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Cognitive behavioural approach improves back pain

Group cognitive behavioural approaches can reduce low-back pain, and at a low cost to the health-care provider, according to researchers at the University of Warwick.

In an article published this week in The Lancet, the research team found the improvement was sustained at 1 year after the start of treatment. 

Persistent low-back pain is increasingly common, and it can be debilitating, ranking as one of the top three most disabling conditions in the developed world. It is also costly to treat as it is such a common condition.

Professor Sarah Lamb and colleagues from Warwick Medical School, University of Warwick, undertook a randomised controlled trial of 701 patients with troublesome subacute or chronic low-back pain from general practices across England.

The researchers’ goal was to determine whether a group cognitive behavioural approach (CBA) would offer any additional benefit to best practice advice in primary care. This advice included guidance on staying active and appropriate use of pain medication. The patients were then randomly assigned to two groups: 468 participants were given up to six sessions of group CBA, and 233 controls were given no additional treatment. 85% of participants in each group completed the study. Primary outcomes were the change at 1 year from baseline in Roland Morris disability questionnaire and modified Von Korff scores, both of which measure pain and disability.

The team found that at 1 year, CBA had significantly improved both disability scores. The change from baseline in the Roland Morris questionnaire was 2.4 points in the CBA group compared with 1.1 points in controls. The Von Korff score changed by 13.8% in the CBA group and 5.4% in controls. Crucially, the treatment was cost-effective. The cost per quality-adjusted life-year was £1786, which is about half that of competing treatments such as acupuncture.

The authors say: “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.”

The authors believe that the treatment could have a wide applicability because the participants were representative of the ethnic mix of the UK, and they came from a mix of rural and urban areas. They also note that 95% of the CBA session time was directed towards achieving psychological goals rather than on supervised exercise.

They conclude: “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. This is a novel approach, which instead of targeting physical risk factors for back pain, targets the way people think about their pain and ability to cope with pain as a way of getting them better – this really is fundamentally different from the traditional way of treating back pain in primary care.”

In an accompanying comment, Laxmaiah Manchikanti, Pain Management Center of Paducah, Paducah, KY, USA, says that Lamb and colleagues’ study “showed rather impressive results”.

Manchikanti sounds a note of caution about the routine availability of group CBA 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 concludes that “the results suggest that cognitive behavioural intervention is an excellent option for primary care physicians before they seek specialty consultations for their patients.”

Notes to editors

For more details, please contact Kelly Parkes-Harrison, Communications Officer, University of Warwick,, 02476 150483, 07824 540863