A short, intensive cognitive behavioral pain management program reduces health-care use in patients with chronic low back pain

Miranda L. van Hooff 0 1 2 Werner ter Avest 0 1 2 Philip P. Horsting 0 1 2 John O'Dowd 0 1 2 Marinus de Kleuver 0 1 2 Wim van Lankveld 0 1 2 Jacques van Limbeek 0 1 2 0 J. O'Dowd The RealHealth Institute , 23-31 Beavor Lane, London W6 9AR, UK 1 P. P. Horsting M. de Kleuver Department of Orthopedics , Sint Maartenskliniek, P.O. Box 9011, 6500 GM Nijmegen, The Netherlands 2 M. L. van Hooff (&) W. ter Avest W. van Lankveld J. van Limbeek Department Research Development and Education , Sint Maartenskliniek, P.O. Box 9011, 6500 GM Nijmegen, The Netherlands Purpose Cognitive behavioral interventions are recommended as non-invasive treatment options for patients with chronic low back pain (CLBP). However, most treatment effects are small and short-lived. Although a 2-week intensive pain management program for patients with CLBP seems to be effective, the long-term results are not known. The purpose of this study is to evaluate the stability of the 2-year follow-up results and whether this is reflected in the use of health-care services. Methods A prospective cohort study was performed. Pretreatment characteristics of patients and data of outcomes obtained at 1-year follow-up were used. At 2-year followup a structured interview was conducted following the principles of a post-marketing survey. Outcomes included daily functioning, quality of life, current intensity of pain, disturbance of pain during daily activities, and indicators of the use of pain medication and health-care services. Results Of the 90 eligible patients 85 (94%) participated in the post-marketing survey. The 1-year clinical relevant effects are maintained at 2-year follow-up. Effect sizes for functioning and quality of life were large. More than 65% reached preset minimal clinically important differences. At pre-treatment all patients consulted their general practitioner (GP) and medical specialist (MS). At 2-year followup 73% reported having consulted neither a GP nor an MS during the previous year. Most of the patients indicated not to use any pain medication (57%) and the percentage patients using opioids have decreased (14%). Moreover, 81% reported to be at work. Conclusions The gained results from selected and motivated patients with longstanding CLBP at 1-year follow-up are stable at 2-year follow-up. Above all, most of the participants are at work and results indicate that the use of both pain medication and health care have decreased substantially. - Low back pain is one of the most common disabling conditions and causes high health expenditure in developed countries [13]. This condition has a high prevalence: over 70% of the adult population experience at least one episode of low back pain [1, 46]. In the Netherlands the annual prevalence in 2003 was approximately 44% [1]. A minority (20%) develop chronic low back pain (CLBP), meaning that the complaints persist at least 3 months [2] and are associated with persistent or recurrent disability. These complaints may result in the individuals experiencing a lower health-related quality of life; they cause a quarter of all sick leave in the employed population [1, 3, 4]. The Dutch National Institute for Public Health and the Environment (RIVM) estimated CLBP-related costs to be 0.9% of total health-care costs in the Netherlands [5], resulting in its being the top three of the highest health-care costs [6]. Moreover, 14% of the adult population with a disability allowance in the Netherlands is diagnosed with CLBP. Therefore, CLBP is not only a burden for the patient but the related health-care costs are also a problem for society. A wide range of interventions to manage CLBP are used including pharmaceutical, surgical, and non-surgical interventions [3, 7, 8]. However, many commonly used interventions lack evidence of clinically relevant longterm effects [4]. International guidelines [911], a Cochrane review [12] as well as recently performed randomized controlled trials have demonstrated that a cognitive behavioral approach most effectively reduces disability in CLBP patients [8, 1315]. Nevertheless, most effects achieved by these non-invasive treatments are small and short-lived [14, 1618]. A systematic review with 1964 randomly allocated patients concluded that 100 h or more of intensive, multidisciplinary rehabilitation with a functional restoration approach including cognitive behavioral interventions reduces pain and improves functionality [19]. Furthermore, most reported treatment programs have a mean duration of 4 weeks [18, 20] or more [8, 1315]. A recently published study by van Hooff et al. [21] evaluated the 1 year results of a cohort of patients, who participated in a 2-week program provided by RealHealth NL. The program is based on cognitive behavioral principles and aims at improving daily functioning by selfmanagement of lower back pain complaints. Participants with longstanding CLBP complaints (12 years on average) learned to manage CLBP, improved fast in daily functioning, and experienced a fast improvement in their quality of life. These results were meaningful and clinically relevant to the participants and comparable to results after spinal surgery and superior to results for rehabilitation programs of longer duration. However, the question remains whether these positive short-term effects are sustained in the long run and whether these benefits are reflected in the degree of health-care use and the use of pain medication. Therefore, in this study the main purpose is to evaluate the stability of the 2-year (long-term) follow-up results of a short, intensive cognitive behavioral pain management program provided by RealHealth NL. The emphasis is on evaluating daily functioning, the use of health-care services, and pain medication 2 years after the intervention. We hope that improvements gained in the first year (shortterm) will be maintained and the use of health-care services and pain medication will be reduced in the second year of follow-up. Materials and methods Study design and setting This study is an extension of a prospective cohort study in which the effectiveness of an intensive cognitive behavioral pain management program was evaluated after 1 year of follow-up [21]. We used data obtained by questionnaire at pre-treatment, including patient characteristics, outcome measures and indicators of health care, and pain medication use. Outcome assessments performed at 1 year after treatment yielded the primary outcome measure and heathrelated quality of life (Short-Form 36). These outcomes were compared with outcome assessments at the 2-year follow-up. To achieve a high response rate a structured interview following the principles of a post-marketing survey was added to obtain data at 2-year follow-up. During this interview, the same questionnaires were used as those completed at pre-treatment. A short description of participants, treatment, and outcome measures follows. Patients and treatment A detailed description of par (...truncated)