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Low back pain sufferers reported improvements in function and levels of pain whether they received 10 weeks of physical therapy or underwent 10 weeks of cognitive therapy, compared to those who received no treatment, researchers said.
However, those on a combination of cognitive and physical therapy did no better than those on either treatment alone.
"People with disabling low back pain should be [active] and this can either be achieved by physical training or cognitive behavioral training," said the study's lead author, Dr. Rob Smeets, a consultant in rehabilitation medicine at the Rehabilitation Centre Blixembosch in the Netherlands.
"Physical training is a little bit more preferable for people with a relatively low level of disability at the start of treatment, but the cognitive behavioral treatment is to be preferred when people are moderately to severely disabled," he said.
Results of the study appear in the Jan. 20 issue of the open access journal Musculoskeletal Disorders from BioMed Central.
Back pain is an extremely common condition, with four out of five Americans suffering from it at some point in their lives, according to the U.S. National Institutes of Health. Fortunately, most back pain is short-term -- called acute. However, if back pain lasts longer than three months, it is considered chronic.
The new study included 212 people with 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 increase back muscle strength. Participants had to ride a bicycle and perform 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.
Treatment lasted for 10 weeks, and the study participants all completed numerous psychological and physical function questionnaires at the start and end of the study. Some of the measures were the Roland Disability Questionnaire, the Pain Rating Index and the Beck Depression Inventory.
Both treatment groups saw an improvement in their function, a drop in levels of complaints, and even their pain scores improved compared to the group that received no treatment. The combination group also improved, but only as much as either treatment group alone did.
For example, the Roland Disability Questionnaire asks 24 questions about physical function and limitation on physical function from back pain. The higher the score, the more disabled a person is by their back pain. The average score on this questionnaire increased by almost three points for the group that received no treatment. But scores went down an average of 2.25 for the active physical therapy group, 2.65 for the cognitive behavioral therapy group, and 2.27 for the combination group.
Dr. Scott Eathorne, medical director of athletic medicine at Providence Hospital in Southfield, Mich., said he wasn't surprised that cognitive behavioral therapy had such an effect.
"People with chronic back pain tend to start avoiding things that may actually be helpful to them, but cognitive behavioral therapy changed how they think about themselves," he said. "CBT not only addresses the physical aspects of the pain but starts to look at how they think about their pain and how they behave."
Both Smeets and Eathorne said they were somewhat surprised that the combination therapy wasn't more effective than either treatment alone. Smeets said it could be that, while each group was taught in a different way, both groups learned how to overcome their pain and improve their physical function, and there may be a limit to that improvement. It's also possible that those in the combination group didn't adhere as closely to the study protocol, or the group might have been too small to produce a statistical difference, he said.
Smeets and his colleagues are following the study participants for a year to see if the results will be long lasting.
"A multi-disciplinary approach to back pain management is really key," said Eathorne. "We need to design treatment approaches to take into account physical, emotional and behavioral aspects of back injuries."
SOURCES: Rob Smeets, M.D., consultant in rehabilitation medicine, the Rehabilitation Centre Blixembosch, the Netherlands; Scott Eathorne, M.D., associate chairman, primary care, and medical director of athletic medicine, Providence Hospital, Southfield, Mich.; January 20, 2006, Musculoskeletal Disorders
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