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Saragiotto B.1, Maher C.1, Traeger A.2, Li Q.1, McAuley J.2
1The George Institute for Global Health, The University of Sydney, Musculoskeletal Division, Sydney, Australia, 2Neuroscience Research Australia (NeuRA), University of New South Wales, Sydney, Australia
Background: Chronic pain represents a major health problem worldwide. Additional to the pain the condition causes disability, emotional distress, and reduced quality of life. Treatment approaches have been strongly influenced by the belief that these non-pain consequences play the dominant role in the experience of chronic pain. The growth in popularity of these non-pain targeted approaches has seen the emergence of a view that contemporary treatments for chronic pain have little or no effect on pain intensity but have larger effects on these other non-pain factors such as disability. Patients are told to accept their pain and not to expect it to improve with treatment. While the view that pain intensity is less important, as it is not responsive to treatment, is widely held in the chronic pain field, there has been little or no evaluation of the validity of this view. To date, no study has evaluated the magnitude of treatment effects on each of these outcomes.
Purpose: The aim of this study was to compare the effect of low back pain (LBP) treatments on pain and disability in trials summarised in Cochrane systematic reviews. We focused on chronic LBP because it is the most common form of chronic pain.
Methods: We retrieved all Cochrane reviews of treatments for chronic LBP and included trials reporting both pain and disability outcomes at the same time point (short-term). For each trial we calculated the treatment effect using standardised mean differences (SMD) and 95% confidence intervals (CI) for both pain and disability. Then, we calculated the difference between the pain and disability SMD for each trial and generated a pooled estimate of the difference with 95% CI.
Results: Our search retrieved 143 Cochrane reviews, 17 fulfilled our inclusion criteria (53 randomised trials, n=5801 participants). The pooled treatment effects were -0.57 (-0.68 to -0.46) for pain intensity and -0.39 (-0.48 to -0.30) for disability. There was a significantly greater effect of treatment on pain intensity than on disability with a pooled difference of -0.20 (-0.27 to -0.06). That means, trials typically report larger effects on pain intensity than on disability.
Conclusion(s): The contemporary view that pain is not the best measure for the treatment of chronic pain does not seem to be evidence-based. Pain intensity should still be measured as a primary outcome in chronic pain research and practice.
Implications: The assumption that other treatment options such as behavioural or psychological therapies mainly reduce disability but not pain is not consistent with the data. These interventions may offer a promising alternative to dangerous medications (ie, opioids) and can be used as analgesic treatments.
Funding acknowledgements: None
Topic: Pain & pain management
Ethics approval: Not required.
All authors, affiliations and abstracts have been published as submitted.
