Abstract
Background: Non-specific chronic low back pain disorders have been proven resistant to change, and there is still a lack of clear evidence for one specific treatment intervention being superior to another.Methods: This randomized controlled trial aimed to investigate the efficacy of a behavioural approach to management, classification-based cognitive functional therapy, compared with traditional manual therapy and exercise. Linear mixed models were used to estimate the group differences in treatment effects. Primary outcomes at 12-month follow-up were Oswestry Disability Index and pain intensity, measured with numeric rating scale. Inclusion criteria were as follows: age between 18 and 65 years, diagnosed with non-specific chronic low back pain for >3 months, localized pain from T12 to gluteal folds, provoked with postures, movement and activities. Oswestry Disability Index had to be >14% and pain intensity last 14 days >2/10. A total of 121 patients were randomized to either classification-based cognitive functional therapy group n = 62) or manual therapy and exercise group (n > = 59).Results: The classification-based cognitive functional therapy group displayed significantly superior outcomes to the manual therapy and exercise group, both statistically (p < 0.001) and clinically. For Oswestry Disability Index, the classification-based cognitive functional therapy group improved by 13.7 points, and the manual therapy and exercise group by 5.5 points. For pain intensity, the classification-based cognitive functional therapy improved by 3.2 points, and the manual therapy and exercise group by 1.5 points.Conclusions: The classification-based cognitive functional therapy produced superior outcomes for non-specific chronic low back pain compared with traditional manual therapy and exercise.
Highlights
62 patients were assigned to the CB-CFT group, and 59 were assigned to the manual therapy and exercise (MT-EX) group (Fig. 1)
A total of 16 of 59 (27.1%) patients assigned to MT-EX and 11 of 62 (17.7%) patients assigned to CB-CFT either did not start treatment or did not complete treatment, and were unavailable for either 3- or 12-month follow-up assessment, which precluded an intention-to-treat analysis
Analysed study participants in the two treatment arms were comparable in terms of baseline characteristics, with the exception of small but significant differences in HSCL and Fear-Avoidance Beliefs Questionnaire (FABQ) work (Table 1)
Summary
The current evidence for management of non-specific chronic low back pain (NSCLBP) reveals that interventions such as manual therapy, exercise, acupuncture, spinal injections and cognitive behavioural therapy are not superior to each other and have a limited long-term impact on the disorder (Assendelft et al, 2004; Furlan et al, 2005; Hayden et al, 2005; Ostelo et al, 2005; Staal et al, 2008).Possible reasons for the failure of current clinical practice to effectively manage NSCLBP are proposed to lie in two main domains: (1) The failure to adequately deal with NSCLBP within a multidimensional biopsychosocial framework (Borkan et al, 2002). The Cochrane Back Review Group proposed that identification of subgroups is a key priority of low back pain (LBP) management in order to deal with the problem of patient heterogeneity (Bouter et al, 2003) Recent research supports this claim, with evidence that NSCLBP subjects can be broadly classified based on psychological factors (Turk, 2005; Boersma and Linton, 2006; Hill et al, 2010), movement and postural behaviours (Dankaerts et al, 2009), neurophysiological factors (Smart et al, 2011) and lifestyle behaviours [sedentary (Bjorck-van Dijken et al, 2008) vs excessive activity (Mitchell et al, 2010)]. Conclusions: The classification-based cognitive functional therapy produced superior outcomes for non-specific chronic low back pain compared with traditional manual therapy and exercise
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