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

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.

Fig 1

Study selection flowchart. *One article reported data on two unique studies, one article reported long term follow-up data, and one article provided additional baseline data that were not available in a related, included article reporting the same study. †One article reported long term follow-up data for two unique studies. LBP=lower back pain

Fig 2

Network plots of physical function and pain intensity at post-intervention and short term follow-up. Adv=advice; BT=behavioural therapy; BT+PC=behavioural therapy delivered with physiotherapy care; CBT=cognitive behavioural therapy; CBT+PC=cognitive behavioural therapy delivered with physiotherapy care; CP=combined psychological approaches; CP+PC=combined psychological approaches delivered with physiotherapy care; Csl=counselling; Csl+PC=counselling delivered with physiotherapy care; GP=general practitioner care; Mind=mindfulness; Mind+PC=mindfulness delivered with physiotherapy care; NI=no intervention; PE=pain education; PE+PC=pain education delivered with physiotherapy care; PC=physiotherapy care; UC=usual care

Fig 3

Network plots of physical function and pain intensity at mid-term and long term follow-up. Adv=advice; BT=behavioural therapy; BT+PC=behavioural therapy delivered with physiotherapy care; CBT=cognitive behavioural therapy; CBT+PC=cognitive behavioural therapy delivered with physiotherapy care; CP=combined psychological approaches; CP+PC=combined psychological approaches delivered with physiotherapy care; Csl=counselling; GP=general practitioner care; Mind=mindfulness; Mind+PC=mindfulness delivered with physiotherapy care; NI=no intervention; PC=physiotherapy care; PE=pain education; PE+PC=pain education delivered with physiotherapy care; UC=usual care

Fig 4

Forest plot of network meta-analysis results for physical function at post-intervention. *Denotes significance at p<0.05. BT=behavioural therapy; CBT=cognitive behavioural therapy; Comb psych=combined psychological approaches; Csl=counselling; GP care=general practitioner care; PE=pain education; SMD=standardised mean difference. Physiotherapy care was the reference comparison group

Fig 5

Forest plot of network meta-analysis results for pain intensity at post-intervention. *Denotes significance at p<0.05. BT=behavioural therapy; CBT=cognitive behavioural therapy; Comb psych=combined psychological approaches; Csl=counselling; GP care=general practitioner care; PE=pain education. SMD=standardised mean difference. Physiotherapy care was the reference comparison group