Ann Intern Med
Physical therapy offers modest edge in chronic low back pain care
Clinical Takeaway: Start with physical therapy for chronic low back pain, but set expectations—functional gains are small and switching or adding therapies may not improve long-term outcomes.
Chronic low back pain affects more than 20% of adults worldwide and is a leading cause of disability, yet most nonpharmacologic treatments yield only modest improvements.
In a large sequential, multiple-assignment randomized trial (SMART) published in Annals of Internal Medicine, researchers evaluated how best to sequence common nonpharmacologic treatments for chronic low back pain across three health care systems.
The OPTIMIZE trial enrolled 749 adults with chronic low back pain who were randomized to 8 weeks of physical therapy (PT) or cognitive behavioral therapy (CBT) as first-stage treatment. Patients who didn’t respond were re-randomized to a second-stage strategy: switching therapies or initiating mindfulness-based care. Outcomes were tracked for 52 weeks using the Oswestry Disability Index (ODI; scale 0–100) and pain intensity (scale 0–10).
After 10 weeks, patients starting with PT showed slightly greater improvement in function compared with CBT, with an adjusted mean ODI difference of 2.8 points (96% confidence interval, 0.38 to 5.1). However, this fell below the minimum clinically important difference of 6 points, and pain intensity didn’t differ between groups.
At 52 weeks, no meaningful differences emerged among second-stage strategies for nonresponders, whether patients switched treatments or added mindfulness-based therapy. As the authors note, “physical therapy may be a reasonable first-line option,” but evolving treatment pathways did not change long-term pain or function.
Overall, the findings reinforce guideline-endorsed use of PT while underscoring the limited magnitude of benefit across nonpharmacologic options.
Source: Fritz JM, et al. (2026, April 21). Ann Intern Med. Effectiveness of Nonpharmacologic Treatments for Chronic Low Back Pain: A Sequential, Multiple-Assignment, Randomized Trial