Targeted interventions for Yellow Flags in persistent low back pain: a systematic review

Target man

Seeing as it is World Mental Health Day today, with its theme “Depression: a Global Crisis”, I thought that it would be appropriate to blog on psychosocial rather than physical interventions; particularly as persistent non-specific low back pain (NSLBP) can result in heightened anxiety, stress and depression. Furthermore, there is an increasing body of evidence that psychosocial risk factors can be more significant obstacles to recovery and return to work than biomedical ones.

Therefore, healthcare professionals, increasingly, are having to widen their skill base to include psychosocial interventions, such as, cognitive behavioural therapy and various forms of physical activity conducted in ways designed to reduce fear of movement and ‘re-injury’. However, it has yet to be determined if the efficacy of interventions for psychosocial risk factors of persistent NSLBP is improved when targeted to people with particular psychosocial characteristics. This is where I thought that a systematic review that I uncovered by Kent and Kjaer (2012) could enlighten me.

Here’s what they did

The authors searched the following databases from inception until June 2011: MEDLINE, EMBASE, CINAHL, MANTIS (Manual Alternative and Natural Therapy Index System), AMED, The Cochrane Central Register of Controlled Trials and PEDro.

Inclusion criteria were randomised controlled trials of targeted psychosocial interventions that used trial designs capable of providing robust information on the efficacy of targeted treatment for the outcomes of pain, activity limitation and psychosocial factors in individuals experiencing NSLBP.

Any treatment was eligible as a ‘psychosocial’ intervention if it was explicitly was designed to address a LBP ‘yellow flag’, such as fear avoidance beliefs, anxiety, depression or catastrophisation. An assessment of method quality was performed according to the method quality criteria recommended by the Cochrane Back Review Group.

Here’s what they found

The review identified four studies that investigated the treatment effects of targeted psychosocial interventions for people with NSLBP. The psychosocial interventions were carried out by physiotherapists or general practitioners (GPs) who had been trained in their delivery. 

Target practise

“The results demonstrated that there is limited evidence that the targeting of psychosocial interventions to high-risk groups is useful, either as a stand-alone treatment or in combination therapy.”

There were only two statistically significant results. 1. Graded activity plus Treatment Based Classification targeted to people with high movement-related fear was more effective than Treatment Based Classification at reducing movement-related fear at 4 weeks. 2. Active rehabilitation (physical exercise classes with cognitive-behavioural principles) was more effective than usual GP care at reducing activity limitation at 12 months, when targeted to people with higher movement-related pain.

Although there were two statistically significant results and some statistical trends, overall these studies provide limited evidence that targeting such psychosocial interventions is effective.

The Musculoskeletal Elf’s view

The Musculoskeletal Elf

The authors state that while it might seem intuitive that the targeting of psychosocial interventions would be effective, their review did not find consistent evidence to support this. Part of this was due to the included studies being underpowered in relation to their sample sizes.

It seems that we still have a bit to go in our investigating of interventions to address Yellow (or Blue) Flags. I think another factor that comes into play is the fact that it can be difficult to get healthcare professionals to break away from the biomedical model and embrace psychosocial interventions as part of their everyday practice. I imagine that this attitudinal and behavioural change would take more than 2.5 hours training, which often is all that is provided to them.

What are your experiences of delivering psychosocial interventions? How much training did you receive prior to doing so? How confident were/ are you as a result of that training? 

Send us your views on this blog and become part of the ever expanding Musculoskeletal Elf community.


Kent, P. & Kjaer, P. 2012, “The efficacy of targeted interventions for modifiable psychosocial risk factors of persistent non-specific low back pain – A systematic review”, Manual Therapy, Vol. 17, no. 5, pp. 385-401  [PubMed abstract]

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