“Back pain may be ‘in the mind’” reported The Daily Telegraph, saying that “researchers believe that counselling, or cognitive behavioural therapy [CBT] sessions, work because if you can help people change their thoughts, it will help them to change the way they feel”.
The newspaper report may give some people the wrong impression about these findings. The researchers did not find that back pain may all be in the mind, and did not assess the psychology of pain.
Instead, they compared a one-off advice session given by a nurse or physiotherapist, with this advice session combined with CBT group support sessions. These were designed to solve patients’ difficulties in keeping physically active as a consequence of back pain, and involved finding appropriate exercises that they could do, and ongoing advice and support on physical activities for improving their fitness and quality of life. People in the trial were also instructed in the appropriate use of pain medications.
It found that patients given the extra support sessions had improved physical fitness and quality of life, compared to patients given one-off advice. This indicates that this sort of treatment may provide a simple and relatively cheap way of improving chronic lower back pain.
Where did the story come from?
This research was carried out by Professor Sarah E Lamb and colleagues from The University of Warwick and the University of Oxford. The study was funded by The National Institute for Health Research Health Technology Assessment Programme. The study was published in the peer-reviewed medical journal The Lancet .
This research was covered well by BBC News, The Independent and the Daily Mail . The Telegraph incorrectly focused on pain “being all in the mind” and inferred that CBT was targeting the psychology of pain, rather than the psychology of how people manage their pain and their feelings about physical activity.
What kind of research was this?
Lower back pain is a common disabling condition in developed countries. Guidance suggests that people with persistent non-specific back pain remain physically active and avoid bed rest. Patients are also advised on how to manage their symptoms and how to use their pain medication appropriately. However, the effect of these lifestyle modifications may be short lived, with pain persisting in the long term.
This randomised controlled trial investigated whether this ‘best practice’ advice was more effective if patients also attended group support sessions and CBT with other people who had lower back pain. Group therapy benefits patients as they can give and receive support from others with similar problems, and treatment can be less expensive than one-on-one care. Here, the researchers wanted to investigate the effectiveness and cost of these interventions.
What did the research involve?
The researchers recruited 701 participants from 56 general practices in seven regions across England. Those who took part were identified from consultations with GPs or practice nurses and from searches from patient records.
To be included, participants had to be over 18. They had to have at least moderately troublesome subacute or chronic back pain for a minimum of six weeks and had visited their GP for help with the pain within the past six months. People were excluded if they had a specific or potentially serious cause for their back pain, such as infection, fracture or cancer. The study also excluded people who have severe psychiatric or psychological disorders and those who had tried CBT similar to that used in this study for their back pain.
The participants were randomly assigned to receive advice alone (control) or advice plus CBT. Before being allocated a treatment, a nurse gave them a 15-minute session of active management advice about maintaining physical activity, appropriate drug use and symptom management. The participants were also given The Back Book , which contains information on the management of back pain.
The 233 people in the control group received no further advice. The 468 people in the CBT group attended the Back Skills Training (BeST) programme, consisting of an individual assessment and six group therapy sessions in groups of around eight people. Each session lasted an hour and a half and targeted physical activity and avoidance of activity. This included countering negative thoughts about activity, and advice on different intensity activities and relaxation techniques.
The researchers measured back pain disability using the Roland Morris disability (0-24 points) questionnaire and the modified Von Korff scale (0-100%). In both of these scales, low scores indicate less disability. The participants’ mental and physical health-related quality of life was assessed using the 12-item short-form health survey at 3, 6 and 12 months. These questionnaires were sent out and returned by post.
What were the basic results?
The researchers found that 63% of participants in the CBT group attended a sufficient number of sessions to potentially benefit from the therapy. Reasons for not attending the sessions included ill health, work or family problems. Older individuals were more likely to attend the sessions.
Compared with advice alone, advice plus cognitive behavioural intervention was associated with significant benefits in disability. On the Roland Morris score, disability improved by 1.1 points in the control group and by 2.4 points in the intervention group at 12 months. The Von Korff score also showed the CBT group had a greater improvement in disability over 12 months than the control group.
When the patients reported how beneficial the treatments had been, 31% of the control group and 59% of the CBT group self-reported recovery at 12 months. Also, more patients in the CBT group were satisfied with their treatment at 12 months. The CBT group also had an improvement in fear avoidance as well as their physical scores, whereas the control group did not.
The total annual costs for each individual were £224.65 in the control group and £421.52 in the CBT group.
How did the researchers interpret the results?
The researchers suggest that compared to other treatments, such as manipulation, exercise, acupuncture and postural approaches, the benefits of CBT for people with chronic lower back pain were broader and lasted for at least 12 months. They also suggest that when the improvement in quality of life is taken into account, this treatment is cost effective.
This well conducted randomised controlled trial found that group CBT was of benefit to people with chronic lower back pain compared with individuals who received one-off advice on how to manage their condition through activity modifications and symptom control.
Although the therapy was effective, the researchers noted that 63% of people attended ‘sufficient’ CBT sessions to potentially benefit and 11% did not attend any of the sessions. Further research would be required to find out how to increase the numbers who attended the sessions. People who received CBT were also unlikely to have been using this intervention in isolation to manage their back pain, as advice was given to them about modifying their activities and pain medications.
It should also be noted that this management strategy would be suitable for chronic ‘nonspecific’ back pain only – that is, pain without an identified medical cause. This type of chronic low back pain is a very common and debilitating condition.
However, there are serious causes of back pain, such as infection, cancer or damage to the spine, that should always be considered and then excluded in a person with persisting or newly developed pain. Likewise, in people who have chronic low back pain without an identified cause, it is always beneficial for health professionals to explore the wider work-related and social or family effects and issues that may be involved with chronic back pain.
This was a randomised controlled trial, the best type of study to determine whether a treatment is effective or not. The study was well-carried out and gives good evidence that CBT can be beneficial in aiding patients to manage their chronic back pain effectively, particularly by maintaining appropriate physical activity leading to improvements in their quality of life.