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Published:  7 July 2010 Authors:  Henschke N, Ostelo RWJG, van Tulder MW, Vlaeyen JWS, Morley S, Assendelft WJJ, Main CJ. Primary Review Group:  Back and Neck Group

Behavioural treatment for chronic low-back pain

Low-back pain is a major health and economical problem that affects populations around the world. Chronic low-back pain, in particular, is a major cause of medical expenses, work absenteeism, and disability.

Current management of chronic low-back pain includes a range of different treatments such as medication, exercise, and behavioural therapy. Research has shown that social roles and psychological factors have a role in the course of chronic low-back pain. 


This review of 30 studies (3438 participants) evaluated three behavioural therapies for chronic low-back pain:

(i) operant (which acknowledges that external factors associated with pain can reinforce it),

(ii) cognitive (dealing with thoughts, feelings, beliefs, or a combination of the three, that trigger the pain),

(iii) respondent (interrupts muscle tension with progressive relaxation techniques or biofeedback of muscle activity).

For pain relief, there was moderate quality evidence that:

(i) operant therapy was more effective than waiting list controls in the short-term,

(ii) there was little or no difference between operant therapy, cognitive therapy; or a combination of behavioural therapies in the short- or intermediate-term,  

(iii) behavioural treatment was more effective than usual care (which usually consists of physical therapy, back school and/or medical treatments) in the short-term. 

Over a longer term, there was little or no difference between behavioural treatment and group exercise for pain relief or reduced depressive symptoms.

The addition of behavioural therapy to inpatient rehabilitation did not appear to increase the effect of inpatient rehabilitation alone. For most of the other comparisons, there was only low or very low quality evidence, which was based on the results of only two or three small trials. There were only a few studies which provided information on the effect of behavioural treatment on functional disability or return to work.

Further research is very likely to have an important impact on the results and our confidence in them.


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