Mix physio with psychological interventions to improve physical function and pain intensity in LBP

Ms Ho and her colleagues point out that adults with long-term low back pain typically experience psychological distress – such as anxiety, depression and ‘fear avoidance’ (avoiding movement due to fear of pain).

But clinical guidelines that recommend using both exercise-based and psychosocial therapies tend to lack detail as to how they should be delivered. The researchers examined randomised control trials that compared psychological interventions with other relevant interventions in adults with long-term, non-specific low back pain. 

They grouped psychological interventions into six types: behavioural interventions, cognitive behaviour therapies (CBT), mindfulness, counselling, pain education programmes, and two or more combined psychological approaches (such as pain education delivered with behavioural therapy).

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

The amount of evidence is growing suggesting that ... exercise providers (mainly physiotherapists) have the capacity to successfully incorporate psychological strategies into treatment for patients with MSK pain conditions [Emma Kwan-Yee Ho et al.]

The researchers included 97 randomised control trials (involving 13,136 participants and 17 treatment approaches), most of which were conducted in Europe and published from 2011 to 2021. They found that, overall, delivering physiotherapy alongside psychological interventions was the most successful way of improving physical function and pain intensity. 

Their call for the widespread adoption of interdisciplinary treatment approaches is accompanied by a recognition that interdisciplinary care can be perceived by patients to be ‘fragmented’, while some clinicians may, for example, feel they lack the necessary knowledge and that they face time constraints.

However, Ms Ho and her colleagues state: ‘The amount of evidence is growing suggesting that, in line with psychologically-informed practice, exercise providers (mainly physiotherapists) have the capacity to successfully incorporate psychological strategies into treatment for patients with musculoskeletal pain conditions.’

They note: ‘Overall, we remind exercise providers that incorporating psychological strategies into treatment is crucial for maximising physical function or reducing pain intensity and fear avoidance.’

Tackling the challenges

The authors suggest that establishing integrated cross-disciplinary clinical networks or coordinated care pathways might help to overcome these challenges. Other options include providing sufficient training (through multi-day workshops that have been co-designed with multidisciplinary input), resources, mentoring, feedback and subsidies for clinicians. They point out that further research involving key stakeholders is needed to improve the support available to clinicians, health systems, and, ultimately, patients with LBP.

Key findings

For pain intensity, behavioural therapy, CBT, and pain education delivered with physiotherapy care led to clinically important effects up to two months after treatment. However, only behavioural therapy delivered with physiotherapy care maintained these clinically important effects on pain intensity up to 12 months after treatment.

And while CBT delivered with physiotherapy was the most effective intervention for reducing ‘fear avoidance’ up to two months after treatment, the most sustainable effects for fear avoidance were achieved with pain education programmes delivered with physiotherapy care. 

Of the 20 studies that provided enough information about adverse effects, 12 (60 per cent) 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.

Conclusion

Ms Ho and her colleagues acknowledge that their approach had some limitations – in part because the studies they reviewed lacked a uniform trial design and the quality varied. Nevertheless, they add: ‘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 programmes and behavioural therapy result in the most sustainable effects of treatment; however, uncertainty remains as to their long term effectiveness.’

What this study adds (summary)

• this systematic review with network meta-analysis (a statistical method that enables simultaneous comparison of multiple interventions) investigated the effectiveness of psychological interventions for chronic LBP
• compared with physiotherapy management, the most sustainable effects for physical function and fear avoidance were achieved with pain education programmes delivered with physiotherapy care, and for pain intensity was behavioural therapy delivered with physiotherapy care
• the findings can help to improve the clarity of guideline recommendations regarding the most effective psychological interventions for this population, improving the support available to patients and clinicians in treatment decision-making

To see the full version of the article, titled Psychological interventions for chronic, non-specific low back pain: systematic review with network meta-analysis, visit: https://www.bmj.com/content/376/bmj-2021-067718