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

Low back pain is the leading cause of disability worldwide. Although numerous treatment approaches are recommended by international clinical guidelines, there is still limited understanding of which interventions provide the best value for money. We aimed to critically appraise and summarise the evidence on the cost-effectiveness and costs of interventions endorsed in recent guidelines to manage low back pain (LBP), compared to usual care.

We searched 10 electronic databases (e.g., MEDLINE (OvidSP), EMBASE (OvidSP), PsycINFO (OvidSP)) from inception to 9th of February 2026 for cost-effectiveness studies of guideline-recommended treatments to manage non-specific LBP. The primary outcome was cost/quality-adjusted life year (QALY), which was converted to 2024 Great British Pound values, tabulated and summarised qualitatively. Secondary outcomes were direct costs (total, interventional, health service use, community services and out-of-pocket costs) and indirect costs (e.g., lost wages, lost productivity, absenteeism). We assessed methodological quality using the Consensus Health Economics Criteria (CHEC) checklist for within-trial economic evaluations or the Philips checklist for modelling studies. Our review included 20 studies (17 within-trial economic evaluations and three modelling studies), published between 2005 and 2026. Half (n = 10) focussed on chronic LBP (>3-month duration), and eight included mixed populations (i.e., acute, subacute and chronic). All studies were of non-pharmacological, non-surgical interventions, both single-modality and multimodal interventions (e.g., exercise plus spinal manipulation; diet plus physical activity). Most interventions are cost-effective at a willingness-to-pay threshold of £20,000. Moreover, interventions aiming to reduce fear and stress or support self-management in people with chronic LBP, as well as clinician-delivered interventions including yoga, acupuncture, cognitive therapy and self-management support are potentially cost-saving from the healthcare, societal and payer's perspectives, as they are both more effective and less costly than usual care (e.g., first contact management, including advice and medication). All of the evidence is derived from high-income countries, and from a considerable heterogenous body of literature. Evidence on cost-effective treatments in low- and middle-income countries remains limited.

Non-pharmacological, non-surgical interventions that include education, psychological support, acupuncture and exercise seem to be cost-effective for managing LBP, compared to usual care. Improved access to and implementation of these effective treatments is urgently needed so more people can benefit from them in routine care.

The review was registered on PROSPERO (https://www.crd.york.ac.uk; CRD42024510270).