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NIHR Signal Cognitive behavioural therapy may help people with persistent low back pain

Published on 14 October 2015

doi: 10.3310/signal-000132

This NIHR-funded systematic review aimed to assess the effectiveness of talking therapies in improving outcomes for people with non-specific low back pain. It found that cognitive behavioural therapies were more effective than no treatment and provided some benefit compared with other active treatments like physiotherapy with education, home and clinic based exercise, or to less active treatments like manual therapy or pain reliving drugs. It adds to other reviews by including older patients, who tend to experience back pain more often, and by including people with recent persistent symptoms (for under three months). This makes it particularly useful for decision makers, given the number of older people experiencing lower back pain and the risk of ongoing problems for those with recent symptoms. However, the review included many different interventions, many of which were not properly described, which limit the uptake and implementation of findings in practice. It is likely that a substantial increase in NHS capacity would be needed to deliver cognitive behavioural therapies for the many people with persistent low back pain. This may be important though, as the provision of programmes that combine psychological and physical treatments are seen by some as the biggest gap in care for people with low back pain that has become disabling over more than six months.

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Why was this study needed?

Low back pain is common, affecting around one third of UK adults each year. Treating all types of back pain cost the NHS over £1 billion a year in 2000 and the figure for 2015 is likely to be much higher. Back pain related time off work and productivity losses cost the UK economy at least £3.5 billion per year.

A number of drug and non-drug treatment options for pain relief are available. However, they don’t usually cure the problem which leaves around 62% of people still having back pain a year after a 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 down 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. The majority 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% 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% CI -0.93 to -0.04) compared with guideline-derived active treatments and was better still at improving disability (SMD -0.61 95% 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 (6 to 12 weeks) and long term (6 to 12 months). However there was a 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 on this issue?

The 2009 NICE guideline on persistent low back pain recommends that people should be 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 of physical and psychological treatment programme including a cognitive behavioural approach and exercise.

The 2006 European guidelines for management of chronic low back pain recommend supervised exercise therapy as a first-line treatment. Cognitive behavioural therapy is also recommended as are other 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 trial evidence that cognitive behavioural interventions for people with persistent low back pain may improve 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

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. 2015 Aug 5;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.

Bibliography

Airaksinen O, Brox JI, Cedraschi C, et al. Chapter 4. European guidelines for the management of chronic nonspecific low back pain. Eur Spine J. 2006;15 Suppl 2:S192-300.

NHS Choices. Cognitive behavioural therapy (CBT) [internet]. London: Department of Health; 2014.

NICE. Low back pain: Early management of persistent non-specific low back pain. CG88. London: National Institute for Health and Care Excellence; 2009.

NICE. CG88 Low back pain: commissioning fact sheet. London: National Institute for Health and Care Excellence; 2009.

van Tulder M, Becker A, Bekkering T, et al. Chapter 3. European guidelines for the management of acute nonspecific low back pain in primary care. Eur Spine J. 2006;15 Suppl 2:S169-91.

Why was this study needed?

Low back pain is common, affecting around one third of UK adults each year. Treating all types of back pain cost the NHS over £1 billion a year in 2000 and the figure for 2015 is likely to be much higher. Back pain related time off work and productivity losses cost the UK economy at least £3.5 billion per year.

A number of drug and non-drug treatment options for pain relief are available. However, they don’t usually cure the problem which leaves around 62% of people still having back pain a year after a 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 down 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. The majority 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% 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% CI -0.93 to -0.04) compared with guideline-derived active treatments and was better still at improving disability (SMD -0.61 95% 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 (6 to 12 weeks) and long term (6 to 12 months). However there was a 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 on this issue?

The 2009 NICE guideline on persistent low back pain recommends that people should be 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 of physical and psychological treatment programme including a cognitive behavioural approach and exercise.

The 2006 European guidelines for management of chronic low back pain recommend supervised exercise therapy as a first-line treatment. Cognitive behavioural therapy is also recommended as are other 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 trial evidence that cognitive behavioural interventions for people with persistent low back pain may improve 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

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. 2015 Aug 5;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.

Bibliography

Airaksinen O, Brox JI, Cedraschi C, et al. Chapter 4. European guidelines for the management of chronic nonspecific low back pain. Eur Spine J. 2006;15 Suppl 2:S192-300.

NHS Choices. Cognitive behavioural therapy (CBT) [internet]. London: Department of Health; 2014.

NICE. Low back pain: Early management of persistent non-specific low back pain. CG88. London: National Institute for Health and Care Excellence; 2009.

NICE. CG88 Low back pain: commissioning fact sheet. London: National Institute for Health and Care Excellence; 2009.

van Tulder M, Becker A, Bekkering T, et al. Chapter 3. European guidelines for the management of acute nonspecific low back pain in primary care. Eur Spine J. 2006;15 Suppl 2:S169-91.

The Effectiveness of Cognitive Behavioural Treatment for Non-Specific Low Back Pain: A Systematic Review and Meta-Analysis

Published on 6 August 2015

Richmond, H.,Hall, A. M.,Copsey, B.,Hansen, Z.,Williamson, E.,Hoxey-Thomas, N.,Cooper, Z.,Lamb, S. E.

PLoS One Volume 10 , 2015

OBJECTIVES: To assess whether cognitive behavioural (CB) approaches improve disability, pain, quality of life and/or work disability for patients with low back pain (LBP) of any duration and of any age. METHODS: Nine databases were searched for randomised controlled trials (RCTs) from inception to November 2014. Two independent reviewers rated trial quality and extracted trial data. Standardised mean differences (SMD) and 95% confidence intervals were calculated for individual trials. Pooled effect sizes were calculated using a random-effects model for two contrasts: CB versus no treatment (including wait-list and usual care (WL/UC)), and CB versus other guideline-based active treatment (GAT). RESULTS: The review included 23 studies with a total of 3359 participants. Of these, the majority studied patients with persistent LBP (>6 weeks; n=20). At long term follow-up, the pooled SMD for the WL/UC comparison was -0.19 (-0.38, 0.01) for disability, and -0.23 (-0.43, -0.04) for pain, in favour of CB. For the GAT comparison, at long term the pooled SMD was -0.83 (-1.46, -0.19) for disability and -0.48 (-0.93, -0.04) for pain, in favour of CB. While trials varied considerably in methodological quality, and in intervention factors such as provider, mode of delivery, dose, duration, and pragmatism, there were several examples of lower intensity, low cost interventions that were effective. CONCLUSION: CB interventions yield long-term improvements in pain, disability and quality of life in comparison to no treatment and other guideline-based active treatments for patients with LBP of any duration and of any age. SYSTEMATIC REVIEW REGISTRATION: PROSPERO protocol registration number: CRD42014010536.

Non-specific low back pain is described as pain, discomfort or stiffness in the lower back region for which it is not possible to identify a specific cause. In some people the pain may also spread to the thighs.

Cognitive behavioural therapy is a form of psychological treatment that aims to change the way people think and behave. It is mostly used for mental health conditions such as anxiety and depression, but can also be used for physical health problems. It can be provided by different health professionals such as clinical psychologists, counsellors or other therapists.

Author commentary

The National Spinal Taskforce has identified the combined provision of psychological and physical treatments as the biggest gap in current UK low back pain service provision. Our systematic review supports the need to address this gap, providing the most up to date evidence that these programmes yield greater changes in long term patient outcomes (e.g. pain, disability) when combined with, or compared to, other guidelines based treatments (e.g. manual therapy).

The results from this review should help inform the new UK low back pain management guideline that is currently under review by the National Institute for Health and Care Excellence (NICE).

Dr Helen Richmond, Centre for Rehabilitation Research, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford