Abstract

Background

Behavioural treatment is commonly used in the management of chronic low‐back pain (CLBP) to reduce disability through modification of maladaptive pain behaviours and cognitive processes. Three behavioural approaches are generally distinguished: operant, cognitive, and respondent; but are often combined as a treatment package.

Objectives

To determine the effects of behavioural therapy for CLBP and the most effective behavioural approach.

Search methods

The Cochrane Back Review Group Trials Register, CENTRAL, MEDLINE, EMBASE, and PsycINFO were searched up to February 2009. Reference lists and citations of identified trials and relevant systematic reviews were screened.

Selection criteria

Randomised trials on behavioural treatments for non‐specific CLBP were included.

Data collection and analysis

Two review authors independently assessed the risk of bias in each study and extracted the data. If sufficient homogeneity existed among studies in the pre‐defined comparisons, a meta‐analysis was performed. We determined the quality of the evidence for each comparison with the GRADE approach.

Main results

We included 30 randomised trials (3438 participants) in this review, up 11 from the previous version. Fourteen trials (47%) had low risk of bias. For most comparisons, there was only low or very low quality evidence to support the results. There was moderate quality evidence that:

i) operant therapy was more effective than waiting list (SMD ‐0.43; 95%CI ‐0.75 to ‐0.11) for short‐term pain relief;

ii) little or no difference exists between operant, cognitive, or combined behavioural therapy for short‐ to intermediate‐term pain relief;

iii) behavioural treatment was more effective than usual care for short‐term pain relief (MD ‐5.18; 95%CI ‐9.79 to ‐0.57), but there were no differences in the intermediate‐ to long‐term, or on functional status;

iv) there was little or no difference between behavioural treatment and group exercise for pain relief or depressive symptoms over the intermediate‐ to long‐term;

v) adding behavioural therapy to inpatient rehabilitation was no more effective than inpatient rehabilitation alone.

Authors' conclusions

For patients with CLBP, there is moderate quality evidence that in the short‐term, operant therapy is more effective than waiting list and behavioural therapy is more effective than usual care for pain relief, but no specific type of behavioural therapy is more effective than another. In the intermediate‐ to long‐term, there is little or no difference between behavioural therapy and group exercises for pain or depressive symptoms. Further research is likely to have an important impact on our confidence in the estimates of effect and may change the estimates.

Author(s)

Nicholas Henschke, Raymond WJG Ostelo, Maurits W van Tulder, Johan WS Vlaeyen, Stephen Morley, Willem JJ Assendelft, Chris J. Main

Abstract

Plain language summary

Behavioural treatment for chronic low‐back pain

Low‐back pain is a major health and economical problem that affects populations around the world. Chronic low‐back pain, in particular, is a major cause of medical expenses, work absenteeism, and disability. Current management of chronic low‐back pain includes a range of different treatments such as medication, exercise, and behavioural therapy. Research has shown that social roles and psychological factors have a role in the course of chronic low‐back pain. 

This review of 30 studies (3438 participants) evaluated three behavioural therapies for chronic low‐back pain: (i) operant (which acknowledges that external factors associated with pain can reinforce it), (ii) cognitive (dealing with thoughts, feelings, beliefs, or a combination of the three, that trigger the pain), (iii) respondent (interrupts muscle tension with progressive relaxation techniques or biofeedback of muscle activity).

For pain relief, there was moderate quality evidence that:

(i) operant therapy was more effective than waiting list controls in the short‐term,

(ii) there was little or no difference between operant therapy, cognitive therapy; or a combination of behavioural therapies in the short‐ or intermediate‐term, and 

(iii) behavioural treatment was more effective than usual care (which usually consists of physical therapy, back school and/or medical treatments) in the short‐term. 

Over a longer term, there was little or no difference between behavioural treatment and group exercise for pain relief or reduced depressive symptoms. The addition of behavioural therapy to inpatient rehabilitation did not appear to increase the effect of inpatient rehabilitation alone.

For most of the other comparisons, there was only low or very low quality evidence, which was based on the results of only two or three small trials. There were only a few studies which provided information on the effect of behavioural treatment on functional disability or return to work.

Further research is very likely to have an important impact on the results and our confidence in them.

Author(s)

Nicholas Henschke, Raymond WJG Ostelo, Maurits W van Tulder, Johan WS Vlaeyen, Stephen Morley, Willem JJ Assendelft, Chris J. Main

Reviewer's Conclusions

Authors' conclusions 

Implications for practice 

Operant therapy was found to be an effective treatment modality for short‐term pain reduction in patients with chronic low‐back pain when compared to a waiting list. However, no significant differences were detected when operant therapy was compared to other types of behavioural treatment. Behavioural treatment was found to be more effective than usual care for pain relief in the short‐term, but no differences were found over the long‐term or on functional status measures. No differences were found between behavioural treatment and a group exercise program on pain relief or for symptoms of depression. It is still unknown what type of patients benefit most from what type of behavioral treatment. Whether clinicians should refer chronic low‐back pain patients to behavioural treatments or to other active conservative treatments cannot be concluded from this review.

Implications for research 

More fundamental or basic research is warranted to identify which psychological factors have the strongest influence on a patient's experience of LBP and which of these factors can be utilised as appropriate outcome measures. Only after these factors are better understood can possible mechanisms of behavioural therapy on pain relief be determined and subsequent improvements made to the interventions. In future trials, we advocate the use of valid and reliable outcome measures in the low‐back pain field and also a move to determine the most reliable and valid outcome measures in the behavioural domain. Finally, in future studies, behavioural treatment should be compared to other active treatments for CLBP, and a cost‐effectiveness analysis should be included.

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