Low Back Pain: Early Physical Therapy of Modest Benefit

When compared with usual care, treatment of recent-onset low back pain (LBP) with early physical therapy resulted in a statistically significant improvement in disability, but the benefit was not clinically significant, according to results from a randomized clinical trial published in the October 13 issue of JAMA.

Julie M. Fritz, PhD, PT, from the University of Utah, Salt Lake City, and colleagues compared the efficacy of early physical therapy (four sessions over the course of 3 weeks, consisting of manipulation and exercise) vs usual care among patients being seen for LBP in a primary care setting. In addition to evaluating changes in disability from baseline, the researchers also evaluated secondary outcomes such as “change in pain intensity, pain catastrophizing, fear-avoidance beliefs, patient-reported health state and success, and health care utilization.”

Between March 2011 and November 2013, the researchers enrolled 220 adult participants who were evaluated for acute LBP (<16 days) and who had an Oswestry Disability Index (ODI) score of 20 or higher. The researchers excluded patients with previous lumbar surgery, other LBP treatment in the last 6 months, pregnancy, or clinical signs suggestive of nonmusculoskeletal back pain. The majority of the enrolled participants were women, with a mean age of 37.4 years.

The researchers randomly assigned patients to receive physical therapy (n = 108) or usual care (n = 112), consisting of patient education and instructions for physical activity. Data for 207 participants were available at the 1-year follow-up.

Compared with usual care, the researchers found a statistically significant improvement in disability among participants in the physical therapy group after 3 months.

Table. Change in ODI Score

	Early Physical Therapy	Usual Care
Mean ODI score at baseline	41.3 (95% confidence interval, 38.7 – 44.0)	40.9 (95% confidence interval, 38.6 – 43.1)
Mean ODI score at 3 months	6.6 (95% confidence interval, 4.7 – 8.5)	9.8 (95% confidence interval, 7.9 – 11.7)

The between-group difference at 3 months was −3.2 (95% confidence interval, −5.9 to −0.47; P = .02). A significant difference was also found after 4 weeks of therapy (between-group difference, −3.5; 95% confidence interval, −6.8 to −0.08; P = .045). However, the authors note that the difference was modest and did not persist at the 1-year follow-up (between-group difference, −2.0; 95% confidence interval, −5.0 to 1.0;P = .19).

Further, the authors found that although there were statistically significant improvements in pain catastrophizing scores, self-rated success, and fear-avoidance beliefs for work, other outcomes, such as pain intensity and fear-avoidance beliefs for physical activity, showed no improvements. Healthcare use was similar between the 2 groups.

The authors acknowledge possible limitations of the study, such as the fact that, despite more than 90% participation at 1 year, more patients in the usual care group dropped out compared with in the physical therapy group. In addition, the researchers did not adjust secondary outcomes for multiple comparisons.

“Early physical therapy resulted in statistically significant improvement in disability relative to usual care but the magnitude of the difference was modest and did not achieve the minimum difference considered clinically important at the individual patient level,” write Dr Fritz and colleagues.

The study authors note that primary care physicians are often the first point of contact for patients with LBP. The ability of primary care physicians to recognize which patients would benefit the most from physical therapy is key to improved outcomes that lessen the risk for prolonged disability or invasive procedures. The study findings, they continue, suggest that “[t]he potential benefits of early physical therapy should be considered in light of the time and effort required to participate in physical therapy.”