Integrated Approach for Low Back Pain May Shift Standard of Care

Pauline Anderson

May 02, 2018

VANCOUVER, British Columbia — A 12-week rehabilitation program that offers cognitive-behavioral therapy (CBT) in addition to physical therapy is proving beneficial for patients with chronic low back pain.

Results of a new study show patients completing the program improved on several outcomes, including the extent to which pain interfered with daily life, perceived disability, depression, and anxiety.

Dr Sarah Rispinto

"We're hoping that this is something that can change the way chronic low back pain is treated," author Sarah Rispinto, PhD, a psychologist at the Cleveland Clinic in Ohio, told Medscape Medical News.

The study was presented here at the American Academy of Pain Medicine (AAPM) 2018 Annual Meeting.

Major Public Health Problem

Chronic back pain is a major public health problem. Current approaches to treating the condition often fail to address psychosocial factors that have been repeatedly demonstrated to predict pain-related outcomes affecting chronic pain.

The "typical order of care" for such patients is "highly medicalized," said Rispinto.

In 2016, the Cleveland Clinic launched the Back on TREK program, where frontline behavioral medicine specialists and physical therapists teach patients self-management using CBT for pain and psychologically informed physical therapy. 

Researchers collected data on 116 patients who had chronic low back pain for at least 3 months. Over 12 weeks, study participants devoted at least 1 hour three times a week to individual and group sessions focusing on physical or behavioral therapy.

At the beginning and end of the program, study participants completed the Oswestry Disability Index (ODI) and Patient-Reported Outcomes Measurement Information System (PROMIS) assessments. 

The study revealed clinically significant changes across multiple functional measures, including the ODI and all PROMIS measure subscales (such as social role satisfaction, fatigue, pain and global physical health).

Another PROMIS subscale that assesses the degree to which pain interferes with functioning also improved.

Close to half of the participants completing the program showed clinically significant changes in depression and anxiety.

This initiative aims to change the standard of care for back pain, said Rispinto.

"We're hoping that patients try this interdisciplinary approach first, that this can be a first-line treatment as opposed to a tertiary approach."

Rispinto and colleagues are now assessing whether the program affected opioid use.

"One of the goals of the program is to reduce the reliance on opioids, so we're hoping to look into that to see how much of a reduction there was — how many patients came into the program on opioids, and how many were discharged without opioids."

A future goal is to compare those who went through program to those who did not, said Rispinto. The investigators also want to replicate the program to treat other chronic conditions. Rispinto noted that many patients with chronic low back pain have comorbidities, such as fibromyalgia.

Notable Exclusion

Commenting on the study for Medscape Medical News, Lynn Webster, MD, vice president of scientific affairs, PRA Health Sciences, Salt Lake City, Utah, said the results highlight the importance of interdisciplinary care for patients with chronic low back pain. 

However, Webster noted that the study excluded patients with severe mental health instability. 

"As with most interventions, the success of their treatment was influenced by the type of patients they enrolled in their study. A huge percentage of people with chronic back pain also have serious mental health disorders. We need to find solutions for this population as well."   

But the study results "show that nonpharmacologic treatments should be available for people who might benefit from the treatments," said Webster. 

No funding source or relevant financial relationships were reported

American Academy of Pain Medicine (AAPM) 2018 Annual Meeting. Abstract 186. Presented April 27, 2018.

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