Group cognitive behavioural interventions for low back pain in primary care: Extended follow-up of the Back Skills Training Trial (ISRCTN54717854) Sarah E. Lamb a,b,⇑ , Dipesh Mistry a , Ranjit Lall a , Zara Hansen a , David Evans a , Emma J. Withers a , Martin R. Underwood a , On behalf of the Back Skills Training Trial Group. a Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK b Kadoorie Critical Care Research Centre, Nuffield Department of Orthopaedic Surgery, University of Oxford, Oxford, UK Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article. article info Article history: Received 7 March 2011 Received in revised form 10 November 2011 Accepted 14 November 2011 Keywords: Clinical trial Cognitive behaviour therapy Extended follow-up Low back pain abstract Group cognitive behavioural intervention (CBI) is effective in reducing low back pain and disability over a 12-month period, in comparison to best practice advice in primary care. The aim was to study the effects of this CBI beyond 12 months. We undertook an extended follow-up of our original randomised, con- trolled trial of a group CBI and best practice advice in primary care, in comparison to best practice advice alone. Participants were mailed a questionnaire including measures of disability, pain, health services resource use, and health-related quality of life. The time of extended follow-up ranged between 20 and 50 months (mean 34 months). Fifty-six percent (395 of 701) of the original cohort provided extended follow-up. Those who responded were older and had less disability and pain at baseline than did the ori- ginal trial cohort. After 12 months, the improvements in pain and disability observed with CBI were sus- tained. For disability measures, the treatment difference in favour of CBI persisted (mean difference 1.3 Roland and Morris Disability Questionnaire points, 95% confidence interval 0.27 to 2.26; 5.5 Modified von Korff Scale disability points, 95% confidence interval 0.27 to 10.64). There was no between-group differ- ence in Modified von Korff Scale pain outcomes. The results suggest that the effects of a group CBI are maintained up to an average of 34 months. Although pain improves in response to best practice advice, longer-term recovery of disability remains substantially less. Ó 2011 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved. 1. Introduction Low back pain (LBP) is amongst the top 6 most costly health conditions, and one of the top 3 most disabling health conditions [9]. LBP ranges in presentation from acute pain (66 weeks’ dura- tion), subacute pain (>6 to 612 weeks’ duration), and chronic pain (>12 weeks’ duration) [26]. Chronic LBP is the most complex and costly presentation [20]. Most LBP is managed by primary care practitioners. Long-last- ing effective treatments are elusive, particularly for subacute and chronic pain [20]. Most clinical guidelines recommend that pri- mary care practitioners give advice to remain physically active, prescribe appropriate medication, and, when symptoms persist, provide referral for nonpharmacological therapies [1,20,31]. Advice to remain active is better than usual general (family) practice [24] but has a short-lived effect [28]. Exercise, acupuncture, manipula- tion, and postural approaches produce small to moderate short- term (64 months) benefits; but longer-term (P12 months) bene- fits are typically small or not statistically significant [19,21,22,33]. Cognitive behavioural interventions (CBIs) are recognized as potentially effective treatments for LBP in primary care, but there is uncertainty and a need for definitive evaluations with long-term follow-up [19,21,22,31,33]. CBIs encompass a growing number of variants, including Internet-based, one-to-one sessions delivered by a clinical psychologist, group CBI, condition specific, generic for- mats, behavioural activation, and mindfulness-based cognitive therapy [10,11]. Other factors which may influence the effective- ness of CBIs include the professional background and training of practitioners and the intensity and duration of the intervention. The evidence to support lower intensity CBIs (<100 h duration), which are most suited to primary care, is equivocal [31]. In a previously published randomized controlled trial, we eval- uated a group-based CBI suitable for primary care. The intervention was designed to be delivered by a range of primary care practitio- ners (nurses, physical and occupational therapists, psychologists) and was of relatively low intensity and delivered in a group format. We designed a short training course for qualified health care 0304-3959/$36.00 Ó 2011 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.pain.2011.11.016 ⇑ Corresponding author. Address: Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK. Tel.: +44 (0)24 7657 4658; fax: +44 (0)24 7657 4657. E-mail address: S.lamb@warwick.ac.uk (S.E. Lamb). www.elsevier.com/locate/pain PAIN Ò 153 (2012) 494–501