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How Much Treatment is Needed for Chronic Low Back Pain?

I often talk about the importance of exercise dosage for attaining targeted improvements. If we strictly look at pain, what dose of treatment is needed to achieve a positive outcome? This systematic review and meta-analysis sought to determine the effectiveness (pain intensity, disability, and health-related quality of life) using low-dose primary care biopsychosocial interventions (PCBI).

PCBI is a combination of physical training (bio) and psychosocial cognitive treatment (cognitive behavioral therapy, pain-neuroscience education or other psychosocial concepts) in a primary setting. The research question of this study was, “are low-dosed primary care biopsychosocial interventions, consisting of an active physical component and at least one psychological, social, or occupational component, with a maximum of 15 treatment hours, more effective in reducing pain intensity and improving physical function than other active outpatient physical treatment approaches for adult patients with nonspecific CLBP?”

At first glance, this may look like a PCP vs PT study but the methods provided a broader definition of primary care. The active component was face-to-face and the primary care could be a general practitioner, a physiotherapist in local facilities, a primary care practice in hospitals, or other outpatient healthcare professions. So, while PT is included, the study does not differentiate who is delivering the treatment. The results are focused on the interventions, not the provider, and suggest all of these providers are equally capable.

The psychological, social, or occupational component of care did not have to be face-to-face (e.g., telephone, web-based). The face-to-face treatments were limited to 15 hours (HEP did not count toward the hour limit). The comparators were physical treatment with an active component such as exercise, physical activity or usual physiotherapy treatment. The final review included 18 RCTs.

For pain intensity, the pooled data showed statistically significantly greater improvements for the PCBI group at immediate, 12-month, and 18-60 month follow-ups (not for months 1-6). The magnitude was below clinical significance, however (0.79 - 1.13). Similar results were found for function. Quality of life was only different at 18-60 month follow-up, favoring PCBI. Subgroup analysis suggests CBT was the most important psychosocial component, yielding the largest differences from control. When breaking down by individual and group settings, only the individual setting favored PCBI for pain, as the group setting showed no difference between the intervention types. Lastly, dosage (<10 or 10-15 hours) did not matter. This data shows an individualized biopsychosocial approach is likely superior to an active-only approach for non-specific low back pain, but the differences in outcomes are small.

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