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Led by Ms Emma Ho and Professor Paulo Ferreira from the University of Sydney, Australia, it suggests that a combination of physiotherapy alongside psychological interventions are more effective for improving physical function and pain intensity–findings that can help improve the clarity of guideline recommendations to better support patients and clinicians in treatment decision making.

Adults with chronic low back pain (lasting for more than 12 weeks) not only experience physical disability but can also suffer psychological distress in the form of anxiety, depression and fear avoidance (avoiding movement for fear of pain).

Clinical guidelines therefore consistently recommend a combination of exercise and psychosocial therapies for managing chronic low back pain. But not much is known about the different types of psychological therapies available and their effectiveness, leaving doctors and patients often unclear about the best choice of treatment.

To address this uncertainty, researchers based in Australia and Canada set out to investigate the comparative effectiveness and safety of common psychological interventions on physical function and pain intensity in adults with chronic low back pain.

They trawled research databases for randomized controlled trials comparing psychological interventions with any comparison intervention in adults with chronic, non-specific low back pain.

Psychological interventions were clustered into six nodes: behavioral interventions, cognitive behavioral therapies (often called ‘talking treatments’), mindfulness, counseling, pain education programs, and two or more combined psychological approaches (eg. pain education delivered with behavioral therapy).

Comparison interventions were classified as physiotherapy care, general practitioner care, advice, no intervention, and usual care.

A total of 97 randomized controlled trials involving 13,136 participants and 17 treatment approaches were included, most of which were published between 2011 and 2021 and were conducted in Europe.

Overall, the researchers found that compared with physiotherapy care alone, physiotherapy delivered with psychological interventions were more effective for improving physical function and pain intensity.

Compared with physiotherapy care alone, the results show that both cognitive behavioral therapy and pain education delivered with physiotherapy care led to clinically important improvements in physical function up to 2 months after treatment.

However, the clinical benefits of pain education on physical function was more sustainable, lasting up to 6 months after treatment.

For pain intensity, behavioral therapy, cognitive behavioral therapy, and pain education delivered with physiotherapy care led to clinically important effects up to 2 months after treatment.

However, only behavioral therapy delivered with physiotherapy care maintained these clinically important effects on pain intensity up to 12 months after treatment.

And while cognitive behavioral therapy delivered with physiotherapy was the most effective intervention for reducing fear avoidance up to 2 months after treatment, the most sustainable effects for fear avoidance were achieved with pain education programs delivered with physiotherapy care.

Finally, of the 20 studies that provided enough information about adverse effects, 12 (60%) clearly reported that no adverse events occurred in any intervention group. However, the researchers raise some concerns about the poor quality of safety data reporting.

This was a well-designed review that captured a broad range of common psychological interventions and investigated outcomes that are meaningful to patients and clinicians. But the researchers do acknowledge some limitations, including differences in trial design and quality that may have influenced their results.

Nevertheless, they write: “For people with chronic, non-specific low back pain, psychological interventions are most effective when delivered in conjunction with physiotherapy care (mainly structured exercise). Pain education programs and behavioral therapy result in the most sustainable effects of treatment; however, uncertainty remains as to their long term effectiveness.”

They conclude: “Findings from our study can be used to inform clearer guideline recommendations regarding the use of specific psychological interventions for managing chronic, non-specific low back pain and support decision making for patients and clinicians.”

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More information:
Psychological interventions for chronic, non-specific low back pain: systematic review with network meta-analysis, The BMJ (2022). DOI: 10.1136/bmj-2021-067718

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British Medical Journal