An article published in this week’s issue of The Lancet reports that group cognitive behavioral therapy (CBT) can reduce low-back pain at a low cost to the health-care provider. Furthermore, one year after the start of treatment, the improvement was sustained.

Ranked as one of the top three most disabling conditions in the developed World, persistent low-back pain is increasingly common. It can be very debilitating. Because it is so widespread, back pain is also costly to treat.

A randomized controlled trial was undertaken by Professor Sarah E Lamb, at the Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK, and colleagues. It included a total of 701 patients with troublesome subacute or chronic low-back pain from general practices across England. The researchers aimed to determine whether group cognitive behavioral therapy would offer any added benefit to best practice advice in primary care. This advice included recommendations on staying active and correct use of pain medication.

The patients were then randomly assigned to two groups:
• 468 participants were given up to six sessions of group CBT
• 233 controls were given no additional treatment

In each group, 85 percent of participants completed the study. Primary outcomes were the change at one year from baseline in Roland Morris disability questionnaire and modified Von Korff scores. Both are tools to measure pain and disability.

After one year, results indicate that CBT had significantly improved both disability scores. The change from baseline in the Roland Morris questionnaire was 2.4 points in the CBT group compared with 1.1 points in controls. The Von Korff score changed by 13.8 percent in the CBT group and 5.4 percent in controls. Importantly, the treatment was cost-effective. The cost per quality-adjusted life-year was about half that of competing treatments such as acupuncture.

The authors comment: “Effective treatments that result in sustained improvements in low-back pain are elusive. This trial shows that a bespoke cognitive behavioural intervention package, BeST, is effective in managing subacute and chronic low-back pain in primary care. 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.”

Because the participants were representative of the ethnic mix of the UK and came from a mix of rural and urban areas, the authors consider that the treatment could have a broad applicability. They also observe that 95 percent of the CBT session time was intended towards achieving psychological goals rather than on supervised exercise.

They write in conclusion: “A bespoke cognitive behavioural intervention package for low-back pain has an important and sustained effect at 1 year on disability from low-back pain at a low cost to the health-care provider.”

In an associated note, Dr Laxmaiah Manchikanti, Pain Management Center of Paducah, Paducah, KY, USA, comments that Lamb and colleagues’ study “showed rather impressive results.”

Manchikanti warns about the routine availability of group CBT for low-back pain in primary care. It “might be feasible in countries with national health-care systems, but not in a country like the USA.”

He says in closing that “the results suggest that cognitive behavioural therapy is an excellent option for primary care physicians before they seek specialty consultations for their patients.”

“Group cognitive behavioural treatment for low-back pain in primary care: a randomised controlled trial and cost-effectiveness analysis”
Sarah E Lamb, Zara Hansen, Ranjit Lall, Emanuela Castelnuovo, Emma J Withers, Vivien Nichols, Rachel Potter, Martin R Underwood, on behalf of the Back Skills Training Trial investigators
DOI: 10.1016/S0140-6736(09)62164-4
The Lancet

Written by Stephanie Brunner (B.A.)