University of Sydney study sheds light on psychological therapies for chronic low back pain

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The best treatment for chronic low back pain doesn't just focus on the physical but rather combines traditional physiotherapy treatments with those that focus on the mind, according to new research from the University of Sydney.

The study published in The BMJ sheds more light on the most effective psychological interventions for people with chronic low back pain, defined as pain that lasts more than 12 weeks.

The research, led by Professor Paulo Ferreira and PhD candidate Emma Ho from the University’s Charles Perkins Centre and Faculty of Medicine and Health combined and analysed evidence from almost 100 trials worldwide involving over 13,000 patients.

The analysis reveals that a combination of physiotherapy alongside psychological interventions, predominately behavioural therapy and pain education, produced the most sustainable benefits for physical function and pain intensity.

The researchers say these results could help improve the clarity of guidelines to better support patients and clinicians in making treatment decisions. However further research is needed into the long-term effectiveness of such treatments.

Lead author PhD candidate Emma Ho said it is well known that adults with chronic low back pain not only experience physical disability, but often also suffer psychological distress in the form of anxiety, depression or fear of pain from movement.

“Clinical guidelines consistently recommend a combination of exercise and psychosocial therapies for managing chronic low back pain, however very little is actually known about the different types of psychological therapies available and their effectiveness. This leaves doctors and patients often unclear about the best choice of treatment. It is this uncertainty that motivated us to conduct the study.” she said.

To address this uncertainty, the research team from Australia and Canada set out to investigate the comparative effectiveness and safety of common psychological interventions on physical function and pain intensity in adults with chronic low back pain.

They trawled research databases for randomised controlled trials comparing psychological interventions with any comparison intervention in adults with chronic, non-specific low back pain. 

Psychological interventions were clustered into six nodes: behavioural interventions, cognitive behavioural therapies (often called ‘talking treatments’), mindfulness, counselling, pain education programmes, and two or more combined psychological approaches (eg. pain education delivered with behavioural therapy). Comparison interventions were classified as physiotherapy care, general practitioner care, advice, no intervention, and usual care. 

A total of 97 randomised controlled trials involving 13,136 participants and 17 treatment approaches were included, most of which were published between 2011 and 2021 and were conducted in Europe. 

Overall, the researchers found that compared with physiotherapy care alone, physiotherapy delivered with psychological interventions were more effective for improving physical function and pain intensity. Compared with physiotherapy care alone, the results show that both cognitive behavioural therapy and pain education delivered with physiotherapy care led to clinically important improvements in physical function up to 2 months after treatment.

However, the clinical benefits of pain education on physical function was more sustainable, lasting up to six months after treatment.

For pain intensity, behavioural therapy, cognitive behavioural therapy, and pain education delivered with physiotherapy care led to clinically important effects up to two months after treatment. However, only behavioural therapy delivered with physiotherapy care maintained these clinically important effects on pain intensity up to 12 months after treatment.

And while cognitive behavioural therapy delivered with physiotherapy was the most effective intervention for reducing fear avoidance up to two months after treatment, the most sustainable effects for fear avoidance were achieved with pain education programs delivered with physiotherapy care. 

Finally, of the 20 studies that provided enough information about adverse effects, 12 (60%) clearly reported that no adverse events occurred in any intervention group. However, the researchers raise some concerns about the poor quality of safety data reporting.

The review captured a broad range of common psychological interventions and investigated outcomes that are meaningful to patients and clinicians. But the researchers do acknowledge some limitations, including differences in trial design and quality that may have influenced their results.

Nevertheless, they write: “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 and behavioural therapy result in the most sustainable effects of treatment; however, uncertainty remains as to their long term effectiveness. Findings from our study can be used to inform clearer guideline recommendations regarding the use of specific psychological interventions for managing chronic, non-specific low back pain and support decision making for patients and clinicians.”