Time works better than physical therapy for lower back pain

Most people are going to have lower-back pain at some point in their lives — roughly 70 percent of us. But what do you do when that aching back strikes? The answer is, take it slow.

Getting into physical therapy right away may help, a study finds, but so will the passage of time. The key is not to jump into expensive, invasive procedures that could make things worse.

Researchers have learned in recent years that treating back pain too aggressively early on adds to health care costs without helping patients recover more quickly. But studies haven't explored the impact of early physical therapy.

This study, which was published Tuesday in JAMA, the journal of the American Medical Association, looked at more than 200 patients with lower-back pain to see whether physical therapy sessions would make a difference if they started the sessions soon after they began having pain. Current guidelines suggest that physical therapy be held off for a few weeks to see whether patients will recover on their own, something these researchers wanted to investigate. The patients were split into two groups, where half received four sessions of physical therapy and half received usual care. At the three-month checkup, those who had received physical therapy had a modestly improved ability to perform daily tasks, such as sitting, standing, walking and lifting things. But the level of pain in the two groups was the same. At one year, the difference between the two groups evaporated and was not considered "clinically important."

But that doesn't mean that physical therapy won't help some patients.

"The average amount of improvement over 100 patients was small, but within that group, there were certainly patients that experienced large improvement and then others who didn't receive much benefit at all," says lead author Julie Fritz, a professor in the department of physical therapy and the associate dean for research in the College of Health at the University of Utah.

Many patients when they arrive at a doctor's office complaining of low-back pain just need to hear that nothing is permanently wrong and the pain will most likely go away with time, Fritz says. But some patients will want more help. "That's when physical therapy can play its most important role," she says.

While most lower-back pain does improve on its own, Fritz says that in some cases, patients are stuck in a cycle where the pain doesn't completely go away and then the patient does something to re-exacerbate it, creating a pattern of recurring pain that can be challenging for health care providers to stop.

A very small percentage of people — less than 1 percent, Fritz says — have a serious problem causing their back pain, such as a tumor, fracture or bone infection. In other cases of sudden low-back pain, patients may be dealing with anything from cancer to kidney stones. There are often other signs and symptoms that hint at those more severe medical issues, Fritz says, and in those cases, early imaging and specialist referrals would be appropriate.

Tread hesitantly toward more invasive treatments, such as MRI, she says. Imaging is probably going to find something suspect in any patient over the age of 30, and it may be completely irrelevant, yet still sound ominous to the patient. "Not only is that just sort of a waste of money," Fritz says, "but imaging often contributes to people's fears is that something is really seriously wrong with their back."

Though nonsteroidal anti-inflammatory medications and acetaminophen are fine for patients to take at the start of back pain, Fritz says that imaging, specialist referrals and opioid medications should only be considered further down the line if physical therapy doesn't help and if the patient is still experiencing difficulty.

"We get into trouble and we do real potential harm to patients when we accelerate them down a pathway too rapidly and that can end in expensive, invasive procedures that patients really don't want when they start seeking care," Fritz says.

Each patient is different, and there are no cookie-cutter solutions to lower-back pain. Where research needs to go in the future is toward determining who will benefit from physical therapy early on versus who just needs a little advice and reassurance – and time to heal. "We don't understand that really well yet," Fritz says.

Although this study found that physical therapy doesn't have a statistically significant effect on lower-back pain, it can still impact the patients going through it, Fritz says. "People who feel that they're being treated and cared for will improve a bit more rapidly regardless of what's actually being provided to them."

And while we've traditionally labeled that as a placebo effect, part of medical treatment is about allowing patients to feel more optimistic because they're being helped. "And that's not something we should try to limit," Fritz says. "It's indeed something we should try to maximize and take advantage of." Copyright 2019 NPR. To see more, visit https://www.npr.org.