CBT and mindfulness showed little added benefit after initial treatment failure.
Physical therapy may modestly improve function in patients with chronic low back pain, but switching to mindfulness or cognitive behavioural therapy after initial treatment failure offers little added benefit, a major US trial suggests.
Researchers enrolled 749 adults across three healthcare systems in a sequential, multiple-assignment trial designed to test both first-line and follow-up nonpharmacological treatments for chronic low back pain.
Results of the randomised trial have been published in the Annals of Internal Medicine.
“Many treatments are recommended for chronic low back pain (cLBP), but comparative effectiveness and adaptive interventions have not been adequately studied,” the researchers wrote.
Participants were initially randomised to receive either eight weeks of physical therapy or CBT. Those who did not respond to treatment were then re-randomised to either switch therapies or receive mindfulness-based therapy.
At 10 weeks, patients in the physical therapy group recorded greater improvement in function, measured using the Oswestry Disability Index (ODI), than those receiving CBT.
The adjusted mean difference was 2.8 points, but this remained below the minimum clinically important difference of six points.
There was no significant difference between the two groups for pain intensity.
The findings suggest physical therapy may provide some short-term functional benefit as an initial treatment strategy for chronic low back pain, but the magnitude of effect may be limited in clinical practice.
The second stage of the trial found no clear advantage for any subsequent treatment strategy among patients who failed to respond initially.
After 52 weeks, there were no meaningful differences in either function or pain intensity between patients who switched therapies and those assigned to mindfulness treatment.
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The researchers said the results highlighted the ongoing difficulty of identifying effective nonpharmacological options for patients whose chronic low back pain persists despite recommended first-line care.
The study had several limitations, including lower-than-expected enrolment due to the covid pandemic, reduced treatment initiation rates (particularly for CBT) and the inability to blind participants to treatment allocation.
The authors concluded that while physical therapy may offer modest functional improvement as a first-line treatment for chronic low back pain, alternative second-stage strategies such as mindfulness or switching therapies did not demonstrate superiority for patients who did not initially respond.
