A comprehensive new study involving more than 13,000 patients suggests that the best treatments for chronic back pain should cover both physical and mental aspects – rather than concentrating solely on physical remedies.
Through a systematic review of 97 previous trials covering 17 different approaches to handling chronic back pain, researchers found that adding psychological interventions to treatments – mainly behavioral therapy and pain education – led to the most sustainable benefits for both physical function and pain intensity.
In the US, around 8 percent of adults are thought to experience persistent or chronic back pain, and that leads to costs in terms of both health care and missed days of work. Thanks to the new study, treatments could become more targeted and more effective.
"Clinical guidelines consistently recommend a combination of exercise and psychosocial therapies for managing chronic low back pain," says physiotherapist Emma Ho from the University of Sydney in Australia.
"However very little is actually known about the different types of psychological therapies available and their effectiveness."
As a result, doctors and patients alike can often be unsure about the best way forward with treatment, according to Ho. One of the motivations behind the new study was to bring some clarity as to what's available and what works best.
Six main types of psychological interventions were identified for the study's statistical analysis, including behavioral interventions, cognitive behavioral therapies, mindfulness, counseling, and pain educational programs. The sixth type was trials where two or more psychological approaches were combined.
For improving physical function, both cognitive behavioral therapy with physiotherapy and pain education with physiotherapy were better than physiotherapy alone. For helping pain intensity, behavioral therapy, cognitive behavioral therapy, and pain education were all shown to be effective additions.
The effectiveness changed over time though, with different trials operating over different durations. Pain education and behavioral therapy were shown to have the most impact over six and 12 months after treatment. Based on the available data, these interventions appear to be safe too.
"Examining the comparative effectiveness and safety of the wide range of available psychological interventions for chronic lower back pain might help to improve the clarity of guideline recommendations and better support clinicians and patients in treatment decision making," the researchers write in their paper.
Chronic back pain is defined as pain that lasts more than 12 weeks, and it often comes with psychological effects attached, including anxiety and depression. Those mental health impacts can then cause the physical health of an individual to deteriorate further.
The outcomes that the team looked at besides physical function and pain intensity were health-related quality of life, safety, compliance with treatment, and fear avoidance – that is, avoiding movement through the fear of pain. Again, treatments with added psychological measures were shown to get better results.
There are some limitations to the study to talk about: the researchers say the long-term effectiveness of these treatments (beyond 12 months) still needs to be assessed, and some of the trials used in the analysis had poor quality safety reporting data.
However, taken as a whole, the new research provides important insights into which psychological interventions work best, and how much more effective complementary treatments can be overall compared to relying solely on physical treatments and exercises.
"Clinicians should consider incorporating psychological interventions with physiotherapy care (mainly structured exercise) to maximize improvements in health outcomes," write the researchers.
The research has been published in the BMJ.