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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
KCE reports vol. 40 APPENDICES Physiotherapy 97 Il y a des preuves importantes que la behavioral therapy est plus efficace que le placebo à court terme en cas de chonic low back pain. Cette efficacité se confirme également dans les études en première ligne. Les patients n étaient pas sélectionnés sur base de problèmes psychosociaux sous-jacents. Il ne semble pas y avoir de différences entre l efficacité des thérapies comportementales et celles des autre traitements comme les exercices ou la spinal fusion surgery. Le niveau de preuve est cependant modéré : peu d études et de qualité méthodologique allant de faible à bon. Par contre, a graded activity programme using a behavioural approach is more effective than traditional care for returning patients at work. Il ne semble pas y avoir de bénéfice à ajouter une thérapie comportementale en complément d un autre traitement, mais les conclusions des guidelines sur ce point sont divergentes. Tous les guidelines s accordent pour conclure qu il n y a pas de différence d efficacité entre les méthodes de thérapie comportementale. Thérapies comportementales versus placebo: Tous les guidelines s accordent pour affirmer que les thérapies comportementales sont plus efficaces que le placebo (ou pas de traitement ou inscription sur une liste d attente) : SBU 2000 concluded that there is strong evidence for behavioral therapy, ANAES 2000 efficace dans la prise en charge de la douleur à court terme et éventuellement dans l amélioration du handicap (sur base de 7 études de faible qualité méthodologique) CBO 2003 conclut que les thérapies comportementales sont plus efficaces qu une attitude attentiste (strong evidence). L effet est surtout positif en ce qui concerne l intensité de la douleur, tandis que l effet est faible sur le statut fonctionnel (sur base de la systematic review de Van Tulder 2001 comprenant 21 RCTs). Une méta-analyse de Turner 1996 étudie l efficacité des thérapies comportementales chez les patients lombalgiques en première ligne. 14 études répondent à ce critère. Les conclusions rejoignent celles de la systematic review de Van Tulder 2001. COST B13 2004 concluded that there is strong evidence that behavioural treatment is more effective for pain, functional status and behavioural outcomes than placebo/no treatment/waiting list control (van Tulder et al 2000, van Tulder et al 2004; 2 RCTs de bonne qualité et 5 RCTs de faible qualité): Le rapport du NHS centre for reviews and dissemination (NHS CRD 2000) aboutit aux mêmes conclusions, également basées sur la Cochrane systematic review de van Tulder 2000. One more recent update of the Cochrane systematic review on the topic (Ostelo 2006) includes only randomised trials on behavioural treatment for non-specific CLBP. Seven studies (33%) were included and considered as high quality studies. Comparing behavioural treatment to waiting list control revealed strong evidence (4 trials, 134 people) in favour of a combined respondent-cognitive therapy for a medium effect on pain, and moderate evidence (2 trials, 39 people) in favour of progressive relaxation for a large positive effect on pain and behavioural outcomes (short-term only). When comparing operant treatment to waiting list control no significant differences could be detected on general function status (strong evidence: 2 trials, 87 people) or on behavioural outcomes (moderate evidence: 3 trials, 153 people) (short term only). L efficacité semble indépendante de facteurs psychosociaux sous-jacents. En effet, Cost B13 2004 précise que in most trials included in the review, patients with severe, long-lasting chronic non specific low back pain were recruited. Patients were usually not selected through screening for psychosocial factors. Thérapie comportementale versus autres traitements L ANAES 2000 ne peut conclure (à partir d études de faible qualité). Le CBO 2003 (à partir de la SR de Van Tulder 2001) conclut que l efficacité des thérapies comportementales versus un autre traitement n est pas claire. La Cochrane systematic review (OSTELO 2006) conclut with limited evidence (1 trial, 39 people) that there are no differences between behavioural treatment and exercises. COST B13 2004 conclut également à une limited evidence (one low quality trial: Turner et al 1990) that there is no difference between the effects of behavioural therapy and exercise therapy in terms of pain, functional status or depression up to 1 year after treatment. COST B13 2004 Concludes also that there is limited evidence (one high quality trial: Brox et al 2003) that in patients with CLBP and lower lumbar disc degeneration there is no difference between the effects of cognitive-behavioural therapy and spinal fusion in terms of disability 1 year after treatment. Par contre, COST B13 2004 conclut that there is strong evidence (2 RCTs de bonne qualité: Lindstrom et al 1992, Staal et al 2004) that a graded activity programme using a behavioural approach is more effective than traditional care for returning patients at work. Il est à noter que l étude de Lindstrom concerne des subacute LBP. Ostelo 2006 concludes also that there is limited evidence (1 trial, 98 people) that a graded activity program in an industrial setting is more effective than usual care for early return to work and reduced long-term sick leave. Thérapie comportementale en complément d un autre traitement versus l autre traitement seul : L ANAES 2000 conclut que les thérapies comportementales associées à un autre traitement (exercice physique, kinésithérapie, etc) semblent plus efficaces (6 études de faible qualité méthodologique) sur la douleur que ce même traitement seul. Tandis que COST B13 2004 concludes that there is moderate evidence (6 low quality RCTs) that the addition of cognitive behavioural treatment to another treatment has neither short or long term effects on functional status and behavioural outcomes. Les conclusions de la Cochrane systematic review (Ostelo 2006) sont similaires : there were no significant
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