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96 APPENDICES Physiotherapy KCE reports vol. B
A more recent Cochrane systematic review (Heymans 2006) find that only six trials were to be high quality. In general the
clinical relevance of the studies was rated as insufficient. It was not possible to perform relevant subgroup analyses for LBP
with radiation or without radiation. There is moderate evidence suggesting that back schools have better short and
intermediate-terms effects on pain and functional status than other treatments for patients with recurrent and chronic low
back pain.
According to COST B13 2004, there is moderate evidence for no difference between back schools and other treatments
with regard to their long-term effects and functional status (2 RCTs de faible qualité).
Back school in an occupational setting:
According to CBO 2003, il y a des preuves limitées que l école du dos en entreprise donne moins d absentéisme que le
placebo (Van Tulder 1999 et 2000). There Cochrane systematic review (Heymans 2006) also concluded that there is
moderate evidence suggesting that back school for CLBP in an occupational setting, are more effective than other
treatments and placebo or waiting list controls on pain, functional status and return to work during short and
intermediate-term follow-up.
Conclusion:
There is moderate evidence (level B) suggesting that back schools have better short and intermediate-terms effects on pain
and function in patients with recurrent or chronic low back pain than other traditional treatments.
There is moderate evidence (level B) suggesting that back school in an occupational setting, is effective in reducing pain,
improving function and return to work rate during short and intermediate-term follow-up.
However, back schools programs usually include education, exercise and interventions on movement and postures
ergonomics in proportions and quantities that may considerably vary. More studies should be conducted to identify the
optimal proportion of the different components of back schools programs as well as the characteristics of the total
program in terms of number, frequency, duration and composition of the sessions.
1.5. Psychotherapeutical interventions
1.5.1 Cognitivo-behavioral intervention
Ce point est abordé dans les guidelines: SBU 2000, ANAES 2000, CBO 2003, COST 13 2004. les systematic reviews de
base sont van Tulder 2000, van Tulder 2001 et van Tulder 2004. Les études citées par rapport à l efficacité des traitements
sont celles de Turner 1996, Brox et al 2003, Lindstrom et al 1992, Staal et al 2004, Kole-Snijders et al 1999, Turner and
Clancy 1988. Notre recherche complémentaire a mis en évidence une Cochrane systematic review (Ostelo 2006) et un
rapport HTA (NHS CRD 2000).
According to COST B13 definition, cognitive and behavioural methods involve procedures where changes in the cognitions and
behaviours are the main aspect of the treatment offered. They are commonly used in the treatment of chronic (disabling) low back
pain. The main assumption of a behavioural approach is the pain and pain disability are not only influenced by somatic pathology, if
found, but also by psychological and social factors (e.g., patients attitudes and beliefs, psychosocial distress, and illness behaviour)
(Waddell 1987).
Consequently, the treatment of chronic low back pain is not primarily focused on removing an underlying organic pathology, but at
the reduction of disability through the modification of environmental contingencies and cognitive processes. In general, three
behavioural treatment approaches can be distinguished: operant, cognitive and respondent (Turk and Flor 1984) (Vlaeyen et al
1995). Each of these focuses on the modification of one of the three response systems that characterize emotional experiences, that
is behaviour, cognitions, and physiological reactivity. Operant treatments are based on the operant conditioning principles of Skinner
(Skinner 1993) and applied to pain by Fordice (Fordyce 1976) and include positive reinforcement of healthy behaviours and
consequent withdrawal of attention towards pain behaviours, time-contingent of pain-contingent pain management, and spouse
involvement. The graded activity programme is one example of operant treatment for chronic low back pain (Lindstrom et al 1992).
Cognitive treatment aims to identify and modify patients cognitions regarding their pain and disability. Cognitions (the meaning of
pain, expectations regarding control over pain) can be modified directly by cognitive restructuring techniques (such as imagery and
attention diversion), or indirectly by the modification of maladaptive thoughts, feelings and beliefs (Turner and Jensen 1993).
Respondent treatment aims to modify the physiological response system directly, e.g., by reduction of muscular tension. Respondent
treatment includes providing the patient with a model of the relationship between tension and pain, and teaching the patient to
replace muscular tension by a tension-incompatible reaction, such as the relaxation response. Electromyographic (EMG) biofeedback,
progressive relaxation and applied relaxation are frequently used (Turk and Flor 1984) (Vlaeyen et al 1985).
A large variety of behavioural treatment modalities are used for chronic low back pain, because there is no general consensus about
the definition of operant and cognitive methods. Furthermore, behavioural treatment often consists of a combination of these
modalities or is applied in combination with other therapies (such as medication or exercises). Although they may vary in aims and
methods, cognitive and behavioural treatments have in common 1) the assumption that the individual s feelings and behaviours are
influenced by his/her thoughts; 2) the use of structured techniques to help patients identify, monitor and change maladaptive
thoughts, feelings and behaviours; 3) an emphasis on teaching skills that patients can apply to a variety of problems (Turner 1996).
Results