PO:38:278 | Cognitive behavioural therapy vs. physical therapy for chronic primary low back pain: a systematic review with meta-analysis of randomised controlled trials

Luca Castioni¹, Stefano Salvioli² | ¹Università degli studi di Ferrara; ²Scuola di fisioterapia Claudiana, Bolzano, Italy

Background. Over recent decades, chronic primary low back pain (CPLBP) has shown a consistent epidemiological increase worldwide. Although cognitive behavioural therapy (CBT) is not among the most commonly used interventions for this condition, several recent systematic reviews h ave demonstrated its efficacy. Given its limited implementation in clinical practice, this review aimed to assess the therapeutic validity of CBT by comparing it with physiotherapy (PT) interventions, designed according to the most recent clinical guidelin es for CPLBP.

Materials and Methods: Randomised controlled trials (RCTs) comparing CBT and PT in adults with CPLBP were included. The databases PubMed, Cochrane CENTRAL, Embase, CINAHL, Scopus, and PEDro were searched from inception to March 3, 2025. Risk of bias was independently assessed by two reviewers using the Cochrane Risk of Bias 2.0 (RoB 2.0) tool. Based on extracted data, several meta analyses were conducted, grouping outcomes into early phase, acute phase, and late phase follow ups. The certainty of evidence was evaluated according to the GRADE approach.

Results: Twelve RCTs were included, comprising a total of 1,762 participants. Meta analyses indicated very low certainty evidence that CBT is more effective than PT in reducing pain in the early p hase (n = 650, MD = −1.29, 95% CI = −2.00 to −0.59, p = 0.0003, I² = 83%), acute phase (n = 337, SMD = −0.16, 95% CI = −0.38 to +0.05, p = 0.14, I² = 0%), and late phase (n = 1108, SMD = −0.45, 95% CI = −0.87 to −0.03, p = 0.03, I² = 91%), as well as in de creasing disability in the early phase (n = 650, SMD = −1.00, 95% CI = −1.55 to −0.44, p = 0.0004, I² = 90%), acute phase (n = 337, MD = −0.27, 95% CI = −2.43 to +1.88, p = 0.80, I² = 75%), and late phase (n = 1108, SMD = −0.97, 95% CI = −1.52 to −0.41, p = 0.0007, I² = 95%). The results for early phase and late phase outcomes, for both pain and disability, were statistically significant.

Conclusions: Although supported by very low certainty evidence, these findings suggest that cognitive behavioural therap y may be a valuable intervention to integrate into clinical practice to reduce pain and improve disability in individuals with chronic primary low back pain. Further high quality randomised controlled trials are needed to confirm these results and draw more robust conclusions.