Chronic low back pain (CLBP) is defined by symptoms that persist for a period of more than three months. These can include pain, impaired function, anxiety and depression with subsequent effects both socially and recreationally.
Recent research suggests that CLBP accounts for more years lived with disability than any other health condition (Vos et al, 2012). Recognition of the widespread effects of CLBP has led to the formulation of the biopsychosocial model of intervention (combination of physical, psychological and educational interventions). I was inquisitive about the evidence for multidisciplinary intervention and sourced a recent systematic review.
Here’s what they did
The objective of the review and meta-analysis was to estimate the effectiveness of multidisciplinary rehabilitation (MDR) on decreasing pain, disability and work absenteeism in people with CLBP. The authors searched the Cochrane Back Review Group Trials Register, CENTRAL, Medline, Embase, PsycINFO and CINAHL databases from 1998 to 2014, to update findings from a previous Cochrane review published in 2001. Quality of evidence was assessed using the GRADE approach.
Here’s what they found
Search results yielded 6189 studies of which 31 were deemed appropriate in addition to 10 studies from the previous review.
- There is moderate quality evidence favouring MDR in comparison to usual care (where usual care is at the discretion of their healthcare provider) for long-term pain relief and disability, but no difference for work absenteeism.
- When compared to physical treatment (including heat, electrotherapeutic modalities, exercises, manual therapies, and or education) there is low quality evidence favouring MDR for long-term disability with statistics for pain just failing to reach significance. However, MDR improves the odds of being at work one year after intervention.
The authors concluded
Multidisciplinary biopsychosocial rehabilitation interventions were more effective than usual care and physical treatments in decreasing pain and disability. For work outcomes, MDR seems to be more effective than physical treatment but not more effective than usual care.
The Musculoskeletal Elf’s view
The vast majority of the studies were conducted in Europe and the authors advise caution when applying the results in the UK.
Subsequent to the nature of the interventions, blinding of patients, clinicians or assessors was not possible. Sensitivity analysis including studies with high bias, however, did not suggest over estimation of the effectiveness of MDR.
Unfortunately, there is no definition as to what MDR involves – just that it is delivered by healthcare professionals from at least two different backgrounds. One would have to, therefore, further investigate individual studies for this information. There is also no definition of ‘usual care’.
Although there is moderate and low quality evidence for MDR in comparison to usual care and physical treatments respectively, the clinical significance is relatively small, i.e. a reduction of 0.5 points on pain rating scale of 0 – 10 and a reduction of 1.5 points on 0 – 24 Roland and Morris disability questionnaire.
The authors have cautioned that the modest effects produced should be weighed against monetary costs and time commitments associated with MDR, therefore it would seem prudent to refer only those patients suffering major physical and psychological symptoms secondary to CLBP.
This surely leads to a further question – what ‘type’ of patient would be most suited to a MDR approach?
What do you think?
- Do you work directly alongside other healthcare professionals in the management of CLBP? If so, are there any referral criteria to your service? Would you suggest that your patients experience similar benefits to those documented?
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Kamper, S. J., Apeldoorn, A. T., Chiarotto, A., Smeets, R. J. E. M., Ostelo, R. W. J. G., Guzman, J., & van Tulder, M. W. (2015). Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: Cochrane systematic review and meta-analysis. BMJ: British Medical Journal, 350 [Abstract]
Vos, T., Flaxman, A. D., Naghavi, M., Lozano, R., Michaud, C., Ezzati, M., … & Brooks, P. (2012). 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, 380(9859), 2163-96 [Abstract]
Multidisciplinary biopsychosocial rehabilitation for chronic low back pain – does it work? http://t.co/paOXkowoGr
@MSK_Elf check out the spine clinic at Virginia mason and @PalmettoHealth
Thanks for featuring our review on the blog. I think your final assessment is a fair and reasonable summary of the study. One thing I would add is that those seeking more detail can go to the Cochrane website to see more complete explanation of Methods and Results and extended Discussion (the BMJ publication is condensed version). In particular more details about the MDR and comparator interventions are available. The link is as follows: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000963.pub3/abstract
I also agree that the question of to whom MDR should be targeted is of great relevance. I think we have reasonable estimates of average effects, but I also think it is probably unfeasible that everyone with chronic symptoms receive MDR. In my opinion, addressing this question would be a useful direction for future research.
Multidisciplinary biopsychosocial rehabilitation for chronic low back pain – does it work? http://t.co/qoCqw3eCOw @MSK_Elf
I think that the recent draft NICE guidance on low back pain was done rather well, though the conclusions were cloaked in NICE-speak. It listed a large number of things that do not seem to work (“do not offer”), including acupuncture, imaging and spinal injections. Almost everything else was listed as “consider”, rather than “offer”. That is an admission that nothing works well. I just wish they’d said more clearly that low back pain is, in most cases, an unsolved problem.