Adults with chronic non-specific low back pain (LBP) not only experience physical disability but can also suffer psychological distress in the form of anxiety, depression and fear avoidance.

Professor Paulo Ferreira, from the Charles Perkins Centre, Faculty of Medicine and Health at the University of Sydney, says more than half of patients who suffer chronic back pain are also diagnosed with depression.

Clinical guidelines consistently recommend a combination of exercise and psychosocial therapies for managing chronic LBP.

However, not much is known about the different types of psychological therapies available or their comparative effectiveness and safety.

Physiotherapist-turned-researcher Emma Ho, a PhD candidate from the Charles Perkins Centre, Faculty of Medicine and Health, says this uncertainty can leave practitioners and patients feeling unclear about the best choice of treatment for LBP. 

A team of researchers from the University of Sydney and Dalhousie University in Canada, led by Paulo and Emma, conducted a systematic review with network meta-analysis of randomised controlled trials investigating psychological interventions for people with chronic non-specific LBP.

Network meta-analysis is a statistical method that enables the simultaneous comparison and ranking of multiple interventions available for a given clinical condition within a single analysis.

Results of a network meta-analysis can provide clinicians with critical information to support decision-making.

The review authors examined almost 100 randomised controlled trials that have been conducted worldwide and have involved more than 13,000 patients.

‘Our main finding was that compared with physiotherapy care by itself (mainly referring to structured exercise programs), psychological interventions are most effective for people with chronic non-specific LBP when they are delivered in conjunction with physiotherapy care,’ Emma says.

‘Specifically, adding pain education to physiotherapy care led to the greatest and most sustainable health benefits for improving physical function and reducing fear avoidance, lasting up to six months after the end of treatment.

‘On the other hand, 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 the end of treatment,’ she says.

‘Based on limited available data, psychological interventions are likely to be safe for this population.’

But what are pain education and behavioural therapy approaches?

Emma Ho and Professor Paulo Ferreira led a systematic review of trials investigating psychological interventions for people with chronic non-specific low back pain. 

Pain education programs aim to improve patient understanding and knowledge about pain mechanisms and, importantly, focus on reconceptualising patients’ negative pain beliefs.

For example, negative thoughts such as ‘my back is weak and damaged’ can be addressed by helping the patient understand that pain does not necessarily equal harm or damage, that our spines are ‘strong’ and built to handle movement and pressure and that it is perfectly safe and important to maintain activity.

Behavioural therapy interventions aim to remove positive reinforcement of pain behaviours and promote healthy behaviours.

Examples include teaching patients how to perform progressive muscle relaxation techniques and using graded exposure techniques to support patients with progressively engaging in fearful movements or activities.

Behavioural therapy can also involve educating family members about unhelpful pain behaviours and positive health behaviours to increase awareness of how their own pain responses could affect others.

How can physiotherapists incorporate these strategies and interventions into treatment?

Physiotherapists are well positioned to promote early and cohesive co-delivery of structured exercise with psychological strategies or interventions for people with chronic LBP.

‘Exercise prescription is a core component of a physiotherapist’s treatment toolkit.

'There is evidence suggesting that with sufficient training, physiotherapists can successfully incorporate psychological strategies such as cognitive behavioural therapy techniques into treatment for people with musculoskeletal conditions.

'The concept of psychologically informed practice is certainly not new,’ Paulo says.

Although, he adds, there are still challenges with integrating the two different therapies in clinical practice.

‘Several qualitative studies have shown that clinician-perceived barriers continue to exist.

'Physiotherapists have reported a lack of knowledge and training on the use of psychological strategies, the time constraints of treatment sessions and patient reluctance to engage in these types of treatments,’ he says.

‘The establishment of integrated cross-disciplinary clinical networks and coordinated care services and the provision of subsidised multiday workshops with ongoing mentoring are potential strategies to overcome these challenges,’ Emma says.

Alternatively, physiotherapists might consider concurrently referring patients to a psychologist at the outset of treatment, ensuring they work closely with the psychologist to coordinate care.

However, Paulo and Emma believe that further research is necessary.

‘Our review has identified that high-quality clinical trials, with large sample sizes and follow-up periods greater than 12 months after the end of treatment, are still needed.

'Particularly, there is a lack of studies investigating mindfulness or counselling-based approaches for people with chronic non-specific LBP,’ Paulo says.

‘Improved measurement and reporting of safety data are also vital, as this information can help clinicians and patients weigh up the risk–benefit ratio of health interventions.’

Nonetheless, the key message is clear—treatments for chronic LBP should address both physical health and the mind, they say.

‘Early referral to physical and psychological therapies at the outset of treatment will optimise health outcomes for this population,’ Emma says.

>> Emma Ho has clinical experience in both the hospital and the private healthcare sectors. Emma is currently completing her PhD at the University of Sydney, investigating lifestyle interventions to support people with chronic non-specific low back pain. She is a recipient of a Research Training Program PhD Scholarship and is an associate investigator on a National Health and Medical Research Council grant evaluating the effectiveness of a discharge support system for people with chronic non-specific low back pain. She coordinates the Charles Perkins Centre Musculoskeletal Research Hub at the University of Sydney, led by Professor Paulo Ferreira.

>> 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. He is the world’s most published researcher in low back pain and twins and the world’s second in physical activity and low back pain. His research interests also include genetics, e-health and lifestyle in chronic pain. He is one of the leaders of the senior editorial group that led a 2018 Lancet series on back pain. His research has shifted to how low back pain is managed through lifestyle management and the impact has attracted media attention nationally and internationally.