Comparative effectiveness of nonpharmacological interventions in reducing psychological symptoms among patients with chronic low back pain

Abstract

Objectives: Chronic low back pain (CLBP) can seriously impair the quality of life of patients and has a remarkable comorbidity with psychological symptoms, which, in turn, can further exacerbate the symptoms of CLBP. Psychological treatments are critical and nonnegligent for the management of CLBP, and thus, should attract sufficient attention. However, current evidence does not suggest the superiority and effectiveness of nonpharmacological interventions in reducing psychological symptoms among patients with CLBP.Thus, this study was designed to compare the effectiveness of nonpharmacological interventions for depression, anxiety, and mental health among patients with CLBP and to recommend preferred strategies for attenuating psychological symptoms in clinical practice.

Methods: In this systematic review and network meta-analysis (NMA), PubMed, Embase Database, Web of Science, and Cochrane Library were searched from database inception until March 2022. Randomized clinical trials (RCTs) that compare different nonpharmacological interventions for depression, anxiety, and mental health among patients with CLBP were eligible. The Preferred Reporting Items for Systematic Reviews and Meta-analyses statement was used. Four reviewers in pairs and divided into two groups independently performed literature selection, data extraction, and risk of bias, and certainty of evidence assessments. This NMA was conducted with a random effects model under a frequentist framework. The major outcomes were depression, anxiety, and mental health presented as the standardized mean difference (SMD) with the corresponding 95% CI.

Results: A total of 66 RCTs that randomized 4806 patients with CLBP met the inclusion criteria. The quality of evidence was typically low or some risks of bias (47 out of 66 trials, 71.3%), and the precision of summary estimates for effectiveness varied substantially. In addition, 7 categories of interventions with 26 specific treatments were evaluated. For depression, mind body therapy (pooled SMD = -1.20, 95% CI: -1.63 to -0.78), biopsychosocial approach (pooled SMD = -0.41, 95% CI: -0.70 to -0.12), and physical therapy (pooled SMD = -0.26, 95% CI: -0.50 to -0.02) exhibited remarkable effectiveness in reducing depression compared with the control group. For managing anxiety, mind body therapy (pooled SMD = -1.35, 95% CI: -1.90 to -0.80), multicomponent intervention (pooled SMD = -0.47, 95% CI: -0.88 to -0.06), and a biopsychosocial approach (pooled SMD = -0.46, 95% CI: -0.79 to -0.14) were substantially superior to the control group. For improving mental health, multicomponent intervention (pooled SMD = 0.77, 95% CI: 0.14 to 1.39), exercise (pooled SMD = 0.60, 95% CI: 0.08 to 1.11), and physical therapy (pooled SMD = 0.47, 95% CI: 0.02-0.92) demonstrated statistically substantial effectiveness compared with the control group. The rank probability indicated that mind body therapy achieved the highest effectiveness in reducing depression and anxiety among patients with CLBP. Besides, the combined results should be interpreted cautiously based on the results of analyses evaluating the inconsistency and certainty of the evidence.

Conclusion: This systemic review and NMA suggested that nonpharmacological interventions show promise for reducing psychological symptoms among patients with CLBP. In particular, mind body therapy and a biopsychosocial approach show considerable promise, and mind body therapy can be considered a priority choice in reducing depression and anxiety. These findings can aid clinicians in assessing the potential risks and benefits of available treatments for CLBP comorbidity with psychological symptoms and provide evidence for selecting interventions in clinical practice. More RCTs involving different interventions with rigorous methodology and an adequate sample size should be conducted in future research.

Figure 1

PRISMA-NMA flow diagram for literature search and selection.

Figure 2

Summary results on risk of bias (using RoB 2) of including RCTs.

Figure 3

Network plot of comparisons in the network meta-analysis of different categories of interventions for depression. Nodes’ sizes and line widths represent the number of randomized patients and controlled trials for each treatment, respectively. The size of the node corresponds to the number of patients randomized to each treatment, whereas the line width indicates the number of randomized controlled trials comparing each pair of treatments. BA, biopsychosocial approach; CO, control; EX, exercise; EDU, education; MBT, mind body therapy; MUI, multicomponent intervention; PT, physical therapy; TM, telemedicine. Interventions details are described in Appendix 3 (Supplemental Digital Content 5, http://links.lww.com/JS9/B123).

Figure 4

Network plot of comparisons in the network meta-analysis of different categories of interventions for anxiety. Nodes’ sizes and line widths represent the number of randomized patients and controlled trials for each treatment, respectively. The size of the node corresponds to the number of patients randomized to each treatment, whereas the line width indicates the number of randomized controlled trials comparing each pair of treatments. BA, biopsychosocial approach; CO, control; EX, exercise; EDU, education; MBT, mind body therapy; MUI, multicomponent intervention; PT, physical therapy; TM, telemedicine. Interventions details are described in Appendix 3 (Supplemental Digital Content 5, http://links.lww.com/JS9/B123).

Figure 5

Network plot of comparisons in the network meta-analysis of different categories of interventions for mental health. Nodes’ sizes and line widths represent the number of randomized patients and controlled trials for each treatment, respectively. The size of the node corresponds to the number of patients randomized to each treatment, whereas the line width indicates the number of randomized controlled trials comparing each pair of treatments. BA, biopsychosocial approach; CO, control; EX, exercise; EDU, education; MBT, mind body therapy; MUI, multicomponent intervention; PT, physical therapy; TM, telemedicine. Interventions details are described in Appendix 3 (Supplemental Digital Content 5, http://links.lww.com/JS9/B123).