primary healthcare

Group-based CBT for troublesome low back pain

These two papers have created a bit of a storm in the health news recently – a six-session CBT group programme for chronic low back pain that not only provides good outcomes, but is also cost-effective?  Unbelievable!  And it’s not delivered exclusively by any specific health professionals.  AND it’s delivered in primary care!

My take on this study is, much like others, very positive.  I think it’s wonderful that an intervention that has been used for years in secondary and tertiary health care has been successfully translated into primary care.  It seems to have used a pragmatic study methodology, and pretty fairly represents the kind of person that, at least in New Zealand anyway, misses out on pain management of this kind unless they’re funded by ACC (Accident Compensation Corporation).

Let’s take a look at the methodology first up.

The justification for this intervention is very clearly described in the first paper by Hansen, Dayken and Lamb.  Their brief was to develop and deliver a 6-week CB group programme delivered by a health professional for patients in primary care, who received this in addition to active management, which comprised a session of advice supported by the ‘Back Book’.  The ‘active management’ arm of the study then allowed these participants to seek any other treatment they wanted, while the researchers reviewed outcomes at 12 months after the intervention.

Hansen, Dayken and Lamb identify that “CB [approach] may be useful in modifying … health behaviours and risk factors [for disability from LBP] through targeted action on beliefs and positive coping strategies.”

Their research questions were:

• What does the research on risk factors for chronic LBP identify as potentially important health behaviours, beliefs and psychological constructs to incorporate into an intervention?
• What does the CB treatment model consider important in the design of a CB intervention?
• What is the optimal delivery method to balance clinical effectiveness and cost-effectiveness?

CB approaches, as regular readers of this blog will know, suggest that how an individual views his or her situation can influence emotions and behaviours in a bidirectional relationship.  Chronic pain management using this model suggests that by adopting a positive, self management approach, developing effective thinking strategies and learning appropriate problem solving techniques, disability and distress associated with ongoing pain can be reduced.

There has been a great deal of research into the use of CB approaches in chronic pain, sub-acute pain and across a range of types of pain.  Results have been mixed in some instances, but overall show short term positive outcomes for pain and disability, while longer term outcomes have not always been studied (mind you, ‘long term’ for drug trials is often three months!).  There seem to be no major differences between group-based or individual therapy, although group-based approaches appear to be more cost-effective (try telling that to the organisation I work for!).  Similarly there appear to be no major differences between who delivers the intervention, although most studies have clinical psychologists providing the cognitive behavioural components, while mostly physiotherapists deliver the exercise or activity components.

The key targets for this trial were:

• to increase activity levels;
• to manage periods of overactivity;
• to specifically address catastrophising and fear avoidance;
• to improve coping skills.

The rationale for session focus and content is detailed in this paper, and the group eventually arrived at a six-session programme with one additional session prior to the programme for assessment.

Each session is detailed (although not the exact content – but certainly the headings!), and they look very similar to, for example, the content of Turk & Winter’s book ‘The Pain Survival Guide’.

Content covered the following:

Understanding pain

Benefits of exercise

Pain fluctuations

Working out starting point for exercises or activities

How to set goals

Unhelpful thoughts and feelings


Restarting activities or hobbies

When pain worries us

Coping with flare-ups

Group sessions included group-based learning activities (experiential learning), with guided discovery as a primary method for helping people discover, for themselves, the issues and options available to them.

There was a standard agenda for each session:

Structure of BeST group sessions.
Agenda setting
The topics to be covered in the session are outlined at the start of
the session and the participants are asked if they have any
questions or problems that they would also like covered.
Review of homework/setting of homework
All sessions involve some home tasks. These are designed to
allow the participants to practice skills taught in the sessions.
Review of homework allows for group problem solving.
Each session covers one or two new topics as shown in Table 1.
There is also a quick review of the previous session at the start.
Each session involves a 10-minute break to allow participants to
move around or exercise, and for the therapist to check exercise
programmes with participants as required.

A couple of interesting points:

– the sessions were delivered in a community setting

– sessions were 90 minutes long

– sessions were delivered by a range of different health professionals

– group sizes were an average of 8 but between 4 – 12

– each group was facilitated by one therapist

If you’re wanting a simple outline of the rationale for, and the content included in a CB group programme, this paper certainly delivers.  It’s got a good number of references, and although brief, provides the sort of summary that a technically-minded health policy group could cope with.  Abbreviated a little more, it would be a useful summary for a group of managers.

Now to the results:  Lamb, Hansen, Lall, Castelnuova et al (2010) published this study in The Lancet – and it’s had, as I mentioned, wide coverage.  Cutting to the chase, this programme was able to demonstrate effective outcomes both in terms of functional outcomes (reduced disability, distress etc), but also cost effectiveness – The additional quality-adjusted life-year (QALY) gained from cognitive behavioural intervention was 0·099; the incremental cost per QALY was £1786, and the probability of cost-eff ectiveness was greater than 90% at a threshold of £3000 per QALY. There were no serious adverse events attributable to either treatment.

That last point is pretty good to hear – it’s one of the ‘costs’ of treatment we don’t often hear about when looking at, for example, injections, medications or surgery.

So, to be sure, this study compared a simple ‘advice-giving’ option plus ‘usual care’ with the six week CB approach, so the costs of the alternative were potentially quite low – but at the same time, the outcomes were quite impressive.

Were these patients like the patients typically referred to tertiary pain management centres?  Well, compared with those referred to the facility I work in, no.  They were much less distressed, less disabled, and more of them were working.  Many were retired folk, but there were far fewer who were receiving benefits than those I typically see.

I’ll continue with the review of this paper tomorrow – because there are some interesting things to be learned from it.  I hope this outline of the content at least whets the appetite for more!

Hansen, Z., Daykin, A., & Lamb, S. (2010). A cognitive-behavioural programme for the management of low back pain in primary care: a description and justification of the intervention used in the Back Skills Training Trial (BeST; ISRCTN 54717854) Physiotherapy, 96 (2), 87-94 DOI: 10.1016/
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