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Research

Psychological interventions for chronic, non-specific low back pain: systematic review with network meta-analysis

BMJ 2022; 376 doi: https://doi.org/10.1136/bmj-2021-067718 (Published 30 March 2022) Cite this as: BMJ 2022;376:e067718
  1. Emma Kwan-Yee Ho, doctoral student1 2,
  2. Lingxiao Chen, doctoral student2,
  3. Milena Simic, associate professor1,
  4. Claire Elizabeth Ashton-James, associate professor3 4,
  5. Josielli Comachio, research assistant1,
  6. Daniel Xin Mo Wang, research assistant1,
  7. Jill Alison Hayden, associate professor5,
  8. Manuela Loureiro Ferreira, professor2,
  9. Paulo Henrique Ferreira, professor1
  1. 1Sydney Musculoskeletal Health, School of Health Sciences, Charles Perkins Centre, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
  2. 2Sydney Musculoskeletal Health, The Kolling Institute, School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
  3. 3Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
  4. 4Pain Management Research Institute, Kolling Institute, University of Sydney, Sydney, NSW, Australia
  5. 5Department of Community Health and Epidemiology, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
  1. Correspondence to: E Ho emma.ho{at}sydney.edu.au (or @EmmaK_Ho on Twitter)
  • Accepted 1 February 2022

Abstract

Objective To determine the comparative effectiveness and safety of psychological interventions for chronic low back pain.

Design Systematic review with network meta-analysis.

Data sources Medline, Embase, PsycINFO, Cochrane Central Register of Controlled Trials, Web of Science, SCOPUS, and CINAHL from database inception to 31 January 2021.

Eligibility criteria for study selection Randomised controlled trials comparing psychological interventions with any comparison intervention in adults with chronic, non-specific low back pain. Two reviewers independently screened studies, extracted data, and assessed risk of bias and confidence in the evidence. Primary outcomes were physical function and pain intensity. A random effects network meta-analysis using a frequentist approach was performed at post-intervention (from the end of treatment to <2 months post-intervention); and at short term (≥2 to <6 months post-intervention), mid-term (≥6 to <12 months post-intervention), and long term follow-up (≥12 months post-intervention). Physiotherapy care was the reference comparison intervention. The design-by-treatment interaction model was used to assess global inconsistency and the Bucher method was used to assess local inconsistency.

Results 97 randomised controlled trials involving 13 136 participants and 17 treatment nodes were included. Inconsistency was detected at short term and mid-term follow-up for physical function, and short term follow-up for pain intensity, and were resolved through sensitivity analyses. For physical function, cognitive behavioural therapy (standardised 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, behavioural therapy (1.08, 0.22 to 1.94), cognitive behavioural 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 behavioural 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).

Conclusions 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 (low to moderate quality evidence) and behavioural therapy (low to high quality evidence) result in the most sustainable effects of treatment; however, uncertainty remains as to their long term effectiveness. Although inconsistency was detected, potential sources were identified and resolved.

Systematic review registration PROSPERO CRD42019138074.

Footnotes

  • Contributors: EK-YH and LC (lche4036{at}uni.sydney.edu.au) are joint corresponding authors and contributed equally to this work. EK-YH drafted the manuscript. PHF and MLF share senior authorship. EK-YH, JC, and DXMW contributed to study screening and data extraction. JC and DXMW evaluated the risk of bias within studies. EK-YH evaluated the confidence in the cumulative evidence. EK-YH and LC performed data analysis. EK-YH prepared the graphs and tables. All authors (EK-YH, LC, MS, CEA-J, JC, DXMW, JAH, MLF, and PHF) contributed substantially to revisions of the manuscript, and all authors (EK-YH, LC, MS, CEA-J, JC, DXMW, JAH, MLF, and PHF) approved the final version of the manuscript. EK-YH and LC are the guarantors. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted.

  • Funding: This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. EK-YH is funded by an Australian Government Research Training Programme Scholarship. PHF and MLF are funded by National Health and Medical Research Council of Australia Research Fellowships. MS is funded by a Sydney University SOAR fellowship. LC is funded by Northern Clinical School Higher Degree Research Support Scholarship.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/disclosure-of-interest/ and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years, no other relationships or activities that could appear to have influenced the submitted work.

  • The lead authors (EK-YH and LC) affirm 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 originally planned (and, if relevant, registered) have been explained.

  • Dissemination to participants and related patient and public communities: We will disseminate our findings to clinician and patient organisations, and through traditional media and social media outlets. Study results will be presented in a variety of national and international conferences and forums.

  • Provenance and peer review: Not commissioned; externally peer reviewed.

Data availability statement

Requests for data sharing should be sent to the corresponding authors: Emma K Ho (emma.ho{at}sydney.edu.au) or Lingxiao Chen (lche4036{at}uni.sydney.edu.au)

http://creativecommons.org/licenses/by-nc/4.0/

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

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