Treating more than just the back: the role of individualised multidimensional care for chronic low back pain

Introduction: Non-specific chronic low back pain (NSCLBP) is a common and costly musculoskeletal disorder, resulting in a significant personal, social and economic burden. NSCLBP is a multidimensional disorder, involving different factors across the biopsychosocial spectrum, whose interaction may vary between individuals. Many conservative interventions are delivered with an emphasis on physical or psychological components or both, and in an individual or group format. It remains unclear what is the most effective content and mode of delivery for NSCLBP interventions. A recent randomised controlled trial (RCT) in Norway suggests that an individualised multidimensional intervention called Cognitive Functional Therapy (CFT) is more effective than most current interventions for NSCLBP. The aims of this doctoral thesis were to systematically review the effectiveness of current conservative interventions for NSCLBP, investigate the factors that may enhance patient-therapist interactions, and compare the effectiveness of CFT with a group delivered multidimensional intervention in people with NSCLBP. Methods: In the first part of this thesis (Chapter 2-three studies), three systematic reviews were completed. Study I compared the effectiveness of physical, behavioural/psychological and combined interventions in people with non-specific chronic spinal pain (NSCSP). Study II compared the effectiveness of individual and group physiotherapy interventions that incorporated exercise in people with musculoskeletal conditions (MSCs). Study III investigated physiotherapists’ and patients’ perceptions of factors that influence the patienttherapist interaction in musculoskeletal settings. In the second part (Chapter 3-two studies), a RCT was carried out. Study IV detailed the protocol for the RCT. Study V presented the preliminary data regarding the clinical effectiveness of individualised CFT compared to a multidimensional group exercise and education intervention. Results: Study I demonstrated no clinically significant differences between physical, behavioural/psychological and combined interventions for reducing pain and disability in NSCSP. All interventions yielded similar small effects on pain and disability. Similarly, Study II demonstrated no clinically significant differences between individual and group physiotherapy interventions that incorporated exercise on pain and disability in MSCs. All interventions yielded similar small effects on pain and disability. Study III demonstrated that physiotherapist communication and interpersonal skills, physiotherapist practical skills, individualised patient-centred care and organisational and environmental factors are perceived to influence the patient-therapist interaction in musculoskeletal settings. Study V demonstrated preliminary results (n=171) that CFT led to superior outcomes for pain and disability compared to a group multidimensional exercise and education intervention at postintervention, six months and 12 months post-randomisation. Conclusion: This doctoral thesis demonstrates that most current interventions for NSCLBP have similar small effects on pain and disability. It demonstrates that a mix of interpersonal, clinical and organisational factors are perceived to influence the patient-therapist interaction. This thesis provides preliminary results that CFT has superior outcomes for NSCLBP compared to a multidimensional group intervention. Overall, the findings of this thesis suggest that neither the content nor mode of delivery of most current conservative interventions is critical as effects are generally small. However, the RCT in this thesis, along with the previous RCT using the same approach in Norway, suggests that better outcomes can be yielded by adopting an individualised multidimensional approach to NSCLBP. These promising findings must be interpreted with caution until data collection, including an intention to treat analysis of all randomised participants is completed. Additional analysis of the mediators and moderators of outcome will be analysed to examine the mechanisms of effect. Furthermore, costs and qualitative interviews will also be analysed.