Abstract
Low back pain (LBP) is a leading cause of global disability, with a 7.2% prevalence and up to 80% lifetime risk, substantially impairing functionality and imposing a major economic burden. This review evaluates the cost-effectiveness trade-offs between pharmacological and non-pharmacological therapies for non-specific LBP, drawing on recent, high-quality evidence from a comprehensive PubMed search. Evaluated approaches included physical therapy, pharmacological management, cognitive behavioral therapy (CBT), chiropractic manipulation, acupuncture, yoga, and massage therapy. Non-steroidal anti-inflammatory drugs (NSAIDs) remain widely prescribed, yet their safety concerns contrast with the more sustainable benefits of physical therapy and spinal manipulation, with specialized physical therapy yielding 74% greater improvement than conventional therapy combined with NSAIDs. Nevertheless, physical therapy faces limitations related to practitioner variability, accessibility in rural or low-resource settings, upfront costs, and patient adherence. CBT demonstrates significant psychosocial benefits but is constrained by limited availability of qualified practitioners, high costs, and the active participation required from patients. Complementary approaches such as acupuncture and yoga show moderate efficacy and potential economic benefits; however, evidence consistency, delivery infrastructure, and adherence remain challenges, with yoga in particular showing high dropout rates in low-resource contexts. Importantly, acupuncture and yoga may still provide valuable benefits as part of a multimodal strategy. However, the available evidence is heavily concentrated in high-income countries, while studies from low- and middle-income countries remain scarce and unevenly distributed. Only a few LMICs have reported findings, with particularly limited data from Southeast Asia, underscoring critical research gaps in these regions. No single therapy emerges as universally superior for non-specific LBP, as effectiveness depends on patient profile, healthcare context, and cost. These findings highlight the importance of integrated, scalable, and accessible multidisciplinary models aligned with the biopsychosocial framework to optimize long-term outcomes.