Oh, My Aching Back! Psychological Interventions May Help

For adult patients with chronic low back pain (LBP), the best way to improve physical function and pain intensity is delivering psychological interventions alongside physiotherapy care, according to findings from a systematic review and meta-analysis.

Adults suffering from chronic LBP, or pain lasting longer than 12 weeks, are forced to grapple with more than just pain and physical disability—this patient population is also vulnerable to a number of psychological factors, including depression, anxiety, catastrophic thinking, and fear avoidance, or avoiding physical movement out of fear of pain, Paulo H. Ferreira, PhD, Faculty of Medicine and Health, University of Sydney in Sydney, Australia, and colleagues explained in The BMJ. For this reason, most clinical practice guidelines for chronic LBP recommend using psychological treatments alongside physical therapy; however, "existing guidelines typically provide generic or incomplete recommendations," and it is unclear which interventions are most effective in producing specific treatment outcomes, Ferreira and colleagues wrote.

Ferreira and colleagues conducted their systematic review and meta-analysis to investigate the comparative efficacy of various psychological interventions for improving physical function, pain intensity, fear avoidance, health-related quality of life (QoL), and intervention compliance among patients with chronic LBP.

"Compared with physiotherapy care alone (mainly structured exercise), psychological interventions are most effective for people with chronic, non-specific LBP when they are delivered in conjunction with physiotherapy care," the researchers found. "Although the clinical effectiveness of psychological interventions diminishes over time, the most sustainable effects of treatment for physical function and fear avoidance are achieved with pain education programs. The most sustainable effects of treatment for pain intensity are noted with behavioral therapy."

While the evidence was limited, they consistently suggested that psychological interventions are safe for this patient population, and treatment effects are maintained "at least in the short-term to mid-term after treatment… Ultimately, to optimize improvement in patient outcomes, clinicians should consider strategies to promote early and cohesive co-delivery of structured exercise and psychological strategies or interventions together," they wrote.

For their systematic review, Ferreira and colleagues searched Medline, Embase, PsycINFO, Cochrane Central Register of Controlled Trials, Web of Science, SCOPUS, and CINAHL via OVID from database inception until Aug. 31, 2020, with an updated search up to Jan. 31, 2021. Studies were eligible for inclusion if they covered randomized clinical trials comparing psychological interventions against any comparator intervention among adults with chronic, non-specific back pain, with or without leg pain.

Psychological intervention approaches were categorized into five "treatment nodes": behavioral therapy, cognitive behavioral therapy, mindfulness, counseling, and pain education. The primary outcomes of interest were physical function and pain intensity; secondary outcomes included fear avoidance, health-related QoL, intervention compliance, and safety.

A random effects network meta-analysis was performed at several time points—post-intervention (end of treatment to <2 months) and short-term (2 months to <6 months), mid-term (6 months to <12 months), and long-term follow-up (≥12 months).

The final review consisted of 97 articles involving 13,136 patients with chronic, non-specific LBP. Among the findings:

• "For physical function, cognitive behavioral therapy (standardized mean difference 1.01, 95% confidence interval 0.58 to 1.44), and pain education (0.62, 0.08 to 1.17), delivered with physiotherapy care, resulted in clinically important improvements at post-intervention (moderate quality evidence). The most sustainable effects of treatment for improving physical function were reported with pain education delivered with physiotherapy care, at least until mid-term follow-up (0.63, 0.25 to 1.00; low quality evidence). No studies investigated the long-term effectiveness of pain education delivered with physiotherapy care.
• "For pain intensity, behavioral therapy (1.08, 0.22 to 1.94), cognitive behavioral therapy (0.92, 0.43 to 1.42), and pain education (0.91, 0.37 to 1.45), delivered with physiotherapy care, resulted in clinically important effects at post-intervention (low to moderate quality evidence). Only behavioral therapy delivered with physiotherapy care maintained clinically important effects on reducing pain intensity until mid-term follow-up (1.01, 0.41 to 1.60; high quality evidence)."

Cognitive behavioral therapy delivered alongside physiotherapy proved most effective for reducing fear avoidance at the post-intervention time point, they added; however, pain education alone or with physiotherapy was most effective at short-term follow-up.

Of the 20 studies that provided enough information regarding adverse effects during the intervention period, 12 (60%) reported no adverse events in any intervention group. That said, Ferreira and colleagues raised concerns regarding the poor quality of safety data reporting in these trials.

"Most studies did not have sufficient information regarding adverse events, for relatedness (that is, whether the adverse event was a direct result of participating in the study intervention), temporality (that is, whether the adverse event occurred during the intervention period or during the follow-up period), severity (that is, mild, moderate, or severe), and independence (that is, most studies reported a total count of adverse events across the entire study population and did not report whether multiple adverse events were experienced by the same participants)," they wrote. "… The development and implementation of standardized reporting guidelines for adverse events that are tailored for psychological interventions might improve accuracy of reporting and synthesizing data and strengthen the risk-benefit assessment of their clinical value."

Ferreira and colleagues concluded that their study "fills an important gap in research" into psychological interventions for patients with chronic LBP, and the findings "can be used to inform clearer guideline recommendations regarding the use of specific psychological interventions for managing chronic, non-specific LBP and support decision making for patients and clinicians."

Study limitations included possible heterogeneity of combinations of psychological interventions included within each treatment node, as well as poor and inconsistent reporting of patient involvement in design/development of interventions, as well as other patient data.

The study authors had no relevant relationships to disclose.

Ferreira PH, et al "Psychological interventions for chronic, non-specific low back pain: Systematic review with network meta-analysis" BMJ 2022; 376: e067718.