Medications and Low Back Pain: an ISICO commentary of a Cochrane review

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The Cochrane review “Pharmacological treatments for low back pain in adults: an overview of Cochrane Reviews” has recently been published. This extensive and methodologically robust work significantly updates our understanding of the effectiveness—and the limitations—of the medications most commonly used for low back pain: from paracetamol to NSAIDs, as well as muscle relaxants, opioids, antidepressants, and antiepileptics.

Alongside the review, an editorial commentary by Prof. Stefano Negrini, ISICO Scientific Director, and Dr. Carlotte Kiekens, physiatrist, has also been published.
Their contribution offers a valuable interpretative perspective, helping to clarify what these findings really mean for clinicians working daily with spinal disorders and rehabilitation.

What the review shows

The central message is clear: medications alone play a very limited role in the management of low back pain.

Paracetamol is no more effective than placebo; NSAIDs provide only mild and short-term relief; muscle relaxants may help in the immediate phase but come with relevant adverse effects; and opioids show an unfavorable risk–benefit profile. For many other drug classes, the evidence remains insufficient.

The review does not deny the usefulness of medications in acute phases, but it highlights how they do not represent a long-term solution nor a first-line treatment.

“Low back pain is not a condition that can be treated with a pill. Medications may have a role, but they do not address what truly generates pain,” explains Negrini. “They do not improve function, they do not modify motor behavior, they do not change movement quality.
The real risk is prolonging the search for quick relief while postponing the interventions that actually work: exercise, rehabilitation, and education”.

Kiekens emphasizes the complexity of low back pain, particularly when it overlaps with structural conditions such as adult scoliosis: “Low back pain is generally multifactorial. It is the result of an interaction between muscles, joints, posture, degeneration, and lifestyle. This is why it is unrealistic to expect medication to resolve it. In clinical practice, what truly works is a multimodal approach: movement, awareness, load-management strategies, and active rehabilitation pathways.”

Medications may therefore have a role as a support, but they cannot guide the treatment: rehabilitation is what truly enables patients to get better. An active, multidisciplinary approach—combining medical care, rehabilitation, and lifestyle strategies—is essential for restoring function and achieving long-term improvement. This is exactly what patients can expect at ISICO.

Chronic Pain: Diet Also Plays a Significant Role

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What we eat can influence not only our overall health, but also the way we perceive pain. A recent Australian study has revealed a surprising connection between a balanced diet and the reduction of chronic pain, extending beyond the simple association with obesity.

Chronic Pain: A Multidimensional Challenge

Chronic pain is a complex condition affecting millions of people worldwide. Although it is often associated with specific injuries or diseases, scientific evidence shows that less obvious factors — such as lifestyle and diet — can modulate the perception of pain.

Recent studies, Pain trends among American Adults e Increases in BMI and chronic pain for US adults in midlife, 1992 to 2016 conducted in the United States have demonstrated that an increase in body mass index (BMI) is associated with chronic pain, with prevalence rates ranging from 10% to 32%.
However, the relationship between adiposity and pain is not unidirectional:
“Pain itself can contribute to weight gain,” explains Dr Irene Ferrario, clinical psychologist at ISICO, “as many individuals tend to reduce physical activity or develop an increasing fear of movement.”

Within this context, another study conducted at the University of South Australia examined how diet influences bodily pain levels. The most noteworthy finding? The benefits of a healthy diet are not limited to individuals who are overweight but also extend to those with a normal BMI.

“It is important to understand that there is no single cause of chronic pain. Factors such as diet, physical activity and stress management should be viewed as components of an integrated care approach,” says Francesco Saveri, physiotherapist at ISICO.

Diet and Pain: More Than a Matter of Weight

Traditionally, body weight has been considered the main link between diet and chronic pain. Excessive weight can overload joints and promote inflammation, thereby worsening pain.
However, the Australian study showed that diet plays an independent role. Participants who followed a diet rich in fruit, vegetables, whole grains, lean meats and dairy products reported significantly lower pain levels, regardless of their BMI. This suggests that a balanced diet may positively influence inflammatory and oxidative processes that heighten pain perception.

“Educating patients to improve their diet is essential — not only to reduce pain, but also to promote a healthier long-term lifestyle. It is an investment in their quality of life,” adds Saveri.

Key Components of a “Pain-Reducing” Diet

Which foods should be included in a diet aimed at alleviating pain? According to experts, it is essential to prioritise:

  • Fruit and vegetables: rich in antioxidants and anti-inflammatory compounds.
  • Whole grains: due to their lower glycaemic impact, they help regulate blood sugar levels and reduce inflammation.
  • Lean proteins: fish and poultry provide essential amino acids for tissue repair.
  • Healthy fats: such as olive oil and nuts, which support the nervous system and reduce oxidative stress.

Why Diet Matters

The key lies in inflammatory processes. A diet high in simple sugars, saturated fats and ultra-processed foods increases oxidative stress and pro-inflammatory cytokines, thereby exacerbating pain.
Conversely, a balanced diet helps maintain an appropriate inflammatory equilibrium, improving not only general health but also overall quality of life.

“Intervening through diet represents an accessible strategy, without high costs and with minimal difficulties — apart from those linked to modifying daily habits.”

“The benefits of a balanced diet are numerous and substantial: in addition to promoting weight reduction, it helps decrease systemic inflammation, thereby reducing pain perception and significantly improving quality of life and physical functioning for millions of individuals,” concludes Saveri.

Long-term stability in PWS scoliosis without surgery

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It is rare for a single case to so clearly demonstrate the power of a conservative approach. This is what emerges from the article published in the Journal of Clinical Medicine (Effective Conservative Management of Severe Scoliosis in a Girl with Prader–Willi Syndrome: A 20-Year Case Study Follow-Up, MDPI, 2024).

Prader–Willi syndrome (PWS) is a rare genetic disorder characterized by muscle hypotonia, obesity, and cognitive difficulties, often associated with severe scoliosis.
“In many of these cases, surgery is considered the only possible solution,” explains Dr. Francesco Negrini, author of the study. “In contrast, we present the clinical case of a young patient followed for twenty years with a conservative approach, based on scoliosis-specific exercises and customized braces, from Milwaukee to Sforzesco.”

Despite an initial curve exceeding 50° Cobb, the patient avoided surgery, maintaining long-term stability of the deformity and a good quality of life.

“This case highlights the potential of a well-organized, long-term conservative approach to managing scoliosis in PWS,” adds Negrini. “It suggests that, under specific conditions, surgery may be avoided or postponed. Most importantly, it underscores the need for further research to establish standardized protocols and to support clinical decision-making in the conservative treatment of scoliosis in PWS patients. We are already working on specific protocols for ambulatory patients with scoliosis secondary to neurological diseases,” concludes Negrini. “These protocols are urgently needed, as at present they do not yet exist.”

Scoliosis in children and teenagers: could dental problems be the cause?

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During a patient’s first medical visit, the parents were concerned after taking their twelve-year-old daughter to the dentist. During the dental check-up, a problem of malocclusion and swallowing emerged. The dentist suggested that this combination of factors might have contributed to the development of scoliosis.
But is it really possible that a problem in the mouth could lead to scoliosis? Let’s clear things up.

Malocclusion is a problem of how the teeth fit together: the upper and lower teeth do not align properly. It may mean crooked or crowded teeth or a jaw that protrudes or recedes. Sometimes it can affect chewing, the posture of the neck, or cause discomfort such as cervical pain.

Scoliosis. The majority of scoliosis cases in young people (around 80%) are defined as idiopathic, meaning without an identifiable cause. Despite decades of research, we still do not have a clear understanding of its origin.
What we do know, however, is that idiopathic scoliosis tends to appear in individuals with a genetic predisposition: it is often found to run in families. It is not a condition caused by bad habits, poor posture, injuries, or factors such as malocclusion.

It is important to stress this point to avoid attributing unnecessary blame or choosing therapeutic approaches that are not supported by scientific evidence.

At present, according to the data available, we know that malocclusion can influence the posture of the head and neck. In fact, malocclusion may cause the head to tilt forward or backwards and, in some cases, may even be associated with increased cervical pain. Nevertheless, while malocclusion can directly affect head position, it does not seem to have any effect on the risk of developing scoliosis, nor on the potential worsening of spinal curvature.

The same is true the other way around: a worsening scoliosis does not seem to influence malocclusion.

In patients with scoliosis, slight asymmetries are often seen in other parts of the body, including the face: this also involves the teeth and jaw. Studies have shown that people with scoliosis are about twice as likely to present with malocclusion (Class II or crossbite).
The correlation between malocclusion and scoliosis, although without a proven causal link and still not fully understood, highlights the importance of a multidisciplinary approach. Teamwork is essential in these cases.

How? Dentists and orthodontists may be among the first to detect possible postural changes that require attention. In the same way, the rehabilitation team managing conservative treatment for scoliosis can recommend a preventive orthodontic consultation.

Working as a team makes it possible to:

• monitor both conditions during growth;
• optimise the timing and therapeutic pathways;
• avoid false expectations: not assuming that one treatment will automatically affect the other, whether positively or negatively.

How should treatment proceed?
There are no contraindications to treating scoliosis and malocclusion at the same time: both orthodontic treatment and rehabilitation based on specific exercises can run in parallel, even when a brace is being worn, without fears of negative interference. No orthodontic treatment worsens scoliosis, and vice versa.

As far as we know today, no orthodontic treatment can worsen or improve scoliosis, just as no scoliosis treatment can worsen or improve malocclusion.

Dental treatment is essential for oral health and aesthetics, while scoliosis treatment is crucial for managing and controlling the curve over time.

Even though each specialist works on a different area, and there is no definite cause-and-effect relationship between malocclusion and scoliosis, working as part of a team made up of medical specialists, physiotherapists, and psychologists ensures higher-quality care.
This allows families to receive clear, timely, and reliable answers and enables professionals to share expertise in order to optimise timing and offer a clear, comprehensive, and highly personalised care pathway, tailored to each child.

Back to school with a brace

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Going back to school is not always easy for adolescents with scoliosis who wear a brace.—-> with scoliosis, and who need to wear a brace
Some are able to talk about it and share their difficulties, while others keep everything inside — and often they are the ones who suffer the most.

Of course, not all of our adolescent patients will struggle, but we need to pay particular attention to those who are changing schools: moving from primary to middle school, from middle to high school, or even simply to a new class.

Facing new teachers, new subjects, and above all new classmates is always an exciting challenge, full of curiosity… but no one knows  is aware about the brace!

It is natural, when entering a new environment, to want to give our best and show the best version of ourselves. It’s natural to want to give your best and show the best version of yourself when entering a new environment.But then comes the question: what about the brace?

“What will they think of me?”
“I can’t let them see me with the brace! Please, Mom, Dad, just the first few days without it and then I promise I’ll wear it again!”
“I’ll take it off at school and I promise I’ll put it back on afterward. In the afternoon I just do homework, I never go out anyway!”

Who could blame them? And above all, when this happens, how can we really help? It’s difficult — for the teenagers, for you the parents, and also for us professionals who care for them.

How to deal with it

If the prescribed “brace-free” hours allow it , it’s fine to leave the brace at home in the very first days. But if the free hours are limited (at least 3–4 in addition to school hours), then after a short initial adjustment it becomes important to face the class with the brace on. No adolescent will spend every afternoon locked indoors: there will be sports, birthdays, parties, get-togethers…

If, on the other hand, many hours of therapy are still required and free time is very limited, then it’s better to tackle the challenge right away. We know it’s tough, but once the “wall” is broken down, the path becomes much easier.

What we usually tell our patients

First of all, we remind them that they cannot live in seclusion. They have done nothing wrong to deserve a sort of “house arrest”: wearing the brace is already challenging enough, they shouldn’t also give up their social life.

Then we propose a kind of exercise: imagine it isn’t you with the brace, but one of your classmates. This classmate, afraid of being judged, chooses not to follow the treatment properly and doesn’t wear the brace the required hours. Nobody will ever know, because this classmate never had the courage to show up with the brace. But meanwhile, their spine is getting worse.

And then we ask: what would you want for this classmate? That they trusted you and asked for help, or that they considered you incapable of supporting them — so much so that they gave up their own health?

As always, when we put ourselves in someone else’s shoes, the answer becomes clear.

A special wish

Good luck to all the adolescents who are about to return to school wearing a brace — and good luck also to all their parents!

ISICO Online Master 2026: let’s start

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Registrations for the 11th edition of the ISICO Online Master “Principles and Practice of Scoliosis Conservative Treatment – PPSCT” will open on October 15th, 2025. The course will start in January 2026.

This training program has now become a well-established part of ISICO’s educational offer, alongside the Italian Master, the SEAS courses, and the course on Sforzesco brace construction.

A truly international training program

Since its launch in 2016, the Master has welcomed 334 participants from 66 different countries:

  • 126 European
  • 96 Asian
  • 74 from the Americas
  • 18 from Africa
  • 20 from Oceania

A genuine global learning event, giving professionals from different cultures the chance to meet, exchange ideas, and grow together.

“The organisation is very didactic, starting with the basic knowledge and evaluation techniques, evolving to more specific subjects, and finally, when the students already have some knowledge framework, focusing on the suggestion and discussion of clinical cases. The live lecture was a perfect conclusion for the discussion groups. Most of the recorded lectures had great quality content and very good visual presentation.”
— Leonardo, Brazil

Course structure

The Master is delivered entirely online and self-administered through a dedicated learning platform. It is organized into 16 modules lasting two or three weeks each, including:

  • three recorded lectures of about 45 minutes;
  • scientific papers for in-depth study;
  • a final assignment for each module;
  • discussion sessions for interaction and exchange among participants.

The experience of a global community

One of the most valued aspects is the opportunity to connect with colleagues from all over the world: a unique chance to discover treatment practices, expectations, and experiences in different countries.

“From this course, I hope to gain in-depth knowledge of scoliosis, learn from renowned experts, and connect with specialists from all over the world to understand how they manage it in their own countries.”
— Joy Igudia-Akumabor, Nigeria

Early bird registration is available until December 8th, 2025.

From therapy to dance: ISICO patients perform at AIFI

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Two young ISICO patients made the recent AIFI event truly special, held on 13 September in Pavia, in the Aula Magna of ICS Maugeri.

The meeting, “Connected Bodies: the Physiotherapy of the Future between Human Relationships, Identity and Digital Innovation”, featured not only contributions from professionals and lecturers, but also the performance of Chiara and Silvia, dancers, who brought to the stage the fruits of their passion and determination.

Chiara first came to ISICO three years ago, already a professional dancer, performing for the Ukrainian Academy in Milan. “During my fitness-for-competition assessment, they noticed an anomaly in my back,” recalls Chiara. “From there, together with my parents, we looked for a specialist centre and arrived at ISICO, where I was diagnosed with adolescent idiopathic scoliosis, with a thoracic curve of about 40 degrees. The journey was not easy, especially at the beginning when I had to wear the brace for 23 hours a day while doing SEAS exercises daily. I had to find a balance between treatment and passion, without giving up my four hours of lessons each day.”

Chiara wore a “Sforzesco Open Pelvis” brace, designed to leave the hips completely free and allow greater mobility of the hip joints. This meant she was able to take part in her daily classes wearing the brace, using her hour of freedom for modern dance lessons, as the brace was too restrictive for this discipline.

Today, as she nears skeletal maturity, Chiara wears her brace for only 14 hours a day and has achieved a stability that allows her to look to the future with a healthy, functional back—ready to support her on stage as in life.

Silvia, on the other hand, completed her treatment some time ago but still does maintenance exercises and, of course, continues to dance!

We thank them both for this moving moment, which reminded us that, alongside innovation and professional perspectives, physiotherapy is above all about caring for people—their talents and their dreams.

Scientific free Tools for Clinical Practice: ISYQOL and IS-GROWTH

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With a demanding condition such as scoliosis, it is essential to build a relationship of trust with the patient and guide them through a treatment path that allows for a good quality of life.

For this reason, at ISICO we have developed two free tools available online.

ISYQOL – Italian Spine Youth Quality of Life

Originally created as a questionnaire in which our patients could describe the impact of brace treatment on their daily life, ISYQOL has evolved into a digital model consisting of 10 questions, allowing anyone to evaluate their own well-being in the presence of scoliosis, kyphosis, or other spinal disorders.

Its strength lies in being based on the concerns expressed directly by patients, making it particularly suitable for adolescents with idiopathic scoliosis who have not undergone surgery. Over the years, it has been translated and validated into several languages ( English, Chinese, Polish, Korean, Arabic, Persian, French, Spanish, Greek, and Turkish) and is now recognised as one of the most reliable questionnaires for measuring quality of life in brace wearers.

Measure your ISYQOL online

IS-GROWTH – Idiopathic Scoliosis Graphical Representation Of Worsening Trend of Natural History

IS-GROWTH is a visual model that shows the expected evolution of a scoliosis curve in each patient during growth (pre-pubertal, pubertal, and post-pubertal phases).

Developed from more than 3,000 radiographs of nearly 2,000 untreated patients, and validated on more than 500 additional cases, the model reaches 95% accuracy after correcting for radiographic measurement error. The graph displays a range of expected progression (between minimum and maximum scenarios), into which the patient’s real clinical data are gradually added over time.

This tool has proven extremely useful in clearly communicating the natural history of scoliosis and in supporting long-term treatment decisions during growth.

Access it here – IS-GROWTH online

Watch the video alongside to see how to use them in practice.

ISYQOL video: https://youtu.be/bFLuaTNrsA4  
Is-Growth video: https://youtu.be/0dt_38tTiCQ

More and more students suffer from neck pain: what to do

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Almost one in two students regularly suffers from neck pain, but the problem starts much earlier: over 40% of teenagers report having experienced at least one episode of neck pain in the past year.
The prevalence increases with age, affects girls more frequently and intensifies during periods of heavy school workload and intensive use of digital devices.
These figures are clear: neck pain is no longer a condition limited to adults or sedentary workers.
It has become a problem affecting young people and children alike, fuelled by inactivity, hours spent in front of screens and school-related stress.

A silent epidemic
In recent years, especially during the COVID-19 pandemic, we have witnessed a considerable rise in neck pain, particularly among young students. Studying from home, hours spent in front of computers or phones, workload and stress have contributed to this real “silent epidemic.
Neck pain, also known as cervicalgia, concerns the upper part of the spine and can manifest as discomfort, stiffness or more intense pain, sometimes limiting movement and negatively affecting daily life and concentration while studying.
“We increasingly see adolescents complaining of significant cervical symptoms, despite their young age,” comments Martina Poggio, ISICO physiotherapist. “It is a phenomenon that appears early on, sometimes as early as secondary school.”

Poor digital habits and stress
During the pandemic, teaching methods changed drastically, forcing students to spend many hours sitting in front of electronic devices.
The intensive use of smartphones, tablets and computers has often led to poor posture: neck bent forward, curved back, sitting for too long without breaks.
Past events, such as injuries or trauma to the neck and shoulders, make a recurrence of pain more likely. Furthermore, students in the final years of university tend to experience more pain, perhaps due to the heavier study load and accumulated pressure.
Sleepless nights and irregular habits, like staying up late, negatively affect muscle health and contribute to the issue.
“Posture maintained for long periods, especially with the head bent forward, is one of the strongest factors linked to neck pain in young people,” Poggio continues. “Worsening the situation is the lifestyle: inactivity, insufficient sleep, exam stress, and personal pressures create fertile ground for cervical pain.”
Equally important are emotional and psychological factors: anxiety, stress and emotional problems affect not only our mood but also pain perception and muscle condition. Women appear to be affected more often, although the precise reasons for this difference are still not fully understood.

Let’s analyse the causes
Research has identified eleven main factors associated with neck pain, including:

  • prolonged poor posture
  • improper use of the pillow
  • lack of physical activity
  • poor quality sleep
  • previous trauma
  • anxiety and stress

Among these, those who do not exercise enough, risk having weaker and less flexible muscles, less able to properly support the head and spine.
“No single sport is better than another, but it is important that it includes exercises for the upper limbs as well,” Poggio adds, “and that it comprises strengthening exercises, not just stretching and lengthening, because the neck needs to be prepared to cope with daily strains.”

Furthermore, incorrect pillow use is particularly significant: a pillow that is too high or too low, too soft or too firm can compromise neck position during sleep and cause pain on waking.
Curiously, neck pain affects girls more than boys. Emotional aspects, pain perception and hormonal factors may play a role.

Prevention: what can we do
Fortunately, many causes can be prevented with simple care:

  • choose a suitable pillow that keeps the neck in a natural position during rest
  • maintain good posture: sit with a straight back, keep the screen at eye level, avoid crossing legs or slouching in the chair
  • take frequent breaks from PC or phone screens to relax the muscles
  • practise regular physical exercise
  • get enough sleep
  • manage stress with relaxation techniques (yoga, breathing exercises)

“The problem is not so much a relaxed posture for a short time, but spending hours bent forward. So besides paying attention to how you sit, it is important to get up frequently, even just for short breaks, which greatly helps manage neck strain,” explains Poggio. “Accumulated stress tends to tighten muscles, increasing pain and stiffness. Practising relaxing activities such as yoga or breathing techniques can help keep body and mind in balance.”

In conclusion
Neck pain is an increasingly common complaint among young students, but understanding its causes and taking early action can prevent worsening and improve quality of life.
Small daily attentions can prevent this troublesome problem, keeping the back and neck healthy and ready to support all the challenges of study and life.

Bibliography
Gao Y, Chen Z, Chen S, Wang S, Lin J. Risk factors for neck pain in college students: a systematic review and meta-analysis. BMC Public Health. 2023 Aug 8;23(1):1502. doi: 10.1186/s12889-023-16212-7.

Geldhof E, De Clercq L, et al. The Prevalence of Neck Pain and Its Associated Factors in Children and Adolescents: A Systematic Review and Meta-Analysis. J Orthop Sports Phys Ther. 2023.

ISICO at the 2025 SRS Annual Meeting

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The 60th Annual Meeting of the Scoliosis Research Society (SRS) will take place from September 16 to 20, 2025, in Charlotte, USA. This is the most important international conference dedicated to scoliosis, with a particular focus on surgical treatment.
Once again this year, ISICO will take part, contributing to the scientific program with two studies selected by the congress committee.

Specifically:

  • The study “The More You Use the Brace, the Better the Results” has been selected for an oral presentation and is among the finalists for the prestigious Russell A. Hibbs Award for clinical research.
    “This is ISICO’s first-ever nomination for this award,” comments Professor Stefano Negrini, Scientific Director of ISICO. “It’s an important sign: our rehabilitative approach is gaining growing international recognition, even in contexts that have traditionally focused on surgery.”
    The presentation is scheduled for September 19, during the award finalists’ session.
  • Dr. Greta Jurenaite will present an e-presentation of the study “Lumbar Scheuermann Disease: Prevalence and Clinical Characteristics from a Cohort of 11,891 Consecutive Children of a Tertiary Referral Institute”, which investigates the prevalence and clinical features of the lumbar variant of Scheuermann’s disease in a large pediatric cohort.

    Participation in the SRS Annual Meeting provides ISICO with a valuable opportunity for international scientific exchange and highlights the relevance of rehabilitative research within the multidisciplinary scoliosis landscape.
    For more information, visit the official event website.