The role of psychological therapy in back pain
The recently published NICE guideline on Low back pain has recognised the value of psychological therapy, when combined with an intensive physical treatment programme.
It is estimated that 2.6 million people in the UK consult their GP about back pain each year.1 Although many episodes resolve rapidly, one third of patients continue to experience disabling low back pain 12 months later.2
The NICE guideline covers the management of patients whose pain has persisted for > 6 weeks, but for < 12 months. Initial management comprises education about the nature of non-specific low back pain, advice to stay physically active and to exercise, pain relief, and a choice of either a structured exercise programme, a course of manual therapy or acupuncture.
For patients who continue to have significant disability and/or psychological distress despite receiving at least one less intensive treatment, referral for a combined physical and psychological treatment programme is suggested. This should include a cognitive behavioural approach and exercise, and provide around 100 hours of treatment over a period of up to 8 weeks.
Chronic low back pain (>12 weeks) has been classified as one of the functional somatic syndromes (FSS).3 The NICE guidance can therefore be usefully compared with the stepped care approach for the management of FSS.3 For patients with uncomplicated FSS, the approach is the same, namely reassurance, explanation, pain relief and advice to exercise. For patients with repeated presentations, persistent organic causal attribution or associated anxiety and depression, it is also recommended that we consider antidepressant treatment and encourage patients to reframe their symptoms within a biopsychosocial framework. In contrast, NICE found no clear evidence that antidepressants are more effective than placebo in the management of patients with chronic back pain.1
Pain and depression commonly occur together.
A quarter of primary care patients with pain have concurrent major depression.4 An RCT from an American primary care setting has compared managed care of depression followed by a pain self-management programme with usual care for patients with persistent (>3 months) low back, knee or hip pain and depression (PHQ-9 score ?10). At 12 months' follow-up, 37.4% of patients from the intervention group had ?50% reduction in depression severity compared with 16.5% of controls. And 41.5% of the patients in the intervention group had a clinically significant reduction in pain compared with 17.3% of controls. The mean duration of antidepressant treatment in the intervention group was 9.2 months compared with 2.0 months in the controls.5
CBT for patients with FSS involves the recognition, evaluation and reframing of unhelpful health beliefs and negative beliefs. For example, patients with low back pain may believe that their pain is caused by a defect of the spinal column, that pain is harmful and that they should avoid activities that cause pain. They may regard their inability to work as a sign of failure, believe that others do not regard their symptoms as genuine, and expect that their pain will never stop. These beliefs may be linked to unhelpful behaviours such as avoidance and social withdrawal.6,7
CBT is recognised as an effective treatment for FSS, with strong evidence of benefit in chronic fatigue syndrome and chronic low back pain, and moderate evidence of benefit in IBS and fibromyalgia.3
Rather than restrict psychological interventions to patients with treatment-resistant low back pain, a case can be made for early brief interventions for patients identified as having adverse psychosocial prognostic factors. However, a Dutch study found no evidence of benefit 12 months after a 20-minute intervention, although it is doubtful whether the intensity of the intervention was adequate.7
Providing that the recommended treatment programmes are made available, the NICE guidance provides a helpful framework for the management of persistent low back pain. It is just a pity that the importance of recognising and effectively treating concurrent depression has not been emphasised.Author
Dr Phillip Bland
BA BM BCh MRCGP DRCOG