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Comparative Effectiveness of Conservative Interventions for Nonspecific Chronic Spinal Pain: Physical, Behavioral/Psychologically Informed, or Combined? A Systematic Review and Meta-Analysis

PainSci » bibliography » O’Keeffe et al 2016
Tags: treatment, back pain, pain problems, spine

One article on PainSci cites O’Keeffe 2016: Cognitive Behavioural Therapy for Chronic Pain

PainSci commentary on O’Keeffe 2016: ?This page is one of thousands in the bibliography. It is not a general article: it is focused on a single scientific paper, and it may provide only just enough context for the summary to make sense. Links to other papers and more general information are provided wherever possible.

Pain might be powered by a rich and funky stew of social and psychological factors as well as biological ones, like injury and pathology. Treatment strategies inspired by the biopsychosocial (BPS) model of healthcare — a humanistic, holistic vision of care that tries to integrate all that stuff (see Engel) — have become quite fashionable in the last twenty years. So it’s worth testing them. Is BPS-ified pain treatment effective? Or is it just another faddish strike out?

I think it’s fair to say we just don’t know yet. And you should not hold your breath until we do. But we do have some data.

This meta-analysis of pooled data from two dozen trials showed almost no differences between the results of BPS-inspired therapy and traditional “just physical” therapy: it’s all equally underwhelming. Specifically, “behavioral/psychologically informed interventions,” with or without physical ones added into the mix, performed just as poorly as physical treatments alone.

The meta-analysis is flawed (as most of them are), and it was harshly criticized in a letter to the editor. However, that complaint might be mostly a case of sour grapes, because the letter’s authors “know” that BPS-inspired treatments are effective (oh, if only). While those turf-defending motives are depressingly clear, everyone is probably right in some important way: nothing about the BPS model of pain, even if completely valid, suggests it’s going to be easy to treat it “biopsychosocially.” On the contrary, the model suggests it will be a beast to apply! But that doesn’t mean that it makes no sense and we shouldn’t be trying and checking.

Dr. Lorimer Mosely wrote of this kerfuffle: “The biopsychosociality of pain might not necessarily mean biopsychosocial treatments work.” And we should expect BPS-inspired treatment to be hard to standardize and test — because it’s messy by nature! Hell, that’s part of the point of the BPS model. And so the poor performance of “psychologically informed” treatments in the scientific literature so far is hardly any kind of a surprise, and BPS-inspired treatment could still have has unconfirmed virtues, could still be one of the least bad options we have for pain.

~ Paul Ingraham

original abstract Abstracts here may not perfectly match originals, for a variety of technical and practical reasons. Some abstacts are truncated for my purposes here, if they are particularly long-winded and unhelpful. I occasionally add clarifying notes. And I make some minor corrections.

Nonspecific chronic spinal pain (NSCSP) is highly disabling. Current conservative rehabilitation commonly includes physical and behavioral interventions, or a combination of these approaches. Physical interventions aim to enhance physical capacity by using methods such as exercise, manual therapy, and ergonomics. Behavioral/psychologically informed interventions aim to enhance behaviors, cognitions, or mood by using methods such as relaxation and cognitive behavioral therapy. Combined interventions aim to target physical and also behavioral/psychological factors contributing to patients' pain by using methods such as multidisciplinary pain management programs. Because it remains unclear whether any of these approaches are superior, this review aimed to assess the comparative effectiveness of physical, behavioral/psychologically informed, and combined interventions on pain and disability in patients with NSCSP. Ten electronic databases were searched for randomized controlled trials (RCTs) including participants reporting NSCSP. Studies were required to have an "active" conservative treatment control group for comparison. Studies were not eligible if the interventions were from the same domain (eg, if the study compared 2 physical interventions). Study quality was assessed used the Cochrane Back Review Group risk of bias criteria. The treatment effects of physical, behavioral/psychologically informed, and combined interventions were assessed using meta-analyses. Twenty-four studies were included. No clinically significant differences were found for pain and disability between physical, behavioral/psychologically informed, and combined interventions. The simple categorization of interventions into physical, behavioral/psychologically informed, and combined could be considered a limitation of this review, because these interventions may not be easily differentiated to allow accurate comparisons to be made. Further work should consider investigating whether tailoring rehabilitation to individual patients and their perceived risk of chronicity, as seen in recent RCTs for low back pain, can enhance outcomes in NSCSP.

PERSPECTIVE: In this systematic review of RCTs in NSCSP, only small differences in pain or disability were observed between physical, behavioral/psychologically informed, and combined interventions.

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