Physical Therapy Provides Only Modest Relief For Chronic Lower Back Pain

By Pat Anson

Physical therapy, cognitive behavioral therapy (CBT), and mindfulness are often recommended as non-pharmacological treatments for chronic lower back pain. The World Health Organization even calls them first-line treatments in a 2023 guideline for back pain that discourages the use of most pain medications. 

But a new study, published in the Annals of Internal Medicine, found that physical therapy provided only minor improvements in physical function for patients with chronic low back pain, with no change in pain intensity compared to CBT and mindfulness.

A research team led by the University of Utah enrolled 749 adults with chronic low back pain (cLBP) to compare the effectiveness of physical therapy with other non-pharmacological treatments.

Participants were randomly assigned to 8 weeks of either physical therapy or CBT. Those who did not improve were reassigned to a second treatment, either switching therapies or trying mindfulness-based care for another 8 weeks.

The physical therapy was provided by licensed therapists, while mental health care professionals provided CBT and mindfulness training. CBT is a form of psychotherapy, in which a therapist works with a patient to reduce unhelpful thinking and behavior; while mindfulness focuses on increasing awareness and acceptance of physical discomfort to minimize its impact on daily life.

After 10 weeks, participants who started with physical therapy showed a small improvement in function, while pain levels were similar between groups. After one year, no meaningful differences were seen among the second-stage treatments. 

The findings suggest physical therapy (PT) may be a reasonable first option for chronic low back pain, but switching or adding other psychological therapies may not change long-term outcomes.

“We found some benefits to PT as the first treatment offered to patients, but we could not detect subgroup differences and effect sizes were small. Our results support PT as a first-line option for cLBP and no differences in potential benefits of second-line care with mindfulness or switching for nonresponders,” researchers concluded.

The study does not mean that CBT and/or mindfulness are ineffective, just that they’re impact is minor. That finding is similar to another recent study of patients with chronic low back pain, which found that CBT and mindfulness reduced pain levels by about 10% after a year. 

That’s nice, but not the kind of pain relief most people are looking for. 

Chronic low back pain is the leading cause of disability worldwide. It usually begins with acute pain caused by muscle strain or musculoskeletal injuries, and becomes chronic over time when it fails to resolve. Chronic low back pain mostly affects adults of working age in lower socioeconomic groups, who often have physically demanding jobs.  

For such a common disorder, affecting about 500 million people at any given time, there is little consensus on how to treat it. 

A 2018 review in The Lancet by an international team of researchers found that cLBP is often treated with bad advice, inappropriate tests, risky surgeries and painkillers. The authors said there was limited evidence to support the use of opioids for chronic low back pain, and epidural steroid injections and acetaminophen (paracetamol) were not recommended at all.