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CHANCES are high that you, someone you know, or your patients have experienced low back pain. In fact, it is estimated that 577 million people in the world experience low back pain at any time point. The lifetime prevalence of low back pain is estimated to be 84%.
Approximately 90% of cases are not attributable to a specific pathoanatomical cause, and is commonly termed non-specific low back pain in the literature.
Adults with chronic non-specific low back pain (ie, pain which lasts for more than 3 months) not only experience physical disability but can also suffer psychological distress in the form of anxiety, depression, and fear avoidance.
Which psychological interventions are best for chronic low back pain?
Clinical guidelines for low back pain consistently recommend a combination of exercise and psychosocial therapies for managing chronic low back pain.
However, not much is known about the different types of psychological therapies available, as well as their comparative effectiveness and safety.
This uncertainty can leave clinicians and patients feeling unclear about the best choice of treatment for low back pain.
We, and our colleagues from Dalhousie University in Canada, conducted a systematic review with network meta-analysis of randomised controlled trials investigating psychological interventions for people with chronic non-specific low back pain.
In total, evidence from 97 trials, which have been conducted worldwide and have involved over 13 000 patients, was examined.
Compared with physiotherapy care by itself (mainly referring to structured exercise programs), psychological interventions are most effective for people with chronic non-specific low back pain when they are delivered in conjunction with physiotherapy care.
Specifically, adding pain education to physiotherapy care led to the greatest and most sustainable health benefits for improving physical function and reducing fear avoidance, which can last up to 6 months after treatment ends.
Adding behavioural therapy to physiotherapy care led to the greatest and most sustainable health benefits for reducing pain intensity, which can last up to 12 months after treatment ends.
Pain education and behavioural therapy
Pain education programs aim to improve patient understanding and knowledge of pain mechanisms and focus on reconceptualising patients’ negative pain beliefs.
In contrast, behavioural therapy interventions aim to remove positive reinforcement of pain behaviour and promote healthy behaviour. This includes teaching patients how to overcome stressful situations through relaxation skills.
Safety of psychological interventions
Of the 20 studies that provided enough information to assess safety, 12 (60%) clearly reported that no adverse events occurred in any intervention group.
Five studies reported that no serious adverse effects or adverse effects related to the psychological intervention occurred.
Three studies reported that the psychological intervention under investigation resulted in adverse effects, including increased back pain, worsening of symptoms during treatment, and emergence of painful emotional memories.
Based on limited available data, the current evidence suggests that psychological interventions are likely to be safe for people with chronic non-specific low back pain.
However, there are concerns about the poor quality of safety data reporting. Firstly, only 20 of the 97 included studies (20%) reported adequate information to examine safety. The remaining studies did not report any information on adverse events or harms, or the studies did not report enough information about the relatedness, timing, severity, and/or independence of the adverse events experienced by participants. An explanation of these concepts has been provided in the published article.
Direction for future research
Higher quality clinical trials, with large sample sizes and follow-up periods greater than 12 months after treatment, are still needed. This includes randomised controlled trials of interventions based on behavioural therapy, mindfulness or counselling for people with chronic non-specific low back pain.
Importantly, as identified by a rapid response provided to the systematic review, improved measurement and reporting of safety data are critical to support understanding of experiencing unwanted effects associated with different treatments. This information may be beneficial to help clinicians and patients weigh up the risk–benefit ratio of health interventions.
Key takeaway for clinicians
All in all, the key message is clear: treatments for chronic low back pain should address both physical health and the mind.
Doctors and allied health professionals should promote early and cohesive codelivery of structured exercise with psychological strategies or interventions to maximise health outcomes in people with chronic low back pain; for example, referring patients to both a physiotherapist and psychologist at the outset of treatment.
Alternatively, refer patients to a physiotherapist with recommendations to incorporate pain education or behavioural therapeutic strategies, with a structured exercise program.
Findings from our review will also provide doctors and specialists with improved capacity to generate patient referrals with specific instructions for the type of psychological interventions that should be prescribed to the patient, depending on the clinical outcome of interest.
Ms Emma Ho is a physiotherapist currently completing her PhD at the University of Sydney, investigating lifestyle interventions to support people with chronic non-specific low back pain.
Professor Paulo Ferreira is a Professor at the Faculty of Medicine and Health and Director of the Musculoskeletal Research Hub at the Charles Perkins Centre, University of Sydney.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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There are very few medical problems that are just left with a label such as the one we use for chtronic low back pain. It is as though there are only two types of back pain. Firstly acute and that gets better. Secondly,chronic and that does not get better. I fully agree with Dr Yeo’s letter. For goodness sake we should be able to accurately diagnose the cause of the pain and each different cause should be individually studied to arrive at best management rather than lumping them into the rather convenient label that seems to be used when someone wants to prove their profeesion has the answers and the others dont.
Excellent response John. Unfortunately, there is a ‘cart’ that keeps going down the same path and that is the “non-specific low back pain” cart. I see that the article used as a reference for that term was published in 2006 – surely there has been some advances in diagnosing chronic back pain since 2006? No one in this field would discount the important part the mind plays in experiencing and coping with pain. But this ‘cart’ sufferes chronic cognitive bias and insists that practitioners should not seek out a specific diagnosis. Those steering this cart trivialise chronic back conditions into a the cart of ‘non specific’ when, in fact, until diagnosed, it should be called ‘undiagnosed chronic back pain.’ Certainly, without red flags and while managable, chronic back pain does not need to be diagnosed but when it becomes unmanagable and affects an individual’s ADLs to a significant degree, it merits investigation and diagnosis without without the usual Choosing Wisely retorts of “unnecessary investigation and treatment” if that is the course taken by the patient and their specialists.
Back Pain is a symptom not a diagnosis
Your article fails to emphasis the importance of the accurate and appropriate examination which does not necessarily involve MRI studies.
Please don’t encourage putting the cart before the horse