Chronic Low Back Pain: Are We Finally Returning to First Principles?

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Clinical Disclaimer

This article is intended for educational and informational purposes only. It does not constitute medical advice and should not replace individual consultation with a qualified healthcare professional.

Gerry Gajadharsingh writes:

“Chronic low back pain remains one of the most common and costly health problems worldwide, yet despite enormous advances in imaging, pharmacology, and interventional medicine, many patients continue to experience persistent pain, disability, and frustration. Increasingly, however, research is beginning to reaffirm something many experienced clinicians have observed for decades: movement, function, behavioural adaptation, and rehabilitation often matter more than structural “findings” alone.

A recent large-scale study published in the Annals of Internal Medicine explored whether physical therapy or cognitive behavioural therapy (CBT) should be considered the preferred first-line treatment for chronic low back pain. Interestingly, while the overall differences were modest, physical therapy produced slightly better functional outcomes and reinforced its position as an effective and accessible first-line strategy. 

What makes this particularly important is not simply the comparison between two therapies, but the broader shift in thinking it represents. Chronic low back pain is increasingly understood not as a purely structural problem, but as a complex interaction between biomechanics, nervous system regulation, behaviour, stress physiology, conditioning, breathing patterns, movement confidence, sleep, and emotional processing. In other words, low back pain is rarely “just a back problem.”

As an osteopath and diagnostic consultant working within an integrated medicine framework, I see this repeatedly in clinical practice. Patients often arrive believing that a scan finding — disc degeneration, facet arthropathy, “wear and tear,” or bulging discs — fully explains their symptoms. Yet many individuals with significant imaging findings have little or no pain, while others with relatively minor structural changes can experience profound disability. This disconnect highlights the importance of understanding the person, not simply the MRI.

In this blog, I want to explore what the latest evidence is really telling us about chronic low back pain, and perhaps more importantly, what it is not telling us. While modern medicine has become extraordinarily sophisticated in its ability to image, classify, and label spinal pathology, the lived experience of chronic back pain often extends far beyond the structural findings seen on a scan. This is one of the major challenges — and misunderstandings — surrounding persistent musculoskeletal pain.

For many patients, the journey begins with a mechanical event: lifting, twisting, prolonged sitting, stress, deconditioning, injury, or sometimes no obvious trigger at all. Yet over time, the problem frequently evolves into something far more complex. Protective muscle guarding develops, breathing patterns alter, sleep becomes disturbed, stress physiology becomes amplified, and the nervous system itself may become increasingly sensitised. Fear of movement, reduced activity, loss of confidence, and hypervigilance toward symptoms can gradually reinforce the cycle. In this context, pain is no longer simply a reflection of tissue injury; it becomes part of a broader systems-based physiological response.

This is why conservative approaches continue to matter so profoundly. Effective rehabilitation is not simply about “stretching a tight muscle” or strengthening the core in isolation. Rather, it involves helping the body regain adaptability, resilience, efficiency of movement, and a greater sense of physiological safety. The goal is not merely pain reduction, but restoration of function, confidence, and overall regulatory balance.

Physical therapy, Osteopathic Manual Treatment (OMT), and other rehabilitation-based approaches may therefore work through multiple overlapping mechanisms. These can include improving movement variability and biomechanics, reducing excessive muscular guarding, restoring thoracic and diaphragmatic mobility, improving breathing efficiency, modulating autonomic nervous system activity, increasing circulation and tissue perfusion, and gradually reducing fear-avoidance behaviours. Even relatively simple interventions — walking, graded exposure to movement, improved sleep habits, or breathing retraining — may exert surprisingly powerful effects when applied consistently and in the right context.

Equally important is the growing recognition that chronic low back pain cannot always be separated from broader aspects of human physiology and psychology. Emotional stress, unresolved anxiety, chronic hyperarousal, occupational pressures, trauma history, poor recovery, sedentary lifestyles, and modern behavioural patterns all influence how pain is experienced and processed within the nervous system. This does not mean the pain is “psychological” or imagined. Rather, it reflects the reality that the brain, autonomic nervous system, immune system, endocrine system, and musculoskeletal system are deeply interconnected and constantly communicating with one another.

From an integrated medicine and osteopathic perspective, this broader systems-based model is extremely important. It encourages us to move beyond reductionist thinking and away from the idea that every chronic pain problem has a single structural explanation waiting to be identified and “fixed.” Instead, it invites a more nuanced understanding of how posture, breathing mechanics, movement behaviour, autonomic balance, stress physiology, sleep quality, conditioning, metabolic health, and emotional resilience all contribute to recovery — or to ongoing dysfunction.”

 

PT Safe and Effective First-Line Treatment for Chronic Low Back Pain

Medscape

Marcia Frellick

Physical therapy is effective as a first-line strategy for chronic low back pain (LBP), as current practice guidelines state, but the size of the effects is small, according to results of the OPTIMIZE study, which compared outcomes with physical therapy (PT) and cognitive-behavioral therapy (CBT) in real-world circumstances.

The findings were reported online on April 20 in the Annals of Internal Medicine.

Researchers, led by Julie Fritz, PhD, PT, with the Department of Physical Therapy and Athletic Training at the University of Utah in Salt Lake City, conducted a sequential, multiple assignment, randomized trial to compare the effectiveness of PT and CBT for 8 weeks as the first stage of treatment for adults with chronic BP. In the second stage, patients who didn’t respond to the assigned therapy were randomly assigned again to 8 weeks of either switching (to CBT or PT) or mindfulness. Co-primary function and pain outcomes were measured at 3 points over a year.

PT Slightly Better for Function

“We found on average, patients who got referred to physical therapy as opposed to CBT did a little better for the outcome of function but not for the outcome of pain. We think that’s because physical therapy is a more commonly used treatment for back pain and health systems are a little better at providing it,” Fritz told Medscape Medical News.

“I don’t think it in any way should be interpreted that something like CBT is not a viable option because the differences weren’t that big. Also, part of the benefit for physical therapy was greater accessibility for patients and not necessarily the treatment itself,” she said.

Potentially eligible participants aged 8-64 years were identified from electronic health records in three health systems — University of Utah Health and Intermountain Health in Salt Lake City and Johns Hopkins Medicine in Baltimore. Criteria included having an LBP-related healthcare visit in the past 90 days and having LBP for at least 3 months with pain on at least half of the days in the past 6 months. Pain intensity ≥ 4 on a 0-10 pain scale and an Oswestry Disability Index (ODI) score ≥ 24 on a 0-100 scale were required.

The sample included 749 participants. After 10 weeks, there was greater improvement in function in the PT group (adjusted mean ODI difference, 2.8 on a scale of 0-100; 96% CI, 0.38-5.1) and no difference in pain intensity (adjusted mean difference, 0.32; 99% CI, -0.07 to 0.71). The difference in ODI was below the minimum important difference of 6. After 52 weeks, there were no differences in stage II treatments for nonresponders for either function (adjusted mean ODI difference, 0.43; 96% CI, -0.29 to 2.4) or pain (adjusted mean difference, -0.05; 96% CI, -0.58 to 0.48).

Study Addresses an Unmet Need

“This study addresses an unmet need,” Peter Whang, MD, told Medscape Medical News. “Chronic low back pain is ubiquitous, and one of the fundamental problems is so many things can cause back pain,” noted Whang, professor of medicine in the Department of Orthopaedics and Rehabilitation at Yale School of Medicine in New Haven, Connecticut, who was not part of the study. “The data supporting optimal care is just not there, and that’s why this study is very important.”

In primary care, he said, treatments for chronic LBP are likely to start with a conservative approach, including activity modification and anti-inflammatory medications, but “I certainly would consider physical therapy to be a first-line treatment,” he said. “This study was well designed and provides high-level evidence that physical therapy was more effective than some other secondary modalities such as CBT or other treatments.”