Take Home Messages:

Improved cognitive coping strategies and decreased disability both assist patients with chronic lower back pain (LBP) to return to work: reductions in pain and increases in physical performance factors have little or no impact.

Positive outcomes for exercise, behavioural and multimodal treatment programs seem to be associated with decreased perceptions of a link between disability and pain. This is achieved through the development of effective cognitive coping strategies, which:

• Reduce fear-avoidance beliefs; and
• Discourage catastrophising.

The benefits of exercise are thought to relate to improving self-esteem and challenging participants to cope with pain and disability. 

Why the study matters:

Many treatments exist for chronic low back pain. Some are effective, some are expensive and some – such as rest – can do harm if not managed appropriately.

Previous studies have shown that exercise, behavioural and multimodal treatment programs are effective.

Back pain is a major cause of long term work absence and is a major contributor to long term suffering and costs. It is important to know what treatments assist a patient’s recovery.

What the study involved:

The researchers searched a large database to find previous studies on non-operative treatment for chronic low back pain. A total of 13 studies which studied the effect of exercise, behavioural or multimodal treatment were selected to be analysed.  

The main outcomes of treatment analysed were:

• Pain;
• Return to work; and
• Disability/functioning.

The main variables in treatment that were included in the studies were:

• Pain- subjective pain intensity;
• Disability/functioning- limitations of daily living and work due to pain;
• Cognitive coping and appraisal- strategies to manage pain and beliefs of health and illness;
• Mood/affect; and
• Physical performance factors- strength, flexibility and mobility.

Summary of study findings:

The study found that patients who returned to work earlier reported improved disability and better cognitive coping. Reduction in pain and improved physical performance has no effect.

An overall reduction in pain was associated with:

• Increased physical performance;
• Improved disability/functioning; and
• Improved cognitive coping.

Improved disability/functioning was associated with:

• Lower reported pain; and
• Improved cognitive coping.

Functional coping strategies and pain reduction are associated with a decrease in disability in patients with low back pain. The authors therefore believe that treatment of low back pain should focus more on altering coping strategies.

Functional coping strategies:

• Reduce fear-avoidance beliefs;
• Discourage catastrophising; and
• Enhance experiences that decrease perceptions of a link between disability and pain. 

The effects of exercise are thought to be related to improving self-belief and challenging misconceptions about pain and disability.

Original research:

What predicts outcome in non-operative treatments of chronic low back pain? A systematic review

Wessels T, van Tulder M, Sigl T, Ewert T, Limm H, Stucki G.

Eur Spine J. 2006 Nov;15(11):1633-44. Epub 2006 Mar 31.

  Link to PubMed abstract