International Journal of Rehabilitation Research:
Psychological interventions in the rehabilitation of patients with chronic low back pain: evidence and recommendations from systematic reviews and guidelines
Reese, Christina; Mittag, Oskar
Department of Quality Management and Social Medicine, University Medical Center Freiburg, Freiburg, Germany
Correspondence to Christina Reese, MSc, Department of Quality Management and Social Medicine, University Medical Center Freiburg, Engelbergerstr. 21, D-79106 Freiburg, Germany Tel: +49 761 270 18510; fax: +49 761 270 73310; e-mail: email@example.com
Received June 13, 2012
Accepted September 10, 2012
The purpose of the article is to summarize evidence and recommendations for psychological interventions in the rehabilitation of patients with chronic low back pain. We carried out a systematic literature search in several databases and on the websites of professional associations to identify relevant reviews and guidelines. In addition to the electronic search, a handsearch was carried out. Eligible publications were selected. We extracted and summarized both evidence for psychological interventions and recommendations on psychological diagnostics and interventions. Six systematic reviews and 14 guidelines were included. We collected recommendations and partially restricted evidence on the following psychological interventions: behavioural therapy, fear-avoidance training, stress management, relaxation therapy, patient education and back school. Most available evidence for psychological interventions in the rehabilitation of patients with chronic low back pain is of moderate to low quality. In addition, some of the older evidence is inapplicable to modern interventions using a biopsychosocial approach. Thus, high quality and current evidence is needed. The summary of guidelines shows that multimodal, multidisciplinary programmes including psychological interventions have become standard in the rehabilitation of patients with chronic low back pain. In most guidelines, however, there are no recommendations on which (psychological) intervention should be considered for which specific problem (problem–treatment pairs). Suggestions for future research and future guidelines are made.
Chronic back pain is a common disease in developed countries. In the overall adult German population, a 12-month prevalence of 19% has been reported for chronic back pain (defined as daily or almost daily back pain over a period of 3 months) (Neuhauser et al., 2005). In a large European survey of chronic pain, back pain was the most frequently mentioned pain location: almost half of the patients with chronic pain reported pain in the back (Breivik et al., 2006). Back pain is nonspecific in about 90% of cases, which means that no relevant physical cause of the pain can be identified, and its origins remain unclear (Koes et al., 2006). Nevertheless, the literature indicates that psychosocial factors are important predictors for both the initial onset of back pain and for its becoming chronic (Linton, 2000).
For patients with chronic low back pain, intensive, multidisciplinary biopsychosocial rehabilitation has proven effective (Guzmán et al., 2001). In Germany, chronic low back pain is one of the most common reasons for rehabilitation (Deutsche Rentenversicherung Bund, 2012). However, from analyses using data from routine documentation, we know that there are large differences between German rehabilitation facilities in terms of the rates of patients who receive specific treatments (Gülich et al., 2003). Although most patients with chronic low back pain participate in treatments such as physical exercise therapy, the rate of patients receiving psychological interventions varies between 30 and 100% (Gülich et al., 2003). It is alarming that these differences seem to be largely independent of relevant patient characteristics such as psychological burden (Irle et al., 2002) or pain behaviour (Schreiber et al., 2004). Similarly, another more recent examination found little standardization of psychological practice in medical rehabilitation of patients with chronic low back pain (Reese et al., 2012).
The implementation of guidelines is one relevant means of standardizing clinical practice. In line with available evidence, national and international guidelines for chronic low back pain recommend multimodal, multidisciplinary rehabilitation including psychological interventions (e.g. Airaksinen et al., 2006; BÄK et al., 2010). Nevertheless, most of these recommendations for psychological interventions lack enough detail to guide psychologists in their daily practice.
Against this background, we have developed detailed, evidence-based practice guidelines for psychological interventions in the rehabilitation of patients with chronic low back pain. [Within the project: ‘Psychological interventions in the rehabilitation of patients with chronic low back pain or coronary heart disease: systematic development of practice guidelines’. Funding: German Statutory Pension Insurance (Deutsche Rentenversicherung Bund).] The underlying definition of ‘psychological interventions’ includes diagnostics, education and/or therapy on the basis of a psychological model or framework.
One important step in our project was the analysis of systematic reviews and guidelines to extract available evidence and recommendations for psychological interventions in the rehabilitation of patients with chronic low back pain. In the following article, we present a summary of the evidence and recommendations.
We searched systematically for reviews and guidelines dealing with psychological interventions in the treatment or rehabilitation of patients with chronic low back pain.
We searched databases and websites of relevant professional associations (Table 1). The search was carried out using keywords and standard vocabulary (MeSH). Search strategies can be obtained from the authors.
The systematic literature search covered the period from January 1990 to November 2009. In the ‘Cochrane Database of Systematic Reviews’, we updated the search in December 2011. The electronic search was supplemented by handsearching reference lists of an elaborated national guideline (BÄK et al., 2010) and of a guidelines clearing report (Banzer et al., 2005).
Selection of publications
A primary selection of publications was made on the basis of title and abstract. In a second step, the full text of all potentially eligible publications was retrieved. A publication was included, provided all eligibility criteria (Table 2) had been fulfilled.
Extraction and summary of contents
Relevant evidence and recommendations were extracted and a narrative summary was drawn up. Particular attention was paid to the following:
Recommendations for psychological assessment or diagnostics.
Evidence and recommendations for psychological interventions.
Differential indications for psychological interventions.
Literature search and inclusion of publications
The flowcharts in Figs 1 and 2 summarize the search process. Six reviews and 14 guidelines fulfilled the inclusion criteria.
Guidelines from the following countries or regions (number of guidelines) were included: Austria (two), Canada (one), Europe (two), France (one), Germany (three), Great Britain (two), Switzerland (one) and USA (two). One guideline from the Swiss Medical Association consisting of two parts (Keel et al., 1997; Keel et al. 1998) is counted as one guideline in Fig. 2.
Assessment of psychosocial risk factors
Psychosocial factors that increase the risk of long-term disability and work loss associated with low back pain are often referred to as ‘yellow flags’ (Kendall et al., 1997). Several guidelines propose that ‘yellow flags’ be considered to assess the risk of chronification or to assess the prognosis of patients with chronic low back pain [Keel et al., 1997; Keel et al., 1998; Airaksinen et al., 2006; Arzneimittelkommission der deutschen Ärzteschaft (AkdÄ), 2007; Friedrich and Likar, 2007; Institute for Clinical Systems Improvement (ICSI), 2008; Ludwig Boltzmann Institut, 2008; National Health Service (NHS) Clinical Knowledge Summaries (CKS), 2009; BÄK et al., 2010]. Three recent guidelines, however, report a lack of adequate evidence to recommend any specific instrument for assessing psychosocial risk factors or emotional distress (Chou et al., 2007; Savigny et al., 2009; BÄK et al., 2010).
A Canadian guideline (Rossignol et al., 2007) recommends that the clinician identify biopsychosocial obstacles to returning to activity. To assess these obstacles, a clinical consultation, exploration of the patient’s history and a job description should be performed. In addition, several assessment tools are recommended. One guideline from the USA [Institute for Clinical Systems Improvement (ICSI), 2008] contains psychosocial screening and assessment tools in its appendix. A Swiss guideline (Keel et al., 1998) offers a detailed description of how to take the patient’s medical history while giving special consideration to psychosocial aspects.
Behavioural therapy, fear-avoidance training
Evidence from systematic reviews
Two systematic reviews, one a Cochrane Review, found evidence of moderate quality in terms of the effectiveness of behavioural therapy for chronic low back pain (Jonsson, 2000; Henschke et al., 2010). Another systematic review evaluates the effectiveness of fear-avoidance training – an intervention addressing fears and encouraging both normal activities and physical exercise (Brox et al., 2008). There is moderate evidence showing no difference between rehabilitation (including fear-avoidance training) and spinal fusion in back pain, disability or sick leave.
Most guidelines recommend behavioural interventions [Agence Nationale d'Accréditation et d’Évaluation en Santé (ANAES), 2000; Arzneimittelkommission der deutschen Ärzteschaft (AkdÄ), 2007; Friedrich and Likar, 2007; Rossignol et al., 2007; Deutsche Rentenversicherung (DRV), 2010] or cognitive-behavioural interventions [Keel et al., 1997; Keel et al., 1998; European Bone and Joint Health Strategies Project, 2004; Airaksinen et al., 2006; Chou et al., 2007; Ludwig Boltzmann Institut, 2008; National Health Service (NHS) Clinical Knowledge Summaries (CKS), 2009; Savigny et al., 2009; BÄK et al., 2010]. Several guidelines from German-speaking countries (Keel et al., 1997; Friedrich and Likar, 2007; BÄK et al., 2010) recommend considering fear-avoidance beliefs and behaviour while working towards a return to normal activity.
Evidence from systematic reviews
Guidelines from German-speaking countries recommend the teaching of stress management strategies [Keel et al., 1997; Keel et al., 1998; Friedrich and Likar, 2007; BÄK et al., 2010; Deutsche Rentenversicherung (DRV), 2010]. The authors of the Swiss recommendations (Keel et al., 1997; Keel et al., 1998) specify strategies for stress management. Such strategies include learning to say ‘no’, asserting oneself in conflict situations, becoming less perfectionistic, lowering unrealistic expectations towards oneself and taking more time for oneself.
Evidence from systematic reviews
One review states that there is moderate evidence suggesting that EMG biofeedback is ineffective in the treatment of chronic low back pain (Jonsson, 2000). In contrast, a Cochrane Review (Henschke et al., 2010) reports low-quality evidence that EMG biofeedback is more effective than waiting-list control for short-term pain relief. In terms of an improvement in functional status, however, they report very low-quality evidence that there is no significant difference between EMG biofeedback and waiting-list control in the short term (Henschke et al., 2010).
In the same review (Henschke et al., 2010), the authors found low-quality evidence that progressive relaxation is more effective than waiting-list control for pain relief or at improving functional status in the short term. In another systematic review (Hoffman et al., 2007), self-regulatory treatments (biofeedback, relaxation or hypnosis) were compared with waiting-list controls. Self-regulatory treatments proved superior in reducing post-treatment pain intensity and depression. The quality of evidence was not assessed in this review.
Several guidelines comprise general recommendations for relaxation therapy [Chou et al., 2007; Friedrich and Likar, 2007; National Health Service (NHS) Clinical Knowledge Summaries (CKS), 2009]. German guidelines provide quite specific recommendations for relaxation techniques such as autogenic training, progressive muscle relaxation and biofeedback [Arzneimittelkommission der deutschen Ärzteschaft (AkdÄ), 2007; BÄK et al., 2010; Deutsche Rentenversicherung (DRV), 2010]. One guideline from Switzerland (Keel et al., 1998) recommends progressive muscle relaxation for patients who have difficulties engaging in meditative techniques such as autogenic training; however, autogenic training is considered suitable for patients who get along with this method. According to the Swiss guideline, biofeedback (which requires staff support and technical equipment) should only be applied when other techniques for self-treatment have failed to work. Two European guidelines (European Bone and Joint Health Strategies Project, 2004; Airaksinen et al., 2006) suggest applying progressive muscle relaxation or biofeedback.
Evidence from systematic reviews
A Cochrane review concludes that the effectiveness of individual education remains unclear for patients with chronic low back pain (Engers et al., 2008). Another review (Brox et al., 2008) evaluates the effectiveness of brief education. The authors found strong evidence that brief education in the clinical setting is not more effective than usual care related to pain reduction. However, brief education proved more effective than usual care in terms of short-term disability and sick leave.
With one exception (Friedrich and Likar, 2007), all guidelines advise including patient consultation and education as part of rehabilitation. Most guidelines agree that encouraging a return to normal activities and to physical activity is one of the central goals of patient consultation and education in rehabilitation. Psychologically relevant subjects of consultation or education include information on the nature and generally positive prognosis of nonspecific low back pain [Keel et al., 1998; Chou et al., 2007; Rossignol et al., 2007; Ludwig Boltzmann Institut, 2008; National Health Service (NHS) Clinical Knowledge Summaries (CKS), 2009; Savigny et al., 2009], the interdependence of pain, strain, fear and depression [Keel et al., 1998; Arzneimittelkommission der deutschen Ärzteschaft (AkdÄ), 2007; National Health Service (NHS) Clinical Knowledge Summaries (CKS), 2009] and instructions for self-help [Keel et al., 1998; Airaksinen et al., 2006; Arzneimittelkommission der deutschen Ärzteschaft (AkdÄ), 2007; Chou et al., 2007; Institute for Clinical Systems Improvement (ICSI), 2008; Ludwig Boltzmann Institut, 2008; National Health Service (NHS) Clinical Knowledge Summaries (CKS), 2009; BÄK et al., 2010].
The contents of back schools vary widely and have been modified over the last few years because of a paradigm shift in the treatment of chronic low back pain (Waddell, 1987). The previous focus on correct posture and movement and the application of a ‘right or wrong dichotomy’ has moved to a biopsychosocial approach and focus on physical exercise (Meng et al., 2009).
Evidence from systematic reviews
A Cochrane review (Heymans et al., 2004) found moderate evidence suggesting that back schools have better short-term and intermediate-term effects on pain and functional status than other treatments. However, most of the studies included date back to the late 1980s or the early 1990s and refer to older concepts of back schools not adopting a biopsychosocial approach. Another review (Brox et al., 2008) evaluating the effectiveness of back schools is largely based on the same (older) studies included in the Cochrane Review. The authors summarize that there is conflicting evidence for back schools compared with other treatments, waiting list or placebo.
Two German guidelines recommend back schools, provided that they follow a biopsychosocial approach [Arzneimittelkommission der deutschen Ärzteschaft (AkdÄ), 2007; BÄK et al., 2010]. Other recommendations from Germany [Deutsche Rentenversicherung (DRV), 2010] propose that most patients with chronic low back pain participate in a back school containing education, physical training, realistic goal setting and strategies for transfer into daily life. A European guideline (Airaksinen et al., 2006) favours back schools for short-term (<6 weeks) pain relief and improvements in functional status because of moderate evidence that back schools are more effective than other treatments (simple advice, exercises only, manipulation) in the short term. In terms of long-term effects, the guideline authors found moderate evidence that there is no difference between back schools and other treatments as to pain and functional status (Airaksinen et al., 2006). Thus, the guideline does not recommend back schools when the aim is long-term effects (>12 months).
We carried out an extensive literature search to identify systematic reviews and guidelines referring to psychological interventions in the treatment of patients with chronic low back pain.
As to the evidence, we found systematic reviews for several psychological interventions in the rehabilitation of chronic low back pain. In general, the evidence available on the effects of psychological interventions is not all that convincing. There is only low-quality to moderate-quality evidence for behavioural therapy (Jonsson, 2000; Henschke et al., 2010), fear-avoidance training (Brox et al., 2008), relaxation therapy (Henschke et al., 2010) and back schools (Heymans et al., 2004). One review (Engers et al., 2008) reported inconsistent evidence for individual patient education, and no systematic review could be identified on the effectiveness of stress management interventions (recommended in several guidelines for the treatment of patients with chronic low back pain). Also, some of the evidence seems outdated, having been published in the 1980s or the early 1990s. Specific contents and topics of rehabilitation programmes for chronic low back pain, for example back school programmes (Meng et al., 2009), have changed since then because of a paradigm shift towards a biopsychosocial approach. Summing up, we conclude that there is still a need for high-quality evidence of the effectiveness of psychological interventions in the context of modern multidisciplinary rehabilitation programmes.
The results of our systematic search were quite encouraging with respect to guidelines. Detailed national and international guidelines have been developed recently (e.g. Airaksinen et al., 2006; BÄK et al., 2010). Although this shows that chronic low back pain has attracted considerable attention of late as a serious health problem with a high economic burden in many industrialized nations (Dagenais et al., 2008; Wenig et al., 2009), it also highlights the essential role of tertiary prevention in restoring function, activities and participation. Guidelines recognize the inter-relation of psychosocial variables and chronic low back pain and concur that a multimodal, biopsychosocial approach should be applied when treating chronic low back pain. The traditional medical view of chronic back pain widely shared in the late 1980s has generally been replaced by the biopsychosocial view as suggested by Waddell (1987). Thus, we were able to extract numerous recommendations for psychological interventions from guidelines.
However, our systematic analysis of guidelines uncovered shortcomings that reveal possibilities for optimization. Most guidelines make no recommendations as to which specific problem of patients with chronic low back pain be addressed by which (psychological) intervention (problem–treatment pairs). As chronic low back pain is after all a disorder with diverse origins, individual treatment programmes should be applied targeting individual risk factors and specific problems (e.g. Bahrke et al., 2006; Liddle et al., 2007). Accordingly, the risk factors and specific problems of patients with low back pain need to be assessed systematically so that appropriate interventions can be chosen. Although we identified some recommendations on how to assess psychosocial risk factors (yellow flags), there were no further specifications as to which interventions to apply as a consequence. Therefore, it is not only recommendations on how to assess individual (psychosocial) risk factors and problems of patients with chronic low back pain that are necessary: there is also a need for specific recommendations on interventions addressing these individual problems and risk factors. Were such information available, the implementation of tailored interventions could be facilitated.
When analysing guidelines, we paid particular attention to identifying recommendations addressing subgroups of patients, such as those with low socioeconomic status or a foreign background. We found no such specific recommendations. This is disturbing, as educational level (as an indicator of socioeconomic status) is inversely related to the duration and recurrence of back pain (Dionne et al., 2001); a stronger consideration of the demands of patients with low socioeconomic status might improve prognosis. Similarly, a stronger consideration of the cultural background of patients could help to change inappropriate beliefs about the origin and treatment of low back pain, generate more realistic expectations regarding rehabilitation and thereby enhance outcomes (Sloots et al., 2009). We also did not find any sex-specific recommendations referring to interventions tailored for women. The lack of recommendations for patient subgroups reflects the lack of research findings in this field (e.g. Schmidt et al., 2001, for sex-specific aspects in chronic low back pain rehabilitation). Consequently, further research should focus stronger on which treatment works best for whom. In doing so, an empirical basis for detailed recommendations and tailored interventions could be created. This in turn might well improve the efficacy and efficiency of low back pain rehabilitation.
This study has been funded by the German Statutory Pension Insurance (Deutsche Rentenversicherung Bund), Grant No. 0423-40-64-50-18.
Conflicts of interest
There are no conflicts of interest.
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