Adding psychological interventions to physical therapy for low back pain may boost effectiveness
The authors of a new systematic review urge clinicians to consider strategies that promote both structured exercise and psychological interventions, such as pain education, for patients with chronic, nonspecific low back pain.
Psychological interventions are most effective for improving physical function and pain intensity in patients with chronic, nonspecific low back pain when delivered with physical therapy, a review found.
The systematic review with network meta-analysis included 97 randomized controlled trials involving 13,136 participants and 17 treatment categories. Trials compared psychological interventions with any comparison intervention in adults with chronic, nonspecific low back pain. To minimize heterogeneity, the researchers separated different types of psychological interventions into five broad categories: behavioral interventions, cognitive behavioral therapies, mindfulness, counseling, and pain education. Comparison interventions were physical therapy care (reference comparator), general practitioner care, advice, no intervention, and usual care. Primary outcomes were physical function and pain intensity. Results were published March 30 by The BMJ.
For physical function, cognitive behavioral therapy (standardized mean difference, 1.01; 95% CI, 0.58 to 1.44) and pain education (standardized mean difference, 0.62; 95% CI, 0.08 to 1.17), both delivered with physical therapy, resulted in clinically important improvements up to two months after the intervention (moderate-quality evidence). The most sustainable effects of treatment for improving physical function were reported with pain education delivered with physical therapy from six to 12 months after the intervention (standardized mean difference, 0.63; 95% CI, 0.25 to 1.00; low-quality evidence), although no studies looked at the long-term effectiveness of the combined intervention.
For pain intensity, behavioral therapy (standardized mean difference, 1.08; 95% CI, 0.22 to 1.94), cognitive behavioral therapy (standardized mean difference, 0.92; 95% CI, 0.43 to 1.42), and pain education (standardized mean difference, 0.91; 95% CI, 0.37 to 1.45), each delivered with physical therapy, resulted in clinically important effects up to two months after the intervention (low- to moderate-quality evidence). Only behavioral therapy delivered with physical therapy sustained clinically important effects on reducing pain intensity from six to 12 months after the intervention (standardized mean difference, 1.01; 95% CI, 0.41 to 1.60; high-quality evidence).
Categorizing combined psychological interventions into one treatment node may have resulted in heterogeneity, the study authors noted. They added that they included a trial of hypnosis in the review but excluded it from the network meta-analysis due to an inadequate number of studies available for pooling.
“Compared with physiotherapy care alone (mainly structured exercise), psychological interventions are most effective for people with chronic, non-specific [low back pain] when they are delivered in conjunction with physiotherapy care. … 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,” the authors concluded.