Clinical Takeaway
: New trial results favor physical therapy as first-line treatment, with cognitive behavioral therapy and mindfulness as potential backups if needed.
Context
Patients with chronic low back pain are often referred to physical therapy (PT), but nonphysical approaches such as cognitive behavioral therapy (CBT) and mindfulness are also available in some practice settings. How do these various modalities compare with one another? And how do they work in sequence?
In this trial, 750 adults with at least 3 months of moderate to severe low back pain were randomized to either PT or CBT for 8 weeks. Those who didn’t have at least a 50% improvement in disability by 10 weeks (nonresponders) were then randomized to switch to whichever modality they didn’t receive the first time or to mindfulness, again for 8 weeks. All interventions were administered in concordance with evidence-based guidelines.
Key Results
- At 10 weeks, function scores improved significantly more with PT than with CBT (by 9 points vs. 6 on a 100-point scale), while pain scores improved to the same extent in both groups (by ≈1 point on a 10-point scale).
- Overall, 75% of the PT group and 86% of the CBT group were considered nonresponders and were rerandomized. All treatment switches led to similar changes in pain and disability at 52 weeks.
Comment
PT appears to be a slightly better first-line treatment than CBT for this condition. However, any of the three interventions can benefit patients who don’t respond to their initial treatment, and the choice can be guided by patient preference. I’ve long emphasized with my patients the importance of focusing on improving function, not strictly reducing pain, and these nonpharmacologic approaches can help with both goals.