Lifestyle intervention as an addition to treatment of LBP

...does it improve cost-effectivity?

  • Lifestyle intervention by telephone with ten coaching conversations
  • Only cost effective if labour costs are included
  • Pain, daily function and quality of life did not differ from the control group

People with chronic low back pain and obesity who follow a healthy lifestyle intervention next to regular treatment, use less healthcare and medication and have significantly lower absenteeism (absence from work). An international research group concludes, that from a social-economic perspective, it seems more cost-effective to mostly conduct lifestyle intervention by telephone. To determine this, they executed a cost-effectiveness analysis using data of a six-month randomised controlled study from 2015 which included 160 Australian low back pain patients with obesity.

No benefit

Patients did not benefit from the lifestyle intervention. That is: researchers did not find any differences after 6 months for pain, daily function, body mass index (BMI), weight and QALY (see frame) between intervention – and control groups. Scientists determined the outcome by measuring the Numeric Pain Rating Scale (NPRS), Roland Morris Disability Questionaire (RMDQ), self-reported weight and the second version of the 12-item Short Form Health Survey (SF-12.v2), at baseline, 6 weeks and 6 months, respectively.


Scientists approached all patients with chronic low back pain on a waiting list for a policlinical orthopaedic consult at a hospital. They included patients with a BMI between 27 and 40, who had non-specific low back pain over three months, and scored three points or higher on the NPRS. Patients were not allowed to follow a diet during the study period, but they could, at their own judgment, consult other allied healthcare professionals if they wanted.


PEDro score: Very good (9/10)

> From: Williams et al., Eur J Pain 23 (2019) 621-634 . All rights reserved to European Pain Federation. Click here for the online summary.


Quality adjusted life year (QALY) stands for an extra year of life in good health. QALY is used often to determine effectiveness of treatment in cost-utility- and cost-effectiveness analysis. The benefit of a treatment on lifespan and -quality can be expressed in mean increase of QALY; from this, the costs per average QALY won can be calculated.

Roland Morris Disability Questionnaire

The Roland Morris Disability Questionnaire (RMDQ) is a questionnaire consisting of 24 items, which reviews daily functioning in people with low back pain. Every item equals one point. The higher the score, the more disability someone experiences in their daily life. 

Expert opinion by Erik Peper

A most interesting study, which reported that the patients’ illness behaviour (costs of healthcare utilisation and absenteeism from work) was significantly reduced, despite the absence of significant clinical improvement. The reduction of healthcare and absenteeism costs more than covered the costs of the lifestyle modification program. This study goes beyond the traditional clinical outcome assessment and practical guidelines that primarily focus on the reduction of pain and disability. In this randomised controlled study, the intervention group received a one-hour clinical consultation with a physiotherapist and a 6-month telephone-based health coaching intervention in addition to usual care. The telephone coaching consisted of ten five-minute telephone sessions that focused on lifestyle changes, to support the individuals to modify their eating behaviors, increase physical activity, achieve and maintain a healthy weight, and where appropriate included referral to smoking cessation services. The limitation of the study, as in most randomised controlled studies, was that patients with known or suspected serious pathology were excluded. Thus, the findings are limited to the patients with chronic low back pain in which there is no evident physiological cause.

I wish that the authors had explored the reasons for this surprising outcome. I hypothesise that the coaching intervention, which focused on a healthy lifestyle, was perceived by the patient as caring and attention - two important qualities that are not reimbursed by third party payers (such as insurance companies) and tend to be eliminated from treatment because of time constraints or absence of published efficacy studies. When people experience caring and support in changing diet and exercise, they may feel more empowered and hopeful - they have control over what they are doing. The focus is not on discomfort, but lifestyle changes that are within the patients’ control. Thus, they experience less urgency to seek additional health care interventions or to stay home from work even though their discomfort did not change. 

This may be an important contributing reason why patients with low back pain report that postural modifications are most useful: because they are taught skills and receive attention that they can continue to do at home.

Take home message: The findings of this study are highly relevant to policy makers, since the study suggests that healthy lifestyle coaching would reduce societal economic costs. It also suggests that therapists working with patients, who have chronic low back pain and are overweight, may want to include lifestyle modification coaching. If therapists continue to remind patients even in follow-up telephone calls to modify their lifestyle, it may help patients reduce absenteeism or unnecessary medical care utilisation. 

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