Cognitive behavioral therapy (CBT) has “small-to-medium effects” for disability and pain catastrophizing in chronic low back pain patients. (Photo by Alex Green)
A team of international researchers found that exercise, cognitive behavioral therapy (CBT), mindfulness, and multidisciplinary care could reduce chronic low back pain and disability for one year or longer. Although these treatments have at least a moderate level of certainty, about 68% of the studies have a high risk of bias. These risks of bias include missing outcome data, outcome assessment, and selective reporting.
They found:
- CBT and mindfulness showed small to moderate reductions in pain intensity and disability
- Goal setting and needling had small reductions in disability
- Multidisciplinary care and exercise may have small to moderate reductions in pain intensity and disability, but the certainty level of evidence is lower. (Multidisciplinary care is where at least two different health care practitioners collaborate on a patient case.)
- Radiofrequency denervation showed a large reduction in pain intensity and disability, but the certainty level of evidence is “very low”
- For studies that last two or more years, only a low certainty level of evidence was available, including multidisciplinary care for pain reduction and exercise in reducing disability
Led by Dr. Hazel Jenkins from the Department of Chiropractic at Macquarie University, the researchers reviewed 75 randomized-controlled trials (15,395 participants) and evaluated the long-term effectiveness of non-surgical treatments for adults with chronic low back pain. They examined pain intensity and disability outcomes over a one to two-year span, using data from databases up to May 2024.
Jenkins told Massage & Fitness that while short-term effect is important, she and her colleagues thought that long-term effects are just as important, given the long duration and recurrent nature of chronic low back pain.
“If a treatment was known to produce effective results for longer, we thought it would be more likely to address the challenges of chronic low back pain,” she said. “We started to look for evidence of long-term effects and realised that little research had been done in this space so it was difficult to determine what the most effective interventions would be over the long-term.”
“These large-scale reviews are important to bring attention to important aspects of healthcare where change is needed,” Jenkins added. “I feel that this review has really helped to focus attention on the need for long-term effectiveness of interventions for low back pain.”
To measure pain intensity and disability, Jenkins and her colleagues used standardized tools, such as the Numerical Pain Rating Scale (NPRS) and the Visual Analogue Scale (VAS) for pain and the Oswestry Disability Index (ODI) and the Roland-Morris Disability Questionnaire (RMDQ) for disability.
The trials included those with follow-up data at 12 months or longer to assess the long-term (one year) or very long-term (two years or more) effects of the interventions.
Studies were excluded if they involved participants with pathological causes of low back pain—such as cancer, infections, or inflammatory arthritis—or if they had undergone spine surgery in the last six months.
Jenkins and her colleagues wrote that the World Health Organization (WHO) published the guidelines for chronic low back pain based on short-term studies (those that lasted six months or less).
“Although we identified some interventions with long-term effects for people with chronic low back pain, the clinical importance of the effects is uncertain,” the researchers wrote. “Interventions produced mostly small effects on pain intensity, disability, or both, of up to ten points on a 100-point scale, a threshold previously identified as the smallest worthwhile effect in people with moderate back pain or disability at baseline.”
They added that the such “smallest worthwhile effects” have not been investigated in the long term or across a range of interventions in the review.
“Therefore, it is unclear whether the effects found in this review would be considered clinically meaningful by people with chronic low back pain,” Jenkins and her colleagues wrote.
Making sense of the research
Even so, Jenkins said that interventions that addressed psychological and physical components tended to have better long-term effects.
“This fits very well with the biopsychosocial model of low back pain, where there are multiple contributors to chronic pain, [and] addressing all of the contributors is more likely to create longer term effects,” she said.
Regarding national health polices, Jenkins hopes that this review will “continue to drive the need for high-quality research in chronic low back pain with more focus on long-term effects.
“These results should also promote the use of combined interventions, focusing on both the psychological and physical components of low back pain within healthcare practice,” she said. “I would like to see results like this change Medicare and insurance rebates to prioritise the delivery of interventions with proven long-term effects.”
Nick Ng is the editor of Massage & Fitness Magazine and the managing editor for My Neighborhood News Network.
An alumni from San Diego State University with a bachelor’s degree in graphic communications, Nick had completed his massage therapy training at International Professional School of Bodywork in San Diego in 2014. In 2021, he earned an associate’s degree in journalism at Palomar College.
When he gets a chance, he enjoys weightlifting at the gym, salsa dancing, and exploring new areas in the Puget Sound area in Washington state.
