CBT Significantly Improves Low Back Pain in the Short and Long Term
By Pam Harrison
Medscape Medical News
March 2, 2010 — Cognitive behavioral therapy (CBT) significantly improves subacute and chronic low back pain both in the short term and during 1 year compared with advice alone and is highly cost-effective, new research suggests.
Published online February 26 in The Lancet, investigators found that disability scores as measured by the Roland Morris questionnaire — a measure of back pain disability — improved by 2.4 points at the end of 12 months in the "bespoke" CBT (Back Skills Training [BeST]) group compared with 1.1 points among control patients.
The CBT intervention used in this study was specifically designed to address risk factors leading to disability from back pain. Change from baseline to 12 months in the modified Von Korff disability score was 13.8% in the intervention group vs 5.4% in controls, whereas change in the modified Von Korff pain score at the same endpoint was 13.4% in the CBT group and 6.4% in controls.
Per quality-adjusted life-year, the cost of the BeST strategy totaled ￡1786 — less than half that of competing interventions, such as acupuncture, the investigators note.
"Effective treatments that result in sustained improvements in low back pain are elusive," the study authors note, "and this trial shows that a bespoke cognitive behavioral intervention package, BeST, is effective in managing subacute and chronic low back pain in primary care."
Moderately Troublesome
For the study, Sarah Lamb, PhD, University of Warwick, Coventry, United Kingdom, and colleagues randomized 701 patients with moderately troublesome subacute or chronic low back pain to group CBT or to advice alone.
A total of 468 patients were treated with up to 6 sessions of group CBT, whereas 233 controls received no additional treatment other than a 15-minute session of active management advice, including the benefit of how to remain active, how to avoid bed rest, and the appropriate use of pain medication. All participants were also given The Back Book (Spine. 1999;24:2484).
Those randomized to the CBT group attended the BeST program, which consisted of an individual assessment of up to 1.5 hours and 6 sessions of group therapy again lasting 1.5 hours. "Training consisted of guided discovery, identifying and countering negative automatic thoughts, pacing, graded activity, relaxation, and other skills," the study authors explain, "and each group started with a mean of 8 participants."
For most participants, treatment started within 45 days of randomization, and 75% of the CBT group completed the intervention within 3 months of randomization.
According to self-rated benefit from treatment, results showed that 59% of patients assigned to the BeST program reported recovery at 12 months compared with 31% of controls (P < .0001).
"More participants in the cognitive behavioral intervention group than the control group were satisfied with their treatment at 12 months," the study authors add — at 65% of the intervention group vs 28% of controls.
Fear avoidance, pain self-efficacy, and the 12-item Short Form Health Survey physical scores also improved "substantially" in the CBT group but not in the control group.
Table. Test Scores for the Control and Advice Plus CBT Groups
Test Control Group Advice Plus CBT Group P Value
Roland Morris questionnaire score at 12 months 1.1 points 2/4 points .0008
Modified Von Korff disability score at 12 months 5.4% 13.8% .0001
Modified Von Korff pain score at 112 months 6.4% 13.4% <.0001
CBT = cognitive behavioral therapy
Cost-Effective
As the investigators note, the BeST program was highly cost-effective relative to virtually any other intervention used to treat low back pain. Per person, the mean total healthcare costs for 1 year were ￡224.65 for advice alone and ￡421.52 for advice plus CBT, whereas the mean cost per person was ￡16.32 for advice alone and ￡187.00 for advice plus CBT.
"The difference in total healthcare costs was attributable almost entirely to the additional cost of the cognitive behavioral intervention," the investigators write. Further, they note that "the short-term effects (?4 months) are similar to those seen in high-quality studies and systematic reviews of manipulation, exercise, acupuncture, and postural approaches in primary care."
Furthermore, unlike many other treatments, the benefits of CBT were wide-ranging and maintained at 12 months. "We have known for quite some time that increasing physical activity is key to breaking the cycle between pain, inactivity, and more pain," Dr. Lamb told Medscape Psychiatry.
On the other hand, physicians acknowledge that it is difficult for patients to become more active when they have pain and that they can in fact be afraid to move for fear of making things worse.
"We teach people how to challenge these thoughts and to test out ways of improving their activity so CBT helps people to change the way they think about pain and, hence, how they behave when they have it," Dr. Lamb added.
Note of Caution
Laxmaiah Manchikanti, MD, Pain Management Center of Paducah, Kentucky, sounded a note of caution about the routine availability of group CBT for low back pain in primary care — at least in the United States, where there is no national healthcare system in place.
He also points out in an accompanying editorial that only 63% of patients assigned to CBT met the compliance threshold, whereas 11% of them did not receive any CBT. Practitioners must also consider how cost-effective CBT really is, given that the average cost of advice was only ￡16.32 compared with ￡187 for CBT, "a substantial difference," he notes.
Still, Dr. Manchikanti said the results were impressive and suggest that CBT "is an excellent option for primary care physicians before they seek specialty consultations for their patients” because in these individuals the treatment is “feasible clinically and economically [although] not a panacea."
The trial was funded by the National Institute for Health Research Health Technology Assessment Programme. The study authors have disclosed no relevant financial relationships.
The Lancet. Published online February 26, 2010.
