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Superior short term results for back and neck pain with cognitive-behavioral program
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April 2013
Superior short term results for back and neck pain with cognitive-behavioral program
Study Type:Therapy
OE Level Evidence:2
Journal Level of Evidence:N/A
Subacute and chronic, non-specific back and neck pain: Cognitive-behavioural rehabilitation versus primary care. A randomized controlled trial
BMC Musculoskelet Disord. 2008 Dec 30;9:172Did you know you're eligible to earn 0.5 CME credits for reading this report? Click Here
Synopsis
125 patients with subacute or chronic non-specific back and neck pain (BNP) were randomized to either receive cognitive-behavioural rehabilitation or primary-care. The results indicated that for patients presenting with both subacute and chronic back and neck pain, there was no difference between a cognitive-rehabilitation program compared to primary-care at 18 months. However, this study demonstrated that for subacute patients the cognitive-rehabilitation program may be superior in terms of sick-listing and number of health-care visits. Whereas, for chronic patients the cognitive-rehabilitation program was only superior in terms of health-care visits.
Publication Funding Details
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Funding:
Non-Industry funded
Sponsor:
Stockholm County Social Insurance Agency, Stockholm County Council, Ministry of Health and Social Affairs, VÃ¥rdal Foundation, Cardionics and Pharmacia (industry)
Conflicts:
None disclosed
Was the allocation sequence adequately generated?
Was allocation adequately concealed?
Blinding Treatment Providers: Was knowledge of the allocated interventions adequately prevented?
Blinding Outcome Assessors: Was knowledge of the allocated interventions adequately prevented?
Blinding Patients: Was knowledge of the allocated interventions adequately prevented?
Was loss to follow-up (missing outcome data) infrequent?
Are reports of the study free of suggestion of selective outcome reporting?
Were outcomes objective, patient-important and assessed in a manner to limit bias (ie. duplicate assessors, Independent assessors)?
Was the sample size sufficiently large to assure a balance of prognosis and sufficiently large number of outcome events?
Was investigator expertise/experience with both treatment and control techniques likely the same (ie.were criteria for surgeon participation/expertise provided)?
Yes = 1
Uncertain = 0.5
Not Relevant = 0
No = 0
The Reporting Criteria Assessment evaluates the transparency with which authors report the methodological and trial characteristics of the trial within the publication. The assessment is divided into five categories which are presented below.
3/4
Randomization
3/4
Outcome Measurements
4/4
Inclusion / Exclusion
4/4
Therapy Description
4/4
Statistics
Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65
The Fragility Index is a tool that aids in the interpretation of significant findings, providing a measure of strength for a result. The Fragility Index represents the number of consecutive events that need to be added to a dichotomous outcome to make the finding no longer significant. A small number represents a weaker finding and a large number represents a stronger finding.
Why was this study needed now?
In Sweden, back and neck pain, particularly non-specific pain, is the main cause of sick-listing. Return to work is extremely important; however, there is minimal consistency and comprehensiveness regarding the most effective way to measure return to work. Effective multidisciplinary treatment for subacute and chronic back and neck pain includes reactivation and progressive increase in level of activity, a cognitive-behavioural program to address dysfunctional beliefs as well as occupational interventions. Although these interventions as treatment for back pain have been investigated in randomized controlled trials, there is a lack of evidence concerning the most appropriate treatment for neck pain and no evidence from RCT's evaluating this intervention program for patients with back and neck pain (BNP). Currently, primary care is considered the standard form of treatment for patients with BNP. This study was needed to compare these two types of interventions in patients with chronic back and neck pain.
What was the principal research question?
What is the effect of a multidisciplinary cognitive-behavioural programme compared to primary care, on sick-listings and number of health-care visits, in patients with subacute and chronic back and neck pain, measured at 18 months follow up?
Study Characteristics
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Population:
125 patients, <60 years of age, with subacute/chronic and non-specific back and neck pain.
Intervention:
Cognitive-behavioural rehabilitation group: Participants in this group received manual therapy (consisting of manipulation, mobilization, and stabilizing training) and cognitive behavioural therapy that aimed to achieve a maximal degree of work ability for at least 30 consecutive days (Mean age: 42.2 (Range: 39.8 to 44.6), n=62, 61 completed follow up, F=33).
Comparison:
Primary-care group: Patients in this group received primary care for their back and neck pain from their GP and from any consultants the GP's referred their patients to (could be an orthopedist or neurologist) (Mean age: 43.0 (Range: 40.4 to 45.7), n=63, 62 completed follow up, F=35).
Outcomes:
The primary outcome measure was return-to-work share (percentage of patients who regained any work ability for at least 30 successive days). Secondary outcomes included return-to-work chance (chance of attaining any degree of work ability), net days (sick-listing) as well as the total number of health care visits.
Methods:
RCT: Multi-center
Time:
Follow up measures completed at 6, 12, and 18 months
What were the important findings?
- For all patients there were no significant differences between the cognitive-rehabilitation and the primary care groups in terms of Return-to-work share (20/35 vs. 25/35, respectively)) and Return-to-work chance (p>0.05 for both).
- For all patients at the 18 month follow up period, there were no significant differences between the two treatment groups with respect to net days and number of health-care visits (p>0.05). However, over the three six-month time periods a more rapid decrease was observed in the patients that underwent the cognitive-behavioural rehabilitation program (p<0.05).
- For subacute patients only, return-to-work share and net days (sick listing) was equivalent between the two treatment groups at the final follow-up; however, the rehabilitation group had a significantly more rapid decrease in net days over the six-month periods, and in the third period there were 31 fewer days. At 18 months, the subacute rehabilitation group had a significantly greater Return-to-work chance (hazard ratio 3.5 [95% CI 1.001-12.2]).
- Regarding the number of health-care visits, the two treatment groups demonstrated non-significant differences, though there were half as many visits in the third period in the rehabilitation group.
- For only chronic patients, Return-to-work share, Return-to-work chance, and net days were equivalent between treatment groups. The number of health-care visits at 18 months were not significantly different; however, the rehabilitation group had a more rapid decrease compared to the primary care group. There were half as many visits in the third period in the rehabilitation group.
What should I remember most?
The results demonstrated equivalency between the rehabilitation and primary care groups at 18 months; however, the analyses at the three six-month periods indicated that cognitive-rehabilitation generated fewer sick days and a lower number of health-care visits compared to primary care, especially in patients with subacute back and neck pain.
How will this affect the care of my patients?
Results of the study suggest that cognitive-behavioural rehabilitation in the long run may be superior to primary care in terms of sick-listing and health-care visits, but further research with longer follow up duration's are required to verify these findings.
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