Behavioral Therapy Turns Subacute Back Pain Patients Toward RecoveryWhen is the best time to intervene with back pain? Studies show that most people get better after an episode of acute low back pain. A small percent go on to develop chronic, costly, disabling low back pain. At what point should treatment be done for these folks? In this study, patients in the subacute phase of their first ever episode of low back pain are treated. In this case, subacute meant they all had back pain that lasted six to 10 weeks and were unable to do their job.
The study was conducted at a naval medical center, so the patients were all otherwise healthy adults between the ages of 18 and 50. They had back pain despite conservative care but were not candidates for surgery. No one in the study had back pain from a serious medical problem such as cancer, infection, or fracture.
There is some evidence that psychosocial factors are part of the reason patients develop chronic pain that ends in disability. It seems that the subacute phase is when these influences have their greatest effect. Psychosocial variables refer to beliefs, moods, and coping. To explore the effect of targeting psychosocial factors, the patients in this pilot study were divided into two treatment groups.
The first group received four one-hour sessions of behavioral medicine. The model of behavioral medicine puts the focus on self-management of pain, slowly increasing activity, reducing fear of movement or reinjury, and changing beliefs about pain. Anatomy of the spine and physiologic function were reviewed to help patients understand their back pain.
Patients in this group were given exercises and activities to complete at home. Vocational counseling and stress management were offered to those who needed it. The role of attitude, emotions, and interpersonal relationships as these relate to back pain were discussed.
The second group received four one-hour sessions of attention control condition. They received empathy, support, and assurance from counselors who listened to them. They were encouraged to go back to the orthopedic physician or physical therapist whenever they needed help to manage their pain and speed up recovery.
Patients in both groups also received two one-hour booster sessions. These maintenance sessions were designed to review what patients had learned. The goal was to keep them on track during the first weeks after therapy was completed.
To compare treatment outcomes between the two groups, patients completed several surveys before and after treatment. They rated their pain, level of disability in daily activities, and general health status. They also completed a questionnaire that assessed their pain beliefs and ability to function despite pain. The physician reviewed their medical records and rated their work disability.
This battery of tests was given to the patients six and 12 months after the start of their pain. The main outcome was defined as recovery when there was an absence of pain and no longer any disability limiting function. The tests had cut off scores to help in dividing patients into those who recovered and those who did not.
Recovery rates were three times higher in the behavioral medicine group than in the attention control group. More patients in the behavioral medicine group recovered at six months and were back to work full-time at their pre-back pain level of activity. Those who attended the booster sessions had even better results. Test results showed that patients in the behavioral medicine group also changed their attitudes about seeing pain as disabling.
The authors say that although this was a small study limited to military personnel, the results suggest that a behavioral approach may be a very useful way to move patients with subacute back pain toward recovery. Preventing chronic back pain from developing saves money but also saves people from suffering unnecessarily. Empathy and therapist support may be a feel good approach. But it appears that directive treatment guiding patients through rehab has better results.
Mark A. Slater, PhD, et al. Preventing Progression to Chronicity in First Onset, Subacute Low Back Pain: An Exploratory Study. In Archives of Physical Medicine and Rehabilitation. April 2009. Vol. 90. No. 4. Pp. 545-552.
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