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Three Part Question

[In patients with chronic low back pain] is [behavioural therapy better than other conservative treatments] at [reducing pain and increasing function]

Clinical Scenario

A 55 year old man attends his GP with ongoing simple low back pain. He has no red flag symptoms and has tried analgesics in the past. You assess him and he tells you that he is very concerned about his pain and is very worried that he is doing more damage by continuing to work. You try and reassure him but wonder if some formal behaviour therapy might benefit him.

Search Strategy

Medline 1966-July 2005
Cochrane 2005 Edition 3
Cochrane - Behaviour therapy
Medline, AMED, - [exp Behavior Therapy/ or behaviour therapy.mp.] and [exp Back Pain/ or exp Low Back Pain/ or lumbar pain.mp.]

Search Outcome

Cochrane - 572 record of which one was directly relevant.
Medline - 213 references found of which 2 postdated the cochrane systematic review.
AMED - 24 references. One new reference found

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Ostelo RWJG 2005 Netherlands	RCTs and systematic reviews of behavioural therapy in low back pain.	Systematic review	Number of papers found	21 studies were found relevant to the review	A wellconducted systematic review. The differences are most marked against no-intervention controls. It would appear to show benefit, but whether it is better than anything else is not determined by this review.
			Quality of papers	7 (33%) were considered high quality studies
			Respondant therapy (progressive relaxation) treatment versus waiting list controls	Moderate evidence for pregressive relaxation on pain and behavioural outcomes in the short term. Limited evidence for progressive relaxation benefiting generic functional status. Medium positie effect of progressive relaxation on back-specific functional status.
			Respondent therapy (EMG biofeedback) versus waiting list controls	There is moderate evidence (3 trials, 88 people) that there is no significant difference between EMG biofeedback and waiting list control on behavioural outcomes in the short-term. There is conflicting evidence (2 trials, 60 people) on the effectiveness of EMG versus waiting list control on general functional status. Furthermore, there is limited evidence (1 trial, 28 people) for a small short-term positive effect of EMG biofeedback on back specific functional status.
			Operant therapy versus waiting list controls	There is strong evidence (2 trials, 87 people) that there is no difference between operant therapy and waiting list control on general functional status on the short-term. There is no evidence (level 4) regarding the effectiveness of operant therapy on back-specific functional status.
			Combined respondent and cognitive therapy versus waiting list controls	There is strong evidence (4 trials, 134 people) that there are no differences between combined respondent and cognitive therapy and the waiting list control on behavioural outcomes and general functional status in the short term
			Cognitive versus operant therapy	There is limited evidence (1 trial, 20 people) that there are no differences between cognitive and operant therapy.
			Cognitive versus respondent therapy	There is moderate evidence (2 trials, 67 people) that there are no significant differences between the effects of respondent and cognitive therapy on improving pain intensity, generic functional status, or behavioural outcomes.
			Operant versus respondent therapy	There is no evidence
			Cognitive-behavioural versus cognitive therapy	There is limited evidence (1 trial, 33 people) that there are no differences in the short-term or long-term outcomes between groups receiving cognitive-behavioural or cognitive therapy.
			Cognitive-behavioural versus operant therapy	Cognitive-behavioural versus operant therapy
			Cognitive-behavioural versus respondent therapy	There is limited evidence (1 trial, 28 people) that there are no differences in either the short-term or long-term effectiveness between cognitive-behavioural and respondent therapy.
			Behavioural treatment versus other kinds of treatment	There is limited evidence (1 trail, 39 people) that there are no differences between behavioural treatment and exercises.
			Behavioural treatment in addition to another treatment versus the other treatment alone	There is moderate evidence (6 trials, 210 people) that there are no significant differences in the short-term or long-term effectiveness of the addition of behavioural components to usual treatment programs for CLBP on pain intensity, generic functional status and behavioural outcomes.
Buhrman M 2004 Sweden	51 patients with chronic low back pain. aged 18-65. Pain longer than 3 months. Access to internet. Prior assessmen tby physician. Randomised to either waiting list control or 8 week internet based pain management program. Intervention assessed against a coping strategies questionnaire, Multidimendsional pain inventory and hopital anxiety and depression scale.	Randomised controlled trial	Follow up	92% follow up at 3 months	Select population. Small numbers. Multiple analyses not accounted for. Probably an excess of subgroup analyses.
			CSQ	Better for intervention. MANOVA p=o.o47
			MPI	No difference
			HADS	No difference
			Pain diary	No difference
Linton SJ 2005 Sweden	185 patients seeking care for nonspecific low back pain. Thought to be at risk of prolonged absenteeism. Recruited after being declined for surgery. The intervention group had a 5 day course. Follow up lasted 12 months.	Randomised controlled trial.	Follow up	165 approached. 152 randomised. 123 completed 12 month follow up.	Rather select group of participants. Exercise was a major component of the intervention as well as cognitive training. Only self reported data used.
			Pain	No difference in pain scores at 3 (RR 1.02) or 12 (RR 0.98) months.
			Coping strategies	at 3 months coping was better in the intervention group (53.8% vs. 31.6%). At 12 months it was 61% and 28.6%.
			Physical fitness and exercise	No significant differences found.
Jensen IB 2005 Sweden	221 patients with long term nonspecific low back pain. Sick listed from between 1 and 6 months. The intervention included psychological, ergonomic, medical and physiological education, workplace visits. Interventions initially lasted 4 weeks with subsequent booster sessions. Patients received cognitive-orientated physiotherapy(PT), cognitive behaviour therapy (CBT), full time behavioural medicine rehabilitation(BM i.e. both CBT and PT) or normal care. Follow up was for 3 years.	Randomised Controlled Trial	Abscence from work in average days	Better for combined treatment. In women BM=439, PT=522, CBT=542, CG=572. In men BM=494, PT=541, CBT=629. Differences only significant in women.	Some arguments circular, in that the intervention groups consulted health care less, but had already had an intervention by health care. Most analysis between full vs. no intervention. Less information available on the other two intervention groups.
			Health related quality of life	No formal testing done due to low response.
			Health care utilisation	Numerous analyses, few differences.

Comment(s)

Back pain is increasingly recognised as a major problem in Western societies. There is increasing evidence that a purely medical/interventionalist approach is insufficient and that the problem must be treated in the round. A biopsychsocial approach to the problem is now regularly advocated, and a component of this is usually some form of behaviour therapy. This review shows that there is evidence to support behavious therapy in the management of low back pain. However, as with many other interventions in chronic low back pain the benefits cannot be described as dramatic.

Clinical Bottom Line

There is evidence to support the role of behaviour therapy in the management of chronic nonspecific low back pain.

References

1. RWJG Ostelo, MW van Tulder, JWS Vlaeyen, SJ Linton, SJ Morley, WJJ Assendelft Behavioural treatment for chronic low-back pain Cochrane database of systematic reviews 2004, Issue 3. Art. No.: CD002014. DOI: 10.1002/14651858.CD002014.pub2.
2. Buhrman M, Faltenhag S, Strom L, Andersson G Controlled trial of internet-based treatment with telephone support for back pain Pain 2004;111:368-377
3. Magnussen L, Roghsvag T, Tveito TH, Eriksen HR. Effect of brief cognitive training programme in patients with long lasting back pain evaluated as unfit for surgery. Journal of Helpth Psychology 2005;10:233-243
4. Jensen IB, Bergstrom G, Ljungquist T, Bodin L. A 3-year follow up of a multidisciplinary rehabilitation program for back and neck pain. Pain 2005;115:273-283