BABCP

Readers may have seen news coverage of a large randomised controlled trial published in The Lancet in February (and available to view here), which showed clinical effectiveness of a cognitive-behavioural (CB) approach for subacute/chronic low back pain (LBP). This is an exciting result for both the world of LBP and CBT.

The trial was conducted at the University of Warwick by a team in the Clinical Trials Unit led by Professor Sallie Lamb. In the trial, 701 participants with moderate to severely troublesome LBP of longer than six weeks duration were randomised to either a single session of advice (233 participants) or a single session of advice plus a group CB approach (468 participants). The single session of advice followed the Active Management Strategy and was supported by a small publication called The Back Book. Key messages of the Active Management Strategy are to keep active, return to normal activities as quickly as possible, take regular painkillers and seek advice from a G.P. when required. The advice session lasted up to 20 minutes and was delivered by a research nurse or physiotherapist.

The group CB approach consisted of an initial assessment session on a one-to-one basis lasting up to 90 minutes. This session included a discussion of problems and goals. Unhelpful beliefs around back pain were elicited and were challenged where appropriate and participants were shown a series of exercises that they could try. This session was followed by a weekly group session lasting for 90 minutes for six weeks. Group sessions were structured although flexible to participants needs, covering a range of areas from the more educational topics such as understanding pain, influence of deconditioning, through to cognitive behavioural techniques such as identifying and challenging unhelpful thoughts around back pain, understanding fear avoidance and hypervigilance vicious cycles, relaxation, and typical symptom management skills such as pacing, graded activity, and managing flare-ups. Session topics and skills covered were selected based on a maintenance model of LBP that was developed for the trial.

Health professionals (physiotherapists, occupational therapists, nurses and psychologists) were trained to deliver the manualised approach over two days and were then provided with supervision (on average 45 minutes per group run). The health professionals were instructed on basic guided discovery techniques so that the emphasis was for the professional running the group to act as a facilitator for discussion.

Two thirds of those allocated to the groups attended at least three of the six group sessions and 85% of participants in each group completed the study follow up. Primary outcomes were the change at one year from baseline in the Roland Morris disability questionnaire and modified Von Korff scores, both of which measure pain and disability.

The team found that at one year, the CB approach had significantly improved both disability scores. The change from baseline in the Roland Morris questionnaire was 2.4 points in the CB group compared with 1.1 points in controls. The Von Korff score changed by 13.8% in the CB group and 5.4% in controls. In addition, significant improvements were seen in a range of other measures such as self efficacy, fear avoidance, and general health.

The short-term effects (≤ four months) were similar to those seen in high-quality studies and systematic reviews of manipulation, exercise, acupuncture, and postural approaches in primary care (those treatments currently recommended in guidelines). However, many trials of these interventions have not shown improvements sustained at one year.

Importantly, the treatment was cost-effective. The cost per quality-adjusted life-year was £1786: at least half the cost of the other interventions mentioned, which will make it an interesting treatment option for health care providers.

Zara Hansen (zara.hansen@warwick.ac.uk)
Physiotherapist and Cognitive Behavioural Therapist
Clinical Research Fellow on the Back Skills Training Trial, University of Warwick