Medication, Physiotherapy and Cognitive Behavior Therapy for the Treatment of Chronic Back Pain: A Clinical Trial
Onac, Ioana A., Moldovan, Adela R., Onac, Ioan, Igna, Raluca, Pop, Liviu, Journal of Evidence-Based Psychotherapies
Chronic back pain is a burdening health problem, both at an individual level (in terms of pain, disability, emotional distress associated) and at a more general, society level (important costs resulting from treatment and disability, loss of working capability). Current clinical guidelines recommend drug therapy, physiokinetotherapy and psychotherapy in the treatment of chronic back pain. Our objective for this study was to analyze the efficiency of combining these treatments into three treatment conditions (medication alone, medication and physiokinetotherapy, medication, physiokinetotherapy and CBT). A total of 75 patients with chronic back pain were randomized to one of the three treatment conditions. The outcome measures were: pain intensity, disability related to back pain and emotional distress. Results show better pain outcomes for medication and physiokinetotherapy and medication, physiokinetotherapy and CBT as compared to the group receiving only medication. No significant between-group differences were found for disability related to back pain or emotional distress. Clinical implications of results and future study directions are discussed.
Keywords: chronic back pain, physiokinetotherapy, Cognitive Behavior Therapy, clinical trial
Sciatica, a clinical feature of lumbar disc hernia, is considered to be a negative predictor in terms of chronic back pain, more sever disability and missing work. Epidemiological reviews from 1980 to 2008 revealed a prevalence of 13-43% for this condition (Konstantinou & Dunn, 2008; Stafford, Peng, & Hill, 2007). Several studies (i.e., Atlas, Keller, Chang, Deyo, & Singer, 2001, Nykvist, Hurme, Alaranta, & Einola, 1989; Weber, Holme, & Amlie, 1993) which followed up people with sciatica over the course of 5 years revealed that about 50-72% of the patients remained with a chronic pain despite treatment of an initial sciatica episode. The cost of treatment for patients with chronic low back pain (representing about 10% of the patients who suffer from low back pain at some point in their lives) is around 50 billion dollars/year in United States, and this represents about 80-90% of all costs entailed for low back pain (DeLisa, 2005). Chronic pain, unlike acute pain, serves no useful purpose (Winterowd, Beck, & Gruener, 2003) and it represents a challenging problem for the patient especially from a psychological point of view (Winterowd, Beck, & Gruener, 2003). This is shown by the high rates of depression among chronic pain patients (Banks & Kern, 1996). Moreover, it seems that patients with chronic back pain not only have a much higher emotional distress, but also a higher probability of developing psychiatric symptoms, of which the most common are depression, substance abuse and anxiety disorders (Polatin, Kinney, Gatchel, Lillo & Mayer, 1993).
One of the proposed pathophysiological mechanisms for sciatica is lumbar disc hernia. Herniation of lumbar disc which results in symptomatic sciatica is around 1 to 10%. For patients presenting with this type of pain, clinical studies have shown that, in time, the nucleus pulposus protrusion, extrusion will resorb (Hakan, Selcuk, & Erdener, 2008; Sakai, Tsuji, Asazuma, Yato, Matsubara, & Nemoto, 2007; Saal, Saal, & Herzog, 1990). However, for a group of patients, pain continues even after such improvements in their vertebral pathology. Thus, the treatment for low back pain resulting from a herniated lumbar disk consists of (1) pharmacologic treatment to address the central and peripheral pain mechanisms; (2) physiokinetotherapy to help restore and improve mobility and also address pain; (3) psychotherapy to address potential psychological mechanisms that might be responsible for the persistence of pain even after significant improvements in pathology (e.g., pain catastrophizing - Forsythe, Dunbar, Hennigar, Sullivan, & Gross, 2008; Picavet, Vlaeyen, & Schouten, 2002). …