People who have chronic lower-back pain can benefit as much from cognitive behavioral therapy as they do from physical therapy, a new Dutch study suggests.

Study participants who had low-back pain reported improvements in function and reductions in pain whether they received 10 weeks of physical therapy or 10 weeks of cognitive therapy, according to researchers. Interestingly, those people who received a combination of cognitive and physical therapy did not do better than those on either treatment alone.

The Study

The study looked at 212 people who had chronic low-back pain. The participants were randomly assigned to one of four groups-active physical therapy (APT), cognitive behavioral therapy (CBT), a combination of APT and CBT or no treatment at all.

Active physical therapy was designed to restore aerobic capability and to increase back muscle strength. Participants rode a bicycle and did back-strengthening exercises. Cognitive behavioral therapy helped the patients cope with their pain and taught them how to overcome their reluctance to undertake physical activity.

The Results

At the end of the 1O-week study, both treatment groups had an improvement in their function and pain scores and a drop in their levels of complaints compared with the group that received no treatment. The combination group also improved, but only as much as either treatment group alone.

The study participants all completed numerous psychological and physical function questionnaires at the start and end of the study. One questionnaire that was used to gauge improvement was the Roland Disability Questionnaire, which asks 24 questions about the limitation on physical function due to back pain. The higher the score, the more disabled a person is by back pain. The average score on this questionnaire increased by almost three points for the group that received no treatment. However, scores went down an average of 2.25 points for the active physical therapy group, 2.65 points for the cognitive behavioral therapy group and 2.27 points for the combination group.

"People with disabling low-back pain should be [active], and this can either be achieved by physical training or cognitive behavioral training," says lead author, Dr. Rob Smeets, a consultant in rehabilitation medicine at the Rehabilitation Centre Blixembosch in the Netherlands.

"Physical training is slightly preferable for people with a relatively low level of disability at the start of treatment, but the cognitive behavioral treatment is preferred when people are moderately to severely disabled," he says.

The Benefits Of CBT

Dr. Scott Eathorne, medical director of athletic medicine at Providence Hospital in Southfield, Michigan, says he wasn't surprised that cognitive behavioral therapy had such an effect.

"People who have chronic back pain tend to start avoiding things that may actually be helpful to them. But cognitive behavioral therapy can change how they think about themselves," he says. "CBT not only addresses the physical aspects of the pain, but it starts to look at how the patients think about their pain and how they behave."

Both Smeets and Eathorne say they were somewhat surprised that the combination therapy wasn't more effective than either treatment alone. Smeets says it could be that there is a limit to the amount of improvement that's possible. It also could be that the people in the combination treatment group didn't adhere as closely to the study protocol as the other treatment groups, or the combination group might have been too small to produce any statistical difference, he says.

Smeets and his colleagues are following the study participants to see if the results will be long lasting.

"A multidisciplinary approach to back pain management is really key," says Eathorne." We need to design treatment approaches to take into account physical, emotional and behavioral aspects of back injuries."

Back pain is an extremely common condition, affecting four out of five Americans at some point in their lives, according to the National Institutes of Health (NIH).

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