Low back pain is a common disorder which often follows a chronic course.  It is estimated that 2.6 million people seek advice about back pain from their GP each year.¹ One year after an initial episode of back pain, approximately one third of patients report intermittent or continuing pain of at least moderate intensity and one in five report substantial limitation of activities.² Group CBT is an effective, low-cost intervention for adults with persistent non-specific, low back pain, a randomised controlled trial from primary care has shown.³

A total of 701 patients with at least moderately troublesome, persistent (>6 weeks) back pain were recruited into the Back Skills Training Trial from 56 general practices across England. The average age was 53, 60% were female, and the average duration of back pain was 13 years since first onset.

All participants were given advice on active management and were provided with a copy of The Back Book.  Two-thirds (468) were then randomised to receive an intervention consisting of an individual assessment followed by six 1.5hr sessions of group CBT. Each group started with an average of eight participants and was led by a trained physiotherapist, nurse, psychologist or occupational therapist.

At baseline and at 12-month follow-up, participants completed the 24-item Roland Morris disability questionnaire which has a range from 0 (no disability) to 24 (severe disability). The mean baseline score was 9. At 12 months, the mean score reduction was 1.1 in the control group and 2.4 in the CBT intervention group, giving a significant between-group difference of

1.3 (95% CI: 0.56-2.06). There was also a small but significant reduction in the Von Korff disability and pain scores (differences between groups were 8.4% and 7.0% respectively).

These results can be compared with those from the UK back pain exercise and manipulation (BEAM) trial. Participants were randomised to a group exercise programme, a course of manual therapy, combination therapy or best care (active management plus The Back Book). Compared with best care, only manual therapy and combination therapy achieved a significant reduction in Roland disability scores at 12 months (1.0 and 1.3 respectively).⁴

For group CBT, the incremental cost per QALY was calculated to be £1,786, which is substantially less than the cost for exercise (£8,300), manipulation (£8,700), combination therapy (£3,800)5 or acupuncture (£4,242).

A reduction of 1.3 in the Roland disability score means that participants can perform an average of 1.3 additional personal functions, such as being able to get out of a chair without holding on to something, or walk at a normal pace. Clearly, this is only a small effect, and for an individual patient would not be considered to be of clinical significance. At a population level, however, small differences in clinical outcomes may have large economic benefits.

NICE recommends that patients with persistent non-specific back pain should be offered either a structured exercise programme, a course of manual therapy or acupuncture.¹ This trial suggests that group CBT is at least as effective, and may be preferable as it is cheaper and produces more sustained benefits.

However, it is unlikely that many UK practices will currently have access to group CBT interventions for patients with persistent low back pain. Nevertheless,

I think it is important that we should recognise the contribution of psychosocial factors to the development of chronic low back pain.

Brief CBT can be effective for patients with unhelpful health beliefs and negative beliefs, and there is now evidence that recognition and effective treatment of depression can produce a clinically significant long-term reduction in pain.⁶