title: Physiotherapist-delivered cognitive-behavioural interventions are effective for low back pain, but can they be replicated in clinical practice? A systematic review.
abstract: OBJECTIVE
  To determine if physiotherapist-led cognitive-behavioural (CB) interventions are effective for low back pain (LBP) and described sufficiently for replication.
  
  
  METHODS
  Randomised controlled trials (RCTs) of patients with LBP treated by physiotherapists using a CB intervention were included. Outcomes of disability, pain, and quality of life were assessed using the GRADE approach. Intervention reporting was assessed using the Template for Intervention Description and Replication.
  
  
  RESULTS
  Of 1898 titles, 5 RCTs (n = 1390) were identified. Compared to education and/or exercise interventions, we found high-quality evidence that CB had a greater effect (SMD; 95% CI) on reducing disability (-0.19; -0.32, -0.07), pain (-0.21; -0.33, -0.09); and moderate-quality evidence of little difference in quality of life (-0.06; -0.18 to 0.07). Sufficient information was provided on dose, setting, and provider; but not content and procedural information. Studies tended to report the type of CB component used (e.g., challenging unhelpful thoughts) with little detail on how it was operationalised. Moreover, access to treatment manuals, patient materials and provider training was lacking.
  
  
  CONCLUSIONS
  With additional training, physiotherapists can deliver effective CB interventions. However, without training or resources, successful translation and implementation remains unlikely. Researchers should improve reporting of procedural information, provide relevant materials, and offer accessible provider training. Implications for Rehabilitation Previous reviews have established that traditional biomedical-based treatments (e.g., acupuncture, manual therapy, massage, and specific exercise programmes) that focus only on physical symptoms do provide short-term benefits but the sustained effect is questionable. A cognitive-behavioural (CB) approach includes techniques to target both physical and psychosocial symptoms related to pain and provides patients with long-lasting skills to manage these symptoms on their own. This combined method has been used in a variety of settings delivered by different health care professionals and has been shown to produce long-term effects on patient outcomes. What has been unclear is if these programmes are effective when delivered by physiotherapists in routine physiotherapy settings. Our study synthesises the evidence for this context. We have confirmed with high-quality evidence that with additional training, physiotherapists can deliver CB interventions that are effective for patients with back pain. Physiotherapists who are considering enhancing their treatment for patients with low back pain should consider undertaking some additional training in how to incorporate CB techniques into their practice to optimise treatment benefits and help patients receive long-lasting treatment effects. Importantly, our results indicate that using a CB approach, including a variety of CB techniques that could be easily adopted in a physical therapy setting, provides greater benefits for patient outcomes compared to brief education, exercise or physical techniques (such as manual therapy) alone. This provides further support that a combined treatment approach is likely better than one based on physical techniques alone. Notably, we identified a significant barrier to adopting any of these CB interventions in practice. This is because no study provided a description of the intervention or accessible training materials that would allow for accurate replication. Without access to provider training and/or resources, we cannot expect this evidence to be implemented in practice with optimal effects. Thus, we would urge physiotherapists to directly contact authors of the studies for more information on how to incorporate their interventions into their settings.
authors.affiliation: a The George Institute for Global Health, Oxford Martin School, University of Oxford , Oxford , UK.|b Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences , University of Oxford , Oxford , UK.
authors.forename: Amanda
authors.initials: A
authors.lastname: Hall
authors.affiliation: b Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences , University of Oxford , Oxford , UK.
authors.forename: Helen
authors.initials: H
authors.lastname: Richmond
authors.affiliation: b Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences , University of Oxford , Oxford , UK.
authors.forename: Bethan
authors.initials: B
authors.lastname: Copsey
authors.affiliation: b Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences , University of Oxford , Oxford , UK.
authors.forename: Zara
authors.initials: Z
authors.lastname: Hansen
authors.affiliation: b Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences , University of Oxford , Oxford , UK.
authors.forename: Esther
authors.initials: E
authors.lastname: Williamson
authors.affiliation: b Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences , University of Oxford , Oxford , UK.
authors.forename: Gillian
authors.initials: G
authors.lastname: Jones
authors.affiliation: b Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences , University of Oxford , Oxford , UK.
authors.forename: Beth
authors.initials: B
authors.lastname: Fordham
authors.affiliation: c Department of Psychiatry , University of Oxford , Oxford , UK.
authors.forename: Zafra
authors.initials: Z
authors.lastname: Cooper
authors.affiliation: b Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences , University of Oxford , Oxford , UK.
authors.forename: Sarah
authors.initials: S
authors.lastname: Lamb
mesh_terms: D015928:Cognitive Behavioral Therapy / Q000379:methods*; D003131:Combined Modality Therapy; D003695:Delivery of Health Care; D006801:Humans; D017116:Low Back Pain / Q000523:psychology / Q000534:rehabilitation; D059825:Physical Therapists; D026741:Physical Therapy Modalities
keywords: Physical activity; implementation; rehabilitation