The nurse practitioner provides education about treatments to a 48-year-old woman with a diagnosis of chronic low back pain. Which of the following is NOT considered a first-line treatment for chronic low back pain?

Choice A reason: Exercise therapy is widely considered a first-line treatment for chronic low back pain. It helps improve flexibility, strength, and endurance of the muscles supporting the spine, reduces pain, and improves function. Both aerobic and strengthening exercises are recommended as part of a comprehensive management plan. Choice B reason: Cognitive behavioral therapy (CBT) is considered a first-line treatment for chronic low back pain because it addresses the psychological component of chronic pain. CBT helps patients develop coping strategies, modify maladaptive thoughts related to pain, and improve overall functioning and quality of life. Choice C reason: Spinal manipulation is not considered a first-line treatment for chronic low back pain. While it may provide temporary relief for some patients, it is typically used as a complementary or second-line therapy rather than a primary approach due to limited evidence of long-term benefit and potential risks if performed improperly. Choice D reason: Advice to remain active is a cornerstone of first-line treatment for chronic low back pain. Remaining active prevents deconditioning, reduces fear-avoidance behaviors, and promotes faster recovery compared to prolonged rest.