Chronic back pain: Behavioural treatments sent to the naughty step?

We have written a fair amount here about back pain. We’ve criticised some of the information patients get, shown how data has undermined many widely held beliefs about back pain (here and here), and acknowledged the rather desperate state of the evidence in terms of treatment efficacy. It is becoming more popular to see back pain as a problem of pain rather than of the spine (see Jason Silvernail’s recent contribution) and since the Biopsychosocial model first rose to popularity, treatments aimed at altering the behaviour and beliefs of back pain sufferers  to improve function have become common. Probably the best known of these approaches is Cognitive Behavioural Therapy (CBT).

Last year the Cochrane Review of behavioural treatments for chronic back pain was updated to include more recent studies. It drew the following conclusions:

  • Operant therapy was more effective than waiting list for short-term pain relief
  • little or no difference exists between operant, cognitive, or combined behavioural therapy for short- to intermediate-term pain relief (i.e. no type of behavioural approach is clearly superior)
  • behavioural treatment was more effective than usual care for short-term pain relief
  • there were no differences in the intermediate- to long-term, or on functional status
  • there was little or no difference between behavioural treatment and group exercise for pain relief or depressive symptoms over the intermediate- to long-term;
  • adding behavioural therapy to inpatient rehabilitation was no more effective than inpatient rehabilitation alone.

We could focus on a few positives in here but that would be to ignore some really pressing questions that arise for these treatment approaches.

In terms of effect size we can be fairly confident that the average effects on short term pain do not exceed a small 1 point change on a 10 point scale, and are likely to be less than that.  Perhaps worse, for approaches that seek to help patients  by teaching them long term self management skills, the lack of any measurable benefit beyond the immediate and short term is not encouraging.  In fairness these approaches to not seek to treat pain, they seek to enable patients with pain to function more effectively.

But the real humdinger in here is that the data do not indicate any effect of behavioural intervention on functional status.  Not for any comparisons. Focus on improving function is at the heart of these approaches and this seems a major blow. It is worth noting that there was not a lot of data for most of these comparisons and, as the authors suggest, it is likely that future research could change the conclusions.

We have discussed here before that the role of psychological variables in the course of back pain is currently not entirely clear.  We shouldn’t conclude that these results from behavioural treatments invalidate the importance of cognitive and behavioural factors in back pain. It does not necessarily follow that the failure of a treatment directed at them implies that they are not important, just that our attempts to influence them may not be effective.

Nonetheless it seems that our current best estimates do not give a resounding slap on the back for behavioural treatments for chronic back pain. More likely they send them to the naughty step with a stern talking to. Meanwhile back pain gets to behave as badly as it likes. Where is Supernanny when you need her?

About Neil

Neil O’Connell is a researcher in the Centre for Research in Rehabilitation, Brunel University, West London, UK. He divides his time between research and training new physiotherapists and previously worked extensively as a musculoskeletal physiotherapist. He also tweets! @NeilOConnell

Neil is currently fighting his way through a PhD investigating chronic low back pain and cortically directed treatment approaches. He is particularly interested in low back pain, pain generally and the rigorous testing of treatments. He also tends to get all geeky over controlled trials.


Henschke N, Ostelo RWJG, van Tulder MW, Vlaeyen JWS, Morley S, Assendelft WJJ, Main CJ. (2010). Behavioural treatment for chronic low-back pain. Cochrane Database of Systematic Reviews (7)


  1. This therapy wasn’t helpful at all. It doesn’t get rid of the pain, or make it easier to live with. I just felt punished, along with being miserable. “Don’t worry, be happy, you hurt because you’re negative.” It’s another slap in the face because you get that stage-mother voice that maybe this doesn’t work because you don’t try hard enough. My pain is as bad when I’m happy as it is when I’m depressed. What I want is it to just go away, period.

  2. Chris Barnett says

    Good work Neil,

    But it’s such a damn shame and i almost don’t want to beleive it!
    What do i tell my students or new graduate staff about complex back pain, when it comes to effective treatment?

    I certainly don’t want them over subscribing to as Eyal Lederman would call it a “postural-structural-biomechanical model” ( see the latest Journal of Bodywork and Movement Therapies in press for interesting discussion and invited commentary)

    But what do i tell them??, we know there are numerous yellow flags that appear to be prognostic modifiers but as yet we seem to have little evidence that these factors can change due to our intervention.

    Cheers Chris

  3. This may be another example where sub-grouping may be needed. We need to stop looking at people with low back pain as a homogeneous group.

  4. Good questions, Julia, and great responses, Neil! Thank you.

    My own quaint way of paraphrasing what Neil just said is that CBT is failing the “impress me” test. If CBT is more effective for a certain kind of patient, apparently there are not enough of those kinds of patients, or the effect is not big enough, to have any discernible effect on the average. If it is being washed out, it is being washed out too easily. CBT might work, a little, for some, but such scraps of efficacy hardly seem worth fighting over …

    Neil O'Connell Reply:

    Thanks Paul (I can see everyones comments again woohoo!), thats precisely what I meant, only articulated better!

  5. Julia Hush says

    Thanks for another interesting post Neil. I completely concur with the sad state of affairs regarding evidence for LBP treatment efficacy. I would like to play devil’s advocate and defend the “one size doesn’t fit all” theory (if for no other reason than to provoke Nick now he has returned to Oz!)

    I think we are all aware that an inherent limitation of most systematic reviews is that it is difficult to produce a summary statement that adequately addresses the intrinsic heterogeneity of patients and treatments. This emphasizes the need to carefully examine studies included in reviews and I think this example is a good case in point.

    The majority of studies included in this review excluded patients who would be typical of patients referred for treatment to a pain clinic: ie. compensation/litigation or unemployed, widespread pain, previous/scheduled back surgery, psychiatric conditions such as clinical depression etc. It’s a bit like excluding patients with radiating leg pain for a trial to see if McKenzie therapy works.

    The broad brush of “behavioural treatment” is another dilemma, which is certainly not limited to this review. The term is often used to mean quite different things, by different people. In this review, behavioural treatments were quite variable (eg. 10 brief relaxation training sessions in some studies and in others >100 hours of an intensive rehabilitation programme of education and exercise based on principles of cognitive-behaviour therapy).

    There is reasonable empirical as well as anecdotal evidence that a “typical” chronic back pain patient attending a pain clinic may respond far better to an intensive behavioural program than a weekly session on how to relax. For example, a previous systematic review [1] found the best results in a depressed and disabled population obtained from more intensive programs (> 100 hours). In this current review, some studies used very brief interventions (eg 17.5 hours of combined cognitive behavioural therapy and physiotherapy over 5 weeks) to treat patients with clinically significant levels of depression and disability (eg [2]). Trying to tease this out further, trials in this Cochrane review that used higher intensity programs (eg [3-4]) did report much higher effect sizes.

    Regarding acute/subacute back pain, there is evidence from a recent review for superior outcomes in studies where patients were selected on the basis of heightened psychological risk factors for poor outcomes [5]. This conclusion is consistent with the results of a large randomised controlled trial with mixed chronic musculoskeletal pain patients in Norway [6]. In that study, patients who were identified as having poor prognosis achieved significantly better long-term outcomes (including function) when treated in a comprehensive, multidisciplinary behaviourally-based pain management program compared with two less comprehensive interventions by general medical practitioners and physiotherapists. In contrast, these less comprehensive (and cheaper) interventions were just as effective with those patients with good and moderate prognoses, such as the patient described here.

    So perhaps one size doesn’t fit all. If patient selection and matching to an appropriate dose and content of behavioural treatment can influence outcome, it is possible that there is a “wash-out effect” in the main conclusions of this systematic review. Where do we go from here? Ask Nick!

    1. Guzman J, Esmail R, Karjalainen K, Malmivaara A, Irvin E, Bombardier C. Multidisciplinary rehabilitation for chronic low back pain: systematic review. BMJ. 2001;322(7301):1511-6.
    2. Nicholas MK, Wilson PH, Goyen J. Comparison of Cognitive-behavioural group treatment and an alternative non-psychological treatment for chronic low back pain. Pain 1992;48:339-47.
    3. Williams AC, Nicholas MK, Richardson PH, Pither CE, Fernandes J. Generalizing from a controlled trial: the effects of patient preference versus randomization on the outcome of inpatient versus outpatient chronic pain management. Pain. 1999;83:57-65.
    4. van Hooff M, van der Merwe J, O’Dowd J, Pavlov P, Spruit M, de Kleuver M, et al. Daily functioning and self-management in patients with chronic low back pain after an intensive cognitive behavioral programme for pain management. European Spine Journal. 2010;19(9):1517-26.
    5. Nicholas MK, Linton SJ, Watson PJ, Main CJ. The early identification and management of psychological risk factors (Yellow Flags) in patients with low back pain: A reappraisal. Physical Therapy. (in press, 2011).
    6. Haldorsen EMH, Grasdal AL, Skouen JS, et al. Is there a right treatment for a particular patient group? Comparison of ordinary treatment, light multidisciplinary treatment, and extensive multidisciplinary treatment for long-term sick-listed employees with musculoskeletal pain. Pain. 2002;95:49-63.

    Neil O'Connell Reply:

    Oi julia! Now you’re making work for me!,

    I understand you concerns. I have just had a quick squizz through the exclusion criteria for all those studies comparing with waiting list/ no treatment – only 2 have criteria that particularly concern me (compensation patients and back surgery etc, but the bulk do not seem to). As for widespread pain that is a reasonable exclusion crtieria since the research question is related to chronic back pain specifically. I’m not sure that we can conclude that the bulk of research in CBT for back pain picked the wrong patients to treat.

    The review does separate analyses to types of approach although this still involves heterogeneity. But we should also consider the biases in favour of finding an effect – unblinded or partially blinded trials (inevitably), the effect of attention versus no attention etc. And we can see no effect on function at all.

    The washout argument suggests that some people respond to some interventions. Maybe, but we don’t really see a positive trend on function so for things to average out at nought we might have to assume that the therapies actively hurt as many patients as they helped? Seems unlikely. Also if the problem is one of lack of power, if we dichotomised our outcomes into the numbers of responders/ non responders (and we think our non-responders are washing out the responders), I wonder what kind of number needed to treat we might come up with? Might be prohibitively high.

    In pragmatic clinical terms I would not consider 17.5 hours of face to face contact as “very brief”. It is compared with >100 hours for sure but given the scale of the CLBP burden the ugly spectre of cost-efficacy rears its head, particularly for an effect size which, if there at all, is likely to be modest to small.

    Targeted treatment may well throw up more compelling data and I haven’t read the Nicholas paper. The group at Keele have a trial underway at the moment subgrouping by severity I think.The great thing about subgrouping is that you can choose whatever subgroups you like (do it by your favoured diagnosis, do it by the severity of psychological factors, the severity of symptoms, use a clinical prediction rule). Unfortunately the groups are only sometimes led by data (rarely) and the prospective data tells us little about what those groups might be (as Nick will tell you!) – the temptation to data mine is hard to resist. I am open to the idea of subgroups but at the moment I am not convinced.

  6. Neil

    a timely reminder of how far the pendulum has swung with the biopsychosocial model and “the decade of the flags”.

    I’m reminded of a lengthy discussion with Prof Mick Sullivan on castrophisation, belief systems and the multitude of other inventories out there. My disquiet was with the interpretation and implication of scores from such tools. Ultimately, they indicate mild , moderate or strong tendencies to certain charactaristics which may positively or negatively influence outcome (allegedly!!).

    My contention was that it is more relevant clinically to ask a direct specific question.
    When do you plan to go back to work.

    What do you think is wrong with you.

    What is preventing you doing xyz….

    The answers to these questions force the clinician to challenge distorted beliefs (or ignore them if they can’t handle it) , or recognise non-modifiable variables which even the good Lord could’nt change.

    In fairness, we reached consensus which may explain the poor CBT outcomes you suggest using the existing outcome tools.

    As for designing a research protocol to accommodate this…. – I’d like to keep what hair I have but we’ve trashed that one around long enough on another thread.

    Maybe some of the data collection experts could shed some light?



    Neil O'Connell Reply:

    Hi David,

    The research protocol is simple. You want to know if strategies to modify these beliefs and behaviours can improve patients clinically. You perform an RCT. You can choose whatever you wish to compare it to. Care is reasonably individualised with this approach form a psychosocial perspective since strategies for each patient are predicated on the findings of the psychosocial assessment. You then measure the outcome that you think is important – say function/ disability….and when we do that…

    I’m not sure the pendulum ever did swing that far towards the biopsychosocial. Much simpler models have enjoyed greater popularity – like instability, mm balance etc with equally banal results.

  7. Is “the naughty step” an Australianism?

    I am comfy with Googling, of course, but sometimes it’s more fun to ask.

    Neil O'Connell Reply:

    The naughty step is a form of “time out” for recidivist children! My 3 year old is reasonably familiar with it…

  8. neil o'connell says

    Thanks Anoop,

    I think the review throws up significant problems for behavioural treatments. The “one size doesn’t fit all” argument would say that only some of those participants may have been likely to respond to behavioural therapy and so the effect gets washed out. I do not personally subscribe to this view for the reasons that as my colleague Ben and I argued in the first half of this paper:

    The lack of any effect on function from what are essentially unblinded trials is stark.

    Where does one go from here? I don’t have that answer.

  9. Hi Neil,

    So does it mean that behavioral strategies don’t work for low back pain or there are methodological issues with the studies or the review? Where do you go from here.

    Thanks. And I really like how you are so cautious about your conclusions.

  10. Thanks for this thoughtful review – and yes, time for behavioural strategies to get with the programme! Of course, these approaches at least don’t mean invasive procedures and don’t delay recovery while waiting for them – and none of the other treatments do a lot either, so I guess back pain will be with us for a while longer. What a pain!

    neil o'connell Reply:

    Its all a bit sad and you’re right: the risk profile is low but looking at the review for what is really the primary target of behavioural treatment there is nothing there. My challenge for 2011 is to try to find a good news back pain story to blog. Might have to be about something other than efficacy!