Research Findings: CBT and back pain

Why was this study needed?

Low back pain is common, affecting around a third of adults in the UK each year. Treating all types of back pain cost the NHS over £1 billion a year in 2000. Back pain related time off work and productivity losses cost the economy at least £3.5 billion per year.

A number of drug and non-drug treatment options for pain relief are available but don’t usually cure the problem, which leaves around 62 per cent of people still having back pain a year after the first episode. The significant burden of persistent or recurring lower back pain could be reduced by finding a treatment that is effective in the long term. This partially NIHR-funded systematic review aimed to assess the effectiveness of cognitive behavioural interventions in comparison with no treatment or guideline-based treatments for people with low back pain that was not due to a specific cause like injury or disease.

What did this study do?

This systematic review included 23 randomised controlled trials with 3,359 people with low back pain. Most of the trials (20) included people with persistent back pain lasting more than six weeks. The trials compared cognitive behavioural interventions with any guideline-based active treatment, or with no treatment, during the study period, described as waiting list or usual care. Active treatments came from 2006 European guidelines for acute and chronic low back pain, including information, reassurance and advice to stay active, various drugs for pain relief and supervised exercise therapy (only for chronic low back pain). Overall, the quality of reporting of the included trials was poor. The results of the included studies were combined using meta-analysis.

What did it find?

• At long-term follow up (six months to a year) the improvements in pain for cognitive behavioural interventions compared with no treatment were small but significant, standardised mean difference (SMD), -0.23 (95 per cent confidence interval (CI) -0.43 to -0.04).
• Over the same period there was no difference between cognitive behavioural interventions and no treatment for change in disability or quality of life.
• At long-term follow up (over a year) the improvement in pain for cognitive behavioural interventions was moderate (SMD 0.48 95 per cent, CI -0.93 to -0.04) compared with guideline-derived active treatments and was better still at improving disability (SMD -0.61 95 per cent, CI -1.05 to -0.17). There was no difference in quality of life between the interventions and no treatment.
• Most trials favoured cognitive behavioural interventions compared with no treatment, or active treatment, both in the short (six to 12 weeks) and long term (six to 12 months). However, there was considerable variation in the results across trials so The pooled effect sizes should be viewed with caution. For example, cognitive behavioural approaches differed from trial to trial in content, modes of delivery, number of sessions and length of treatment. No specific therapy stood out as the best.

What does current guidance say?

The 2009 NICE guideline on persistent low back pain recommend that people are offered advice and information to promote self-management. It also recommends drugs for pain relief and one or more of the following non-drug treatment options: structured exercise programme, manual therapy or acupuncture. For people with high levels of disability and psychological distress, the guideline recommends a combination physical and psychological treatment programme, including a cognitive behavioural approach, and exercise.

The 2006 European guidelines recommend supervised exercise therapy as a first-line treatment. Cognitive behavioural therapy is also recommended as are treatments like manual therapy (but not massage), brief information or educational interventions and various types of drugs for pain relief. Pain relieving drugs and manual therapies are also recommended for people with low back pain lasting less than six weeks. However, exercise therapy and behavioural treatments are not recommended in this group.

What are the implications?

Cognitive behavioural interventions for low back pain are not routinely offered by the NHS but can be an option for people with chronic treatment-resistant pain. This systematic review found evidence that cognitive behavioural interventions may reduce pain and disability in the long term. Overall, the detail of what was done, by whom and for how long was rarely reported and this hinders implementation of these interventions in practice. There is currently a lack of capacity in the NHS to provide cognitive behavioural therapy for mental health conditions so, if the same practitioners were used, a significant increase in capacity would be needed to extend provision to the large number of people with persistent low back pain.

Citation and Funding

• Richmond H, Hall AM, Copsey B, et al. The Effectiveness of Cognitive Behavioural Treatment for Non-Specific Low Back Pain: A Systematic Review and Meta-Analysis. PLoS One. August 5 2015;10(8):e0134192.
• This project was funded by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care Oxford at Oxford Health NHS Foundation Trust.
• The full NIHR Signal and additional expert commentary was published on 14 October 2015 and can be found here: bit.ly/2L3Ri4n 

Commentary

Sarah Wilson gives her reaction:

The  most recent National Institute for Health and Care Excellence (NICE) guidelines which were published in 2016 recommend a combined approach of psychological therapies and exercise (with or without manual therapy) and reflect the findings of this review. This, however, presents a challenge in terms of access and understanding of what is meant by psychological therapies.

Pain management programmes can support patients with a high level of complexity but these services will never cope with the diverse nature of demands of patients who struggle with low back pain. Furthermore this intensity of treatment is not required by all. 

Physiotherapists are well placed to deliver cognitive behavioural approaches for patients with lower levels of complexity in their presentation. However, there is also evidence that training alone may not be enough to change physiotherapy practice, with barriers such as feeling unskilled being reported as a barrier to implementation. 

The physiotherapy profession faces a challenge to continue to develop, refine and deliver packages of care that are underpinned by clear, evidence-based psychology models to reduce the impact of low back pain. Ongoing development of undergraduate and post-graduate training will be essential to ensure competence in practice.

• Sarah Wilson is a clinical specialist physiotherapist, Bath Centre for Pain Services, and Chair of the Physiotherapy Pain Association