Physical therapy is effective as a first-line strategy for chronic low back pain (LBP), as current practice guidelines state, but the size of the effects is small, according to results of the OPTIMIZE study, which compared outcomes with physical therapy (PT) and cognitive-behavioral therapy (CBT) in real-world circumstances.

The findings were reported online on April 20 in the Annals of Internal Medicine.

Researchers, led by Julie Fritz, PhD, PT, with the Department of Physical Therapy and Athletic Training at the University of Utah in Salt Lake City, conducted a sequential, multiple assignment, randomized trial to compare the effectiveness of PT and CBT for 8 weeks as the first stage of treatment for adults with chronic BP. In the second stage, patients who didn’t respond to the assigned therapy were randomly assigned again to 8 weeks of either switching (to CBT or PT) or mindfulness. Co-primary function and pain outcomes were measured at 3 points over a year.

PT Slightly Better for Function

“We found on average, patients who got referred to physical therapy as opposed to CBT did a little better for the outcome of function but not for the outcome of pain. We think that’s because physical therapy is a more commonly used treatment for back pain and health systems are a little better at providing it,” Fritz told Medscape Medical News.

“I don’t think it in any way should be interpreted that something like CBT is not a viable option because the differences weren’t that big. Also, part of the benefit for physical therapy was greater accessibility for patients and not necessarily the treatment itself,” she said.

Potentially eligible participants aged 8-64 years were identified from electronic health records in three health systems — University of Utah Health and Intermountain Health in Salt Lake City and Johns Hopkins Medicine in Baltimore. Criteria included having an LBP-related healthcare visit in the past 90 days and having LBP for at least 3 months with pain on at least half of the days in the past 6 months. Pain intensity ≥ 4 on a 0-10 pain scale and an Oswestry Disability Index (ODI) score ≥ 24 on a 0-100 scale were required.

The sample included 749 participants. After 10 weeks, there was greater improvement in function in the PT group (adjusted mean ODI difference, 2.8 on a scale of 0-100; 96% CI, 0.38-5.1) and no difference in pain intensity (adjusted mean difference, 0.32; 99% CI, -0.07 to 0.71). The difference in ODI was below the minimum important difference of 6. After 52 weeks, there were no differences in stage II treatments for nonresponders for either function (adjusted mean ODI difference, 0.43; 96% CI, -0.29 to 2.4) or pain (adjusted mean difference, -0.05; 96% CI, -0.58 to 0.48).

Study Addresses an Unmet Need

“This study addresses an unmet need,” Peter Whang, MD, told Medscape Medical News. “Chronic low back pain is ubiquitous, and one of the fundamental problems is so many things can cause back pain,” noted Whang, professor of medicine in the Department of Orthopaedics and Rehabilitation at Yale School of Medicine in New Haven, Connecticut, who was not part of the study. “The data supporting optimal care is just not there, and that’s why this study is very important.”

In primary care, he said, treatments for chronic LBP are likely to start with a conservative approach, including activity modification and anti-inflammatory medications, but “I certainly would consider physical therapy to be a first-line treatment,” he said. “This study was well designed and provides high-level evidence that physical therapy was more effective than some other secondary modalities such as CBT or other treatments.”

He said while CBT was shown to have some benefit in this study, it has typically been hard to access. “It can be hard to find a cognitive-behavioral therapist,” he said.

“There’s no easy answer for back pain,” Whang said. “It continues to plague us.”

The study was funded by the Patient-Centered Outcomes Research Institute. Author disclosure forms are available with the article online. Whang reported having no relevant financial relationships.

Marcia Frellick is an independent healthcare journalist and a regular contributor to Medscape.