What’s best for chronic spinal back pain? Physical, behavioural/psychologically or combined interventions?

Non-specific chronic spinal pain (NSCSP), particularly low back pain (LBP) and neck pain (NP), results in significant personal, social and economic burden(here and here).[1,2]

Our research group has recently published a systematic review and meta-analysis[3] in the Journal of Pain comparing the effectiveness of conservative interventions for NSCSP. The reason we undertook this review was that despite many interventions being available for treating spinal pain, it is unclear which intervention has the greatest level of supporting evidence. Current conservative interventions can be broadly divided into (i) physical, (ii) behavioural and/or psychological and (iii) interventions which combine these approaches.  Physical interventions include using exercise, manual therapy and ergonomic advice. Behavioural and/or psychologically informed interventions aim to improve behaviours, cognitions or mood by using methods such as relaxation and cognitive behavioural therapy (CBT). Combined interventions aim to improve physical and psychological factors contributing to patients’ pain by using some combination of both approaches, up to an including multidisciplinary pain management programmes.  Therefore, by conducting this systematic review and meta-analysis we wanted to answer the question: What is the relative effectiveness of different conservative interventions for reducing pain and disability in people with NSCSP: physical, behavioural/psychological or combined?

We included RCTs involving participants with NSCSP (neck, thoracic, low back, or pelvic) for greater than 12 weeks duration. RCTs had to measure pain and/or disability and have a minimum follow-up period of 12 weeks.  We only included RCTs that had an “active” conservative treatment control group for comparison (i.e. no treatment or waiting list comparisons were excluded). We excluded RCTs if the interventions were from the same domain (e.g. if the study compared two physical interventions like aerobic exercise versus strength training).  We excluded RCTs that involved participants with specific pathologies/conditions (e.g. pregnancy, rheumatoid arthritis) or “red flag” disorders.

So what did we find?

We included 24 RCTs. 22 of these RCTs could be included in the meta-analysis, with the remaining two studies being too heterogeneous to be pooled for analysis. The sample sizes of the included studies ranged from 30 to 393 participants. The average age of the participants in these studies ranged from 39 to 54 years. 18 RCTs investigated patients with LBP, while six studies investigated participants with NP.

No statistically significant differences were found for pain and disability between (i) physical and behavioural and/or psychologically informed or between (ii) behavioural and/or psychologically informed and combined groups.  While a small statistically significant difference was found for both pain and disability between the physical and combined treatment groups (favouring the combined group), this difference was small and likely to be of limited clinical significance. Therefore, we found only small differences between physical, behavioural and/or psychologically informed and combined interventions for reducing pain and disability in NSCSP patients.

What do these findings tell us?

Current interventions for NSCSP result have similarly small effectiveness on pain and disability. Choosing the most cost-efficient and feasible may be reasonable, based on the evidence to date. There is still a lot of work to be done to find a long-term clinically effective intervention for NSCSP. While the more multi-dimensional combined therapies examined in this review offer a slightly greater effect, the increased costs are not easy to justify for large groups of people with NSCSP. It is possible, though far from certain, that attempts to better combine different components of therapy for people with NSCSP might show better results.

About Mary O’Keeffe

Mary OKeeffeMary O’Keeffe is a PhD student at the University of Limerick (UL). Her PhD research is examining whether tailoring multidimensional rehabilitation to the individual chronic LBP patient enhances effectiveness, and is worth the additional time (and costs!) involved. Her supervisors are Dr Kieran O’Sullivan and Dr Norelee Kennedy from UL and Prof Peter O’Sullivan from Curtin University, Perth.

Email: Mary.OKeeffe@ul.ie

Twitter: @MaryOKeeffe007

About Kieran O’Sullivan

University of Limerick Kieran O'SullivanDr Kieran O’Sullivan is a physiotherapist, and lectures in the Department of Clinical Therapies at UL. His international research group promotes evidence-based assessment and management of chronic pain through www.pain-ed.com .

Email: Kieran.OSullivan@ul.ie

Twitter: @kieranosull

References

[1] Hoy D, March L, Woolf A, Blyth F, Brooks P, Smith E, Vos T, Barendregt J, Blore J, Murray C, Burstein R, Buchbinder R. The global burden of neck pain: estimates from the Global Burden of Disease 2010 study. (2014) Ann Rheum Dis. 73:1309-1315.

[2] Ma VY, Chan L, Carruthers KJ. Incidence, prevalence, costs, and impact on disability of common conditions requiring rehabilitation in the United States: stroke, spinal cord injury, traumatic brain injury, multiple sclerosis, osteoarthritis, rheumatoid arthritis, limb loss, and back pain. (2014) Arch Phys Med Rehabil. 95:986-995.

[3] O’Keeffe M, Purtill H, Kennedy N, et al. Comparative effectiveness of conservative interventions for non-specific chronic spinal pain: Physical, behavioural/psychologically informed or combined? A systematic review and meta-analysis. (2016) The Journal of Pain. In Press.

Commissioning Editor:  Neil O’Connell