No Clinical Benefit for Early Physical Therapy in Recent-Onset Low Back Pain

Summary and Comment |
October 15, 2015

No Clinical Benefit for Early Physical Therapy in Recent-Onset Low Back Pain

  1. Thomas L. Schwenk, MD

Results support clinical practice guidelines advising against early physical therapy.

  1. Thomas L. Schwenk, MD

Increasing use of imaging, opioids, and interventions (both percutaneous and surgical) in patients with low back pain is expensive and is not associated with better outcomes. Early physical therapy (PT) has been proposed to avoid these interventions, but clinical practice guidelines recommend against such use (NEJM JW Gen Med Nov 15 2007 and Ann Intern Med 2007; 147:478). Researchers in Utah randomized 220 adults (mean age, 37) with recent-onset low back pain (<16 days), and without radicular symptoms below the knees, to PT or usual care. PT (started within 3 days of enrollment) consisted of four sessions during 3 weeks emphasizing spinal range-of-motion exercises, core strengthening, and home exercises. Both groups were encouraged to exercise and were educated about the favorable prognosis of low back pain.

Adherence to PT sessions in the intervention group was nearly 100%. Blinded assessments of a variety of outcomes at 1, 3, and 12 months were mixed, with several small statistically significant differences favoring the PT group but with no clinically important differences between groups. On the primary outcome (a 100-point standardized scale that assesses pain, function, and disability), a 3.5-point difference between groups was recorded at 4 weeks (P=0.045). No difference was found between groups in healthcare use; adverse effects in the PT group were minimal.


I suspect that, in many cases, primary care clinicians order early PT just to offer patients something tangible, but this study suggests that most patients derive little if any clinical benefit from this intervention. Overall, these results support guidelines that recommend against early PT.

Editor Disclosures at Time of Publication

  • Disclosures for Thomas L. Schwenk, MD at time of publication Editorial boards UpToDate


Reader Comments (3)

I Campbell-Taylor, MB ChB, PhD Other, Neurology, Private practice

It is beyond frustrating to try to deal with workers Compensation Boards that, probably because they have contracts with physical therapy organizations, force injured persons into early PT, only to produce more injury or, at best, no improvement. These injuries are then, not compensated. Perhaps his information may have some positive effect for those with common low back pain, as well as those with unusual injuries causing such discomfort.

SEHELLY JAHAN Physician, Neurology, Bangladesh medical college

As with possible irritation in the spinal nerves / radicals , exercise might increase pain , when pain is reduced in intensity then exercise should b started gradually , though the pt should not b bed bound at any time .

Silverstein, MD Physician, Internal Medicine, Preventive Medicine Center

Admittedly, 33% of physicians graduated in the lower third of their class. The implication of that humorous statement is that not every physician is the sharpest knife in the drawer. When large studies like this are done, it is the bottom third of competency that pulls the top third of competency & ethics down. There are some physical therapists who are literally magical in their ability to deal most effectively with back etc. pain, and and even "early on." HRS, MD, FACC

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