Psychological intervention plus physiotherapy care most effective for low back pain

Psychological interventions for people with chronic, nonspecific low back pain work better when given together with physiotherapy care, particularly structured exercise, suggests a study.

Pain education programs (low to moderate quality evidence) and behavioural therapy (low to high quality) deliver the most sustainable treatment effects, but there remains uncertainty regarding their effectiveness in the long term.

“Limited but consistent evidence suggests that psychological interventions are safe for people with chronic, nonspecific low back pain, and the effects of treatment are maintained at least from postintervention until the short term to midterm after treatment,” the researchers said.

This systematic review and network meta-analysis sourced studies from the databases of Medline, Embase, PsycINFO, Cochrane Central Register of Controlled Trials, Web of Science, SCOPUS, and CINAHL from inception to 31 January 2021. Randomized controlled trials comparing psychological interventions with any comparison intervention in adults with chronic, nonspecific low back pain were included.

Two reviewers independently screened studies, extracted data, and evaluated the risk of bias and confidence in the evidence. The researchers performed a random effects network meta-analysis using a frequentist approach at postintervention (from end of treatment to <2 months postintervention), and at short- (≥2 to <6 months postintervention), mid- (≥6 to <12 months postintervention), and long-term follow-up (≥12 months postintervention).

Ninety-seven trials, including 13,136 participants and 17 treatment nodes, met the eligibility criteria. Inconsistencies were found at short- and midterm follow-up for physical function, and short-term follow-up for pain intensity, but were resolved through sensitivity analyses. [BMJ 2022;376:e067718]

Clinically important improvements for physical function were observed at postintervention (moderate quality evidence) when cognitive behavioural therapy (standardized mean difference [SMD], 1.01, 95 percent confidence interval [CI], 0.58‒1.44) and pain education (SMD, 0.62, 95 percent CI, 0.08‒1.17) were delivered with physiotherapy care.

Treatment effects for improving physical function were most sustainable with pain education given with physiotherapy care, at least until midterm follow-up (SMD, 0.63, 95 percent CI, 0.25‒1.00; low quality evidence). None of the included studies examined the long-term effectiveness of pain education delivered with physiotherapy care.

Pain reduction

Moreover, behavioural therapy (SMD, 1.08, 95 percent CI, 0.22‒1.94), cognitive behavioural therapy (SMD, 0.92, 95 percent CI, 0.43‒1.42), and pain education (SMD, 0.91, 95 percent CI, 0.37‒1.45), delivered with physiotherapy care, led to clinically important effects for pain intensity at postintervention (low to moderate quality evidence).

Only behavioural therapy plus physiotherapy care maintained such effects on reducing pain intensity until midterm follow-up (SMD, 1.01, 95 percent CI, 0.41–1.60; high quality evidence).

“Consistent with psychologically informed practice, an approach described more than a decade ago, our results reinforce the clinical advantages of integrating physiotherapy care with psychological strategies or interventions,” the researchers said. [Phys Ther 2018;98:398-407; Phys Ther 2011;91:820-824]

“Specifically, in conjunction with physiotherapy care, pain education provides the most sustainable effects for improving physical function, and behavioural therapy has the most sustainable effects for reducing pain intensity,” they added.

Of note, the comparative effectiveness of psychological intervention for improving health-related quality of life is unclear due to heterogeneity of reporting, according to the researchers.

“Ultimately, to optimize improvement in patient outcomes, clinicians should consider strategies to promote early and cohesive codelivery of structured exercise and psychological strategies or interventions together,” they said.