Elsevier

Manual Therapy

Volume 17, Issue 5, October 2012, Pages 385-401
Manual Therapy

Systematic review
The efficacy of targeted interventions for modifiable psychosocial risk factors of persistent nonspecific low back pain – A systematic review

https://doi.org/10.1016/j.math.2012.02.008Get rights and content

Abstract

Background

There is considerable interest in whether best practice management of nonspecific low back pain (NSLBP) should include the targeting of treatment to subgroups of people with identifiable clinical characteristics. However, there are no published systematic reviews of the efficacy of targeted psychosocial interventions.

Aim

This review aimed to determine if the efficacy of interventions for psychosocial risk factors of persistent NSLBP is improved when targeted to people with particular psychosocial characteristics.

Method

Bibliographic databases were searched. Inclusion criteria were randomised controlled trials of targeted psychosocial interventions that used trial designs capable of providing robust information on the efficacy of targeted treatment (treatment effect modification) for the outcomes of pain, activity limitation and psychosocial factors (fear avoidance, catastrophisation, anxiety and depression).

Results and conclusion

Four studies met the inclusion criteria and collectively investigated nine hypotheses about targeted treatment on 28 subgroup/treatment outcomes. There were only two statistically significant results. Graded activity plus Treatment Based Classification targeted to people with high movement-related fear was more effective than Treatment Based Classification at reducing movement-related fear at 4 weeks. Active rehabilitation (physical exercise classes with cognitive-behavioural principles) was more effective than usual GP care at reducing activity limitation at 12 months, when targeted to people with higher movement-related pain.

Few studies have investigated targeted psychosocial interventions in NSLBP, using trial designs suitable for measuring treatment effect modification, and they do not provide consistent evidence supporting such targeting. There is a need for appropriately designed and adequately powered trials to investigate targeted psychosocial interventions.

Section snippets

Background

Low back pain (LBP) is common, costly and recurrent. For some people, their LBP becomes persistent and has considerable consequences for their participation in work and social activities (Walker et al., 2004).

Due to diagnostic uncertainties and the high prevalence of false positive pathoanatomic findings, a definitive diagnosis of pain-related pathology cannot be reached for most LBP in primary care and is therefore labelled as non-specific low back pain (NSLBP). Research during the last decade

Types of participants

Participants needed to be experiencing NSLBP, but not pregnant. Studies with more than 15% of participants below the age of 18 years or containing participants aged below 12 years, or containing participants with specific LBP (eg caused by fracture, cancer, inflammatory arthritis) were excluded. Trials containing participants with both LBP and leg pain were included if they had no symptoms or signs of neurocompression (numbness, pins and needles or lower limb muscle weakness) or contained less

Search yield

A flow chart (Fig. 2) documents the selection process of trials included in the review. Four studies met the inclusion criteria (Klaber Moffett et al., 2004; Jellema et al., 2005; Hough et al., 2007; George et al., 2008). All were two-group plus subgroup covariate RCTs and the characteristics of the included studies are shown in Table 1. The reasons for the exclusion of other trials retrieved in full text are noted in Table 2.

Quality assessment

The quality assessment/risk of bias scores for the included studies

Discussion

To the authors’ knowledge, this is the first systematic review investigating the additional effect attributable to targeting psychosocial interventions in people with NSLBP. The four studies included in this review investigated nine hypotheses about targeted psychosocial interventions. Of the 28 subgroup/treatment outcomes tested, only two examples of treatment effect modification were statistically significant (p < 0.05) using the statistical methods employed in this review. These results need

Conclusion

This review identified four studies that investigated the treatment effects of targeted psychosocial interventions for people with non-specific low back pain (NSLBP). Although there were two statistically significant results and some statistical trends, overall these studies provide limited evidence that targeting such psychosocial interventions is effective. Most of the studies were underpowered to appropriately detect treatment effect modification. If it is important to determine if targeting

Authors' contributions

Both authors were involved in the design of the review, analysis and interpretation of data, drafting and revision of the manuscript, and gave final approval of the manuscript.

Competing interests

The manuscript submitted does not contain information about medical devices or drugs. No benefits in any form have been, or will be, received from a commercial party related directly or indirectly to the subject of this manuscript.

Acknowledgement

The authors are grateful to Dr Mark Hancock for comments on a draft manuscript.

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