Tools for Practice


#309 Can our brains help our pain? Psychological interventions for chronic low back pain (Free)


CLINICAL QUESTION
In adults with chronic low back pain, do psychological interventions improve pain?

BOTTOM LINE
Psychological interventions, specifically cognitive behavioral therapy and mindfulness-based stress reduction, lead to clinical improvements in pain for approximately 30-60% of patients compared to 20-30% with control at 18 to 52 weeks. The specific intervention chosen should be guided by patient preference and accessibility.


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EVIDENCE
  • Results statistically significant unless otherwise noted.
  • One randomized controlled trial (RCT)1 [342 patients, baseline “pain-bothersomeness” 6 on 10-point scale (lower score=better)] compared 8 weekly sessions of cognitive behavioral therapy (CBT) to 8 weekly sessions (with optional retreat) of mindfulness-based stress reduction (MBSR) or usual medical care.
    • Global Improvement (pain “much better” or “completely gone”) at 52 weeks.
      • 32% CBT, 30% MBSR, 18% control; number needed to treat (NNT) versus control: 7 to 8.
    • ≥30% reduction in pain-bothersomeness scale:
      • 40% CBT (not statistically different from either), 49% MBSR, 31% control at 52 weeks, NNT 6 for MBSR over control.
    • No difference for either outcome at 104 weeks.2
  • One RCT3 (701 patients, baseline pain 59/100) randomized to receive up to 6 sessions of group CBT or usual care/education. After 12 months:
    • Proportion “recovered”: 59% versus 31% (control), NNT 4.
  • One RCT4 [156 patients, baseline pain ~56 on 100-point scale (lower=better)]; 10-14 one-hour CBT sessions versus waitlist. At 18 weeks:
    • Clinically meaningful pain improvement (≥18-point decrease): 44% versus 23% waitlist, NNT 4.
  • Three systematic reviews reported similar results.5-7
  • Limitations:
    • Systematic reviews report standard mean differences.
    • Control interventions not consistent and not always well defined.
Context
  • No RCTs were found for Acceptance Commitment Therapy (ACT).
  • MBSR is a mind-body approach which focuses on increasing awareness and acceptance of moment-to-moment experiences including physical discomfort and difficult emotions.1
  • Psychological interventions were provided by a trained healthcare professional.
  • Can be delivered online or in-person, with limited evidence on best delivery model. Patient preference should guide decision on specific therapy chosen.
  • Interactive tools such as decision aids8 or pain calculators9 can be helpful in discussing management options with patients.
February 24, 2022

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Author(s):

  • Danielle Perry RN MSc
  • Jennifer Potter MD CCFP
  • Jessica Kirkwood MD CCFP (AM)

1. Cherkin DC, Sherman KJ, Balderson BH, et al. JAMA. 2016; 315(12):1240-1249.

2. Cherkin DC, Anderson ML, Sherman KJ, et al. JAMA. 2017; 317(6):642-644.

3. Lamb SE, Hansen Z, Lall R, et al. Lancet. 2010; 375(9718):916-923.

4. Siemonsma PC, Stuive I, Roorda LD, et al. Phys Ther. 2013; 93(4):435-448.

5. Skelly AC, Chou R, Dettori JR, et al. AHRQ publication No. 22-EHC002. Rockville, MD: Agency for Healthcare Research and Quality; October 2021. Available at: Available at https://effectivehealthcare.ahrq.gov/sites/default/files/pdf/cer-251-integrated-pain-management.pdf Accessed November 30, 2021.

6. Chou R, Deyo R, Friedly J, et al. Ann Intern Med. 2017; 166(7):493-505.

7. Anheyer D, Haller H, Barth J, et al. Ann Intern Med. 2017; 166(11):799-807.

8. Kirkwood J, Allan GM, Korownyk CS, et al. Can Fam Physician. 2021; 67(1):31-34.

9. Comparing Treatment Options for Pain: The C-TOP Tool. Available at https://www.pain-calculator.com Accessed January 27, 2022.

Authors do not have any conflicts of interest to declare.