Physiotherapist-delivered cognitive-behavioural interventions are effective for low back pain, but can they be replicated in clinical practice? A systematic review

Abstract

With additional training, physiotherapists can deliver effective CB interventions. However, without training or resources, successful translation and implementation remains unlikely. Researchers should improve reporting of procedural information, provide relevant materials, and offer accessible provider training. Implications for Rehabilitation Previous reviews have established that traditional biomedical-based treatments (e.g., acupuncture, manual therapy, massage, and specific exercise programmes) that focus only on physical symptoms do provide short-term benefits but the sustained effect is questionable. A cognitive-behavioural (CB) approach includes techniques to target both physical and psychosocial symptoms related to pain and provides patients with long-lasting skills to manage these symptoms on their own. This combined method has been used in a variety of settings delivered by different health care professionals and has been shown to produce long-term effects on patient outcomes. What has been unclear is if these programmes are effective when delivered by physiotherapists in routine physiotherapy settings. Our study synthesises the evidence for this context. We have confirmed with high-quality evidence that with additional training, physiotherapists can deliver CB interventions that are effective for patients with back pain. Physiotherapists who are considering enhancing their treatment for patients with low back pain should consider undertaking some additional training in how to incorporate CB techniques into their practice to optimise treatment benefits and help patients receive long-lasting treatment effects. Importantly, our results indicate that using a CB approach, including a variety of CB techniques that could be easily adopted in a physical therapy setting, provides greater benefits for patient outcomes compared to brief education, exercise or physical techniques (such as manual therapy) alone. This provides further support that a combined treatment approach is likely better than one based on physical techniques alone. Notably, we identified a significant barrier to adopting any of these CB interventions in practice. This is because no study provided a description of the intervention or accessible training materials that would allow for accurate replication. Without access to provider training and/or resources, we cannot expect this evidence to be implemented in practice with optimal effects. Thus, we would urge physiotherapists to directly contact authors of the studies for more information on how to incorporate their interventions into their settings.

Effectiveness of Primary Care Interventions Using a Biopsychosocial Approach in Chronic Low Back Pain: A Systematic Review

“…It is important to select therapists based on their BPS skills or to adequately educate and support them in providing BPS elements. The essential role of sufficient training and resources (eg, treatment protocols and support) in complex behavioral interventions can be confirmed by the current literature . Both studies suggest that if physiotherapists receive appropriate training and resources, and possess sufficient competencies, physiotherapists will be able to effectively provide a cognitive‐behavioral intervention.…”

“…Compared with physical treatments, Kamper et al found low‐quality evidence for greater effectiveness of behavioral treatments, and Henschke et al moderate‐quality evidence. Hall et al even reported high‐quality evidence for greater effectiveness of BPS interventions compared with exercise interventions. Our systematic review did not detect a difference between a BPS intervention and physical activity therapy.…”

“…The essential role of sufficient training and resources (eg, treatment protocols and support) in complex behavioral interventions can be confirmed by the current literature. 9,36 Both studies suggest that if physiotherapists receive appropriate training and resources, and possess sufficient competencies, physiotherapists will be able to effectively provide a cognitive-behavioral intervention. Trained physiotherapists might furthermore be able to identify patients with LBP at risk for developing chronic complaints and treat them at an early stage without the need of referral.…”

“…A BPS intervention is not regularly implemented by physiotherapists in primary care, however, and the evidence for BPS interventions for patients with CLBP is lacking. Few systematic reviews have investigated the evidence from existing BPS primary care interventions but focused instead only on BPS interventions in patients with LBP in general (ie, acute, subacute, and chronic) or (sub)acute LBP specifically . No systematic review has been performed in patients with CLBP until now.…”

Physical therapists’ experiences of learning and delivering a complex behavioral medicine intervention to adolescents with pain

“…Combining PT and cognitive behavioral therapy improves functioning in children experiencing pain (Ayling Campos, Amaria, Campbell, and McGrath, 2011;Lee et al, 2002;Sherry et al, 1999). Physical therapist delivered cognitive-behavioral interventions are more effective than other guideline based treatments (Hall et al, 2018).…”