Multidisciplinary biopsychosocial rehabilitation for chronic low back pain.

Multidisciplinary biopsychosocial rehabilitation for chronic low back pain (Review) Kamper SJ, Apeldoorn AT, Chiarotto A, Smeets RJ, Ostelo RWJG, Guzman J, van Tulder MW

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library 2014, Issue 9 http://www.thecochranelibrary.com

Multidisciplinary biopsychosocial rehabilitation for chronic low back pain (Review) Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

TABLE OF CONTENTS HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . SUMMARY OF FINDINGS FOR THE MAIN COMPARISON . . . . . . . . . BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 5. . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 6. . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 7. . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 8. . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 9. . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 10. . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 11. . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 12. . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 13. . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 14. . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 15. . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 16. . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 17. . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 18. . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 19. . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 20. . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 21. . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 22. . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 23. . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 24. . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 25. . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 26. . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 27. . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 28. . . . . . . . . . . . . . . . . . . . . . . . . . . . Figure 29. . . . . . . . . . . . . . . . . . . . . . . . . . . . ADDITIONAL SUMMARY OF FINDINGS . . . . . . . . . . . . . . . . DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.1. Comparison 1 MBR versus usual care, Outcome 1 Back pain short term. . Analysis 1.2. Comparison 1 MBR versus usual care, Outcome 2 Back pain medium term. Analysis 1.3. Comparison 1 MBR versus usual care, Outcome 3 Back pain long term. . Analysis 1.4. Comparison 1 MBR versus usual care, Outcome 4 Disability short term. . Analysis 1.5. Comparison 1 MBR versus usual care, Outcome 5 Disability medium term. Analysis 1.6. Comparison 1 MBR versus usual care, Outcome 6 Disability long term. . Analysis 1.7. Comparison 1 MBR versus usual care, Outcome 7 Work short term. . . Multidisciplinary biopsychosocial rehabilitation for chronic low back pain (Review) Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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1 1 2 4 6 6 6 9 10 12 13 14 15 16 17 17 17 18 18 18 19 19 19 21 21 21 22 22 23 23 24 24 25 26 26 26 27 27 33 35 35 36 47 106 115 116 117 118 119 120 121 i

Analysis 1.8. Comparison 1 MBR versus usual care, Outcome 8 Work medium term. . . . . . . . . . . . Analysis 1.9. Comparison 1 MBR versus usual care, Outcome 9 Work long term. . . . . . . . . . . . . . Analysis 1.10. Comparison 1 MBR versus usual care, Outcome 10 QoL SF36 PCS short term. . . . . . . . . Analysis 1.11. Comparison 1 MBR versus usual care, Outcome 11 QoL SF36 MCS short term. . . . . . . . . Analysis 1.12. Comparison 1 MBR versus usual care, Outcome 12 QoL SF36 PCS medium term. . . . . . . . Analysis 1.13. Comparison 1 MBR versus usual care, Outcome 13 QoL SF36 MCS medium term. . . . . . . Analysis 1.14. Comparison 1 MBR versus usual care, Outcome 14 Catastrophising short term. . . . . . . . . Analysis 1.15. Comparison 1 MBR versus usual care, Outcome 15 Catastrophising long term. . . . . . . . . Analysis 1.16. Comparison 1 MBR versus usual care, Outcome 16 Fear avoidance short term. . . . . . . . . Analysis 1.17. Comparison 1 MBR versus usual care, Outcome 17 Fear avoidance long term. . . . . . . . . Analysis 2.1. Comparison 2 MBR versus physical treatment, Outcome 1 Pain short term. . . . . . . . . . . Analysis 2.2. Comparison 2 MBR versus physical treatment, Outcome 2 Pain medium term. . . . . . . . . . Analysis 2.3. Comparison 2 MBR versus physical treatment, Outcome 3 Pain long term. . . . . . . . . . . Analysis 2.4. Comparison 2 MBR versus physical treatment, Outcome 4 Disability short term. . . . . . . . . Analysis 2.5. Comparison 2 MBR versus physical treatment, Outcome 5 Disability medium term. . . . . . . . Analysis 2.6. Comparison 2 MBR versus physical treatment, Outcome 6 Disability long term. . . . . . . . . Analysis 2.7. Comparison 2 MBR versus physical treatment, Outcome 7 Work short term. . . . . . . . . . Analysis 2.8. Comparison 2 MBR versus physical treatment, Outcome 8 Work medium term. . . . . . . . . Analysis 2.9. Comparison 2 MBR versus physical treatment, Outcome 9 Work long term. . . . . . . . . . . Analysis 2.10. Comparison 2 MBR versus physical treatment, Outcome 10 QoL short term. . . . . . . . . . Analysis 2.11. Comparison 2 MBR versus physical treatment, Outcome 11 Quality of Life medium term. . . . . Analysis 2.12. Comparison 2 MBR versus physical treatment, Outcome 12 Healthcare visits long term. . . . . . Analysis 2.13. Comparison 2 MBR versus physical treatment, Outcome 13 Depression short term. . . . . . . Analysis 2.14. Comparison 2 MBR versus physical treatment, Outcome 14 Depression medium term. . . . . . Analysis 2.15. Comparison 2 MBR versus physical treatment, Outcome 15 Depression long term. . . . . . . . Analysis 2.16. Comparison 2 MBR versus physical treatment, Outcome 16 Coping short term. . . . . . . . . Analysis 2.17. Comparison 2 MBR versus physical treatment, Outcome 17 Coping medium term. . . . . . . . Analysis 2.18. Comparison 2 MBR versus physical treatment, Outcome 18 Coping long term. . . . . . . . . Analysis 2.19. Comparison 2 MBR versus physical treatment, Outcome 19 Self-efficacy short term. . . . . . . Analysis 2.20. Comparison 2 MBR versus physical treatment, Outcome 20 Self-efficacy medium term. . . . . . Analysis 2.21. Comparison 2 MBR versus physical treatment, Outcome 21 Anxiety short term. . . . . . . . . Analysis 2.22. Comparison 2 MBR versus physical treatment, Outcome 22 Anxiety medium term. . . . . . . . Analysis 3.1. Comparison 3 MBR versus surgery, Outcome 1 Pain long term. . . . . . . . . . . . . . . Analysis 3.2. Comparison 3 MBR versus surgery, Outcome 2 Disability long term. . . . . . . . . . . . . Analysis 3.3. Comparison 3 MBR versus surgery, Outcome 3 Work long term. . . . . . . . . . . . . . Analysis 3.4. Comparison 3 MBR versus surgery, Outcome 4 Adverse events/complications. . . . . . . . . . Analysis 3.5. Comparison 3 MBR versus surgery, Outcome 5 QoL SF36 PCS long term. . . . . . . . . . . Analysis 3.6. Comparison 3 MBR versus surgery, Outcome 6 QoL SF36 MCS long term. . . . . . . . . . . Analysis 4.1. Comparison 4 MBR versus wait list, Outcome 1 Pain short term. . . . . . . . . . . . . . Analysis 4.2. Comparison 4 MBR versus wait list, Outcome 2 Disability short term. . . . . . . . . . . . . Analysis 4.3. Comparison 4 MBR versus wait list, Outcome 3 Depression short term. . . . . . . . . . . . Analysis 5.1. Comparison 5 MBR versus usual care, sensitivity and subgroup analyses, Outcome 1 Pain short term - all studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 5.2. Comparison 5 MBR versus usual care, sensitivity and subgroup analyses, Outcome 2 Pain short term sensitivity and subgroup analyses. . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 5.3. Comparison 5 MBR versus usual care, sensitivity and subgroup analyses, Outcome 3 Pain medium term - all studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 5.4. Comparison 5 MBR versus usual care, sensitivity and subgroup analyses, Outcome 4 Pain medium term sensitivity and subgroup analyses. . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 5.5. Comparison 5 MBR versus usual care, sensitivity and subgroup analyses, Outcome 5 Pain long term - all studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 5.6. Comparison 5 MBR versus usual care, sensitivity and subgroup analyses, Outcome 6 Pain long term sensitivity and subgroup analyses. . . . . . . . . . . . . . . . . . . . . . . . . . . . Multidisciplinary biopsychosocial rehabilitation for chronic low back pain (Review) Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Analysis 5.7. Comparison 5 MBR versus usual care, sensitivity and subgroup analyses, Outcome 7 Disability short term all analyses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 5.8. Comparison 5 MBR versus usual care, sensitivity and subgroup analyses, Outcome 8 Disability short term sensitivity and subgroup analyses. . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 5.9. Comparison 5 MBR versus usual care, sensitivity and subgroup analyses, Outcome 9 Disability medium term - all studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 5.10. Comparison 5 MBR versus usual care, sensitivity and subgroup analyses, Outcome 10 Disability medium term - sensitivity and subgroup analyses. . . . . . . . . . . . . . . . . . . . . . . . . Analysis 5.11. Comparison 5 MBR versus usual care, sensitivity and subgroup analyses, Outcome 11 Disability long term all studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 5.12. Comparison 5 MBR versus usual care, sensitivity and subgroup analyses, Outcome 12 Disability long term sensitivity and subgroup analyses. . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 5.13. Comparison 5 MBR versus usual care, sensitivity and subgroup analyses, Outcome 13 Work short term - all studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 5.14. Comparison 5 MBR versus usual care, sensitivity and subgroup analyses, Outcome 14 Work short term sensitivity and subgroup analyses. . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 5.15. Comparison 5 MBR versus usual care, sensitivity and subgroup analyses, Outcome 15 Work medium term all studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 5.16. Comparison 5 MBR versus usual care, sensitivity and subgroup analyses, Outcome 16 Work medium term sensitivity and subgroup analyses. . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 5.17. Comparison 5 MBR versus usual care, sensitivity and subgroup analyses, Outcome 17 Work long term - all studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 5.18. Comparison 5 MBR versus usual care, sensitivity and subgroup analyses, Outcome 18 Work long term sensitivity and subgroup analyses. . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 6.1. Comparison 6 MBR versus physical treatment, sensitivity and subgroup analyses, Outcome 1 Pain short term - all studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 6.2. Comparison 6 MBR versus physical treatment, sensitivity and subgroup analyses, Outcome 2 Pain short term - sensitivity and subgroup analyses. . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 6.3. Comparison 6 MBR versus physical treatment, sensitivity and subgroup analyses, Outcome 3 Pain medium term - all studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 6.4. Comparison 6 MBR versus physical treatment, sensitivity and subgroup analyses, Outcome 4 Pain medium term - sensitivity and subgroup analyses. . . . . . . . . . . . . . . . . . . . . . . . . Analysis 6.5. Comparison 6 MBR versus physical treatment, sensitivity and subgroup analyses, Outcome 5 Pain long term - all studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 6.6. Comparison 6 MBR versus physical treatment, sensitivity and subgroup analyses, Outcome 6 Pain long term - sensitivity and subgroup analyses. . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 6.7. Comparison 6 MBR versus physical treatment, sensitivity and subgroup analyses, Outcome 7 Disability short term - all studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 6.8. Comparison 6 MBR versus physical treatment, sensitivity and subgroup analyses, Outcome 8 Disability short term - sensitivity and subgroup analyses. . . . . . . . . . . . . . . . . . . . . . . . . Analysis 6.9. Comparison 6 MBR versus physical treatment, sensitivity and subgroup analyses, Outcome 9 Disability medium term - all studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 6.10. Comparison 6 MBR versus physical treatment, sensitivity and subgroup analyses, Outcome 10 Disability medium term - sensitivity and subgroup analyses. . . . . . . . . . . . . . . . . . . . . . Analysis 6.11. Comparison 6 MBR versus physical treatment, sensitivity and subgroup analyses, Outcome 11 Disability long term - all studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 6.12. Comparison 6 MBR versus physical treatment, sensitivity and subgroup analyses, Outcome 12 Disability long term - sensitivity and subgroup analyses. . . . . . . . . . . . . . . . . . . . . . . . Analysis 6.13. Comparison 6 MBR versus physical treatment, sensitivity and subgroup analyses, Outcome 13 Work short term - all studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 6.14. Comparison 6 MBR versus physical treatment, sensitivity and subgroup analyses, Outcome 14 Work short term - sensitivity and subgroup analyses. . . . . . . . . . . . . . . . . . . . . . . . . Multidisciplinary biopsychosocial rehabilitation for chronic low back pain (Review) Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Analysis 6.15. Comparison 6 MBR versus physical treatment, sensitivity and subgroup analyses, Outcome 15 Work medium term - all studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 6.16. Comparison 6 MBR versus physical treatment, sensitivity and subgroup analyses, Outcome 16 Work medium term - sensitivity and subgroup analyses. . . . . . . . . . . . . . . . . . . . . . Analysis 6.17. Comparison 6 MBR versus physical treatment, sensitivity and subgroup analyses, Outcome 17 Work long term - all studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 6.18. Comparison 6 MBR versus physical treatment, sensitivity and subgroup analyses, Outcome 18 Work long term - sensitivity and subgroup analyses. . . . . . . . . . . . . . . . . . . . . . . . . APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . DIFFERENCES BETWEEN PROTOCOL AND REVIEW . . . . . . . . . . . . . . . . . . . . . INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .


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[Intervention Review]

Multidisciplinary biopsychosocial rehabilitation for chronic low back pain Steven J Kamper1 , Andreas T Apeldoorn2 , Alessandro Chiarotto3 , Rob J.E.M. Smeets4 , Raymond WJG Ostelo5 , Jaime Guzman6 , Maurits W van Tulder7 1 Musculoskeletal

Division, The George Institute for Global Health, Sydney, Australia. 2 Department of Epidemiology and Biostatistics and the EMGO Institute for Health and Care Research, VU University Medical Centre, Amsterdam, Netherlands. 3 Department of Health Sciences, Faculty of Earth and Life Sciences, VU University Amsterdam, Amsterdam, Netherlands. 4 Rehabilitation Medicine Department, Maastricht University Medical Centre, Maastricht, Netherlands. 5 Department of Health Sciences, EMGO Institute for Health and Care Research, VU University, Amsterdam, Netherlands. 6University of British Columbia, Vancouver, Canada. 7 Department of Health Sciences, Faculty of Earth and Life Sciences, VU University, Amsterdam, Netherlands Contact address: Steven J Kamper, Musculoskeletal Division, The George Institute for Global Health, PO Box M201, Missenden Road, Camperdown, Sydney, NSW, 2050, Australia. [email protected]. Editorial group: Cochrane Back Group. Publication status and date: New search for studies and content updated (conclusions changed), published in Issue 9, 2014. Review content assessed as up-to-date: 1 January 2014. Citation: Kamper SJ, Apeldoorn AT, Chiarotto A, Smeets RJ, Ostelo RWJG, Guzman J, van Tulder MW. Multidisciplinary biopsychosocial rehabilitation for chronic low back pain. Cochrane Database of Systematic Reviews 2014, Issue 9. Art. No.: CD000963. DOI: 10.1002/14651858.CD000963.pub3. Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

ABSTRACT Background Low back pain (LBP) is responsible for considerable personal suffering worldwide. Those with persistent disabling symptoms also contribute to substantial costs to society via healthcare expenditure and reduced work productivity. While there are many treatment options, none are universally endorsed. The idea that chronic LBP is a condition best understood with reference to an interaction of physical, psychological and social influences, the ’biopsychosocial model’, has received increasing acceptance. This has led to the development of multidisciplinary biopsychosocial rehabilitation (MBR) programs that target factors from the different domains, administered by healthcare professionals from different backgrounds. Objectives To review the evidence on the effectiveness of MBR for patients with chronic LBP. The focus was on comparisons with usual care and with physical treatments measuring outcomes of pain, disability and work status, particularly in the long term. Search methods We searched the CENTRAL, MEDLINE, EMBASE, PsycINFO and CINAHL databases in January and March 2014 together with carrying out handsearches of the reference lists of included and related studies, forward citation tracking of included studies and screening of studies excluded in the previous version of this review. Selection criteria All studies identified in the searches were screened independently by two review authors; disagreements regarding inclusion were resolved by consensus. The inclusion criteria were published randomised controlled trials (RCTs) that included adults with non-specific LBP of longer than 12 weeks duration; the index intervention targeted at least two of physical, psychological and social or work-related factors; and the index intervention was delivered by clinicians from at least two different professional backgrounds. Multidisciplinary biopsychosocial rehabilitation for chronic low back pain (Review) Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Data collection and analysis Two review authors extracted and checked information to describe the included studies, assessed risk of bias and performed the analyses. We used the Cochrane risk of bias tool to describe the methodological quality. The primary outcomes were pain, disability and work status, divided into the short, medium and long term. Secondary outcomes were psychological functioning (for example depression, anxiety, catastrophising), healthcare service utilisation, quality of life and adverse events. We categorised the control interventions as usual care, physical treatment, surgery, or wait list for surgery in separate meta-analyses. The first two comparisons formed our primary focus. We performed meta-analyses using random-effects models and assessed the quality of evidence using the GRADE method. We performed sensitivity analyses to assess the influence of the methodological quality, and subgroup analyses to investigate the influence of baseline symptom severity and intervention intensity. Main results From 6168 studies identified in the searches, 41 RCTs with a total of 6858 participants were included. Methodological quality ratings ranged from 1 to 9 out 12, and 13 of the 41 included studies were assessed as low risk of bias. Pooled estimates from 16 RCTs provided moderate to low quality evidence that MBR is more effective than usual care in reducing pain and disability, with standardised mean differences (SMDs) in the long term of 0.21 (95% CI 0.04 to 0.37) and 0.23 (95% CI 0.06 to 0.4) respectively. The range across all time points equated to approximately 0.5 to 1.4 units on a 0 to 10 numerical rating scale for pain and 1.4 to 2.5 points on the Roland Morris disability scale (0 to 24). There was moderate to low quality evidence of no difference on work outcomes (odds ratio (OR) at long term 1.04, 95% CI 0.73 to 1.47). Pooled estimates from 19 RCTs provided moderate to low quality evidence that MBR was more effective than physical treatment for pain and disability with SMDs in the long term of 0.51 (95% CI -0.01 to 1.04) and 0.68 (95% CI 0.16 to 1.19) respectively. Across all time points this translated to approximately 0.6 to 1.2 units on the pain scale and 1.2 to 4.0 points on the Roland Morris scale. There was moderate to low quality evidence of an effect on work outcomes (OR at long term 1.87, 95% CI 1.39 to 2.53). There was insufficient evidence to assess whether MBR interventions were associated with more adverse events than usual care or physical interventions. Sensitivity analyses did not suggest that the pooled estimates were unduly influenced by the results from low quality studies. Subgroup analyses were inconclusive regarding the influence of baseline symptom severity and intervention intensity. Authors’ conclusions Patients with chronic LBP receiving MBR are likely to experience less pain and disability than those receiving usual care or a physical treatment. MBR also has a positive influence on work status compared to physical treatment. Effects are of a modest magnitude and should be balanced against the time and resource requirements of MBR programs. More intensive interventions were not responsible for effects that were substantially different to those of less intensive interventions. While we were not able to determine if symptom intensity at presentation influenced the likelihood of success, it seems appropriate that only those people with indicators of significant psychosocial impact are referred to MBR.

PLAIN LANGUAGE SUMMARY Multidisciplinary treatment for back pain Review question Is treatment involving a team of therapists from several different clinical professions helpful for people with long-term back pain? Background Low back pain (LBP) is a condition that causes a great deal of pain and suffering across the world and also accounts for large costs to society due to healthcare spending and missed work. Previous research has shown that LBP that has persisted for several months or years is often associated with psychological and social problems. Multidisciplinary treatments target physical as well as psychological and social aspects of LBP and involve a team of healthcare providers with different professional backgrounds and training. Study characteristics We collected all the published studies up to February 2014; there were 41 studies (with 6858 participants) that compared multidisciplinary treatment to other treatments. Most studies compared a multidisciplinary treatment to usual care (such as care by a general Multidisciplinary biopsychosocial rehabilitation for chronic low back pain (Review) Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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practitioner) or to treatments that only addressed physical factors (such as exercise or physiotherapy). All the people in the studies had LBP for more than three months and most had received some other sort of treatment previously. Key results There was moderate quality evidence that multidisciplinary treatment results in larger improvements in pain and daily function than usual care or treatments aimed only at physical factors. The difference was not very large, about 1 point on a 10 point scale for pain, but this may be important for people whose symptoms have not responded to other treatments. There was also moderate evidence that multidisciplinary treatment doubled the likelihood that people were able to work in the next 6 to 12 months compared to treatments aimed at physical factors. While these programs seem to be more effective than alternatives, the effects needs to be balanced with their costs in terms of money, resources and time. Multidisciplinary treatment programs are often quite intensive and expensive, so they are probably most appropriate for people with quite severe or complex problems.


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S U M M A R Y O F F I N D I N G S F O R T H E M A I N C O M P A R I S O N [Explanation]

Multidisciplinary compared to usual care for chronic low back pain Patient or population: Patients with chronic low back pain Intervention: Multidisciplinary Biopsychosocial Rehabilitation Comparison: Usual care Outcomes

Baseline

Quality of the evidence (GRADE)

Comments

The mean back pain long term in the MBR groups 821 was (7 studies) 0.21 standard deviations lower (0.37 to 0.04 lower)

⊕⊕⊕ moderate1

This is a small effect that may be clinically relevant in this patient group

Disability long term # The baseline for the The mean disability long term in the MBR groups was 722 Mostly Roland Morris most representative 0.23 standard deviations lower (6 studies) 24-point scale where 0 study is 11.4 out of 24 (0.4 to 0.06 lower) equals no disability at all and 24 is seriously disabled. Follow-up: median 12 mth

⊕⊕⊕ moderate1

This is a small effect that may be clinically relevant in this patient group

This difference is not statistically or clinically relevant

Back pain long term # The baseline for the 0-10 Numerical or visual most representative scale, where 0 equals no study is 5.8 out of 10 pain at all and 10 is the worst pain imaginable. Follow-up: median 12 mth

Assumed risk* Usual care

Comparative effect (95% CI)

No. of participants (studies)

Corresponding risk MBR

Relative effect (95% CI)

Work long term 744 per 1000 Proportion working Follow-up: median 12 mth

751 per 1000 (679 to 810)

OR 1.04 (0.73 to 1.47)

1360 (7 studies)

⊕⊕⊕ moderate1

Adverse events

not estimable

not estimable

0

No evidence

not estimable

4


#Of the included trials for this outcome, we chose the study that has the largest weighting in the overall result in Revman (Von Korff 2005). This figure represents the baseline mean in the control group of this particular study *The basis for the assumed risk is the median control group risk across studies. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; OR: Odds ratio 1

High risk of bias in included studies

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BACKGROUND

Description of the condition Low back pain (LBP) and the associated disability are responsible for a significant personal burden globally. Recent epidemiological research suggests LBP is the leading cause of years lived with disability (Vos 2012). There is also a substantial societal burden, with costs attributable to healthcare services and to loss of work productivity running into the billions of dollars annually in many western countries (Maetzal 2002). Lifetime prevalence rates are high, approaching 70% to 80% according to some studies, and a significant proportion of patients develop chronic symptoms lasting three months or more (Henschke 2008). Chronic LBP results in ongoing personal suffering for the involved individuals and most of the substantial economic costs associated with the condition (Lambeek 2011; Maetzal 2002). The focus of this review was on patients with chronic LBP.

Description of the intervention Despite the large volume of clinical research focused on identifying effective treatments for chronic LBP (Artus 2010; Ferreira 2010; Machado 2009) optimal management remains a source of contention (Koes 2010). One treatment approach is founded on the conceptualisation of LBP as a biopsychosocial problem (Waddell 2004). This approach is supported by the observation that LBP, particularly at the chronic stage, is characterised by a combination of physical, psychological and social dysfunctions (Costa 2009). Further, it appears that psychological and social factors may play a role in the development and maintenance of pain and disability (den Hollander 2010; Linton 2011; Nicholas 2011). This has led to the design of interventions to address multiple factors, typically involving a combination of physical, psychological and educational components and often delivered by a team of clinicians with different skills (Guzman 2006; Smeets 2006). Recent decades have seen an increase in research into a multidisciplinary approach due to wider acceptance of the biopsychosocial model (Foster 2011), the ineffectiveness of monotherapies (Artus 2010), and promising reports from clinical practice. Multidisciplinary biopsychosocial rehabilitation (MBR) may be delivered in multidisciplinary pain clinics, rehabilitation centres or outpatient settings. Recent Cochrane reviews have addressed behavioural treatment for chronic LBP (Henschke 2011), physical conditioning programs for improving work outcomes in workers with back pain (Schaafsma 2013), and individual patient education for LBP (Engers 2008). These reviews generally report small effects that arise from single-discipline interventions in the population of interest. Karjalainen 2003 investigated the effects of multidisciplinary treatments on subacute back pain, however they identified

only two studies that met their inclusion criteria. The previous version of this Cochrane review was published in 2001, with searches performed up to 1998. It has subsequently been withdrawn by The Cochrane Collaboration due to being out of date (Guzman 2006).

How the intervention might work The theoretical basis of the intervention comes from the biopsychosocial model (Waddell 2004). According to the theory, chronic LBP involves impairments of physical, psychological and social functioning, and effective treatment requires intervention that specifically addresses these problems. Multidisciplinary biopsychosocial rehabilitation includes elements aimed at improving back-related physical dysfunction as well as addressing psychological issues or targeting social or work-related behaviours, or both. There is some evidence from systematic reviews to suggest that these interventions may have a positive effect on work participation outcomes in the long term (Norlund 2009; van Geen 2007).

Why it is important to do this review Although promising, it is notable that MBR often involves investment of substantial staffing and financial resources by the heathcare system. The indirect costs burden employers, insurance companies and patients as well. The value of MBR has often been questioned because data are lacking regarding its effectiveness and costeffectiveness (Smeets 2009). While two meta-analyses on the effectiveness of MBR have been published (Cutler 1994; Flor 1992), they were completed more than 20 years ago and are now clearly out of date. More recently performed reviews have not included a quantitative synthesis of the evidence. The most recent Cochrane review that directly assessed the effectiveness of MBR on patients with chronic LBP was published in 2001, but this review was withdrawn in 2006 because the literature search was out of date (Guzman 2006). Collection and synthesis of the evidence relevant to the effectiveness of MBR for chronic LBP was overdue.

OBJECTIVES To review the evidence on the effectiveness of MBR for patients with chronic LBP. The focus was on comparisons with usual care and with physical treatments measuring outcomes of pain, disability and work status, particularly in the long term.

METHODS


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Criteria for considering studies for this review

Types of studies Only randomised controlled trials (RCTs) published in full in peer-reviewed journals were included, all other study types were excluded.

Types of participants RCTs that investigated male or female participants, or both, with non-specific chronic LBP and who were older than 18 years of age were included. Chronic LBP was defined as back pain that had persisted for 12 weeks or more. If a RCT recruited LBP patients with a mixed duration of symptoms (that is it also included patients with < 12 weeks duration), it was included if data for the chronic LBP patients were presented separately or if greater than 75% of participants had symptoms for more than 12 weeks. Trials that recruited patients with spinal pain at any level were included if > 75% of participants had LBP. Trials including participants with clearly diagnosed radiculopathy or only patients who had back surgery in the previous 12 months were excluded. Trials were also excluded if they included participants with specific LBP caused by infection, neoplasm, metastasis, rheumatoid arthritis or other inflammatory articular conditions (for example ankylosing spondylitis), spinal stenosis or fracture. Diagnoses such as disc degeneration or bulging discs, facet joint dysfunction and sacroiliac joint pain were included in the review.

Types of interventions MBR was defined as an intervention that involves a physical component (for example an exercise program) and at least one other element from the biopsychosocial model, that is psychological or social and occupational. The intervention program had to have been delivered by clinicians from different disciplines, that is a minimum of two healthcare professionals from different professional backgrounds had to be involved in the intervention delivery. The different components of the intervention had to be offered as an integrated program involving communication between the providers responsible for the different components. We expected clinicians would include physicians, psychologists, physiotherapists, social workers, occupational therapists and exercise therapists. The authors acknowledge that there is no consensus regarding the definition of multidisciplinary treatment. We chose to align our conceptualisation of multidisciplinary treatment with a biopsychosocial model of LBP and included studies with interventions that addressed at least two parts of the model (Guzman 2006; Ravenek 2010; van Geen 2007). While there is some overlap (in terms of included studies) with the Cochrane review of behavioural treatments (Henschke 2011), the review of physical conditioning

as part of a return to work strategy (Schaafsma 2013), and the review of back schools (Heymans 2010), we expected that the total set of included trials would be substantially different. Any type of control intervention was included, but the following comparisons were evaluated separately. Comparisons 1 and 2 represent the main focus of this review. 1. MBR versus usual care. 2. MBR versus physical treatment. 3. MBR versus surgery. 4. MBR versus waiting list. Where there was more than one MBR program assessed against a non-MBR control in the same trial, the more intensive program was used in the comparison. Studies that compared different MBR programs with each other were included and described but between group differences were not synthesised. Types of outcome measures Patient-centred outcomes formed the principle target for this review. Outcomes were categorised in three groups according to the follow-up time after randomisation. • Short term: up to three months. • Medium term: > three months and less than 12 months. • Long term: 12 months or more. Where a study reported multiple follow-up times, the time points closest to three, six and 12 months were used in the meta-analyses. Primary outcomes

• Pain • Back-specific disability or functional status • Work status (return to work, sick leave) Measures collected at long-term follow-up were considered primary outcomes. Secondary outcomes

• Generic health or quality of life (QoL) • Healthcare service ulitilisation • Global improvement • Psychological and cognitive function (depression, anxiety, fear avoidance, coping strategies) • Adverse events

Search methods for identification of studies Electronic searches Relevant RCTs meeting our inclusion criteria were identified by a computer-aided search of CENTRAL (The Cochrane Library), which includes the Cochrane Back Review Group Trials Register;


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MEDLINE (OvidSP); EMBASE (OvidSP); PsycINFO (OvidSP) and CINAHL (EBSCOhost) databases. Databases were searched from 1998 (the date of the search conducted for the previous version of this review) until January and March 2014. The search strategies can be found in Appendix 1. The searches were devised and run by a research librarian from the Cochrane Back Review Group according to their guidelines (Furlan 2009). A highly sensitive search strategy for retrieval of controlled trials was run in conjunction with specific searches for LBP and multidisicplinary treatment. We considered RCTs published in any language. All search results were screened independently by two of three authors (SK, AA, AC). Clearly ineligible studies were excluded based on title and abstract. Full text articles were retrieved for all remaining studies and these were again screened independently by two authors for inclusion. Disagreements regarding inclusion were resolved via consensus or via a third author (RO), where necessary. Searching other resources Following the electronic searches, the reference lists of relevant publications were screened; these included systematic reviews relevant to the topic and studies included in this review. Citation tracking of included RCTs was also conducted using Science Citation Index. All articles included in the previous version of this review (Guzman 2006) were included and studies listed as excluded in that review were screened against the inclusion criteria.

• Outcome data (baseline and follow-up): pain, disability or function, work-related outcomes, global improvement, healthcare service utilisation, QoL, psychological function, adverse events. Outcome data were entered into RevMan for analysis. Assessment of risk of bias in included studies Risk of bias was assessed using the Cochrane Back Review Group risk of bias tool (Furlan 2009). Assessments were conducted independently by two authors (SK, AA) and disagreements were resolved by consensus. Where necessary, a third author (RO) was involved to resolve disagreements. Sensitivity analyses using the results of the risk of bias assessments are described below. Measures of treatment effect Clinical homogeneity regarding the control intervention, outcome measure and timing of measurement was assessed prior to pooling. Random-effects models were used to quantify pooled treatment effect sizes. Unit of analysis issues All included studies randomised participants and analysed results at the individual patient level. Dealing with missing data

Data collection and analysis

Selection of studies Studies were included in the review according to the following inclusion criteria: • randomised controlled trial (RCT); • included adult patients with chronic LBP; • compared MBR intervention with a control intervention or waiting list; • published as full text in a peer-reviewed journal. Data extraction and management Data were extracted from all included studies by one author (SK) and checked by a second author (AC). Extracted data included the following. • Population characteristics: participant source or setting, mean age, gender proportions, duration of symptoms, baseline pain and disability measures. • Intervention characteristics: description of interventions (index and control), duration and number of sessions, delivery type (e.g. individual or group), clinicians responsible for delivery.

For meta-analysis of continuous outcomes we extracted and analysed group means, standard deviations and sample sizes at each follow-up point. For dichotomous outcomes we used event counts and sample sizes. Where medians instead of means were reported, these were substituted into the analysis. Where follow-up standard deviations were not reported, we used the standard deviation for the same measure at baseline, or follow-up, as a substitute. Where neither the baseline or follow-up standard deviation was reported, we calculated an estimate of the standard deviation from the same measure reported in other studies within the comparison. Attempts were made to contact authors of the original studies to supply data where insufficient data were reported in the article. Where no estimate was possible using the aforementioned methods, the data were not used in the meta-analysis. Assessment of heterogeneity I2 statistics were inspected and taken into account when assessing the quality of evidence; they were not used to determine whether or not to perform meta-analysis. in the GRADE assessment the quality of the evidence for an effect was downgraded by one level for inconsistency where the I2 statistic was greater than 60% (that is substantial heterogeneity as described in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011)).


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Assessment of reporting biases Inspection of funnel plots was conducted to investigate reporting bias where there were sufficient trials in a particular comparison.

Data synthesis Dichotomous outcomes were analysed by calculating the pooled odds ratio (OR). Continuous outcomes were analysed by calculating the pooled mean difference (MD) when the same instrument was used to measure outcomes, or the standardised mean difference (SMD) when different instruments were used. The uncertainty was expressed with 95% confidence intervals (95% CI). The outcome measures from the individual trials were combined through meta-analysis where possible (in terms of clinical comparability of population, intervention and outcomes between trials) using random-effects models. We assessed the overall quality of the evidence for each outcome using the GRADE approach, as recommended in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011) and by the Cochrane Back Review Group (Furlan 2009). Factors that may decrease the quality of the evidence were: study design and risk of bias, inconsistency of results, indirectness, imprecision and other factors (for example reporting bias). The quality of the evidence for a specific outcome was reduced by a level according to the performance of the studies in a particular comparison against these five factors. The quality of evidence was graded down by one level for risk of bias where any studies included in a comparison did not meet the threshold of six items on the risk of bias scale (Furlan 2009). The quality of the evidence was downgraded for inconsistency of results where the I2 statistic was greater than 60% (substantial heterogeneity according to the Cochrane Handbook for Systematic Reviews of Interventions), and graded down for precision where there were less than a total of 400 participants in the comparison (Guyatt 2011).

Subgroup analysis and investigation of heterogeneity We conducted pre-planned subgroup analyses based on the following parameters.

• Baseline symptom intensity. Studies were categorised according to the mean score for all participants at baseline on a pain scale and a back-specific disability measure. Where mean scores were 60% or greater of the scale maximum for both pain and disability the studies were categorised as high intensity, all others others were considered low intensity. • Intervention intensity. Interventions that involved more than 100 face-to-face hours delivered on a daily basis were categorised as high intensity, and interventions that involved less that 30 hours delivered on a non-daily basis were categorised as low intensity for the subgroup analyses. Other interventions were categorised as mid-intensity and were excluded from these subgroup analyses (Guzman 2006). In cases where insufficient information was reported to categorise a study, the study was excluded from the subgroup analysis. Sensitivity analysis We performed sensitivity analyses to see if the overall estimates of effectiveness changed when only evidence from studies with low risk of bias was considered. Two definitions of low risk of bias were defined: 1) fulfilling six or more risk of bias criteria, and 2) reporting adequate concealment of treatment allocation.

RESULTS

Description of studies Results of the search The electronic searches yielded a total of 6168 potentially eligible titles, a further 11 articles where identified through checking of reference lists and citation tracking. Following the search and screening and retrieval of 164 full text articles, 31 studies were determined to be eligible (Figure 1). These were added to the 10 studies included in the previous version of the review to make a total of 41 included studies.


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Figure 1. Study flow diagram.


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Included studies Most of the included studies were conducted in Europe (33 studies), three were from Iran, three from North America, and two from Australia. Sample sizes ranged from 20 to 542, with a total of 6858 participants included (Characteristics of included studies). Sixteen studies reported on a comparison of MBR with usual care, 19 with physical treatment, two with surgery, and four with a wait list; 12 studies reported comparisons between two different types of MBR intervention, see below. Participants in the included studies were usually referred to rehabilitation units by primary care practitioners or insurance providers. In most studies the average age of participants was between 40 and 45 years, gender balance was varied, and the average duration of symptoms was usually more than one year. Four studies reported high baseline symptom intensity (> 60% on pain and disability scales), 33 studies were categorised as low baseline symptom intensity, and there were insufficient data reported to categorise four studies. Fifteen studies reported high intervention intensity (> 100 hours contact time delivered on a daily basis), 15 studies were categorised as low intervention intensity (< 30 hours contact time delivered on a nondaily basis), and 11 studies were neither high nor low intensity according to these criteria. 1. MBR versus usual care (Abbassi 2012; Basler 1997; Bendix ’A’ 1996/1998; Lambeek 2010; Linton 2005; Lukinmaa 1989; Mitchell 1994; Moix 2003; Morone 2011; Morone 2012; Skouen 2002; Strand 2001; Tavafian 2008; Tavafian 2011; Vollenbroek-Hutten 2004; Von Korff 2005).

2. MBR versus physical treatment (Alaranta 1994; Bendix ’B’ 1995/1998; Bendix ’C’ 2000; Coole 2013; Harkapaa 1989; Henchoz 2010; Jousset 2004; Kaapa 2006; Kool 2007; Mangels 2009; Monticone 2013; Morone 2012; Nicholas 1991; Nicholas 1992; Roche 2007/2011; Schweikert 2006; Smeets 2006/2008; Streibelt 2009; Turner 1990). 3. MBR versus surgery (Fairbank 2005; Hellum 2011). 4. MBR versus waiting list (Jackel 1990; Kole-Snijders 1999; Smeets 2006/2008; Turner 1990). Studies that compared two MBR programs: Abbassi 2012; Bendix ’B’ 1995/1998; Harkapaa 1989; Kole-Snijders 1999; Leeuw 2008; Linton 2005; Mangels 2009; Meng 2011; Nicholas 1991; Skouen 2002; Smeets 2006/2008; Van den Hout 2003. Excluded studies There were 133 studies retrieved in full text format and eventually excluded (Characteristics of excluded studies). The most common reasons for exclusion were: study design other than RCT, inclusion of participants other than those with chronic LBP, and index interventions that did not include two or more elements of the biopsychosocial model or were not delivered by clinicians of different clinical backgrounds.

Risk of bias in included studies Included studies met one to nine of the 12 criteria for low risk of bias. Thirteen of the 41 studies (32%) were assessed as low risk of bias since they met six or more criteria (Figure 2; Figure 3).


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Figure 2. Risk of bias graph: review authors’ judgements about each risk of bias item presented as percentages across all included studies.


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Figure 3. Risk of bias summary: review authors’ judgements about each risk of bias item for each included study.


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Allocation All studies were described as randomised but only 29 studies clearly described an adequate randomisation procedure, and 23 studies described concealment of allocation.

explicitly stated in the manuscript, or all the outcomes listed in a published protocol of the study were reported in the manuscript. Only one study met this criterion.

Blinding

Other potential sources of bias

The nature of the interventions and the primary outcomes (pain and disability) meant that blinding of patients, clinicians or assessors was not possible in the included studies.

Sufficient information to determine that randomised groups were comparable at baseline was reported in 31 studies, treatment compliance was assessed as adequate in seven studies, and risk of bias arising from the use of co-interventions was assessed as low in six studies. Timing of assessment was clearly the same across groups in 40 studies. Funnel plots were created for comparisons with at least 10 included studies (Higgins 2011) and they were inspected visually to assess the risk of publication bias (Figure 4; Figure 5; Figure 6). Three analyses (pain and disability in the short term and disability in the long term) in the MBR versus physical treatment comparison met this criterion. None of the plots showed substantial asymmetry aside from one outlying medium-sized study that reported very large effects in favour of MBR (Monticone 2013).

Incomplete outcome data A total of 26 studies reported outcome data that met the criteria for completeness, 16 studies reported an intention-to-treat analysis. Selective reporting The criterion regarding the potential presence of reporting bias was assessed on a strict basis. A study was only listed as low risk of bias if the fact that all collected outcomes were reported was

Figure 4. Funnel plot of comparison: MBR versus physical treatment. Pain short term.


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Figure 5. Funnel plot of comparison: MBR versus physical treatment. Disability short term.


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Figure 6. Funnel plot of comparison: MBR versus physical treatment. Disability long term.

Effects of interventions See: Summary of findings for the main comparison Multidisciplinary compared to usual care for chronic low back pain; Summary of findings 2 Multidisciplinary compared to physical treatment for chronic low back pain; Summary of findings 3 Multidisciplinary compared to surgery for chronic low back pain; Summary of findings 4 Multidisciplinary compared to wait list for chronic low back pain MBR versus usual care

Primary outcomes

are provided in the individual study descriptions (Characteristics of included studies). Between six and nine studies provided data for pain outcomes at each time point (total n = 740 to 879), six to nine studies for disability outcomes (total n = 722 to 939) and two to seven for work outcomes (total n = 373 to 1360). For pain, point estimates for the pooled between group differences ranged from 0.21 to 0.60 (SMD) in the short, medium and long term (Figure 7; Figure 8; Figure 9); in all cases the 95% CIs did not cross zero, indicating a statistically significant effect in favour of MBR over usual care. For disability, estimates ranged from 0.23 to 0.43 (SMD) and were all significant in favour of MBR (Figure 10; Figure 11; Figure 12). The pooled effects on work outcomes ranged from 1.4 to 1.6 (OR) and were not statistically significant at any time point (Figure 13; Figure 14; Figure 15).

Sixteen studies reported on the effect of a MBR intervention versus usual care. More details regarding the content of the interventions


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Figure 7. Forest plot of comparison: 1 Multidisciplinary versus usual care, outcome: 1.1 Back pain short term.

Figure 8. Forest plot of comparison: 1 Multidisciplinary versus usual care, outcome: 1.2 Back pain medium term.

Figure 9. Forest plot of comparison: 1 Multidisciplinary versus usual care, outcome: 1.3 Back pain long term.


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Figure 10. Forest plot of comparison: 1 Multidisciplinary versus usual care, outcome: 1.4 Disability short term.

Figure 11. Forest plot of comparison: 1 Multidisciplinary versus usual care, outcome: 1.5 Disability medium term.

Figure 12. Forest plot of comparison: 1 Multidisciplinary versus usual care, outcome: 1.6 Disability long term.


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Figure 13. Forest plot of comparison: 1 Multidisciplinary versus usual care, outcome: 1.7 Work short term.

Figure 14. Forest plot of comparison: 1 Multidisciplinary versus usual care, outcome: 1.8 Work medium term.

Figure 15. Forest plot of comparison: 1 Multidisciplinary versus usual care, outcome: 1.9 Work long term.

The effects on pain and disability translated to approximately 0.5 to 1.4 points on a 0 to 10 numerical rating scale (NRS) and 1.4 to 2.5 points on a 0 to 24 Roland Morris Disability Questionnaire, respectively. The lower end of the estimate was reported for longterm outcomes and the upper end for short and medium-term outcomes.

The included studies provided low quality evidence that MBR was more effective than usual care on pain in the short and medium term, and moderate quality evidence for the effect in the long term. The quality of evidence for the effect on disability was moderate at all time points. The quality of evidence for no effect on work


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outcomes was low in the short and medium term and moderate in the long term. The quality of evidence was downgraded for risk of bias for all outcomes and further downgraded for inconsistency for some outcomes (Summary of findings for the main comparison). Heterogeneity

Pooled estimates should be considered in the light of significant statistical heterogeneity amongst the effect sizes of the included studies; in six (of the nine) instances the I2 statistic was in excess of the ’moderate’ threshold of 30%, in three instances it was above the ’substantial’ threshold of 60%.

Sensitivity analyses

In general, the pooled effect sizes from the high quality studies were of similar magnitude to those from all included studies, and this was the case regardless of how high quality was defined. However, few studies met the high quality criteria, which resulted in larger CIs around the estimates and meant that some estimates that were significant in the complete analysis were no longer significant in the sensitivity analysis. Overall, inclusion of low quality studies in the meta analyses did not appear to result in a bias towards overestimation of the effect of MBR versus usual care.

Subgroup analyses

While a subgroup analysis for symptom intensity was planned, only one study in the comparison met our a priori determined criteria for high mean baseline pain and disability intensity. A second subgroup analysis was performed on intervention intensity. In most cases the effect estimates from high and low intensity interventions were quite similar and there was substantial overlap of CIs. There was no pattern of smaller or larger effects for either intervention category. Overall, the intensity of the intervention appeared to have little influence on the effect of MBR versus usual care (Analysis 5.2; Analysis 5.4; Analysis 5.6; Analysis 5.8; Analysis 5.10; Analysis 5.12; Analysis 5.14; Analysis 5.16; Analysis 5.18).

Secondary outcomes

Three studies reported on QoL (Short Form (SF)-36) outcomes in the short and medium term that could be used to calculate pooled effect sizes. Precision was low but these analyses suggested an effect on the SF-36 mental components subscale (MD in the short term of 15.25, in the medium term of 7.59) in favour of MBR (Analysis 1.11; Analysis 1.13), but no effect on the physical components subscale (MD in the short term of 13.45, in the medium term of 7.41) (Analysis 1.10; Analysis 1.12). Pooled estimates of effect on psychological outcomes showed a statistically significant effect in favour of MBR on catastrophising in the short term (SMD 0.43) (Analysis 1.14) and long term (SMD 0.40) (Analysis 1.15) and an effect on fear avoidance at the long (SMD of 0.29) (Analysis 1.17), but not the short term (SMD of 0.69) (Analysis 1.16). The only study that mentioned adverse events (Lambeek 2010) reported none in the MBR group, it was unclear whether adverse events in the usual care group were recorded.

MBR versus physical treatment Nineteen studies reported on the effect of an MBR intervention versus physical treatment; more details regarding the content of the interventions are provided in the individual study descriptions (Characteristics of included studies). Between 9 and 12 studies provided data for the pain outcomes at each time point (total n = 531 to 1661), 8 to 13 studies for disability outcomes (total n = 511 to 1878) and 3 to 8 for work outcomes (total n = 221 to 1006). For pain, pooled estimates were in favour of MBR and ranged from 0.28 to 0.51 (SMD) with a statistically significant effect in the short and medium term (Figure 16; Figure 17) but not at long term (Figure 18). For disability, effects ranged from 0.21 to 0.68 (SMD) in favour of MBR; they were significant for the short and long term (Figure 19; Figure 20) but not for medium term (Figure 21).


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Figure 16. Forest plot of comparison: 2 Multidisciplinary versus physical treatment, outcome: 2.1 Pain short term.

Figure 17. Forest plot of comparison: 2 Multidisciplinary versus physical treatment, outcome: 2.2 Pain medium term.

Figure 18. Forest plot of comparison: 2 Multidisciplinary versus physical treatment, outcome: 2.3 Pain long term.


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Figure 19. Forest plot of comparison: 2 Multidisciplinary versus physical treatment, outcome: 2.4 Disability short term.

Figure 20. Forest plot of comparison: 2 Multidisciplinary versus physical treatment, outcome: 2.6 Disability long term.


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Figure 21. Forest plot of comparison: 2 Multidisciplinary versus physical treatment, outcome: 2.5 Disability medium term.

Pooled effect sizes on pain and disability in the short and long term were heavily influenced by one low risk of bias study that reported a very large effect, three to five times the size of the effects reported by the other studies (SMD 1.99 to 5.32) (Monticone 2013). Inclusion of this study introduced substantial heterogeneity into the meta-analyses. Removal from the pooled analyses reduced the I2 values substantially, from 81% to 92% to 0% to 49% for pain, and from 88% to 94% to 60% to 61% for disability. If this study was removed from the meta-analyses, the pooled effect

estimates for pain ranged from 0.14 to 0.28 (SMD) and were statistically significant in the short and medium term but not long term, and for disability the estimates ranged from 0.18 to 0.21 (SMD) and they were statistically significant in the short but not medium or long term. For work outcomes, the between group differences at short term were not significant (Figure 22) but there were significant ORs of 1.87 to 2.14 in favour of MBR for the medium and long term (Figure 23; Figure 24).

Figure 22. Forest plot of comparison: 2 Multidisciplinary versus physical treatment, outcome: 2.7 Work short term.


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Figure 23. Forest plot of comparison: 2 Multidisciplinary versus physical treatment, outcome: 2.8 Work medium term.

Figure 24. Forest plot of comparison: 2 Multidisciplinary versus physical treatment, outcome: 2.9 Work long term.

The effects on pain and disability translated to approximately 0.6 to 1.2 points on a 0 to 10 NRS and 1.2 to 4.0 points on a 0 to 24 Roland Morris Disability Questionnaire, respectively. The upper end of the estimates was reported for the outcomes at long term. Regarding work outcomes, the estimates indicated that people receiving a MBR intervention had approximately twice the odds of those receiving a purely physical treatment of being at work six and 12 months after the intervention. The included studies provided low quality evidence that MBR was more effective than physical treatment on pain and disability in the short and long term, and moderate quality evidence for the effect in the medium term. For work outcomes, there was low quality evidence of no effect at short term, low quality evidence of a positive effect at medium term, and moderate quality evidence of an effect at long term (Summary of findings 2). Heterogeneity

Pooled estimates should be considered in the light of significant statistical heterogeneity amongst the effect sizes of the included

studies. For all six pain and disability comparisons the I2 statistic was in excess of the ’moderate’ threshold of 30%, and in four instances it was above the ’substantial’ threshold of 60% (Higgins 2011). Removal of the outlier study from the analyses generally reduced inconsistency from substantial to moderate levels. Statistical heterogeneity was minor for work outcomes.

Sensitivity analyses

For pain and disability outcomes the effect sizes for the short and long-term analyses from the high quality studies were comparable to those from the complete analyses. In many cases, however, the estimate was no longer statistically significant, likely because of the reduced precision due to fewer included studies. For pain and disability in the medium term, the estimates were substantially lower for the first sensitivity analysis but comparable for the second as compared to the complete analyses. In all cases, both the sensitivity analyses and the complete analysis effect estimates were


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non-significant. For work outcomes at short and medium term, sensitivity analyses had only one or two studies included, making interpretation difficult. For long-term work outcomes, estimates from the high quality studies were very similar to those from the complete analyses. Overall, inclusion of low quality studies in the meta-analysis did not appear to result in a bias towards overestimation of the effect of MBR versus physical treatment.

Subgroup analyses

The participants in two studies were categorised as having high baseline symptom intensity according to our criteria. One of these studies (Monticone 2013) reported a very large effect in favour of MBR, three to five times the size of the effects reported by other studies in the comparison. Due to the influence of this study, the estimates of effect for high baseline symptom intensity were substantially larger than those for low intensity. Given these circumstances, the influence of baseline symptom intensity on the effect of MBR versus physical rehabilitation was unclear. The low intensity interventions had substantially larger effect estimates for pain and disability at all time points, although only one estimate (for pain at short term) was statistically significant; there was substantial overlap of CIs around the estimates for the two intervention types. No low intensity intervention studies reported work outcomes, hence the influence of this variable could not be assessed. The influence of intervention intensity on the effect of MBR versus physical rehabilitation was unclear (Analysis 6.2; Analysis 6.4; Analysis 6.6; Analysis 6.8; Analysis 6.10; Analysis 6.12; Analysis 6.14; Analysis 6.16; Analysis 6.18).

Secondary outcomes

Three studies reported QoL (SF-36) outcomes in the short and medium term that could be used to calculate pooled effect sizes (Analysis 2.10; Analysis 2.11). Precision was low and the results showed no difference between the groups. Two studies contributed to a pooled estimate of the effect on the number of healthcare visits in the long term (Analysis 2.12), which showed no difference between groups. Seven studies reported on depression (Analysis 2.13; Analysis 2.14; Analysis 2.15), anxiety (Analysis 2.21; Analysis 2.22) and self-efficacy (Analysis 2.19; Analysis 2.20); the pooled estimates showed no effect in the short, medium or long term. Pooled effects of MBR on coping were statistically significant in the medium and long term (Analysis 2.17; Analysis 2.18) but not in the short term (Analysis 2.16). No included studies reported adverse events specifically associated with the study interventions. One study reported ’side effects’ (Smeets 2006/2008), although it was not clear that these were actually adverse events associated with the study interventions.

MBR versus surgery Two studies reported on the effect of an MBR intervention versus surgery, both studies reported pain and disability in the long term (total n = 423) and one study reported on work outcome in the long term (n = 133). The pooled effect estimates were not significantly different between MBR and surgery for pain (SMD of 0.25) (Figure 25), disability (SMD of 0.25) (Figure 26) or work; the quality of the evidence was low (Summary of findings 3). In both studies adverse events associated with the surgical interventions were reported: 19 complications in Fairbank 2005 and six complications in Hellum 2011 with no complications reported in the MBR group in either study (Figure 27).

Figure 25. Forest plot of comparison: 3 Multidisciplinary versus surgery, outcome: 3.1 Pain long term.


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Figure 26. Forest plot of comparison: 3 Multidisciplinary versus surgery, outcome: 3.2 Disability long term.

Figure 27. Forest plot of comparison: 3 MBR versus surgery, outcome: 3.4 Adverse events/complications.

Sensitivity and subgroup analyses were not conducted for this comparison due to the small number of included studies. MBR versus waiting list Four studies reported on the effect of an MBR intervention versus a waiting list control, and three studies (total n = 213) reported on pain and disability in the short term. For pain there was a statistically significant difference of 0.73 (SMD) (Figure 28), and for disability a statistically significant difference of 0.49 (SMD) (Figure 29) in the short term. These estimates translated to a difference of approximately 1.7 points on a 0 to 10 pain NRS and 2.9 on a 0 to 24 Roland Morris Disability Questionnaire. The quality of the evidence was very low for pain and low for disability. Figure 28. Forest plot of comparison: 4 Multidisciplinary versus wait list, outcome: 4.1 Pain short term.


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Figure 29. Forest plot of comparison: 4 Multidisciplinary versus wait list, outcome: 4.2 Disability short term.

Sensitivity and subgroup analyses were not conducted for this comparison due to the small number of included studies. Other included studies Twelve studies compared outcomes from two different MBR interventions. A description of these individual studies is provided (Characteristics of included studies) but pooled between group analyses were not conducted. We made this decision because such comparisons did not address the question of whether MBR is more effective that alternative interventions.


27


A D D I T I O N A L S U M M A R Y O F F I N D I N G S [Explanation]

Multidisciplinary compared to physical treatment for chronic low back pain Patient or population: Patients with chronic low back pain Intervention: Multidisciplinary Biopsychosocial Rehabilitation Comparison: Physical treatment Outcomes

Baseline

Comparative effect (95% CI)

Pain long term # The baseline for the The mean pain long term in the MBR groups was 0-10 Numerical or visual most representative study 0.51 standard deviations lower scale, where 0 equals no is 4.5 out of 10 (1.04 lower to 0.01 higher) pain at all and 10 is the worst pain imaginable. Follow-up: median 12 mth



Comments

872 (9 studies)

⊕⊕

low1,2

This is a moderate effect that is probably clinically relevant in this patient group

⊕⊕

low1,2



Disability long term # The baseline for the The mean disability long term in the MBR groups was 1169 Various most representative study 0.68 standard deviations lower (10 studies) Follow-up: median 12 is 51 out of 100 on the (1.19 to 0.16 lower) Daily Activities subscale mth of the Dallas Questionnaire; 0 equals no disability and 100 is seriously disabled Assumed risk* Physical treatment



Work long term 659 per 1000 Proportion working Follow-up: median 12 mth

783 per 1000 (729 to 830)

OR 1.87 (1.39 to 2.53)

1006 (8 studies)

⊕⊕⊕ moderate1

Adverse events

not estimable

not estimable

0

No evidence

not estimable

28


#Of the included trials for this outcome, we chose the study that used a NRS pain scale that has the largest weighting in the overall result in Revman (Roche 2007/2011). This figure represents the baseline mean in the control group of this particular study *The basis for the assumed risk is the median control group risk across studies. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; OR: Odds ratio 1 2

High risk of bias in included studies Substantial heterogeneity, I2 > 60%


29


Multidisciplinary compared to surgery for chronic low back pain Patient or population: Patients with chronic low back pain Intervention: Multidisciplinary Biopsychosocial Rehabilitation Comparison: Surgery Outcomes

Baseline

Comparative effects (95% CI)



Comments

The mean pain long term in the MBR groups was 0.25 standard deviations higher (0.04 lower to 0.53 higher)

385 (2 studies)

⊕⊕

low1,2


Disability long term # The baseline for the The mean disability long term in the MBR groups was 423 Oswestry; 100-point most representative 0.25 standard deviations higher (2 studies) scale where 0 equals no study is 46.5 out of 100 (0.08 lower to 0.57 higher) disability and 100 is seriously disabled. Follow-up: median 24 mth

⊕⊕

low1,3


Pain long term # The baseline for the SF-36 Pain subscale; most representative where 100 equals pain- study is 28.6 out of 100 free Follow-up: median 24 mth

Work long term Proportion working Follow-up: 24 months

Assumed risk* Surgery



309 per 1000

230 per 1000

OR 0.67 (0.31 to 1.45)

133 (1 study)

⊕⊕

low1,2


0 per 1000

OR 28.25 (3.77 to 211.93)

385 (2 studies)

⊕⊕

low1,2

This difference may be clinically relevant in this patient group

Adverse events 127 per 1000 Adverse events due to study interventions

30


#Of the included trials for this outcome, we chose the study that has the largest weighting in the overall result in Revman (Fairbank 2005). This figure represents the baseline mean in the control group of this particular study *The basis for the assumed risk is the median control group risk across studies. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; OR: Odds ratio 1 2 3

High risk of bias in included studies Total sample size 60%


31


Multidisciplinary compared to wait list for chronic low back pain Patient or population: Patients with chronic low back pain Intervention: Multidisciplinary Biopsychosocial Rehabilitation Comparison: Wait list Outcomes

Assumed risk

Comparative effects (95% CI)



Comments

Pain long term # The baseline for the not estimable 0-100 Visual scale, where most representative 0 equals no pain at all study is 51.02 out of 100 and 100 is the worst pain imaginable

0

No evidence

Only short-term results available for this comparison

Disability long term # The baseline for the Mostly Roland Morris most representative 24-point scale where 0 study is 13.96 out of 24 equals no disability at all and 24 is seriously disabled

0

No evidence

Only short-term results available for this comparison

not estimable

Assumed risk Wait List



Work long term

not estimable

not estimable

not estimable

0

No evidence

Adverse events

not estimable

not estimable

not estimable

0

No evidence

#Of the included trials for this outcome, we chose the study that has the largest weighting in the overall result in Revman (Smeets 2006/2008). This figure represents the baseline mean in the control group of this particular study. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval

32

DISCUSSION Summary of main results We set out to conduct an updated review on the impact of multidisciplinary rehabilitation on people with chronic low back pain (LBP). We found 31 recently published randomised clinical trials which added to the 10 included in the previous review to form a substantial evidence base, with data on close to 7000 people. Overall we found that when compared with usual care, MBR decreased pain and disability to a moderate degree but had little to no effect on work outcomes. When compared with physical rehabilitation, MBR showed moderate effects on pain, disability and work outcomes. Although the quality of the evidence was moderate or low depending on the comparison, the overall size of the effects of MBR was quite consistent. They translate to an average difference in pain of about 1 to 2 points on a 10-point scale, and an average difference in disability of 2 to 4 points on the 24-point Roland Morris questionnaire. The improvement of work outcomes with MBR when compared to physical rehabilitation translates to about double the odds of being at work 12 months later. It would seem unlikely that conducting further RCTs will substantially change our view of the mean effect that can be expected from MBR programs. Several factors need to be taken into account when interpreting our findings to formulate recommendations regarding clinical implementation. The resources and costs associated with delivering MBR programs should be considered and weighed against those of usual care or physical training regimens. For example, MBR in 15 of the included studies required more than 100 face-to-face hours of training. Cost-effectiveness data were not extracted as part of this review. The proportion of people that experienced a clinically relevant improvement was not typically reported in the RCTs and did not form a part of this review; as such we cannot be sure the extent to which the between group difference reflects an important change on behalf of the participants. On the other hand, the people referred to these programs had long-standing symptoms which had not responded to previous treatments. As a longer duration of symptoms is an indicator of poor prognosis, a modest improvement in symptom severity compared to another treatment may be significant for this population. For our main comparisons, pooled effects do not appear to have been overestimated due to inclusion of low quality studies. The influence of baseline symptom intensity on the effectiveness of MBR is unclear because the subgroup analyses were hampered by the small numbers of studies that included samples with symptom intensity that met our a priori threshold. Samples recruited to the included studies typically reported moderate levels of pain intensity (4 to 6 points on the NRS) and disability (8 to 12 points on the Roland Morris Questionnaire). When we divided the included studies according to the hours of face-to-face intervention we did not find a consistent pattern in favour of either high or low intensity interventions.

The inconsistent nature of data collection and reporting made drawing conclusions regarding the secondary outcomes of quality of life, healthcare utilisation and adverse events difficult. Comparable estimates for these outcomes were reported by too few studies to estimate the effect of MBR. MBR did not appear to have any additional significant effect on symptoms of depression compared to physical rehabilitation. Only two and four RCTs, respectively, were included in comparisons of MBR with surgery or waiting list controls. From each comparison a pooled estimate was generated for pain and disability at one time point. There was low quality evidence of no significant difference between MBR and surgery. The effects in favour of MBR versus waiting list controls were of moderate size, but the quality of the evidence was very low to low. While 12 studies included a comparison of one MBR intervention versus another, we did not perform a synthesis of these data. Synthesis was not undertaken as it does not directly inform decisions as to whether MBR or some other intervention should be administered in this patient group.

Overall completeness and applicability of evidence Work outcomes and healthcare utilisation are key considerations for assessing the effects of MBR in this population, since they are primary determinants of the societal burden of the condition (Maetzal 2002). Many of the included studies did not report these outcomes, and when reported they were measured in different ways. The lack of standardisation of measurement in these areas makes quantitative synthesis of the body of evidence problematic. For example, in the MBR versus physical treatment comparison 13 of the 19 studies reported a work-related outcome measure yet only three, three and eight studies (short, medium, long term) could be included in the meta-analyses. The fact that these data were not reported in a comparable manner limits our ability to estimate the true effect of MBR for this critical outcome. The subgroup analysis that investigated the influence of high baseline symptom intensity proved inconclusive, largely because so few studies recruited a sample with high enough intensity. The threshold we chose to indicate high intensity (greater than 60% of the maximum possible score on a pain and a disability measure) is admittedly arbitrary, but it is surprising that only three of the 41 included studies met this criterion. While there is evidence that higher symptom severity at presentation is a prognostic indicator of poor outcome following MBR (van de Hulst 2005; van Hooff 2014; Verkerk 2013), direct evidence that it is a modifier of the effect of MBR is lacking. It could be argued that only those with severe physical symptoms and psychological dysfunction are likely to require, and therefore preferentially benefit from, a comprehensive MBR program. Matching of a more comprehensive and complex intervention with more clinically complex patients makes


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intuitive sense, and this is supported by recent evidence from the primary care setting (Hill 2011).

Quality of the evidence Only 32% of the included studies met our threshold for low risk of bias (fulfilling at least six items from the CBRG risk of bias tool) and not surprisingly all meta-analyses included studies with high risk of bias. We applied a stringent rule that inclusion of any (one or more) studies at high risk of bias in a meta-analysis meant downgrading the quality of the evidence by one level within the GRADE system. Such decisions involve a degree of subjective judgement and a more relaxed interpretation of the risk of bias may have resulted in the conclusion that the quality of the evidence in support of the effectiveness of MBR was stronger. To explore this issue we conducted sensitivity analyses. Although not conclusive, the sensitivity analyses did not indicate that inclusion of lower quality studies resulted in overestimation of the effect. This, along with the consistency of the size of the pooled effects on pain and disability, gives confidence that the reported estimates for the primary outcomes are robust. Quality of evidence was also commonly downgraded for inconsistency, this was particularly evident when one outlying study was included in the meta analyses. Exclusion of this study resulted in more consistent and precise pooled estimates for pain and disability across the time points in the MBR versus physical treatment comparison, and provides further evidence that the estimates are robust.

Potential biases in the review process There is no universally accepted definition of what constitutes MBR. The authors have chosen a definition based on their interpretation of the biopsychosocial model and reflective of the different expertise within the various clinical professions. Presumably it is possible that selection of a different definition could result in inclusion of different studies and hence different effect estimates. The MBR interventions evaluated in the included studies differed from each other in a number of ways. There were differences in the number of face-to-face sessions and the intensity of the treatment; differences in the settings; differences in the balance of the interventions in terms of focus on physical, psychological and social factors; and differences in the backgrounds of the clinicians that administered the interventions. This clinical heterogeneity is likely due to varying conceptualisations of MBR and also to uncertainty regarding the pathological cause of non-specific LBP. Further heterogeneity is also introduced by differences in the control interventions. By using a random-effects model for generating the pooled estimates and incorporating the I2 statistic into the evidence quality assessment we have attempted to account for this heterogeneity.

While most studies measured pain intensity in a similar manner, there was great variability in the measures used for other domains. Despite the efforts of initiatives such as COMET (Williamson 2012) and IMMPACT (Dworkin 2005), the findings indicate that there is little consensus on the choice of measurement instruments. This renders meaningful synthesis of the body of evidence difficult and may also introduce bias as decisions must be made regarding which outcome measures should be included in the pooled effect estimates. In addition, the lack of a core outcome measurement set increases the chances of selective reporting of results of trials (Williamson 2012). Only one study in this review met the criterion for absence of reporting bias (Tavafian 2011). It is to be hoped that current efforts to increase the registration of trials (Costa 2012) and publication of detailed protocols will improve this situation in the future. The influence of publication bias on the results is difficult to assess due to the number of studies contributing to each pooled estimate. Only three estimates included the minimum 10 studies recommended by The Cochrane Collaboration for formal assessment of publication bias. The funnel plots for these estimates indicate the possibility of small study bias, a possibility also reported in the review conducted by Norlund 2009.

Agreements and disagreements with other studies or reviews Guzman 2006 reviewed the literature up to 1998 and found that intensive MBR programs had important effects on disability outcomes and small effects on pain. Evidence regarding work outcomes was equivocal. A ’levels of evidence’ synthesis performed by van Geen 2007 reported positive effects on work participation but not on pain or disability; their study performed searches up until 2003 and included 10 studies, of which seven are in the current review. Ravenek 2010 included 12 studies from 1998 onwards, of which seven were common to this review, and the authors reported conflicting evidence from low quality studies on work outcomes, no effect on pain, and no effect on function. Norlund 2009 conducted a systematic review of studies involving people with subacute or chronic LBP and included three studies with chronic LBP, all are in this review. Their meta-analysis showed no effect on return to work for MBR interventions in the chronic LBP studies. It is somewhat surprising that the present review showed no impact of MBR on work outcomes when compared to usual care but a moderate impact when compared to physical treatment. One possibility is that studies comparing MBR to usual care included populations with less severe occupational impairment (thus harder to show an impact). Another possibility is that physical treatment when not paired with concomitant psychological or social interventions may promote a sick role and interfere with attainment of occupational goals. Few included studies involved an explicitly designed and focused workplace intervention, an issue also identified by Ravenek 2010.


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They also observed that occupational therapists were rarely involved in multidisciplinary rehabilitation interventions despite the fact that improvement of work-related outcomes is an often stated goal. They and others (Ektor-Andersen 2008) also pointed out the need for a greater degree of cooperation between workers, employers and insurers to facilitate these outcomes. No clear conclusions can be drawn regarding whether the intensity of the intervention had an influence on the size of the treatment effect. While the previous version of this review suggested that this factor may be important, a recent systematic review (Waterschoot 2014) was inconclusive and found that dose factors could not be disentangled from content factors when determining their influence on the effect size. Individual RCTs conducted by Rose 1997 and Skouen 2002 reported no substantial differences in effect between multidisciplinary programs of differing intensity. At this point in time it is unclear how much face-to-face time is optimal for MBR interventions. This is a critical question given the role of face-to-face time in driving the cost of MBR.

AUTHORS’ CONCLUSIONS Implications for practice Choosing an MBR intervention over usual care or a physical treatment program for chronic low back pain is likely to result in a positive effect on pain and disability outcomes. It is also likely that MBR will have a beneficial effect on work outcomes compared to physical treatment. However, given the moderate size of these effects and the potentially high cost of an intensive intervention, in terms of both the monetary and time burden, the decision to refer to MBR requires some consideration. While our subgroup analyses were inconclusive regarding the influence of higher or lower symptom intensity at baseline, it would appear there is little to gain by referring those without substantial physical and psychosocial impacts of their condition to such an intervention. Clinical practice guidelines (Dagenais 2010) commonly recommend assessment and treatment of physical and psychosocial factors and referral to appropriately trained clinicians for management of these factors where present. This recommendation would seem more appropriate than a recommendation of MBR simply based on chronicity of symptoms.

Implications for research The quality of the evidence regarding the primary outcomes is at best moderate, although consistent in terms of effect size. Despite this, the volume of evidence is substantial and conducting further, similar studies is unlikely to greatly change the estimate of the effectiveness of MBR versus usual care or physical treatment. This being the case, it is important to consider whether the effect is clinically worthwhile. The ideal methods for determining whether an

effect is clinically worthwhile are far from settled (Ferreira 2012) but the point has been made that such an estimation needs to take the cost of the intervention into account. In this case costs include not only those of the intervention in terms of time, inconvenience and money but also costs of other healthcare utilisation (for example medications, visits to healthcare providers) and costs of productivity losses due to low back pain, as compared to those associated with other options. The results of this review could be said to mirror those of others in the low back pain field in that small effects are observed between the index and control interventions (Hayden 2005; Henschke 2011; Rubinstein 2011). This situation is largely due to the fact that the pathology underlying non-specific low back pain is, at best, unclear. Given that this is the case, it is unsurprising that the mechanism of effect of the different intervention options is also unknown. Studies that investigate the mechanism of effect of different treatments (Mansell 2013; Smeets 2006) and investigate the effectiveness of treatments in subgroups (Foster 2013; Hancock 2009; Kamper 2010) of patients have the potential to improve our understanding of the condition. Recent studies that have conducted cost-effectiveness analyses of MBR for chronic pain have produced conflicting results. Lambeek 2010 found that their MBR program was cost-effective compared to usual care in the Netherlands; Smeets 2009 reported that while graded activity plus problem solving was cost-effective compared to a physical program, the combination of graded activity, problem solving and physical therapy was not cost-effective compared to physical therapy only. Interpretation of cost-effectiveness studies requires some sophistication, not least of all consideration of to whom the costs and benefits are apportioned. Substantial benefits may be evident at a societal level despite a modest mean clinical effect at an individual level, but the issue is complicated by the question of whether the costs are borne by the state, by insurers, or by the individual. Most of the societal costs associated with back pain are indirect costs, primarily work productivity losses (Lambeek 2011; Maetzal 2002). Of interest then is whether research should focus on improving our capacity to identify those people at greatest risk of work disability (prognostic studies) and treat them distinctly from those whose back pain typically does not result in work absences or reduced productivity. Further, incorporation into MBR of treatment modalities that specifically focus on re-integration to the work place would be of value. It is recognised that in order to do so communication and collaboration barriers between employers, the healthcare system and insurance companies must be addressed.

ACKNOWLEDGEMENTS The authors would like to thank Teresa Marin, Rachel Couban and Shireen Harbin from the Cochrane Back Review group for


35

support and for developing and conducting the electronic searches.

REFERENCES

References to studies included in this review Abbassi 2012 {published data only} ∗ Abbasi M, Dehghani M, Keefe FJ, Jafari H, Behtash H, Shams J. Spouse-assisted training in pain coping skills and the outcome of multidisciplinary pain management for chronic low back pain treatment: A 1-year randomized controlled trial. European Journal of Pain 2012;16(7): 1033–43. Alaranta 1994 {published data only} ∗ Alaranta H, Rytökoski U, Rissanen A, Talo S, Rönnemaa T, Puukka P, et al.Intensive physical and psychosocial training program for patients with chronic low back pain. A controlled clinical trial. Spine 1994;19:1339–49. Basler 1997 {published data only} ∗ Basler H, Jakle C, Kroner-Herwig B. Incorporation of cognitive behavioral treatment into the medical care of chronic low back patients: A controlled randomized study in German pain treatment centers. Patient Education & Counseling 1997;31:113–24. Bendix ’A’ 1996/1998 {published data only} Bendix AE, Bendix T, Haestrup C, Busch E. A prospective, randomized 5-year follow-up study of functional restoration in chronic low back pain patients. European Spine Journal 1998;7(2):111–9. ∗ Bendix AF, Bendix T, Vaegter K, Lund C, Frolund L, Holm L. Multidisciplinary intensive treatment for chronic low back pain: a randomized, prospective study. Cleveland Clinic Journal of Medicine 1996;63:62–9. Bendix ’B’ 1995/1998 {published data only} Bendix AE, Bendix T, Haestrup C, Busch E. A prospective, randomized 5-year follow-up study of functional restoration in chronic low back pain patients. European Spine Journal 1998;7(2):111–9. ∗ Bendix AF, Bendix T, Ostenfeld S, Bush E, Andersen A. Active treatment programs for patients with chronic low back pain: a prospective, randomized, observer blinded study. European Spine Journal 1995;4:149–52. Bendix ’C’ 2000 {published data only} ∗ Bendix T, Bendix A, Labriola M, Haestrup C, Ebbehoj N. Functional restoration versus outpatient physical training in chronic low back pain: a randomized comparative study. Spine 2000;25(19):2494–500. Coole 2013 {published data only} ∗ Coole C, Drummond A, Watson P. Individual work support for employed patients with low back pain: a randomized controlled pilot trial. Clinical Rehabilitation 2013;27(1):40–50. Fairbank 2005 {published data only} ∗ Fairbank J, Frost H, Wilson-MacDonald J, Yu L-M, Barker K, Collins R. Randomised controlled trial to

compare surgical stabilisation of the lumbar spine with an intensive rehabilitation programme for patients with chronic low back pain: the MRC spine stabilisation trial. BMJ 2005;330(7502):1233–8. Rivero-Arias O, Campbell H, Gray A, Fairbank J, Frost H. Surgical stabilisation of the spine compared with a programme of intensive rehabilitation for the management of patients with chronic low back pain: cost utility analysis based on a randomised controlled trial. BMJ 2005;330 (7502):1239–43. Harkapaa 1989 {published data only} ∗ Harkapaa K, Jarvikoski A, Mellin G, Hurri H. Pain, disability, compliance, and reported treatment benefits three months after treatment. Scandinavian Journal of Rehabilitation Medicine 1989;21:81–9. Hellum 2011 {published data only} ∗ Hellum C, Johnsen LG, Storheim K, Nygaard O P, Brox JI, Rossvoll I, et al.Surgery with disc prosthesis versus rehabilitation in patients with low back pain and degenerative disc: two year follow-up of randomised study. BMJ 2011;342:d2786. Henchoz 2010 {published data only} ∗ Henchoz Y, de Goumoens P, So AK, Paillex R. Functional multidisciplinary rehabilitation versus outpatient physiotherapy for non specific low back pain: randomized controlled trial. Swiss Medical Weekly 2010;140(w13133): 1–7. Jackel 1990 {published data only} ∗ Jackel WH, Cziske R, Gerdes N, Jacobi E. Assessment of the effectiveness of inpatient rehabilitation measures in patients with chronic low back pain: a prospective, randomized, controlled study [German]. Rehabilitation 1990;29:129–33. Jousset 2004 {published data only} ∗ Jousset N, Fanello S, Bontoux L, Dubus V, Billabert C, Vielle B. Effects of functional restoration versus 3 hours per week physical therapy: a randomized controlled study. Spine 2004;29(5):487–94. Kaapa 2006 {published data only} ∗ Kaapa EH, Frantsi K, Sarna S, Malmivaara A. Multidisciplinary group rehabilitation versus individual physiotherapy for chronic nonspecific low back pain: a randomized trial. Spine 2006;31(4):371–6. Kole-Snijders 1999 {published data only} Goossens ME, Rutten-Van Molken MP, Kole-Snijders AM, Vlaeyen JW, Van Breukelen G, Leidl R. Health economic assessment of behavioural rehabilitation in chronic low back


36

pain: a randomized clinical trial. Health Economics 1998;7: 39–51. ∗ Kole-Snijders AMJ, Vlaeyen JWS, Goossens MEJB, Rutten-Van Molken MPMH, Heuts PHTG, Van Breukelen G, Van Eek H. Results of a randomized clinical trial. Journal of Consulting and Clinical Psychology 1999;67(6):931–44. Kool 2007 {published data only} ∗ Kool J, Bachmann S, Oesch P, Knuesel O, Ambergen T, de Bie R. Function-centered rehabilitation increases work days in patients with nonacute nonspecific low back pain: 1-year results from a randomized controlled trial. Archives of Physical Medicine and Rehabilitation 2007;88(9):1089–94. Lambeek 2010 {published data only} Lambeek LC, Bosmans JE, van Royen BJ, van Tulder MW, van Mechelen W, Anema JR. Effect of integrated care for sick listed patients with chronic low back pain: economic evaluation alongside a randomised controlled trial. BMJ 2010;341:6414. ∗ Lambeek LC, van Mechelen W, Knol DL, Loisel P, Anema JR. Randomised controlled trial of integrated care to reduce disability from chronic low back pain in working and private life. BMJ 2010;340(7749):750. Leeuw 2008 {published data only} Leeuw M, Goossens MEJB, van Breukelen GJP, de Jong JR, Heuts PHTG, Smeets RJEM, et al.Exposure in vivo versus operant graded activity in chronic low back pain patients: results of a randomized controlled trial. Pain 2008;138: 192–207. Linton 2005 {published data only} ∗ Linton SJ, Boersma K, Jansson M, Svärd L, Botvalde M. The effects of cognitive-behavioral and physical therapy preventive interventions on pain-related sick leave: a randomized controlled trial. Clinical Journal of Pain 2005; 21(2):109–19. Lukinmaa 1989 {published data only} ∗ Lukinmaa A. Low back pain as a biopsychosocial problem. A controlled clinical trial and a costeffectiveness analysis [Finnish]. Kansanelakelaitoksen Julkaisuja 1989;ML:1–90. Mangels 2009 {published data only} ∗ Mangels M, Schwarz S, Worringen U, Holme M, Rief W. Evaluation of a behavioral-medical inpatient rehabilitation treatment including booster sessions: a randomized controlled study. Clinical Journal of Pain 2009;25(5): 356–64.

Moix 2003 {published data only} ∗ Moix J, Canellas M, Osorio C, Bel X, Girvent F, Martos A. Efficacy of an interdisciplinary educational program in patients with chronic back pain [Spanish]. Dolor 2003;18 (3):149–57. Monticone 2013 {published data only} ∗ Monticone M, Ferrante S, Rocca B, Baiardi P, Dal Farra F, Foti C. Effect of a long-lasting multidisciplinary program on disability and fear-avoidance behaviors in patients with chronic low back pain: results of a randomized controlled trial. Clinical Journal of Pain 2013;29(11):929–38. Morone 2011 {published data only} ∗ Morone G, Paolucci T, Alcuri MR, Vulpiani MC, Matano A, Bureca I. Quality of life improved by multidisciplinary back school program in pat ents with chronic non-specific low back pain: a single blind randomized controlled trial. Europan Journal of Physical and Rehabilitation Medicine 2011;47(4):533–41. Morone 2012 {published data only} ∗ Morone G, Iosa M, Paolucci T, Fusco A, Alcuri R, Spadini E. Efficacy of perceptive rehabilitation in the treatment of chronic nonspecific low back pain through a new tool: a randomized clinical study. Clinical Rehabilitation 2012;26 (4):339–50. Nicholas 1991 {published data only} ∗ Nicholas MK, Wilson PH, Goyen J. Operant-behavioural and cognitive behavioural treatment for chronic low back pain. Behavioural Research and Therapy 1991;29:225–38. Nicholas 1992 {published data only} ∗ Nicholas MK, Wilson PH, Goyen J. Comparison of cognitive behavioral group treatment and an alternative non-psychological treatment for chronic low back pain. Pain 1992;48:339–47. Roche 2007/2011 {published data only} ∗ Roche G, Ponthieux A, Parot-Shinkel E, Jousset N, Bontoux L, Dubus V. Comparison of a functional restoration program with active individual physical therapy for patients with chronic low back pain: a randomized controlled trial. Archives of Physical Medicine and Rehabilitation 2007;88(10):1229–35. Roche-Leboucher G, Petit-Lemanach A, Bontoux L, DubusBausiere V, Parot-Shinkel E, Fanello S. Multidisciplinary intensive functional restoration versus outpatient active physiotherapy in chronic low back pain: A randomized controlled trial. Spine 2011;36(26):2235–42.

Meng 2011 {published data only} ∗ Meng K, Seekatz B, Roband H, Worringen U, Vogel H, Faller H. Intermediate and long-term effects of a standardized back school for inpatient orthopedic rehabilitation on illness knowledge and self-management behaviors: a randomized controlled trial. Clinical Journal of Pain 2011;27(3):248–57.

Schweikert 2006 {published data only} ∗ Schweikert B, Jacobi E, Seitz R, Cziske R, Ehlert A, Knab J. Effectiveness and cost-effectiveness of adding a cognitive behavioral treatment to the rehabilitation of chronic low back pain. Journal of Rheumatology 2006;33(12):2519–26.

Mitchell 1994 {published data only} ∗ Mitchell RI, Carmen GM. The functional restoration approach to the treatment of chronic pain in patients with soft tissue and back injuries. Spine 1994;19:633–42.

Skouen 2002 {published data only} ∗ Skouen JS, Grasdal AL, Haldorsen EM, Ursin H. Relative cost-effectiveness of extensive and light multidisciplinary treatment programs versus treatment as usual for patients


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with chronic low back pain on long-term sick leave: randomized controlled study. Spine 2002;27(9):901–9. Smeets 2006/2008 {published data only} Smeets RJ, Severens JL, Beelen S, Vlaeyen JW, Knottnerus JA. More is not always better: cost-effectiveness analysis of combined, single behavioral and single physical rehabilitation programs for chronic low back pain. European Journal of Pain 2009;13(1):71–81. Smeets RJEM, Vlaeyen JWS, Hidding A, Kester ADM, van der Heijden GJMG, Knottnerus JA. Chronic low back pain: Physical training, graded activity with problem solving training, or both? The one-year post-treatment results of a randomized controlled trial. Pain 2008;134(8):263–76. ∗ Smeets RJEM, Vlaeyen JWS, Hidding A, Kester ADM, van der Heijden GJMG, van Geel ACM, Knottnerus JA. Active rehabilitation for chronic low back pain: Cognitive-behavioral, physical, or both? First direct posttreatment results from a randomized controlled trial. BMC Musculoskeletal Disorders 2006;7:5.

of a multidisciplinary treatment between subgroups of chronic low back pain patients defined using two multiaxial assessment instruments: the Multidimensional Pain Inventory and lumbar dynamometry. Clinical Rehabilitation 2004;18(5):566–79. Von Korff 2005 {published data only} ∗ Von Korff M, Balderson BH, Saunders K, Miglioretti DL, Lin EH, Berry S. A trial of an activating intervention for chronic back pain in primary care and physical therapy settings. Pain 2005;113(3):323–30.

References to studies excluded from this review Akhmadeeva 2009 {published data only} Akhmadeeva L, Setchenkova N, Magzhanov R. Effectiveness of transcutaneous dynamic electrical nerve stimulation in low back pain: A pilot randomized controlled trial. Journal of Neurological Sciences 2009;285:S320.

Strand 2001 {published data only} ∗ Strand LI, Ljunggren AE, Haldorsen EMH, Espehaug B. The impact of physical function and pain on work status at 1-year follow-up in patients with back pain. Spine 2001;26 (7):800–8.

Albaladejo 2010 {published data only} Albaladejo C, Kovacs FM, Royuela A, del Pino R, Zamora J. The efficacy of a short education program and a short physiotherapy program for treating low back pain in primary care: a cluster randomized trial. Spine 2010;35(5): 483–96.

Streibelt 2009 {published data only} ∗ Streibelt M, Thren K, Muller-Fahrnow W. Effects of FCE-based multidisciplinary rehabilitation in patients with chronic musculoskeletal disorders - results of a randomized controlled trial [German]. Physikalische Medizin Rehabilitationsmedizin Kurortmedizin 2009;19(1): 34–41.

Andrade 2008 {published data only} Andrade SC, Araujo AG, Vilar MJ. [Back school for patients with non-specific chronic low-back pain: benefits from the association of an exercise program with patient’s education]. [Portuguese]. Acta Reumatologica Portuguesa 2008;33(4): 443–50.

Tavafian 2008 {published data only} ∗ Tavafian SS, Jamshidi AR, Montazeri A. A randomized study of back school in women with chronic low back pain: quality of life at three, six, and twelve months follow-up. Spine 2008;33(15):1617–21.

Anema 2007 {published data only} Anema JR, Steenstra IA, Bongers PM, de Vet HC, Knol DL, Loisel P, van Mechelen W. Multidisciplinary rehabilitation for subacute low back pain: graded activity or workplace intervention or both? A randomized controlled trial. Spine 2007;32(3):291–300.

Tavafian 2011 {published data only} ∗ Tavafian SS, Jamshidi AR, Mohammad K. Treatment of chronic low back pain: a randomized clinical trial comparing multidisciplinary group-based rehabilitation program and oral drug treatment with oral drug treatment alone. Clinical Journal of Pain 2011;27(9):811–8. Turner 1990 {published data only} Turner JA, Clancy S, McQuade KJ, Cardenas DD. Effectiveness of behavioral therapy for chronic low back pain: a component analysis. Journal of Consulting and Clinical Psychology 1990;58(5):573–9. Van den Hout 2003 {published data only} ∗ van den Hout JHC, Vlaeyen JWS, Heuts PH, Zijlema JH, Wijnen JA. Secondary prevention of work-related disability in nonspecific low back pain: does problem-solving therapy help? A randomized clinical trial. Clinical Journal of Pain 2003;19(2):87–96. Vollenbroek-Hutten 2004 {published data only} ∗ Vollenbroek-Hutten MMR, Hermens HJ, Wever D, Gorter M, Rinket J, IJerman MJ. Differences in outcome

Angst 2009 {published data only} Angst F, Verra ML, Lehmann S, Brioschi R, Aeschlimann A. Clinical effectiveness of an interdisciplinary pain management programme compared with standard inpatient rehabilitation in chronic pain: a naturalistic, prospective controlled cohort study. Journal of Rehabilitation Medicine 2009;41(7):569–75. Bachmann 2009 {published data only} Bachmann S, Wieser S, Oesch P, Schmidhauser S, Knusel O, Kool J. Three-year cost analysis of function-centred versus pain-centred inpatient rehabilitation in patients with chronic non-specific low back pain. Journal of Rehabilitation Medicine 2009;41(11):919–23. Bahrke 2006 {published data only} Bahrke U, Bandemer-Greulich U, Fikentscher E, Muller K, Schreiber B, Konzag TA. [Chronic low back pain with endurant pain coping--optimizing rehabilitation success in a hitherto neglected patient group]. [German]. Rehabilitation 2006;45(6):336–44.


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Bandemeer-Greulich 2006 {published data only} Bandemer-Greulich U, Schreiber B, Fikentscher E, Bahrke U. Protective and repressive factors for success in rehabilitation of chronic low back pain. [German]. Physikalische Medizin Rehabilitationsmedizin Kurortmedizin 2006;16(5):297–302. Bandemeer-Greulich 2008 {published data only} Bandemer-Greulich U, Bosse B, Fikentscher E, Konzag TA, Bahrke U. [Efficacy of psychological interventions on pain coping strategies in orthopedic rehabilitation of chronic low back pain]. [German]. Psychotherapie, Psychosomatik, Medizinische Psychologie 2008;58(1):32–7. Basler 2007 {published data only} Basler HD, Bertalanffy H, Quint S, Wilke A, Wolf U. TTMbased counselling in physiotherapy does not contribute to an increase of adherence to activity recommendations in older adults with chronic low back pain - A randomised controlled trial. European Journal of Pain 11;1:31–7. Bastiaenen 2004 {published data only} Bastiaenen CH, de Bie RA, Wolters PM, Vlaeyen JW, Bastiaanssen JM, Klabbers AB, et al.Treatment of pregnancy-related pelvic girdle and/or low back pain after delivery design of a randomized clinical trial within a comprehensive prognostic cohort study. BMC Public Health 2004;4:67. Becker 2000 {published data only} Becker N, Sjogren P, Bech P, Olsen AK, Eriksen J. Treatment outcome of chronic non-malignant pain patients managed in a Danish multidisciplinary pain centre compared to general practice: a randomised controlled trial. Pain 2000; 84(2-3):203–11.

chronic pain management groups?. Clinical Journal of Pain 2007;23(4):361–74. Brox 2003 {published data only} Brox JI, Sorensen R, Friis A, Nygaard O, Indahl A, Keller A, et al.Randomized clinical trial of lumbar instrumented fusion and cognitive intervention and exercises in patients with chronic low back pain and disc degeneration. Spine 2003;17:1913–21. Buhrman 2011 {published data only} Buhrman M, Nilsson-Ihrfeldt E, Jannert M, Strom L, Andersson G. Guided internet-based cognitive behavioural treatment for chronic back pain reduces pain catastrophizing: a randomized controlled trial. Journal of Rehabilitation Medicine 2011;43(6):500–5. Bultman 2009 {published data only} Bultmann U, Sherson D, Olsen J, Hansen CL, Lund T, Kilsgaard J. Coordinated and tailored work rehabilitation: a randomized controlled trial with economic evaluation undertaken with workers on sick leave due to musculoskeletal disorders. Journal of Occupational Rehabilitation 2009;19(1):81–93. Busch 2011 {published data only} Busch H, Bodin L, Bergstrom G, Jensen IB. Patterns of sickness absence a decade after pain-related multidisciplinary rehabilitation. Pain 2011;152(8):1727–33. Campello 2012 {published data only} Campello M, Ziemke G, Hiebert R, Weiser S, Brinkmeyer M, Fox B, et al.Implementation of a multidisciplinary program for active duty personnel seeking care for low back pain in a U.S. Navy Medical Center: a feasibility study. Military Medicine 2012;177(9):1075–80.

Bendix 1998a {published data only} Bendix AF, Bendix T, Haestrup C. Can it be predicted which patients with chronic low back pain should be offered tertiary rehabilitation in a functional restoration program? A search for demographic, socioeconomic, and physical predictors. Spine 1998;23(16):1775–84.

Cecchi 2012 {published data only} Cecchi F, Negrini S, Pasquini G, Paperini A, Conti AA, Chiti M, et al.Predictors of functional outcome in patients with chronic low back pain undergoing back school, individual physiotherapy or spinal manipulation. European Journal of Physical and Rehabilitation Medicine 2012;48(3): 371–8. Christiansen 2010 {published data only} Christiansen S, Oettingen G, Dahme B, Klinger R. A short goal-pursuit intervention to improve physical capacity: a randomized clinical trial in chronic back pain patients. Pain 2010;149(3):444–52.

Bethge 2011 {published data only} Bethge M, Herbold D, Trowitzsch L, Jacobi C. Work status and health-related quality of life following multimodal work hardening: a cluster randomised trial. Journal of Back and Musculoskeletal Rehabilitation 2011;24(3):161–72.

Demoulin 2006 {published data only} Demoulin C, Maquet D, Tomasella M, Croisier J, Crielaard J, Vanderthommen M. Benefits of a physical training program after back to school for chronic low back pain patients. Journal of Musculoskeletal Pain 2006;14(2):21–31.

Binder 2007 {published data only} Binder A. [Chronic backache with neuropathic component. Individual basic therapy plus multimodal approach]. [German]. MMW Fortschritte der Medizin 2007;149(20): 49.

Dibbelt 2006 {published data only} Dibbelt S, Greitemann B, Schel C. Long-term efficiency of orthopedic rehabilitation in chronic back pain -- the integrative orthopedic psychosomatic concept (IopKo) [German]. Rehabilitation 2006;45(6):324–35.

Bliokas 2007 {published data only} Bliokas VV, Cartmill TK, Nagy BJ. Does systematic graded exposure in vivo enhance outcomes in multidisciplinary

Dobscha 2009 {published data only} Dobscha SK, Corson K, Perrin NA, Hanson GC, Leibowitz RQ, Doak MN, et al.Collaborative care for chronic pain in

Becker 2008 {published data only} Becker A, Leonhardt C, Kochen MM, Keller S, Wegscheider K, Baum E, et al.Effects of two guideline implementation strategies on patient outcomes in primary care: a cluster randomized controlled trial. Spine 2008;33(5):473–80.


39

primary care: a cluster randomized trial. JAMA 2009;301 (12):1242–52. Donzelli 2006 {published data only} Donzelli S, Di Domenica F, Cova AM, Galletti R, Giunta N. Two different techniques in the rehabilitation treatment of low back pain: A randomized controlled trial. Europa Medicophysica 2006;42(3):205–10. Driessen 2011a {published data only} Driessen MT, Proper KI, Anema JR, Knol DL, Bongers PM, van der Beek AJ. Participatory ergonomics to reduce exposure to psychosocial and physical risk factors for low back pain and neck pain: results of a cluster randomised controlled trial. Occupational and Environmental Medicine 2011;68(9):674–81. Driessen 2011b {published data only} Driessen MT, Proper KI, Anema JR, Knol DL, Bongers PM, van der Beek AJ. The effectiveness of participatory ergonomics to prevent low-back and neck pain - results of a cluster randomized controlled trial. Scandinavian Journal of Work, Environment and Health 2011;37(5):383–93. Dufour 2010 {published data only} Dufour N, Thamsborg G, Oefeldt A, Lundsgaard C, Stender S. Treatment of chronic low back pain: a randomized, clinical trial comparing group-based multidisciplinary biopsychosocial rehabilitation and intensive individual therapist-assisted back muscle strengthening exercises. Spine 35;5:469–76.

Friedberg 2010 {published data only} Friedberg MW. Group cognitive behavioral treatment improves chronic low back pain in a cost-effective manner. Journal of Clinical Outcomes Management 2010;17(6):7–9. Friedrich 1998 {published data only} Friedrich M, Gittler G, Halberstadt Y, Cermak T, Heiller I. Combined exercise and motivation program: effect on the compliance and level of disability of patients with chronic low back pain: A randomized controlled trial. Archives of Physical Medical Rehabilitation 1998;79:475–87. Friedrich 2005 {published data only} Friedrich M, Gittler G, Arendasy M, Friedrich KM. Longterm effect of a combined exercise and motivational program on the level of disability of patients with chronic low back pain. Spine 2005;30(9):995–1000. Froholdt 2011 {published data only} Froholdt A, Holm I, Keller A, Gunderson RB, Reikeraas O, Brox JI. No difference in long-term trunk muscle strength, cross-sectional area, and density in patients with chronic low back pain 7 to 11 years after lumbar fusion versus cognitive intervention and exercises. Spine Journal 2011;11 (8):718–25. Froholdt 2012 {published data only} Froholdt A, Reikeraas O, Holm I, Keller A, Brox JI. No difference in 9-year outcome in CLBP patients randomized to lumbar fusion versus cognitive intervention and exercises. European Spine Journal 2012;21(12):2531–8.

Dysvik 2005 {published data only} Dysvik E, Natvig GK, Eikeland OJ, Brattberg G. Results of a multidisciplinary pain management program: A 6- and 12-month follow-up study. Rehabilitation Nursing 2005;30 (5):198–206.

Frost 1998 {published data only} Frost H, Lamb SE, Klaber Moffett JA, Fairbank JC, Moser JS. A fitness programme for patients with chronic low back pain: 2-year follow-up of a randomised controlled trial. Pain 1998;75(2-3):273–9.

Ektor-Andersen 2008 {published data only} Ektor-Andersen J, Ingvarsson E, Kullendorff M, Orbaek P. High cost-benefit of early team-based biomedical and cognitive-behaviour intervention for long-term pain-related sickness absence. Journal of Rehabilitation Medicine 40;1: 1–8.

Gatchel 2003 {published data only} Gatchel RJ, Polatin PB, Noe C, Gardea M, Pulliam C, Thompson J. Treatment- and cost-effectiveness of early intervention for acute low-back pain patients: a one-year prospective study. Journal of Occupational Rehabilitation 2003;13(1):1–9.

Esmer 2010 {published data only} Esmer G, Blum J, Rulf J, Pier J. Mindfulness-based stress reduction for failed back surgery syndrome: a randomized controlled trial. Journal of the American Osteopathic Association 2010;110(11):646–52.

George 2009 {published data only} George SZ, Teyhen DS, Wu SS, Wright A, Dugan JL, Yang G, et al.Psychosocial education improves low back pain beliefs: results from a cluster randomized clinical trial (NCT00373009). The Journal of Orthopaedic and Sports Physical Therapy 2009;39(1):A30–1.

Ewert 2009 {published data only} Ewert T, Limm H, Wessels T, Rackwitz B, Von Garnier K, Freumuth R, Stucki G. The comparative effectiveness of a multimodal program versus exercise alone for the secondary prevention of chronic low back pain and disability. Physical Medicine and Rehabilitation 2009;1(9):798–808.

George 2010a {published data only} George SZ, Robinson ME. Patient satisfaction with behavioral physical therapy interventions: secondary analysis from a randomized clinical trial. The Journal of Orthopaedic and Sports Physical Therapy 2010;40(1):A22.

Ferrari 2006 {published data only} Ferrari R, Fipaldini E, Birbaumer N. Individual characteristics and results of biofeedback training and operant treatment in patients with chronic pain. [Italian]. Psicoterapia Cognitiva e Comportamentale 2006;12(2): 161–79.

George 2010b {published data only} George SZ, Wittmer VT, Fillingim RB, Robinson ME. Comparison of graded exercise and graded exposure clinical outcomes for patients with chronic low back pain. The Journal of Orthopaedic and Sports Physical Therapy 2010;40 (11):694–704.


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George 2011 {published data only} George SZ, Childs JD, Teyhen DS, Wu SS, Wright AC, Dugan JL, Robinson ME. Brief psychosocial education, not core stabilization, reduced incidence of low back pain: Results from the Prevention of Low Back Pain in the Military (POLM) cluster randomized trial. BMC Medicine 2011;9:128. Glattacker 2012 {published data only} Glattacker M, Heyduck K, Meffert C. Illness beliefs, treatment beliefs and information needs as starting points for patient information-Evaluation of an intervention for patients with chronic back pain. Patient Education & Counseling 2012;86(3):378–89. Glombiewski 2010 {published data only} Glombiewski JA, Hartwich-Tersek J, Rief W. Two psychological interventions are effective in severely disabled, chronic back pain patients: a randomised controlled trial. International Journal of Behavioral Medicine 2010;17(2): 97–107. Glomsrod 2001 {published data only} Glomsrod B, Lonn JH, Soukup MG, Bo K, Larsen S. “Active back school”, prophylactic management for low back pain: Three-year follow-up of a randomized, controlled trial. Journal of Rehabilitation Medicine 2001;33 (1):26–30. Gohner 2006 {published data only} Gohner W, Schlicht W. Preventing chronic back pain: evaluation of a theory-based cognitive-behavioural training programme for patients with subacute back pain. Patient Education & Counseling 2006;64(1-3):87–95. Greitemann 2006 {published data only} Greitemann B, Dibbelt S, Buschel C. [Multidisciplinary orthopedic rehabilitation program in patients with chronic back pain and need for changing job situation -- long-term effects of a multimodal, multidisciplinary program with activation and job development]. [German]. Zeitschrift fur Orthopadie und Ihre Grenzgebiete 2006;144(3):255–66. Hagen 2006 {published data only} Hagen EM. [Does light mobilization treatment reduce long-term sick leave for low back pain? ] [Norwegian]. Norsk Epidemiologi 2006;16(2):137–44. Hagen 2010 {published data only} Hagen EM, Odelien KH, Lie SA, Eriksen HR. Adding a physical exercise programme to brief intervention for low back pain patients did not increase return to work. Scandinavian Journal of Public Health 2010;38(7):731–8. Hallegraeff 2009 {published data only} Hallegraeff JM, de Greef M, Winters JC, Lucas C. Manipulative therapy and clinical prediction criteria in treatment of acute nonspecific low back pain. Perceptual and Motor Skills 2009;108(1):196–208. Hampel 2009 {published data only} Hampel P, Graef T, Krohn-Grimberghe B, Tlach L. Effects of gender and cognitive-behavioral management of depressive symptoms on rehabilitation outcome among

inpatient orthopedic patients with chronic low back pain: A 1 year longitudinal study. European Spine Journal 2009; 18(12):1867–80. Henchoz 2010a {published data only} Henchoz Y, de Goumoens P, Norberg M, Paillex R, So AK. Role of physical exercise in low back pain rehabilitation: a randomized controlled trial of a three-month exercise program in patients who have completed multidisciplinary rehabilitation. Spine 2010;35(12):1192–9. Henchoz 2010b {published data only} Henchoz Y, Pinget C, Wasserfallen JB, Paillex R, de Goumoens P, Norberg M, Kai-Lik So A. Cost-utility analysis of a three-month exercise programme vs usual care following multidisciplinary rehabilitation for chronic low back pain. Journal of Rehabilitation Medicine 2010;42(9): 846–52. Heymans 2006 {published data only} Heymans MW, de Vet HC, Bongers PM, Knol DL, Koes BW, van Mechelen W. The effectiveness of high-intensity versus low-intensity back schools in an occupational setting: a pragmatic randomized controlled trial. Spine 2006;31 (10):1075–82. Hlobil 2005 {published data only} Hlobil H, Staal JB, Twisk J, Koke A, Ariens G, Smid T, van Mechelen W. The effects of a graded activity intervention for low back pain in occupational health on sick leave, functional status and pain: 12-Month results of a randomized controlled trial. Journal of Occupational Rehabilitation 2005;15(4):569–80. Hodselmans 2001 {published data only} Hodselmans AP, Jaegers SM, Goeken LN. Short-term outcomes of a back school program for chronic low back pain. Archives of Physical and Medical Rehabilitation 2001; 82:1099–105. Huge 2006 {published data only} Huge V, Schloderer U, Steinberger M, Wuenschmann B, Schops P, Beyer A, Azad SC. Impact of a functional restoration program on pain and health-related quality of life in patients with chronic low back pain. Pain Medicine 2006;7(6):501–8. Jensen 2005 {published data only} Jensen IB, Bergstrom G, Ljungquist T, Bodin L. A 3-year follow-up of a multidisciplinary rehabilitation programme for back and neck pain. Pain 2005;115(3):273–83. Jensen 2007 {published data only} Jensen I, Bergstrom G, Bodin L, Ljungquist T, Nygren A. [Effects of rehabilitation after seven years. Evaluation of two rehabilitation programs in Sweden]. [Swedish]. Lakartidningen 2007;103(23):1829–30. Jensen 2009 {published data only} Jensen IB, Busch H, Bodin L, Hagberg J, Nygren A, Bergstrom G. Cost effectiveness of two rehabilitation programmes for neck and back pain patients: A seven year follow-up. Pain 2009;152(3):202–8.


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Jensen 2011 {published data only} Jensen C, Jensen OK, Christiansen DH, Nielsen CV. Oneyear follow-up in employees sick-listed because of low back pain: randomized clinical trial comparing multidisciplinary and brief intervention. Spine 2011;36(15):1180–9. Jensen 2012 {published data only} Jensen, C.Jensen, O. K.Nielsen, C. V. Sustainability of return to work in sick-listed employees with low-back pain. Two-year follow-up in a randomized clinical trial comparing multidisciplinary and brief intervention. BMC Musculoskeletal Disorders 2012;13:156. Jensen 2013 {published data only} Jensen C, Nielsen CV, Jensen O, Petersen K. Costeffectiveness and cost-benefit analyses of a multidisciplinary intervention compared with a brief intervention to facilitate return to work in sick-listed patients with low back pain. Spine 2013;38(13):1059–67. Johnson 2013 {published data only} Johnsen LG, Brinckmann P, Hellum C, Rossvoll I, Leivseth G. Segmental mobility, disc height and patient-reported outcomes after surgery for degenerative disc disease: a prospective randomised trial comparing disc replacement and multidisciplinary rehabilitation. Bone & Joint Journal 2013;95B(1):81–9. Kainz 2006 {published data only} Kainz B, Lich M, Engel E, Ckel WH. Comparison of three outpatient therapy forms for treatment of chronic low back pain -- findings of a multicentre, cluster randomized study [German]. Rehabilitation 2006;45(2):65–77. Kolip 2001 {published data only} Kolip P, Czujek J, Greitemann B, Rosowski E, Schmidt B, Slangen K. [“Zest for life instead of strain of illness” implementation and evaluation of a programme activating chronic back pain patients in a rehabilitation clinic] [German]. Die Rehabilitation 2001;40(5):267–74. Kumar 2010 {published data only} Kumar S, Sharma VP, Shukla R, Dev R. Comparative efficacy of two multimodal treatments on male and female sub-groups with low back pain. Journal of Back and Musculoskeletal Rehabilitation 2010;23(1):1–9. Lamb 2010 {published data only} Lamb SE, Hansen Z, Lall R, Castelnuovo E, Withers EJ, Nichols V, et al.Group cognitive behavioural treatment for low-back pain in primary care: a randomised controlled trial and cost-effectiveness analysis. Lancet 2010;75(9718): 916–23. Lang 2003 {published data only} Lang E, Liebig K, Kastner S, Neundorfer B, Heuschmann P. Multidisciplinary rehabilitation versus usual care for chronic low back pain in the community: effects on quality of life. Spine Journal 2003;3(4):270–6. Lee 2013 {published data only} Lee WYA, Lee WCE, Law SW, Lau WKA, Leung SM, Sieh KM, et al.Managing psychosocial contributors in low back pain patients--a randomised controlled trial. Journal of Orthopaedics, Trauma and Rehabilitation 2013;17:46–51.

Le Gall 2001 {published data only} Le Gall S, Ozguler A, Piciotti M, Morel-Fatio M, Leclerc A, Boureau F. Predictive factors of chronic low-back pain and evaluation of a multidisciplinary pain management program in a population still in activity. [French]. Archives des Maladies Professionnelles et de Medecine du Travail 2001; 62(7):575. Leon 2009 {published data only} Leon Mateos L, Jover Jover JA, Abasolo Alcazar L, Loza Santamaria E, Perez Nieto MA, Redondo Delgado MM. Functional recovery in low back pain: Efficacy of an early cognitive behavioral intervention. Arthritis and Rheumatism (Arthritis Care and Research) 2009;61(7):996–1003. Lindell 2008 {published data only} Lindell O, Johansson SE, Strender LE. Subacute and chronic, non-specific back and neck pain: cognitivebehavioural rehabilitation versus primary care. A randomized controlled trial. BMC Musculoskeletal Disorders 2008;9:172. Linton 2000 {published data only} Linton SJ, Andersson T. Can chronic disability be prevented? A randomized trial of a cognitive-behavior intervention and two forms of information for patients with spinal pain. Spine 2000;25(21):2825–31. Ljungkvist 2000 {published data only} Ljungkvist I. Short- and long-term effects of a 12-week intensive functional restoration programme in individuals work-disabled by chronic spinal pain. Scandinavian Journal of Rehabilitation Medicine. Supplement 2000;40:1–14. Loisel 2002 {published data only} Loisel P, Lemaire J, Poitras S, Durand MJ, Champagne F, Stock S, et al.Cost-benefit and cost-effectiveness analysis of a disability prevention model for back pain management: a six year follow up study. Occupational and Environmental Medicine 2002;59(12):807–15. Lonn 1999 {published data only} Lønn JH, Glomsrød B, Soukup MG, Bø K, Larsen S. Active back school: prophylactic management for low back pain. A randomized, controlled, 1-year follow-up study. Spine 1999;24(9):865–71. Mannion 2001 {published data only} Mannion AF, Müntener M, Taimela S, Dvorak J. Comparison of three active therapies for chronic low back pain: results of a randomized clinical trial with one-year follow-up. Rheumatology 2001;40(7):772–8. Mannion 2013 {published data only} Mannion AF, Brox JI, Fairbank JCT. Comparison of spinal fusion and nonoperative treatment in patients with chronic low back pain: Long-term follow-up of three randomized controlled trials. Spine Journal 2013;11:1438–48. Martin 2000 {published data only} Martin C, Carney T, Obonyo T, Lamont L. Setting up a pain management programme. The Ayrshire experience. Scottish Medical Journal 2000;45(2):45–8.


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Mattila 2007 {published data only} Mattila R, Malmivaara A, Kastarinen M, Kivel SL, Nissinen A. The effects of lifestyle intervention for hypertension on low back pain: a randomized controlled trial. Spine 2007; 32(26):2943–7. Meyer 2005 {published data only} Meyer K, Fransen J, Huwiler H, Uebelhart D, Klipstein A. Feasibility and results of a randomised pilot-study of a work rehabilitation programme. Journal of Back and Musculoskeletal Rehabilitation 2005;18:67–78. Mohr 2009 {published data only} Mohr B, Krohn-Grimberghe B, Graf T, Schulze J, Petermann F, Hampel P. [Patients with chronic low back pain: the impact of psychosocial features]. [German]. Rehabilitation 2009;48(5):288–97. Molde 2003 {published data only} Molde Hagen E, Grasdal A, Eriksen HR. Does early intervention with a light mobilization program reduce longterm sick leave for low back pain: a 3-year follow-up study. Spine 2003;28(20):2309–15. Nazzal 2013 {published data only} Nazzal ME, Saadah MA, Saadah LM, Al-Omari MA, Al-Oudat ZA, Nazzal MS, et al.Management options of chronic low back pain. A randomized blinded clinical trial. Neurosciences 2013;18(2):152–9. Nicholas 2013 {published data only} Nicholas MK, Asghari A, Blyth FM, Wood BM, Murray R, McCabe R, et al.Self-management intervention for chronic pain in older adults: A randomised controlled trial. Pain 2013;154(6):824–35. Niemisto 2005 {published data only} Niemisto YL, Rissanen P, Sarna S, Lahtinen-Suopanki T, Lindgren K, Hurri H. Cost-effectiveness of combined manipulation, stabilizing exercises, and physician consultation compared to physician consultation alone for chronic low back pain: a prospective randomized trial with 2-year follow-up. Spine 2005;30(10):1109–15.

Rantonen 2012 {published data only} Rantonen J, Luoto S, Vehtari A, Hupli M, Karppinen J, Malmivaara A, Taimela S. The effectiveness of two active interventions compared to self-care advice in employees with non-acute low back symptoms: a randomised, controlled trial with a 4-year follow-up in the occupational health setting. Occupational and Environmental Medicine 2012;69 (1):12–20. Rossignol 2000 {published data only} Rossignol M, Abenhaim L, Seguin P, Neveu A, Collet JP, Ducruet T, Shapiro S. Coordination of primary health care for back pain. A randomized controlled trial. Spine 2000; 25(2):251–8. Rothman 2013 {published data only} Rothman MG, Ortendahl M, Rosenblad A, Johansson AC. Improved quality of life, working ability, and patient satisfaction after a pretreatment multimodal assessment method in patients with mixed chronic muscular pain: a randomized-controlled study. Clinical Journal of Pain 2013; 29(3):195–204. Sahin 2011 {published data only} Sahin N, Albayrak I, Durmus B, Ugurlu H. Effectiveness of back school for treatment of pain and functional disability in patients with chronic low back pain: a randomized controlled trial. Journal of Rehabilitation Medicine 2011;43 (3):224–9. Shete 2012 {published data only} Shete KM, Suryawanshi P, Gandhi N. Management of low back pain in computer users: A multidisciplinary approach. Journal of Craniovertebral Junction and Spine 2012;3(1): 7–10. Siemonsma 2013 {published data only} Siemonsma P, Stuive I, Roorda L, Vollebregt J, Walker M, Lankhorst G, Lettinga A. Cognitive treatment of illness perceptions in patients with chronic low back pain: a randomized controlled trial. Physical Therapy 2013;93(4): 435–48.

Padua 2009 {published data only} Padua R, Bondi R, Ceccarelli E, Alviti F. A randomized study of back school in women with chronic low back pain. Quality of life at three, six, and twelve months follow-up. Spine 2009;34(12):1336.

Sjostrum 2010 {published data only} Sjostrom R, Asplund R, Alricsson M. Two-year outcome of a multidisciplinary vocational rehabilitation programme focused on range of motion of the neck and back. Work 2010;37(4):341–8.

Paolucci 2012 {published data only} Paolucci T, Morone G, Iosa M, Fusco A, Alcuri R, Matano A, Bureca I, Saraceni VM, Paolucci S. Psychological features and outcomes of the Back School treatment in patients with chronic non-specific low back pain. A randomized controlled study. European Journal of Physical and Rehabilitation Medicine 2012;48(2):245–53.

Sleptsova 2013 {published data only} Sleptsova M, Wossmer B, Grossman P, Langewitz W. Culturally sensitive group therapy for Turkish patients suffering from chronic pain: A randomised controlled intervention trial. Swiss Medical Weekly 2013;Nov:143.

Rainville 2002 {published data only} Rainville J, Jouve CA, Hartigan C, Martinez E, Hipona MJ. Comparison of short- and long-term outcomes for aggressive spine rehabilitation delivered two versus three times per week. Spine 2002;2(6):402–7.

Sorensen 2010 {published data only} Sorensen PH, Bendix T, Manniche C, Korsholm L, Lemvigh D, Indahl A. An educational approach based on a noninjury model compared with individual symptom-based physical training in chronic LBP. A pragmatic, randomised trial with a one-year follow-up. BMC Musculoskeletal Disorders 2010;11:212.


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Staal 2004 {published data only} Staal JB. Graded activity for low back pain in occupational health care: a randomized, controlled trial. Annals of Internal Medicine 2004;140(2):77–84. Stapelfeldt 2011 {published data only} Stapelfeldt CM, Christiansen DH, Jensen OK, Nielsen CV, Petersen KD, Jensen C. Subgroup analyses on return to work in sick-listed employees with low back pain in a randomised trial comparing brief and multidisciplinary intervention. BMC Musculoskeletal Disorders 2011;12:112. Steenstra 2006 {published data only} Steenstra IA, Anema JR, Bongers PM, de Vet HC, Knol DL, van Mechelen W. The effectiveness of graded activity for low back pain in occupational healthcare. Occupational and Environmental Medicine 2006;63(11):718–25. Stier 2001 {published data only} Stier R, Gerdes N, Buhrlen B, Haaf HG, Jackel WH. [Reconditioning in groups: an effective programme for the rehabilitation of patients with low back pain?] [German]. Rehabilitation 2001;40(6):321–31.

Trapp 2009 {published data only} Trapp K, Glombiewski JA, Hartwich-Tersek J, Rief W. Chronic back pain: What does biofeedback add to cognitive-behavioral treatment? A randomized controlled trial. Pain Practice 2009;9:114. Tsauo 2009 {published data only} Tsauo J, Chen W, Liang H, Jang Y. The effectiveness of a functional training programme for patients with chronic low back pain -- a pilot study. Disability & Rehabilitation 2009;31(13):1100–6. Turk 1998 {published data only} Turk DC, Okifuji A. Treatment of chronic pain patients: clinical outcomes, cost-effectiveness, and cost-benefits of multidisciplinary pain centers. Critical Reviews in Physical and Rehabilitation Medicine 1998;10(2):181–208. Underwood 2004 {published data only} Underwood M. United Kingdom back pain exercise and manipulation (UK BEAM) randomised trial: cost effectiveness of physical treatments for back pain in primary care. BMJ 2004;329(7479):1381–5.

Storheim 2003 {published data only} Storheim K, Brox JI, Holm I, Koller AK, Bø K. Intensive group training versus cognitive intervention in subacute low back pain: short-term results of a single-blind randomized controlled trial. Journal of Rehabilitation Medicine 2003;35(3):132–40.

van Beurden 2012 {published data only} van Beurden KM, Vermeulen SJ, Anema JR, van der Beek AJ. A participatory return-to-work program for temporary agency workers and unemployed workers sick-listed due to musculoskeletal disorders: a process evaluation alongside a randomized controlled trial. Journal of Occupational Rehabilitation 2012;22(1):217–40.

Storro 2004 {published data only} Storro S, Moen J, Svebak S. Effects on sick-leave of a multidisciplinary rehabilitation programme for chronic low back, neck or shoulder pain: comparison with usual treatment. Journal of Rehabilitation Medicine 2004;36(1): 12–6.

van der Roer 2008 {published data only} van der Roer N, van Tulder M, Barendse J, Knol D, van Mechelen W, De Vet H. Intensive group training protocol versus guideline physiotherapy for patients with chronic low back pain: A randomised controlled trial. European Spine Journal 2008;17(9):1193–200.

Strong 2006 {published data only} Strong LL, Von Korff M, Saunders K, Moore JE. Costeffectiveness of two self-care interventions to reduce disability associated with back pain. Spine 2006;31(15): 1639–45.

van Hoof 2010 {published data only} Van Hooff ML, Van Der Merwe JD, O’Dowd J, Pavlov PW, Spruit M, De Kleuver M, van Limbeek J. Daily functioning and self-management in patients with chronic low back pain after an intensive cognitive behavioral programme for pain management. European Spine Journal 2010;19(9):1517–26.

Sundberg 2009 {published data only} Sundberg T, Petzold M, Wandell P, Ryden A, Falkenberg T. Exploring integrative medicine for back and neck pain - a pragmatic randomised clinical pilot trial. BMC Complementary and Alternative Medicine 2009;9:33. Tlach 2011 {published data only} Tlach L, Hampel P. Long-term effects of a cognitivebehavioral training program for the management of depressive symptoms among patients in orthopedic inpatient rehabilitation of chronic low back pain: A 2-year follow-up. European Spine Journal 2011;20(12):2143–51. Torstensen 1998 {published data only} Torstensen TA, Ljunggren AE, Meen HD, Odland E, Mowinckel P, af Geijerstam S. Efficiency and costs of medical exercise therapy, conventional physiotherapy, and self-exercise in patients with chronic low back pain - A pragmatic, randomized, single-blinded, controlled trial with 1-year follow-up. Spine 1998;23(23):2616–24.

Verbeek 2002 {published data only} Verbeek JH, van der Weide WE, van Dijk FJ. Early occupational health management of patients with back pain: a randomized controlled trial. Spine 2002;27(17):1844–51. Vermeulen 2011 {published data only} Vermeulen SJ, Anema JR, Schellart AJM, Knol DL, van Mechelen W, van der Beek AJ. A participatory returnto-work intervention for temporary agency workers and unemployed workers sick-listed due to musculoskeletal disorders: results of a randomized controlled trial. Journal of Occupational Rehabilitation 2011;21(3):313–24. Verra 2012 {published data only} Verra ML, Angst F, Beck T, Lehmann S, Brioschi R, Schneiter R, Aeschlimann A. Horticultural therapy for patients with chronic musculoskeletal pain: results of a pilot study. Alternative Therapies in Health and Medicine 2011;18 (2):44–50.


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Vibe Fersum 2013 {published data only} Vibe Fersum K, O’Sullivan P, Skouen JS, Smith A, Kvale A. Efficacy of classification-based cognitive functional therapy in patients with non-specific chronic low back pain: A randomized controlled trial. European Journal of Pain 2013; 17(6):916–23.

Artus 2010 Artus M, van der Windt DA, Jordan KP, Hay EM. Low back pain symptoms show a similar patternof improvement following a wide range of primary care treatments: a systematic review of randomized clinical trials. Rheumatology 2010;49:2346–56.

Vlaeyen 1995 {published data only} Vlaeyen JWS, Haazen IWCJ, Schuerman JA, Kole-Snijders AMJ, Van Eek H. Behavioural rehabilitation of chronic low back pain: Comparison of an operant treatment, an operant-cognitive treatment and an operant-respondent treatment. British Journal of Clinical Psychology 1995;34(1): 95–118.

Costa 2009 Costa Lda C, Maher CG, McAuley JH, Hancock MJ, Herbert RD, Refshauge KM, Henschke N. Prognosis for patients with chronic low back pain: inception cohort study. BMJ 2009;339:3829.

Vong 2011 {published data only} Vong SK, Cheing GL, Chan F, So EM, Chan CC. Motivational enhancement therapy in addition to physical therapy improves motivational factors and treatment outcomes in people with low back pain: A randomized controlled trial. Archives of Physical Medicine and Rehabilitation 2011;92(2):176–83. Wagner 2007 {published data only} Wagner E, Ehrenhofer B, Lackerbauer E, Pawelak U, Siegmeth W. Rehabilitation of non-specific low back pain: Results of a multidisciplinary in-patient program. [German]. Schmerz 2007;21(3):226–33. Wand 2004 {published data only} Wand BM, Bird C, McAuley JH, Dore CJ, MacDowell M, De Souza LH. Early intervention for the management of acute low back pain: A single-blind randomized controlled trial of biopsychosocial education, manual therapy, and exercise. Spine 2004;29(21):2350–6. Wessels 2007 {published data only} Wessels T, Ewert T, Limm H, Rackwitz B, Stucki G. Change factors explaining reductions of “interference” in a multidisciplinary and an exercise prevention program for low back pain. Clinical Journal of Pain 2007;23(7):629–34. Whitfill 2010 {published data only} Whitfill T, Haggard R, Bierner SM, Pransky G, Hassett RG, Gatchel RJ. Early intervention options for acute low back pain patients: a randomized clinical trial with one-year follow-up outcomes. Journal of Occupational Rehabilitation 2010;20(2):256–63. Wilkey 2008 {published data only} Wilkey A, Gregory M, Byfield D, McCarthy PW. A comparison between chiropractic management and pain clinic management for chronic low-back pain in a national health service outpatient clinic. Journal of Alternative and Complementary Medicine 2008;14(5):465–73. Yang 2010 {published data only} Yang EJ, Park WB, Shin HI, Lim JY. The effect of back school integrated with core strengthening in patients with chronic low-back pain. American Journal of Physical Medicine & Rehabilitation 2010;89(9):744–54.

Additional references

Costa 2012 Costa LO, Lin CW, Grossi DB, Mancini MC, Swisher AK, Cook C. Clinical trial registration in physiotherapy journals: recommendations from the International Society of Physiotherapy Journal Editors. Journal of Physiotherapy 2012;58(4):211–3. Cutler 1994 Cutler RB, Fishbain DA, Rosomoff HL, Abdel-Moty E, Khalil TM, Rosomoff RS. Does nonsurgical pain center treatment ofchronic pain return patients to work? A review and meta-analysis of the literature. Spine 1994;19:643–52. Dagenais 2010 Dagenais S, Tricco AC, Haldeman S. Synthesis of recommendations for the assessment and management of low back pain from recent clinical practice guidelines. The Spine Journal 2010;10:514–29. den Hollander 2010 den Hollander M, de Jong JR, Volders S, Goossens ME, Smeets RJ, Vlaeyen JW. Fear reduction in patients with chronic pain: a learning theory perspective. Expert Reviews in Neurotherapy 2010;10(11):1733–45. Dworkin 2005 Dworkin RH, Turk DC, Farrar JT, Haythornthwaite JA, Jensen MP, Katz NP. Core outcome measures for chronic pain clinical trials: IMMPACT recommendations. Pain 2005;113(1-2):9–19. Engers 2008 Engers A, Jellema P, Wensing M, van der Windt DA, Grol R, van Tulder MW. Individual patient education for low back pain. Cochrane Database of Systematic Reviews 2008, Issue 1. [DOI: 10.1002/14651858.CD004057.pub3] Ferreira 2010 Ferreira ML, Smeets RJ, Kamper SJ, Ferreira PH, Machado LA. Can we explain heterogeneity among randomized clinical trials of exercise for chronic back pain? A metaregression analysis of randomized controlled trials. Physical Therapy 2010;90(10):1383–403. Ferreira 2012 Ferreira ML, Herbert RD, Ferreira PH, Latimer J, Ostelo RW, Nascimento DP, Smeets RJ. A critical review of methods used to determine the smallest worthwhile effect of interventions for low back pain. Journal of Clinical Epidemiology 2012;65(3):253–61.


45

Flor 1992 Flor H, Fydrich T, Turk DC. Efficacy of multidisciplinary pain treatment centers: A meta-analytic review. Pain 1992; 48:221–30. Foster 2011 Foster NE. Barriers and progress in the treatment of low back pain. BMC Medicine 2011;9:108. Foster 2013 Foster NE, Hill JC, O’Sullivan P, Hancock M. Stratified models of care. Best Practice & Research. Clinical Rheumatology 2013;27(5):649–61. Furlan 2009 Furlan AD, Pennick V, Bombardier C, van Tulder MW. Updated method guidelines for systematic reviews in the Cochrane Back Review Group. Spine 2009;34(18): 1929–41. Guyatt 2011 Guyatt GH, Oxman AD, Kunz R, Brozeka J, Alonso-Coello P, Rind D, et al.GRADE guidelines 6. Rating the quality of evidencedimprecision. Journal of Clinical Epidemiology 2011;64:1283–93.

(STarT Back): a randomised controlled trial. Lancet 2011; 378(9802):1560–71. Kamper 2010 Kamper SJ, Maher CG, Hancock MJ, Koes BW, Croft P, Hay EM. Treatment-based subgroups of low back pain: a guide to appraisal of research studies and a summary of current evidence. Best Practice & Research. Clinical Rheumatology 2010;24:181–91. Karjalainen 2003 Karjalainen KA, Malmivaara A, van Tulder MW, Roine R, Jauhiainen M, Hurri H, Koes BW. Multidisciplinary biopsychosocial rehabilitation for subacute low-back pain among working age adults. Cochrane Database of Systematic Reviews 2003, Issue 2. [DOI: 10.1002/ 14651858.CD002193] Koes 2010 Koes BW, van Tulder MW, Lin CWC, Macedo LG, McAuley JH, Maher CG. An updated overview of clinical guidelines for the managementof non-specific low back pain in primary care. European Spine Journal 2010;19:2075–94.

Hancock 2009 Hancock M, Herbert RD, Maher CG. A guide to interpretation of studies investigating subgroups of responders to physical therapy interventions. Physical Therapy 2009;89(7):698–704.

Lambeek 2011 Lambeek LC, van Tulder MW, Swinkels ICS, Koppes LLJ, Anema JR, van Mechelen W. The trend in total cost of back pain in the Netherlands in the period 2002 to 2007. Spine 2011;36(13):1050–8.

Hayden 2005 Hayden JA, van Tulder MW, Tomlinson G. Systematic review: Strategies for using exercise therapy to improve outcomes in chronic low back pain. Annals of Internal Medicine 2005;142:776–85.

Linton 2011 Linton SJ, Shaw WS. Impact of psychological factors in the experience of pain. Physical Therapy 2011;91(5):700–11.

Henschke 2008 Henschke N, Maher CG, Refshauge KM, Herbert RD, Cumming RG, Bleasel J, et al.Prognosis in patients with recent onset low back pain in Australian primary care: inception cohort study. BMJ 2008;337:171. Henschke 2011 Henschke N, Ostelo RWJG, van Tulder MW, Vlaeyen JWS, Morley S, Assendelft WJJ, Main CJ. Behavioural treatment for chronic low-back pain. Cochrane Database of Systematic Reviews 2010, Issue 7. [DOI: 10.1002/ 14651858.CD002014.pub3] Heymans 2010 Heymans MW, van Tulder MW, Esmail R, Bombardier C, Koes BW. Back schools for acute and subacute non-specific low-back pain. Cochrane Database of Systematic Reviews 2010, Issue 1. [DOI: 10.1002/14651858.CD008325] Higgins 2011 Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions. Version 5.1.0 Updated March 2011; Vol. The Cochrane Collaboration. Hill 2011 Hill JC, Whitehurst DG, Lewis M, Bryan S, Dunn KM, Foster NE, et al.Comparison of stratified primary care management for low back pain with current best practice

Machado 2009 Machado LA, Kamper SJ, Herbert RD, Maher CG, McAuley JH. Analgesic effects of treatments for nonspecific low back pain: a meta-analysis of placebo-controlled randomized trials. Rheumatology 2009;48(5):520–7. Maetzal 2002 Maetzel A, Li L. The economic burden of low back pain:A review of studies published between 1996 and 2001. Best Practice & Research. Clinical Rheumatology 2002;16(1): 23–30. Mansell 2013 Mansell G, Kamper SJ, Kent P. Why and how back pain interventions work: What can we do to find out?. Best Practice & Research. Clinical Rheumatology 2013;27(5): 685–97. Nicholas 2011 Nicholas MK, Linton SJ, Watson PJ, Main CJ. Early identification and management of psychological risk factors (“yellow flags”) in patients with low back pain: a reappraisal. Physical Therapy 2011;91(5):737–53. Norlund 2009 Norlund A, Ropponen A, Alexanderson K. Multidisciplinary interventions: Review of studies of return to work after rehabilitation for low back pain. Journal of Rehabilitation Medicine 2009;41(3):115–21.


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Ravenek 2010 Ravenek MJ, Hughes ID, Ivanovich N, Tyrer K, Desrochers C, Klinger L, Shaw L. A systematic review of multidisciplinaryoutcomes in the management of chronic lowback pain. Work 2010;35:349–67. Rose 1997 Rose MJ, Reilly JP, Pennie B, Bowen-Jones K, Stanley IM, Slade PD. Chronic low back pain rehabilitation programs: a study of the optimum duration of treatment and a comparison of group and individual therapy. Spine 1997; 22:2246–53. Rubinstein 2011 Rubinstein SM, van Middelkoop M, Assendelft WJ, de Boer MR, van Tulder MW. Spinal manipulative therapy for chronic low-back pain. Cochrane Database of Systematic Reviews 2011, Issue 2. [DOI: 10.1002/ 14651858.CD008112.pub2]

van Geen 2007 van Geen JW, Edelaar, MJ Janssen M, van Eijk JT. The long-term effect of multidisciplinary back training: A systematic review. Spine 2007;32(2):249–55. van Hooff 2014 van Hooff ML, Spruit M, O’Dowd JK, van Lankveld W, Fairbank JCT, van Limbeek J. Predictive factors for successful clinical outcome 1 year after an intensive combined physical and psychologicalprogramme for chronic low back pain. European Spine Journal 2014;23:102–12. Verkerk 2013 Verkerk K, Luijsterburg PAJ, Heymans MW, Ronchetti I, Pool-Goudzwaard AL, Miedema HS, Koes BW. Prognosis and Course of Disability in Patients With Chronic Nonspecific Low Back Pain: A 5- and 12-Month Follow-up Cohort Study. Physical Therapy 2013;93(12):1603–14. Vos 2012 Vos T, Flaxman AD, Naghavi M, Lozano R, Michaud C, Ezzat M. Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012;380:2163–96.

Schaafsma 2013 Schaafsma FG, Whelan K, van der Beek AJ, van der EsLambeek LC, Ojajärvi A, Verbeek JH. Physical conditioning as part of a return to work strategy to reduce sickness absence for workers with back pain. Cochrane Database of Systematic Reviews 2013, Issue 8. [DOI: 10.1002/ 14651858.CD001822.pub3]

Waddell 2004 Waddell G. The Back Pain Revolution. 2nd Edition. Vol. 1, London: Churchill Livingston, 2004.

Smeets 2006 Smeets RJEM, Vlaeyen JWS, Kester ADM, Knottnerus JA. Reduction of pain catastrophizing mediates the outcome of both physical and cognitive-behavioral treatment in chronic low back pain. The Journal of Pain 2006;7(4):261–71.

Waterschoot 2014 Waterschoot FPC, Dijkstra PU, Hollak NJ, de Vries HJ, Geertzen JHB, Reneman M. Dose or content? Effectiveness of pain rehabilitation programs forpatients with chronic low back pain: A systematic review. Pain 2014;155:179–89.

Smeets 2009 Smeets RJ, Severens JL, Beelen S, Vlaeyen JW, Knottnerus JA. More is not always better: cost-effectiveness analysis of combined, single behavioral and single physical rehabilitation programs for chronic low back pain. European Journal of Pain 2009;13(1):71–81. van de Hulst 2005 van der Hulst M, Vollenbroek-Hutten MMR, IJzerman MJ. A systematic review of sociodemographic, physical, and psychological predictors of multidisciplinary rehabilitationor, back school treatment outcome in patients with chronic low back pain. Spine 2005;30(7):813–25.

Williamson 2012 Williamson PR, Altman DG, Blazeby JM, Clarke M, Devane D, Gargon E, Tugwell P. Developing core outcome sets for clinical trials: issues to consider. Trials 2012;13:132.

References to other published versions of this review Guzman 2006 Guzman J, Esmail R, Karjalainen KA, Malmivaara A, Irvin E, Bombardier C. Multidisciplinary bio-psycho-social rehabilitation for chronic low-back pain. Cochrane Database of Systematic Reviews 2006, Issue 2. [DOI: 10.1002/ 14651858.CD000963.pub2] ∗ Indicates the major publication for the study


47

CHARACTERISTICS OF STUDIES

Characteristics of included studies [ordered by study ID] Abbassi 2012 Methods

RCT conducted in Iran

Participants

Patients referred to a pain clinic at a university medical centre with LBP >6 months, age 18-70, married. 33 patients randomised, 88% female, average age 45 years, median duration of pain 74 months

Interventions

MBR (P-MPMP): Group Rx (6/group) 7x weekly sessions 2 hours each session, + 1 session with doctor, + 1 session with physiotherapist. Light mobilisation, coping skills training, education regarding anatomy, physiology, medication, exercise session Usual (SMC): standard medical care, pain medication MBR-2 (SA-MPMP): As per P-MPMP with involvement of spouse

Outcomes

Pain (VAS), disability (RMDQ), catastrophising (PCS), fear avoidance (TSK) Follow-ups: ST (7 weeks), LT (12 months)

Notes

Subgroup analyses: Low intensity intervention, Low baseline symptom intensity ( 6 months, age 30-47, less than 2 back surgeries, no contraindications to exercise. 293 patients randomised, 56% female, average age 40.5 years, mean duration of pain not reported

Interventions

MBR (Akseli): 3 weeks daily HEP then 3 weeks inpatient program (42 hours per week) . Program: strength training, aerobic training, relaxation, stretching, CBT, discussion groups Physical (control): 3 weeks inpatient program: passive physiotherapy (electrotherapies, massage, traction), muscle training, pool exercises, back school

Outcomes

Disability (Million Pain Disability questionnaire), Work (WHO occupational handicap scale, sick leave days), Utilisation (reduction in physician visits, reduction in physiotherapist visits) Follow-ups: ST (3 months), LT (12 months)

Notes

Subgroup analyses: High intensity intervention, Low baseline symptom intensity (30%, degenerative disc changes. 173 patients randomised, 50.8% female, average age 41 years, mean duration of pain 81 months

Interventions

MBR (Rehabilitation): Outpatient treatment in groups, 60 hours over 2 to 5 weeks. Education (anatomy, psychology, imaging, coping, medication, family, work and social life), daily exercises (endurance, strength, coordination), challenging beliefs Surgery (Surgery): Disc replacement with artificial disc (ProDisc)

Outcomes

Pain (SF-36 bodily pain), Disability (ODI), General Health (SF-36 and EQ5D), Work (% return to work), Satisfaction (% satisfied with outcome), Fear Avoidance (FABQ), Self-Efficacy Follow-ups: ST (6 weeks and 3 months), MT (6 months), LT (1 and 2 years)

Notes

Subgroup analyses: Mid intensity intervention, Low baseline symptom intensity (6 weeks. 109 patients randomised, 32% female, average age 39.8 yers, mean duration of pain not reported

Interventions

MBR (Multidisciplinary Rehabilitation): 3 weeks with sessions 5 days/week, 5-7 hours/ day, in groups (n=5) and individual. Intensive physical and ergonomic training, psychological pain management, back school, social and work-related education, tailored medication programme Physical (Control): 18 physiotherapy sessions (45min) over 9 weeks. Active exercise and passive modalities to manage pain, improve mobility and increase activity level

Outcomes

Disability (ODI), Work (% working) Follow-ups: LT (3 weeks), MT (6 weeks), LT (1 year)

Notes

Subgroup analyses: High intensity intervention, Low baseline symptom intensity (3 months with RMDQ score >3 and Tampa Scale for Kinesiophobia score >33. 85 patients randomised, 48% female, average age 45 years, mean duration of pain 9 years

Interventions

MBR (EXP): 16x 2 session/week, 1 hours/session. Information re: diagnosis, imaging, continued active approach, treatment rationale. Establishment of heirachy of feared activities, explanation of fear avoidance model, gradual, systematic exposure to feared activities. Behvioural experiments to test consequences of engagement in feared activities MBR-2 (GA): 26x 2 session/week, 1 hoursr/session. Information re: diagnosis, imaging, continued active approach, treatment rationale. Identification of functional treatment goals, quota-based gradual increase in perfomance of functional activities

Outcomes

Pain (McGill), Disability (Quebec), main complaints (Patient specific complaints scale) , harmfulness of activities (PHODA), pain Catastrophizing (PCS), daily activity (acceleromoeter) Follow-ups: LT (12 months)

Notes

Subgroup analyses: Low intensity intervention, Low baseline symptom intensity (3 months, RMDQ score >3, ability to walk at least 100 meters. 212 patients randomised, 41.6% female, average age 47.2 years, mean duration of pain 4.7 years

Interventions

MBR (CT): 10 weeks, active physical training (3 times/week for 1 hour 45 minutes sessions): aerobic training, strengthening, stretching. CBT: operant behavioural graded activity (18 sessions), problem-solving (10 sessions), modification of dysfunctional beliefs, HEP increasing activity Physical (APT, Control 1): 10/52 Rx. Active physical training (3 times/week for 1 hour 45 minutes): aerobic training, strengthening, stretching MBR-2 (CBT, Control 2): operant behavioural graded activity (18 sessions), problemsolving (10 sessions), modification of dysfunctional beliefs, HEP increasing activity Waiting list (control 3)

Outcomes

Pain (VAS), Disability (RMDQ), Main Complaints, Self-Perceived Improvement, Work, Health Care Utilization (number of visits), Depression (BDI), Catastrophising (PCL) Follow-ups: ST (post-treatment), MT (6 months), LT (1 year)

Notes

Subgroup analyses: Mid-intensity intervention, Low baseline symptom intensity (8 weeks due to LBP. 117 patients randomised, 61% female, average age 43.6 years, mean duration of pain 10 years

Interventions

MBR (Multidisciplinary Rehabilitation): 4 weeks, 5 days/week, 6 hours/day. Physical treatment (strengthening, body awareness, aerobic fitness, relaxation), education, CBT (coping, responsibility for Rx, focus away from pain), workplace intervention Usual (Control): usual care in the community, most had physiotherapy, 1/3 have alternative interventions

Outcomes

Work (% return to work) Follow-ups: ST (post-treatment), MT (8 months), LT (1 year)

Notes

Subgroup analyses: High intensity intervention, Low baseline symptom intensity (18 years, LBP >3 months. 102 patients randomised, 100% female, average age 42.9 years, mean duration of pain 9.1 months

Interventions

MBR (Education): 4 days, 5 sessions, based on Back school. Education: anatomy, physiology, pathology of LBP, self-care, health behaviours, biomechanics, lifestyle factors, prevention. Psychologist: coping skills, anger management, relaxation. Physiotherapist: stretching, strengthening, posture, functional movement advice (HEP) Usual (Control): medical management, mostly medication prescription (analgesics, muscle relaxants, NSAIDs, anti-depressants)

Outcomes

Pain (SF-36 bodily pain), General Health (SF-36) Follow-ups: ST (3 months), MT (6 months), LT (12 months)

Notes

Subgroup analyses: Mid-intensity intervention, Low baseline symptom intensity ( 18 years, LBP >3 months. 197 patients randomised, 22% female, average age 45. 3 years, mean duration of pain 6.8 years

Interventions

MBR (Education): 5 sessions of 2 hours in one week, plus monthly booster sessions and monthly telephone counselling, group setting. Education (anatomy, risk factors, lifestyle advice, posture, diagnosis, pain education). Streching, strengthening, relaxation exercises (HEP). Psychologist: coping, stress, perceptions of stress and control, emotional reactions, problem solving, relaxation. CBT: maladaptive cognitions, fear avoidance, activity participation, adjustment to pain. Motivational counselling. Medications prescribe as needed (analgesics, muscle relaxants, NSAIDs, anti-depressants) Usual (Control): Medical management, mostly medication prescription (analgesics, muscle relaxants, NSAIDs, anti-depressants)

Outcomes

Pain (SF-36 bodily pain), Disability (RMDQ), General Health (SF-36) Follow-ups: ST (3 months), MT (6 months)

Notes

Subgroup analyses: Mid-intensity intervention, Low baseline symptom intensity ( 20-65 years, LBP >6 months. 96 patients randomised, 49% female, average age 44 years, mean duration of pain 12.9 years

Interventions

MBR (Behav/Exerc): 8 sessions, 1x/ week for 2 hours, in groups of 5-10. Behavioral: Education about pain behaviours (with spouse), communication training, goal-setting for behavioural activities, group discussions, homework. Exercise (10-20min 5x /week HEP): gradually progressed walking/jogging on a quota system, warm-up and cool-down stretches Physical (Exercise): 8 sessions, 1x/ week for 2 hours, in groups of 5-10. Exercise (1020min 5x /week HEP): gradually progressed walking/jogging on a quota system, warmup and cool-down stretches Waiting list (Control)


94

Turner 1990

(Continued)

Outcomes

Pain (McGill), Disability (Sickness Impact Profile), Depression (CES-D) Follow-ups: ST (2 months), MT (6 months) ST (12 months)

Notes

Subgroup analyses: Low intensity intervention, Low baseline symptom intensity (20% at post-treatment assessment

Intention to treat analysis

High risk

pg.575 Immediate treatment effects. Only compliers analysed

Selective reporting (reporting bias)

Unclear risk

No protocol

Comparability of groups at baseline

Low risk

pg.575 Analysis of pre-treatment differences. Groups comparable on relevant demographic and clinical variables

Compliance

Unclear risk

Not stated

Cointerventions

Unclear risk

Not stated

Timing of assessment

Low risk

pg.574 Outcome measures. A comprehensive set of measures, described below, was administered immediately before and after treatment and 6 and 12 months following treatment”


95

Van den Hout 2003 Methods

RCT conducted in the Netherlands

Participants

Patients with recent work absence due to LBP, referred by GP, occupational or rehabilitation physician with age 18-65 years, LBP >6 months, on sick leave for LBP >6 weeks. 84 patients randomised, 33.7% female, average age 40.5 years, mean duration of pain 1.6 years

Interventions

MBR (GAPS): 19 half day sessions over 8 weeks, in groups (n=5). Graded activity: gradual increase in physical activities, including work-specific tasks, as directed by occupational therapist included a work visit, back education and lifting instructions, ADLs, leisure activities, housework. Problem solving: CBT approach to problem solving skills, training and application of skills to daily life, included homework assignments. Group education sessions related to back and back pain MBR-2 (CAGE): 19 half day sessions over 8 weeks, in groups (n=5). Graded activity: gradual increase in physical activities, including work-specific tasks, as directed by occupational therapist included a work visit, back education and lifting instructions, ADLs, leisure activities, houeswork. Group education sessions related to back and back pain

Outcomes

Work (% working). Follow-ups: MT (6 months), LT (1 year)

Notes

Subgroup analyses: Mid intensity intervention, Low baseline symptom intensity (6 months, no surgery in the last 3 months. 163 patients randomised, % female not reported, average age 39 years, mean duration of pain 5 years

Interventions

MBR (RRP): 9 hours/week for 7 weeks in groups of 8 patients. Education: back pain, chronicity, interaction of reduced physical activity and pain. Physical training: aerobic training, swimming, physiotherapy. Occupational therapy Usual (Control): unconstrained, usual care in the Netherlands

Outcomes

Disability (RMDQ), General Health (EQ-5D), Fear Avoidance (TSK) Follow-ups: ST (post-treatment), MT (6 months)

Notes

Subgroup analyses: Mid-intensity intervention, Low baseline symptom intensity (7/23 on RMDQ. 240 patients randomised, 62.5% female, average age 49.8 years, mean duration of pain not reported

Interventions

MBR (Intervention): 4 visits of 90 minutes. Psychologist: identify fears, relationship b/w activity and pain, goal setting, relaxation, managing flare-ups. Physiotherapist: discussed concerns and identify barriers to increasing activity, stretches, exercises to achieve activity goals (HEP). Self-management book Usual (Control): usual care in the community, usually included medication

Outcomes

Pain (NRS), Disability (RMDQ), General Health (SF-36), Work (% able to work), Fear Avoidance (TSK) Follow-ups: ST (2 months), MT (6 months), LT (1 and 2 years)

Notes

Subgroup analyses: Low intensity intervention, Low baseline symptom intensity (60% on pain & disability scales) 2.4 Low baseline symptom intensity (100 hours, daily contact) 2.6 Low intervention intensity (60% on pain & disability scales) 4.4 Low baseline symptom intensity (100 hours, daily contact) 4.6 Low intervention intensity (60% on pain & disability scales) 6.4 Low baseline symptom intensity (100 hours, daily contact) 6.6 Low intervention intensity (60% on pain & disability scales) 8.4 Low baseline symptom intensity (100 hours, daily contact) 8.6 Low intervention intensity (60% on pain & disability scales) 10.4 Low baseline symptom intensity (100 hours, daily contact) 10.6 Low intervention intensity (60% on pain & disability scales) 12.4 Low baseline symptom intensity (100 hours, daily contact) 12.6 Low intervention intensity (60% on pain & disability scales) 14.4 Low baseline symptom intensity (100 hours, daily contact) 14.6 Low intervention volume (60% on pain & disability scales) 16.4 Low baseline symptom intensity (100 hours, daily contact) 16.6 Low intervention volume (60% on pain & disability scales) 18.4 Low baseline symptom intensity (100 hours, daily contact) 18.6 Low intervention volume (60% on pain & disability scales) 2.4 Low baseline symptom intensity (100 hours, daily contact) 2.6 Low intervention intensity 1 (60% on pain & disability scales) 4.4 Low baseline symptom intensity (100 hours, daily contact) 4.6 Low intervention intensity 1 (60% on pain & disability scales) 6.4 Low baseline symptom intensity (100 hours, daily contact) 6.6 Low intervention intensity 1 (60% on pain & disability scales) 8.4 Low baseline symptom intensity (100 hours, daily contact) 8.6 Low intervention intensity 1 (60% on pain & disability scales)

9 9

872

Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI)

-0.51 [-1.04, 0.01] Subtotals only

5

655

Std. Mean Difference (IV, Random, 95% CI)

-0.66 [-1.50, 0.17]

6

675


-0.65 [-1.41, 0.10]

1

90


-3.41 [-4.07, -2.76]

8

782


-0.15 [-0.37, 0.06]

5

628


-0.23 [-0.45, -0.01]

3

140


-1.25 [-3.64, 1.13]

13 13

1878

Std. Mean Difference (IV, Random, 95% CI) Std. Mean Difference (IV, Random, 95% CI)

-0.39 [-0.68, -0.10] Subtotals only

5

691


-0.56 [-1.27, 0.15]

10

1244


-0.43 [-0.84, -0.02]

2

453


-1.25 [-4.18, 1.69]

11

1425


-0.23 [-0.36, -0.11]

7

1552


-0.16 [-0.38, 0.06]

5

219


-0.87 [-1.93, 0.19]

9

511


-0.21 [-0.48, 0.06]


Subtotals only

9

2

219


0.11 [-0.15, 0.38]

6

359


-0.35 [-0.75, 0.05]

0

0


0.0 [0.0, 0.0]


112

10.4 Low baseline symptom intensity (100 hours, daily contact) 10.6 Low intervention intensity 1 (60% on pain & disability scale) 12.4 Low baseline symptom intensity (100 hours, daily contact) 12.6 Low intervention intensity 1 (60% on pain & disability scales) 14.4 Low baseline symptom intensity (100 hours, daily contact) 14.6 Low intervention volume (60% on pain & disability scales) 16.4 Low baseline symptom intensity (100 hours, daily contact) 16.6 Low intervention volume (60% on pain & disability scales) 18.4 Low baseline symptom intensity (100 hours, daily contact) 18.6 Low intervention volume (

Biopsychosocial analysis of low back pain.

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Dose or content? Effectiveness of pain rehabilitation programs for patients with chronic low back pain: A systematic review. Aurthor reply.

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Chronic low back pain patient and spouse.

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