Multidisciplinary rehabilitation for chronic low back pain

It is more or less well-accepted nowadays that back pain, particularly when chronic, is best understood within a biopsychosocial framework. The implication is that treatment is more likely to be successful if it includes components that target not only physical issues but also psychological and/or social factors. This is the premise that underpins multidisciplinary biopsychosocial rehabilitation (MBR); an intervention program that involves several treatment components that target different factors associated with the chronic pain presentation, and is delivered by practitioners from different clinical backgrounds.

Given that the most recent systematic review of MBR for patients with chronic low back pain was published more than 10 years ago, we decided that it was time for an update and conducted a Cochrane review. We did all the usual things you’ll see in a Cochrane review to make sure the findings are as robust as possible like; a-priori decisions regarding methods, sensitive searches of multiple databases, independent screening of articles and data extraction, methodological assessment of included studies and detailed description of all the analyses and findings. Those of you familiar with Cochrane Reviews will know that the downside of all this rigid methodological process is that the final article tends to be very long. And that is the case with our review, the full version is a bit of a beast, although there is a brief lay summary within it, and a condensed version also appears in the BMJ.

We included 41 RCTs in the review, most of which assessed MBR versus usual care (16 RCTs) or MBR versus physical treatments; usually exercise programs, plus or minus hands-on therapy (19 RCTs). We were most interested in the effect on pain, disability and work outcomes like absenteeism, especially at long term. What we found was that MBR had smallish effects on pain and disability versus both comparators, a moderate effect on work when compared to physical treatment, but no effect on work when compared to usual care.

Notwithstanding some limitations, the most significant of which is probably heterogeneity in the estimates of effect versus physical treatment, what do we make of this? We could say: “Another review showing small effects of treatment for LBP, add it to the pile…” But I would argue for a slightly more optimistic take. The population represented in the included studies had, on average, more than a year’s duration of symptoms and most had also already received some form of treatment prior to the study. Further, this effect of MBR was over and above that of well-established and plausible interventions.

A difficult question though, is whether the size of the estimated effect, 0.5 to 1.5 points on a 0-10 pain NRS and 1.2 to 4 points on a 0-24 Roland Morris disability scale are enough to make the effort, cost and resource expenditure worthwhile for the individual. There is no simple answer to this, determining the size of a clinically worthwhile effect is a fiendishly difficult exercise for a whole lot of reasons, and the question also involves consideration of individual patient preferences, availability of services, and costs to the healthcare system. We are in the midst of trying to shed some light on the last of these by reviewing cost-effectiveness data from these studies, those results will be available at a later date.

On the whole though, these results suggest that MBR should be considered an option for patients with persistent symptoms. The size of the expected extra benefit, along with the demands and time-commitment required can be discussed with the patient to determine their preference. Given the effort involved, it probably makes most sense to recommend MBR to patients whose symptoms have clear psychosocial impacts. These might include general psychological distress, aberrant beliefs or unhelpful cognitions.

Two questions that we tried, unsuccessfully, to get at were; whether more intensive programs with more contact hours were more effective than those with less, and whether the programs were more effective for people with higher symptom severity on presentation. Unfortunately, the available studies did not enable us to make firm conclusions on these matters. These are probably two logical directions for further research to target: a) what is the optimal intensity of intervention? And b) given the cost, time and effort, for whom should we prioritise access to MBR?

About Steve Kamper

Having completed Physiotherapy at USyd and a PhD at the George Institute in Sydney, Steve is currently “working” in Amsterdam at the EMGO+ Institute on an NHMRC fellowship. The thing Steve likes most about being funded by a government fellowship are the endless opportunities to remind mates that they are, in fact paying for every beer he has. Work involves research into the influence of patient expectations on outcome, back and neck pain, outcome measurement and the ongoing search for European conferences to ensure all holidays are tax deductible. Steve likes to spend his spare-time running around next to canals, riding his bike, giving blank looks to people who ask questions in Dutch and making sure he gets at least twice the recommended daily dose of ICECReam (www.theicecream.org/).

Ref

KKamper SJ, Apeldoorn AT, Chiarotto A, Smeets RJ, Ostelo RW, Guzman J, & van Tulder MW (2014). Multidisciplinary biopsychosocial rehabilitation for chronic low back pain. The Cochrane database of systematic reviews, 9 PMID: 25180773