICE (2016) and KNGF (2021) all recommend it as first choice. It is also one of the few treatments that beats a placebo, though the difference is small (Cashin et al., 2025).
Physiotherapy
How do we rate this?
We look at whether the pain decreases and whether people can move and function better again, not at how satisfied patients were with the treatment, because that says little about whether it really works. Strong comparative research is scarce for back pain, so some ratings are based on limited evidence.
Exercise therapy, manual therapy and pain education combined, directly accessible without a referral. Guidelines recommend it for persistent back pain. The Dutch Zorginstituut reviewed 42 studies in 2024 and concluded the added value over no physiotherapy is not sufficiently demonstrated (standpunt 2024).
Manual therapy and chiropractic
How do we rate this?
We look at whether the pain decreases and whether people can move and function better again, not at how satisfied patients were with the treatment, because that says little about whether it really works. Strong comparative research is scarce for back pain, so some ratings are based on limited evidence.
For chronic back pain, spinal manipulation is one of the few treatments that beats a placebo, though by a small margin (Cashin et al., 2025). For recent back pain it added nothing over ordinary care in a 1,000-person trial (PACBACK, JAMA 2025).
Acupuncture
How do we rate this?
We look at whether the pain decreases and whether people can move and function better again, not at how satisfied patients were with the treatment, because that says little about whether it really works. Strong comparative research is scarce for back pain, so some ratings are based on limited evidence.
Better than no treatment, but barely better than sham acupuncture, which suggests most of the effect is context. NICE advises against it and Dutch GP literature calls the effect mainly placebo; the WHO recommends it conditionally.
Massage
How do we rate this?
We look at whether the pain decreases and whether people can move and function better again, not at how satisfied patients were with the treatment, because that says little about whether it really works. Strong comparative research is scarce for back pain, so some ratings are based on limited evidence.
Temporary pain relief at best; evidence for a lasting effect on pain and function is lacking (Cochrane 2015). Can be useful as adjunct to exercise therapy. NICE does not actively recommend it.
Category
Medication
Sometimes useful as temporary support, never the solution itself.
NSAIDs
How do we rate this?
We look at whether the pain decreases and whether people can move and function better again, not at how satisfied patients were with the treatment, because that says little about whether it really works. Strong comparative research is scarce for back pain, so some ratings are based on limited evidence.
Modest effect for acute back pain. Use short-term (max 7-14 days), lowest effective dose. Stomach protection for risk factors. Not for kidney disease or heart failure.
Paracetamol (acetaminophen)
How do we rate this?
We look at whether the pain decreases and whether people can move and function better again, not at how satisfied patients were with the treatment, because that says little about whether it really works. Strong comparative research is scarce for back pain, so some ratings are based on limited evidence.
The PACE trial (Lancet 2014) showed paracetamol is no better than placebo for acute low back pain, so WHO and NICE do not recommend it. Your Dutch GP still starts here, because it has the fewest side effects (Thuisarts).
Opioids
How do we rate this?
We look at whether the pain decreases and whether people can move and function better again, not at how satisfied patients were with the treatment, because that says little about whether it really works. Strong comparative research is scarce for back pain, so some ratings are based on limited evidence.
OPAL trial (Lancet 2023): no better than placebo for acute back pain, more side effects. High risk of dependence. WHO and NICE do not recommend opioids for back pain.
Category
Mind & behaviour
Pain is never 'just in your head', but your brain does play a part. These approaches work.
Multidisciplinary rehabilitation
How do we rate this?
We look at whether the pain decreases and whether people can move and function better again, not at how satisfied patients were with the treatment, because that says little about whether it really works. Strong comparative research is scarce for back pain, so some ratings are based on limited evidence.
Combination of physiotherapy, psychology and medical guidance. Effective for chronic back pain with psychosocial factors. More effective than single-discipline approaches on pain and function (Cochrane 2014).
Cognitive behavioural therapy (CBT)
How do we rate this?
We look at whether the pain decreases and whether people can move and function better again, not at how satisfied patients were with the treatment, because that says little about whether it really works. Strong comparative research is scarce for back pain, so some ratings are based on limited evidence.
Addresses negative thought patterns and fear-avoidance, and is one of the few treatments with demonstrated benefit one to two years later, though the effect is small (Jenkins et al., Lancet Rheumatol 2025). Works best combined with exercise.
Cognitive Functional Therapy (CFT)
How do we rate this?
We look at whether the pain decreases and whether people can move and function better again, not at how satisfied patients were with the treatment, because that says little about whether it really works. Strong comparative research is scarce for back pain, so some ratings are based on limited evidence.
Integrates pain education, graded exposure and lifestyle modification. RESTORE trial (Lancet 2023): greater reduction in pain and daily-life limitations than usual care in chronic back pain, still present at 12 months.
Category
Injections & surgery
Only useful in specific situations. Be critical.
Surgery (emergency)
How do we rate this?
We look at whether the pain decreases and whether people can move and function better again, not at how satisfied patients were with the treatment, because that says little about whether it really works. Strong comparative research is scarce for back pain, so some ratings are based on limited evidence.
Surgery is necessary and urgent for cauda equina syndrome: decompression within 24 to 48 hours gives the best chance of recovering bladder function and muscle strength. Also indicated for progressive severe neurological deficit from herniation not responding to conservative treatment.
Herniated disc surgery
How do we rate this?
We look at whether the pain decreases and whether people can move and function better again, not at how satisfied patients were with the treatment, because that says little about whether it really works. Strong comparative research is scarce for back pain, so some ratings are based on limited evidence.
About 75% recovers within three months without surgery. A discectomy relieves faster, but after one to two years the result is comparable (Peul et al., NEJM 2007). For sciatica lasting 4 to 12 months surgery does come out clearly better (Bailey et al., NEJM 2020).
Epidural injection (radiating pain)
How do we rate this?
We look at whether the pain decreases and whether people can move and function better again, not at how satisfied patients were with the treatment, because that says little about whether it really works. Strong comparative research is scarce for back pain, so some ratings are based on limited evidence.
For severe pain radiating into the leg an epidural corticosteroid injection can be considered when pain medication falls short (NL guideline LRS). The effect is real but small and short-lived: about 5 points less leg pain on a scale of 0 to 100 (Cochrane 2020).
Facet and SI joint injections
How do we rate this?
We look at whether the pain decreases and whether people can move and function better again, not at how satisfied patients were with the treatment, because that says little about whether it really works. Strong comparative research is scarce for back pain, so some ratings are based on limited evidence.
The Dutch MINT trials (JAMA 2017) found no clinically relevant benefit of radiofrequency denervation on top of an exercise programme. Since 1 January 2016 facet and SI injections and denervations are no longer part of Dutch basic insurance (Zorginstituut).
Surgery (non-specific back pain)
How do we rate this?
We look at whether the pain decreases and whether people can move and function better again, not at how satisfied patients were with the treatment, because that says little about whether it really works. Strong comparative research is scarce for back pain, so some ratings are based on limited evidence.
Surgery is not effective for non-specific back pain. Spinal fusion for non-specific complaints shows no better results than intensive rehabilitation (Brox et al., Spine 2003). NICE also advises against disc replacement.
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