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Meta-Analysis
. 2010 Jul 7;2010(7):CD002014.
doi: 10.1002/14651858.CD002014.pub3.

Behavioural treatment for chronic low-back pain

Nicholas Henschke  1 , Raymond Wjg Ostelo, Maurits W van Tulder, Johan Ws Vlaeyen, Stephen Morley, Willem Jj Assendelft, Chris J Main
Affiliations
Meta-Analysis

Behavioural treatment for chronic low-back pain

Nicholas Henschke et al. Cochrane Database Syst Rev. .

Abstract

Background: Behavioural treatment is commonly used in the management of chronic low-back pain (CLBP) to reduce disability through modification of maladaptive pain behaviours and cognitive processes. Three behavioural approaches are generally distinguished: operant, cognitive, and respondent; but are often combined as a treatment package.

Objectives: To determine the effects of behavioural therapy for CLBP and the most effective behavioural approach.

Search strategy: The Cochrane Back Review Group Trials Register, CENTRAL, MEDLINE, EMBASE, and PsycINFO were searched up to February 2009. Reference lists and citations of identified trials and relevant systematic reviews were screened.

Selection criteria: Randomised trials on behavioural treatments for non-specific CLBP were included.

Data collection and analysis: Two review authors independently assessed the risk of bias in each study and extracted the data. If sufficient homogeneity existed among studies in the pre-defined comparisons, a meta-analysis was performed. We determined the quality of the evidence for each comparison with the GRADE approach.

Main results: We included 30 randomised trials (3438 participants) in this review, up 11 from the previous version. Fourteen trials (47%) had low risk of bias. For most comparisons, there was only low or very low quality evidence to support the results. There was moderate quality evidence that:i) operant therapy was more effective than waiting list (SMD -0.43; 95%CI -0.75 to -0.11) for short-term pain relief;ii) little or no difference exists between operant, cognitive, or combined behavioural therapy for short- to intermediate-term pain relief;iii) behavioural treatment was more effective than usual care for short-term pain relief (MD -5.18; 95%CI -9.79 to -0.57), but there were no differences in the intermediate- to long-term, or on functional status;iv) there was little or no difference between behavioural treatment and group exercise for pain relief or depressive symptoms over the intermediate- to long-term;v) adding behavioural therapy to inpatient rehabilitation was no more effective than inpatient rehabilitation alone.

Authors' conclusions: For patients with CLBP, there is moderate quality evidence that in the short-term, operant therapy is more effective than waiting list and behavioural therapy is more effective than usual care for pain relief, but no specific type of behavioural therapy is more effective than another. In the intermediate- to long-term, there is little or no difference between behavioural therapy and group exercises for pain or depressive symptoms. Further research is likely to have an important impact on our confidence in the estimates of effect and may change the estimates.

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Conflict of interest statement

Johan Vlaeyen is co‐author of four of the trials included in this review, and Maurits van Tulder is the co‐author of one of the included trials. Risk of bias assessment and data extraction of these trials was done by two other review authors (Nicholas Henschke and Raymond Ostelo).

Figures

1
1
Summary of risks of bias for each included study
1.1
1.1. Analysis
Comparison 1 Respondent therapy (progressive relaxation) versus waiting list control, Outcome 1 Pain (short‐term).
1.2
1.2. Analysis
Comparison 1 Respondent therapy (progressive relaxation) versus waiting list control, Outcome 2 Functional status (short term).
1.3
1.3. Analysis
Comparison 1 Respondent therapy (progressive relaxation) versus waiting list control, Outcome 3 Depression (short term).
2.1
2.1. Analysis
Comparison 2 Respondent therapy (EMG biofeedback) versus waiting list control, Outcome 1 Pain (short term).
2.2
2.2. Analysis
Comparison 2 Respondent therapy (EMG biofeedback) versus waiting list control, Outcome 2 Functional status (short term).
3.1
3.1. Analysis
Comparison 3 Operant therapy versus waiting list control, Outcome 1 Pain (short term).
3.2
3.2. Analysis
Comparison 3 Operant therapy versus waiting list control, Outcome 2 Functional status (short term).
3.3
3.3. Analysis
Comparison 3 Operant therapy versus waiting list control, Outcome 3 Depression (short term).
4.1
4.1. Analysis
Comparison 4 Cognitive therapy versus waiting list control, Outcome 1 Pain (short term).
4.2
4.2. Analysis
Comparison 4 Cognitive therapy versus waiting list control, Outcome 2 Functional status (short term).
5.1
5.1. Analysis
Comparison 5 Cognitive‐behavioural therapy versus waiting list control, Outcome 1 Pain (short term).
5.2
5.2. Analysis
Comparison 5 Cognitive‐behavioural therapy versus waiting list control, Outcome 2 Functional status (short term).
5.3
5.3. Analysis
Comparison 5 Cognitive‐behavioural therapy versus waiting list control, Outcome 3 Depression (short term).
6.1
6.1. Analysis
Comparison 6 Cognitive therapy versus operant therapy, Outcome 1 Pain (short term).
6.2
6.2. Analysis
Comparison 6 Cognitive therapy versus operant therapy, Outcome 2 Pain (intermediate term).
7.1
7.1. Analysis
Comparison 7 Cognitive‐behavioural therapy versus cognitive therapy, Outcome 1 Pain (short‐term).
7.2
7.2. Analysis
Comparison 7 Cognitive‐behavioural therapy versus cognitive therapy, Outcome 2 Pain (intermediate‐term).
7.3
7.3. Analysis
Comparison 7 Cognitive‐behavioural therapy versus cognitive therapy, Outcome 3 Pain (long‐term).
7.4
7.4. Analysis
Comparison 7 Cognitive‐behavioural therapy versus cognitive therapy, Outcome 4 Functional status (short‐term).
7.5
7.5. Analysis
Comparison 7 Cognitive‐behavioural therapy versus cognitive therapy, Outcome 5 Functional status (intermediate‐term).
7.6
7.6. Analysis
Comparison 7 Cognitive‐behavioural therapy versus cognitive therapy, Outcome 6 Functional status (long‐term).
7.7
7.7. Analysis
Comparison 7 Cognitive‐behavioural therapy versus cognitive therapy, Outcome 7 Depression (short‐term).
7.8
7.8. Analysis
Comparison 7 Cognitive‐behavioural therapy versus cognitive therapy, Outcome 8 Depression (intermediate‐term).
7.9
7.9. Analysis
Comparison 7 Cognitive‐behavioural therapy versus cognitive therapy, Outcome 9 Depression (long‐term).
8.1
8.1. Analysis
Comparison 8 Cognitive‐behavioural therapy versus operant therapy, Outcome 1 Pain (short‐term).
8.2
8.2. Analysis
Comparison 8 Cognitive‐behavioural therapy versus operant therapy, Outcome 2 Pain (intermediate‐term).
8.3
8.3. Analysis
Comparison 8 Cognitive‐behavioural therapy versus operant therapy, Outcome 3 Pain (long‐term).
8.4
8.4. Analysis
Comparison 8 Cognitive‐behavioural therapy versus operant therapy, Outcome 4 Functional status (short‐term).
8.5
8.5. Analysis
Comparison 8 Cognitive‐behavioural therapy versus operant therapy, Outcome 5 Functional status (intermediate‐term).
8.6
8.6. Analysis
Comparison 8 Cognitive‐behavioural therapy versus operant therapy, Outcome 6 Functional status (long‐term).
9.1
9.1. Analysis
Comparison 9 Cognitive‐behavioural therapy versus respondent therapy, Outcome 1 Pain (short term).
9.2
9.2. Analysis
Comparison 9 Cognitive‐behavioural therapy versus respondent therapy, Outcome 2 Pain (intermediate term).
9.3
9.3. Analysis
Comparison 9 Cognitive‐behavioural therapy versus respondent therapy, Outcome 3 Functional status (short term).
9.4
9.4. Analysis
Comparison 9 Cognitive‐behavioural therapy versus respondent therapy, Outcome 4 Functional status (intermediate term).
9.5
9.5. Analysis
Comparison 9 Cognitive‐behavioural therapy versus respondent therapy, Outcome 5 Depression (short term).
9.6
9.6. Analysis
Comparison 9 Cognitive‐behavioural therapy versus respondent therapy, Outcome 6 Depression (intermediate term).
10.1
10.1. Analysis
Comparison 10 Behavioural treatment versus other treatments (usual care), Outcome 1 Pain (short term).
10.2
10.2. Analysis
Comparison 10 Behavioural treatment versus other treatments (usual care), Outcome 2 Pain (intermediate term).
10.3
10.3. Analysis
Comparison 10 Behavioural treatment versus other treatments (usual care), Outcome 3 Back specific functional status (short term).
10.4
10.4. Analysis
Comparison 10 Behavioural treatment versus other treatments (usual care), Outcome 4 Back specific functional status (intermediate term).
11.1
11.1. Analysis
Comparison 11 Behavioural treatment versus other treatments (group exercise), Outcome 1 Pain (short term).
11.2
11.2. Analysis
Comparison 11 Behavioural treatment versus other treatments (group exercise), Outcome 2 Pain (intermediate term).
11.3
11.3. Analysis
Comparison 11 Behavioural treatment versus other treatments (group exercise), Outcome 3 Pain (long term).
11.4
11.4. Analysis
Comparison 11 Behavioural treatment versus other treatments (group exercise), Outcome 4 Depression (short term).
11.5
11.5. Analysis
Comparison 11 Behavioural treatment versus other treatments (group exercise), Outcome 5 Depression (intermediate term).
11.6
11.6. Analysis
Comparison 11 Behavioural treatment versus other treatments (group exercise), Outcome 6 Depression (long term).
12.1
12.1. Analysis
Comparison 12 Behavioural treatment versus other treatments (surgery), Outcome 1 Back specific functional status (long term).
13.1
13.1. Analysis
Comparison 13 Behavioural treatment in addition to physiotherapy versus physiotherapy, Outcome 1 Pain intensity (short term).
13.2
13.2. Analysis
Comparison 13 Behavioural treatment in addition to physiotherapy versus physiotherapy, Outcome 2 Pain Intensity (intermediate term).
13.3
13.3. Analysis
Comparison 13 Behavioural treatment in addition to physiotherapy versus physiotherapy, Outcome 3 Depression (short term).
13.4
13.4. Analysis
Comparison 13 Behavioural treatment in addition to physiotherapy versus physiotherapy, Outcome 4 Depression (intermediate term).
13.5
13.5. Analysis
Comparison 13 Behavioural treatment in addition to physiotherapy versus physiotherapy, Outcome 5 Functional status (short term).
13.6
13.6. Analysis
Comparison 13 Behavioural treatment in addition to physiotherapy versus physiotherapy, Outcome 6 Functional status (intermediate term).
14.1
14.1. Analysis
Comparison 14 Behavioural treatment in addition to inpatient rehabilitation versus inpatient rehabilitation, Outcome 1 Pain intensity (short term).
See this image and copyright information in PMC

Update of

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