Cognitive behavioural therapy, mindfulness and exercise have emerged as some of the most effective individual treatments for low back pain over the long term, a meta-analysis by Macquarie University researchers shows.
And combining physical and psychological therapies appears to have even greater effects for those with back pain, the team finds.
Their review of 75 clinical trials assessed the effect of 20 different non-surgical treatments of chronic low back pain over one year or more.
Interventions such as massage, manipulation, nutritional supplements, pain education, injections and goal setting were considered in their review.
The study, published in Lancet Rheumatology, is the first review and meta-analysis to specifically assess the long-term effectiveness of interventions for chronic low back pain.
Lead author Dr Hazel Jenkins, a senior lecturer in the Department of Chiropractic, says the findings are important because they assess longer term outcomes rather than short term results.
“The positive news is that we now know there are a number of different types of treatments that have some evidence of effect over the longer term,” says Dr Jenkins.
“The individual treatments that stood out for reducing pain and disability, were psychological treatments such as CBT and mindfulness, and physical treatments like exercise and manipulation.”
Promising combinations
But combining treatments that target the physical, psychological and social factors in back pain, shows the most promise, especially in reducing disability from back pain, she says.
On average the effective interventions decreased disability by about 20 per cent – a clinically meaningful difference for many people.
Around 4 million Australians are living with lower back pain, which affects one in six people at any point in time. Four out of five will experience lower back pain at least once in their lifetime.
I think people should be cautious of treatments that are very short term, symptomatic treatments, that require multiple visits to a practitioner.
Typically it’s not a one-off episode either. Most people who experience lower back pain find it comes back over months and years and is a leading cause of disability and reduced quality of life.
Yet senior co-author, Professor in Physiotherapy Mark Hancock says most recommendations and guidance on low back pain refer to treatments that might have only short-term benefits.
“That’s why we were interested in doing this review of the evidence on what interventions have effects beyond the one-year mark,” Professor Hancock says.
“A lot of back pain management focuses on treating the symptoms rather than addressing what might be the underlying causes and problems.”
One of the multi-component treatments that showed some of the largest positive effects in their review was an approach called cognitive functional therapy.
A key element of cognitive functional therapy is addressing unhelpful cognitions, emotions, and behaviours that contribute to an individual’s back pain.
The other aspect focusses on returning to the daily activities that are most important to patients, but are often avoided due to fear or pain.
“A lot of these more effective treatments are about giving people the skills and confidence to manage their own condition, including future episodes if they occur,” says Professor Hancock who has been involved in evaluating cognitive functional therapy trials.
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Their review also pointed to therapies that didn’t have a long-term effect --which tended to be interventions for easing symptoms.
“Obviously massage or medication are appropriate for short term symptom control, but if patients are looking for longer term treatments, then the multi-component approaches are more effective,” he says.
“I think people should be cautious of treatments that are very short term, symptomatic treatments, that require multiple visits to a practitioner,” he says.
The researchers also caution that many of the trials they reviewed had small sample sizes, high risk of bias, or varying results, limiting the certainty of evidence.
“Large high-quality studies designed to specifically test long term effects are needed,” says Dr Jenkins.
Mark Hancock is a Professor of Physiotherapy in the Faculty of Medicine and Health Science, Macquarie University.
Dr Hazel Jenkins is a Senior lecturer in the Department of Chiropractic, Macquarie University.
