Psychological interventions for chronic low back pain are effective, a new review of studies has found. Not only do these approaches improve psychological outcomes such as depression and health-related quality of life, they also reduce patients' experience of pain.
"Because this analysis was both more inclusive and more conservative than previous reviews, we have the best evidence to date that these interventions are helpful," said psychologist and review lead author Robert Kerns, Ph.D., of the VA Connecticut Healthcare System.
The review, part of a new article series, appears in the January issue of the journal Health Psychology. Each evidence-based review centers on a specific psychological assessment or treatment conducted in the context of a physical disease process or risk reduction effort.
To evaluate the effects of psychological interventions on pain-related outcomes, Kerns and his team gathered data from 22 randomized trials published between 1982 and 2003. Trials were limited to adults with nonmalignant low back pain that had persisted for at least three months. However, most patients had been living with pain for much longer. The average duration was seven and a half years.
The studies were not limited to any one psychological approach. Included in the review were behavioral and cognitive-behavioral techniques; self-regulatory techniques such as hypnosis, biofeedback, and relaxation; and supportive counseling.
The review reports on 12 pain-related outcomes, including pain intensity, pain interference, depression, health care use, disability and health-related quality of life.
In the broadest analysis, psychological interventions -- alone or as part of a multidisciplinary approach -- proved to be superior to waiting lists or standard treatments on the entire range of pain-related outcomes.
When the researchers analyzed specific outcomes, they found that the largest and most consistent effect was a reduction in pain intensity.
This was somewhat surprising, Kerns said, because when psychologists first began developing interventions for chronic pain several decades ago, the goal was not to reduce pain but to help patients live with their pain more successfully.
"However, a growing body of knowledge suggests that these interventions are actually having a primary effect on people's experience of pain," he said.
The review found that psychological interventions also yielded improvements in health-related quality of life, work-related disability, interference of pain with daily living and depression.
Not all treatments were equally effective. Cognitive-behavioral and self-regulatory treatments seemed to yield the greatest effects, particularly when compared to waiting list control groups. Multidisciplinary approaches that included a psychological component also stood out on some measures, reducing pain interference and work-related disability when compared to other active treatments.
According to Dennis Turk, Ph.D., a professor of anesthesiology and pain research at the University of Washington in Seattle, patients with chronic pain sometimes fail to recognize the value of psychological treatments because they've been set up to expect a cure.
"Even the latest and greatest treatments don't cure people with chronic pain," he said. "Psychological interventions are not cures, but they do reduce pain and improve function and they are important components in the treatment of people with chronic pain."
Turk added that psychological interventions are also cost-effective when compared to other treatments for chronic low back pain -- a key finding, considering that estimates for treatment-related costs range from $20 billion to $80 billion a year in the United States.
"Surgery, opioids, nerve blocks, spinal cord stimulators, implantable drug delivery systems -- every one of those particular alternatives is much more expensive and has poorer or at best equal outcomes compared to rehabilitation programs that include psychological components," said Turk. "The paradox is that, despite data on the effectiveness of psychological interventions, insurers are less willing to pay for them."
Getting the word out that these treatments are effective and cost-effective is a challenge that psychologists will have to tackle head-on, Kerns said.
"We need to specifically target health care system administrators and third-party payers to try to engage them in a more productive dialogue about the importance of these interventions," he said. "We continue to have a huge, very costly problem in our society, but we have an intervention that is effective, and we need to do a better job of creating access to these services."
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