Effectiveness of Nonpharmacologic Treatments for Chronic Low Back Pain : A Sequential, Multiple-Assignment,
Julie M Fritz1, Richard L Skolasky2, Gerard Brennan3
1Department of Physical Therapy and Athletic Training, College of Health, University of Utah, Salt Lake City, Utah (J.M.F., E.L., A.T.).
Annals of Internal Medicine
|April 20, 2026
Summary
Physical therapy (PT) may be a beneficial first-line treatment for chronic low back pain (cLBP). However, subsequent treatments for non-responders showed no significant differences in outcomes.
Area of Science:
- Rehabilitation Medicine
- Pain Management
- Clinical Trials
Background:
- Chronic low back pain (cLBP) management lacks comparative effectiveness data for adaptive interventions.
- Existing treatments for cLBP are numerous but their comparative effectiveness is not well-studied.
Purpose of the Study:
- To compare physical therapy (PT) and cognitive behavioral therapy (CBT) as initial treatments for cLBP.
- To evaluate the effectiveness of switching treatments or using mindfulness as a second-stage intervention for non-responders.
Main Methods:
- A multisite sequential, multiple-assignment randomized trial with 52-week follow-up was conducted.
- Participants received 8 weeks of either PT or CBT, with non-responders randomly assigned to a second-stage treatment.
- Co-primary outcomes included function (Oswestry Disability Index) and pain intensity.
Main Results:
- After 10 weeks, PT showed a statistically significant improvement in function compared to CBT, though below the minimum important difference.
- No significant differences in pain intensity were observed between PT and CBT at 10 weeks.
- No significant differences in function or pain intensity were found for any second-stage treatments at 52 weeks.
Conclusions:
- Physical therapy may be a beneficial first-line treatment for patients with chronic low back pain.
- For patients not responding to initial treatment, subsequent interventions including mindfulness or switching treatments did not yield differential benefits in function or pain.
