Effectiveness of biobehavioral therapeutic education in chronic low back pain intensity and disability: a systematic review
Resumen
Background: Chronic low back pain (CLBP) is a prevalent musculoskeletal issue that could lead to significant disability. CLBP involves persistent pain and psychological factors contributing to its complexity. Therapeutic education combining cognitive-behavioral approaches may aid in managing CLBP.
Objectives: This systematic review evaluates the efficacy of therapeutic education based on a biobehavioral approach in modifying beliefs and promoting active coping strategies in CLBP patients.
Methods: Following PRISMA guidelines, we searched PubMed, EBSCO host, and Google Scholar for randomized controlled trials (RCTs) and quasi-experimental studies from March 27 to April 16, 2022, with an update on June 15, 2024. Inclusion criteria focused on adults with CLBP undergoing therapeutic education aimed at behavioral modification. Methodological quality was assessed using the PEDro scale, and risk of bias was evaluated using RoB 2.0.
Results: Out of 532 studies, four met the inclusion criteria. The interventions combined therapeutic education with therapeutic exercise or conventional physical therapy. Pain intensity and disability were the main outcomes measured. One study found significant improvements in pain and disability, while others showed trends towards improvement without statistical significance. The quality of evidence was very low.
Conclusion: Combining therapeutic education with active coping strategies and other therapies may reduce pain intensity and disability in CLBP patients. However, the evidence quality is very low, highlighting the need for further research.
Cómo citar
Referencias
Airaksinen, O., Brox, J. I., Cedraschi, C., Hildebrandt, J., Klaber-Moffett, J., Kovacs, F., Mannion, A. F., Reis, S., Staal, J. B., Ursin, H., & Zanoli, G. (2006). Chapter 4: European guidelines for the management of chronic nonspecific low back pain. European Spine Journal, 15(SUPPL. 2), s192–s300. https://doi.org/10.1007/S00586-006-1072-1/METRICS
Apkarian, A. V., Hashmi, J. A., & Baliki, M. N. (2011). Pain and the brain: Specificity and plasticity of the brain in clinical chronic pain. Pain, 152(SUPPL.3). https://doi.org/10.1016/J.PAIN.2010.11.010
Baloochi Beydokhti, T., Heshmati Nabavi, F., Ilkhani, M., & Karimi Moonaghi, H. (2020). Information need, learning need and educational need, definitions and measurements: A systematic review. Patient Education and Counseling, 103(7), 1272–1286. https://doi.org/10.1016/J.PEC.2020.02.006
Balshem, H., Helfand, M., Schünemann, H. J., Oxman, A. D., Kunz, R., Brozek, J., Vist, G. E., Falck-Ytter, Y., Meerpohl, J., Norris, S., & Guyatt, G. H. (2011). GRADE guidelines: 3. Rating the quality of evidence. Journal of Clinical Epidemiology, 64(4), 401–406. https://doi.org/10.1016/j.jclinepi.2010.07.015
Brodal, P. (2017). A neurobiologist’s attempt to understand persistent pain. Scandinavian Journal of Pain, 15, 140–147. https://doi.org/10.1016/J.SJPAIN.2017.03.001
Castro, M. M. C., Quarantini, L. C., Daltro, C., Pires-Caldas, M., Koenen, K. C., Kraychete, D. C., & de Oliveira, I. R. (2011). Comorbid depression and anxiety symptoms in chronic pain patients and their impact on health-related quality of life. Archives of Clinical Psychiatry (São Paulo), 38(4), 126–129. https://doi.org/10.1590/S0101-60832011000400002
Catley, M. J., O’Connell, N. E., Berryman, C., Ayhan, F. F., & Moseley, G. L. (2014). Is tactile acuity altered in people with chronic pain? A systematic review and meta-analysis. Journal of Pain, 15(10), 985–1000. https://doi.org/10.1016/j.jpain.2014.06.009
Chou, R., Qaseem, A., Snow, V., Casey, D., Cross, T. J., Shekelle, P., & Owens, D. K. (2007). Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society. Annals of Internal Medicine, 147(7), 478–491. https://doi.org/10.7326/0003-4819-147-7-200710020-00006
Cohen, J. (1960). A Coefficient of Agreement for Nominal Scales. Educational and Psychological Measurement, 20(1), 37–46. https://doi.org/10.1177/001316446002000104
Cox, T., Louw, A., & Puentedura, E. J. (2016). An abbreviated therapeutic neuroscience education session improves pain knowledge in first-year physical therapy students but does not change attitudes or beliefs. Http://Dx.Doi.Org/10.1080/10669817.2015.1122308, 25(1), 11–21. https://doi.org/10.1080/10669817.2015.1122308
Da Luz, M. A., Costa, L. O. P., Fuhro, F. F., Manzoni, A. C. T., De Oliveira, N. T. B., & Cabral, C. M. N. (2013). Effectiveness of mat Pilates or equipment-based Pilates in patients with chronic non-specific low back pain: A protocol of a randomised controlled trial. BMC Musculoskeletal Disorders, 14(1), 1–5. https://doi.org/10.1186/1471-2474-14-16/FIGURES/1
de Morton, N. A. (2009). The PEDro scale is a valid measure of the methodological quality of clinical trials: a demographic study. Australian Journal of Physiotherapy, 55(2), 129–133. https://doi.org/10.1016/S0004-9514(09)70043-1
Denison, E., Åsenlöf, P., & Lindberg, P. (2004). Self-efficacy, fear avoidance, and pain intensity as predictors of disability in subacute and chronic musculoskeletal pain patients in primary health care. Pain, 111(3), 245–252. https://doi.org/10.1016/J.PAIN.2004.07.001
Fourney, D. R., Andersson, G., Arnold, P. M., Dettori, J., Cahana, A., Fehlings, M. G., Norvell, D., Samartzis, D., & Chapman, J. R. (2011). Chronic low back pain: A heterogeneous condition with challenges for an evidence-based approach. Spine, 36(21 SUPPL.). https://doi.org/10.1097/BRS.0B013E31822F0A0D
Galan-Martin, M. A., Montero-Cuadrado, F., Lluch-Girbes, E., Coca-López, M. C., Mayo-Iscar, A., & Cuesta-Vargas, A. (2020). Pain Neuroscience Education and Physical Therapeutic Exercise for Patients with Chronic Spinal Pain in Spanish Physiotherapy Primary Care: A Pragmatic Randomized Controlled Trial. Journal of Clinical Medicine 2020, Vol. 9, Page 1201, 9(4), 1201. https://doi.org/10.3390/JCM9041201
Geneen, L. J., Martin, D. J., Adams, N., Clarke, C., Dunbar, M., Jones, D., McNamee, P., Schofield, P., & Smith, B. H. (2015). Effects of education to facilitate knowledge about chronic pain for adults: A systematic review with meta-analysis. Systematic Reviews, 4(1), 132. https://doi.org/10.1186/s13643-015-0120-5
Grande-Alonso, M., Suso-Martí, L., Cuenca-Martínez, F., Pardo-Montero, J., Gil-Martínez, A., & La Touche, R. (2019). Physiotherapy Based on a Biobehavioral Approach with or Without Orthopedic Manual Physical Therapy in the Treatment of Nonspecific Chronic Low Back Pain: A Randomized Controlled Trial. Pain Medicine, 20(12), 2571–2587. https://doi.org/10.1093/PM/PNZ093
Grotle, M., Foster, N. E., Dunn, K. M., & Croft, P. (2010). Are prognostic indicators for poor outcome different for acute and chronic low back pain consulters in primary care? Pain, 151(3), 790–797. https://doi.org/10.1016/J.PAIN.2010.09.014
Guyatt, G., Oxman, A. D., Akl, E. A., Kunz, R., Vist, G., Brozek, J., Norris, S., Falck-Ytter, Y., Glasziou, P., Debeer, H., Jaeschke, R., Rind, D., Meerpohl, J., Dahm, P., & Schünemann, H. J. (2011). GRADE guidelines: 1. Introduction - GRADE evidence profiles and summary of findings tables. Journal of Clinical Epidemiology, 64(4), 383–394. https://doi.org/10.1016/j.jclinepi.2010.04.026
Hancock, M. J., Maher, C. G., Latimer, J., Herbert, R. D., & McAuley, J. H. (2009). Can rate of recovery be predicted in patients with acute low back pain? Development of a clinical prediction rule. European Journal of Pain, 13(1), 51–55. https://doi.org/10.1016/J.EJPAIN.2008.03.007
Hayden, J. A., Van Tulder, M. W., & Tomlinson, G. (2005). Systematic review: strategies for using exercise therapy to improve outcomes in chronic low back pain. Annals of Internal Medicine, 142(9), 776–785. https://doi.org/10.7326/0003-4819-142-9-200505030-00014
Hoy, D., Bain, C., Williams, G., March, L., Brooks, P., Blyth, F., Woolf, A., Vos, T., & Buchbinder, R. (2012). A systematic review of the global prevalence of low back pain. Arthritis and Rheumatism, 64(6), 2028–2037. https://doi.org/10.1002/ART.34347
Ibrahim, A. A., Akindele, M. O., & Ganiyu, S. O. (2023). Effectiveness of patient education plus motor control exercise versus patient education alone versus motor control exercise alone for rural community-dwelling adults with chronic low back pain: a randomised clinical trial. BMC Musculoskeletal Disorders, 24(1), 1–19. https://doi.org/10.1186/s12891-022-06108-9
Lin, I., Wiles, L., Waller, R., Goucke, R., Nagree, Y., Gibberd, M., Straker, L., Maher, C. G., & O’Sullivan, P. P. B. (2020). What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. British Journal of Sports Medicine, 54(2), 79–86. https://doi.org/10.1136/BJSPORTS-2018-099878
López-de-Uralde-Villanueva, I., Beltran-Alacreu, H., Fernández-Carnero, J., & La Touche, R. (2020). Pain management using a multimodal physiotherapy program including a biobehavioral approach for chronic nonspecific neck pain: a randomized controlled trial. Physiotherapy Theory and Practice, 36(1), 45–62. https://doi.org/10.1080/09593985.2018.1480678
Louw, A., Diener, I., Butler, D. S., & Puentedura, E. J. (2011). The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Archives of Physical Medicine and Rehabilitation, 92(12), 2041–2056. https://doi.org/10.1016/j.apmr.2011.07.198
Louw, A., Nijs, J., & Puentedura, E. J. (2017). A clinical perspective on a pain neuroscience education approach to manual therapy. Journal of Manual and Manipulative Therapy, 25(3), 160–168. https://doi.org/10.1080/10669817.2017.1323699
Louw, A., Zimney, K., Puentedura, E. J., & Diener, I. (2016). The efficacy of pain neuroscience education on musculoskeletal pain: A systematic review of the literature. Physiotherapy Theory and Practice, 32(5), 332–355. https://doi.org/10.1080/09593985.2016.1194646
Lumley, M. A., Cohen, J. L., Borszcz, G. S., Cano, A., Radcliffe, A. M., Porter, L. S., Schubiner, H., & Keefe, F. J. (2011). Pain and emotion: a biopsychosocial review of recent research. Journal of Clinical Psychology, 67(9), 942–968. https://doi.org/10.1002/JCLP.20816
Maher, C. G., Sherrington, C., Herbert, R. D., Moseley, A. M., & Elkins, M. (2003). Reliability of the PEDro scale for rating quality of randomized controlled trials. Physical Therapy, 83(8), 713–721. https://doi.org/10.1093/ptj/83.8.713
Matias, B. A., Vieira, I., Pereira, A., Duarte, M., & Silva, A. G. (2019). Pain neuroscience education plus exercise compared with exercise in university students with chronic idiopathic neck pain. Https://Doi.Org/10.12968/Ijtr.2018.0084, 26(7). https://doi.org/10.12968/IJTR.2018.0084
McConnell, R., Lane, E., Webb, G., LaPeze, D., Grillo, H., & Fritz, J. (2024). A multicenter feasibility randomized controlled trial using a virtual reality application of pain neuroscience education for adults with chronic low back pain. Annals of Medicine, 56(1), 2311846. https://doi.org/10.1080/07853890.2024.2311846
Meeus, M., Nijs, J., Van Oosterwijck, J., Van Alsenoy, V., & Truijen, S. (2010). Pain physiology education improves pain beliefs in patients with chronic fatigue syndrome compared with pacing and self-management education: a double-blind randomized controlled trial. Archives of Physical Medicine and Rehabilitation, 91(8), 1153–1159. https://doi.org/10.1016/J.APMR.2010.04.020
Moseley, G. L. (2003). A pain neuromatrix approach to patients with chronic pain. Manual Therapy, 8(3), 130–140. https://doi.org/10.1016/S1356-689X(03)00051-1
Moseley, G. L., & Flor, H. (2012). Targeting cortical representations in the treatment of chronic pain: A review. Neurorehabilitation and Neural Repair, 26(6), 646–652. https://doi.org/10.1177/1545968311433209
Moseley, L. (2003). Unraveling the barriers to reconceptualization of the problem in chronic pain: The actual and perceived ability of patients and health professionals to understand the neurophysiology. Journal of Pain, 4(4), 184–189. https://doi.org/10.1016/S1526-5900(03)00488-7
Murray, C. J. L., Barber, R. M., Foreman, K. J., Ozgoren, A. A., Abd-Allah, F., Abera, S. F., Aboyans, V., Abraham, J. P., Abubakar, I., Abu-Raddad, L. J., Abu-Rmeileh, N. M., Achoki, T., Ackerman, I. N., Ademi, Z., Adou, A. K., Adsuar, J. C., Afshin, A., Agardh, E. E., Alam, S. S., … Vos, T. (2015). Global, regional, and national disability-adjusted life years (DALYs) for 306 diseases and injuries and healthy life expectancy (HALE) for 188 countries, 1990-2013: Quantifying the epidemiological transition. The Lancet, 386(10009), 2145–2191. https://doi.org/10.1016/S0140-6736(15)61340-X
Nijs, J., Meeus, M., Cagnie, B., Roussel, N. A., Dolphens, M., Van Oosterwijck, J., & Danneels, L. (2014). A modern neuroscience approach to chronic spinal pain: combining pain neuroscience education with cognition-targeted motor control training. Physical Therapy, 94(5), 730–738. https://doi.org/10.2522/PTJ.20130258
Nijs, J., van Wilgen, C. P., Oosterwijck, J. Van, van Ittersum, M., & Meeus, M. (2011). How to explain central sensitization to patients with “unexplained” chronic musculoskeletal pain: practice guidelines. Manual Therapy, 16(5), 413–418. https://doi.org/10.1016/J.MATH.2011.04.005
O’Sullivan, P. B., Caneiro, J. P., O’Keeffe, M., Smith, A., Dankaerts, W., Fersum, K., & O’Sullivan, K. (2018). Cognitive Functional Therapy: An Integrated Behavioral Approach for the Targeted Management of Disabling Low Back Pain. Physical Therapy, 98(5), 408–423. https://doi.org/10.1093/PTJ/PZY022
Page, M. J., McKenzie, J. E., Bossuyt, P. M., Boutron, I., Hoffmann, T. C., Mulrow, C. D., Shamseer, L., Tetzlaff, J. M., Akl, E. A., Brennan, S. E., Chou, R., Glanville, J., Grimshaw, J. M., Hróbjartsson, A., Lalu, M. M., Li, T., Loder, E. W., Mayo-Wilson, E., McDonald, S., … Moher, D. (2021). Declaración PRISMA 2020: una guía actualizada para la publicación de revisiones sistemáticas. Revista Española de Cardiología (English Edition), 74(9), 790–799. https://doi.org/10.1016/j.rec.2021.07.010
Parreira, P., Heymans, M. W., van Tulder, M. W., Esmail, R., Koes, B. W., Poquet, N., Lin, C. W. C., & Maher, C. G. (2017). Back Schools for chronic non-specific low back pain. The Cochrane Database of Systematic Reviews, 8(8). https://doi.org/10.1002/14651858.CD011674.PUB2
Picavet, H. S. J., Vlaeyen, J. W. S., & Schouten, J. S. A. G. (2002). Pain Catastrophizing and Kinesiophobia: Predictors of Chronic Low Back Pain. American Journal of Epidemiology, 156(11), 1028–1034. https://doi.org/10.1093/AJE/KWF136
Rice, D., McNair, P., Huysmans, E., Letzen, J., & Finan, P. (2019). Best evidence rehabilitation for chronic pain part 5: Osteoarthritis. Journal of Clinical Medicine, 8(11). https://doi.org/10.3390/jcm8111769
Sheng, J., Liu, S., Wang, Y., Cui, R., & Zhang, X. (2017). The Link between Depression and Chronic Pain: Neural Mechanisms in the Brain. Neural Plasticity, 2017. https://doi.org/10.1155/2017/9724371
Song, J., Kim, H., Jung, J., & Lee, S. (2023). Soft-Tissue Mobilization and Pain Neuroscience Education for Chronic Nonspecific Low Back Pain with Central Sensitization: A Prospective Randomized Single-Blind Controlled Trial. Biomedicines, 11(5), 1249. https://doi.org/10.3390/biomedicines11051249
Stanton, T. R., Latimer, J., Maher, C. G., & Hancock, M. J. (2010). How do we define the condition “recurrent low back pain”? A systematic review. European Spine Journal, 19(4), 533–539. https://doi.org/10.1007/S00586-009-1214-3/METRICS
Sterne, J. A. C., Savović, J., Page, M. J., Elbers, R. G., Blencowe, N. S., Boutron, I., Cates, C. J., Cheng, H. Y., Corbett, M. S., Eldridge, S. M., Emberson, J. R., Hernán, M. A., Hopewell, S., Hróbjartsson, A., Junqueira, D. R., Jüni, P., Kirkham, J. J., Lasserson, T., Li, T., … Higgins, J. P. T. (2019). RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ (Clinical Research Ed.), 366. https://doi.org/10.1136/BMJ.L4898
Stone, P. W. (2002). Popping the (PICO) question in research and evidence-based practice. Applied Nursing Research, 15(3), 197–198. https://doi.org/10.1053/apnr.2002.34181
Sullivan, M. J. L., Thibault, P., Andrikonyte, J., Butler, H., Catchlove, R., & Larivière, C. (2009). Psychological influences on repetition-induced summation of activity-related pain in patients with chronic low back pain. Pain, 141(1–2), 70–78. https://doi.org/10.1016/J.PAIN.2008.10.017
Sullivan, M. J. L., Thorn, B., Haythornthwaite, J. A., Keefe, F., Martin, M., Bradley, L. A., & Lefebvre, J. C. (2001). Theoretical perspectives on the relation between catastrophizing and pain. The Clinical Journal of Pain, 17(1), 52–64. https://doi.org/10.1097/00002508-200103000-00008
Tegner, H., Frederiksen, P., Esbensen, B. A., & Juhl, C. (2018). Neurophysiological Pain Education for Patients with Chronic Low Back Pain. In Clinical Journal of Pain (Vol. 34, Issue 8). https://doi.org/10.1097/AJP.0000000000000594
Turner, J. A., Ersek, M., & Kemp, C. (2005). Self-efficacy for managing pain is associated with disability, depression, and pain coping among retirement community residents with chronic pain. Journal of Pain, 6(7), 471–479. https://doi.org/10.1016/j.jpain.2005.02.011
Van Tulder, M., Becker, A., Bekkering, T., Breen, A., Del Real, M. T. G., Hutchinson, A., Koes, B., Laerum, E., & Malmivaara, A. (2006). Chapter 3: European guidelines for the management of acute nonspecific low back pain in primary care. European Spine Journal, 15(SUPPL. 2), 169–191. https://doi.org/10.1007/s00586-006-1071-2
Vibe Fersum, K., Smith, A., Kvåle, A., Skouen, J. S., & O’Sullivan, P. (2019). Cognitive functional therapy in patients with non-specific chronic low back pain-a randomized controlled trial 3-year follow-up. European Journal of Pain (London, England), 23(8), 1416–1424. https://doi.org/10.1002/EJP.1399
Vos, T., Abajobir, A. A., Abbafati, C., Abbas, K. M., Abate, K. H., Abd-Allah, F., Abdulle, A. M., Abebo, T. A., Abera, S. F., Aboyans, V., Abu-Raddad, L. J., Ackerman, I. N., Adamu, A. A., Adetokunboh, O., Afarideh, M., Afshin, A., Agarwal, S. K., Aggarwal, R., Agrawal, A., … Murray, C. J. L. (2017). Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet (London, England), 390(10100), 1211–1259. https://doi.org/10.1016/S0140-6736(17)32154-2
Watson, J. A., Ryan, C. G., Cooper, L., Ellington, D., Whittle, R., Lavender, M., Dixon, J., Atkinson, G., Cooper, K., & Martin, D. J. (2019). Pain Neuroscience Education for Adults With Chronic Musculoskeletal Pain: A Mixed-Methods Systematic Review and Meta-Analysis. The Journal of Pain, 20(10), 1140.e1-1140.e22. https://doi.org/10.1016/J.JPAIN.2019.02.011
Woby, S. R., Roach, N. K., Urmston, M., & Watson, P. J. (2007). The relation between cognitive factors and levels of pain and disability in chronic low back pain patients presenting for physiotherapy. European Journal of Pain, 11(8), 869–877. https://doi.org/10.1016/J.EJPAIN.2007.01.005
Woby, S. R., Watson, P. J., Roach, N. K., & Urmston, M. (2004). Are changes in fear-avoidance beliefs, catastrophizing, and appraisals of control, predictive of changes in chronic low back pain and disability? European Journal of Pain, 8(3), 201–210. https://doi.org/10.1016/J.EJPAIN.2003.08.002
Wood, L., & Hendrick, P. A. (2019). A systematic review and meta-analysis of pain neuroscience education for chronic low back pain: Short-and long-term outcomes of pain and disability. European Journal of Pain (London, England), 23(2), 234–249. https://doi.org/10.1002/EJP.1314
Zheng, F., Liu, S., Zhang, S., Yu, Q., Lo, W. L. A., Li, T., & Wang, C. H. (2022). Does m-health-based exercise (guidance plus education) improve efficacy in patients with chronic low-back pain? A preliminary report on the intervention’s significance. Trials, 23(1), 190. https://doi.org/10.1186/s13063-022-06116-z