Behavioral treatment for chronic low back pain - A systematic review within the framework of the Cochrane Back Review Group

Study Design. A systematic review of randomized controlled trials. Summary of Background Data. The treatment of chronic low back pain is not p rimarily focused on removing an underlying organic disease but at the reduc tion of disability through the modification of environmental contingencies and cognitive processes. Behavioral interventions are commonly used in the treatment of chronic (disabling) low back pain. Objectives. To determine whether behavioral therapy is more effective than reference treatments for chronic nonspecific low back pain and which type o f behavioral treatment is most effective. Methods. The authors searched the Medline and PsychLit databases and the Co chrane Controlled Trials Register up to April 1999, and Embase up to Septem ber 1999. Also screened were references of identified randomized trials and relevant systematic reviews. Methodologic quality assessment and data extr action were performed independently by two reviewers. The magnitude of effe ct was assessed by computing a pooled effect size for each domain (i.e., be havioral outcomes, overall improvement, back pain-specific and generic func tional status, return to work, and pain intensity) using the random effects model. Results. Only six (25%) studies were high quality. There is strong evidence (level 1) that behavioral treatment has a moderate positive effect on pain intensity (pooled effect size 0.62; 95% confidence interval [Cl] 0.25, 0.9 8), and small positive effects on generic functional status (pooled effect size 0.35; 95% CI: -0.04, 0.74) and behavioral outcomes (pooled effect size 0.40; 95% Cl: 0.10, 0.70) of patients with chronic low back pain when comp ared with waiting-list controls or no treatment. There is moderate evidence (level 2) that a addition of behavioral component to a usual treatment pro gram for chronic low backpain has no positive short-term effect on generic functional status (pooled effect size 0.31; 95% Cl: -0.01, 0.64), pain inte nsity (pooled effect size 0.03; 95% Cl: -0.30, 0.36), and behavioral outcom es (pooled effect size 0.19; 95% Cl: -0.08, 0.45). Conclusions. Behavioral treatment seems to be an effective treatment for pa tients with chronic low back pain,but it is still unknown what type of pati ents benefit most from what type of behavioral treatment.