The effectiveness of low‐dosed outpatient biopsychosocial interventions compared to active physical interventions on pain and disability in adults with nonspecific chronic low back pain: A systematic review with meta‐analysis

Abstract Objective To evaluate the effectiveness of low‐dosed outpatient biopsychosocial interventions versus active physical interventions on pain intensity and disability in adults with nonspecific chronic low back pain. Introduction Research has shown that primary care biopsychosocial interventions (PCBI) can reduce pain intensity and disability. While scattered studies support low‐dosed (≤ 15 treatment hours) PCBI, no systematic review exists comparing the effectiveness of low‐dosed PCBI treatment with traditional physical activity interventions in adults with nonspecific chronic low back pain (CLBP). Inclusion Criteria Randomized controlled trials that evaluate low‐dosed PCBI compared to physical treatment with an active component such as exercise, physical activity or usual physiotherapy treatment for adult participants (18 years or older), who suffer from CLBP were included. Not recommended interventions that feature only passive therapies, spinal surgery or pharmacological treatment, and studies with inpatient multidisciplinary‐based rehabilitation (MBR) were excluded. Methods Databases were searched from inception to December 31, 2021. Language was restricted to English or German. Keywords and derivatives of “chronic back pain”, “exercise intervention”, “cognitive‐behavioral therapy”, “primary care” and “randomized controlled trials” were used. Sources were CINAHL, Cochrane Central Register of Controlled Trials (CENTRAL), Ovid Medline, Physiotherapy Evidence Database (PEDro), PubMed and Web of Science. Search was finished on March 08, 2022. Data appraisal, extraction and synthesis followed JBI guidance for systematic reviews of effectiveness. Risk of Bias was assessed using JBI 13‐item checklist for randomized controlled trials. The GRADE approach for grading the certainty of evidence was followed. Systematic Review Registration Number PROSPERO 2022 CRD42022302771. Results Eighteen RCTs were found eligible and 15 trials comprising a total of 1531 participants suffering from CLBP were entered in the meta‐analyses. Risk of Bias was low. Overall evidence was moderate. Significant effects in favor of PCBI were found for pain intensity post‐treatment (standardized mean difference (SMD) = −1.09, 95% confidence interval (CI) = −1.84 to −0.34, I 2 = 97%, p = 0.004) as well as at short‐term (SMD = −0.23, 95% CI = −0.39 to −0.08, I 2 = 0%, p = 0.004), long term (SMD = −0.79, 95% CI = −1.42 to −0.17, I 2 = 96%, p = 0.01) and very long‐term (SMD = −1.13, 95% CI = −1.93 to −0.33, I 2 = 94%, p = 0.005) follow‐up. Significant effects in favor of PCBI for physical function were found post‐treatment (SMD = −1.33, 95% CI = −2.17 to −0.49, I 2 = 97%, p = 0.002) at short‐term (SMD = −0.20, 95% CI = −0.36 to −0.04, I 2 = 0%, p = 0.01) and at long‐term follow‐up (SMD = −1.17, 95% CI = −2.06 to −0.28, I 2 = 98%, p = 0.01). The results were characterized by high heterogeneity due to different types (cognitive behavioral therapy, pain‐neuroscience education, mindfulness, and motivation), delivery modes (individual and/or group), durations (3–12 weeks) and contact times (2–15 h) of PCBI. In sensitivity analysis outliers were removed to reduce heterogeneity. The results remained significant for pain intensity at short‐term (SMD = −0.23, 95% CI = −0.39 to −0.08, I 2 = 0%, p = 0.004) and long‐term follow‐up (SMD = −0.22, 95% CI = −0.41 to −0.03, I 2 = 39%, p = 0.02). Conclusions This meta‐analysis suggests that low‐dosed PCBI has favorable effects in terms of disability and pain intensity compared to active physical treatments alone. All conducted meta‐analyses indicate that biopsychosocial interventions produce better outcomes than active physical treatment alone. Therefore, we strongly recommend decision makers and clinical practitioners to analyze how psychosocial elements can be introduced into outpatient (low‐dosed) CLBP interventions.