Health Technology Assessment & Transfer

European Spine Journal

, Volume 20, Issue 7, pp 1024-1038

First online:

Open Access This content is freely available online to anyone, anywhere at any time.

Cost-effectiveness of guideline-endorsed treatments for low back pain: a systematic review

  • Chung-Wei Christine LinAffiliated withThe George Institute for Global Health and Sydney Medical School, The University of Sydney Email author 
  • , Marion HaasAffiliated withCentre for Health Economics Research and Evaluation, The University of Technology
  • , Chris G. MaherAffiliated withThe George Institute for Global Health and Sydney Medical School, The University of Sydney
  • , Luciana A. C. MachadoAffiliated withDepartamento de Fisioterapia e Terapia Ocupacional, Universidade Federal de Minas Gerais
  • , Maurits W. van TulderAffiliated withDepartment of Health Sciences and the EMGO Institute for Health and Care Research, Faculty of Earth and Life Sciences, VU University


Healthcare costs for low back pain (LBP) are increasing rapidly. Hence, it is important to provide treatments that are effective and cost-effective. The purpose of this systematic review was to investigate the cost-effectiveness of guideline-endorsed treatments for LBP. We searched nine clinical and economic electronic databases and the reference list of relevant systematic reviews and included studies for eligible studies. Economic evaluations conducted alongside randomised controlled trials investigating treatments for LBP endorsed by the guideline of the American College of Physicians and the American Pain Society were included. Two independent reviewers screened search results and extracted data. Data extracted included the type and perspective of the economic evaluation, the treatment comparators, and the relative cost-effectiveness of the treatment comparators. Twenty-six studies were included. Most studies found that interdisciplinary rehabilitation, exercise, acupuncture, spinal manipulation or cognitive-behavioural therapy were cost-effective in people with sub-acute or chronic LBP. Massage alone was unlikely to be cost-effective. There were inconsistent results on the cost-effectiveness of advice, insufficient evidence on spinal manipulation for people with acute LBP, and no evidence on the cost-effectiveness of medications, yoga or relaxation. This review found evidence supporting the cost-effectiveness of the guideline-endorsed treatments of interdisciplinary rehabilitation, exercise, acupuncture, spinal manipulation and cognitive-behavioural therapy for sub-acute or chronic LBP. There is little or inconsistent evidence for other treatments endorsed in the guideline.


Low back pain Cost-effectiveness analysis Systematic review