Low back pain (LBP) is a widespread condition characterised by pain, muscle tension, or stiffness in the lower back, with or without radiating leg pain. When LBP persists beyond twelve weeks, it is classified as chronic, leading to significant challenges in daily functioning. Chronic LBP can reduce mobility, decrease quality of life, and cause financial strain due to medical expenses and loss of productivity.

Psychological factors play an essential role in the experience of chronic LBP. Conditions such as depression, anxiety, and social stress contribute to heightened pain perception and increased disability. Fear avoidance beliefs, in particular, mediate the relationship between pain and functional impairment. Individuals with strong fear avoidance beliefs tend to limit their activities, leading to deconditioning and further disability. These psychological influences not only impact health-related quality of life but also drive higher healthcare utilisation rates. Psychological factors can influence a person’s ability to cope with pain, the likelihood of seeking treatment, and their adherence to medical recommendations. This makes it crucial for healthcare providers to integrate psychological considerations into treatment plans for chronic LBP patients.

Psychological Interventions for Chronic LBP

Psychological interventions aim to alleviate pain-related distress by reshaping negative beliefs, behaviours, and coping strategies. Cognitive behavioural therapy (CBT) and behavioural therapies have been the most studied approaches, though newer modalities like cognitive functional therapy and acceptance and commitment therapy are gaining attention. Psychological interventions focus on modifying maladaptive thoughts about pain, promoting active coping strategies, and improving emotional regulation. These therapies are often delivered in structured sessions, either individually or in groups, and can be implemented through face-to-face consultations, digital platforms, or self-help materials.

Despite the growing recognition of psychological interventions, there remains a knowledge gap in understanding their comparative effectiveness and long-term impact. Systematic reviews have primarily focused on CBT and behavioural therapy, leaving other promising interventions underexplored. Additionally, there is a lack of standardised protocols for delivering these interventions, making it difficult to compare their effectiveness across different patient populations. Further research is required to assess the impact of psychological interventions in diverse settings and to determine the optimal duration and intensity of treatment.

Clinical Guidelines and the Need for Specificity

Current clinical guidelines broadly recommend psychological treatments for chronic LBP but often lack specificity regarding the effectiveness of different interventions. CBT remains the most widely endorsed approach, yet other psychological modalities have demonstrated significant benefits. Furthermore, there is limited evidence on the durability of psychological treatment outcomes over time. Addressing these gaps is essential for optimising treatment recommendations. Clinicians require detailed, evidence-based guidance on selecting the most appropriate psychological interventions based on individual patient characteristics, symptom severity, and comorbid conditions.

Role of Network Meta-Analysis

To address the need for comparative effectiveness research, a systematic review utilising a Network Meta-Analysis (NMA) approach was conducted. This method allows for the simultaneous evaluation and ranking of multiple psychological interventions within a single treatment network. The primary outcomes assessed included improvements in physical function, pain intensity, fear avoidance beliefs, health-related quality of life, and intervention compliance. NMA offers a comprehensive approach by integrating direct and indirect comparisons of treatment effects, providing clinicians with valuable insights into the relative efficacy of different psychological interventions.

Effectiveness of Combined Treatment

Findings suggest that physiotherapy alone is less effective than when combined with psychological interventions. Among the various approaches, CBT integrated with physiotherapy demonstrated the greatest short-term improvements in physical function. However, these effects tended to diminish over time. Pain education, when combined with physiotherapy, provided moderate yet more sustainable benefits. The combination of psychological interventions with physiotherapy enhances patient engagement, encourages adherence to treatment, and addresses both physical and psychological components of chronic LBP.

For pain intensity reduction, behavioural therapy with physiotherapy showed the most significant post-intervention effects, with benefits lasting into the mid-term. Additionally, CBT with physiotherapy was the most effective approach for reducing fear avoidance beliefs, with improvements sustained through long-term follow-up. Among individuals without leg pain, pain education alone or in combination with physiotherapy was the most effective for short-term fear avoidance reduction.

Intervention compliance was also enhanced when psychological interventions were integrated with physiotherapy care, suggesting a synergistic effect that fosters engagement and adherence. Patients who receive psychological support alongside physiotherapy may be more likely to complete their treatment plans and sustain the benefits of therapy over time.

Sustainability and Longevity of Treatment Effects

Despite the initial benefits of psychological interventions, their effectiveness tends to diminish over time, typically beyond twelve months post-intervention. However, pain education programs demonstrated the most sustainable improvements in physical function and fear avoidance, while behavioural therapy yielded the longest-lasting reductions in pain intensity. To improve long-term outcomes, larger sample sizes and extended follow-up studies are necessary. Future research should also explore ways to reinforce the benefits of psychological interventions, such as incorporating booster sessions, digital tools, or self-management resources.

Safety and Clinical Recommendations

Psychological interventions appear to be safe for individuals with chronic, non-specific LBP. To maximise treatment efficacy, clinicians should integrate psychological interventions with physiotherapy, particularly structured exercise programs. Early screening for psychological factors can also help adapt interventions to individual patient needs, improving overall treatment outcomes. Identifying patients at risk of developing chronic pain-related disability through psychological assessment tools can allow for earlier and more targeted interventions.

Strengths and Limitations

One of the major strengths of this review was its use of NMA to compare a diverse range of psychological interventions. It employed a rigorous classification method to distinguish psychological interventions, ensuring more precise outcome evaluations. The review also prioritised clinically relevant measures, including physical function, pain intensity, and fear avoidance.

However, limitations must be acknowledged. Categorising psychological interventions broadly may introduce heterogeneity, affecting the interpretation of results. Additionally, inconsistencies in reporting safety data and long-term effects limit the reliability of conclusions regarding intervention durability. Some modalities, such as hypnosis, were underrepresented in the analysis. Furthermore, poor reporting of socioeconomic factors and comorbidities poses challenges in generalising findings across diverse patient populations. Finally, the inherent difficulty in blinding psychological intervention trials may introduce bias.

Comparison with Previous Reviews

Prior systematic and Cochrane reviews have investigated behavioural interventions for LBP but lacked the analytical rigor of an NMA approach. Earlier reviews often grouped different psychological interventions together, making it difficult to assess their individual effectiveness. The review improves upon past research by differentiating between behavioural therapy, CBT, and other psychological approaches, providing more nuanced insights into their comparative benefits.

Implications for Clinical Practice

The management of chronic LBP requires a multimodal approach that integrates biopsychosocial factors. The review highlights the varying effectiveness of psychological interventions depending on their application, whether as standalone treatments or in combination with physiotherapy. Clinicians should modify treatment decisions based on the patient’s primary complaints, concurrent symptoms, and long-term rehabilitation goals.

Barriers to Implementation

Despite the demonstrated benefits of psychological and exercise-based therapies for LBP, they remain underutilised. Key barriers include low referral rates by general practitioners, lack of coordination among healthcare providers, and fragmented healthcare systems that hinder integrated care delivery. Addressing these challenges requires interdisciplinary collaboration to facilitate the co-delivery of psychological and physiotherapy interventions. Additionally, clinician barriers such as inadequate training, time constraints, and reimbursement concerns must be tackled to improve patient access.

Future Research 

Further research is needed to enhance the evidence base for psychological interventions in LBP management. Specifically, high-quality trials on behavioural therapy, mindfulness-based interventions, and counselling approaches should be prioritised. Studies assessing long-term treatment effects beyond twelve months are also essential. Improved consistency in measuring health-related quality of life and safety outcomes will provide more reliable data for clinical decision-making. Additionally, standardised guidelines for reporting adverse events in psychological interventions should be developed. Lastly, exploring the underlying mechanisms by which psychological interventions enhance outcomes for chronic LBP patients could lead to more targeted and effective treatments.

Reference

Ho, E., Ferreira, M., Chen, L., Simic, M., Ashton-James, C., Comachio, J., Hayden, J., & Ferreira, P. (2020). Psychological interventions for chronic non-specific low back pain: protocol of a systematic review with network meta-analysis. BMJ Open, 10(9), e034996. https://doi.org/10.1136/bmjopen-2019-034996