I briefly discussed yesterday the content of this six-session group-based cognitive behavioural approach for chronic pain, delivered in the community. Today I want to look a little more closely at the way the programme was delivered and how the findings might differ from what happens in New Zealand.
To refresh your memory, this is a study of around 700 people with sub-acute or chronic ‘troublesome’ low back pain, recruited via their GP, who were randomised into two groups – while both groups received ‘advice’ in the form of ‘The Back Book’, the CBT group also received the CBT programme, while the other group were able to seek their ‘usual care’. The programme was delivered to groups of roughly 8 participants by a single therapist, and the therapist could be from a number of different health professions (physiotherapy, occupational therapy, psychology etc). Each session was intended to be 90 minutes long, and include guided discussion and some individual attention about the exercise component. Content was along the lines of ‘standard’ CBT for chronic pain management.
The study was commissioned by the UK’s National Institute for Health Research Health Technology Assessment Programme, and was a ‘pragmatic’ trial – in other words, assumed to be pretty much how it would be delivered long-term, with ‘real’ patients from differing backgrounds and so on. What’s nice about the whole process is that there have been several papers published on it over the time the project was run, so it’s well-documented and it’s easy for other providers and researchers to see how the team went about it. Very helpful if you’re wanting to establish something similar elsewhere!
I was firstly interested in how participants were recruited to this study. The study indicates that people were recruited from GP surgeries, either because they’d been seen by their GP or practice nurse, or identified through clinic records. One of the ongoing problems with self-management for pain is the difficulty obtaining suitable referrals – both health providers and patients often want a ‘medical’ approach with diagnosis and removal or reduction of pain – so it’s not always easy to find people who are ready for self management or a CBT approach. This paper doesn’t discuss how the participants were approached – which would have been nice to know. It does, however, discuss how many were approached but declined to participate: over 460 to the CBT group, 75 of these didn’t proceed, while 233 received the advice with 6 withdrawing from the study. Probably not unexpectedly, many withdrew from the study because of the number of questionnaires!
The ‘completion’ criteria used to establish whether participants had completed the CBT component of the study was very interesting to me – participating in the initial assessment, and attending 3 of the six sessions. I think this is quite a conservative ‘completion’ criterion, given that each session planned had very specific aspects of the CBT approach within it – those that didn’t attend all six sessions would have missed out on what I’d think were quite important aspects. Of course, we don’t know which aspects of the CBT approach do the therapeutic ‘work’, so maybe it’s moot!
Now for the good news: Compared with advice alone, advice plus cognitive behavioural intervention was associated with significant benefits in nearly all outcomes at 3, 6, and 12 months. Not only this, but more participants in the CBT programme were satisfied with their treatment. BUT, the mean total health-care costs per person for low-back pain (including the intervention) over 1 year were £224·65 for advice alone, and £421·52 for advice plus cognitive behavioural intervention. The mean cost per person was £16·32 for advice alone and £187·00 for advice plus cognitive behavioural intervention. The difference in total health-care costs was attributable almost entirely to the additional cost of the cognitive behavioural intervention. It’s not cheaper to deliver a CBT approach compared with advice plus usual care – and, unfortunately, there were no significant differences in the use of NHS or private health care between groups during the year of the study. Darn. This type of programme shouldn’t be seen as a cost saving exercise – it’s something else entirely for me.
For me it’s about some of the longer term benefits as well as the breadth of the benefits to the individual. Here’s what I mean: The study authors suggest that “the short-term effects (≤4 months) are similar to those seen in high-quality studies and systematic reviews of manipulation, exercise, acupuncture, and postural approaches in primary care.” They go on to add that “Unlike many of these other treatments, the benefits of cognitive behavioural intervention were broad ranging and maintained at 12 months, suggesting that these benefits will translate into substantial health gain at a population level.”
My point is that unlike manipulation and acupuncture, the skills these people developed can be used anywhere, don’t require health care provider input once they’ve been learned, and can be applied to several types of health problem. They don’t just address pain reduction and range of movement, but also influence overall disability, fear of moving despite pain, confidence to do things despite pain, and mental health.
Once the calculations are carried out (and, no I’m no health economist), it seems that the Quality Adjusted Life Years (go here for a brief discussion of QALY) for the CBT approach are much greater than for the control group (advice only). By comparison with the costs of other treatments I can think of (like injections or surgery), the up-front cost of this approach is much less.
In New Zealand, unless your back pain develops from an ‘accident’ as defined in the ACC legislation, you’re not very likely to get consistent advice a la The Back Book. This means that simply by providing The Back Book to people with back pain, the ‘control’ condition in this trial probably got something that many people in NZ don’t get: consistent advice that moving despite pain is good for back pain, and brief coverage of some of the methods to help manage distress and pain. One study by Cameron Crawford, Kathleen Ryan, and Edward Shipton (2007) found that 90% of people with low back pain were managed by the GP alone, but few of the GP’s considered psychosocial yellow flags – and their orientation towards managing low back pain was primarily biophysical. Whether this meant that people seeing their GP received advice to continue with activity, or whether this advice was supported by any printed material is unknown but it seems probable that few patients received the consistent information provided by The Back Book in this study.
The study authors make several points about this approach by comparison with other ways of managing low back pain in the community.
1. The primary intention of the BeST programme was to challenge beliefs and change a range of behaviours in people with low back pain. This is quite a different approach from the pain reduction focus of most treatments found in the community setting for low back pain.
2. Over 95% of the intervention contact time was directed toward psychological goals. This is in contrast with the ACC-sponsored focus ‘Activity Focused Programme’ in New Zealand which often consists of little more than regular attendance at a gym or other fitness activity.
3. The authors estimate that direct supervision of exercise occurred in less than 20% of participants for less than 5% of the intervention time. This is quite different from many physiotherapy-based approaches in New Zealand, where direct supervision is a requirement.
4. The programmes were delivered by experienced clinicians (an average of 9 years post-graduate experience) from a range of backgrounds, mostly physiotherapists, with a single therapist involved. Training in the programme took only two days. This is also quite different from the AFP approach adopted in New Zealand by ACC which mainly involves multiple professionals and the CBT component must be delivered by a clinical psychologist.
5. The outcomes, while significantly different for the CBT approach as compared with the control group, were not enormous in real terms – only 1 – 2 points on the Roland Morris Disability Questionnaire. Despite this, the authors say “there is evidence of moderate effect with the BeST intervention, there is no evidence of harm within the sample, and it is accepted that the consequences of developing and sustaining chronic low-back pain are important at the individual and societal level.” They go on to add “small to moderate effect sizes are important at a population level and that pragmatic trials will yield lower effects. The results of the cost-utility analysis re-enforce the conclusion that this is a clinically worthwhile intervention” and finally, they state “Recent UK and US clinical guidelines have made positive recommendations for other therapist delivered interventions on the basis of results from trials with smaller or unsustained effects.”
I can’t say that New Zealand health services have made similar errors – there have been no recent guidelines for managing low back pain published in New Zealand for some years.
Where does this leave me now?
Excited that a practical approach to helping people live well without needing ongoing input has been demonstrated.
Keen to look at the gaps in service delivery within New Zealand – particularly with the very large group of people who don’t receive ACC funding for treatment for their pain, and for the even larger group of people who can’t access CBT pain management because it’s not readily available in many centres (unless funded by ACC – and even then, it’s patchy).
Concerned that there doesn’t appear to be a systematic approach to developing community-based pain management using a CBT approach in New Zealand, despite the number of people living with chronic pain.
And concerned that the prevailing view in some sectors of health service delivery is that ‘only’ specific professional groups have the skills to deliver a CBT approach for pain management.
Where to from here?
I guess I want to encourage managers and policy development people to consider the ways pain management services are delivered, and the current focus on pain reduction and a biomedical approach to be expanded to include a CBT approach based in the community. As an old TV commercial used to say ‘One day, Roger Fitch, one day…!’
Lamb, S., Hansen, Z., Lall, R., Castelnuovo, E., Withers, E., Nichols, V., Potter, R., & Underwood, M. (2010). Group cognitive behavioural treatment for low-back pain in primary care: a randomised controlled trial and cost-effectiveness analysis The Lancet, 375 (9718), 916-923 DOI: 10.1016/S0140-6736(09)62164-4