Chronic Low Back Pain Disappointments in a Randomized Trial Save

Annals of Internal Medicine reports that patients with chronic low back pain (cLBP) may benefit from physical therapy (PT); but when that fails, other secondary measures (cognitive behavioral therapy (CBT) or mindfulness) may not be effective. 

 

A 52 week randomized trial from three health care systems, enrolled 749 adults with cLBP who were randomized to received 8 weeks of PT or CBT in (stage I). Nonresponders were then randomized stage II treatment (switching or mindfulness therapy).  Co-primary outcomes were function measured with the Oswestry Disability Index (ODI; range, 0 to 100) and pain intensity (range, 0 to 10) at 10 (stage I), 26, and 52 (stage II) weeks.

 

Stage I results: after 10 weeks, there was greater improvement in function in the PT group (adjusted mean difference 2.8 [96% CI, 0.38 to 5.1]) but no difference in pain intensity (adjusted mean difference, 0.32 [99% CI, −0.07 to 0.71]).   The mean difference in ODI was below the minimum important difference of 6. 

 

Stage II results: after 52 weeks, the nonresponders show no benefit in stage II treatments for either function or pain intensity.

 

The study was limited by lower enrollment COVID pandemic) and patients were not blinded. Treatment initiation was lower than expected, particularly for CBT. 

 

While cLBP patients may benefit from PT as first-line treatment, the magnitude of effect may not have been clinically meaningful. Moreover, nonresponders showed no particular superiority to alternative second-stage treatments (eg, mindfulness or switching).