Physical therapy yields modest improvements in chronic low back pain

1. In this randomized controlled trial, physical therapy (PT) was associated with a modest improvement in function compared with cognitive behavioural therapy (CBT) as a first-line treatment for chronic low back pain (cLBP).

2. Patients treated with PT reported greater improvements in anxiety, fatigue, pain interference, physical function, sleep disturbance, and social role performance.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Current guidelines recommend initial non-pharmacologic management of chronic low back pain (cLBP), including physiotherapy (PT), cognitive behavioural therapy (CBT), and mindfulness-based approaches. However, treatment effects are often heterogeneous in real-world practice, and there is limited guidance on optimal first-line selection or sequencing of therapies. This study compared PT and CBT as first-stage interventions and evaluated mindfulness versus treatment switching as second-stage options for patients with cLBP. At 10 weeks, PT was associated with a modest improvement in physical function compared with CBT, although there were no statistically or clinically significant differences in pain intensity. The functional benefit did not reach the minimally important difference but was consistent across sensitivity analyses. PT was also associated with broader improvements in patient-reported outcomes, including anxiety, fatigue, pain interference, sleep disturbance, physical function, and social participation, while depression scores were similar between groups. Patients receiving PT required fewer injections, although there were no meaningful differences in opioid use, imaging, surgery, or emergency department visits. Among participants who did not respond to initial therapy, neither mindfulness nor treatment switching resulted in significant differences in pain or function. Limitations include lower-than-expected treatment uptake and follow-up, lack of blinding, and a relatively small sample size, which may limit generalizability. Overall, these findings suggest that PT may offer modest advantages over CBT as a first-line treatment for cLBP, particularly in improving function and broader patient-reported outcomes.

Click to read this study in AIM

Relevant Reading: Evidence-based interventions to treat chronic low back pain: treatment selection for a personalized medicine approach

In-Depth [randomized controlled trial]: This study compared physiotherapy (PT) and cognitive behavioural therapy (CBT) as first-line treatments for chronic low back pain (cLBP), and evaluated mindfulness versus treatment switching as second-stage options for initial non-responders. Participants were recruited from three U.S. health systems between March 2019 and September 2023, with a temporary pause during the COVID-19 pandemic. Eligible adults were aged 18–64 years with low back pain lasting at least 3 months, pain on ≥50% of days in the prior 6 months, recent healthcare utilization for back pain, pain intensity ≥4/10, and an Oswestry Disability Index (ODI) ≥24. Exclusion criteria included serious spinal pathology, recent surgery, pregnancy, recent participation in similar interventions, or active substance use disorder treatment. The primary outcomes were back pain–related function (ODI) and pain intensity (0–10 scale). Secondary outcomes included PROMIS-29 health domains, opioid use, and healthcare utilization. A total of 749 participants were randomized (375 CBT, 374 PT). At 10 weeks, 576 participants (76.9%) completed follow-up. Response rates were higher with PT than CBT (24.7% vs 13.6%), with CBT participants less likely to respond (RR 0.55, 95% CI 0.39–0.79). Treatment initiation occurred in 63.2% overall. At 10 weeks, PT showed a small but statistically significant improvement in function compared with CBT (adjusted mean difference 2.8 points on ODI), though this was below the minimally important difference. No significant difference was seen in pain intensity. Sensitivity analyses confirmed the robustness of functional findings. PT was associated with greater improvements in anxiety, fatigue, pain interference, sleep disturbance, physical function, and social participation, with minimal differences in depression. Fewer patients in the PT group received injections compared with CBT (4.2% vs 11.3%). There were no meaningful differences in opioid use, imaging, surgery, or emergency department visits. Among initial non-responders, mindfulness and treatment switching did not differ significantly across outcomes. Serious adverse events were rare and similar between groups. Overall, PT may provide modest functional advantages over CBT as first-line therapy for cLBP.

Image: PD

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