Led by Ms Emma Ho and Professor Paulo Ferreira from the University of Sydney, Australia, it suggests that a combination of physiotherapy along with psychological interventions is most effective in improving physical function and pain intensity, findings that may help improve clarity of guideline recommendations to better support patients and physicians in making treatment decisions.
Adults with chronic low back pain (lasting more than 12 weeks) not only experience physical disability, but may also suffer psychological distress in the form of anxiety, depression, and fear avoidance (avoiding movement for fear of pain).
Therefore, clinical guidelines consistently recommend a combination of exercise and psychosocial therapies to manage 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 unsure of the best treatment option.
To address this uncertainty, researchers 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 searched research databases for randomized controlled trials comparing psychological interventions with any comparator intervention in adults with chronic, non-specific low back pain.
Psychological interventions were grouped into six nodes: behavioral interventions, cognitive behavioral therapies (often called “talking treatments”), mindfulness, counseling, pain education programs, and two or more combined psychological approaches (e.g., pain education provided with behavioral therapy).
Comparison interventions were classified as physical therapy care, general medical care, counseling, no intervention, and usual care.
A total of 97 randomized controlled trials with 13,136 participants and 17 treatment approaches were included, the majority of which were published between 2011 and 2021 and were conducted in Europe.
Overall, the researchers found that, compared to physical therapy care alone, physical therapy administered with psychological interventions was more effective in improving physical function and pain intensity.
Compared with physical therapy care alone, results show that both cognitive behavioral therapy and pain education delivered with physical therapy care produced clinically important improvements in physical function up to 2 months after treatment.
However, the clinical benefits of pain education on physical function were more sustainable and lasted up to 6 months after treatment.
For pain intensity, behavioral therapy, cognitive behavioral therapy, and pain education provided with physical therapy care produced clinically important effects up to 2 months after treatment.
However, only behavioral therapy administered with physical therapy care maintained these clinically important effects on pain intensity up to 12 months after treatment.
And although cognitive behavioral therapy delivered with physical therapy 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 physical therapy care. .
Finally, of the 20 studies that provided sufficient information on adverse effects, 12 (60%) clearly reported that no adverse events occurred in any intervention group. However, researchers raise some concerns about the poor quality of safety data reporting.
This was a well-designed review that captured a wide range of common psychological interventions and investigated outcomes that are meaningful to patients and clinicians. But the researchers acknowledge some limitations, including differences in trial design and quality that may have influenced their results.
However, they write: “For people with chronic, nonspecific low back pain, psychological interventions are most effective when administered in conjunction with physical therapy care (mainly structured exercise). Pain education programs and behavioral therapy result in the most sustainable effects of treatment; however, uncertainty remains regarding its long-term effectiveness.”
They conclude: "The findings of our study can be used to inform clearer guideline recommendations regarding the use of specific psychological interventions to manage chronic, nonspecific low back pain and support decision making for patients and clinicians."
Conclusions
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