There are many treatments for chronic low back pain. One paper recently reviewed the range of treatments as if they were available on a supermarket shelf – they made the point that ‘When a new treatment approach is being considered in fields as cardiology, infectious diseases, acute trauma, or neurology, there is a general expectation that adequate research will support its effectiveness, safety, and cost effectiveness before it is endorsed as a viable treatment option. With CLBP, however, treatment options appear virtually endless and increasing every year, have strong and vocal advocates, and often limited scientific evidence.‘ (Hageman & Dagenais, 2008)(my emphasis).
Multidisciplinary pain management has been accused of being complex, expensive and seemingly slower to produce results – and often purchasers of health care would much prefer to buy ‘quick fix’ solutions, or single discipline approaches in the belief that it will provide just as much benefit as a more expensive multidisciplinary programme. After all, the more quickly you get someone back to work, the more quickly a case can be closed – or is it?
This study by a group of researchers in Sweden has found that even after seven years, an intensive multidisciplinary pain management programme with a cognitive behavioural approach to self management, reactivation and return to work was more effective than a lower intensity manual therapy (physiotherapy) programme. There were some other bells and whistles to the intensive programme, which also included post-programme follow-up such as workplace intervention, training and support; and the manual therapy approach also included work-related intervention within the workplace, but did not include the cognitive therapy elements.
Some interesting differences were evident between the two groups – people on the intensive programme were more likely to be smokers, female and to be foreign to Sweden. The intensive programme also had people who were more sedentary and had lower mood. There is evidence now to show that people who are smokers are more likely to have chronic pain, and to have more difficulty recovering even after multidisciplinary pain management (Fishbain, Lewis, Cutler, Cole, Steele Rosomoff, & Rosomoff, 2008).
What do these findings mean? Well a couple of things spring to my mind.
1. The first is that in both treatment types, the best results were obtained for people who had lower rates of time off work. Those that took more time of work (or had taken more time off work) tended not to benefit as much as those who didn’t.
We don’t know the factors that influenced how much time a person takes off work (it could be that the person is working in a job where the policy is to be fully fit, or not attend work; perhaps the certifying doctor is more likely to recommend taking time off work; perhaps the person asks for time off work because of lack of confidence to be there), but it is clear that a programme cannot directly alter the general tendency to take time off work.
Despite this, people who attend an intensive pain management programme are more likely to return to work and take less time off than those who simply attend a manual therapy programme. Something in the ingredients of an intensive cognitive behavioural therapy approach makes a difference, and it does so for up to 7 years.
Now I don’t know about you, but I can’t think of a medication that we can take that has an effect for up to eight years!
2. The second thing that strikes me is that manual therapy has been shown to have an effect on pain intensity in people with acute low back pain: it’s an effective treatment along with general reactivation. There are quite a few treatments that lower pain intensity, and even directly influence activity level. Despite this, in this study it became clear that simply reducing pain doesn’t necessarily influence time off work – and it’s time off work that costs the person, the employer, the compensation system and the economy dearly.
While this study clearly acknowledges some of the assumptions made (especially with regard to economic savings), it’s nice to see that a real-life observational study can demonstrate that an up-front investment in multidisciplinary cognitive behavioural pain management has a positive outcome so long after the initial treatment. Let’s hope that policy-makers around the world take note that while it’s initially less expensive to provide a lower intensity programme, they just don’t provide the results in the long term.
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I.B. Jensen, H. Busch, L. Bodin, J. Hagberg, Å. Nygren, G. Bergström (2009). Cost effectiveness of two rehabilitation programmes for neck and back pain patients: A seven year follow-up Pain DOI: 10.1016/j.pain.2008.12.015
Fishbain, D. A., Lewis, J. E., Cutler, R., Cole, B., Steele Rosomoff, R., & Rosomoff, H. L. (2008). Does smoking status affect multidisciplinary pain facility treatment outcome? Pain Medicine, 9(8), 1081-1090.
Haldeman, S., & Dagenais, S. (2008). A supermarket approach to the evidence-informed management of chronic low back pain. Spine Journal: Official Journal of the North American Spine Society, 8(1), 1-7.