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Cited by 220Musculoskeletal pain and rehabilitationPain Management and TreatmentHealth Policy Implementation Science

Psychological interventions for chronic, non-specific low back pain: systematic review with network meta-analysis

Open access
Ho, Emma Kwan-Yee, Chen, Lingxiao, Simic, Milena, Ashton-James, Claire Elizabeth, Comachio, Josielli, Wang, Daniel Xin Mo, Hayden, Jill Alison, Ferreira, Manuela Loureiro +1 more·2022·BMJ
DOI 10.1136/bmj-2021-067718PMC PMC8965745
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Abstract

Objective: To determine the comparative effectiveness and safety of psychological interventions for chronic low back pain. Design: Systematic review with network meta-analysis. Data sources: Medline, Embase, PsycINFO, Cochrane Central Register of Controlled Trials, Web of Science, SCOPUS, and CINAHL from database inception to 31 January 2021. Eligibility criteria for study selection: Randomised controlled trials comparing psychological interventions with any comparison intervention in adults with chronic, non-specific low back pain. Two reviewers independently screened studies, extracted data, and assessed risk of bias and confidence in the evidence. Primary outcomes were physical function and pain intensity. A random effects network meta-analysis using a frequentist approach was performed at post-intervention (from the end of treatment to <2 months post-intervention); and at short term (≥2 to <6 months post-intervention), mid-term (≥6 to <12 months post-intervention), and long term follow-up (≥12 months post-intervention). Physiotherapy care was the reference comparison intervention. The design-by-treatment interaction model was used to assess global inconsistency and the Bucher method was used to assess local inconsistency. Results: 97 randomised controlled trials involving 13 136 participants and 17 treatment nodes were included. Inconsistency was detected at short term and mid-term follow-up for physical function, and short term follow-up for pain intensity, and were resolved through sensitivity analyses. For physical function, cognitive behavioural therapy (standardised mean difference 1.01, 95% confidence interval 0.58 to 1.44), and pain education (0.62, 0.08 to 1.17), delivered with physiotherapy care, resulted in clinically important improvements at post-intervention (moderate quality evidence). The most sustainable effects of treatment for improving physical function were reported with pain education delivered with physiotherapy care, at least until mid-term follow-up (0.63, 0.25 to 1.00; low quality evidence). No studies investigated the long term effectiveness of pain education delivered with physiotherapy care. For pain intensity, behavioural therapy (1.08, 0.22 to 1.94), cognitive behavioural therapy (0.92, 0.43 to 1.42), and pain education (0.91, 0.37 to 1.45), delivered with physiotherapy care, resulted in clinically important effects at post-intervention (low to moderate quality evidence). Only behavioural therapy delivered with physiotherapy care maintained clinically important effects on reducing pain intensity until mid-term follow-up (1.01, 0.41 to 1.60; high quality evidence). Conclusions: For people with chronic, non-specific low back pain, psychological interventions are most effective when delivered in conjunction with physiotherapy care (mainly structured exercise). Pain education programmes (low to moderate quality evidence) and behavioural therapy (low to high quality evidence) result in the most sustainable effects of treatment; however, uncertainty remains as to their long term effectiveness. Although inconsistency was detected, potential sources were identified and resolved. Systematic review registration: PROSPERO CRD42019138074.

AI snapshot

Written from the paper’s full text.

TL;DR

In adults with chronic, non-specific low back pain, psychological interventions were most effective when delivered with physiotherapy care, mainly structured exercise. Pain education and behavioural therapy showed the most sustainable effects, but long-term effectiveness remains uncertain.

Key findings

  • Across 97 randomised controlled trials (13,136 participants, 17 treatment nodes), cognitive behavioural therapy plus physiotherapy care improved physical function at post-intervention (SMD 1.01, 95% CI 0.58 to 1.44; moderate quality), as did pain education plus physiotherapy care (0.62, 0.08 to 1.17; moderate quality). Pain education plus physiotherapy care had the most sustainable physical function effect until mid-term follow-up (0.63, 0.25 to 1.00; low quality), with no long-term studies.
  • For pain intensity at post-intervention, behavioural therapy plus physiotherapy care (SMD 1.08, 95% CI 0.22 to 1.94), cognitive behavioural therapy plus physiotherapy care (0.92, 0.43 to 1.42), and pain education plus physiotherapy care (0.91, 0.37 to 1.45) had clinically important effects. Only behavioural therapy plus physiotherapy care maintained clinically important effects until mid-term follow-up (1.01, 0.41 to 1.60; high quality).
  • For fear avoidance, cognitive behavioural therapy plus physiotherapy care had a large effect at post-intervention (SMD 1.77, 95% CI 0.65 to 2.90; moderate quality); pain education alone or with physiotherapy care also showed large short-term effects. Safety data were limited: of 20 studies with clear adverse-event information, 12 reported no adverse events, and reported events were not considered serious.

Methods

  • Systematic review with random-effects network meta-analysis using a frequentist approach; searched Medline, Embase, PsycINFO, Cochrane Central Register of Controlled Trials, Web of Science, SCOPUS, and CINAHL from inception to 31 January 2021.
  • Included randomised controlled trials of adults with chronic, non-specific low back pain comparing psychological interventions with any comparison intervention; primary outcomes were physical function and pain intensity, with physiotherapy care as the reference comparison.
  • Analysed 97 trials involving 13,136 participants and 17 treatment nodes at post-intervention, short term (≥2 to <6 months), mid-term (≥6 to <12 months), and long term (≥12 months); used SMDs, CINeMA, Cochrane risk-of-bias 2, and design-by-treatment/Bucher methods for inconsistency.

Limitations

  • The paper states that combining two or more psychological approaches into one treatment node could introduce heterogeneity; hypnosis met inclusion criteria but was excluded from the network meta-analysis; inconsistency was detected at some time points but resolved through sensitivity analyses; poor reporting of socioeconomic factors, comorbidities, and patient involvement limited subgroup analyses and interpretation; blinding participants was not possible; and the physiotherapy care node combined exercise, passive therapy, and mixed care.
  • The paper also states that health-related quality of life and safety could not be meta-analysed because of heterogeneous assessment or reporting, and that long-term follow-up had small sample sizes and wide confidence intervals.
  • Evident from the text: most included studies were judged to have some concerns or high risk of bias (for physical function, 58/61 some concerns and 3/61 high risk; for pain intensity, 62/66 some concerns and 4/66 high risk; for fear avoidance, 29/30 some concerns and 1/30 high risk), and the fear avoidance network became disconnected at long-term follow-up.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1136/bmj-2021-067718

Cites

Statistics

Nothing to recompute.

Claims the paper makes

0 of 63 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    97 randomised controlled trials involving 13,136 participants and 17 treatment nodes were included in the systematic review.

    “97 randomised controlled trials involving 13 136 participants and 17 treatment nodes were included.”
    Quote in the paperSubstantial claim
  • Findingown data

    Pain education delivered with physiotherapy care resulted in clinically important effects on reducing pain intensity at post-intervention (SMD 0.91, 95% CI 0.37 to 1.45; low to moderate quality evidence).

    “For pain intensity, behavioural therapy (1.08, 0.22 to 1.94), cognitive behavioural therapy (0.92, 0.43 to 1.42), and pain education (0.91, 0.37 to 1.45), delivered with physiotherapy care, resulted in clinically important effects at post-intervention (low to moderate quality evidence).”
    Quote in the paperSubstantial claim
  • Findingown data

    No studies investigated the long term effectiveness of pain education delivered with physiotherapy care.

    “No studies investigated the long term effectiveness of pain education delivered with physiotherapy care.”
    Quote in the paperNot a substantial claim
  • Findingown data

    Pain education delivered with physiotherapy care produced the most sustainable effects of treatment for improving physical function, at least until mid-term follow-up (SMD 0.63, 95% CI 0.25 to 1.00; low quality evidence).

    “The most sustainable effects of treatment for improving physical function were reported with pain education delivered with physiotherapy care, at least until mid-term follow-up (0.63, 0.25 to 1.00; low quality evidence).”
    Quote in the paperSubstantial claim
  • Findingown data

    Pain education delivered with physiotherapy care resulted in clinically important improvements in physical function at post-intervention (SMD 0.62, 95% CI 0.08 to 1.17; moderate quality evidence).

    “For physical function, cognitive behavioural therapy (standardised mean difference 1.01, 95% confidence interval 0.58 to 1.44), and pain education (0.62, 0.08 to 1.17), delivered with physiotherapy care, resulted in clinically important improvements at post-intervention (moderate quality evidence).”
    Quote in the paperSubstantial claim
  • May combine two claims. 44
  • Classified as probably not a substantial claim. 35

  • May combine two claims.

    Findingown data

    Inconsistency was detected at short term and mid-term follow-up for physical function, and at short term follow-up for pain intensity, and these inconsistencies were resolved through sensitivity analyses.

    “Inconsistency was detected at short term and mid-term follow-up for physical function, and short term follow-up for pain intensity, and were resolved through sensitivity analyses.”
    • Also stated in: § Conclusions · plain
      “Although inconsistency was detected, potential sources were identified and resolved.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Twenty-one unique studies were not included in the NMA for physical function and pain intensity, and eight unique studies were not included in the NMA for fear avoidance.

    “Twenty one unique studies were not included in the NMA for physical function and pain intensity, and eight unique studies were not included in the NMA for fear avoidance (see supplementary G).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The effect of pain education delivered with physiotherapy care on pain intensity remained significant at mid-term follow-up, although the effect was small and not clinically important (SMD 0.41, 95% CI 0.13 to 0.95; moderate quality evidence).

    “The effect of treatment remained significant at mid-term follow-up, although the effect was small and not clinically important (0.41, 0.13 to 0.95; moderate quality evidence).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    In a pairwise meta-analysis at long term follow-up, cognitive behavioural therapy delivered with physiotherapy care had no significant effect on fear avoidance compared with physiotherapy care alone, but the 95% confidence interval suggested results might favour cognitive behavioural therapy delivered with physiotherapy care.

    “Owing to disconnection of the network at long term follow-up, we performed only a pairwise meta-analysis of cognitive behavioural therapy delivered with physiotherapy care and physiotherapy care alone. The results were not significant; however, the 95% confidence interval suggested that results might favour cognitive behavioural therapy delivered with physiotherapy care (3.21, 0.00 to 6.41).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    At mid-term follow-up, pain education delivered with physiotherapy care had no significant effect on physical function in both primary analysis (SMD 0.67, 95% CI -0.03 to 1.37; low quality evidence) and sensitivity analysis (SMD 0.39, 95% CI -0.17 to 0.95; low quality evidence).

    “at mid-term follow-up, results from both the primary analysis (0.67, −0.03 to 1.37; low quality evidence) and sensitivity analysis (resolving inconsistency) (0.39, −0.17 to 0.95; low quality evidence) found that treatment effects were no longer significant”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Significance for cognitive behavioural therapy delivered with physiotherapy care on pain intensity was attenuated at mid-term (SMD 0.28, 95% CI -0.01 to 0.57; moderate quality evidence) and long term follow-up (SMD 1.19, 95% CI -0.10 to 2.48; moderate quality evidence).

    “significance was attenuated at mid-term (0.28, −0.01 to 0.57; moderate quality evidence) and long term follow-up (1.19, −0.10 to 2.48; moderate quality evidence)”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Sensitivity analysis excluding three studies with high risk of bias produced similar effect estimates for pain intensity at post-intervention for behavioural therapy with physiotherapy care (SMD 1.14, 95% CI 0.04 to 2.24), cognitive behavioural therapy with physiotherapy care (0.91, 0.37 to 1.46), and pain education with physiotherapy care (0.91, 0.35 to 1.48).

    “Sensitivity analysis, excluding three studies with high risk of bias, produced similar effect estimates (1.14, 0.04 to 2.24 for behavioural therapy with physiotherapy care; 0.91, 0.37 to 1.46 for cognitive behavioural therapy with physiotherapy care; and 0.91, 0.35 to 1.48 for pain education with physiotherapy care; supplementary N).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    At long term follow-up, behavioural therapy delivered with physiotherapy care had a large effect on reducing pain intensity but the result was not significant (SMD 0.86, 95% CI -1.12 to 2.84; moderate quality evidence).

    “Effect estimates at long term follow-up suggested a large effect of treatment; however, the results were not significant (0.86, −1.12 to 2.84; moderate quality evidence).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Both primary analysis (SMD 1.04, 95% CI 0.19 to 1.88; moderate quality evidence) and sensitivity analysis (SMD 1.06, 95% CI 0.56 to 1.55) found that pain education delivered with physiotherapy care maintained a large and clinically important effect on reducing pain intensity at short term follow-up.

    “Both the primary analysis (SMD 1.04, 95% confidence interval 0.19 to 1.88; moderate quality evidence; supplementary I) and sensitivity analysis (1.06, 0.56 to 1.55; supplementary N) found that pain education delivered with physiotherapy care maintained a large and clinically important effect at short term follow-up.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The systematic review included 97 articles involving 97 unique studies and 13,136 people with chronic, non-specific low back pain.

    “In total, 97 articles involving 97 unique studies and 13 136 people with chronic, non-specific LBP were included in the systematic review (fig 1).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    In sensitivity analysis removing inconsistency at short term follow-up, behavioural therapy delivered with physiotherapy care became disconnected from the network, so no SUCRA results were available; instead, pain education delivered with physiotherapy care was the most highly ranked intervention (SUCRA 92.3%).

    “In sensitivity analysis (removing inconsistency) at short term follow-up, behavioural therapy delivered with physiotherapy care became disconnected from the network, therefore, no SUCRA results were available. Instead, pain education delivered with physiotherapy care was the most highly ranked intervention (SUCRA 92.3%) at this time point.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    No cluster randomised controlled trials were eligible for inclusion in the review.

    “No cluster randomised controlled trials were eligible for inclusion in our review.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The authors were unable to impute arm-level socioeconomic data from the remaining studies because of heterogeneity of reporting, precluding subgroup analyses or meta-regression.

    “we attempted but were unable to impute arm level data from the remaining studies, owing to heterogeneity of reporting by study authors, precluding subgroup analyses or meta-regression.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Meta-regression did not suggest that mean age or proportion of males were effect modifiers.

    “Nonetheless, meta-regression did not suggest that either mean age or proportion of males were effect modifiers (supplementary Y).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    At short term and mid-term follow-up, pain education delivered with physiotherapy care ranked first for physical function (short term SUCRA 85.6%, mean rank 2.7; mid-term SUCRA 90.7%, mean rank 2.3).

    “At short term and mid-term follow-up, pain education delivered with physiotherapy care ranked first (for short term, 85.6% and 2.7; for mid-term, 90.7% and 2.3).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The physiotherapy care node mainly consisted of exercise interventions only, followed by a smaller number of studies investigating exercise delivered with passive therapy.

    “Overall, the physiotherapy care node mainly consisted of exercise interventions only, followed by a smaller number of studies investigating exercise delivered with passive therapy.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingcitation

    Available evidence suggests that pain education delivered alone or with physiotherapy care, cognitive behavioural therapy delivered with physiotherapy care, and counselling delivered with physiotherapy care are more effective than physiotherapy care alone for improving health related quality of life.

    “The available evidence suggests that pain education delivered alone68 70 or in conjunction with physiotherapy care,85 86 cognitive behavioural therapy delivered with physiotherapy care,87 88 and counselling delivered with physiotherapy care89 are more effective than physiotherapy care alone for improving health related quality of life.”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites 68 70

      Not checked in the free run.

    • cites 85 86

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    • cites 87 88

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  • May combine two claims.

    Findingown data

    No evidence suggested that mean age, percentage of males, or mean baseline levels of fear avoidance were effect modifiers.

    “We did not find any evidence suggesting that mean age, percentage of males, or mean baseline levels of fear avoidance were effect modifiers (supplementary Y).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingcitation

    Four studies reported adverse events during the intervention period, but none was related to the psychological interventions under investigation.

    “Four studies reported on the occurrence of adverse events during the intervention period54 61 100 101; however, none was related to the psychological interventions under investigation.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites 54 61 100 101

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  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Most studies included in the review were published between 2011 and 2021.

    “As reported in table 2, most studies included in our review were published between 2011 and 2021.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    The assessment and reporting of data for health related quality of life and safety across studies of psychological interventions for chronic, non-specific low back pain is highly heterogeneous and generally absent, preventing network meta-analysis for both outcomes.

    “In addition, the assessment and reporting of data for health related quality of life and safety across studies of psychological interventions for chronic, non-specific LBP is highly heterogenous and generally absent, which prevented us from performing NMA for both outcomes.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductcitation

    Small-study effects were evaluated by visual inspection of comparison-adjusted funnel plots and meta-regression using total sample size.

    “Small-study effects were evaluated by visual inspection of comparison-adjusted funnel plots, including only comparisons with at least one study available, for asymmetry.49 We performed meta-regression using the total sample size to detect small-study effects.51”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [49] source

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    • cites [51] source

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    Study design and conductcitation

    Confidence in the cumulative evidence was evaluated using the CINeMA framework.

    “Confidence in the cumulative evidence was evaluated using the Confidence in NMA (CINeMA) framework,36 a web application of the Grading of Recommendations Assessment, Development, and Evaluation ratings approach.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [36] Institute of Social and Preventive Medicine. CINeMA: Confidence in Network Meta-Analysis University of Bern; 2017. https://cinema.ispm.unibe.ch/.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductcitation

    The systematic review with network meta-analysis was reported in accordance with the PRISMA statement for systematic reviews and the PRISMA extension for network meta-analysis.

    “This systematic review with NMA was reported in accordance with the PRISMA statement for systematic reviews23 and the PRISMA extension for NMA (PRISMA-NMA).24”
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    • cites [23] source

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    • cites [24] source

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    Study design and conductown data

    Two reviewers independently assessed risk of bias for relevant outcomes in studies included in the network meta-analysis using the revised Cochrane risk-of-bias 2 tool.

    “After pilot testing, two reviewers (JC and DXMW) independently assessed risk of bias for the relevant outcomes, only in studies included in the NMA, using the licensed Excel tool to implement the revised Cochrane risk-of-bias 2 tool for randomised trials.33 34”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites 33 34

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  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    We performed sensitivity analyses excluding data imputed from median and interquartile range values for the primary outcomes.

    “We performed sensitivity analyses excluding data imputed from median and interquartile range values, which was only relevant to the primary outcomes, to examine the robustness of our primary analyses.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    We attempted but were unable to perform a meta-analysis for health related quality of life and safety owing to heterogeneity of assessment or reporting or both.

    “We attempted but were unable to perform a meta-analysis for health related quality of life and safety, owing to heterogeneity of assessment or reporting or both.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Fear avoidance beliefs, depression, anxiety, catastrophic thinking, and familial and social stress can increase the risk of physical disability in adults with chronic low back pain.

    “Fear avoidance beliefs, depression, anxiety, catastrophic thinking, and familial and social stress are highly prevalent in adults with chronic LBP1 and can increase the risk of physical disability,2 3”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites 2 3

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    Study design and conductown data

    Sensitivity analyses were performed at post-intervention excluding studies with high risk of bias, including only intention-to-treat studies, excluding studies published before 2000, and excluding studies of patients with leg pain.

    “To examine the robustness of our results and to examine sources of potential inconsistency, we performed the following sensitivity analyses at post-intervention: firstly, excluding studies with high risk of bias; secondly, including only studies using intention-to-treat analysis; thirdly, excluding studies published before the year 2000; and finally, excluding studies of patients with leg pain.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductcitation

    The protocol was registered on PROSPERO (registration No CRD42019138074) and the protocol paper was peer reviewed and published in BMJ Open.

    “The protocol was registered on PROSPERO (registration No CRD42019138074) and the protocol paper was peer reviewed and published in BMJ Open.25”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [25] source

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  • May combine two claims.

    Premisereasoning

    Making decisions about psychological interventions for low back pain is difficult owing to lack of information about which psychological interventions are most effective for a specific clinical outcome and a paucity of evidence for comparative longevity of intervention outcomes.

    “However, making decisions about psychological interventions for LBP is fraught with difficulty owing to lack of information about which psychological interventions are most effective to obtain a specific clinical outcome of interest and a paucity of evidence for the comparative longevity of intervention outcomes.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Two reviewers independently extracted all available data.

    “Two reviewers (JC and DXMW) independently extracted all available data for publication (eg, publication year and funding), study design”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Fear avoidance beliefs, depression, anxiety, catastrophic thinking, and familial and social stress are highly prevalent in adults with chronic low back pain.

    “Fear avoidance beliefs, depression, anxiety, catastrophic thinking, and familial and social stress are highly prevalent in adults with chronic LBP1”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [1] source

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    Study design and conductown data

    Two reviewers independently screened eligibility in two stages: citation titles and abstracts, and full text.

    “Two pairs of reviewers (EK-YH and JC, JC and DXMW) independently screened eligibility in two stages: citation titles and abstracts, and full text.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisenone given

    Previous reviews have conducted only independent pairwise meta-analyses, and no attempts have been made to synthesise the results cohesively.

    “Importantly, previous reviews have conducted only independent pairwise meta-analyses, and to our knowledge, no attempts have been made to synthesise the results cohesively.”
    Quote in the paperSubstantial claim

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    Premisecitation

    Cognitive behavioural therapy is the most frequently recommended psychological approach for chronic low back pain, often without mention of evidence for other forms of psychological interventions.

    “Cognitive behavioural therapy is the most frequently recommended psychological approach,16 often without mention of evidence for other forms of psychological interventions.17 18 19”
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    • cites [16] source

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    • cites 17 18 19

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    Study design and conductcitation

    Global inconsistency of the entire network was assessed by the design-by-treatment interaction model, and local inconsistencies were assessed by the Bucher method.

    “Global inconsistency of the entire network was assessed by the design-by-treatment interaction model.49 Local inconsistencies were assessed by the Bucher method.50”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [49] source

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    • cites [50] source

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  • May combine two claims.

    Premisecitation

    Physiotherapy care was selected as the reference comparison intervention because exercise and passive therapies were the most frequently investigated comparison interventions and exercise is the most commonly endorsed treatment approach for managing chronic low back pain.

    “Physiotherapy care was selected because exercise and passive therapies, which are frequently prescribed or used by physiotherapists, were the most frequently investigated comparison interventions in the included studies and because exercise is the most commonly endorsed treatment approach for managing chronic LBP.8 16”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [8] source

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    • cites [16] source

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    Study design and conductown data

    Sensitivity analyses excluding studies with high risk of bias did not substantially affect the results of the global or local inconsistency tests, suggesting studies with high risk of bias were not an important source of inconsistency.

    “Sensitivity analyses excluding studies with high risk of bias did not substantially affect the results of the global or local inconsistency tests, suggesting studies with high risk of bias were not an important source of inconsistency.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    We were unable to perform meta-regression based on intervention dosage or frequency owing to heterogeneity of reporting.

    “Owing to heterogeneity of reporting, we were unable to perform meta-regression based on intervention dosage or frequency.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    We attempted to perform a sensitivity analysis excluding studies with a sample size of less than 100, but did not perform it because it excluded 53 (55%) of 97 studies and led to large changes in network structure.

    “We attempted to perform a sensitivity analysis by excluding studies with a sample size of less than 100; however, this process resulted in the exclusion of 53 (55%) of 97 studies from our systematic review, leading to large changes in our network structure. Therefore, this additional analysis was not performed.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    The review used a careful selection of search terms extracted from existing studies of psychological interventions for chronic pain conditions to capture a broad range of psychological interventions.

    “Further, we used a careful selection of search terms, extracted from many existing studies of psychological interventions for chronic pain conditions, to capture a broad range of psychological interventions.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    Evidence supports the clinical benefits of combining physiotherapy care with specific psychological interventions at the onset of treatment, although clinical effectiveness diminishes over time, particularly in the long term.

    “Although their clinical effectiveness diminishes over time, particularly in the long term (≥12 months post-intervention), evidence supports the clinical benefits of combining physiotherapy care with these specific types of psychological interventions at the onset of treatment.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Study design and conductcitation

    The review assessed core clinical outcomes for evaluating the efficacy or effectiveness of health interventions in people with non-specific low back pain.

    “Importantly, we assessed core clinical outcomes for evaluating the efficacy or effectiveness of health interventions in people with non-specific LBP (eg, physical function, pain intensity, and health related quality of life).103”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [103] source

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    Study design and conductcitation

    The review used the splitting approach proposed by Caldwell et al to separate different types of psychological interventions into distinct categories and to delineate between interventions delivered with or without co-interventions.

    “In summary, we used the splitting approach proposed by Caldwell et al102 to separate different types of psychological interventions into distinct categories, and further, we delineated between psychological interventions delivered with or without co-interventions.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Caldwell et al102

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    Study design and conductcitation

    The review used a meticulous method to classify psychological interventions, described in the protocol paper and supplementary B.

    “Importantly, we used a meticulous method to classify the psychological interventions, which has been described in the protocol paper25 and in supplementary B.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [25] source

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    Interpretationnone given

    Previous reviews have commonly grouped different types of psychological interventions together or grouped psychological interventions with or without co-interventions together in a single comparison, potentially leading to heterogeneous comparisons and inaccurate treatment effect estimates.

    “This method is an important strength of our study because previous reviews have commonly grouped different types of psychological interventions together or grouped psychological interventions with or without co-interventions together, in a single comparison, potentially leading to heterogenous comparisons and inaccurate treatment effect estimates.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Study design and conductreasoning

    The decision to combine exercise, passive therapy, and physiotherapy into one node was pragmatic, but heterogeneity within the node was a potential limitation.

    “Furthermore, although the decision to combine exercise, passive therapy, and physiotherapy into one node was pragmatic (that is, reflecting clinical practice), heterogeneity within the node was a potential limitation.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning

    Interpretation of study findings was made with consideration of the results of both the primary and sensitivity analyses.

    “Interpretation of study findings were made with consideration of the results of both the primary and sensitivity analyses.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    Findings from the review are based on low to high quality evidence.

    “Findings from our review are based on low to high quality evidence.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Premisenone given

    The authors are not aware of any published high quality reviews directly comparing physiotherapy care with interventions based on pain education or counselling, delivered with or without a co-intervention, for people with chronic, non-specific low back pain.

    “We are not aware of any published high quality reviews directly comparing physiotherapy care with interventions based on pain education or counselling (that is, health coaching), delivered with or without a co-intervention, for people with chronic, non-specific LBP.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Fear avoidance, health related quality of life, intervention compliance, and safety were not analysed statistically in the previous Cochrane review.

    “Fear avoidance, health related quality of life, intervention compliance, and safety were not analysed statistically in the previous Cochrane review.14”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [14] source

      Not checked in the free run.

  • May combine two claims.

    Study design and conductown data

    The review performed a thorough examination of potential sources of inconsistency within the network and was able to sufficiently identify and resolve the main sources of inconsistency.

    “However, we performed a thorough examination of potential sources within the network (eg, visually inspecting study and patient characteristics to assess transitivity, exploring potential heterogeneity within the physiotherapy care node, and conducting numerous sensitivity analyses and meta-regressions), and we were able to sufficiently identify and resolve the main sources of inconsistency.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Premisenone given

    If unresolved, the presence of inconsistency can threaten the validity of network meta-analysis results.

    “If unresolved, the presence of inconsistency can threaten the validity of the NMA results.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    The absence of patient advocates involved in the planning and interpretation of the analyses could be considered a limitation of the review.

    “In parallel, the absence of patient advocates involved in the planning and interpretation of the analyses could be considered a limitation of this review.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The Cochrane review by Henschke et al found low to moderate quality evidence that behavioural therapy and group exercise did not differ significantly in reducing pain intensity.

    “The review also found low to moderate quality evidence that behavioural therapy and group exercise did not differ significantly in reducing pain intensity.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Henschke et al14

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Premisecitation

    Chronic pain conditions such as low back pain require multimodal treatment approaches that address biopsychosocial dimensions.

    “Chronic pain conditions such as LBP require multimodal treatment approaches that address biopsychosocial dimensions.8”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [8] source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The Cochrane review by Henschke et al found that behavioural therapy delivered with physiotherapy and back education was not more effective than physiotherapy care and back education alone for pain relief and physical function over the short to intermediate term.

    “The review found that behavioural therapy delivered with physiotherapy and back education was not more effective than was physiotherapy care and back education alone for pain relief and physical function over the short to intermediate term.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Henschke et al14

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    The review investigated the comparative safety of psychological interventions for chronic, non-specific low back pain, which to the authors' knowledge has not been assessed comprehensively in previous reviews.

    “In addition, we investigated the comparative safety of psychological interventions for chronic, non-specific LBP, which to our knowledge, has not been assessed comprehensively in previous reviews and is an important consideration when evaluating the risk-benefit ratio of health interventions.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Premisenone given

    Guidelines are vague regarding the comparative effectiveness and longevity of treatment effectiveness of different types of psychological intervention that should be recommended to patients.

    “However, guidelines are vague regarding the comparative effectiveness, and longevity of treatment effectiveness, of different types of psychological intervention that should be recommended to patients.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning

    The inherent inability to blind participants in clinical trials involving psychological interventions should be considered a potential source of bias.

    “The inherent inability to blind participants in clinical trials involving psychological interventions should also be considered as a potential source of bias (eg, study results could favour psychological interventions, delivered with or without physiotherapy care, over comparison interventions such as usual care, no interventions, or even physiotherapy care alone).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing), S4 (based). May combine two claims.

    Premisenone given

    Exercise is an important component of behavioural therapy or cognitive behavioural therapy, and an adjunct to pain education programs.

    “We also remind psychologists that exercise is an important component of behavioural therapy or cognitive behavioural therapy, and adjunct to pain education programs.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Clinician perceived barriers exist regarding the incorporation of psychological strategies into clinical practice, such as insufficient knowledge, concerns with reimbursement, time constraints, and reluctance of patients to engage in these types of treatment.

    “Clinician perceived barriers exist regarding the incorporation of psychological strategies into clinical practice, such as insufficient knowledge, concerns with reimbursement, time constraints, and reluctance of patients to engage in these types of treatment.116 121”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites 116 121

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationcitation

    Interdisciplinary or intradisciplinary approaches to treatment delivery come with their own challenges.

    “Nonetheless, we recognise that interdisciplinary or intradisciplinary approaches to treatment delivery come with their own challenges.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationreasoning

    The current multidisciplinary model of care for low back pain could be insufficient in meeting patient needs and is likely inadequate for supporting effective integration of care.

    “the current multidisciplinary model of care for LBP could be insufficient in meeting patient needs and is likely to be inadequate for supporting effective integration of care.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Poor cross disciplinary collaboration can proliferate negative perceptions from the patient about illness, delay recovery, and reduce quality of life in patients with low back pain.

    “Considering that poor cross disciplinary collaboration can proliferate negative perceptions from the patient about illness, delay recovery, and reduce quality of life in patients with LBP,115”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [115] Løvschall C Bech M Rasmussen C . Sundhedsstyrelsen M og medecinsk T. Tværdisciplinær og tværsektoriel indsats over for patienter med ondt i ryggen – en medicinsk teknologivurdering. Vol 12. Danish Health Authority, 2010.

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Interpretationreasoning

    Interdisciplinary or intradisciplinary approaches to treatment delivery can be feasible alternatives to optimise co-delivery of exercise and psychological therapies at the onset of treatment.

    “To optimise co-delivery of exercise and psychological therapies at the onset of treatment, interdisciplinary or intradisciplinary approaches to treatment delivery can be feasible alternatives.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based). May combine two claims.

    Premisenone given

    Exercise providers and psychologists traditionally operate in siloed settings, which can lead to disjointed care.

    “Although these findings are alarming, they are not surprising given that exercise providers and psychologists traditionally operate in siloed settings, which can lead to disjointed care.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Interpretationreasoning

    Psychologists are well situated to potentially incorporate structured exercise programmes, guided by a patient's preference, into treatment.

    “Consequently, psychologists are well situated to potentially incorporate structured exercise programmes, guided by a patient’s preference, into treatment.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Patients still perceive cross disciplinary care to be fragmented, and organisational support and collaboration between different health professionals is insufficient.

    “Patients still perceive cross disciplinary care to be fragmented, and organisational support and collaboration between different health professionals is insufficient.119 120”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites 119 120

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Premisenone given

    In clinical psychology, promotion of physical activity and movement are established as inherent components of cognitive behavioural therapy interventions for chronic pain, such as graded activity or graded exposure.

    “In clinical psychology, promotion of physical activity and movement are established as inherent components of cognitive behavioural therapy interventions for chronic pain, such as graded activity or graded exposure.”
    Quote in the paperNot a substantial claim
71 of 71

  • The authors state this as an assumption.

    The heterogeneity variance across different comparisons within the network meta-analysis model was the same.

    “We assumed that the heterogeneity variance across different comparisons within the NMA model were the same.”

  • The authors state this as an assumption.

    The correlation coefficient for calculating change-from-baseline standard deviations was 0.50.

    “assuming a correlation coefficient (r) of 0.50.”

  • The authors state this as an assumption.

    The median is equivalent to the mean when imputing standard deviations from median and interquartile range.

    “we considered the median to be equivalent to the mean.”

  • The authors state this as an assumption.

    Heterogeneity in the physiotherapy care node was unlikely to significantly affect the study results because most relevant studies involved exercise or exercise with passive therapy.

    “we assumed that heterogeneity was unlikely to significantly affect the study results because most relevant studies involved exercise or exercise with passive therapy.”

  • The authors state this as an assumption.

    The rate of referral to psychological services for low back pain is even lower than the rate of referral to physiotherapy.

    “in the absence of data, we postulate that the rate of referral to psychological services for LBP is even lower.”

  • The paper relies on this without support.

    The clinical goal of physiotherapy care is typically grounded in changing behaviour, mainly through the promotion of exercise or physical activity.

    “Furthermore, the clinical goal of physiotherapy care is typically grounded in changing behaviour, mainly through the promotion of exercise or physical activity.”

  • The paper relies on this without support.

    The comparative effectiveness of psychological interventions available for managing chronic low back pain is unknown.

    “- The comparative effectiveness of psychological interventions available for managing chronic low back pain is unknown, potentially contributing to patients and clinicians being uncertain regarding the most optimal choice of treatment”

  • The paper relies on this without support.

    Current guidelines provide limited information regarding the specific types of psychological interventions that should be recommended for different clinical outcomes, as well as the comparative longevity of intervention outcomes.

    “- Current guidelines provide limited information regarding the specific types of psychological interventions that should be recommended for different clinical outcomes, as well as the comparative longevity of intervention outcomes”
8 of 8

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Abstract assigns a short-term result to mid-term follow-up

    Major

    The abstract says pain education with physiotherapy improved physical function until mid-term follow-up, citing an estimate of 0.63. The results identify that estimate as short-term and state that the mid-term effects were not significant.

  • Discussion claims sustained fear-avoidance effects despite nonsignificant follow-up results

    Major

    The discussion says cognitive behavioural therapy with physiotherapy has effects sustained until mid-term and long-term follow-up. The results report no significant effect at short-term or mid-term follow-up and describe the long-term result as nonsignificant.

  • Fear-avoidance scale conversion does not match its stated points

    Minor

    A 3.3-point difference on a 0-to-24 scale is 13.75 points on a 0-to-100 scale, not 13.4.

    Reported 13.4 · recomputed 13.75

  • Fear-avoidance NMA study count differs

    Minor

    The fear-avoidance results say the NMA included 29 unique studies, whereas the risk-of-bias section says 30 unique studies were included in that NMA.

  • Pain-intensity estimate is not centred in its confidence interval

    Minor

    The reported mid-term estimate is 0.41, but the midpoint of its stated 95% confidence interval is 0.54. The paper describes confidence intervals for these standardised mean differences on the same scale as their estimates.

    Reported 0.41 · recomputed 0.54

  • Intervention-compliance publication-year counts exceed the study total

    Minor

    Table 2 lists 30 unique intervention-compliance studies, but its publication-year categories total 31.

    Reported 30 · recomputed 31

  • Pain-intensity funding categories omit two studies

    Minor

    Table 2 reports 86 unique pain-intensity studies, but its four funding categories total only 84.

    Reported 86 · recomputed 84

7 of 7

The citation lists haven’t been fetched yet

References 118 · Cited by 220

Research works printed but not linked: 4

  1. Guevara-López, 2011, Practice guidelines for the management of low back pain, Cir Cir, 79, 264
  2. Higgins J Thomas J , eds. Chapter 6: Choosing effect measures and computing estimates of effect. In: Cochrane Handbook Systematic Reviews of Interventions version 6.0. Cochrane, 2021. www.training.cochrane.org/handbook .
  3. Covidence. Covidence systematic review software: Veritas Health Innovation. Melbourne, Australia.
  4. 10.1136/bmj.l4898 · DOI · Paper page

Authors
Ho, E. K.-Y., Chen, L., Simic, M., Ashton-James, C. E., Comachio, J., Wang, D. X. M., Hayden, J. A., Ferreira, M. L., & Ferreira, P. H.
Affiliations
  • The University of Sydney (AU)
  • Sydney Musculoskeletal Health, School of Health Sciences, Charles Perkins Centre, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
  • Dalhousie University (CA)
Corresponding author
Ho, Emma Kwan-Yee
ORCID
Venue
BMJ
Publisher
BMJ
Published
2022-03-30
Volume
376
Pages
e067718
ISSN
1756-1833 (ISSN-L)
DOI
10.1136/bmj-2021-067718
PMC
PMC8965745
OpenAlex
W4220653098
Cited by
220
References
118
Citations by year
2026: 40 · 2025: 63 · 2024: 48 · 2023: 56 · 2022: 13
FWCI
6.47
Type
journal article
Language
en
Open access
Licence
Locations
  • BMJ (publishedVersion, cc-by-nc)
  • PubMed Central (publishedVersion, cc-by-nc)
  • PubMed (publishedVersion)
Funders
National Health and Medical Research Council
Topics
  • Health Sciences › Medicine › Pharmacology › Musculoskeletal pain and rehabilitation
  • Health Sciences › Medicine › Anesthesiology and Pain Medicine › Pain Management and Treatment
  • Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
Keywords
chronic low back pain, non-specific low back pain, psychological intervention, cognitive behavioral therapy, pain education, behavior therapy, physiotherapy, physical function, pain intensity, comparative effectiveness, treatment safety, long-term outcomes, Bucher method, post-intervention follow-up, post-treatment follow-up
MeSH terms
Network Meta-Analysis as Topic, Network Meta-Analysis, Psychosocial Intervention, Adult, Humans, Research Design, Cognitive Behavioral Therapy, Low Back Pain

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-09.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-09.

Statistics and arithmetic are recomputed, not judged.

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