Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: Cochrane systematic review and meta-analysisBMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h444 (Published 18 February 2015) Cite this as: BMJ 2015;350:h444
- Steven J Kamper, senior research fellow12,
- A T Apeldoorn, research fellow2,
- A Chiarotto, research assistant2,
- R J E M Smeets, professor of rehabilitation medicine3,
- R W J G Ostelo, professor of evidence-based physiotherapy24,
- J Guzman, clinical assistant professor of medicine5,
- M W van Tulder, professor of health technology assessment4
- 1Musculoskeletal Division, George Institute, University of Sydney, Sydney 2050, NSW, Australia
- 2Department of Epidemiology and Biostatistics and the EMGO+ Institute, VU University Medical Centre, Amsterdam 1081BT, Netherlands
- 3Rehabilitation Medicine Department, Maastricht University Medical Centre, Maastricht 6200MD, Netherlands
- 4Department of Health Sciences, Faculty of Earth and Life Sciences, VU University, Amsterdam 1081HV, Netherlands
- 5University of British Columbia, Vancouver, Canada V6T 1Z3
- Correspondence to: S J Kamper, PO Box M201 Missenden Road, Camperdown NSW 2050, Australia
- Accepted 24 December 2014
Objective To assess the long term effects of multidisciplinary biopsychosocial rehabilitation for patients with chronic low back pain.
Design Systematic review and random effects meta-analysis of randomised controlled trials.
Data sources Electronic searches of Cochrane Back Review Group Trials Register, CENTRAL, Medline, Embase, PsycINFO, and CINAHL databases up to February 2014, supplemented by hand searching of reference lists and forward citation tracking of included trials.
Study selection criteria Trials published in full; participants with low back pain for more than three months; multidisciplinary rehabilitation involved a physical component and one or both of a psychological component or a social or work targeted component; multidisciplinary rehabilitation was delivered by healthcare professionals from at least two different professional backgrounds; multidisciplinary rehabilitation was compared with a non- multidisciplinary intervention.
Results Forty one trials included a total of 6858 participants with a mean duration of pain of more than one year who often had failed previous treatment. Sixteen trials provided moderate quality evidence that multidisciplinary rehabilitation decreased pain (standardised mean difference 0.21, 95% confidence interval 0.04 to 0.37; equivalent to 0.5 points in a 10 point pain scale) and disability (0.23, 0.06 to 0.40; equivalent to 1.5 points in a 24 point Roland-Morris index) compared with usual care. Nineteen trials provided low quality evidence that multidisciplinary rehabilitation decreased pain (standardised mean difference 0.51, −0.01 to 1.04) and disability (0.68, 0.16 to 1.19) compared with physical treatments, but significant statistical heterogeneity across trials was present. Eight trials provided moderate quality evidence that multidisciplinary rehabilitation improves the odds of being at work one year after intervention (odds ratio 1.87, 95% confidence interval 1.39 to 2.53) compared with physical treatments. Seven trials provided moderate quality evidence that multidisciplinary rehabilitation does not improve the odds of being at work (odds ratio 1.04, 0.73 to 1.47) compared with usual care. Two trials that compared multidisciplinary rehabilitation with surgery found little difference in outcomes and an increased risk of adverse events with surgery.
Conclusions Multidisciplinary biopsychosocial rehabilitation interventions were more effective than usual care (moderate quality evidence) and physical treatments (low quality evidence) in decreasing pain and disability in people with chronic low back pain. For work outcomes, multidisciplinary rehabilitation seems to be more effective than physical treatment but not more effective than usual care.
We thank Teresa Marin, Rachel Couban, and Shireen Harbin from the Cochrane Back Review Group for support and for developing and conducting the electronic searches.
Contributors: SJK, MWvT, RWJGO, JG, and RJEMS planned the study and developed the protocol. SJK, ATA, and AC screened titles and abstracts. SJK and ATA did the risk of bias assessments. SJK and AC did the hand searches and extracted and checked the data. SJK wrote the initial draft of the manuscript, and all authors critically reviewed successive drafts. SJK is the guarantor.
Funding: No external funding.
Competing Interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: SJK has received grants from the National Health and Medical Research Council of Australia; RJEMS is a member of a scientific advisory board for Philips Pain Management; RWJGO has received grants from the Scientific College of Physiotherapy (Wetenschappelijk College Fysiotherapie) of the Royal Dutch Association for Physiotherapy and from the Health Care Insurance Board (College voor zorgverzekeringen); MWvT has received grants from the Royal Dutch Physiotherapy Association.
Ethical approval: Not needed.
Transparency declaration: The lead author (the manuscript’s guarantor) affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.
Data sharing: Full data are available in the version of this study published by the Cochrane Library.
This review is an abridged version of a previously published Cochrane review: Kamper SJ, Apeldoorn AT, Chiarotto A, Smeets RJ, Ostelo RW, Guzman J, et al. Multidisciplinary biopsychosocial rehabilitation for chronic low back pain. CochraneDatabase Syst Rev 2014;9:CD000963 (see www.thecochranelibrary.com for information). Cochrane reviews are regularly updated as new evidence emerges and in response to feedback, and the Cochrane Database of Systematic Reviews should be consulted for the most recent version of the review.
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