cochrane database of systematic reviews (reviews) || multidisciplinary biopsychosocial...

Multidisciplinary biopsychosocial rehabilitation for chronic

low back pain (Review)

Kamper SJ, Apeldoorn AT, Chiarotto A, Smeets RJ, Ostelo RWJG, Guzman J, van Tulder MW

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library2014, Issue 9

http://www.thecochranelibrary.com

Multidisciplinary biopsychosocial rehabilitation for chronic low back pain (Review)

Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

http://www.thecochranelibrary.com

T A B L E O F C O N T E N T S

1HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

4SUMMARY OF FINDINGS FOR THE MAIN COMPARISON . . . . . . . . . . . . . . . . . . .

6BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

6METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

9RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Figure 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Figure 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Figure 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Figure 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Figure 5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Figure 6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Figure 7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Figure 8. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Figure 9. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Figure 10. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Figure 11. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Figure 12. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Figure 13. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Figure 14. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Figure 15. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Figure 16. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Figure 17. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Figure 18. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Figure 19. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Figure 20. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Figure 21. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Figure 22. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Figure 23. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Figure 24. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Figure 25. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25

Figure 26. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Figure 27. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Figure 28. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Figure 29. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

27ADDITIONAL SUMMARY OF FINDINGS . . . . . . . . . . . . . . . . . . . . . . . . . .

33DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

35AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

35ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

36REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

47CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

106DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Analysis 1.1. Comparison 1 MBR versus usual care, Outcome 1 Back pain short term. . . . . . . . . . . . 115

Analysis 1.2. Comparison 1 MBR versus usual care, Outcome 2 Back pain medium term. . . . . . . . . . . 116

Analysis 1.3. Comparison 1 MBR versus usual care, Outcome 3 Back pain long term. . . . . . . . . . . . 117

Analysis 1.4. Comparison 1 MBR versus usual care, Outcome 4 Disability short term. . . . . . . . . . . . 118

Analysis 1.5. Comparison 1 MBR versus usual care, Outcome 5 Disability medium term. . . . . . . . . . . 119

Analysis 1.6. Comparison 1 MBR versus usual care, Outcome 6 Disability long term. . . . . . . . . . . . 120

Analysis 1.7. Comparison 1 MBR versus usual care, Outcome 7 Work short term. . . . . . . . . . . . . 121

iMultidisciplinary biopsychosocial rehabilitation for chronic low back pain (Review)


Analysis 1.8. Comparison 1 MBR versus usual care, Outcome 8 Work medium term. . . . . . . . . . . . 121

Analysis 1.9. Comparison 1 MBR versus usual care, Outcome 9 Work long term. . . . . . . . . . . . . . 122

Analysis 1.10. Comparison 1 MBR versus usual care, Outcome 10 QoL SF36 PCS short term. . . . . . . . . 123

Analysis 1.11. Comparison 1 MBR versus usual care, Outcome 11 QoL SF36 MCS short term. . . . . . . . . 123

Analysis 1.12. Comparison 1 MBR versus usual care, Outcome 12 QoL SF36 PCS medium term. . . . . . . . 124

Analysis 1.13. Comparison 1 MBR versus usual care, Outcome 13 QoL SF36 MCS medium term. . . . . . . 124

Analysis 1.14. Comparison 1 MBR versus usual care, Outcome 14 Catastrophising short term. . . . . . . . . 125

Analysis 1.15. Comparison 1 MBR versus usual care, Outcome 15 Catastrophising long term. . . . . . . . . 125

Analysis 1.16. Comparison 1 MBR versus usual care, Outcome 16 Fear avoidance short term. . . . . . . . . 126

Analysis 1.17. Comparison 1 MBR versus usual care, Outcome 17 Fear avoidance long term. . . . . . . . . 126

Analysis 2.1. Comparison 2 MBR versus physical treatment, Outcome 1 Pain short term. . . . . . . . . . . 127

Analysis 2.2. Comparison 2 MBR versus physical treatment, Outcome 2 Pain medium term. . . . . . . . . . 128

Analysis 2.3. Comparison 2 MBR versus physical treatment, Outcome 3 Pain long term. . . . . . . . . . . 129

Analysis 2.4. Comparison 2 MBR versus physical treatment, Outcome 4 Disability short term. . . . . . . . . 130

Analysis 2.5. Comparison 2 MBR versus physical treatment, Outcome 5 Disability medium term. . . . . . . . 131

Analysis 2.6. Comparison 2 MBR versus physical treatment, Outcome 6 Disability long term. . . . . . . . . 132

Analysis 2.7. Comparison 2 MBR versus physical treatment, Outcome 7 Work short term. . . . . . . . . . 133

Analysis 2.8. Comparison 2 MBR versus physical treatment, Outcome 8 Work medium term. . . . . . . . . 134

Analysis 2.9. Comparison 2 MBR versus physical treatment, Outcome 9 Work long term. . . . . . . . . . . 135

Analysis 2.10. Comparison 2 MBR versus physical treatment, Outcome 10 QoL short term. . . . . . . . . . 136

Analysis 2.11. Comparison 2 MBR versus physical treatment, Outcome 11 Quality of Life medium term. . . . . 136

Analysis 2.12. Comparison 2 MBR versus physical treatment, Outcome 12 Healthcare visits long term. . . . . . 137

Analysis 2.13. Comparison 2 MBR versus physical treatment, Outcome 13 Depression short term. . . . . . . 138

Analysis 2.14. Comparison 2 MBR versus physical treatment, Outcome 14 Depression medium term. . . . . . 139

Analysis 2.15. Comparison 2 MBR versus physical treatment, Outcome 15 Depression long term. . . . . . . . 140

Analysis 2.16. Comparison 2 MBR versus physical treatment, Outcome 16 Coping short term. . . . . . . . . 141

Analysis 2.17. Comparison 2 MBR versus physical treatment, Outcome 17 Coping medium term. . . . . . . . 141

Analysis 2.18. Comparison 2 MBR versus physical treatment, Outcome 18 Coping long term. . . . . . . . . 142

Analysis 2.19. Comparison 2 MBR versus physical treatment, Outcome 19 Self-efficacy short term. . . . . . . 143

Analysis 2.20. Comparison 2 MBR versus physical treatment, Outcome 20 Self-efficacy medium term. . . . . . 143

Analysis 2.21. Comparison 2 MBR versus physical treatment, Outcome 21 Anxiety short term. . . . . . . . . 144

Analysis 2.22. Comparison 2 MBR versus physical treatment, Outcome 22 Anxiety medium term. . . . . . . . 145

Analysis 3.1. Comparison 3 MBR versus surgery, Outcome 1 Pain long term. . . . . . . . . . . . . . . 145

Analysis 3.2. Comparison 3 MBR versus surgery, Outcome 2 Disability long term. . . . . . . . . . . . . 146

Analysis 3.3. Comparison 3 MBR versus surgery, Outcome 3 Work long term. . . . . . . . . . . . . . 147

Analysis 3.4. Comparison 3 MBR versus surgery, Outcome 4 Adverse events/complications. . . . . . . . . . 147

Analysis 3.5. Comparison 3 MBR versus surgery, Outcome 5 QoL SF36 PCS long term. . . . . . . . . . . 148

Analysis 3.6. Comparison 3 MBR versus surgery, Outcome 6 QoL SF36 MCS long term. . . . . . . . . . . 148

Analysis 4.1. Comparison 4 MBR versus wait list, Outcome 1 Pain short term. . . . . . . . . . . . . . 149

Analysis 4.2. Comparison 4 MBR versus wait list, Outcome 2 Disability short term. . . . . . . . . . . . . 150

Analysis 4.3. Comparison 4 MBR versus wait list, Outcome 3 Depression short term. . . . . . . . . . . . 151

Analysis 5.1. Comparison 5 MBR versus usual care, sensitivity and subgroup analyses, Outcome 1 Pain short term - all

studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152

Analysis 5.2. Comparison 5 MBR versus usual care, sensitivity and subgroup analyses, Outcome 2 Pain short term -

sensitivity and subgroup analyses. . . . . . . . . . . . . . . . . . . . . . . . . . . . 153

Analysis 5.3. Comparison 5 MBR versus usual care, sensitivity and subgroup analyses, Outcome 3 Pain medium term - all

studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155

Analysis 5.4. Comparison 5 MBR versus usual care, sensitivity and subgroup analyses, Outcome 4 Pain medium term -


Analysis 5.5. Comparison 5 MBR versus usual care, sensitivity and subgroup analyses, Outcome 5 Pain long term - all

studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158

Analysis 5.6. Comparison 5 MBR versus usual care, sensitivity and subgroup analyses, Outcome 6 Pain long term -


iiMultidisciplinary biopsychosocial rehabilitation for chronic low back pain (Review)


Analysis 5.7. Comparison 5 MBR versus usual care, sensitivity and subgroup analyses, Outcome 7 Disability short term -

all analyses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161

Analysis 5.8. Comparison 5 MBR versus usual care, sensitivity and subgroup analyses, Outcome 8 Disability short term -


Analysis 5.9. Comparison 5 MBR versus usual care, sensitivity and subgroup analyses, Outcome 9 Disability medium term

- all studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164

Analysis 5.10. Comparison 5 MBR versus usual care, sensitivity and subgroup analyses, Outcome 10 Disability medium

term - sensitivity and subgroup analyses. . . . . . . . . . . . . . . . . . . . . . . . . 165

Analysis 5.11. Comparison 5 MBR versus usual care, sensitivity and subgroup analyses, Outcome 11 Disability long term -

all studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167

Analysis 5.12. Comparison 5 MBR versus usual care, sensitivity and subgroup analyses, Outcome 12 Disability long term -


Analysis 5.13. Comparison 5 MBR versus usual care, sensitivity and subgroup analyses, Outcome 13 Work short term - all

studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169

Analysis 5.14. Comparison 5 MBR versus usual care, sensitivity and subgroup analyses, Outcome 14 Work short term -


Analysis 5.15. Comparison 5 MBR versus usual care, sensitivity and subgroup analyses, Outcome 15 Work medium term

all studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171

Analysis 5.16. Comparison 5 MBR versus usual care, sensitivity and subgroup analyses, Outcome 16 Work medium term -


Analysis 5.17. Comparison 5 MBR versus usual care, sensitivity and subgroup analyses, Outcome 17 Work long term - all

studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173

Analysis 5.18. Comparison 5 MBR versus usual care, sensitivity and subgroup analyses, Outcome 18 Work long term -


Analysis 6.1. Comparison 6 MBR versus physical treatment, sensitivity and subgroup analyses, Outcome 1 Pain short term

- all studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176

Analysis 6.2. Comparison 6 MBR versus physical treatment, sensitivity and subgroup analyses, Outcome 2 Pain short term

- sensitivity and subgroup analyses. . . . . . . . . . . . . . . . . . . . . . . . . . . 177

Analysis 6.3. Comparison 6 MBR versus physical treatment, sensitivity and subgroup analyses, Outcome 3 Pain medium

term - all studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179

Analysis 6.4. Comparison 6 MBR versus physical treatment, sensitivity and subgroup analyses, Outcome 4 Pain medium


Analysis 6.5. Comparison 6 MBR versus physical treatment, sensitivity and subgroup analyses, Outcome 5 Pain long term

- all studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182

Analysis 6.6. Comparison 6 MBR versus physical treatment, sensitivity and subgroup analyses, Outcome 6 Pain long term

- sensitivity and subgroup analyses. . . . . . . . . . . . . . . . . . . . . . . . . . . 183

Analysis 6.7. Comparison 6 MBR versus physical treatment, sensitivity and subgroup analyses, Outcome 7 Disability short

term - all studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185

Analysis 6.8. Comparison 6 MBR versus physical treatment, sensitivity and subgroup analyses, Outcome 8 Disability short


Analysis 6.9. Comparison 6 MBR versus physical treatment, sensitivity and subgroup analyses, Outcome 9 Disability

medium term - all studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 188


medium term - sensitivity and subgroup analyses. . . . . . . . . . . . . . . . . . . . . . 189


long term - all studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191


long term - sensitivity and subgroup analyses. . . . . . . . . . . . . . . . . . . . . . . . 192

Analysis 6.13. Comparison 6 MBR versus physical treatment, sensitivity and subgroup analyses, Outcome 13 Work short

term - all studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194

Analysis 6.14. Comparison 6 MBR versus physical treatment, sensitivity and subgroup analyses, Outcome 14 Work short


iiiMultidisciplinary biopsychosocial rehabilitation for chronic low back pain (Review)


Analysis 6.15. Comparison 6 MBR versus physical treatment, sensitivity and subgroup analyses, Outcome 15 Work

medium term - all studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196

Analysis 6.16. Comparison 6 MBR versus physical treatment, sensitivity and subgroup analyses, Outcome 16 Work

medium term - sensitivity and subgroup analyses. . . . . . . . . . . . . . . . . . . . . . 197

Analysis 6.17. Comparison 6 MBR versus physical treatment, sensitivity and subgroup analyses, Outcome 17 Work long

term - all studies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 198

Analysis 6.18. Comparison 6 MBR versus physical treatment, sensitivity and subgroup analyses, Outcome 18 Work long


201APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

208WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

208HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

208CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

209DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

209SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

209DIFFERENCES BETWEEN PROTOCOL AND REVIEW . . . . . . . . . . . . . . . . . . . . .

209INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

ivMultidisciplinary biopsychosocial rehabilitation for chronic low back pain (Review)


[Intervention Review]

Multidisciplinary biopsychosocial rehabilitation for chroniclow back pain

Steven J Kamper1, Andreas T Apeldoorn2, Alessandro Chiarotto3, Rob J.E.M. Smeets4, Raymond WJG Ostelo5, Jaime Guzman6 ,

Maurits W van Tulder7

1Musculoskeletal Division, The George Institute for Global Health, Sydney, Australia. 2Department of Epidemiology and Biostatistics

and the EMGO Institute for Health and Care Research, VU University Medical Centre, Amsterdam, Netherlands. 3Department of

Health Sciences, Faculty of Earth and Life Sciences, VU University Amsterdam, Amsterdam, Netherlands. 4Rehabilitation Medicine

Department, Maastricht University Medical Centre, Maastricht, Netherlands. 5Department of Health Sciences, EMGO Institute for

Health and Care Research, VU University, Amsterdam, Netherlands. 6University of British Columbia, Vancouver, Canada. 7 Department

of Health Sciences, Faculty of Earth and Life Sciences, VU University, Amsterdam, Netherlands

Contact address: Steven J Kamper, Musculoskeletal Division, The George Institute for Global Health, PO Box M201, Missenden

Road, Camperdown, Sydney, NSW, 2050, Australia. [email protected].

Editorial group: Cochrane Back Group.

Publication status and date: New search for studies and content updated (conclusions changed), published in Issue 9, 2014.

Review content assessed as up-to-date: 1 January 2014.

Citation: Kamper SJ, Apeldoorn AT, Chiarotto A, Smeets RJ, Ostelo RWJG, Guzman J, van Tulder MW. Multidisciplinary biopsy-

chosocial rehabilitation for chronic low back pain. Cochrane Database of Systematic Reviews 2014, Issue 9. Art. No.: CD000963. DOI:

10.1002/14651858.CD000963.pub3.


A B S T R A C T

Background

Low back pain (LBP) is responsible for considerable personal suffering worldwide. Those with persistent disabling symptoms also

contribute to substantial costs to society via healthcare expenditure and reduced work productivity. While there are many treatment

options, none are universally endorsed. The idea that chronic LBP is a condition best understood with reference to an interaction

of physical, psychological and social influences, the ’biopsychosocial model’, has received increasing acceptance. This has led to the

development of multidisciplinary biopsychosocial rehabilitation (MBR) programs that target factors from the different domains,

administered by healthcare professionals from different backgrounds.

Objectives

To review the evidence on the effectiveness of MBR for patients with chronic LBP. The focus was on comparisons with usual care and

with physical treatments measuring outcomes of pain, disability and work status, particularly in the long term.

Search methods

We searched the CENTRAL, MEDLINE, EMBASE, PsycINFO and CINAHL databases in January and March 2014 together with

carrying out handsearches of the reference lists of included and related studies, forward citation tracking of included studies and

screening of studies excluded in the previous version of this review.

Selection criteria

All studies identified in the searches were screened independently by two review authors; disagreements regarding inclusion were resolved

by consensus. The inclusion criteria were published randomised controlled trials (RCTs) that included adults with non-specific LBP of

longer than 12 weeks duration; the index intervention targeted at least two of physical, psychological and social or work-related factors;

and the index intervention was delivered by clinicians from at least two different professional backgrounds.

1Multidisciplinary biopsychosocial rehabilitation for chronic low back pain (Review)


mailto:[email protected]

Data collection and analysis

Two review authors extracted and checked information to describe the included studies, assessed risk of bias and performed the analyses.

We used the Cochrane risk of bias tool to describe the methodological quality. The primary outcomes were pain, disability and work

status, divided into the short, medium and long term. Secondary outcomes were psychological functioning (for example depression,

anxiety, catastrophising), healthcare service utilisation, quality of life and adverse events. We categorised the control interventions as

usual care, physical treatment, surgery, or wait list for surgery in separate meta-analyses. The first two comparisons formed our primary

focus. We performed meta-analyses using random-effects models and assessed the quality of evidence using the GRADE method. We

performed sensitivity analyses to assess the influence of the methodological quality, and subgroup analyses to investigate the influence

of baseline symptom severity and intervention intensity.

Main results

From 6168 studies identified in the searches, 41 RCTs with a total of 6858 participants were included. Methodological quality ratings

ranged from 1 to 9 out 12, and 13 of the 41 included studies were assessed as low risk of bias. Pooled estimates from 16 RCTs provided

moderate to low quality evidence that MBR is more effective than usual care in reducing pain and disability, with standardised mean

differences (SMDs) in the long term of 0.21 (95% CI 0.04 to 0.37) and 0.23 (95% CI 0.06 to 0.4) respectively. The range across all

time points equated to approximately 0.5 to 1.4 units on a 0 to 10 numerical rating scale for pain and 1.4 to 2.5 points on the Roland

Morris disability scale (0 to 24). There was moderate to low quality evidence of no difference on work outcomes (odds ratio (OR) at

long term 1.04, 95% CI 0.73 to 1.47). Pooled estimates from 19 RCTs provided moderate to low quality evidence that MBR was more

effective than physical treatment for pain and disability with SMDs in the long term of 0.51 (95% CI -0.01 to 1.04) and 0.68 (95%

CI 0.16 to 1.19) respectively. Across all time points this translated to approximately 0.6 to 1.2 units on the pain scale and 1.2 to 4.0

points on the Roland Morris scale. There was moderate to low quality evidence of an effect on work outcomes (OR at long term 1.87,

95% CI 1.39 to 2.53). There was insufficient evidence to assess whether MBR interventions were associated with more adverse events

than usual care or physical interventions.

Sensitivity analyses did not suggest that the pooled estimates were unduly influenced by the results from low quality studies. Subgroup

analyses were inconclusive regarding the influence of baseline symptom severity and intervention intensity.

Authors’ conclusions

Patients with chronic LBP receiving MBR are likely to experience less pain and disability than those receiving usual care or a physical

treatment. MBR also has a positive influence on work status compared to physical treatment. Effects are of a modest magnitude and

should be balanced against the time and resource requirements of MBR programs. More intensive interventions were not responsible

for effects that were substantially different to those of less intensive interventions. While we were not able to determine if symptom

intensity at presentation influenced the likelihood of success, it seems appropriate that only those people with indicators of significant

psychosocial impact are referred to MBR.

P L A I N L A N G U A G E S U M M A R Y

Multidisciplinary treatment for back pain

Review question

Is treatment involving a team of therapists from several different clinical professions helpful for people with long-term back pain?

Background

Low back pain (LBP) is a condition that causes a great deal of pain and suffering across the world and also accounts for large costs to

society due to healthcare spending and missed work. Previous research has shown that LBP that has persisted for several months or

years is often associated with psychological and social problems. Multidisciplinary treatments target physical as well as psychological

and social aspects of LBP and involve a team of healthcare providers with different professional backgrounds and training.

Study characteristics

We collected all the published studies up to February 2014; there were 41 studies (with 6858 participants) that compared multidis-

ciplinary treatment to other treatments. Most studies compared a multidisciplinary treatment to usual care (such as care by a general



practitioner) or to treatments that only addressed physical factors (such as exercise or physiotherapy). All the people in the studies had

LBP for more than three months and most had received some other sort of treatment previously.

Key results

There was moderate quality evidence that multidisciplinary treatment results in larger improvements in pain and daily function than

usual care or treatments aimed only at physical factors. The difference was not very large, about 1 point on a 10 point scale for pain,

but this may be important for people whose symptoms have not responded to other treatments. There was also moderate evidence that

multidisciplinary treatment doubled the likelihood that people were able to work in the next 6 to 12 months compared to treatments

aimed at physical factors.

While these programs seem to be more effective than alternatives, the effects needs to be balanced with their costs in terms of money,

resources and time. Multidisciplinary treatment programs are often quite intensive and expensive, so they are probably most appropriate

for people with quite severe or complex problems.



S U M M A R Y O F F I N D I N G S F O R T H E M A I N C O M P A R I S O N [Explanation]

Multidisciplinary compared to usual care for chronic low back pain

Patient or population: Patients with chronic low back pain

Intervention: Multidisciplinary Biopsychosocial Rehabilitation

Comparison: Usual care

Outcomes Baseline Comparative effect (95% CI) No. of participants

(studies)

Quality of the evidence

(GRADE)

Comments

Back pain long term

0-10 Numerical or visual

scale, where 0 equals no

pain at all and 10 is the

worst pain imaginable.

Follow-up: median 12

mth

# The baseline for the

most representative

study is 5.8 out of 10

The mean back pain long term in the MBR groups

was

0.21 standard deviations lower

(0.37 to 0.04 lower)

821

(7 studies)

⊕⊕⊕©

moderate1

This is a small effect that

may be clinically relevant

in this patient group

Disability long term

Mostly Roland Morris

24-point scale where 0

equals no disability at all

and 24 is seriously dis-

abled.


mth


most representative


The mean disability long term in the MBR groups was


(0.4 to 0.06 lower)

722

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⊕⊕⊕©

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This is a small effect that

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Assumed risk*

Usual care

Corresponding risk

MBR

Relative effect

(95% CI)

Work long term

Proportion working


mth

744 per 1000 751 per 1000

(679 to 810)

OR 1.04

(0.73 to 1.47)

1360

(7 studies)

⊕⊕⊕©

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This difference is not sta-

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vant

Adverse events not estimable not estimable not estimable 0 No evidence

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B A C K G R O U N D

Description of the condition

Low back pain (LBP) and the associated disability are responsible

for a significant personal burden globally. Recent epidemiological

research suggests LBP is the leading cause of years lived with dis-

ability (Vos 2012). There is also a substantial societal burden, with

costs attributable to healthcare services and to loss of work produc-

tivity running into the billions of dollars annually in many west-

ern countries (Maetzal 2002). Lifetime prevalence rates are high,

approaching 70% to 80% according to some studies, and a sig-

nificant proportion of patients develop chronic symptoms lasting

three months or more (Henschke 2008). Chronic LBP results in

ongoing personal suffering for the involved individuals and most

of the substantial economic costs associated with the condition

(Lambeek 2011; Maetzal 2002). The focus of this review was on

patients with chronic LBP.

Description of the intervention

Despite the large volume of clinical research focused on identifying

effective treatments for chronic LBP (Artus 2010; Ferreira 2010;

Machado 2009) optimal management remains a source of con-

tention (Koes 2010). One treatment approach is founded on the

conceptualisation of LBP as a biopsychosocial problem (Waddell

2004). This approach is supported by the observation that LBP,

particularly at the chronic stage, is characterised by a combination

of physical, psychological and social dysfunctions (Costa 2009).

Further, it appears that psychological and social factors may play

a role in the development and maintenance of pain and disability

(den Hollander 2010; Linton 2011; Nicholas 2011). This has led

to the design of interventions to address multiple factors, typically

involving a combination of physical, psychological and educa-

tional components and often delivered by a team of clinicians with

different skills (Guzman 2006; Smeets 2006). Recent decades have

seen an increase in research into a multidisciplinary approach due

to wider acceptance of the biopsychosocial model (Foster 2011),

the ineffectiveness of monotherapies (Artus 2010), and promising

reports from clinical practice. Multidisciplinary biopsychosocial

rehabilitation (MBR) may be delivered in multidisciplinary pain

clinics, rehabilitation centres or outpatient settings.

Recent Cochrane reviews have addressed behavioural treatment

for chronic LBP (Henschke 2011), physical conditioning pro-

grams for improving work outcomes in workers with back pain

(Schaafsma 2013), and individual patient education for LBP

(Engers 2008). These reviews generally report small effects that

arise from single-discipline interventions in the population of

interest. Karjalainen 2003 investigated the effects of multidisci-

plinary treatments on subacute back pain, however they identified

only two studies that met their inclusion criteria. The previous ver-

sion of this Cochrane review was published in 2001, with searches

performed up to 1998. It has subsequently been withdrawn by

The Cochrane Collaboration due to being out of date (Guzman

2006).

How the intervention might work

The theoretical basis of the intervention comes from the biopsy-

chosocial model (Waddell 2004). According to the theory, chronic

LBP involves impairments of physical, psychological and social

functioning, and effective treatment requires intervention that

specifically addresses these problems. Multidisciplinary biopsy-

chosocial rehabilitation includes elements aimed at improving

back-related physical dysfunction as well as addressing psycholog-

ical issues or targeting social or work-related behaviours, or both.

There is some evidence from systematic reviews to suggest that

these interventions may have a positive effect on work participa-

tion outcomes in the long term (Norlund 2009; van Geen 2007).

Why it is important to do this review

Although promising, it is notable that MBR often involves invest-

ment of substantial staffing and financial resources by the heath-

care system. The indirect costs burden employers, insurance com-

panies and patients as well. The value of MBR has often been ques-

tioned because data are lacking regarding its effectiveness and cost-

effectiveness (Smeets 2009). While two meta-analyses on the ef-

fectiveness of MBR have been published (Cutler 1994; Flor 1992),

they were completed more than 20 years ago and are now clearly

out of date. More recently performed reviews have not included a

quantitative synthesis of the evidence. The most recent Cochrane

review that directly assessed the effectiveness of MBR on patients

with chronic LBP was published in 2001, but this review was

withdrawn in 2006 because the literature search was out of date

(Guzman 2006). Collection and synthesis of the evidence relevant

to the effectiveness of MBR for chronic LBP was overdue.

O B J E C T I V E S

To review the evidence on the effectiveness of MBR for patients

with chronic LBP. The focus was on comparisons with usual care

and with physical treatments measuring outcomes of pain, disabil-

ity and work status, particularly in the long term.

M E T H O D S



Criteria for considering studies for this review

Types of studies

Only randomised controlled trials (RCTs) published in full in

peer-reviewed journals were included, all other study types were

excluded.

Types of participants

RCTs that investigated male or female participants, or both, with

non-specific chronic LBP and who were older than 18 years of age

were included. Chronic LBP was defined as back pain that had

persisted for 12 weeks or more. If a RCT recruited LBP patients

with a mixed duration of symptoms (that is it also included pa-

tients with < 12 weeks duration), it was included if data for the

chronic LBP patients were presented separately or if greater than

75% of participants had symptoms for more than 12 weeks. Tri-

als that recruited patients with spinal pain at any level were in-

cluded if > 75% of participants had LBP. Trials including partic-

ipants with clearly diagnosed radiculopathy or only patients who

had back surgery in the previous 12 months were excluded. Trials

were also excluded if they included participants with specific LBP

caused by infection, neoplasm, metastasis, rheumatoid arthritis or

other inflammatory articular conditions (for example ankylosing

spondylitis), spinal stenosis or fracture. Diagnoses such as disc de-

generation or bulging discs, facet joint dysfunction and sacroiliac

joint pain were included in the review.

Types of interventions

MBR was defined as an intervention that involves a physical com-

ponent (for example an exercise program) and at least one other

element from the biopsychosocial model, that is psychological or

social and occupational. The intervention program had to have

been delivered by clinicians from different disciplines, that is a

minimum of two healthcare professionals from different profes-

sional backgrounds had to be involved in the intervention delivery.

The different components of the intervention had to be offered

as an integrated program involving communication between the

providers responsible for the different components. We expected

clinicians would include physicians, psychologists, physiothera-

pists, social workers, occupational therapists and exercise thera-

pists.

The authors acknowledge that there is no consensus regarding the

definition of multidisciplinary treatment. We chose to align our

conceptualisation of multidisciplinary treatment with a biopsy-

chosocial model of LBP and included studies with interventions

that addressed at least two parts of the model (Guzman 2006;

Ravenek 2010; van Geen 2007). While there is some overlap (in

terms of included studies) with the Cochrane review of behavioural

treatments (Henschke 2011), the review of physical conditioning

as part of a return to work strategy (Schaafsma 2013), and the re-

view of back schools (Heymans 2010), we expected that the total

set of included trials would be substantially different.

Any type of control intervention was included, but the following

comparisons were evaluated separately. Comparisons 1 and 2 rep-

resent the main focus of this review.

1. MBR versus usual care.

2. MBR versus physical treatment.

3. MBR versus surgery.

4. MBR versus waiting list.

Where there was more than one MBR program assessed against a

non-MBR control in the same trial, the more intensive program

was used in the comparison. Studies that compared different MBR

programs with each other were included and described but be-

tween group differences were not synthesised.

Types of outcome measures

Patient-centred outcomes formed the principle target for this re-

view. Outcomes were categorised in three groups according to the

follow-up time after randomisation.

• Short term: up to three months.

• Medium term: > three months and less than 12 months.

• Long term: 12 months or more.

Where a study reported multiple follow-up times, the time points

closest to three, six and 12 months were used in the meta-analyses.

Primary outcomes

• Pain

• Back-specific disability or functional status

• Work status (return to work, sick leave)

Measures collected at long-term follow-up were considered pri-

mary outcomes.

Secondary outcomes

• Generic health or quality of life (QoL)

• Healthcare service ulitilisation

• Global improvement

• Psychological and cognitive function (depression, anxiety,

fear avoidance, coping strategies)

• Adverse events

Search methods for identification of studies

Electronic searches

Relevant RCTs meeting our inclusion criteria were identified by

a computer-aided search of CENTRAL (The Cochrane Library),which includes the Cochrane Back Review Group Trials Register;



MEDLINE (OvidSP); EMBASE (OvidSP); PsycINFO (OvidSP)

and CINAHL (EBSCOhost) databases. Databases were searched

from 1998 (the date of the search conducted for the previous

version of this review) until January and March 2014. The search

strategies can be found in Appendix 1.

The searches were devised and run by a research librarian from

the Cochrane Back Review Group according to their guidelines

(Furlan 2009). A highly sensitive search strategy for retrieval of

controlled trials was run in conjunction with specific searches for

LBP and multidisicplinary treatment. We considered RCTs pub-

lished in any language.

All search results were screened independently by two of three

authors (SK, AA, AC). Clearly ineligible studies were excluded

based on title and abstract. Full text articles were retrieved for all

remaining studies and these were again screened independently by

two authors for inclusion. Disagreements regarding inclusion were

resolved via consensus or via a third author (RO), where necessary.

Searching other resources

Following the electronic searches, the reference lists of relevant

publications were screened; these included systematic reviews rel-

evant to the topic and studies included in this review. Citation

tracking of included RCTs was also conducted using Science Cita-

tion Index. All articles included in the previous version of this re-

view (Guzman 2006) were included and studies listed as excluded

in that review were screened against the inclusion criteria.

Data collection and analysis

Selection of studies

Studies were included in the review according to the following

inclusion criteria:

• randomised controlled trial (RCT);

• included adult patients with chronic LBP;

• compared MBR intervention with a control intervention or

waiting list;

• published as full text in a peer-reviewed journal.

Data extraction and management

Data were extracted from all included studies by one author (SK)

and checked by a second author (AC). Extracted data included the

following.

• Population characteristics: participant source or setting,

mean age, gender proportions, duration of symptoms, baseline

pain and disability measures.

• Intervention characteristics: description of interventions

(index and control), duration and number of sessions, delivery

type (e.g. individual or group), clinicians responsible for delivery.

• Outcome data (baseline and follow-up): pain, disability or

function, work-related outcomes, global improvement,

healthcare service utilisation, QoL, psychological function,

adverse events.

Outcome data were entered into RevMan for analysis.

Assessment of risk of bias in included studies

Risk of bias was assessed using the Cochrane Back Review Group

risk of bias tool (Furlan 2009). Assessments were conducted in-

dependently by two authors (SK, AA) and disagreements were re-

solved by consensus. Where necessary, a third author (RO) was

involved to resolve disagreements. Sensitivity analyses using the

results of the risk of bias assessments are described below.

Measures of treatment effect

Clinical homogeneity regarding the control intervention, outcome

measure and timing of measurement was assessed prior to pooling.

Random-effects models were used to quantify pooled treatment

effect sizes.

Unit of analysis issues

All included studies randomised participants and analysed results

at the individual patient level.

Dealing with missing data

For meta-analysis of continuous outcomes we extracted and anal-

ysed group means, standard deviations and sample sizes at each

follow-up point. For dichotomous outcomes we used event counts

and sample sizes. Where medians instead of means were reported,

these were substituted into the analysis. Where follow-up stan-

dard deviations were not reported, we used the standard deviation

for the same measure at baseline, or follow-up, as a substitute.

Where neither the baseline or follow-up standard deviation was

reported, we calculated an estimate of the standard deviation from

the same measure reported in other studies within the comparison.

Attempts were made to contact authors of the original studies to

supply data where insufficient data were reported in the article.

Where no estimate was possible using the aforementioned meth-

ods, the data were not used in the meta-analysis.

Assessment of heterogeneity

I2 statistics were inspected and taken into account when assessing

the quality of evidence; they were not used to determine whether

or not to perform meta-analysis. in the GRADE assessment the

quality of the evidence for an effect was downgraded by one level

for inconsistency where the I2 statistic was greater than 60% (that

is substantial heterogeneity as described in the Cochrane Handbookfor Systematic Reviews of Interventions (Higgins 2011)).



Assessment of reporting biases

Inspection of funnel plots was conducted to investigate reporting

bias where there were sufficient trials in a particular comparison.

Data synthesis

Dichotomous outcomes were analysed by calculating the pooled

odds ratio (OR). Continuous outcomes were analysed by calcu-

lating the pooled mean difference (MD) when the same instru-

ment was used to measure outcomes, or the standardised mean

difference (SMD) when different instruments were used. The un-

certainty was expressed with 95% confidence intervals (95% CI).

The outcome measures from the individual trials were combined

through meta-analysis where possible (in terms of clinical compa-

rability of population, intervention and outcomes between trials)

using random-effects models.

We assessed the overall quality of the evidence for each outcome

using the GRADE approach, as recommended in the CochraneHandbook for Systematic Reviews of Interventions (Higgins 2011)

and by the Cochrane Back Review Group (Furlan 2009). Factors

that may decrease the quality of the evidence were: study design

and risk of bias, inconsistency of results, indirectness, imprecision

and other factors (for example reporting bias). The quality of the

evidence for a specific outcome was reduced by a level according to

the performance of the studies in a particular comparison against

these five factors. The quality of evidence was graded down by one

level for risk of bias where any studies included in a comparison

did not meet the threshold of six items on the risk of bias scale

(Furlan 2009). The quality of the evidence was downgraded for

inconsistency of results where the I2 statistic was greater than 60%

(substantial heterogeneity according to the Cochrane Handbook forSystematic Reviews of Interventions), and graded down for precision

where there were less than a total of 400 participants in the com-

parison (Guyatt 2011).

Subgroup analysis and investigation of heterogeneity

We conducted pre-planned subgroup analyses based on the fol-

lowing parameters.

• Baseline symptom intensity. Studies were categorised

according to the mean score for all participants at baseline on a

pain scale and a back-specific disability measure. Where mean

scores were 60% or greater of the scale maximum for both pain

and disability the studies were categorised as high intensity, all

others others were considered low intensity.

• Intervention intensity. Interventions that involved more

than 100 face-to-face hours delivered on a daily basis were

categorised as high intensity, and interventions that involved less

that 30 hours delivered on a non-daily basis were categorised as

low intensity for the subgroup analyses. Other interventions were

categorised as mid-intensity and were excluded from these

subgroup analyses (Guzman 2006).

In cases where insufficient information was reported to categorise

a study, the study was excluded from the subgroup analysis.

Sensitivity analysis

We performed sensitivity analyses to see if the overall estimates of

effectiveness changed when only evidence from studies with low

risk of bias was considered. Two definitions of low risk of bias

were defined: 1) fulfilling six or more risk of bias criteria, and 2)

reporting adequate concealment of treatment allocation.

R E S U L T S

Description of studies

Results of the search

The electronic searches yielded a total of 6168 potentially eligi-

ble titles, a further 11 articles where identified through checking

of reference lists and citation tracking. Following the search and

screening and retrieval of 164 full text articles, 31 studies were

determined to be eligible (Figure 1). These were added to the 10

studies included in the previous version of the review to make a

total of 41 included studies.



Figure 1. Study flow diagram.



Included studies

Most of the included studies were conducted in Europe (33 stud-

ies), three were from Iran, three from North America, and two

from Australia. Sample sizes ranged from 20 to 542, with a total of

6858 participants included (Characteristics of included studies).

Sixteen studies reported on a comparison of MBR with usual care,

19 with physical treatment, two with surgery, and four with a wait

list; 12 studies reported comparisons between two different types

of MBR intervention, see below. Participants in the included stud-

ies were usually referred to rehabilitation units by primary care

practitioners or insurance providers. In most studies the average

age of participants was between 40 and 45 years, gender balance

was varied, and the average duration of symptoms was usually

more than one year. Four studies reported high baseline symptom

intensity (> 60% on pain and disability scales), 33 studies were

categorised as low baseline symptom intensity, and there were in-

sufficient data reported to categorise four studies. Fifteen studies

reported high intervention intensity (> 100 hours contact time

delivered on a daily basis), 15 studies were categorised as low in-

tervention intensity (< 30 hours contact time delivered on a non-

daily basis), and 11 studies were neither high nor low intensity

according to these criteria.

1. MBR versus usual care (Abbassi 2012; Basler 1997; Bendix

’A’ 1996/1998; Lambeek 2010; Linton 2005; Lukinmaa 1989;

Mitchell 1994; Moix 2003; Morone 2011; Morone 2012;

Skouen 2002; Strand 2001; Tavafian 2008; Tavafian 2011;

Vollenbroek-Hutten 2004; Von Korff 2005).

2. MBR versus physical treatment (Alaranta 1994; Bendix ’B’

1995/1998; Bendix ’C’ 2000; Coole 2013; Harkapaa 1989;

Henchoz 2010; Jousset 2004; Kaapa 2006; Kool 2007; Mangels

2009; Monticone 2013; Morone 2012; Nicholas 1991; Nicholas

1992; Roche 2007/2011; Schweikert 2006; Smeets 2006/2008;

Streibelt 2009; Turner 1990).

3. MBR versus surgery (Fairbank 2005; Hellum 2011).

4. MBR versus waiting list (Jackel 1990; Kole-Snijders 1999;

Smeets 2006/2008; Turner 1990).

Studies that compared two MBR programs: Abbassi 2012; Bendix

’B’ 1995/1998; Harkapaa 1989; Kole-Snijders 1999; Leeuw 2008;

Linton 2005; Mangels 2009; Meng 2011; Nicholas 1991; Skouen

2002; Smeets 2006/2008; Van den Hout 2003.

Excluded studies

There were 133 studies retrieved in full text format and eventually

excluded (Characteristics of excluded studies). The most common

reasons for exclusion were: study design other than RCT, inclu-

sion of participants other than those with chronic LBP, and index

interventions that did not include two or more elements of the

biopsychosocial model or were not delivered by clinicians of dif-

ferent clinical backgrounds.

Risk of bias in included studies

Included studies met one to nine of the 12 criteria for low risk of

bias. Thirteen of the 41 studies (32%) were assessed as low risk of

bias since they met six or more criteria (Figure 2; Figure 3).



Figure 2. Risk of bias graph: review authors’ judgements about each risk of bias item presented as

percentages across all included studies.



Figure 3. Risk of bias summary: review authors’ judgements about each risk of bias item for each included

study.



Allocation

All studies were described as randomised but only 29 studies clearly

described an adequate randomisation procedure, and 23 studies

described concealment of allocation.

Blinding

The nature of the interventions and the primary outcomes (pain

and disability) meant that blinding of patients, clinicians or asses-

sors was not possible in the included studies.

Incomplete outcome data

A total of 26 studies reported outcome data that met the criteria for

completeness, 16 studies reported an intention-to-treat analysis.

Selective reporting

The criterion regarding the potential presence of reporting bias

was assessed on a strict basis. A study was only listed as low risk

of bias if the fact that all collected outcomes were reported was

explicitly stated in the manuscript, or all the outcomes listed in a

published protocol of the study were reported in the manuscript.

Only one study met this criterion.

Other potential sources of bias

Sufficient information to determine that randomised groups were

comparable at baseline was reported in 31 studies, treatment com-

pliance was assessed as adequate in seven studies, and risk of bias

arising from the use of co-interventions was assessed as low in six

studies. Timing of assessment was clearly the same across groups

in 40 studies.

Funnel plots were created for comparisons with at least 10 included

studies (Higgins 2011) and they were inspected visually to assess

the risk of publication bias (Figure 4; Figure 5; Figure 6). Three

analyses (pain and disability in the short term and disability in the

long term) in the MBR versus physical treatment comparison met

this criterion. None of the plots showed substantial asymmetry

aside from one outlying medium-sized study that reported very

large effects in favour of MBR (Monticone 2013).

Figure 4. Funnel plot of comparison: MBR versus physical treatment. Pain short term.



Figure 5. Funnel plot of comparison: MBR versus physical treatment. Disability short term.



Figure 6. Funnel plot of comparison: MBR versus physical treatment. Disability long term.

Effects of interventions

See: Summary of findings for the main comparison

Multidisciplinary compared to usual care for chronic low back

pain; Summary of findings 2 Multidisciplinary compared to

physical treatment for chronic low back pain; Summary of

findings 3 Multidisciplinary compared to surgery for chronic low

back pain; Summary of findings 4 Multidisciplinary compared

to wait list for chronic low back pain

MBR versus usual care

Primary outcomes

Sixteen studies reported on the effect of a MBR intervention versus

usual care. More details regarding the content of the interventions

are provided in the individual study descriptions (Characteristics

of included studies). Between six and nine studies provided data

for pain outcomes at each time point (total n = 740 to 879), six

to nine studies for disability outcomes (total n = 722 to 939) and

two to seven for work outcomes (total n = 373 to 1360).

For pain, point estimates for the pooled between group differences

ranged from 0.21 to 0.60 (SMD) in the short, medium and long

term (Figure 7; Figure 8; Figure 9); in all cases the 95% CIs did

not cross zero, indicating a statistically significant effect in favour

of MBR over usual care. For disability, estimates ranged from 0.23

to 0.43 (SMD) and were all significant in favour of MBR (Figure

10; Figure 11; Figure 12). The pooled effects on work outcomes

ranged from 1.4 to 1.6 (OR) and were not statistically significant

at any time point (Figure 13; Figure 14; Figure 15).



Figure 7. Forest plot of comparison: 1 Multidisciplinary versus usual care, outcome: 1.1 Back pain short

term.

Figure 8. Forest plot of comparison: 1 Multidisciplinary versus usual care, outcome: 1.2 Back pain medium

term.

Figure 9. Forest plot of comparison: 1 Multidisciplinary versus usual care, outcome: 1.3 Back pain long term.



Figure 10. Forest plot of comparison: 1 Multidisciplinary versus usual care, outcome: 1.4 Disability short

term.

Figure 11. Forest plot of comparison: 1 Multidisciplinary versus usual care, outcome: 1.5 Disability medium

term.

Figure 12. Forest plot of comparison: 1 Multidisciplinary versus usual care, outcome: 1.6 Disability long

term.



Figure 13. Forest plot of comparison: 1 Multidisciplinary versus usual care, outcome: 1.7 Work short term.

Figure 14. Forest plot of comparison: 1 Multidisciplinary versus usual care, outcome: 1.8 Work medium

term.

Figure 15. Forest plot of comparison: 1 Multidisciplinary versus usual care, outcome: 1.9 Work long term.

The effects on pain and disability translated to approximately 0.5

to 1.4 points on a 0 to 10 numerical rating scale (NRS) and 1.4 to

2.5 points on a 0 to 24 Roland Morris Disability Questionnaire,

respectively. The lower end of the estimate was reported for long-

term outcomes and the upper end for short and medium-term

outcomes.

The included studies provided low quality evidence that MBR was

more effective than usual care on pain in the short and medium

term, and moderate quality evidence for the effect in the long term.

The quality of evidence for the effect on disability was moderate

at all time points. The quality of evidence for no effect on work



outcomes was low in the short and medium term and moderate in

the long term. The quality of evidence was downgraded for risk of

bias for all outcomes and further downgraded for inconsistency for

some outcomes (Summary of findings for the main comparison).

Heterogeneity

Pooled estimates should be considered in the light of significant

statistical heterogeneity amongst the effect sizes of the included

studies; in six (of the nine) instances the I2 statistic was in excess

of the ’moderate’ threshold of 30%, in three instances it was above

the ’substantial’ threshold of 60%.

Sensitivity analyses

In general, the pooled effect sizes from the high quality studies were

of similar magnitude to those from all included studies, and this

was the case regardless of how high quality was defined. However,

few studies met the high quality criteria, which resulted in larger

CIs around the estimates and meant that some estimates that were

significant in the complete analysis were no longer significant in

the sensitivity analysis. Overall, inclusion of low quality studies

in the meta analyses did not appear to result in a bias towards

overestimation of the effect of MBR versus usual care.

Subgroup analyses

While a subgroup analysis for symptom intensity was planned,

only one study in the comparison met our a priori determined

criteria for high mean baseline pain and disability intensity.

A second subgroup analysis was performed on intervention inten-

sity. In most cases the effect estimates from high and low intensity

interventions were quite similar and there was substantial overlap

of CIs. There was no pattern of smaller or larger effects for either

intervention category. Overall, the intensity of the intervention

appeared to have little influence on the effect of MBR versus usual

care (Analysis 5.2; Analysis 5.4; Analysis 5.6; Analysis 5.8; Analysis

5.10; Analysis 5.12; Analysis 5.14; Analysis 5.16; Analysis 5.18).

Secondary outcomes

Three studies reported on QoL (Short Form (SF)-36) outcomes in

the short and medium term that could be used to calculate pooled

effect sizes. Precision was low but these analyses suggested an effect

on the SF-36 mental components subscale (MD in the short term

of 15.25, in the medium term of 7.59) in favour of MBR (Analysis

1.11; Analysis 1.13), but no effect on the physical components

subscale (MD in the short term of 13.45, in the medium term of

7.41) (Analysis 1.10; Analysis 1.12). Pooled estimates of effect on

psychological outcomes showed a statistically significant effect in

favour of MBR on catastrophising in the short term (SMD 0.43)

(Analysis 1.14) and long term (SMD 0.40) (Analysis 1.15) and an

effect on fear avoidance at the long (SMD of 0.29) (Analysis 1.17),

but not the short term (SMD of 0.69) (Analysis 1.16). The only

study that mentioned adverse events (Lambeek 2010) reported

none in the MBR group, it was unclear whether adverse events in

the usual care group were recorded.

MBR versus physical treatment

Nineteen studies reported on the effect of an MBR intervention

versus physical treatment; more details regarding the content of

the interventions are provided in the individual study descriptions

(Characteristics of included studies). Between 9 and 12 studies

provided data for the pain outcomes at each time point (total n

= 531 to 1661), 8 to 13 studies for disability outcomes (total n

= 511 to 1878) and 3 to 8 for work outcomes (total n = 221 to

1006).

For pain, pooled estimates were in favour of MBR and ranged

from 0.28 to 0.51 (SMD) with a statistically significant effect in

the short and medium term (Figure 16; Figure 17) but not at long

term (Figure 18). For disability, effects ranged from 0.21 to 0.68

(SMD) in favour of MBR; they were significant for the short and

long term (Figure 19; Figure 20) but not for medium term (Figure

21).



Figure 16. Forest plot of comparison: 2 Multidisciplinary versus physical treatment, outcome: 2.1 Pain short

term.

Figure 17. Forest plot of comparison: 2 Multidisciplinary versus physical treatment, outcome: 2.2 Pain

medium term.

Figure 18. Forest plot of comparison: 2 Multidisciplinary versus physical treatment, outcome: 2.3 Pain long

term.



Figure 19. Forest plot of comparison: 2 Multidisciplinary versus physical treatment, outcome: 2.4 Disability

short term.


long term.




medium term.

Pooled effect sizes on pain and disability in the short and long

term were heavily influenced by one low risk of bias study that

reported a very large effect, three to five times the size of the effects

reported by the other studies (SMD 1.99 to 5.32) (Monticone

2013). Inclusion of this study introduced substantial heterogeneity

into the meta-analyses. Removal from the pooled analyses reduced

the I2 values substantially, from 81% to 92% to 0% to 49% for

pain, and from 88% to 94% to 60% to 61% for disability. If

this study was removed from the meta-analyses, the pooled effect

estimates for pain ranged from 0.14 to 0.28 (SMD) and were

statistically significant in the short and medium term but not long

term, and for disability the estimates ranged from 0.18 to 0.21

(SMD) and they were statistically significant in the short but not

medium or long term.

For work outcomes, the between group differences at short term

were not significant (Figure 22) but there were significant ORs of

1.87 to 2.14 in favour of MBR for the medium and long term

(Figure 23; Figure 24).

Figure 22. Forest plot of comparison: 2 Multidisciplinary versus physical treatment, outcome: 2.7 Work

short term.




medium term.


long term.

The effects on pain and disability translated to approximately 0.6

to 1.2 points on a 0 to 10 NRS and 1.2 to 4.0 points on a 0 to 24

Roland Morris Disability Questionnaire, respectively. The upper

end of the estimates was reported for the outcomes at long term.

Regarding work outcomes, the estimates indicated that people

receiving a MBR intervention had approximately twice the odds

of those receiving a purely physical treatment of being at work six

and 12 months after the intervention.

The included studies provided low quality evidence that MBR was

more effective than physical treatment on pain and disability in

the short and long term, and moderate quality evidence for the

effect in the medium term. For work outcomes, there was low

quality evidence of no effect at short term, low quality evidence of

a positive effect at medium term, and moderate quality evidence

of an effect at long term (Summary of findings 2).

Heterogeneity

Pooled estimates should be considered in the light of significant

statistical heterogeneity amongst the effect sizes of the included

studies. For all six pain and disability comparisons the I2 statistic

was in excess of the ’moderate’ threshold of 30%, and in four in-

stances it was above the ’substantial’ threshold of 60% (Higgins

2011). Removal of the outlier study from the analyses generally

reduced inconsistency from substantial to moderate levels. Statis-

tical heterogeneity was minor for work outcomes.

Sensitivity analyses

For pain and disability outcomes the effect sizes for the short and

long-term analyses from the high quality studies were comparable

to those from the complete analyses. In many cases, however, the

estimate was no longer statistically significant, likely because of

the reduced precision due to fewer included studies. For pain and

disability in the medium term, the estimates were substantially

lower for the first sensitivity analysis but comparable for the sec-

ond as compared to the complete analyses. In all cases, both the

sensitivity analyses and the complete analysis effect estimates were



non-significant. For work outcomes at short and medium term,

sensitivity analyses had only one or two studies included, making

interpretation difficult. For long-term work outcomes, estimates

from the high quality studies were very similar to those from the

complete analyses. Overall, inclusion of low quality studies in the

meta-analysis did not appear to result in a bias towards overesti-

mation of the effect of MBR versus physical treatment.

Subgroup analyses

The participants in two studies were categorised as having high

baseline symptom intensity according to our criteria. One of these

studies (Monticone 2013) reported a very large effect in favour of

MBR, three to five times the size of the effects reported by other

studies in the comparison. Due to the influence of this study, the

estimates of effect for high baseline symptom intensity were sub-

stantially larger than those for low intensity. Given these circum-

stances, the influence of baseline symptom intensity on the effect

of MBR versus physical rehabilitation was unclear.

The low intensity interventions had substantially larger effect esti-

mates for pain and disability at all time points, although only one

estimate (for pain at short term) was statistically significant; there

was substantial overlap of CIs around the estimates for the two

intervention types. No low intensity intervention studies reported

work outcomes, hence the influence of this variable could not

be assessed. The influence of intervention intensity on the effect

of MBR versus physical rehabilitation was unclear (Analysis 6.2;

Analysis 6.4; Analysis 6.6; Analysis 6.8; Analysis 6.10; Analysis

6.12; Analysis 6.14; Analysis 6.16; Analysis 6.18).

Secondary outcomes

Three studies reported QoL (SF-36) outcomes in the short and

medium term that could be used to calculate pooled effect sizes

(Analysis 2.10; Analysis 2.11). Precision was low and the results

showed no difference between the groups. Two studies contributed

to a pooled estimate of the effect on the number of healthcare visits

in the long term (Analysis 2.12), which showed no difference be-

tween groups. Seven studies reported on depression (Analysis 2.13;

Analysis 2.14; Analysis 2.15), anxiety (Analysis 2.21; Analysis

2.22) and self-efficacy (Analysis 2.19; Analysis 2.20); the pooled

estimates showed no effect in the short, medium or long term.

Pooled effects of MBR on coping were statistically significant in

the medium and long term (Analysis 2.17; Analysis 2.18) but not

in the short term (Analysis 2.16). No included studies reported

adverse events specifically associated with the study interventions.

One study reported ’side effects’ (Smeets 2006/2008), although

it was not clear that these were actually adverse events associated

with the study interventions.

MBR versus surgery

Two studies reported on the effect of an MBR intervention versus

surgery, both studies reported pain and disability in the long term

(total n = 423) and one study reported on work outcome in the

long term (n = 133).

The pooled effect estimates were not significantly different be-

tween MBR and surgery for pain (SMD of 0.25) (Figure 25), dis-

ability (SMD of 0.25) (Figure 26) or work; the quality of the ev-

idence was low (Summary of findings 3). In both studies adverse

events associated with the surgical interventions were reported: 19

complications in Fairbank 2005 and six complications in Hellum

2011 with no complications reported in the MBR group in either

study (Figure 27).

Figure 25. Forest plot of comparison: 3 Multidisciplinary versus surgery, outcome: 3.1 Pain long term.



Figure 26. Forest plot of comparison: 3 Multidisciplinary versus surgery, outcome: 3.2 Disability long term.

Figure 27. Forest plot of comparison: 3 MBR versus surgery, outcome: 3.4 Adverse events/complications.

Sensitivity and subgroup analyses were not conducted for this

comparison due to the small number of included studies.

MBR versus waiting list

Four studies reported on the effect of an MBR intervention versus

a waiting list control, and three studies (total n = 213) reported

on pain and disability in the short term.

For pain there was a statistically significant difference of 0.73

(SMD) (Figure 28), and for disability a statistically significant dif-

ference of 0.49 (SMD) (Figure 29) in the short term. These esti-

mates translated to a difference of approximately 1.7 points on a

0 to 10 pain NRS and 2.9 on a 0 to 24 Roland Morris Disability

Questionnaire. The quality of the evidence was very low for pain

and low for disability.

Figure 28. Forest plot of comparison: 4 Multidisciplinary versus wait list, outcome: 4.1 Pain short term.



Figure 29. Forest plot of comparison: 4 Multidisciplinary versus wait list, outcome: 4.2 Disability short term.

Sensitivity and subgroup analyses were not conducted for this

comparison due to the small number of included studies.

Other included studies

Twelve studies compared outcomes from two different MBR in-

terventions. A description of these individual studies is provided

(Characteristics of included studies) but pooled between group

analyses were not conducted. We made this decision because such

comparisons did not address the question of whether MBR is more

effective that alternative interventions.



A D D I T I O N A L S U M M A R Y O F F I N D I N G S [Explanation]

Multidisciplinary compared to physical treatment for chronic low back pain



Comparison: Physical treatment

Outcomes Baseline Comparative effect (95% CI) No. of participants

(studies)


(GRADE)

Comments

Pain long term

0-10 Numerical or visual

scale, where 0 equals no

pain at all and 10 is the

worst pain imaginable.


mth


most representative study

is 4.5 out of 10

The mean pain long term in the MBR groups was


(1.04 lower to 0.01 higher)

872

(9 studies)

⊕⊕©©

low1,2

This is a moderate ef-

fect that is probably clin-

ically relevant in this pa-

tient group


Various


mth


most representative study

is 51 out of 100 on the

Daily Activities subscale

of the Dallas Question-

naire; 0 equals no disabil-

ity and 100 is seriously

disabled



(1.19 to 0.16 lower)

1169

(10 studies)

⊕⊕©©

low1,2




tient group

Assumed risk*

Physical treatment

Corresponding risk

MBR

Relative effect

(95% CI)

Work long term

Proportion working


mth

659 per 1000 783 per 1000

(729 to 830)

OR 1.87

(1.39 to 2.53)

1006

(8 studies)

⊕⊕⊕©

moderate1




tient group


28

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http://www.thecochranelibrary.com/view/0/SummaryFindings.html

#Of the included trials for this outcome, we chose the study that used a NRS pain scale that has the largest weighting in the overall result in Revman (Roche 2007/2011). This figure

represents the baseline mean in the control group of this particular study

*The basis for the assumed risk is the median control group risk across studies. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison

group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; OR: Odds ratio

1 High risk of bias in included studies2 Substantial heterogeneity, I2 >60%


29

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pain

(Revie

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Multidisciplinary compared to surgery for chronic low back pain



Comparison: Surgery

Outcomes Baseline Comparative effects (95% CI) No. of participants

(studies)


(GRADE)

Comments

Pain long term

SF-36 Pain subscale;

where 100 equals pain-

free


mth


most representative


The mean pain long term in the MBR groups was

0.25 standard deviations higher


385

(2 studies)

⊕⊕©©

low1,2



vant


Oswestry; 100-point

scale where 0 equals no

disability and 100 is seri-

ously disabled.


mth


most representative



0.25 standard deviations higher


423

(2 studies)

⊕⊕©©

low1,3



vant

Assumed risk*

Surgery

Corresponding risk

MBR

Relative effect

(95% CI)

Work long term

Proportion working

Follow-up: 24 months

309 per 1000 230 per 1000 OR 0.67

(0.31 to 1.45)

133

(1 study)

⊕⊕©©

low1,2



vant

Adverse events

Adverse events due to

study interventions

127 per 1000 0 per 1000 OR 28.25

(3.77 to 211.93)

385

(2 studies)

⊕⊕©©

low1,2

This difference may be

clinically relevant in this

patient group

30

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pain

(Revie

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ratio

n.P

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lished

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#Of the included trials for this outcome, we chose the study that has the largest weighting in the overall result in Revman (Fairbank 2005). This figure represents the baseline mean in the

control group of this particular study

*The basis for the assumed risk is the median control group risk across studies. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison

group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; OR: Odds ratio

1 High risk of bias in included studies2 Total sample size <4003 Substantial heterogeneity, I2 >60%


31

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ltidisc

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bio

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pain

(Revie

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Multidisciplinary compared to wait list for chronic low back pain



Comparison: Wait list

Outcomes Assumed risk Comparative effects (95% CI) No. of participants

(studies)


(GRADE)

Comments

Pain long term

0-100 Visual scale, where

0 equals no pain at all

and 100 is the worst pain

imaginable


most representative


not estimable 0 No evidence Only short-term results

available for this compar-

ison


Mostly Roland Morris

24-point scale where 0

equals no disability at all

and 24 is seriously dis-

abled


most representative


not estimable 0 No evidence Only short-term results

available for this compar-

ison

Assumed risk

Wait List

Corresponding risk

MBR

Relative effect

(95% CI)

Work long term not estimable not estimable not estimable 0 No evidence


#Of the included trials for this outcome, we chose the study that has the largest weighting in the overall result in Revman (Smeets 2006/2008). This figure

represents the baseline mean in the control group of this particular study. The corresponding risk (and its 95% confidence interval) is based on the assumed risk

in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval

32

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D I S C U S S I O N

Summary of main results

We set out to conduct an updated review on the impact of multi-

disciplinary rehabilitation on people with chronic low back pain

(LBP). We found 31 recently published randomised clinical trials

which added to the 10 included in the previous review to form

a substantial evidence base, with data on close to 7000 people.

Overall we found that when compared with usual care, MBR de-

creased pain and disability to a moderate degree but had little to no

effect on work outcomes. When compared with physical rehabili-

tation, MBR showed moderate effects on pain, disability and work

outcomes. Although the quality of the evidence was moderate or

low depending on the comparison, the overall size of the effects of

MBR was quite consistent. They translate to an average difference

in pain of about 1 to 2 points on a 10-point scale, and an average

difference in disability of 2 to 4 points on the 24-point Roland

Morris questionnaire. The improvement of work outcomes with

MBR when compared to physical rehabilitation translates to about

double the odds of being at work 12 months later. It would seem

unlikely that conducting further RCTs will substantially change

our view of the mean effect that can be expected from MBR pro-

grams.

Several factors need to be taken into account when interpreting

our findings to formulate recommendations regarding clinical im-

plementation. The resources and costs associated with delivering

MBR programs should be considered and weighed against those

of usual care or physical training regimens. For example, MBR

in 15 of the included studies required more than 100 face-to-face

hours of training. Cost-effectiveness data were not extracted as

part of this review. The proportion of people that experienced a

clinically relevant improvement was not typically reported in the

RCTs and did not form a part of this review; as such we cannot

be sure the extent to which the between group difference reflects

an important change on behalf of the participants. On the other

hand, the people referred to these programs had long-standing

symptoms which had not responded to previous treatments. As a

longer duration of symptoms is an indicator of poor prognosis, a

modest improvement in symptom severity compared to another

treatment may be significant for this population.

For our main comparisons, pooled effects do not appear to have

been overestimated due to inclusion of low quality studies. The

influence of baseline symptom intensity on the effectiveness of

MBR is unclear because the subgroup analyses were hampered by

the small numbers of studies that included samples with symp-

tom intensity that met our a priori threshold. Samples recruited

to the included studies typically reported moderate levels of pain

intensity (4 to 6 points on the NRS) and disability (8 to 12 points

on the Roland Morris Questionnaire). When we divided the in-

cluded studies according to the hours of face-to-face intervention

we did not find a consistent pattern in favour of either high or low

intensity interventions.

The inconsistent nature of data collection and reporting made

drawing conclusions regarding the secondary outcomes of quality

of life, healthcare utilisation and adverse events difficult. Compa-

rable estimates for these outcomes were reported by too few studies

to estimate the effect of MBR. MBR did not appear to have any

additional significant effect on symptoms of depression compared

to physical rehabilitation.

Only two and four RCTs, respectively, were included in compar-

isons of MBR with surgery or waiting list controls. From each

comparison a pooled estimate was generated for pain and disabil-

ity at one time point. There was low quality evidence of no signif-

icant difference between MBR and surgery. The effects in favour

of MBR versus waiting list controls were of moderate size, but

the quality of the evidence was very low to low. While 12 studies

included a comparison of one MBR intervention versus another,

we did not perform a synthesis of these data. Synthesis was not

undertaken as it does not directly inform decisions as to whether

MBR or some other intervention should be administered in this

patient group.

Overall completeness and applicability ofevidence

Work outcomes and healthcare utilisation are key considerations

for assessing the effects of MBR in this population, since they

are primary determinants of the societal burden of the condition

(Maetzal 2002). Many of the included studies did not report these

outcomes, and when reported they were measured in different

ways. The lack of standardisation of measurement in these areas

makes quantitative synthesis of the body of evidence problematic.

For example, in the MBR versus physical treatment comparison

13 of the 19 studies reported a work-related outcome measure yet

only three, three and eight studies (short, medium, long term)

could be included in the meta-analyses. The fact that these data

were not reported in a comparable manner limits our ability to

estimate the true effect of MBR for this critical outcome.

The subgroup analysis that investigated the influence of high base-

line symptom intensity proved inconclusive, largely because so

few studies recruited a sample with high enough intensity. The

threshold we chose to indicate high intensity (greater than 60% of

the maximum possible score on a pain and a disability measure) is

admittedly arbitrary, but it is surprising that only three of the 41

included studies met this criterion. While there is evidence that

higher symptom severity at presentation is a prognostic indicator

of poor outcome following MBR (van de Hulst 2005; van Hooff

2014; Verkerk 2013), direct evidence that it is a modifier of the

effect of MBR is lacking. It could be argued that only those with

severe physical symptoms and psychological dysfunction are likely

to require, and therefore preferentially benefit from, a compre-

hensive MBR program. Matching of a more comprehensive and

complex intervention with more clinically complex patients makes



intuitive sense, and this is supported by recent evidence from the

primary care setting (Hill 2011).


Only 32% of the included studies met our threshold for low risk

of bias (fulfilling at least six items from the CBRG risk of bias

tool) and not surprisingly all meta-analyses included studies with

high risk of bias. We applied a stringent rule that inclusion of

any (one or more) studies at high risk of bias in a meta-analysis

meant downgrading the quality of the evidence by one level within

the GRADE system. Such decisions involve a degree of subjec-

tive judgement and a more relaxed interpretation of the risk of

bias may have resulted in the conclusion that the quality of the

evidence in support of the effectiveness of MBR was stronger. To

explore this issue we conducted sensitivity analyses. Although not

conclusive, the sensitivity analyses did not indicate that inclusion

of lower quality studies resulted in overestimation of the effect.

This, along with the consistency of the size of the pooled effects

on pain and disability, gives confidence that the reported estimates

for the primary outcomes are robust. Quality of evidence was also

commonly downgraded for inconsistency, this was particularly ev-

ident when one outlying study was included in the meta analyses.

Exclusion of this study resulted in more consistent and precise

pooled estimates for pain and disability across the time points in

the MBR versus physical treatment comparison, and provides fur-

ther evidence that the estimates are robust.

Potential biases in the review process

There is no universally accepted definition of what constitutes

MBR. The authors have chosen a definition based on their inter-

pretation of the biopsychosocial model and reflective of the differ-

ent expertise within the various clinical professions. Presumably

it is possible that selection of a different definition could result in

inclusion of different studies and hence different effect estimates.

The MBR interventions evaluated in the included studies differed

from each other in a number of ways. There were differences in

the number of face-to-face sessions and the intensity of the treat-

ment; differences in the settings; differences in the balance of the

interventions in terms of focus on physical, psychological and so-

cial factors; and differences in the backgrounds of the clinicians

that administered the interventions. This clinical heterogeneity

is likely due to varying conceptualisations of MBR and also to

uncertainty regarding the pathological cause of non-specific LBP.

Further heterogeneity is also introduced by differences in the con-

trol interventions. By using a random-effects model for generat-

ing the pooled estimates and incorporating the I2 statistic into the

evidence quality assessment we have attempted to account for this

heterogeneity.

While most studies measured pain intensity in a similar manner,

there was great variability in the measures used for other domains.

Despite the efforts of initiatives such as COMET (Williamson

2012) and IMMPACT (Dworkin 2005), the findings indicate that

there is little consensus on the choice of measurement instruments.

This renders meaningful synthesis of the body of evidence difficult

and may also introduce bias as decisions must be made regarding

which outcome measures should be included in the pooled effect

estimates. In addition, the lack of a core outcome measurement

set increases the chances of selective reporting of results of trials

(Williamson 2012). Only one study in this review met the criterion

for absence of reporting bias (Tavafian 2011). It is to be hoped that

current efforts to increase the registration of trials (Costa 2012)

and publication of detailed protocols will improve this situation

in the future.

The influence of publication bias on the results is difficult to assess

due to the number of studies contributing to each pooled estimate.

Only three estimates included the minimum 10 studies recom-

mended by The Cochrane Collaboration for formal assessment of

publication bias. The funnel plots for these estimates indicate the

possibility of small study bias, a possibility also reported in the

review conducted by Norlund 2009.

Agreements and disagreements with otherstudies or reviews

Guzman 2006 reviewed the literature up to 1998 and found that

intensive MBR programs had important effects on disability out-

comes and small effects on pain. Evidence regarding work out-

comes was equivocal. A ’levels of evidence’ synthesis performed by

van Geen 2007 reported positive effects on work participation but

not on pain or disability; their study performed searches up until

2003 and included 10 studies, of which seven are in the current

review. Ravenek 2010 included 12 studies from 1998 onwards, of

which seven were common to this review, and the authors reported

conflicting evidence from low quality studies on work outcomes,

no effect on pain, and no effect on function. Norlund 2009 con-

ducted a systematic review of studies involving people with suba-

cute or chronic LBP and included three studies with chronic LBP,

all are in this review. Their meta-analysis showed no effect on re-

turn to work for MBR interventions in the chronic LBP studies.

It is somewhat surprising that the present review showed no im-

pact of MBR on work outcomes when compared to usual care but

a moderate impact when compared to physical treatment. One

possibility is that studies comparing MBR to usual care included

populations with less severe occupational impairment (thus harder

to show an impact). Another possibility is that physical treatment

when not paired with concomitant psychological or social inter-

ventions may promote a sick role and interfere with attainment of

occupational goals.

Few included studies involved an explicitly designed and focused

workplace intervention, an issue also identified by Ravenek 2010.



They also observed that occupational therapists were rarely in-

volved in multidisciplinary rehabilitation interventions despite the

fact that improvement of work-related outcomes is an often stated

goal. They and others (Ektor-Andersen 2008) also pointed out

the need for a greater degree of cooperation between workers, em-

ployers and insurers to facilitate these outcomes.

No clear conclusions can be drawn regarding whether the intensity

of the intervention had an influence on the size of the treatment

effect. While the previous version of this review suggested that this

factor may be important, a recent systematic review (Waterschoot

2014) was inconclusive and found that dose factors could not be

disentangled from content factors when determining their influ-

ence on the effect size. Individual RCTs conducted by Rose 1997

and Skouen 2002 reported no substantial differences in effect be-

tween multidisciplinary programs of differing intensity. At this

point in time it is unclear how much face-to-face time is optimal

for MBR interventions. This is a critical question given the role

of face-to-face time in driving the cost of MBR.

A U T H O R S ’ C O N C L U S I O N S

Implications for practice

Choosing an MBR intervention over usual care or a physical treat-

ment program for chronic low back pain is likely to result in a

positive effect on pain and disability outcomes. It is also likely

that MBR will have a beneficial effect on work outcomes com-

pared to physical treatment. However, given the moderate size of

these effects and the potentially high cost of an intensive interven-

tion, in terms of both the monetary and time burden, the deci-

sion to refer to MBR requires some consideration. While our sub-

group analyses were inconclusive regarding the influence of higher

or lower symptom intensity at baseline, it would appear there is

little to gain by referring those without substantial physical and

psychosocial impacts of their condition to such an intervention.

Clinical practice guidelines (Dagenais 2010) commonly recom-

mend assessment and treatment of physical and psychosocial fac-

tors and referral to appropriately trained clinicians for manage-

ment of these factors where present. This recommendation would

seem more appropriate than a recommendation of MBR simply

based on chronicity of symptoms.

Implications for research

The quality of the evidence regarding the primary outcomes is at

best moderate, although consistent in terms of effect size. Despite

this, the volume of evidence is substantial and conducting further,

similar studies is unlikely to greatly change the estimate of the

effectiveness of MBR versus usual care or physical treatment. This

being the case, it is important to consider whether the effect is clin-

ically worthwhile. The ideal methods for determining whether an

effect is clinically worthwhile are far from settled (Ferreira 2012)

but the point has been made that such an estimation needs to

take the cost of the intervention into account. In this case costs

include not only those of the intervention in terms of time, incon-

venience and money but also costs of other healthcare utilisation

(for example medications, visits to healthcare providers) and costs

of productivity losses due to low back pain, as compared to those

associated with other options.

The results of this review could be said to mirror those of others in

the low back pain field in that small effects are observed between

the index and control interventions (Hayden 2005; Henschke

2011; Rubinstein 2011). This situation is largely due to the fact

that the pathology underlying non-specific low back pain is, at

best, unclear. Given that this is the case, it is unsurprising that

the mechanism of effect of the different intervention options is

also unknown. Studies that investigate the mechanism of effect

of different treatments (Mansell 2013; Smeets 2006) and inves-

tigate the effectiveness of treatments in subgroups (Foster 2013;

Hancock 2009; Kamper 2010) of patients have the potential to

improve our understanding of the condition.

Recent studies that have conducted cost-effectiveness analyses of

MBR for chronic pain have produced conflicting results. Lambeek

2010 found that their MBR program was cost-effective compared

to usual care in the Netherlands; Smeets 2009 reported that while

graded activity plus problem solving was cost-effective compared

to a physical program, the combination of graded activity, problem

solving and physical therapy was not cost-effective compared to

physical therapy only. Interpretation of cost-effectiveness studies

requires some sophistication, not least of all consideration of to

whom the costs and benefits are apportioned. Substantial benefits

may be evident at a societal level despite a modest mean clinical

effect at an individual level, but the issue is complicated by the

question of whether the costs are borne by the state, by insurers,

or by the individual. Most of the societal costs associated with

back pain are indirect costs, primarily work productivity losses

(Lambeek 2011; Maetzal 2002). Of interest then is whether re-

search should focus on improving our capacity to identify those

people at greatest risk of work disability (prognostic studies) and

treat them distinctly from those whose back pain typically does not

result in work absences or reduced productivity. Further, incorpo-

ration into MBR of treatment modalities that specifically focus on

re-integration to the work place would be of value. It is recognised

that in order to do so communication and collaboration barriers

between employers, the healthcare system and insurance compa-

nies must be addressed.

A C K N O W L E D G E M E N T S

The authors would like to thank Teresa Marin, Rachel Couban

and Shireen Harbin from the Cochrane Back Review group for



support and for developing and conducting the electronic searches.

R E F E R E N C E S

References to studies included in this review

Abbassi 2012 {published data only}∗ Abbasi M, Dehghani M, Keefe FJ, Jafari H, Behtash H,

Shams J. Spouse-assisted training in pain coping skills and

the outcome of multidisciplinary pain management for

chronic low back pain treatment: A 1-year randomized

controlled trial. European Journal of Pain 2012;16(7):

1033–43.

Alaranta 1994 {published data only}∗ Alaranta H, Rytökoski U, Rissanen A, Talo S, Rönnemaa

T, Puukka P, et al.Intensive physical and psychosocial

training program for patients with chronic low back pain. A

controlled clinical trial. Spine 1994;19:1339–49.

Basler 1997 {published data only}∗ Basler H, Jakle C, Kroner-Herwig B. Incorporation of

cognitive behavioral treatment into the medical care of

chronic low back patients: A controlled randomized study

in German pain treatment centers. Patient Education &

Counseling 1997;31:113–24.

Bendix ’A’ 1996/1998 {published data only}

Bendix AE, Bendix T, Haestrup C, Busch E. A prospective,

randomized 5-year follow-up study of functional restoration

in chronic low back pain patients. European Spine Journal

1998;7(2):111–9.∗ Bendix AF, Bendix T, Vaegter K, Lund C, Frolund L,

Holm L. Multidisciplinary intensive treatment for chronic

low back pain: a randomized, prospective study. Cleveland

Clinic Journal of Medicine 1996;63:62–9.

Bendix ’B’ 1995/1998 {published data only}

Bendix AE, Bendix T, Haestrup C, Busch E. A prospective,

randomized 5-year follow-up study of functional restoration

in chronic low back pain patients. European Spine Journal

1998;7(2):111–9.∗ Bendix AF, Bendix T, Ostenfeld S, Bush E, Andersen A.

Active treatment programs for patients with chronic low

back pain: a prospective, randomized, observer blinded

study. European Spine Journal 1995;4:149–52.

Bendix ’C’ 2000 {published data only}∗ Bendix T, Bendix A, Labriola M, Haestrup C, Ebbehoj N.

Functional restoration versus outpatient physical training in

chronic low back pain: a randomized comparative study.

Spine 2000;25(19):2494–500.

Coole 2013 {published data only}∗ Coole C, Drummond A, Watson P. Individual work

support for employed patients with low back pain: a

randomized controlled pilot trial. Clinical Rehabilitation

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Fairbank 2005 {published data only}∗ Fairbank J, Frost H, Wilson-MacDonald J, Yu L-M,

Barker K, Collins R. Randomised controlled trial to

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an intensive rehabilitation programme for patients with

chronic low back pain: the MRC spine stabilisation trial.

BMJ 2005;330(7502):1233–8.

Rivero-Arias O, Campbell H, Gray A, Fairbank J, Frost

H. Surgical stabilisation of the spine compared with a

programme of intensive rehabilitation for the management

of patients with chronic low back pain: cost utility analysis

based on a randomised controlled trial. BMJ 2005;330

(7502):1239–43.

Harkapaa 1989 {published data only}∗ Harkapaa K, Jarvikoski A, Mellin G, Hurri H. Pain,

disability, compliance, and reported treatment benefits

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Hellum 2011 {published data only}∗ Hellum C, Johnsen LG, Storheim K, Nygaard O P,

Brox JI, Rossvoll I, et al.Surgery with disc prosthesis

versus rehabilitation in patients with low back pain and

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Henchoz 2010 {published data only}∗ Henchoz Y, de Goumoens P, So AK, Paillex R.

Functional multidisciplinary rehabilitation versus outpatient

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controlled trial. Swiss Medical Weekly 2010;140(w13133):

1–7.

Jackel 1990 {published data only}∗ Jackel WH, Cziske R, Gerdes N, Jacobi E. Assessment

of the effectiveness of inpatient rehabilitation measures

in patients with chronic low back pain: a prospective,

randomized, controlled study [German]. Rehabilitation

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Jousset 2004 {published data only}∗ Jousset N, Fanello S, Bontoux L, Dubus V, Billabert C,

Vielle B. Effects of functional restoration versus 3 hours

per week physical therapy: a randomized controlled study.

Spine 2004;29(5):487–94.

Kaapa 2006 {published data only}∗ Kaapa EH, Frantsi K, Sarna S, Malmivaara A.

Multidisciplinary group rehabilitation versus individual

physiotherapy for chronic nonspecific low back pain: a

randomized trial. Spine 2006;31(4):371–6.

Kole-Snijders 1999 {published data only}

Goossens ME, Rutten-Van Molken MP, Kole-Snijders AM,

Vlaeyen JW, Van Breukelen G, Leidl R. Health economic

assessment of behavioural rehabilitation in chronic low back



pain: a randomized clinical trial. Health Economics 1998;7:

39–51.∗ Kole-Snijders AMJ, Vlaeyen JWS, Goossens MEJB,

Rutten-Van Molken MPMH, Heuts PHTG, Van Breukelen

G, Van Eek H. Results of a randomized clinical trial. Journal

of Consulting and Clinical Psychology 1999;67(6):931–44.

Kool 2007 {published data only}∗ Kool J, Bachmann S, Oesch P, Knuesel O, Ambergen T,

de Bie R. Function-centered rehabilitation increases work

days in patients with nonacute nonspecific low back pain:

1-year results from a randomized controlled trial. Archives of

Physical Medicine and Rehabilitation 2007;88(9):1089–94.

Lambeek 2010 {published data only}

Lambeek LC, Bosmans JE, van Royen BJ, van Tulder MW,

van Mechelen W, Anema JR. Effect of integrated care for

sick listed patients with chronic low back pain: economic

evaluation alongside a randomised controlled trial. BMJ

2010;341:6414.∗ Lambeek LC, van Mechelen W, Knol DL, Loisel P, Anema

JR. Randomised controlled trial of integrated care to reduce

disability from chronic low back pain in working and

private life. BMJ 2010;340(7749):750.

Leeuw 2008 {published data only}

Leeuw M, Goossens MEJB, van Breukelen GJP, de Jong JR,

Heuts PHTG, Smeets RJEM, et al.Exposure in vivo versus

operant graded activity in chronic low back pain patients:

results of a randomized controlled trial. Pain 2008;138:

192–207.

Linton 2005 {published data only}∗ Linton SJ, Boersma K, Jansson M, Svärd L, Botvalde M.

The effects of cognitive-behavioral and physical therapy

preventive interventions on pain-related sick leave: a

randomized controlled trial. Clinical Journal of Pain 2005;

21(2):109–19.

Lukinmaa 1989 {published data only}∗ Lukinmaa A. Low back pain as a biopsychosocial problem.

A controlled clinical trial and a costeffectiveness analysis

[Finnish]. Kansanelakelaitoksen Julkaisuja 1989;ML:1–90.

Mangels 2009 {published data only}∗ Mangels M, Schwarz S, Worringen U, Holme M, Rief W.

Evaluation of a behavioral-medical inpatient rehabilitation

treatment including booster sessions: a randomized

controlled study. Clinical Journal of Pain 2009;25(5):

356–64.

Meng 2011 {published data only}∗ Meng K, Seekatz B, Roband H, Worringen U, Vogel

H, Faller H. Intermediate and long-term effects of

a standardized back school for inpatient orthopedic

rehabilitation on illness knowledge and self-management

behaviors: a randomized controlled trial. Clinical Journal of

Pain 2011;27(3):248–57.

Mitchell 1994 {published data only}∗ Mitchell RI, Carmen GM. The functional restoration

approach to the treatment of chronic pain in patients with

soft tissue and back injuries. Spine 1994;19:633–42.

Moix 2003 {published data only}∗ Moix J, Canellas M, Osorio C, Bel X, Girvent F, Martos

A. Efficacy of an interdisciplinary educational program in

patients with chronic back pain [Spanish]. Dolor 2003;18

(3):149–57.

Monticone 2013 {published data only}∗ Monticone M, Ferrante S, Rocca B, Baiardi P, Dal Farra F,

Foti C. Effect of a long-lasting multidisciplinary program

on disability and fear-avoidance behaviors in patients with

chronic low back pain: results of a randomized controlled

trial. Clinical Journal of Pain 2013;29(11):929–38.

Morone 2011 {published data only}∗ Morone G, Paolucci T, Alcuri MR, Vulpiani MC, Matano

A, Bureca I. Quality of life improved by multidisciplinary

back school program in pat ents with chronic non-specific

low back pain: a single blind randomized controlled trial.

Europan Journal of Physical and Rehabilitation Medicine

2011;47(4):533–41.

Morone 2012 {published data only}∗ Morone G, Iosa M, Paolucci T, Fusco A, Alcuri R, Spadini

E. Efficacy of perceptive rehabilitation in the treatment of

chronic nonspecific low back pain through a new tool: a

randomized clinical study. Clinical Rehabilitation 2012;26

(4):339–50.

Nicholas 1991 {published data only}∗ Nicholas MK, Wilson PH, Goyen J. Operant-behavioural

and cognitive behavioural treatment for chronic low back

pain. Behavioural Research and Therapy 1991;29:225–38.

Nicholas 1992 {published data only}∗ Nicholas MK, Wilson PH, Goyen J. Comparison of

cognitive behavioral group treatment and an alternative

non-psychological treatment for chronic low back pain.

Pain 1992;48:339–47.

Roche 2007/2011 {published data only}∗ Roche G, Ponthieux A, Parot-Shinkel E, Jousset N,

Bontoux L, Dubus V. Comparison of a functional

restoration program with active individual physical therapy

for patients with chronic low back pain: a randomized

controlled trial. Archives of Physical Medicine and

Rehabilitation 2007;88(10):1229–35.

Roche-Leboucher G, Petit-Lemanach A, Bontoux L, Dubus-

Bausiere V, Parot-Shinkel E, Fanello S. Multidisciplinary

intensive functional restoration versus outpatient active

physiotherapy in chronic low back pain: A randomized

controlled trial. Spine 2011;36(26):2235–42.

Schweikert 2006 {published data only}∗ Schweikert B, Jacobi E, Seitz R, Cziske R, Ehlert A, Knab

J. Effectiveness and cost-effectiveness of adding a cognitive

behavioral treatment to the rehabilitation of chronic low

back pain. Journal of Rheumatology 2006;33(12):2519–26.

Skouen 2002 {published data only}∗ Skouen JS, Grasdal AL, Haldorsen EM, Ursin H. Relative

cost-effectiveness of extensive and light multidisciplinary

treatment programs versus treatment as usual for patients



with chronic low back pain on long-term sick leave:

randomized controlled study. Spine 2002;27(9):901–9.

Smeets 2006/2008 {published data only}

Smeets RJ, Severens JL, Beelen S, Vlaeyen JW, Knottnerus

JA. More is not always better: cost-effectiveness analysis

of combined, single behavioral and single physical

rehabilitation programs for chronic low back pain. European

Journal of Pain 2009;13(1):71–81.

Smeets RJEM, Vlaeyen JWS, Hidding A, Kester ADM, van

der Heijden GJMG, Knottnerus JA. Chronic low back pain:

Physical training, graded activity with problem solving

training, or both? The one-year post-treatment results of a

randomized controlled trial. Pain 2008;134(8):263–76.∗ Smeets RJEM, Vlaeyen JWS, Hidding A, Kester ADM,

van der Heijden GJMG, van Geel ACM, Knottnerus

JA. Active rehabilitation for chronic low back pain:

Cognitive-behavioral, physical, or both? First direct post-

treatment results from a randomized controlled trial. BMC

Musculoskeletal Disorders 2006;7:5.

Strand 2001 {published data only}∗ Strand LI, Ljunggren AE, Haldorsen EMH, Espehaug B.

The impact of physical function and pain on work status at

1-year follow-up in patients with back pain. Spine 2001;26

(7):800–8.

Streibelt 2009 {published data only}∗ Streibelt M, Thren K, Muller-Fahrnow W. Effects of

FCE-based multidisciplinary rehabilitation in patients

with chronic musculoskeletal disorders - results of a

randomized controlled trial [German]. Physikalische

Medizin Rehabilitationsmedizin Kurortmedizin 2009;19(1):

34–41.

Tavafian 2008 {published data only}∗ Tavafian SS, Jamshidi AR, Montazeri A. A randomized

study of back school in women with chronic low back pain:

quality of life at three, six, and twelve months follow-up.

Spine 2008;33(15):1617–21.

Tavafian 2011 {published data only}∗ Tavafian SS, Jamshidi AR, Mohammad K. Treatment

of chronic low back pain: a randomized clinical trial

comparing multidisciplinary group-based rehabilitation

program and oral drug treatment with oral drug treatment

alone. Clinical Journal of Pain 2011;27(9):811–8.

Turner 1990 {published data only}

Turner JA, Clancy S, McQuade KJ, Cardenas DD.

Effectiveness of behavioral therapy for chronic low back

pain: a component analysis. Journal of Consulting and

Clinical Psychology 1990;58(5):573–9.

Van den Hout 2003 {published data only}∗ van den Hout JHC, Vlaeyen JWS, Heuts PH, Zijlema JH,

Wijnen JA. Secondary prevention of work-related disability

in nonspecific low back pain: does problem-solving therapy

help? A randomized clinical trial. Clinical Journal of Pain

2003;19(2):87–96.

Vollenbroek-Hutten 2004 {published data only}∗ Vollenbroek-Hutten MMR, Hermens HJ, Wever D,

Gorter M, Rinket J, IJerman MJ. Differences in outcome

of a multidisciplinary treatment between subgroups of

chronic low back pain patients defined using two multiaxial

assessment instruments: the Multidimensional Pain

Inventory and lumbar dynamometry. Clinical Rehabilitation

2004;18(5):566–79.

Von Korff 2005 {published data only}∗ Von Korff M, Balderson BH, Saunders K, Miglioretti

DL, Lin EH, Berry S. A trial of an activating intervention

for chronic back pain in primary care and physical therapy

settings. Pain 2005;113(3):323–30.

References to studies excluded from this review

Akhmadeeva 2009 {published data only}

Akhmadeeva L, Setchenkova N, Magzhanov R. Effectiveness

of transcutaneous dynamic electrical nerve stimulation in

low back pain: A pilot randomized controlled trial. Journal

of Neurological Sciences 2009;285:S320.

Albaladejo 2010 {published data only}

Albaladejo C, Kovacs FM, Royuela A, del Pino R, Zamora

J. The efficacy of a short education program and a short

physiotherapy program for treating low back pain in

primary care: a cluster randomized trial. Spine 2010;35(5):

483–96.

Andrade 2008 {published data only}

Andrade SC, Araujo AG, Vilar MJ. [Back school for patients

with non-specific chronic low-back pain: benefits from the

association of an exercise program with patient’s education].

[Portuguese]. Acta Reumatologica Portuguesa 2008;33(4):

443–50.

Anema 2007 {published data only}

Anema JR, Steenstra IA, Bongers PM, de Vet HC, Knol DL,

Loisel P, van Mechelen W. Multidisciplinary rehabilitation

for subacute low back pain: graded activity or workplace

intervention or both? A randomized controlled trial. Spine

2007;32(3):291–300.

Angst 2009 {published data only}

Angst F, Verra ML, Lehmann S, Brioschi R, Aeschlimann

A. Clinical effectiveness of an interdisciplinary pain

management programme compared with standard inpatient

rehabilitation in chronic pain: a naturalistic, prospective

controlled cohort study. Journal of Rehabilitation Medicine

2009;41(7):569–75.

Bachmann 2009 {published data only}

Bachmann S, Wieser S, Oesch P, Schmidhauser S, Knusel

O, Kool J. Three-year cost analysis of function-centred

versus pain-centred inpatient rehabilitation in patients with

chronic non-specific low back pain. Journal of Rehabilitation

Medicine 2009;41(11):919–23.

Bahrke 2006 {published data only}

Bahrke U, Bandemer-Greulich U, Fikentscher E, Muller

K, Schreiber B, Konzag TA. [Chronic low back pain with

endurant pain coping--optimizing rehabilitation success in a

hitherto neglected patient group]. [German]. Rehabilitation

2006;45(6):336–44.



Bandemeer-Greulich 2006 {published data only}

Bandemer-Greulich U, Schreiber B, Fikentscher E,

Bahrke U. Protective and repressive factors for success

in rehabilitation of chronic low back pain. [German].

Physikalische Medizin Rehabilitationsmedizin Kurortmedizin

2006;16(5):297–302.

Bandemeer-Greulich 2008 {published data only}

Bandemer-Greulich U, Bosse B, Fikentscher E, Konzag TA,

Bahrke U. [Efficacy of psychological interventions on pain

coping strategies in orthopedic rehabilitation of chronic

low back pain]. [German]. Psychotherapie, Psychosomatik,

Medizinische Psychologie 2008;58(1):32–7.

Basler 2007 {published data only}

Basler HD, Bertalanffy H, Quint S, Wilke A, Wolf U. TTM-

based counselling in physiotherapy does not contribute to

an increase of adherence to activity recommendations in

older adults with chronic low back pain - A randomised

controlled trial. European Journal of Pain 11;1:31–7.

Bastiaenen 2004 {published data only}

Bastiaenen CH, de Bie RA, Wolters PM, Vlaeyen

JW, Bastiaanssen JM, Klabbers AB, et al.Treatment of

pregnancy-related pelvic girdle and/or low back pain after

delivery design of a randomized clinical trial within a

comprehensive prognostic cohort study. BMC Public Health

2004;4:67.

Becker 2000 {published data only}

Becker N, Sjogren P, Bech P, Olsen AK, Eriksen J. Treatment

outcome of chronic non-malignant pain patients managed

in a Danish multidisciplinary pain centre compared to

general practice: a randomised controlled trial. Pain 2000;

84(2-3):203–11.

Becker 2008 {published data only}

Becker A, Leonhardt C, Kochen MM, Keller S, Wegscheider

K, Baum E, et al.Effects of two guideline implementation

strategies on patient outcomes in primary care: a cluster

randomized controlled trial. Spine 2008;33(5):473–80.

Bendix 1998a {published data only}

Bendix AF, Bendix T, Haestrup C. Can it be predicted

which patients with chronic low back pain should be offered

tertiary rehabilitation in a functional restoration program?

A search for demographic, socioeconomic, and physical

predictors. Spine 1998;23(16):1775–84.

Bethge 2011 {published data only}

Bethge M, Herbold D, Trowitzsch L, Jacobi C. Work status

and health-related quality of life following multimodal work

hardening: a cluster randomised trial. Journal of Back and

Musculoskeletal Rehabilitation 2011;24(3):161–72.

Binder 2007 {published data only}

Binder A. [Chronic backache with neuropathic component.

Individual basic therapy plus multimodal approach].

[German]. MMW Fortschritte der Medizin 2007;149(20):

49.

Bliokas 2007 {published data only}

Bliokas VV, Cartmill TK, Nagy BJ. Does systematic graded

exposure in vivo enhance outcomes in multidisciplinary

chronic pain management groups?. Clinical Journal of Pain

2007;23(4):361–74.

Brox 2003 {published data only}

Brox JI, Sorensen R, Friis A, Nygaard O, Indahl A, Keller

A, et al.Randomized clinical trial of lumbar instrumented

fusion and cognitive intervention and exercises in patients

with chronic low back pain and disc degeneration. Spine

2003;17:1913–21.

Buhrman 2011 {published data only}

Buhrman M, Nilsson-Ihrfeldt E, Jannert M, Strom

L, Andersson G. Guided internet-based cognitive

behavioural treatment for chronic back pain reduces pain

catastrophizing: a randomized controlled trial. Journal of

Rehabilitation Medicine 2011;43(6):500–5.

Bultman 2009 {published data only}

Bultmann U, Sherson D, Olsen J, Hansen CL,

Lund T, Kilsgaard J. Coordinated and tailored work

rehabilitation: a randomized controlled trial with economic

evaluation undertaken with workers on sick leave due

to musculoskeletal disorders. Journal of Occupational


Busch 2011 {published data only}

Busch H, Bodin L, Bergstrom G, Jensen IB. Patterns of

sickness absence a decade after pain-related multidisciplinary

rehabilitation. Pain 2011;152(8):1727–33.

Campello 2012 {published data only}

Campello M, Ziemke G, Hiebert R, Weiser S, Brinkmeyer

M, Fox B, et al.Implementation of a multidisciplinary

program for active duty personnel seeking care for low back

pain in a U.S. Navy Medical Center: a feasibility study.

Military Medicine 2012;177(9):1075–80.

Cecchi 2012 {published data only}

Cecchi F, Negrini S, Pasquini G, Paperini A, Conti AA,

Chiti M, et al.Predictors of functional outcome in patients

with chronic low back pain undergoing back school,

individual physiotherapy or spinal manipulation. European

Journal of Physical and Rehabilitation Medicine 2012;48(3):

371–8.

Christiansen 2010 {published data only}

Christiansen S, Oettingen G, Dahme B, Klinger R. A short

goal-pursuit intervention to improve physical capacity: a

randomized clinical trial in chronic back pain patients. Pain

2010;149(3):444–52.

Demoulin 2006 {published data only}

Demoulin C, Maquet D, Tomasella M, Croisier J, Crielaard

J, Vanderthommen M. Benefits of a physical training

program after back to school for chronic low back pain

patients. Journal of Musculoskeletal Pain 2006;14(2):21–31.

Dibbelt 2006 {published data only}

Dibbelt S, Greitemann B, Schel C. Long-term efficiency

of orthopedic rehabilitation in chronic back pain -- the

integrative orthopedic psychosomatic concept (IopKo)

[German]. Rehabilitation 2006;45(6):324–35.

Dobscha 2009 {published data only}

Dobscha SK, Corson K, Perrin NA, Hanson GC, Leibowitz

RQ, Doak MN, et al.Collaborative care for chronic pain in



primary care: a cluster randomized trial. JAMA 2009;301

(12):1242–52.

Donzelli 2006 {published data only}

Donzelli S, Di Domenica F, Cova AM, Galletti R, Giunta

N. Two different techniques in the rehabilitation treatment

of low back pain: A randomized controlled trial. Europa

Medicophysica 2006;42(3):205–10.

Driessen 2011a {published data only}

Driessen MT, Proper KI, Anema JR, Knol DL, Bongers

PM, van der Beek AJ. Participatory ergonomics to reduce

exposure to psychosocial and physical risk factors for low

back pain and neck pain: results of a cluster randomised

controlled trial. Occupational and Environmental Medicine

2011;68(9):674–81.

Driessen 2011b {published data only}

Driessen MT, Proper KI, Anema JR, Knol DL, Bongers

PM, van der Beek AJ. The effectiveness of participatory

ergonomics to prevent low-back and neck pain - results of a

cluster randomized controlled trial. Scandinavian Journal of

Work, Environment and Health 2011;37(5):383–93.

Dufour 2010 {published data only}

Dufour N, Thamsborg G, Oefeldt A, Lundsgaard C, Stender

S. Treatment of chronic low back pain: a randomized,

clinical trial comparing group-based multidisciplinary

biopsychosocial rehabilitation and intensive individual

therapist-assisted back muscle strengthening exercises. Spine

35;5:469–76.

Dysvik 2005 {published data only}

Dysvik E, Natvig GK, Eikeland OJ, Brattberg G. Results of

a multidisciplinary pain management program: A 6- and

12-month follow-up study. Rehabilitation Nursing 2005;30

(5):198–206.

Ektor-Andersen 2008 {published data only}

Ektor-Andersen J, Ingvarsson E, Kullendorff M, Orbaek

P. High cost-benefit of early team-based biomedical and

cognitive-behaviour intervention for long-term pain-related

sickness absence. Journal of Rehabilitation Medicine 40;1:

1–8.

Esmer 2010 {published data only}

Esmer G, Blum J, Rulf J, Pier J. Mindfulness-based stress

reduction for failed back surgery syndrome: a randomized

controlled trial. Journal of the American Osteopathic

Association 2010;110(11):646–52.

Ewert 2009 {published data only}

Ewert T, Limm H, Wessels T, Rackwitz B, Von Garnier K,

Freumuth R, Stucki G. The comparative effectiveness of a

multimodal program versus exercise alone for the secondary

prevention of chronic low back pain and disability. Physical

Medicine and Rehabilitation 2009;1(9):798–808.

Ferrari 2006 {published data only}

Ferrari R, Fipaldini E, Birbaumer N. Individual

characteristics and results of biofeedback training and

operant treatment in patients with chronic pain. [Italian].

Psicoterapia Cognitiva e Comportamentale 2006;12(2):

161–79.

Friedberg 2010 {published data only}

Friedberg MW. Group cognitive behavioral treatment

improves chronic low back pain in a cost-effective manner.

Journal of Clinical Outcomes Management 2010;17(6):7–9.

Friedrich 1998 {published data only}

Friedrich M, Gittler G, Halberstadt Y, Cermak T, Heiller I.

Combined exercise and motivation program: effect on the

compliance and level of disability of patients with chronic

low back pain: A randomized controlled trial. Archives of

Physical Medical Rehabilitation 1998;79:475–87.

Friedrich 2005 {published data only}

Friedrich M, Gittler G, Arendasy M, Friedrich KM. Long-

term effect of a combined exercise and motivational

program on the level of disability of patients with chronic

low back pain. Spine 2005;30(9):995–1000.

Froholdt 2011 {published data only}

Froholdt A, Holm I, Keller A, Gunderson RB, Reikeraas O,

Brox JI. No difference in long-term trunk muscle strength,

cross-sectional area, and density in patients with chronic

low back pain 7 to 11 years after lumbar fusion versus

cognitive intervention and exercises. Spine Journal 2011;11

(8):718–25.

Froholdt 2012 {published data only}

Froholdt A, Reikeraas O, Holm I, Keller A, Brox JI. No

difference in 9-year outcome in CLBP patients randomized

to lumbar fusion versus cognitive intervention and exercises.

European Spine Journal 2012;21(12):2531–8.

Frost 1998 {published data only}

Frost H, Lamb SE, Klaber Moffett JA, Fairbank JC, Moser

JS. A fitness programme for patients with chronic low back

pain: 2-year follow-up of a randomised controlled trial.

Pain 1998;75(2-3):273–9.

Gatchel 2003 {published data only}

Gatchel RJ, Polatin PB, Noe C, Gardea M, Pulliam C,

Thompson J. Treatment- and cost-effectiveness of early

intervention for acute low-back pain patients: a one-year

prospective study. Journal of Occupational Rehabilitation

2003;13(1):1–9.

George 2009 {published data only}

George SZ, Teyhen DS, Wu SS, Wright A, Dugan JL,

Yang G, et al.Psychosocial education improves low back

pain beliefs: results from a cluster randomized clinical trial

(NCT00373009). The Journal of Orthopaedic and Sports

Physical Therapy 2009;39(1):A30–1.

George 2010a {published data only}

George SZ, Robinson ME. Patient satisfaction with

behavioral physical therapy interventions: secondary

analysis from a randomized clinical trial. The Journal of

Orthopaedic and Sports Physical Therapy 2010;40(1):A22.

George 2010b {published data only}

George SZ, Wittmer VT, Fillingim RB, Robinson ME.

Comparison of graded exercise and graded exposure clinical

outcomes for patients with chronic low back pain. The

Journal of Orthopaedic and Sports Physical Therapy 2010;40

(11):694–704.



George 2011 {published data only}

George SZ, Childs JD, Teyhen DS, Wu SS, Wright AC,

Dugan JL, Robinson ME. Brief psychosocial education,

not core stabilization, reduced incidence of low back pain:

Results from the Prevention of Low Back Pain in the

Military (POLM) cluster randomized trial. BMC Medicine

2011;9:128.

Glattacker 2012 {published data only}

Glattacker M, Heyduck K, Meffert C. Illness beliefs,

treatment beliefs and information needs as starting points

for patient information-Evaluation of an intervention for

patients with chronic back pain. Patient Education &

Counseling 2012;86(3):378–89.

Glombiewski 2010 {published data only}

Glombiewski JA, Hartwich-Tersek J, Rief W. Two

psychological interventions are effective in severely disabled,

chronic back pain patients: a randomised controlled trial.

International Journal of Behavioral Medicine 2010;17(2):

97–107.

Glomsrod 2001 {published data only}

Glomsrod B, Lonn JH, Soukup MG, Bo K, Larsen

S. “Active back school”, prophylactic management for

low back pain: Three-year follow-up of a randomized,

controlled trial. Journal of Rehabilitation Medicine 2001;33

(1):26–30.

Gohner 2006 {published data only}

Gohner W, Schlicht W. Preventing chronic back pain:

evaluation of a theory-based cognitive-behavioural training

programme for patients with subacute back pain. Patient

Education & Counseling 2006;64(1-3):87–95.

Greitemann 2006 {published data only}

Greitemann B, Dibbelt S, Buschel C. [Multidisciplinary

orthopedic rehabilitation program in patients with chronic

back pain and need for changing job situation -- long-term

effects of a multimodal, multidisciplinary program with

activation and job development]. [German]. Zeitschrift fur

Orthopadie und Ihre Grenzgebiete 2006;144(3):255–66.

Hagen 2006 {published data only}

Hagen EM. [Does light mobilization treatment reduce

long-term sick leave for low back pain? ] [Norwegian].

Norsk Epidemiologi 2006;16(2):137–44.

Hagen 2010 {published data only}

Hagen EM, Odelien KH, Lie SA, Eriksen HR. Adding

a physical exercise programme to brief intervention for

low back pain patients did not increase return to work.

Scandinavian Journal of Public Health 2010;38(7):731–8.

Hallegraeff 2009 {published data only}

Hallegraeff JM, de Greef M, Winters JC, Lucas C.

Manipulative therapy and clinical prediction criteria in

treatment of acute nonspecific low back pain. Perceptual

and Motor Skills 2009;108(1):196–208.

Hampel 2009 {published data only}

Hampel P, Graef T, Krohn-Grimberghe B, Tlach L.

Effects of gender and cognitive-behavioral management

of depressive symptoms on rehabilitation outcome among

inpatient orthopedic patients with chronic low back pain:

A 1 year longitudinal study. European Spine Journal 2009;

18(12):1867–80.

Henchoz 2010a {published data only}

Henchoz Y, de Goumoens P, Norberg M, Paillex R, So AK.

Role of physical exercise in low back pain rehabilitation:

a randomized controlled trial of a three-month exercise

program in patients who have completed multidisciplinary

rehabilitation. Spine 2010;35(12):1192–9.

Henchoz 2010b {published data only}

Henchoz Y, Pinget C, Wasserfallen JB, Paillex R, de

Goumoens P, Norberg M, Kai-Lik So A. Cost-utility

analysis of a three-month exercise programme vs usual care

following multidisciplinary rehabilitation for chronic low

back pain. Journal of Rehabilitation Medicine 2010;42(9):

846–52.

Heymans 2006 {published data only}

Heymans MW, de Vet HC, Bongers PM, Knol DL, Koes

BW, van Mechelen W. The effectiveness of high-intensity

versus low-intensity back schools in an occupational setting:

a pragmatic randomized controlled trial. Spine 2006;31

(10):1075–82.

Hlobil 2005 {published data only}

Hlobil H, Staal JB, Twisk J, Koke A, Ariens G, Smid

T, van Mechelen W. The effects of a graded activity

intervention for low back pain in occupational health on

sick leave, functional status and pain: 12-Month results

of a randomized controlled trial. Journal of Occupational


Hodselmans 2001 {published data only}

Hodselmans AP, Jaegers SM, Goeken LN. Short-term

outcomes of a back school program for chronic low back

pain. Archives of Physical and Medical Rehabilitation 2001;

82:1099–105.

Huge 2006 {published data only}

Huge V, Schloderer U, Steinberger M, Wuenschmann

B, Schops P, Beyer A, Azad SC. Impact of a functional

restoration program on pain and health-related quality of

life in patients with chronic low back pain. Pain Medicine

2006;7(6):501–8.

Jensen 2005 {published data only}

Jensen IB, Bergstrom G, Ljungquist T, Bodin L. A 3-year

follow-up of a multidisciplinary rehabilitation programme

for back and neck pain. Pain 2005;115(3):273–83.


Jensen I, Bergstrom G, Bodin L, Ljungquist T, Nygren

A. [Effects of rehabilitation after seven years. Evaluation

of two rehabilitation programs in Sweden]. [Swedish].

Lakartidningen 2007;103(23):1829–30.


Jensen IB, Busch H, Bodin L, Hagberg J, Nygren A,

Bergstrom G. Cost effectiveness of two rehabilitation

programmes for neck and back pain patients: A seven year

follow-up. Pain 2009;152(3):202–8.




Jensen C, Jensen OK, Christiansen DH, Nielsen CV. One-

year follow-up in employees sick-listed because of low back

pain: randomized clinical trial comparing multidisciplinary

and brief intervention. Spine 2011;36(15):1180–9.


Jensen, C.Jensen, O. K.Nielsen, C. V. Sustainability of

return to work in sick-listed employees with low-back

pain. Two-year follow-up in a randomized clinical trial

comparing multidisciplinary and brief intervention. BMC

Musculoskeletal Disorders 2012;13:156.


Jensen C, Nielsen CV, Jensen O, Petersen K. Cost-

effectiveness and cost-benefit analyses of a multidisciplinary

intervention compared with a brief intervention to facilitate

return to work in sick-listed patients with low back pain.

Spine 2013;38(13):1059–67.

Johnson 2013 {published data only}

Johnsen LG, Brinckmann P, Hellum C, Rossvoll I, Leivseth

G. Segmental mobility, disc height and patient-reported

outcomes after surgery for degenerative disc disease: a

prospective randomised trial comparing disc replacement

and multidisciplinary rehabilitation. Bone & Joint Journal

2013;95B(1):81–9.

Kainz 2006 {published data only}

Kainz B, Lich M, Engel E, Ckel WH. Comparison of three

outpatient therapy forms for treatment of chronic low back

pain -- findings of a multicentre, cluster randomized study

[German]. Rehabilitation 2006;45(2):65–77.

Kolip 2001 {published data only}

Kolip P, Czujek J, Greitemann B, Rosowski E, Schmidt

B, Slangen K. [“Zest for life instead of strain of illness” -

implementation and evaluation of a programme activating

chronic back pain patients in a rehabilitation clinic]

[German]. Die Rehabilitation 2001;40(5):267–74.

Kumar 2010 {published data only}

Kumar S, Sharma VP, Shukla R, Dev R. Comparative

efficacy of two multimodal treatments on male and female

sub-groups with low back pain. Journal of Back and

Musculoskeletal Rehabilitation 2010;23(1):1–9.

Lamb 2010 {published data only}

Lamb SE, Hansen Z, Lall R, Castelnuovo E, Withers EJ,

Nichols V, et al.Group cognitive behavioural treatment for

low-back pain in primary care: a randomised controlled

trial and cost-effectiveness analysis. Lancet 2010;75(9718):

916–23.

Lang 2003 {published data only}

Lang E, Liebig K, Kastner S, Neundorfer B, Heuschmann P.

Multidisciplinary rehabilitation versus usual care for chronic

low back pain in the community: effects on quality of life.

Spine Journal 2003;3(4):270–6.

Lee 2013 {published data only}

Lee WYA, Lee WCE, Law SW, Lau WKA, Leung SM, Sieh

KM, et al.Managing psychosocial contributors in low back

pain patients--a randomised controlled trial. Journal of

Orthopaedics, Trauma and Rehabilitation 2013;17:46–51.

Le Gall 2001 {published data only}

Le Gall S, Ozguler A, Piciotti M, Morel-Fatio M, Leclerc

A, Boureau F. Predictive factors of chronic low-back pain

and evaluation of a multidisciplinary pain management

program in a population still in activity. [French]. Archives

des Maladies Professionnelles et de Medecine du Travail 2001;

62(7):575.

Leon 2009 {published data only}

Leon Mateos L, Jover Jover JA, Abasolo Alcazar L, Loza

Santamaria E, Perez Nieto MA, Redondo Delgado MM.

Functional recovery in low back pain: Efficacy of an early

cognitive behavioral intervention. Arthritis and Rheumatism

(Arthritis Care and Research) 2009;61(7):996–1003.

Lindell 2008 {published data only}

Lindell O, Johansson SE, Strender LE. Subacute and

chronic, non-specific back and neck pain: cognitive-

behavioural rehabilitation versus primary care. A

randomized controlled trial. BMC Musculoskeletal Disorders

2008;9:172.

Linton 2000 {published data only}

Linton SJ, Andersson T. Can chronic disability be

prevented? A randomized trial of a cognitive-behavior

intervention and two forms of information for patients with

spinal pain. Spine 2000;25(21):2825–31.

Ljungkvist 2000 {published data only}

Ljungkvist I. Short- and long-term effects of a 12-week

intensive functional restoration programme in individuals

work-disabled by chronic spinal pain. Scandinavian Journal

of Rehabilitation Medicine. Supplement 2000;40:1–14.

Loisel 2002 {published data only}

Loisel P, Lemaire J, Poitras S, Durand MJ, Champagne F,

Stock S, et al.Cost-benefit and cost-effectiveness analysis of

a disability prevention model for back pain management: a

six year follow up study. Occupational and Environmental

Medicine 2002;59(12):807–15.

Lonn 1999 {published data only}

Lønn JH, Glomsrød B, Soukup MG, Bø K, Larsen S. Active

back school: prophylactic management for low back pain.

A randomized, controlled, 1-year follow-up study. Spine

1999;24(9):865–71.

Mannion 2001 {published data only}

Mannion AF, Müntener M, Taimela S, Dvorak J.

Comparison of three active therapies for chronic low back

pain: results of a randomized clinical trial with one-year

follow-up. Rheumatology 2001;40(7):772–8.

Mannion 2013 {published data only}

Mannion AF, Brox JI, Fairbank JCT. Comparison of spinal

fusion and nonoperative treatment in patients with chronic

low back pain: Long-term follow-up of three randomized

controlled trials. Spine Journal 2013;11:1438–48.

Martin 2000 {published data only}

Martin C, Carney T, Obonyo T, Lamont L. Setting up a

pain management programme. The Ayrshire experience.

Scottish Medical Journal 2000;45(2):45–8.



Mattila 2007 {published data only}

Mattila R, Malmivaara A, Kastarinen M, Kivel SL, Nissinen

A. The effects of lifestyle intervention for hypertension on

low back pain: a randomized controlled trial. Spine 2007;

32(26):2943–7.

Meyer 2005 {published data only}

Meyer K, Fransen J, Huwiler H, Uebelhart D, Klipstein

A. Feasibility and results of a randomised pilot-study of

a work rehabilitation programme. Journal of Back and

Musculoskeletal Rehabilitation 2005;18:67–78.

Mohr 2009 {published data only}

Mohr B, Krohn-Grimberghe B, Graf T, Schulze J,

Petermann F, Hampel P. [Patients with chronic low back

pain: the impact of psychosocial features]. [German].


Molde 2003 {published data only}

Molde Hagen E, Grasdal A, Eriksen HR. Does early

intervention with a light mobilization program reduce long-

term sick leave for low back pain: a 3-year follow-up study.

Spine 2003;28(20):2309–15.

Nazzal 2013 {published data only}

Nazzal ME, Saadah MA, Saadah LM, Al-Omari MA,

Al-Oudat ZA, Nazzal MS, et al.Management options of

chronic low back pain. A randomized blinded clinical trial.

Neurosciences 2013;18(2):152–9.

Nicholas 2013 {published data only}

Nicholas MK, Asghari A, Blyth FM, Wood BM, Murray R,

McCabe R, et al.Self-management intervention for chronic

pain in older adults: A randomised controlled trial. Pain

2013;154(6):824–35.

Niemisto 2005 {published data only}

Niemisto YL, Rissanen P, Sarna S, Lahtinen-Suopanki

T, Lindgren K, Hurri H. Cost-effectiveness of combined

manipulation, stabilizing exercises, and physician

consultation compared to physician consultation alone for

chronic low back pain: a prospective randomized trial with

2-year follow-up. Spine 2005;30(10):1109–15.

Padua 2009 {published data only}

Padua R, Bondi R, Ceccarelli E, Alviti F. A randomized

study of back school in women with chronic low back pain.

Quality of life at three, six, and twelve months follow-up.

Spine 2009;34(12):1336.

Paolucci 2012 {published data only}

Paolucci T, Morone G, Iosa M, Fusco A, Alcuri R, Matano

A, Bureca I, Saraceni VM, Paolucci S. Psychological

features and outcomes of the Back School treatment in

patients with chronic non-specific low back pain. A

randomized controlled study. European Journal of Physical

and Rehabilitation Medicine 2012;48(2):245–53.

Rainville 2002 {published data only}

Rainville J, Jouve CA, Hartigan C, Martinez E, Hipona

MJ. Comparison of short- and long-term outcomes for

aggressive spine rehabilitation delivered two versus three

times per week. Spine 2002;2(6):402–7.

Rantonen 2012 {published data only}

Rantonen J, Luoto S, Vehtari A, Hupli M, Karppinen J,

Malmivaara A, Taimela S. The effectiveness of two active

interventions compared to self-care advice in employees with

non-acute low back symptoms: a randomised, controlled

trial with a 4-year follow-up in the occupational health

setting. Occupational and Environmental Medicine 2012;69

(1):12–20.

Rossignol 2000 {published data only}

Rossignol M, Abenhaim L, Seguin P, Neveu A, Collet JP,

Ducruet T, Shapiro S. Coordination of primary health care

for back pain. A randomized controlled trial. Spine 2000;

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Rothman 2013 {published data only}

Rothman MG, Ortendahl M, Rosenblad A, Johansson

AC. Improved quality of life, working ability, and patient

satisfaction after a pretreatment multimodal assessment

method in patients with mixed chronic muscular pain: a

randomized-controlled study. Clinical Journal of Pain 2013;

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Sahin 2011 {published data only}

Sahin N, Albayrak I, Durmus B, Ugurlu H. Effectiveness of

back school for treatment of pain and functional disability

in patients with chronic low back pain: a randomized

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Shete 2012 {published data only}

Shete KM, Suryawanshi P, Gandhi N. Management of low

back pain in computer users: A multidisciplinary approach.

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Siemonsma 2013 {published data only}

Siemonsma P, Stuive I, Roorda L, Vollebregt J, Walker M,

Lankhorst G, Lettinga A. Cognitive treatment of illness

perceptions in patients with chronic low back pain: a

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Sjostrom R, Asplund R, Alricsson M. Two-year outcome of

a multidisciplinary vocational rehabilitation programme

focused on range of motion of the neck and back. Work

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Sleptsova 2013 {published data only}

Sleptsova M, Wossmer B, Grossman P, Langewitz W.

Culturally sensitive group therapy for Turkish patients

suffering from chronic pain: A randomised controlled

intervention trial. Swiss Medical Weekly 2013;Nov:143.

Sorensen 2010 {published data only}

Sorensen PH, Bendix T, Manniche C, Korsholm L, Lemvigh

D, Indahl A. An educational approach based on a non-

injury model compared with individual symptom-based

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trial with a one-year follow-up. BMC Musculoskeletal

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Staal JB. Graded activity for low back pain in occupational

health care: a randomized, controlled trial. Annals of

Internal Medicine 2004;140(2):77–84.

Stapelfeldt 2011 {published data only}

Stapelfeldt CM, Christiansen DH, Jensen OK, Nielsen

CV, Petersen KD, Jensen C. Subgroup analyses on return

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a randomised trial comparing brief and multidisciplinary

intervention. BMC Musculoskeletal Disorders 2011;12:112.

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Steenstra IA, Anema JR, Bongers PM, de Vet HC, Knol

DL, van Mechelen W. The effectiveness of graded activity

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Stier R, Gerdes N, Buhrlen B, Haaf HG, Jackel WH.

[Reconditioning in groups: an effective programme for the

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Storheim K, Brox JI, Holm I, Koller AK, Bø K. Intensive

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Storro S, Moen J, Svebak S. Effects on sick-leave of a

multidisciplinary rehabilitation programme for chronic

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Strong LL, Von Korff M, Saunders K, Moore JE. Cost-

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Sundberg T, Petzold M, Wandell P, Ryden A, Falkenberg

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Tlach L, Hampel P. Long-term effects of a cognitive-

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Torstensen TA, Ljunggren AE, Meen HD, Odland E,

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Tsauo J, Chen W, Liang H, Jang Y. The effectiveness of a

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Turk DC, Okifuji A. Treatment of chronic pain patients:

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Underwood M. United Kingdom back pain exercise

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van Beurden KM, Vermeulen SJ, Anema JR, van der Beek

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van der Roer N, van Tulder M, Barendse J, Knol D, van

Mechelen W, De Vet H. Intensive group training protocol

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Van Hooff ML, Van Der Merwe JD, O’Dowd J, Pavlov PW,

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Verbeek JH, van der Weide WE, van Dijk FJ. Early

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Vermeulen SJ, Anema JR, Schellart AJM, Knol DL, van

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Verra ML, Angst F, Beck T, Lehmann S, Brioschi R,

Schneiter R, Aeschlimann A. Horticultural therapy for

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Vibe Fersum K, O’Sullivan P, Skouen JS, Smith A, Kvale A.

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Vlaeyen JWS, Haazen IWCJ, Schuerman JA, Kole-Snijders

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Vong SK, Cheing GL, Chan F, So EM, Chan CC.

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Wagner E, Ehrenhofer B, Lackerbauer E, Pawelak U,

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Wand BM, Bird C, McAuley JH, Dore CJ, MacDowell M,

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14651858.CD000963.pub2]∗ Indicates the major publication for the study



C H A R A C T E R I S T I C S O F S T U D I E S

Characteristics of included studies [ordered by study ID]

Abbassi 2012

Methods RCT conducted in Iran

Participants Patients referred to a pain clinic at a university medical centre with LBP >6 months,

age 18-70, married. 33 patients randomised, 88% female, average age 45 years, median

duration of pain 74 months

Interventions MBR (P-MPMP): Group Rx (6/group) 7x weekly sessions 2 hours each session, + 1

session with doctor, + 1 session with physiotherapist. Light mobilisation, coping skills

training, education regarding anatomy, physiology, medication, exercise session

Usual (SMC): standard medical care, pain medication

MBR-2 (SA-MPMP): As per P-MPMP with involvement of spouse

Outcomes Pain (VAS), disability (RMDQ), catastrophising (PCS), fear avoidance (TSK)

Follow-ups: ST (7 weeks), LT (12 months)

Notes Subgroup analyses: Low intensity intervention, Low baseline symptom intensity (<60%

of maximum scale score)

Risk of bias

Bias Authors’ judgement Support for judgement

Random sequence generation (selection

bias)

Low risk 2.3. “Patients were randomized to the three groups in blocks

of twelve using a software-generated ramdomization plan”

Allocation concealment (selection bias) Unclear risk Unclear

Blinding of participants High risk Not possible

Blinding of clinicians High risk Not possible

Blinding of outcome assessment (detection

bias)

All outcomes

High risk Not possible; patient reported outcomes

Incomplete outcome data (attrition bias)

All outcomes

Low risk Fig 1. 33 participants assessed at baseline, 29 assessed at fol-

low-up

Intention to treat analysis Low risk 2.6 Statistical analysis. “The results presented are based on

intention to treat analyses”

Selective reporting (reporting bias) Unclear risk No protocol



Abbassi 2012 (Continued)

Comparability of groups at baseline Low risk 3.1 Baseline characteristics. Groups comparable across demo-

graphic and important clinical characteristics

Compliance Low risk 3.2 Adherence. High levels of attendance across all groups

Cointerventions Unclear risk Not stated

Timing of assessment Low risk 2.4 Assessment. Measurement at baseline, end of treatment

and 12 month follow-up

Alaranta 1994

Methods RCT conducted in Finland

Participants Workers on social insurance with back pain > 6 months, age 30-47, less than 2 back

surgeries, no contraindications to exercise. 293 patients randomised, 56% female, average

age 40.5 years, mean duration of pain not reported

Interventions MBR (Akseli): 3 weeks daily HEP then 3 weeks inpatient program (42 hours per week)

. Program: strength training, aerobic training, relaxation, stretching, CBT, discussion

groups

Physical (control): 3 weeks inpatient program: passive physiotherapy (electrotherapies,

massage, traction), muscle training, pool exercises, back school

Outcomes Disability (Million Pain Disability questionnaire), Work (WHO occupational handicap

scale, sick leave days), Utilisation (reduction in physician visits, reduction in physiother-

apist visits)

Follow-ups: ST (3 months), LT (12 months)

Notes Subgroup analyses: High intensity intervention, Low baseline symptom intensity (<60%

of maximum scale score). Included in Guzman 2006

Risk of bias



bias)

Unclear risk Unclear





bias)




Alaranta 1994 (Continued)

All outcomes


All outcomes

Low risk Fig 1. Acceptable 12-month follow-up rate 287/293

Intention to treat analysis Unclear risk Unclear


Comparability of groups at baseline Low risk Table 1. Groups similar on symtpom severity, age and

work characteristics

Compliance Unclear risk Not stated


Timing of assessment Low risk Pg.1341 1st column. “The follow-up examinations were

carried out 3 months and 12 months after the clinical

baseline examination”

Basler 1997

Methods RCT conducted in Germany

Participants Patients referred to a pain treatment centre with a diagnosis of LBP. 76 patients ran-

domised, 75.6% female, average age 49.3 years, mean duration of pain 10.8 years

Interventions MBR (CBT+): 1 session /week for 12 weeks, 150min each session, group format (5-8

people per group), plus homework assignments. CBT (pain education, relaxation, mod-

ifying beliefs, pleasant activity scheduling), posture training, strengthening, stretching +

Pain meds, nerve blocks, TENS, physiotherapy

Usual (control): Pain meds, nerve blocks, TENS, physiotherapy

Outcomes Pain (NRS), Disability (Dusseldorf Disability scale - physical function subscale), Medi-

cation use (medication use in days per week), catastrophising

Follow-ups: ST (3 months)



Risk of bias



bias)

Low risk pg.115 1st column. “Through assignment of random

numbers, patienst were allocated to an experimental or

control group”



Basler 1997 (Continued)





bias)

All outcomes



All outcomes

High risk pg.118 Sample. 76 of 94 randomized patients completed

follow-up

Intention to treat analysis Unclear risk Not stated


Comparability of groups at baseline Low risk pg.118 Sample. “No signififcant differences between ex-

perimental and control subjects in these (baseline) vari-

ables”



Timing of assessment Low risk pg.115 1st column. “Three assessments

were taken: pre-treatment, post-treatment and at a 2.2.

Assessment instruments

6-month follow-up”

Bendix ’A’ 1996/1998

Methods RCT conducted in Denmark

Participants Patients referred to a back centre with disabling LBP >6 months, threatened job situation.

94 patients randomised, 70.2% female, median age 40 years, mean duration of pain not

reported

Interventions MBR (FR): 39 hours/week for 3 weeks inpatient, in groups (7/group), plus 1x 6 hour

session/week for 3 weeks). Aerobic exercise, strength, stretching, simulated work tasks,

biofeedback, pan coping, goal setting, cognitive appraisal, relaxation, job seeking skills,

recreation, ball games, running, swimming

Usual (control): Usual care in Denmark, patients free to seek any treatment

Outcomes Pain (NRS), disability (LBP rating scale), work (working or able to return to work, days

of sick leave), improvement (global rating of change), utilisation (contacts with health

care system, admission to hospital due to LBP, LBP surgery), medication (amount and

type of prescription medication)



Bendix ’A’ 1996/1998 (Continued)

Follow-ups: MT (4 months), LT (2 and 5 years)



Risk of bias



bias)

Low risk pg.63 Methods. “patients were randomly assigned to a

treatment group or a control group according to thmin-

imisation principle”





bias)

All outcomes



All outcomes

Low risk Fig 1. 94/106 randomized participants analysed



Comparability of groups at baseline Low risk Table 1. Groups comparable on demographic and clin-

ical variables



Timing of assessment Low risk pg. 66 Results. Follow-up assessment at 4 months and

12 months

Bendix ’B’ 1995/1998


Participants Patients referred to a back centre with disabling LBP >6 months, threatened job situation.

106 patients randomised, 75.4% female, median age 42 years, mean duration of pain

not reported



Bendix ’B’ 1995/1998 (Continued)





Physical (control): 2x 2 hour sessions/week for 6 weeks, in groups (7-8/group). Aerobics,

progressive strengthening, back school

MBR-2: 2x 2 hour sessions/week for 6 weeks, in groups (7-8/group). Psychological pain

management, warm-up exercises, progressive strengthening



care system, admission to hospital due to LBP, LBP surgery), medication (amount and

type of prescription medication)

Follow-ups: MT (4 months), LT (1, 2 and 5 years)



Risk of bias



bias)

Low risk pg.149 Material and Methods. Block randomization,

following the minimization principle





bias)

All outcomes



All outcomes

Low risk pg.150 1st column. 9% dropout rate



Comparability of groups at baseline Low risk Fig 2. Groups comparable on relevant demographic and

clinical variables

Compliance Low risk Table 3. Adequate compliance in all groups




Bendix ’B’ 1995/1998 (Continued)

Timing of assessment Unclear risk pg. 150 Results. Follow-up at 4 months, 1 year and 5

years

Bendix ’C’ 2000


Participants Patients referred to a back centre with threatened job situation due to LBP. 127 patients

randomised, 65.4% female, median age 41 years, mean duration of pain not reported





Physical (OIT): 1.5 hour sessions, 3x/week for 8 weeks; aerobic and strengthening

exercises



care system, admission to hospital due to LBP, LBP surgery)

Follow-up: LT (5 years)



Risk of bias



bias)

Low risk Pg.2495 “Randomization, or rather stratification by

minimization, 24 was intended to equalize age, gender,

days of sick leave in 3 years, Manniche’s rating scale

score19 (reflecting pain, disability, and physical mea-

sures), and smoking across the two treatments”





bias)

All outcomes

High risk Not possible; patient reported outcome


All outcomes

Low risk Fig 1. “For the participants starting FR and OIT, the

dropout rate during treatment was 14% and 19%, re-

spectively”



Bendix ’C’ 2000 (Continued)

Intention to treat analysis Low risk pg.2497 Statistical Methods. “intention-to-treat analy-

ses were performed to account for dropouts at different

phases of the study”


Comparability of groups at baseline Low risk Table 1. Groups comparable on relevant demographic

and clinical variables



Timing of assessment Low risk pg.2497 Outcome Evaluation. “The 1-year follow-up

evaluation was carried out at a meeting in the Back

Cente”

Coole 2013

Methods RCT conducted in UK

Participants Patients referred to group rehabilitation with LBP >6 weeks, employed, concerned about

work ability. 51 patients randomised, 52.9% female, average age 44 years, mean duration

of pain 88 months

Interventions MBR (Group and Individual Work): Maximum of 10 weeks of 2-3 hours/week. Group

education and physical activity program with CBT approach. Possible referral to psy-

chologist. Individual work support, max. 8 face-to-face contacts of 90min; workplace

assessment, barrier to LBP managements, communication with employer, work-focused

interventions

Physical (Control): Maximum of 10 weeks of 2-3 hours/week. Group education and

physical activity program with CBT approach. Possible referral to psychologist

Outcomes Pain (NRS), Disability (RDQ), Work Ability (Work Ability Index Question), Anxiety

(HADS subscale), Depression (HADS subscale), Fear Avoidance (FAB-Qwork).

Follow-ups: MT (6 months)

Notes Subgroup analyses: Low intervention intensity, Baseline symptom intensity unclear

Risk of bias



bias)





Coole 2013 (Continued)




bias)

All outcomes



All outcomes

High risk Fig 1. 38/59 randomised subjects analysed



Comparability of groups at baseline Low risk Table 1. Groups comparable on relevant demographic and

clinical variables

Compliance High risk Table 5. 35% and 21% of the two groups did not attend

intervention at all


Timing of assessment Low risk Fig 1. Follow-up at 6 months

Fairbank 2005

Methods RCT conducted in the UK

Participants Patients referred to surgical departments of 15 hospitals with age 18-55, LBP >1 year,

surgeon unsure if surgery or rehab more suitable. 349 patients randomised, 50.7% female,

average age not reported, mean duration of pain 8 years

Interventions MBR (Rehabilitation): 5 days/week for 3/52 plus 1 follow-up session. Stretching,

strengthening, stabilisation, cardiovascular endurance, hydrotherapy. CBT approach;

pacing, addressing unhelpful beliefs and fears

Surgery (Surgery): Spinal stabilisation surgery

Outcomes Pain (SF-36 bodily pain), Disability (ODI), General Health (SF-36)

Follow-ups: LT (2 years)

Notes Subgroup analyses: Mid-intensity intervention, Low baseline symptom intensity (<60%


Risk of bias




Fairbank 2005 (Continued)


bias)

Low risk Pg.2 Treatment allocation. “Randomisation was generated

centrally by computer program”





bias)

All outcomes



All outcomes

Low risk Flow chart. 12-month follow-up rate 89%

Intention to treat analysis Low risk pg.2 Statistical Methods. “We carried out an intention to

treat analysis”


Comparability of groups at baseline Low risk Table 1


Cointerventions Low risk Table 3 (Rivero-Arias). Other resource usage comparable

between groups

Timing of assessment Low risk pg.2 Outcome Measures. “We assessed outcomes at base-

line and 6, 12, and 24 months from randomisation”

Harkapaa 1989


Participants Blue collar workers recruited by mail conducting physically strenuous work, with chronic

or recurrent LBP for >2 years, LBP reduces physical capacity and caused sick leave. 459

patients randomised, 37% female, average age 44.9 years, mean duration of pain not

reported

Interventions MBR (Inpatient): 3 weeks inpatient program, sessions in groups (6-8/group). Swedish

back school, back exercises, relaxation exercises, heat/electrotherapy, discussion groups on

coping, discussion on back care. HEP stretching and stretching + massage and strength-

ening and physical exercises. 2nd part (1.5 yr later), 2/52 inpatient program rehearse

and refresh back, self-care skills

Physical (control): Written and oral instructions; back exercises and ergonomics

MBR-2 (outpatient, control): 2 session/week for 2 months (15 sessions). Swedish back



Harkapaa 1989 (Continued)

school, back exercises, relaxation exercises, heat/electrotherapy, discussion groups on

coping, discussion on back care. HEP stretching and stretching. 2nd part (1.5 yr later),

8 sessions inpatient program rehearse and refresh back, self-care skills

Outcomes Pain (Pain Index), Disability (LBP Disability Index).

Follow-ups: ST (3 months).



Risk of bias



bias)






bias)

All outcomes



All outcomes

Low risk pg.82 Materials and Methods. 459/476 randomized pa-

tients followed up




clinical variables

Compliance High risk Table 4. Compliance different between groups


Timing of assessment Low risk pg.82 Procedure. “Follow-ups were carried out 3, 8 and

18 months after the first treatment”



Hellum 2011

Methods RCT conducted in Norway

Participants Patients referred to local hospitals and primary care with age 25-55 years, LBP >1 year,

unsuccessful physio or chiro for 6 months, Oswestry >30%, degenerative disc changes.

173 patients randomised, 50.8% female, average age 41 years, mean duration of pain 81

months

Interventions MBR (Rehabilitation): Outpatient treatment in groups, 60 hours over 2 to 5 weeks.

Education (anatomy, psychology, imaging, coping, medication, family, work and social

life), daily exercises (endurance, strength, coordination), challenging beliefs

Surgery (Surgery): Disc replacement with artificial disc (ProDisc)

Outcomes Pain (SF-36 bodily pain), Disability (ODI), General Health (SF-36 and EQ5D), Work

(% return to work), Satisfaction (% satisfied with outcome), Fear Avoidance (FABQ),

Self-Efficacy

Follow-ups: ST (6 weeks and 3 months), MT (6 months), LT (1 and 2 years)

Notes Subgroup analyses: Mid intensity intervention, Low baseline symptom intensity (<60%


Risk of bias



bias)

Low risk pg.2 Study Design. “They were randomised in blocks with

a website hosted by the medical faculty”

Allocation concealment (selection bias) Low risk pg.2 Study Design. “Allocation was concealed for all peo-

ple involved in the trial”




bias)

All outcomes



All outcomes

Low risk Fig 1. 172/179 patients followed up

Intention to treat analysis Low risk pg.4 Planned analyses. “The main statistical analysis was

in the intention to treat population”


Comparability of groups at baseline High risk pg.5 Patient Characteristics. “Low back pain score and SF-

36 mental health subscores, however, were significantly

worse in the rehabilitation group than in the surgery



Hellum 2011 (Continued)

group”



Timing of assessment Low risk Fig 1. Follow-up at 6 weeks, 3 months, 6 months, 12

months, 24 months

Henchoz 2010

Methods RCT conducted in Switzerland

Participants Patients referred to a hospital rheumatology outpatient clinic with age 18-60 years, LBP

>6 weeks. 109 patients randomised, 32% female, average age 39.8 yers, mean duration

of pain not reported

Interventions MBR (Multidisciplinary Rehabilitation): 3 weeks with sessions 5 days/week, 5-7 hours/

day, in groups (n=5) and individual. Intensive physical and ergonomic training, psy-

chological pain management, back school, social and work-related education, tailored

medication programme

Physical (Control): 18 physiotherapy sessions (45min) over 9 weeks. Active exercise and

passive modalities to manage pain, improve mobility and increase activity level

Outcomes Disability (ODI), Work (% working)

Follow-ups: LT (3 weeks), MT (6 weeks), LT (1 year)



Risk of bias



bias)

Low risk pg.2 Design. “allocated by a secretary not involved in

the study to a functional multidisciplinary rehabilita-

tion programme (FMR) or outpatient physiotherapy

(OP) according to computer-generated random num-

bers”

Allocation concealment (selection bias) Low risk pg.2 Design. “...sealed in opaque envelopes with con-

secutive numbering”





Henchoz 2010 (Continued)


bias)

All outcomes



All outcomes

High risk Fig 1. 67/109 randomized patients followed up

Intention to treat analysis Low risk Fig 1. “Included in ITT analysis”


Comparability of groups at baseline Low risk Tables 1/2. Groups comparable on relevant demo-

graphic and clinical variables



Timing of assessment Low risk pg.3 Outcomes. “ODI was recorded at the beginning

of treatment (T0), at 3-week (T3w), 9-week (T9w)

, 6-month (T6m), 9-month (T9m) and 12-month

(T12m) follow-up”

Jackel 1990


Participants 71 patients randomised, 62% female, average age 48.7 years, mean duration of pain 12.

8 years

Interventions MBR (Therapy): 4-6 weeks of daily therapy. Physical therapy 2x/ day in pool, 1x/ day in

gym. Education: anatomy, lifting instructions. 8-10x mudbaths, 8x massage, 8x electro

therapy. Psychology: pain beliefs, coping, depression, impact of pain on life

Waiting-list (control)

Outcomes Pain, Disability (0-10 Activities of daily living scale)

Follow-up: ST (4 weeks)



Risk of bias



bias)

Unclear risk Not reported



Jackel 1990 (Continued)

Allocation concealment (selection bias) Unclear risk Not reported




bias)

All outcomes



All outcomes

Unclear risk Not reported



Comparability of groups at baseline Low risk Table 2/3. Comparable on clinical characteristics



Timing of assessment Low risk Tables 2/3. 4 weeks

Jousset 2004

Methods RCT conducted in France

Participants Patients referred to a hospital multidisciplinary LBP clinic, by GP, specialists, industrial

physicians, insurance advisors. Age 18-50 years, LBP not relieved by conventional treat-

ment, threatened job situation. 84 patients randomised, 33.3% female, average age 40.

3 years, mean duration of pain not reported

Interventions MBR (FRP): 5 weeks duration, 6 hours/day, 5 day/week in groups (n=6-8). Exercise

with physiotherapist; warm-up, stretching, flexibility, aerobic exercises (walking, run-

ning, cycling), strengthening, muscular endurance, coordination exercises. OT; work

simulations. Psychologist; counselling

Physical (AIT): 5 weeks duration, 3 sessions/week of 1 hour, plus HEP; 2 session/

week of 50 minutes. Active exercise directed by physiotherapist, flexibility, stretching,

strengthening, proprioception exercises, endurance training, HEP; jogging, swimming,

stretching

Outcomes Pain (NRS), Disability (Quebec Disability Scale), Work (% return to work, days of sick

leave, ability to work), Medication, Anxiety/Depression (HAD, Dallas)

Follow-ups: MT (6 months)



Jousset 2004 (Continued)



Risk of bias



bias)

Low risk pg.488 Materials. “Block randomization was performed

using an eightelement permutation table”





bias)

All outcomes



All outcomes

Low risk Fig 1. 42/86 randomized patients followed-up



Comparability of groups at baseline Low risk Tables 1/2. Groups comparable on relevant demographic




Timing of assessment Low risk pg.489, last sentence. “Evaluation at 6 months was per-

formed for all patients at the rehabilitation center”

Kaapa 2006


Participants Patients referred to two Occupational Health centers with age 22-57 years, female health

care workers, daily or nearly daily LBP for the past 1 year. 102 patients randomised,

100% female, average age 46.3 years, mean duration of pain 15 months

Interventions MBR (Multidisciplinary Rehabilitation): 2 weeks for 5 days/week, 6 hours/day, then 5

weeks of 2 sessions of 4 hours/week, 2 weeks HEP. CBT stress management, relaxation,



Kaapa 2006 (Continued)

Swedish Back School (education), aerobic fitness, flexibility, coordination, strengthening,

progressive relaxation

Physical (Control): 10 sessions of 1 hour over 6-8 weeks. Passive treatment (massage,

electro modlities, traction, mobiilsation), active (stretching, mobility, coordination exer-

cises), general increase in physical activity was recommended (walking, swimming, daily

activities)

Outcomes Pain (NRS), Disability (ODI), General Health, Work (Subjective Work Capacity),

Health Care Utilization (Number of Visits), Depression (DEPS)

Follow-ups: ST (post-treatment), MT (6 months), LT (1 and 2 years)



Risk of bias



bias)

Low risk pg.372 Randomization. “The randomization list was gen-

erated by an independent biostatistician using a table of

random numbers”

Allocation concealment (selection bias) Low risk pg.372 Randomization. “The physiotherapist then ran-

domized each patient into one of the two groups by open-

ing an opaque sealed envelope...and the randomization

results were kept in sealed envelopes, one for each patient”




bias)

All outcomes



All outcomes

Low risk Fig 1. 89% and 90% at 12 month follow-up

Intention to treat analysis Low risk pg.373 Statistical analysis. “All patients were included in

the analysis on the basis of their intervention allocation”








Kaapa 2006 (Continued)

Timing of assessment Low risk Fig 1. Post-intervention, 6, 12, 24 months

Kole-Snijders 1999

Methods RCT conducted in the Netherlands

Participants Patients referred to rehabilitation centre by GP or specialist with age 18-65 years, LBP >6

months, discrepancy between objective findings and pain complaints, partner willing to

participate in treatment. 148 patients randomised, 64% female, average age 39.8 years,

mean duration of pain 10 years

Interventions MBR (OPCO): Individual and group, 5 weeks inpatient plus 3 weeks outpatient. Op-

erant behavioural treatment, quota-based activities, standing and sitting tolerance, daily

activity schedule for home, spouse group training (education and discussion). Cognitive

coping skills, increasing pain control and self-efficacy, education, biofeedback

MBR-2 (OPDI, Control 1): Individual and group, 5 weeks inpatient plus 3 weeks outpa-

tient. Operant behavioural treatment, quota-based activities, standing and sitting toler-

ance, daily activity schedule for home, spouse group training (education and discussion)

. Group discussion (attention control for cognitive coping training)

Waiting list (Control 2)

Outcomes Recovery (% improved)

Follow-ups: ST (2 months), MT (6 months), LT (12 months)

Notes Subgroup analyses: High intensity intervention, Baseline symptom intensity unclear

Risk of bias



bias)

Low risk pg.933 Study design. “Allocation to the three

conditions occurred following a randomizationm

procedure”

Allocation concealment (selection bias) Low risk pg.933 Study design. “a number that an indpen-

dent researcher blindly drew and assigned”




bias)

All outcomes



All outcomes

High risk pg.936 Attrition. 107/148 patients available at 12

month follow-up



Kole-Snijders 1999 (Continued)

Intention to treat analysis Low risk pg.936 Intention to treat analysis. “intention to

treat analysis was done”


Comparability of groups at baseline High risk pg.937 Baseline comparisons. Between group dif-

ferences on dependent variables

Compliance Low risk pg.937 Compliance. Similar compliance across

conditions


Timing of assessment Low risk Fig 3. Post-treatment, 6, 12 months

Kool 2007

Methods RCT conducted in Switzerland

Participants Patients referred to work rehabilitation centre with age 20-55 years, non acute NSLBP,

>6 weeks sick leave in the last 6 months. 174 patients randomised, 21.3% female, average

age 42.1 years, mean duration of pain not reported

Interventions MBR (FCT): 6 days/week for 3 weeks, 4 hours/day. Time contingent: work simulation,

endurance training, strengthening, aerobic training. Counselling, education, self-efficacy,

analgesic medication

Physical (PCT): 6 days/week for 3 weeks, 2.5 hours/day. All activity was pain-contingent:

Passive and active mobilisation, stretching, strengthening, min-back school (education)

, heat, electrotherapy, massage, progressive relaxation, analgesic medication

Outcomes Pain (NRS), Work (% at work), Overall Improvement (Likert Scale), Medication (%

taking medication), Self-Efficacy (PACT)

Follow-ups: ST (3 months), LT (12 months)



Risk of bias



bias)

Low risk pg.1080 Design. “Randomization was concealed”

Allocation concealment (selection bias) Unclear risk pg.1080 Design. “Randomization was concealed”




Kool 2007 (Continued)



bias)

All outcomes



All outcomes

Low risk Fig 1. 166/174 randomized patients followed up

Intention to treat analysis Low risk pg.1091 Statistics. “Analysis was based on the inten-

tion-to-treat principle”


Comparability of groups at baseline Low risk Table 1. Groups comparable on relevant demographic


Compliance Low risk pg.1091 Protocol compliance. “All patients attended

at least 90% of the scheduled treatments, and treat-

ment duration was comparable”

Cointerventions Low risk pg.1093 Health Care use. “Interventions after rehabil-

itation were comparable in the FCT and PCT group”

Timing of assessment Low risk pg.1090 Outcome measurement. Follow-up 1 year

Lambeek 2010


Participants Patients referred to a hospital outpatient clinic with age 18-65 years, LBP >3 months, in

paid work. 134 patients randomised, 42% female, average age 46.2 years, mean duration

of pain not reported

Interventions MBR (Integrated Care): up to 12 weeks (26 sessions). CBT-based graded activity, edu-

cation, ergonomics, workplace intervention (including employer)

Usual (Control): usual care in the Netherlands as directed by medical specialist

Outcomes Pain (VAS), Disability (RMDQ), Work (days of sick leave)


Notes Subgroup analyses: Low intensity intervention, High baseline symptom intensity (>60%


Risk of bias




Lambeek 2010 (Continued)


bias)

Low risk pg.3 Randomisation. “For every stratum, an in-

dependent statistician carried out block randomi-

sation of four allocations, using a computer gen-

erated random sequence table. A research assis-

tant prepared opaque, sequentially numbered and

sealed coded envelopes for each stratum”

Allocation concealment (selection bias) Low risk pg.3 Randomisation. “For every stratum, an in-

dependent statistician carried out block randomi-

sation of four allocations, using a computer gen-

erated random sequence table. A research assis-

tant prepared opaque, sequentially numbered and

sealed coded envelopes for each stratum”




bias)

All outcomes



All outcomes

Low risk pg.3 Loss to follow-up. “Data on sick leave were

complete for all patients at baseline, and for 93%

of the patients during the 12 months of follow-

up”

Intention to treat analysis Low risk pg.3 Statistical analysis. “All analyses were done

according to the intention to treat principle”

Selective reporting (reporting bias) High risk Pain coping and QoL not reported

Comparability of groups at baseline Low risk Table 1 & pg.4 Patient characteristics. Groups

comparable on relevant demographic and clinical

variables

Compliance High risk pg.3 Non-compliance. Several cases of non-com-

pliance


Timing of assessment Low risk pg.2 Outcome measures. “Questionnaires were

administered to the patients at baseline and after

3, 6, 9, and 12 months”



Leeuw 2008


Participants Adults referred by physicians from outpatient rehabilitation centres or responded to ad-

vertisements with LBP >3 months with RMDQ score >3 and Tampa Scale for Kine-

siophobia score >33. 85 patients randomised, 48% female, average age 45 years, mean

duration of pain 9 years

Interventions MBR (EXP): 16x 2 session/week, 1 hours/session. Information re: diagnosis, imaging,

continued active approach, treatment rationale. Establishment of heirachy of feared

activities, explanation of fear avoidance model, gradual, systematic exposure to feared

activities. Behvioural experiments to test consequences of engagement in feared activities

MBR-2 (GA): 26x 2 session/week, 1 hoursr/session. Information re: diagnosis, imaging,

continued active approach, treatment rationale. Identification of functional treatment

goals, quota-based gradual increase in perfomance of functional activities

Outcomes Pain (McGill), Disability (Quebec), main complaints (Patient specific complaints scale)

, harmfulness of activities (PHODA), pain Catastrophizing (PCS), daily activity (ac-

celeromoeter)

Follow-ups: LT (12 months)



Risk of bias



bias)

Low risk Randomization procedure. “Patients were ran-

domized to EXP or GA within each treatment

centre, following a predetermined and computer-

generated randomization schedule”

Allocation concealment (selection bias) Low risk Randomization procedure. “After the second

pre-treatment measurement, patients received a

sealed envelop from the research assistant con-

taining a sheet of coloured paper indicating treat-

ment assignment”




bias)

All outcomes



All outcomes

Low risk Fig 1. 73/85 patients completed follow-up



Leeuw 2008 (Continued)

Intention to treat analysis Low risk 2.7.1 Treatment outcomes - Intention-to-treat

analyses


Comparability of groups at baseline Low risk Table 1. Groups comparable on relevant demo-


Compliance High risk 3.1 Flow of participants. “Treatment was prema-

turely terminated either by the

patient or the therapist in 12 patients (29%) of

the EXP condition, and in 14 patients (33%) of

the GA condition for various reasons”

Cointerventions Low risk 2.2 Participants. “Patients were requested not to

seek diagnostic or therapeutic procedures during

therapy other than their allocated treatment”

Timing of assessment Low risk Table 2. Post treatment, 6 month follow-up

Linton 2005

Methods RCT conducted in Sweden

Participants Patients referred to primary care facilities at risk of developing long-term disability,

employed, with back or neck pain (back pain 85%), <4 months of sick leave over the

past year. 185 patients randomised, 83% female, average age 49 years, mean duration of

pain not reported

Interventions MBR (PT+CBT): Physical Therapy (unconstrained volume of treatment); information

on prevention, cause of LBP, activity advice, functional training, personalised programs.

6 weeks, 1 session/week, 2 hours/session plus homework. CBT intervention (groups

n=6-10); pain education, problem solving, coping skills, increase in function, graded

activity, stress management, relaxation, dealing with exacerbations. Minimal intervention

(1 session), education, actvity advice, booklet, patients free to seek any medical care

MBR-2 (CBT, Control 1): 6 weeks, 1 session/week, 2 hoursr/session plus homework,

CBT intervention (groups = 6-10 persons); pain education, problem solving, coping

skills, increase in function, graded activity, stress management, relaxation, dealing with

exacerbations. Minimal intervention (1 session), education, actvity advice, booklet, pa-

tients free to seek any medical care

Usual (Control 2): Minimal intervention (1 session), education, actvity advice, booklet,

patients free to seek any medical care

Outcomes Pain (NRS), Disability (RMDQ), Work (% sick leave), Health Care Utilisation (number

of visits), Medication (number of days of consumption), Fear Avoidance (TSK), Anxiety

(HADS subscale), Depression (HADS subscale), Pain Catastrophising (PCS)




Linton 2005 (Continued)

Notes Subgroup analyses: Low intensity Intervention, Low baseline symptom intensity (<60%


Risk of bias



bias)

Low risk Participants. “randomly assigned to 1 of the 3 groups using

a computer-generated block randomization”





bias)

All outcomes



All outcomes

High risk Completion and participation rates. Differential dropout

between groups

Intention to treat analysis Low risk Completion and participation rates. “An “intention to

treat” approach was used”




Compliance Low risk Completion and participation rates. High attanedance

rates across the groups

Cointerventions High risk Minimal treatment group. Patients free to seek any care

Timing of assessment Low risk Measures and Procedures. 1 year follow-up

Lukinmaa 1989


Participants Patients with LBP referred to a regional hospital. 203 patients randomised, 52.7% female,

average age 43.6 years, mean duration of pain 15.3 months



Lukinmaa 1989 (Continued)

Interventions MBR (Biopsychosocial): 5 days inpatient, treatment according to the biopsychosocial

model

Usual (Biomedical): orthopaedic outpatient treatment according to the biomedical

model

Outcomes Pain (VAS), Disability (RMDQ), General Health (global perceived effect), Work (%

retired)




Risk of bias



bias)






bias)

All outcomes



All outcomes

Low risk pg.137. 78% follow-up



Comparability of groups at baseline Low risk pg.136 Table. Groups comparable on relevant demo-




Timing of assessment Low risk pg.136 Methods of collecting data. One year follow-up



Mangels 2009


Participants Patients referred to an orthopaedic rehabilitation hospital with a musculoskeletal disease,

approximately 85% with dorsalgia (ICD M54). 363 patients randomised, 77.7% female,

average age 48.8 years, mean duration of pain not reported

Interventions MBR (BP + booster): 4 weeks inpatient intervention, individual or group sessions.

Analgesic medication as required, aerobic exercises, coordination exercise, ergonomic

advice, ADL physical capacity training, back school (education), massage, electrotherapy,

hydrotherapy, thermotherapy, nutrition and social advice. CBT-based psychological pain

management (group sessions, n=11), BPS model education, pain coping, progressive

muscle relaxation. 7 booster sessions on telephone over 12/12 to reinnforce inpatient

topics, problem-solving, goal setting, relaxation, coping etc

MBR-2 (BP, Control 1): 4 weeks inpatient intervention, individual or group sessions.

Analgesic medication as required, aerobic exercises, coordination exercise, ergonomic

advice, ADL physical capacity training, back school (education), massage, electrotherapy,

hydrotherapy, thermotherapy, nutrition and social advice. CBT-based psychological pain

management (group sessions, n=11), BPS model education, pain coping, progressive

muscle relaxation

Physical (Control 2): 3 weeks of mostly physical/orthopedic treatment including active

physiotherapy, passive modalities and occupational therapy

Outcomes Sensory Pain (SES), Disability (PDI), General Health (SF-12), Depression (BDI), Ac-

tion-oriented Coping, Self-Efficacy (PSEQ)

Follow-ups: ST (1 month), LT (12 months)



Risk of bias



bias)

Low risk pg.357 Study design and procedure. “Randomization

was carried out by an administration secretary of the

rehabilitation hospital who received random numbers

from the study center”

Allocation concealment (selection bias) Low risk pg.357 Study design and procedure. “treatment was al-

located in a blind way”




bias)

All outcomes




Mangels 2009 (Continued)


All outcomes


Intention to treat analysis Low risk pg.360 Statistical analysis. “all of the patients were fur-

ther analyzed as intended to treat”


Comparability of groups at baseline Low risk pg.360 Sample characteristics. “The groups did not dif-

fer on sex, age, marital status, education, medical diag-

noses, and all pretreatment scores such as disability, de-

pression, self-efficacy, pain perception, life satisfaction,

health status, and pain coping strategies”



Timing of assessment Low risk Fig 1. 12-month follow-up

Meng 2011


Participants Patients referred to orthopaedic rehabilitation hospital with age 18-65 years, muscu-

loskeletal disease, approximately 98% with dorsalgia (ICD M54). 382 patients ran-

domised, 64% female, average age 49 years, mean duration of pain was > 5 years for

46% of patients

Interventions MBR (BPS Back School): 7 sessions of 55 minutes, in groups (n<16). Back school,

education, (anatomy, epidemiology, risk factors, therapy), BPS model, pain education,

fear avoidance, coping, social aspects, muscle training and stabilisation exercises, recom-

mendation for increased physical activity

MBR-2 (Back School, Control): 6 sessions of 55 minutes, in groups (up to 60). Back

school, posture and movement exercises, pain education, coping, education

Outcomes Action-oriented coping

Follow-ups: MT (6 months), LT (12 months)



Risk of bias




Meng 2011 (Continued)


bias)

Low risk pg.249. “Patients were randomly assigned to the 2

groups using a computer-generated list of random num-

bers”

Allocation concealment (selection bias) Low risk pg.249. “Randomization was performed by a scientific

assistant of the research institute (central randomization

per phone or e-mail)”




bias)

All outcomes



All outcomes

Low risk pg.249 2nd column. “Follow-up rates exceeded 75% at

all time points (Fig. 1)”



Comparability of groups at baseline Low risk pg.250 1st column. “No systematic differences existed

between the IG and the CG concerning sociodemo-

graphic and medical data as well as length of stay. Thus,

randomization proved successful.”



Timing of assessment Low risk pg.249 Study design and participants. “Data were as-

sessed at admission, discharge, as well as 6 and 12

months follow-ups”

Mitchell 1994

Methods RCT conducted in Canada

Participants Workers on Worker’s Compensation Board list referred to 2 work rehabilitation clinics.

Injured workers who had not recovered and returned to work after 3 months, with

inappropriate illness behaviour. 542 patients randomised, 28.5% female, average age not

reported, mean duration of pain not reported

Interventions MBR (FR): 8 weeks, 7 hours/day, 5 days/week (total 280 hours), group sessions (n=

10-12). Physical exercise; mobility, strengthening, flexibility, endurance, stretching, ice,

circuit training, work simulation exercises (lifting). Behavioural and cognitive treatment,



Mitchell 1994 (Continued)

correction of unhelpful beliefs, education, relaxation, biofeedback, personal responsibil-

ity

Usual (Control): Usual care, variable including; physio, medication, manipulation,

acupuncture, work hardening, back schools, active exercise

Outcomes Work (% full-time work, days of sick leave)

Follow-ups: LT (1 year)

Notes Subgroup analyses: High intensity intervention, Baseline symptom intensity unclear.

Included in Guzman 2006

Risk of bias



bias)






bias)

All outcomes



All outcomes




Comparability of groups at baseline Unclear risk Not reported



Timing of assessment Low risk pg. 635 Results. 12-month follow-up



Moix 2003

Methods RCT conducted in Spain

Participants Adult patients in a hospital pain clinic with LBP/radiculopathy or cervical pain. 30

patients randomised, 53.3% female, average age 54.3 years, mean duration of pain not

reported

Interventions MBR (Interdisc): Usual care + interdisciplinary program (11 sessions/week, about 60

minutes/session). Interdisciplinary program: psychology

Usual (Control): Usual care, pain control through the treatment of the anaesthesiology

team

Outcomes Pain, Disability, Medication (% reduced use), Depression (BDI), Anxiety (STAI)

Follow-ups: ST (post-treatment)



Risk of bias



bias)

Low risk pg.5 last sentence. “Los sujetos se repartieron al azar en dos

grupos: 1) grupo experimental al que además del tratamiento

estandar se le aplicó el programa interdisciplinar y 2) grupo

control que recibió el tratamiento estándar que consistía en

el control del dolor por parte del equipo de anestesiologia”





bias)

All outcomes



All outcomes

Low risk No loss to follow-up



Comparability of groups at baseline Low risk Table 2. Clinical and demographic variables comparable





Moix 2003 (Continued)

Timing of assessment Low risk Fig 1. Post-treatment

Monticone 2013

Methods RCT conducted in Italy

Participants Patients referred to a rehabilitation centre with LBP >3 months and >18 years. 90 patients

randomised, 57.8% female, average age 49.8 years, mean duration of pain 25.8 months

Interventions MBR (CBT + Physical): 5 weeks program plus 1 year reinforcement. 1 individual CBT

session/week of 60 minutes, then 1 session/month for 12 months. Sessions included fear

avoidance beliefs, catastrophising, inappropriate beliefs, negative thoughts, transferring

attention, graded exposure, motivation, goal-setting. Physical program, individually de-

livered: active and passive mobilisations, stretching, strengthening, postural/motor con-

trol exercises. Up to 10 sessions, 2 sessions/week for 5 weeks, plus home exercise program

Physical (Control): physical program, individually delivered, active and passive mobil-

isations, stretching, strengthening, postural/motor control exercises. Up to 10 sessions,

2 sessions/week for 5 weeks, plus home exercise program

Outcomes Pain (NRS), Disability (RMDQ), General Health (SF-36), Fear Avoidance (TSK)

Follow-ups: ST (post-treatment), LT (1 and 2 years)

Notes Subgroup analyses: Low intensity intervention, High baseline symptom intensity (>60%


Risk of bias



bias)

Low risk pg.2 Randomization. “randomized the patients to one of the

2 treatment programs using a list previously generated by a

biostatistician (SAS PROC PLAN)”

Allocation concealment (selection bias) Low risk pg.2 Randomization. “...delivered to the Principal Investiga-

tor with blinded treatment codes”




bias)

All outcomes



All outcomes

Low risk pg.4 Participant flow. “No patients dropped out during the

course of the study”



Monticone 2013 (Continued)

Intention to treat analysis Low risk Flow chart. No dropout, all patients treated as per protocol



clinical variables



Timing of assessment Low risk pg.3 Outcome measures. “questionnaires were completed be-

fore treatment (T1), 5 weeks later (at the end of the instruc-

tive phase, T2), and then 12 months (post-treatment analy-

sis, T3) and 24 months after the end of the instructive phase

(1-year follow-up, T4)”

Morone 2011


Participants Patients referred to a rehabilitation centre with age 18-80 years and NSLBP >3 months.

73 patients randomised, 64.3% female, average age 60.2 years, mean duration of pain

not reported

Interventions MBR (Back School): 4 weeks, 10 sessions in groups (4-5), each session 1 hour. Education

(anatomy, pain, stress management, workplace, sporting activities, posture), exercise

prescription (ergonomics, ADLs, HEP), stretching, strengthening, core stability

Usual (Control): medical care, mostly pharmacological

Outcomes Pain (VAS), Disability (ODI), General Health (SF-36)

Follow-ups: ST (post-treatment and 3 months), MT (6 months)



Risk of bias



bias)


Allocation concealment (selection bias) Low risk pg.535 last sentence. “The othet physiatrist was involved in

patients’ randomization and was unaware of clinical features”




Morone 2011 (Continued)



bias)

All outcomes



All outcomes

Low risk pg.538 Results. 70/74 ranodmized patients followed up

Intention to treat analysis High risk pg.537 last sentence. “A per-protocol analysis was performed

on primary and secondary outcome measures”


Comparability of groups at baseline Low risk Tables 1/3/4. Groups comparable on relevant demographic




Timing of assessment Low risk pg.536 Outcome measures. Baseline, end of treatment, 3, 6

months

Morone 2012


Participants Italy. Patients referred to an acadeimc hospital with age 18-75 years and NSLBP >3

months. 75 patients randomised, 72% female, average age 55.4 years, mean duration of

pain not reported

Interventions MBR (Back School): 4 weeks, 10 sessions in groups (4-5), each session 1 hour. Education

(anatomy, pain, stress management, workplace, sporting activities, posture), exercise

prescription (ergonomics, ADLs, HEP), stretching, strengthening, core stability

Physical (Control 1): 4/52, 3 sessions per week, proprioceptive and perception tasks

while lying on deformable latex cones

Usual (Control 2): medical care, mostly pharmacological

Outcomes Pain (VAS), Disability (ODI)

Follow-ups: ST (post-treatment and 3 months), MT (6 months)



Risk of bias




Morone 2012 (Continued)


bias)

Low risk pg.342 1st sentence. “Specifically, patients were asked to take

a sealed envelope from a box, containing a piece of paper with

the assignment, which was, concealed until the envelope was

opened”

Allocation concealment (selection bias) Low risk pg.342 1st sentence. “Specifically, patients were asked to take

a sealed envelope from a box, containing a piece of paper with

the assignment, which was, concealed until the envelope was

opened”




bias)

All outcomes



All outcomes

Low risk Fig 3. 70/75 randomized patients analyzed

Intention to treat analysis Low risk pg 344, 1st column, last paragraph. “An intention-to-treat

analysis was performed”


Comparability of groups at baseline Unclear risk Insufficient information reported



Timing of assessment Low risk pg.342 1st paragraph. “Each patient was assessed before and

at the end of treatment and also at the 12- and 24-week

follow-up”

Nicholas 1991

Methods RCT conducted in Australia

Participants Patients referred from pain clinic, GPs or specialist with age 20-60 years, LBP >6 months.

58 patients randomised, 51.7% female, average age 41.2 years, mean duration of pain 7

years

Interventions MBR (Behavioural+Relaxation): 5 weeks, 2 sessions/week. Education (anatomy, back

care, lifting, medication, diet/weight),Strengthening exercises, mobilisation exercises,

hydrotherapy, HEP. Behavioural treatment; goal-setting (social, home, work) and advice,

medication reduction, pacing, given positive reinforcement plus relaxation treatment;



Nicholas 1991 (Continued)

progressive muscle relaxation

Physical (Physiotherapy): 5 weeks, 2 sessions/week. Education (anatomy, back care, lift-

ing, medication, diet/weight), strengthening exercises, mobilisation exercises, hydrother-

apy, HEP

Note: 6 treatment groups in total, only the above groups used for this review

Outcomes Pain (PRC), Disability (SIP), Medication (number of types), Anxiety (STAI), Depression

(BDI), Pain Beliefs (PBQ), Coping (CSQ)

Follow-ups: ST (post-treatment), MT (6 months), LT (12 months)



Risk of bias



bias)


Allocation concealment (selection bias) Low risk pg.226 Experimental design. “The random assignment

was performed after the pretreatment assessment. Thus,

the experiments did not know to which condition a sub-

ject would be assigned at the time the pretreatment as-

sessments were conducted”




bias)

All outcomes



All outcomes

High risk pg.232 Attrition. 39/58 randomized patients followed

up









Timing of assessment Low risk pg.226 Experimental design. “repeated measurements

were conducted on four occasions-pretreatment, post-

treatment, 6 months and 12 months after the end of

treatment”

Nicholas 1992

Methods RCT conducted in Australia

Participants Patients referred from pain clinic, GPs or specialist with age 20-60 years, LBP >6 months.

20 patients randomised, 45% female, average age 43.7 years, mean duration of pain 5.

5 years

Interventions MBR (CBT): 5 weeks, 2 sessions/week. Education (anatomy, back care, lifting, medi-

cation, diet/weight), strengthening exercises, mobilisation exercises, hydrotherapy, HEP,

chronic pain education, coping, attentional porcesses, challenging and altering unhelpful

cognitions, distraction techniques. Relaxation treatment: progressive muscle relaxation

Physical (Control): 5 weeks, 2 sessions/week. Education (anatomy, back care, lifting,

medication, diet/weight), strengthening exercises, mobilisation exercises, hydrotherapy,

HEP. Attention control, general group discussion about living with back pain, no advice

or information provided

Outcomes Pain (PRC), Disability (SIP), Medication (% using), Depression (BDI), Coping (CSQ)

, Self-Efficacy (PSEQ)

Follow-ups: ST (post-treatment), MT (6 months)



Risk of bias



bias)


Allocation concealment (selection bias) Low risk pg.341 1st paragraph. “The random assignment was con-

ducted after the pretreatment assessment and before the

program started. Thus, neither the psychologist nor the

physiotherapist knew to which condition a subject would

be assigned at the time the pretreatment assessments were

conducted”







bias)

All outcomes



All outcomes

Low risk Pg.340 Subjects. 18/20 randomized patients followed up






Timing of assessment Low risk Table 1. Post-treatment, 6 months

Roche 2007/2011

Methods RCT conducted in France

Participants Patients referred to a hospital multidisciplinary LBP clinic with age 18-50 years, LBP

>3 months, on sick leave or at risk of work disability, not in temporary employment.

132 patients randomised, 35% female, average age 39.8 years, mean duration of pain

not reported

Interventions MBR (FR): 5 weeks, 5 days/week in groups (n=6-8), 6 hours/day. Exercise with physio-

therapist: warm-up, stretching, flexibility, aerobic exercises (walking, running, cycling),

strengthening, muscular endurance, coordination exercises. OT: work simulations. Psy-

chologist: counselling

Physical (AIT, Control): 5 weeks, 3 sessions/week of 1 hour each; plus HEP, 2 ses-

sions/week of 50 minutes each. Active exercise directed by physiotherapist, flexibility,

stretching, strengthening, proprioception exercises, endurance training. HEP: jogging,

swimming, stretching

Outcomes Pain (VAS), Disability (Dallas PQ), Work (% return to work, % working full-time, days

of sick leave), Anxiety/Depression (Dallas PQ)

Follow-ups: ST (post-treatment), LT (1 year)



Risk of bias




Roche 2007/2011 (Continued)


bias)

Low risk pg.1230 Population. “Block randomization was under-

taken with an 8-element permutation table established by

an independent methodologist”

Allocation concealment (selection bias) Low risk pg.1230 Population. “Block randomization was under-

taken with an 8-element permutation table established by

an independent methodologist”




bias)

All outcomes



All outcomes

Low risk Fig 1. 119/132 randomized patients followed-up com-

pletely




clinical variables

Compliance Low risk Fig 1. 131/132 received complete interventions


Timing of assessment Low risk pg.1230 last sentence. “patients were off work during the

5 weeks of treatment. At the beginning (t0) and the end of

the treatment (t5), they were assessed in the rehabilitation

center”

Schweikert 2006


Participants Patients with NSLBP >6 months recruited from lists of a work insurer for referral to a

rehabilitation hospital. 409 patients randomised, 17.1% female, average age 46.7 years,

mean duration of pain not reported

Interventions MBR (CBT): 3 weeks inpatient program, small groups. Daily physiotherapy: 2 times/

day exercises, massage, electrotherapies, education, advice about risk factors, back care,

etc. CBT: coping, motivation, pain management, relaxation, distraction, cognitive reap-

praisal

Physical (control): 3 weeks inpatient program, small groups. Daily physiotherapy: 2



Schweikert 2006 (Continued)

times/day exercises, massage, electrotherapies, education, advice about risk factors, back

care, etc

Outcomes Pain (Likert Scale), Disability (Hannover Scale), General Health (EuroQoL), Work (days

off-work), Depression (STAI)


Notes Subgroup analyses: High intensity intervention, High baseline symptom intensity (>60%


Risk of bias



bias)

Low risk pg.2520 Materials and methods. “randomization was

performed by an external biometrical unit using Ran-

code Professional 3.6”

Allocation concealment (selection bias) Low risk pg.2520 Materials and methods. “randomization was

performed by an external biometrical unit using Ran-

code Professional 3.6”




bias)

All outcomes



All outcomes

High risk pg.2521 Results 1st column. Most of the dropouts in

the treatment group


Selective reporting (reporting bias) Unclear risk Unclear




Timing of assessment Low risk Fig 1. 6 month follow-up



Skouen 2002


Participants Employees on National Health Insurance list were invited. Patients with LBP sick-listed

for >8 weeks or at least 2 months/year over the last 2 years. 195 patients randomised,

43.5% female, average age 43.6 years, mean duration of pain not reported

Interventions MBR (Extensive MD): 4 weeks, 5 days/week, 6 hours/day. CBT (group sessions): fear

avoidance, coping strategies. Education: pain mechanisms, anatomy, exercise advice.

Workplace interventions. Graded exercise program: stretching, strengthening, mobility,

coordination exercises, aerobic trainnig. Relaxation, body awareness training. HEP at

the end of the intervention

MBR-2 (Light MD, Control 1): Unspecified number of consultations (average 3) with

physiotherapist and sometimes nurse or psychologist if necessary. Education; exercise,

lifestyle, fear avoidance, advice to reduce illness behaviours and anxiety. HEP program

and advice to stay active and gradually increase activity levels

Usual (Control 2): usual care under GP, involving pain medication, referral to physio-

therapist or chiropractic

Outcomes Work (% return to work)

Follow-ups: LT (1, 1.5 and 2 years)

Notes Subgroup analyses: High intensity intervention, Baseline symptom intensity unclear

Risk of bias



bias)

Low risk pg.902 2nd column. “patients were allocated at random

by means of a sequence of prelabeled cards contained in

sealed envelopes. The allocation sequence was prepared

beforehand by a physician outside the clinic”

Allocation concealment (selection bias) Low risk pg.902 2nd column. “patients were allocated at random

by means of a sequence of prelabeled cards contained in

sealed envelopes. The allocation sequence was prepared

beforehand by a physician outside the clinic”




bias)

All outcomes



All outcomes

Low risk Fig 1A. 195/211 randomized patients followed up




Skouen 2002 (Continued)




Cointerventions Low risk pg 903. Acceptable levels across groups

Timing of assessment Low risk Fig 1B. 3, 6, 12 months follow-up

Smeets 2006/2008


Participants Patients referred by GPs and specialists to 3 rehabilitation centers. Patients with age 18-

65 years, LBP >3 months, RMDQ score >3, ability to walk at least 100 meters. 212

patients randomised, 41.6% female, average age 47.2 years, mean duration of pain 4.7

years

Interventions MBR (CT): 10 weeks, active physical training (3 times/week for 1 hour 45 minutes

sessions): aerobic training, strengthening, stretching. CBT: operant behavioural graded

activity (18 sessions), problem-solving (10 sessions), modification of dysfunctional be-

liefs, HEP increasing activity

Physical (APT, Control 1): 10/52 Rx. Active physical training (3 times/week for 1 hour

45 minutes): aerobic training, strengthening, stretching

MBR-2 (CBT, Control 2): operant behavioural graded activity (18 sessions), problem-

solving (10 sessions), modification of dysfunctional beliefs, HEP increasing activity

Waiting list (control 3)

Outcomes Pain (VAS), Disability (RMDQ), Main Complaints, Self-Perceived Improvement, Work,

Health Care Utilization (number of visits), Depression (BDI), Catastrophising (PCL)

Follow-ups: ST (post-treatment), MT (6 months), LT (1 year)



Risk of bias



bias)

Low risk pg.264 Randomization. “a randomization list was

generated under the supervision of an indepen-

dent statistician”

Allocation concealment (selection bias) Low risk pg.264 Randomization. “Opaque, sequentially

numbered, sealed envelopes were prepared for

each rehabilitation centre before enrolment



Smeets 2006/2008 (Continued)

started”




bias)

All outcomes



All outcomes

Low risk pg.267 Results. 156/172 randomized patients

followed-up

Intention to treat analysis Low risk pg.267 Statistical analyses. “All statistical analyses

were performed according to the intention-to-

treat principle”




Compliance Low risk Fig 1. Adequate compliance across groups

Cointerventions Low risk Fig 1. Few additional treatments across groups

Timing of assessment Low risk pg.266 Outcome measures. “Outcome measures

were recorded at baseline, immediately post-treat-

ment and 6 and 12 months post-treatment”

Strand 2001


Participants Patients sick-listed >8 weeks due to LBP. 117 patients randomised, 61% female, average

age 43.6 years, mean duration of pain 10 years

Interventions MBR (Multidisciplinary Rehabilitation): 4 weeks, 5 days/week, 6 hours/day. Physical

treatment (strengthening, body awareness, aerobic fitness, relaxation), education, CBT

(coping, responsibility for Rx, focus away from pain), workplace intervention

Usual (Control): usual care in the community, most had physiotherapy, 1/3 have alter-

native interventions

Outcomes Work (% return to work)

Follow-ups: ST (post-treatment), MT (8 months), LT (1 year)





Strand 2001 (Continued)

Risk of bias



bias)

Low risk In Haldorsen 1998. “individuals were allocated at random

to one of two groups, the Treatment group or the Control

group, by means of a sequence of pre labeled cards con-

tained in sealed envelopes. The allocation sequence was

prepared beforehand by a physician”

Allocation concealment (selection bias) Low risk In Haldorsen 1998. “individuals were allocated at random

to one of two groups, the Treatment group or the Control

group, by means of a sequence of pre labeled cards con-

tained in sealed envelopes. The allocation sequence was

prepared beforehand by a physician”




bias)

All outcomes



All outcomes

High risk pg.801 Patients. 117/162 randomized patients followed

up




clinical variables



Timing of assessment Low risk pg.801 Procedure. “The same physiotherapist assessed pa-

tients at baseline (before randomization) and at the 1-year

follow-up”



Streibelt 2009


Participants Patients referred to rehabilitation centre from work insurance provider, limited work

ability due to chronic musculoskeletal disorder. 222 patients randomised, 16.7% female,

average age 45.8 years, mean duration of pain not reported

Interventions MBR (FCEMR): 3 weeks inpatient program, 3-4 hours treatment/day. Physical therapy,

exercises, massage, education, relaxation. Focus on work-specific skills and functional

capacity with operant behavioural approach. Coping skills training

Physical (MR, Control): 3 weeks inpatient program, 3-4 hours treatment/day. Physical

therapy, exercises, massage, education, relaxation

Outcomes Disability (PDI), Work (weeks off-work, % return to work)

Follow-ups: LT (1 year)



Risk of bias



bias)

Low risk pg.4 Study design. “A computer-generated randomiza-

tion list was created by a statistician”

Allocation concealment (selection bias) Low risk pg.4 Study design. “Randomized allocation of the pa-

tients in either the treatment or the control group was

done by an external institute”




bias)

All outcomes



All outcomes

High risk pg.7 Sample. >50% dropout rate

Intention to treat analysis Low risk pg.6 Analysis. “Cases were analysed as intended to treat”


Comparability of groups at baseline High risk Baseline characteristics. Groups comparable on relevant

demographic and clinical variables




Streibelt 2009 (Continued)


Timing of assessment Low risk Fig 1. 1 year follow-up

Tavafian 2008


Participants Adult women recruited from outpatient rheumatology clinics with age >18 years, LBP >3

months. 102 patients randomised, 100% female, average age 42.9 years, mean duration

of pain 9.1 months

Interventions MBR (Education): 4 days, 5 sessions, based on Back school. Education: anatomy, phys-

iology, pathology of LBP, self-care, health behaviours, biomechanics, lifestyle factors,

prevention. Psychologist: coping skills, anger management, relaxation. Physiotherapist:

stretching, strengthening, posture, functional movement advice (HEP)

Usual (Control): medical management, mostly medication prescription (analgesics, mus-

cle relaxants, NSAIDs, anti-depressants)

Outcomes Pain (SF-36 bodily pain), General Health (SF-36)




Risk of bias



bias)


Allocation concealment (selection bias) High risk pg.1618 1st column. “The treatment allocation was not con-

cealed”




bias)

All outcomes



All outcomes

High risk pg.1618 Fig 1. 74/102 randomized patients followed up

Intention to treat analysis Unclear risk Unclear



Tavafian 2008 (Continued)



clinical variables

Compliance Unclear risk No stated

Cointerventions Low risk pg.1618 1st column. “cointerventions were avoided for both

group”

Timing of assessment Low risk pg 1617 Study Design. “This was a blind randomized con-

trolled trial with a 3, 6, and 12 months follow up”

Tavafian 2011


Participants Patients referred to rheumatology clinics in 3 teaching hospitals and 1 private clinic with

age > 18 years, LBP >3 months. 197 patients randomised, 22% female, average age 45.

3 years, mean duration of pain 6.8 years

Interventions MBR (Education): 5 sessions of 2 hours in one week, plus monthly booster sessions and

monthly telephone counselling, group setting. Education (anatomy, risk factors, lifestyle

advice, posture, diagnosis, pain education). Streching, strengthening, relaxation exercises

(HEP). Psychologist: coping, stress, perceptions of stress and control, emotional reac-

tions, problem solving, relaxation. CBT: maladaptive cognitions, fear avoidance, activity

participation, adjustment to pain. Motivational counselling. Medications prescribe as

needed (analgesics, muscle relaxants, NSAIDs, anti-depressants)

Usual (Control): Medical management, mostly medication prescription (analgesics,

muscle relaxants, NSAIDs, anti-depressants)

Outcomes Pain (SF-36 bodily pain), Disability (RMDQ), General Health (SF-36)

Follow-ups: ST (3 months), MT (6 months)



Risk of bias



bias)

Low risk pg.812 Study design. “Participants were randomly assigned

into the intervention or control group through random per-

mutation blocking of every 6 participants”

Allocation concealment (selection bias) Low risk pg.812 Study design. “The sequence of allocation was con-

cealed to the rheumatologist who selected the eligible pa-



Tavafian 2011 (Continued)

tients”




bias)

All outcomes



All outcomes


Intention to treat analysis High risk pg.814 Statistical analysis. “no intention-to-treat analysis was

performed”

Selective reporting (reporting bias) Low risk pg.814 Statistical analysis. “All data analyses were carried out

according to the preestablished analysis plan”


clinical variables


Cointerventions Unclear risk Unclear

Timing of assessment Low risk pg.812 Study design. “Data were collected at the time of

randomization (baseline), 3, and 6-month follow-ups”

Turner 1990

Methods RCT conducted in the USA

Participants Patients responded to advertisements or referred by community physicians with age >

20-65 years, LBP >6 months. 96 patients randomised, 49% female, average age 44 years,

mean duration of pain 12.9 years

Interventions MBR (Behav/Exerc): 8 sessions, 1x/ week for 2 hours, in groups of 5-10. Behavioral:

Education about pain behaviours (with spouse), communication training, goal-setting

for behavioural activities, group discussions, homework. Exercise (10-20min 5x /week

HEP): gradually progressed walking/jogging on a quota system, warm-up and cool-down

stretches

Physical (Exercise): 8 sessions, 1x/ week for 2 hours, in groups of 5-10. Exercise (10-

20min 5x /week HEP): gradually progressed walking/jogging on a quota system, warm-

up and cool-down stretches

Waiting list (Control)



Turner 1990 (Continued)

Outcomes Pain (McGill), Disability (Sickness Impact Profile), Depression (CES-D)

Follow-ups: ST (2 months), MT (6 months) ST (12 months)



Risk of bias



bias)

Unclear risk Not stated

Allocation concealment (selection bias) Unclear risk Not stated




bias)

All outcomes



All outcomes

High risk pg.575 Immediate treatment effects. Dropout >20% at

post-treatment assessment

Intention to treat analysis High risk pg.575 Immediate treatment effects. Only compliers

analysed


Comparability of groups at baseline Low risk pg.575 Analysis of pre-treatment differences. Groups

comparable on relevant demographic and clinical vari-

ables



Timing of assessment Low risk pg.574 Outcome measures. A comprehensive set of mea-

sures, described below, was administered immediately be-

fore and after treatment and 6 and 12 months following

treatment”



Van den Hout 2003


Participants Patients with recent work absence due to LBP, referred by GP, occupational or rehabili-

tation physician with age 18-65 years, LBP >6 months, on sick leave for LBP >6 weeks.

84 patients randomised, 33.7% female, average age 40.5 years, mean duration of pain

1.6 years

Interventions MBR (GAPS): 19 half day sessions over 8 weeks, in groups (n=5). Graded activity: gradual

increase in physical activities, including work-specific tasks, as directed by occupational

therapist included a work visit, back education and lifting instructions, ADLs, leisure

activities, housework. Problem solving: CBT approach to problem solving skills, training

and application of skills to daily life, included homework assignments. Group education

sessions related to back and back pain

MBR-2 (CAGE): 19 half day sessions over 8 weeks, in groups (n=5). Graded activity:

gradual increase in physical activities, including work-specific tasks, as directed by occu-

pational therapist included a work visit, back education and lifting instructions, ADLs,

leisure activities, houeswork. Group education sessions related to back and back pain

Outcomes Work (% working).

Follow-ups: MT (6 months), LT (1 year)



Risk of bias



bias)

Low risk pg.88 Study design. “The randomization scheme

was computer-generated and was known only to

the logistics planner of the rehabilitation center”

Allocation concealment (selection bias) Low risk pg.88 Study design. “The randomization scheme

was computer-generated and was known only to

the logistics planner of the rehabilitation center”




bias)

All outcomes



All outcomes

High risk pg.91 Baseline characteristics. 84/108 random-

ized patients followed up




Van den Hout 2003 (Continued)


Comparability of groups at baseline High risk Table 1. Baseline difference in RMDQ



Timing of assessment Low risk pg.90 Statistical analysis. “Differences in work

status were assessed by means of 2 tests regard-

ing work status one week before the intervention,

and 6 and 12 months after the intervention”

Vollenbroek-Hutten 2004


Participants Patients admitted to a multidisciplinary rehabilitation program for LBP with age 18-60

years, pain >6 months, no surgery in the last 3 months. 163 patients randomised, %

female not reported, average age 39 years, mean duration of pain 5 years

Interventions MBR (RRP): 9 hours/week for 7 weeks in groups of 8 patients. Education: back pain,

chronicity, interaction of reduced physical activity and pain. Physical training: aerobic

training, swimming, physiotherapy. Occupational therapy

Usual (Control): unconstrained, usual care in the Netherlands

Outcomes Disability (RMDQ), General Health (EQ-5D), Fear Avoidance (TSK)




Risk of bias



bias)

Low risk pg.568 Protocol. “To enable an adequate as-

signment procedure a computer programme was

used”

Allocation concealment (selection bias) Low risk pg.568 Protocol. “Randomization was performed

by a person not involved in either the treatment

or this study”





Vollenbroek-Hutten 2004 (Continued)


bias)

All outcomes



All outcomes


Intention to treat analysis Unclear risk pg.570 1st column. “For all analyses an intention-

to-treat analysis, including patients with protocol

deviations, was performed”




Compliance Unclear risk pg.570 Compliance. Insufficient information re-

ported

Cointerventions Low risk pg.571 Co-interventions. Negligible visits to

other practitioners

Timing of assessment Low risk pg.569 1st paragraph. “Measurements were per-

formed before randomization (T0), in the week

after treatment or eight weeks after T0 (T1) and

six months after T0 (T5)”

Von Korff 2005

Methods RCT conducted in USA

Participants Members of an insurance scheme receiving primary care for LBP with age 25-60 years,

score >7/23 on RMDQ. 240 patients randomised, 62.5% female, average age 49.8 years,

mean duration of pain not reported

Interventions MBR (Intervention): 4 visits of 90 minutes. Psychologist: identify fears, relationship b/w

activity and pain, goal setting, relaxation, managing flare-ups. Physiotherapist: discussed

concerns and identify barriers to increasing activity, stretches, exercises to achieve activity

goals (HEP). Self-management book

Usual (Control): usual care in the community, usually included medication

Outcomes Pain (NRS), Disability (RMDQ), General Health (SF-36), Work (% able to work), Fear

Avoidance (TSK)

Follow-ups: ST (2 months), MT (6 months), LT (1 and 2 years)





Von Korff 2005 (Continued)

Risk of bias



bias)






bias)

All outcomes



All outcomes

Low risk pg.325 Results. 197/240 randomised patients followed up

Intention to treat analysis Unclear risk pg.325 Analysis. “Intent to treat analyses included all ran-

domized participants for whom follow-up data were avail-

able”



clinical variables

Compliance Unclear risk pg.325 Results. Compliance only reported in intervention

group


Timing of assessment Low risk pg.324 Masking. “At 2, 6, 12 and 24 months after random-

ization, follow-up telephone interviews were conducted by

an interviewer”

Characteristics of excluded studies [ordered by study ID]

Study Reason for exclusion

Akhmadeeva 2009 Not a full paper, conference abstract

Albaladejo 2010 Intervention does not contain two or more elements from the biopsychosocial model



(Continued)

Andrade 2008 Intervention does not contain two or more elements from the biopsychosocial model

Anema 2007 Participants do not all have chronic LBP

Angst 2009 Study is not a RCT

Bachmann 2009 Intervention does not contain two or more elements from the biopsychosocial model

Bahrke 2006 Study is not a RCT

Bandemeer-Greulich 2006 Study is not a RCT

Bandemeer-Greulich 2008 Study is not a RCT

Basler 2007 Intervention not delivered by a multidisciplinary team

Bastiaenen 2004 Study is not a RCT

Becker 2000 Participants do not all have chronic LBP

Becker 2008 Intervention does not contain two or more elements from the biopsychosocial model

Bendix 1998a Study does not compare treatment effects

Bethge 2011 Participants do not all have chronic LBP

Binder 2007 Study is not a RCT

Bliokas 2007 Participants do not all have chronic LBP

Brox 2003 Intervention not delivered by a multidisciplinary team

Buhrman 2011 Intervention not delivered by a multidisciplinary team

Bultman 2009 Participants do not all have chronic LBP

Busch 2011 Participants do not all have chronic LBP

Campello 2012 Participants do not all have chronic LBP

Cecchi 2012 Intervention not delivered by a multidisciplinary team

Christiansen 2010 Intervention not delivered as an integrated program

Demoulin 2006 Study is not a RCT



(Continued)

Dibbelt 2006 Study is not a RCT

Dobscha 2009 Participants do not all have chronic LBP

Donzelli 2006 Intervention does not contain two or more elements from the biopsychosocial model

Driessen 2011a Participants do not all have chronic LBP

Driessen 2011b Participants do not all have chronic LBP

Dufour 2010 Intervention does not contain two or more elements from the biopsychosocial model

Dysvik 2005 Study is not a RCT

Ektor-Andersen 2008 No defined MBR intervention reported

Esmer 2010 Intervention not delivered by a multidisciplinary team

Ewert 2009 Participants do not all have chronic LBP

Ferrari 2006 Participants do not all have chronic LBP

Friedberg 2010 Appraisal of another study

Friedrich 1998 Intervention not delivered by a multidisciplinary team

Friedrich 2005 Intervention not delivered by a multidisciplinary team

Froholdt 2011 Intervention does not contain two or more elements from the biopsychosocial model

Froholdt 2012 Intervention not delivered by a multidisciplinary team

Frost 1998 Intervention does not contain two or more elements from the biopsychosocial model

Gatchel 2003 Participants do not all have chronic LBP

George 2009 Not a full paper, conference abstract

George 2010a Not a full paper, conference abstract

George 2010b Study is not a RCT

George 2011 Participants do not all have chronic LBP

Glattacker 2012 Study is not a RCT



(Continued)

Glombiewski 2010 Intervention not delivered by a multidisciplinary team

Glomsrod 2001 Participants do not all have chronic LBP

Gohner 2006 Participants do not all have chronic LBP

Greitemann 2006 Study is not a RCT

Hagen 2006 Participants do not all have chronic LBP

Hagen 2010 Participants do not all have chronic LBP

Hallegraeff 2009 Participants do not all have chronic LBP

Hampel 2009 Study is not a RCT

Henchoz 2010a Intervention does not contain two or more elements from the biopsychosocial model

Henchoz 2010b Intervention does not contain two or more elements from the biopsychosocial model

Heymans 2006 Participants do not all have chronic LBP

Hlobil 2005 Participants do not all have chronic LBP

Hodselmans 2001 Intervention does not contain two or more elements from the biopsychosocial model

Huge 2006 Study is not a RCT

Jensen 2005 Study is not a RCT



Jensen 2011 Participants do not all have chronic LBP



Johnson 2013 Reported in Hellum 2011

Kainz 2006 Study is not a RCT

Kolip 2001 Study is not a RCT



(Continued)

Kumar 2010 Intervention does not contain two or more elements from the biopsychosocial model

Lamb 2010 Participants do not all have chronic LBP

Lang 2003 Study is not a RCT

Le Gall 2001 Study is not a RCT

Lee 2013 Participants do not all have chronic LBP

Leon 2009 Participants do not all have chronic LBP

Lindell 2008 Participants do not all have chronic LBP

Linton 2000 Study is not a RCT

Ljungkvist 2000 Study is not a RCT

Loisel 2002 Participants do not all have chronic LBP

Lonn 1999 Intervention does not contain two or more elements from the biopsychosocial model

Mannion 2001 Intervention does not contain two or more elements from the biopsychosocial model

Mannion 2013 Intervention not delivered by a multidisciplinary team

Martin 2000 Participants do not all have chronic LBP

Mattila 2007 Participants do not all have chronic LBP

Meyer 2005 Participants do not all have chronic LBP

Mohr 2009 Study is not a RCT

Molde 2003 Participants do not all have chronic LBP

Nazzal 2013 Intervention not delivered by a multidisciplinary team

Nicholas 2013 Participants do not all have chronic LBP

Niemisto 2005 Intervention does not contain two or more elements from the biopsychosocial model

Padua 2009 Study is not a RCT

Paolucci 2012 Reported in Morone 2011



(Continued)

Rainville 2002 Intervention does not contain two or more elements from the biopsychosocial model

Rantonen 2012 Participants do not all have chronic LBP

Rossignol 2000 Participants do not all have chronic LBP

Rothman 2013 Participants do not all have chronic LBP

Sahin 2011 Intervention not delivered by a multidisciplinary team

Shete 2012 Participants do not all have chronic LBP

Siemonsma 2013 Intervention not delivered by a multidisciplinary team

Sjostrum 2010 Study is not a RCT

Sleptsova 2013 Participants do not all have chronic LBP

Sorensen 2010 Intervention does not contain two or more elements from the biopsychosocial model

Staal 2004 Intervention does not contain two or more elements from the biopsychosocial model

Stapelfeldt 2011 Participants do not all have chronic LBP

Steenstra 2006 Intervention does not contain two or more elements from the biopsychosocial model

Stier 2001 Study is not a RCT

Storheim 2003 Intervention does not contain two or more elements from the biopsychosocial model

Storro 2004 Study is not a RCT

Strong 2006 Intervention not delivered by a multidisciplinary team

Sundberg 2009 Participants do not all have chronic LBP

Tlach 2011 Study is not a RCT

Torstensen 1998 Intervention does not contain two or more elements from the biopsychosocial model

Trapp 2009 Not a full paper, conference abstract

Tsauo 2009 Intervention does not contain two or more elements from the biopsychosocial model

Turk 1998 Study is not a RCT



(Continued)

Underwood 2004 Intervention does not contain two or more elements from the biopsychosocial model

van Beurden 2012 Participants do not all have chronic LBP

van der Roer 2008 Intervention not delivered by a multidisciplinary team

van Hoof 2010 Study is not a RCT

Verbeek 2002 Participants do not all have chronic LBP

Vermeulen 2011 Participants do not all have chronic LBP

Verra 2012 Study is not a RCT

Vibe Fersum 2013 Intervention not delivered by a multidisciplinary team

Vlaeyen 1995 Intervention does not contain two or more elements from the biopsychosocial model

Vong 2011 Intervention not delivered by a multidisciplinary team

Wagner 2007 Study is not a RCT

Wand 2004 Participants do not all have chronic LBP

Wessels 2007 Participants do not all have chronic LBP

Whitfill 2010 Participants do not all have chronic LBP

Wilkey 2008 Intervention does not contain two or more elements from the biopsychosocial model

Yang 2010 Intervention not delivered by a multidisciplinary team



D A T A A N D A N A L Y S E S

Comparison 1. MBR versus usual care

Outcome or subgroup titleNo. of

studies

No. of

participants Statistical method Effect size

1 Back pain short term 9 879 Std. Mean Difference (IV, Random, 95% CI) -0.55 [-0.83, -0.28]

2 Back pain medium term 6 740 Std. Mean Difference (IV, Random, 95% CI) -0.60 [-0.85, -0.34]

3 Back pain long term 7 821 Std. Mean Difference (IV, Random, 95% CI) -0.21 [-0.37, -0.04]

4 Disability short term 9 939 Std. Mean Difference (IV, Random, 95% CI) -0.41 [-0.62, -0.19]

5 Disability medium term 6 786 Std. Mean Difference (IV, Random, 95% CI) -0.43 [-0.66, -0.19]

6 Disability long term 6 722 Std. Mean Difference (IV, Random, 95% CI) -0.23 [-0.40, -0.06]

7 Work short term 2 373 Odds Ratio (M-H, Random, 95% CI) 1.07 [0.60, 1.90]

8 Work medium term 3 457 Odds Ratio (M-H, Random, 95% CI) 1.60 [0.52, 4.91]

9 Work long term 7 1360 Odds Ratio (M-H, Random, 95% CI) 1.04 [0.73, 1.47]

10 QoL SF36 PCS short term 2 144 Mean Difference (IV, Random, 95% CI) 13.45 [-9.07, 35.96]

11 QoL SF36 MCS short term 2 144 Mean Difference (IV, Random, 95% CI) 15.25 [2.05, 28.44]

12 QoL SF36 PCS medium term 2 144 Mean Difference (IV, Random, 95% CI) 7.41 [-4.99, 19.81]

13 QoL SF36 MCS medium term 2 144 Mean Difference (IV, Random, 95% CI) 7.59 [1.69, 13.49]

14 Catastrophising short term 2 99 Std. Mean Difference (IV, Random, 95% CI) -0.43 [-0.83, -0.03]

15 Catastrophising long term 2 127 Std. Mean Difference (IV, Random, 95% CI) -0.40 [-0.76, -0.05]

16 Fear avoidance short term 2 253 Std. Mean Difference (IV, Random, 95% CI) -0.69 [-1.52, 0.14]

17 Fear avoidance long term 3 371 Std. Mean Difference (IV, Random, 95% CI) -0.29 [-0.49, -0.08]

Comparison 2. MBR versus physical treatment


studies

No. of


1 Pain short term 12 1661 Std. Mean Difference (IV, Random, 95% CI) -0.30 [-0.54, -0.06]

2 Pain medium term 9 531 Std. Mean Difference (IV, Random, 95% CI) -0.28 [-0.54, -0.02]

3 Pain long term 9 872 Std. Mean Difference (IV, Random, 95% CI) -0.51 [-1.04, 0.01]


5 Disability medium term 9 511 Std. Mean Difference (IV, Random, 95% CI) -0.21 [-0.48, 0.06]

6 Disability long term 10 1169 Std. Mean Difference (IV, Random, 95% CI) -0.68 [-1.19, -0.16]

7 Work short term 3 379 Odds Ratio (M-H, Random, 95% CI) 1.60 [0.92, 2.78]

8 Work medium term 3 221 Odds Ratio (M-H, Random, 95% CI) 2.14 [1.12, 4.10]


10 QoL short term 3 568 Std. Mean Difference (IV, Random, 95% CI) -0.04 [-0.34, 0.26]

11 Quality of Life medium term 2 342 Std. Mean Difference (IV, Random, 95% CI) 0.20 [-0.12, 0.51]

12 Healthcare visits long term 2 226 Std. Mean Difference (IV, Random, 95% CI) -0.06 [-0.32, 0.20]

13 Depression short term 7 911 Std. Mean Difference (IV, Random, 95% CI) 0.05 [-0.12, 0.22]

14 Depression medium term 7 411 Std. Mean Difference (IV, Random, 95% CI) -0.16 [-0.42, 0.09]

15 Depression long term 5 506 Std. Mean Difference (IV, Random, 95% CI) -0.05 [-0.40, 0.30]

16 Coping short term 3 282 Std. Mean Difference (IV, Random, 95% CI) 0.22 [-0.02, 0.45]

17 Coping medium term 2 40 Std. Mean Difference (IV, Random, 95% CI) 1.09 [0.31, 1.87]

18 Coping long term 2 262 Std. Mean Difference (IV, Random, 95% CI) 0.30 [0.06, 0.54]



19 Self-efficacy short term 3 432 Std. Mean Difference (IV, Random, 95% CI) 0.27 [-0.08, 0.61]

20 Self-efficacy medium term 2 58 Std. Mean Difference (IV, Random, 95% CI) 0.26 [-0.40, 0.92]

21 Anxiety short term 2 377 Std. Mean Difference (IV, Random, 95% CI) -0.10 [-0.67, 0.47]

22 Anxiety medium term 2 51 Std. Mean Difference (IV, Random, 95% CI) -0.40 [-1.80, 1.00]

Comparison 3. MBR versus surgery


studies

No. of


1 Pain long term 2 385 Std. Mean Difference (IV, Random, 95% CI) -0.25 [-0.53, 0.04]

2 Disability long term 2 423 Std. Mean Difference (IV, Random, 95% CI) 0.25 [-0.08, 0.57]


4 Adverse events/complications 2 385 Odds Ratio (M-H, Fixed, 95% CI) 28.25 [3.77, 211.93]

5 QoL SF36 PCS long term 2 385 Std. Mean Difference (IV, Random, 95% CI) -0.28 [-0.70, 0.14]

6 QoL SF36 MCS long term 2 385 Std. Mean Difference (IV, Random, 95% CI) -0.03 [-0.25, 0.19]

Comparison 4. MBR versus wait list


studies

No. of


1 Pain short term 3 213 Std. Mean Difference (IV, Random, 95% CI) -0.73 [-1.22, -0.24]


3 Depression short term 3 213 Std. Mean Difference (IV, Random, 95% CI) -0.21 [-0.59, 0.18]

Comparison 5. MBR versus usual care, sensitivity and subgroup analyses


studies

No. of


1 Pain short term - all studies 9 879 Std. Mean Difference (IV, Random, 95% CI) -0.55 [-0.83, -0.28]

2 Pain short term - sensitivity and

subgroup analyses

9 Std. Mean Difference (IV, Fixed, 95% CI) Subtotals only

2.1 High quality 1 - 6 or more

Risk of Bias items

3 334 Std. Mean Difference (IV, Fixed, 95% CI) -0.49 [-0.71, -0.27]

2.2 High quality 2 -

Concealed allocation


2.3 High baseline symptom

intensity (>60% on pain &

disability scales)


2.4 Low baseline symptom

intensity (<60% on pain &

disability scales)




2.5 High intervention

intensity (>100 hours, daily

contact)

0 0 Std. Mean Difference (IV, Fixed, 95% CI) 0.0 [0.0, 0.0]

2.6 Low intervention intensity

(<100 hours, non-daily

contact)


3 Pain medium term - all studies 6 740 Std. Mean Difference (IV, Random, 95% CI) -0.60 [-0.85, -0.34]

4 Pain medium term - sensitivity

and subgroup analyses

6 Std. Mean Difference (IV, Random, 95% CI) Subtotals only


Risk of Bias items

2 306 Std. Mean Difference (IV, Random, 95% CI) -0.49 [-0.72, -0.26]






disability scales)




disability scales)




contact)



(<30 hours, non-daily contact)


5 Pain long term - all studies 7 821 Std. Mean Difference (IV, Random, 95% CI) -0.21 [-0.37, -0.04]

6 Pain long term - sensitivity and

subgroup analyses



Risk of Bias items

2 142 Std. Mean Difference (IV, Random, 95% CI) -0.14 [-0.47, 0.19]






disability scales)




disability scales)




contact)





7 Disability short term - all

analyses


8 Disability short term - sensitivity



8.1 High quality 1 - 6 more or

Risk of Bias items









disability scales)




disability scales)




contact)

0 0 Std. Mean Difference (IV, Random, 95% CI) 0.0 [0.0, 0.0]




9 Disability medium term - all

studies


10 Disability medium term -

sensitivity and subgroup

analyses


10.1 High quality 1 - 6 or

more Risk of Bias items







disability scales)




disability scales)




contact)


10.6 Low intervention

intensity (<30 hours, non-daily

contact)


11 Disability long term - all studies 6 722 Std. Mean Difference (IV, Random, 95% CI) -0.23 [-0.40, -0.06]

12 Disability long term - sensitivity











disability scales)




disability scales)




contact)



intensity (<30 hours, non-daily

contact)




13 Work short term - all studies 2 373 Odds Ratio (M-H, Fixed, 95% CI) 1.07 [0.60, 1.90]

14 Work short term - sensitivity


2 Odds Ratio (M-H, Random, 95% CI) Subtotals only



0 0 Odds Ratio (M-H, Random, 95% CI) 0.0 [0.0, 0.0]






disability scales)




disability scales)



volume (>100 hours, daily

contact)


14.6 Low intervention volume



15 Work medium term all studies 3 457 Odds Ratio (M-H, Random, 95% CI) 1.60 [0.52, 4.91]

16 Work medium term - sensitivity











disability scales)




disability scales)




contact)





17 Work long term - all studies 7 1360 Odds Ratio (M-H, Random, 95% CI) 1.04 [0.73, 1.47]

18 Work long term - sensitivity











disability scales)




disability scales)






contact)





Comparison 6. MBR versus physical treatment, sensitivity and subgroup analyses


studies

No. of


1 Pain short term - all studies 11 1352 Std. Mean Difference (IV, Random, 95% CI) -0.29 [-0.57, -0.01]

2 Pain short term - sensitivity and

subgroup analyses



Risk of Bias items







disability scales)




disability scales)



intensity 1 (>100 hours, daily

contact)



1 (<30 hours, non-daily

contact)


3 Pain medium term - all studies 9 531 Std. Mean Difference (IV, Random, 95% CI) -0.28 [-0.54, -0.02]

4 Pain medium term - sensitivity




Risk of Bias items

2 223 Std. Mean Difference (IV, Random, 95% CI) 0.02 [-0.24, 0.29]






disability scales)




disability scales)




contact)




contact)




5 Pain long term - all studies 9 872 Std. Mean Difference (IV, Random, 95% CI) -0.51 [-1.04, 0.01]

6 Pain long term - sensitivity and

subgroup analyses



Risk of Bias items







disability scales)




disability scales)




contact)




contact)


7 Disability short term - all studies 13 1878 Std. Mean Difference (IV, Random, 95% CI) -0.39 [-0.68, -0.10]

8 Disability short term - sensitivity




Risk of Bias items







disability scales)




disability scales)




contact)




contact)


9 Disability medium term - all

studies


10 Disability medium term -

sensitivity and subgroup

analyses










disability scales)






disability scales)




contact)



intensity 1 (<30 hours,

non-daily contact)


11 Disability long term - all studies 10 1169 Std. Mean Difference (IV, Random, 95% CI) -0.68 [-1.19, -0.16]

12 Disability long term - sensitivity











disability scale)




disability scale)




contact)



intensity 1 (<30 hours,

non-daily contact)


13 Work short term - all studies 3 379 Odds Ratio (M-H, Random, 95% CI) 1.60 [0.92, 2.78]

14 Work short term - sensitivity




more Risk of bias items







disability scales)




disability scales)




contact)





15 Work medium term - all studies 3 221 Odds Ratio (M-H, Random, 95% CI) 2.14 [1.12, 4.10]

16 Work medium term - sensitivity













disability scales)




disability scales)




contact)





17 Work long term - all studies 8 1006 Odds Ratio (M-H, Random, 95% CI) 1.87 [1.39, 2.53]

18 Work long term - sensitivity











disability scales)




disability scales)




contact)







Analysis 1.1. Comparison 1 MBR versus usual care, Outcome 1 Back pain short term.

Review: Multidisciplinary biopsychosocial rehabilitation for chronic low back pain

Comparison: 1 MBR versus usual care

Outcome: 1 Back pain short term

Study or subgroup MBR Usual

Std.Mean

Difference Weight

Std.Mean

Difference

N Mean(SD) N Mean(SD) IV,Random,95% CI IV,Random,95% CI

Abbassi 2012 12 2.6 (2) 11 3.2 (1.6) 6.8 % -0.32 [ -1.14, 0.51 ]

Basler 1997 36 4.08 (2.11) 40 4.18 (1.37) 11.7 % -0.06 [ -0.51, 0.39 ]

Lambeek 2010 60 3.89 (2.54) 62 5.52 (2.35) 13.1 % -0.66 [ -1.03, -0.30 ]

Moix 2003 13 14.5 (3.2) 15 14.9 (3.2) 7.7 % -0.12 [ -0.86, 0.62 ]

Morone 2011 41 4.5 (2.3) 29 7.6 (2.1) 10.5 % -1.38 [ -1.91, -0.85 ]

Morone 2012 25 5 (2.2) 25 8 (2.2) 9.2 % -1.34 [ -1.96, -0.72 ]

Tavafian 2008 44 -71.5 (16.2) 47 -56.6 (30) 12.2 % -0.61 [ -1.03, -0.19 ]

Tavafian 2011 92 -65.82 (22.56) 97 -56.35 (23.62) 14.3 % -0.41 [ -0.70, -0.12 ]

Von Korff 2005 110 4.9 (2) 120 5.3 (1.9) 14.7 % -0.20 [ -0.46, 0.05 ]

Total (95% CI) 433 446 100.0 % -0.55 [ -0.83, -0.28 ]

Heterogeneity: Tau2 = 0.12; Chi2 = 28.85, df = 8 (P = 0.00034); I2 =72%

Test for overall effect: Z = 3.90 (P = 0.000098)

Test for subgroup differences: Not applicable

-2 -1 0 1 2

Favours Multidis Favours Usual



Analysis 1.2. Comparison 1 MBR versus usual care, Outcome 2 Back pain medium term.



Outcome: 2 Back pain medium term


Std.Mean

Difference Weight

Std.Mean

Difference


Bendix ’A’ 1996/1998 45 5.7 (2.1) 49 6.9 (2.1) 16.2 % -0.57 [ -0.98, -0.15 ]

Lambeek 2010 58 3.61 (2.59) 60 4.84 (2.41) 17.7 % -0.49 [ -0.86, -0.12 ]

Morone 2011 41 4.4 (2.5) 29 6.5 (1.9) 13.5 % -0.91 [ -1.41, -0.41 ]

Morone 2012 25 4 (2.2) 25 7 (2.2) 10.7 % -1.34 [ -1.96, -0.72 ]

Tavafian 2011 92 -72.34 (22.77) 96 -60.27 (25.82) 20.5 % -0.49 [ -0.78, -0.20 ]

Von Korff 2005 110 4.2 (2) 110 4.7 (2.2) 21.4 % -0.24 [ -0.50, 0.03 ]

Total (95% CI) 371 369 100.0 % -0.60 [ -0.85, -0.34 ]


Test for overall effect: Z = 4.55 (P < 0.00001)


-2 -1 0 1 2




Analysis 1.3. Comparison 1 MBR versus usual care, Outcome 3 Back pain long term.



Outcome: 3 Back pain long term


Std.Mean

Difference Weight

Std.Mean

Difference


Abbassi 2012 12 3.7 (2.5) 11 4.3 (1.4) 3.7 % -0.28 [ -1.10, 0.54 ]

Bendix ’A’ 1996/1998 50 6 (2.2) 49 6.5 (2.2) 13.3 % -0.23 [ -0.62, 0.17 ]

Lambeek 2010 59 4.16 (2.68) 60 4.47 (2.68) 15.4 % -0.11 [ -0.47, 0.24 ]

Linton 2005 61 2.9 (2) 47 4.1 (2.6) 13.8 % -0.52 [ -0.91, -0.14 ]

Lukinmaa 1989 86 47.3 (20.5) 72 44.6 (20.5) 18.7 % 0.13 [ -0.18, 0.44 ]

Strand 2001 81 37.2 (20.5) 36 42.5 (20.5) 13.4 % -0.26 [ -0.65, 0.14 ]

Von Korff 2005 99 4 (2.3) 98 4.7 (2.1) 21.6 % -0.32 [ -0.60, -0.04 ]

Total (95% CI) 448 373 100.0 % -0.21 [ -0.37, -0.04 ]




-2 -1 0 1 2




Analysis 1.4. Comparison 1 MBR versus usual care, Outcome 4 Disability short term.



Outcome: 4 Disability short term


Std.Mean

Difference Weight

Std.Mean

Difference


Abbassi 2012 12 6.2 (4.4) 11 3.2 (3.2) 5.0 % 0.75 [ -0.11, 1.60 ]

Basler 1997 36 1.63 (0.87) 40 1.84 (0.62) 11.1 % -0.28 [ -0.73, 0.17 ]

Lambeek 2010 60 8.8 (5.58) 62 13.16 (5.39) 13.2 % -0.79 [ -1.16, -0.42 ]

Moix 2003 13 14.7 (4.4) 15 16.8 (3.4) 5.9 % -0.52 [ -1.28, 0.23 ]

Morone 2011 41 18 (12.9) 29 25.8 (14.1) 10.3 % -0.58 [ -1.06, -0.09 ]

Morone 2012 25 12 (13.5) 25 26 (13.5) 8.3 % -1.02 [ -1.61, -0.43 ]

Tavafian 2011 92 9.01 (5.71) 97 10.56 (5.78) 15.5 % -0.27 [ -0.56, 0.02 ]

Vollenbroek-Hutten 2004 72 11 (5) 79 13 (5) 14.5 % -0.40 [ -0.72, -0.08 ]

Von Korff 2005 110 10.2 (6.3) 120 11.5 (5.8) 16.3 % -0.21 [ -0.47, 0.05 ]

Total (95% CI) 461 478 100.0 % -0.41 [ -0.62, -0.19 ]




-2 -1 0 1 2




Analysis 1.5. Comparison 1 MBR versus usual care, Outcome 5 Disability medium term.



Outcome: 5 Disability medium term


Std.Mean

Difference Weight

Std.Mean

Difference


Lambeek 2010 58 7.94 (5.99) 60 11.88 (5.76) 16.9 % -0.67 [ -1.04, -0.30 ]

Morone 2011 41 16.8 (14.2) 29 26 (16.1) 12.9 % -0.61 [ -1.09, -0.12 ]

Morone 2012 25 10 (15.2) 25 26 (15.2) 10.1 % -1.04 [ -1.63, -0.44 ]

Tavafian 2011 92 7.03 (5.49) 96 8.8 (5.68) 20.3 % -0.32 [ -0.60, -0.03 ]

Vollenbroek-Hutten 2004 68 10 (5) 72 11 (5) 18.4 % -0.20 [ -0.53, 0.13 ]

Von Korff 2005 110 9.2 (6.6) 110 10.1 (6.4) 21.4 % -0.14 [ -0.40, 0.13 ]

Total (95% CI) 394 392 100.0 % -0.43 [ -0.66, -0.19 ]




-2 -1 0 1 2




Analysis 1.6. Comparison 1 MBR versus usual care, Outcome 6 Disability long term.



Outcome: 6 Disability long term


Std.Mean

Difference Weight

Std.Mean

Difference


Abbassi 2012 12 8.8 (5.9) 11 10.4 (6.2) 4.0 % -0.26 [ -1.08, 0.57 ]

Lambeek 2010 59 7.49 (6.15) 60 10.58 (6.5) 17.3 % -0.49 [ -0.85, -0.12 ]

Linton 2005 61 3.4 (4) 47 4 (4.7) 16.1 % -0.14 [ -0.52, 0.24 ]

Lukinmaa 1989 86 8 (5.7) 72 8.3 (5.7) 21.9 % -0.05 [ -0.37, 0.26 ]

Strand 2001 81 42 (12.9) 36 48.8 (12.9) 14.9 % -0.52 [ -0.92, -0.13 ]

Von Korff 2005 99 8.4 (7) 98 9.1 (6.3) 25.8 % -0.10 [ -0.38, 0.17 ]

Total (95% CI) 398 324 100.0 % -0.23 [ -0.40, -0.06 ]




-2 -1 0 1 2




Analysis 1.7. Comparison 1 MBR versus usual care, Outcome 7 Work short term.



Outcome: 7 Work short term

Study or subgroup MBR Usual Odds Ratio Weight Odds Ratio

n/N n/N

M-H,Random,95%

CI

M-H,Random,95%

CI

Skouen 2002 25/57 35/86 71.8 % 1.14 [ 0.58, 2.24 ]

Von Korff 2005 103/110 113/120 28.2 % 0.91 [ 0.31, 2.69 ]

Total (95% CI) 167 206 100.0 % 1.07 [ 0.60, 1.90 ]

Total events: 128 (MBR), 148 (Usual)

Heterogeneity: Tau2 = 0.0; Chi2 = 0.12, df = 1 (P = 0.73); I2 =0.0%



0.05 0.2 1 5 20

Favours Usual Favours Multidis

Analysis 1.8. Comparison 1 MBR versus usual care, Outcome 8 Work medium term.



Outcome: 8 Work medium term


n/N n/N

M-H,Random,95%

CI

M-H,Random,95%

CI

Bendix ’A’ 1996/1998 29/45 14/49 33.6 % 4.53 [ 1.90, 10.81 ]

Skouen 2002 33/57 39/86 36.5 % 1.66 [ 0.84, 3.26 ]

Von Korff 2005 100/110 105/110 29.8 % 0.48 [ 0.16, 1.44 ]

Total (95% CI) 212 245 100.0 % 1.60 [ 0.52, 4.91 ]





0.05 0.2 1 5 20




Analysis 1.9. Comparison 1 MBR versus usual care, Outcome 9 Work long term.



Outcome: 9 Work long term


n/N n/N

M-H,Random,95%

CI

M-H,Random,95%

CI

Bendix ’A’ 1996/1998 26/50 25/49 13.8 % 1.04 [ 0.47, 2.29 ]

Linton 2005 57/61 36/43 6.2 % 2.77 [ 0.76, 10.14 ]

Lukinmaa 1989 70/86 61/72 12.6 % 0.79 [ 0.34, 1.83 ]

Mitchell 1994 214/271 211/271 28.9 % 1.07 [ 0.71, 1.61 ]

Skouen 2002 35/57 40/86 16.8 % 1.83 [ 0.93, 3.62 ]

Strand 2001 38/81 21/36 13.7 % 0.63 [ 0.29, 1.40 ]

Von Korff 2005 89/99 93/98 8.1 % 0.48 [ 0.16, 1.46 ]

Total (95% CI) 705 655 100.0 % 1.04 [ 0.73, 1.47 ]





0.05 0.2 1 5 20




Analysis 1.10. Comparison 1 MBR versus usual care, Outcome 10 QoL SF36 PCS short term.



Outcome: 10 QoL SF36 PCS short term

Study or subgroup MBR UsualMean

Difference WeightMean

Difference


Morone 2011 41 45.5 (6.8) 29 43 (9.1) 52.4 % 2.50 [ -1.41, 6.41 ]

Tavafian 2008 37 76.7 (17.3) 37 51.2 (28.1) 47.6 % 25.50 [ 14.87, 36.13 ]

Total (95% CI) 78 66 100.0 % 13.45 [ -9.07, 35.96 ]




-100 -50 0 50 100


Analysis 1.11. Comparison 1 MBR versus usual care, Outcome 11 QoL SF36 MCS short term.



Outcome: 11 QoL SF36 MCS short term



Difference


Morone 2011 41 47.3 (11) 29 37.9 (15.9) 57.0 % 9.40 [ 2.70, 16.10 ]

Tavafian 2008 37 80.4 (22.8) 37 57.4 (29.5) 43.0 % 23.00 [ 10.99, 35.01 ]

Total (95% CI) 78 66 100.0 % 15.25 [ 2.05, 28.44 ]




-100 -50 0 50 100




Analysis 1.12. Comparison 1 MBR versus usual care, Outcome 12 QoL SF36 PCS medium term.



Outcome: 12 QoL SF36 PCS medium term



Difference


Morone 2011 41 45 (8.2) 29 42.6 (8.4) 61.5 % 2.40 [ -1.56, 6.36 ]

Tavafian 2008 37 66.6 (27.5) 37 51.2 (28.8) 38.5 % 15.40 [ 2.57, 28.23 ]

Total (95% CI) 78 66 100.0 % 7.41 [ -4.99, 19.81 ]




-100 -50 0 50 100


Analysis 1.13. Comparison 1 MBR versus usual care, Outcome 13 QoL SF36 MCS medium term.



Outcome: 13 QoL SF36 MCS medium term



Difference


Morone 2011 41 47.1 (11.6) 29 39.9 (15.5) 78.3 % 7.20 [ 0.53, 13.87 ]

Tavafian 2008 37 66.9 (29.9) 37 57.9 (25.5) 21.7 % 9.00 [ -3.66, 21.66 ]

Total (95% CI) 78 66 100.0 % 7.59 [ 1.69, 13.49 ]




-100 -50 0 50 100




Analysis 1.14. Comparison 1 MBR versus usual care, Outcome 14 Catastrophising short term.



Outcome: 14 Catastrophising short term


Std.Mean

Difference Weight

Std.Mean

Difference


Abbassi 2012 12 24.3 (8.6) 11 25.7 (6.7) 23.8 % -0.17 [ -0.99, 0.65 ]

Basler 1997 36 2 (0.75) 40 2.39 (0.78) 76.2 % -0.50 [ -0.96, -0.05 ]

Total (95% CI) 48 51 100.0 % -0.43 [ -0.83, -0.03 ]




-2 -1 0 1 2


Analysis 1.15. Comparison 1 MBR versus usual care, Outcome 15 Catastrophising long term.



Outcome: 15 Catastrophising long term


Std.Mean

Difference Weight

Std.Mean

Difference


Abbassi 2012 12 24.3 (7.3) 11 24.6 (7.8) 19.0 % -0.04 [ -0.86, 0.78 ]

Linton 2005 61 13 (6.4) 43 16.9 (9.7) 81.0 % -0.49 [ -0.88, -0.09 ]

Total (95% CI) 73 54 100.0 % -0.40 [ -0.76, -0.05 ]




-2 -1 0 1 2




Analysis 1.16. Comparison 1 MBR versus usual care, Outcome 16 Fear avoidance short term.



Outcome: 16 Fear avoidance short term


Std.Mean

Difference Weight

Std.Mean

Difference


Abbassi 2012 12 18.3 (6.7) 11 27.2 (7.1) 37.2 % -1.24 [ -2.15, -0.34 ]

Von Korff 2005 110 36.4 (9.3) 120 39.9 (9.7) 62.8 % -0.37 [ -0.63, -0.11 ]

Total (95% CI) 122 131 100.0 % -0.69 [ -1.52, 0.14 ]




-2 -1 0 1 2


Analysis 1.17. Comparison 1 MBR versus usual care, Outcome 17 Fear avoidance long term.



Outcome: 17 Fear avoidance long term


Std.Mean

Difference Weight

Std.Mean

Difference


Abbassi 2012 12 25.1 (6.9) 11 29.7 (9.6) 6.0 % -0.53 [ -1.37, 0.30 ]

Linton 2005 61 20 (6) 47 21.1 (6.4) 29.0 % -0.18 [ -0.56, 0.20 ]

Von Korff 2005 119 34.3 (10) 121 37.4 (9.5) 65.0 % -0.32 [ -0.57, -0.06 ]

Total (95% CI) 192 179 100.0 % -0.29 [ -0.49, -0.08 ]




-2 -1 0 1 2




Analysis 2.1. Comparison 2 MBR versus physical treatment, Outcome 1 Pain short term.


Comparison: 2 MBR versus physical treatment

Outcome: 1 Pain short term

Study or subgroup MBR Physical

Std.Mean

Difference Weight

Std.Mean

Difference


Harkapaa 1989 156 128 (82) 153 162 (82) 10.6 % -0.41 [ -0.64, -0.19 ]

Kaapa 2006 59 3.3 (2.5) 61 3.4 (2.4) 9.3 % -0.04 [ -0.40, 0.32 ]

Kool 2007 85 5.85 (2.3) 85 6.59 (2.2) 9.9 % -0.33 [ -0.63, -0.02 ]

Mangels 2009 111 15.9 (5.3) 131 16.4 (5.8) 10.4 % -0.09 [ -0.34, 0.16 ]

Monticone 2013 45 2.69 (0.97) 45 4.96 (1.27) 7.7 % -1.99 [ -2.50, -1.48 ]

Morone 2012 25 5 (2.2) 25 5 (2.2) 7.2 % 0.0 [ -0.55, 0.55 ]

Nicholas 1991 9 2.73 (0.6) 11 3.16 (0.66) 4.4 % -0.65 [ -1.56, 0.26 ]

Nicholas 1992 10 3.07 (0.79) 10 2.72 (0.77) 4.5 % 0.43 [ -0.46, 1.32 ]

Roche 2007/2011 67 2.8 (2.1) 64 3 (2.1) 9.5 % -0.09 [ -0.44, 0.25 ]

Schweikert 2006 170 5.5 (1.3) 193 5.7 (1.3) 10.8 % -0.15 [ -0.36, 0.05 ]

Smeets 2006/2008 55 42.31 (25.56) 52 44.63 (28.86) 9.1 % -0.08 [ -0.46, 0.29 ]

Turner 1990 18 14.78 (11.44) 21 17.52 (10.2) 6.5 % -0.25 [ -0.88, 0.38 ]

Total (95% CI) 810 851 100.0 % -0.30 [ -0.54, -0.06 ]

Heterogeneity: Tau2 = 0.13; Chi2 = 56.19, df = 11 (P<0.00001); I2 =80%



-2 -1 0 1 2

Favours Multidis Favours Phys



Analysis 2.2. Comparison 2 MBR versus physical treatment, Outcome 2 Pain medium term.



Outcome: 2 Pain medium term


Std.Mean

Difference Weight

Std.Mean

Difference


Bendix ’B’ 1995/1998 40 2.7 (2.5) 31 4.4 (2.5) 13.1 % -0.67 [ -1.16, -0.19 ]

Coole 2013 19 5.19 (1.87) 19 5.33 (2.18) 9.9 % -0.07 [ -0.70, 0.57 ]

Jousset 2004 42 3.1 (2.5) 41 4 (2.8) 14.3 % -0.34 [ -0.77, 0.10 ]

Kaapa 2006 59 3.3 (2.5) 60 3.4 (2.5) 16.3 % -0.04 [ -0.40, 0.32 ]

Morone 2012 20 4 (2.2) 25 5 (2.2) 10.7 % -0.45 [ -1.04, 0.15 ]

Nicholas 1991 9 1.87 (0.73) 11 3.18 (0.72) 4.8 % -1.73 [ -2.80, -0.67 ]

Nicholas 1992 10 2.89 (0.64) 10 2.75 (1.11) 6.5 % 0.15 [ -0.73, 1.03 ]

Smeets 2006/2008 53 49.53 (22.24) 51 47.14 (27.3) 15.6 % 0.10 [ -0.29, 0.48 ]

Turner 1990 14 13.29 (9.15) 17 15.65 (9.15) 8.7 % -0.25 [ -0.96, 0.46 ]

Total (95% CI) 266 265 100.0 % -0.28 [ -0.54, -0.02 ]




-2 -1 0 1 2




Analysis 2.3. Comparison 2 MBR versus physical treatment, Outcome 3 Pain long term.



Outcome: 3 Pain long term


Std.Mean

Difference Weight

Std.Mean

Difference


Bendix ’B’ 1995/1998 38 3.3 (2.6) 31 5.3 (2.6) 11.3 % -0.76 [ -1.25, -0.27 ]

Bendix ’C’ 2000 48 5.1 (2.6) 50 5.7 (2.6) 11.7 % -0.23 [ -0.63, 0.17 ]

Kaapa 2006 53 3.6 (2.7) 54 3.4 (2.5) 11.7 % 0.08 [ -0.30, 0.46 ]

Mangels 2009 111 16.3 (5.7) 131 17.3 (6.1) 12.1 % -0.17 [ -0.42, 0.08 ]

Monticone 2013 45 1.38 (1.07) 45 5.33 (1.22) 10.5 % -3.41 [ -4.07, -2.76 ]

Nicholas 1991 9 2.66 (1.06) 11 3.22 (0.69) 9.1 % -0.61 [ -1.52, 0.29 ]

Roche 2007/2011 64 2.9 (2.4) 48 3.5 (2.3) 11.8 % -0.25 [ -0.63, 0.12 ]

Smeets 2006/2008 53 52.87 (24.47) 51 47.24 (27.53) 11.7 % 0.21 [ -0.17, 0.60 ]

Turner 1990 14 18.21 (13.31) 16 14.94 (7.86) 10.1 % 0.30 [ -0.43, 1.02 ]

Total (95% CI) 435 437 100.0 % -0.51 [ -1.04, 0.01 ]




-2 -1 0 1 2




Analysis 2.4. Comparison 2 MBR versus physical treatment, Outcome 4 Disability short term.





Std.Mean

Difference Weight

Std.Mean

Difference


Alaranta 1994 147 27.9 (22.1) 139 35.3 (20.6) 9.0 % -0.35 [ -0.58, -0.11 ]

Harkapaa 1989 156 14 (7.9) 153 16.5 (7.9) 9.1 % -0.32 [ -0.54, -0.09 ]

Henchoz 2010 56 25.7 (15.8) 44 35 (12.3) 8.1 % -0.64 [ -1.05, -0.24 ]

Kaapa 2006 59 20.9 (10.1) 61 21.6 (11.4) 8.4 % -0.06 [ -0.42, 0.29 ]

Mangels 2009 111 21.7 (13.3) 131 21 (13.3) 8.9 % 0.05 [ -0.20, 0.31 ]

Monticone 2013 45 5.04 (2.04) 45 11.04 (2.27) 6.9 % -2.76 [ -3.34, -2.17 ]

Morone 2012 25 12 (10.7) 25 16 (10.7) 7.1 % -0.37 [ -0.93, 0.19 ]

Nicholas 1991 9 19.26 (9.79) 11 21.96 (4.59) 5.1 % -0.35 [ -1.24, 0.54 ]

Nicholas 1992 10 18.81 (10.97) 10 26.08 (16.14) 5.1 % -0.50 [ -1.40, 0.39 ]

Roche 2007/2011 68 30.3 (23.3) 64 33.8 (23.3) 8.5 % -0.15 [ -0.49, 0.19 ]

Schweikert 2006 169 73.2 (18.8) 194 68.7 (18.8) 9.1 % 0.24 [ 0.03, 0.45 ]

Smeets 2006/2008 55 11.4 (5.25) 52 11.9 (5.9) 8.2 % -0.09 [ -0.47, 0.29 ]

Turner 1990 18 3.63 (2.98) 21 5.49 (7.79) 6.6 % -0.30 [ -0.93, 0.33 ]

Total (95% CI) 928 950 100.0 % -0.39 [ -0.68, -0.10 ]




-2 -1 0 1 2




Analysis 2.5. Comparison 2 MBR versus physical treatment, Outcome 5 Disability medium term.



Outcome: 5 Disability medium term


Std.Mean

Difference Weight

Std.Mean

Difference


Coole 2013 19 8.79 (6.76) 19 7.32 (6.06) 10.1 % 0.22 [ -0.41, 0.86 ]

Henchoz 2010 34 28.6 (18.4) 21 35.4 (15) 11.8 % -0.39 [ -0.94, 0.16 ]

Jousset 2004 42 22 (16) 41 22.9 (17.7) 14.6 % -0.05 [ -0.48, 0.38 ]

Kaapa 2006 58 20.4 (11.6) 57 18 (11.5) 16.2 % 0.21 [ -0.16, 0.57 ]

Morone 2012 20 10 (11.6) 25 20 (11.6) 10.5 % -0.85 [ -1.46, -0.23 ]

Nicholas 1991 9 15.44 (14.12) 11 29.78 (8.76) 5.7 % -1.20 [ -2.17, -0.23 ]

Nicholas 1992 10 18.3 (11.18) 10 25.31 (14.34) 6.5 % -0.52 [ -1.42, 0.37 ]

Smeets 2006/2008 53 11.34 (5.66) 51 11.29 (6.15) 15.7 % 0.01 [ -0.38, 0.39 ]

Turner 1990 14 4.51 (4.68) 17 6.25 (10.08) 8.9 % -0.21 [ -0.92, 0.50 ]

Total (95% CI) 259 252 100.0 % -0.21 [ -0.48, 0.06 ]




-2 -1 0 1 2




Analysis 2.6. Comparison 2 MBR versus physical treatment, Outcome 6 Disability long term.





Std.Mean

Difference Weight

Std.Mean

Difference


Alaranta 1994 149 29.4 (23.5) 138 35.5 (24.8) 11.0 % -0.25 [ -0.48, -0.02 ]

Henchoz 2010 49 26.2 (18) 25 38 (18.4) 10.2 % -0.64 [ -1.14, -0.15 ]

Kaapa 2006 53 18.9 (12.2) 54 18.5 (12.4) 10.6 % 0.03 [ -0.35, 0.41 ]

Mangels 2009 111 22.6 (16) 131 20.6 (13.5) 11.0 % 0.14 [ -0.12, 0.39 ]

Monticone 2013 45 1.31 (1.59) 45 11 (2) 8.4 % -5.32 [ -6.21, -4.42 ]

Nicholas 1991 9 12.8 (8.62) 11 25.18 (8.08) 7.9 % -1.42 [ -2.43, -0.42 ]

Roche 2007/2011 64 31.4 (22.9) 49 39.1 (21.9) 10.6 % -0.34 [ -0.72, 0.03 ]

Smeets 2006/2008 53 11.75 (5.81) 51 10.94 (5.66) 10.6 % 0.14 [ -0.24, 0.53 ]

Streibelt 2009 55 27.7 (16.5) 47 31.1 (16.5) 10.6 % -0.20 [ -0.59, 0.19 ]

Turner 1990 14 4.75 (3.4) 16 4.73 (7.85) 9.2 % 0.00 [ -0.71, 0.72 ]

Total (95% CI) 602 567 100.0 % -0.68 [ -1.19, -0.16 ]




-2 -1 0 1 2




Analysis 2.7. Comparison 2 MBR versus physical treatment, Outcome 7 Work short term.



Outcome: 7 Work short term

Study or subgroup MBR Physical Odds Ratio Weight Odds Ratio

n/N n/N

M-H,Random,95%

CI

M-H,Random,95%

CI

Jousset 2004 27/39 24/36 26.2 % 1.13 [ 0.43, 2.97 ]

Kool 2007 40/86 23/86 48.7 % 2.38 [ 1.26, 4.51 ]

Roche 2007/2011 59/68 55/64 25.2 % 1.07 [ 0.40, 2.90 ]

Total (95% CI) 193 186 100.0 % 1.60 [ 0.92, 2.78 ]

Total events: 126 (MBR), 102 (Physical)




0.05 0.2 1 5 20

Favours Phys Favours Multidis



Analysis 2.8. Comparison 2 MBR versus physical treatment, Outcome 8 Work medium term.



Outcome: 8 Work medium term


n/N n/N

M-H,Random,95%

CI

M-H,Random,95%

CI

Bendix ’B’ 1995/1998 30/40 15/31 41.9 % 3.20 [ 1.17, 8.73 ]

Henchoz 2010 31/40 20/27 32.7 % 1.21 [ 0.39, 3.76 ]

Jousset 2004 38/42 33/41 25.5 % 2.30 [ 0.64, 8.35 ]

Total (95% CI) 122 99 100.0 % 2.14 [ 1.12, 4.10 ]





0.05 0.2 1 5 20




Analysis 2.9. Comparison 2 MBR versus physical treatment, Outcome 9 Work long term.





n/N n/N

M-H,Random,95%

CI

M-H,Random,95%

CI

Alaranta 1994 134/149 116/138 18.3 % 1.69 [ 0.84, 3.42 ]

Bendix ’B’ 1995/1998 34/38 18/31 5.7 % 6.14 [ 1.75, 21.60 ]

Bendix ’C’ 2000 36/48 35/51 11.6 % 1.37 [ 0.57, 3.31 ]

Henchoz 2010 31/40 21/27 6.6 % 0.98 [ 0.30, 3.18 ]

Kaapa 2006 33/53 30/54 15.1 % 1.32 [ 0.61, 2.86 ]

Kool 2007 49/82 35/84 23.6 % 2.08 [ 1.12, 3.86 ]

Roche 2007/2011 60/64 41/48 5.4 % 2.56 [ 0.70, 9.31 ]

Streibelt 2009 35/54 19/45 13.6 % 2.52 [ 1.12, 5.69 ]

Total (95% CI) 528 478 100.0 % 1.87 [ 1.39, 2.53 ]





0.05 0.2 1 5 20




Analysis 2.10. Comparison 2 MBR versus physical treatment, Outcome 10 QoL short term.



Outcome: 10 QoL short term


Std.Mean

Difference Weight

Std.Mean

Difference


Kaapa 2006 59 7.74 (5.45) 60 9.83 (5.4) 29.7 % -0.38 [ -0.75, -0.02 ]

Schweikert 2006 158 70.3 (19.3) 184 68.6 (19.5) 41.7 % 0.09 [ -0.13, 0.30 ]

Smeets 2006/2008 55 0.6 (0.25) 52 0.56 (0.31) 28.6 % 0.14 [ -0.24, 0.52 ]

Total (95% CI) 272 296 100.0 % -0.04 [ -0.34, 0.26 ]




-2 -1 0 1 2


Analysis 2.11. Comparison 2 MBR versus physical treatment, Outcome 11 Quality of Life medium term.



Outcome: 11 Quality of Life medium term


Std.Mean

Difference Weight

Std.Mean

Difference


Schweikert 2006 105 70 (17.7) 133 63.8 (19.9) 60.0 % 0.33 [ 0.07, 0.58 ]

Smeets 2006/2008 53 0.6 (0.26) 51 0.6 (0.29) 40.0 % 0.0 [ -0.38, 0.38 ]

Total (95% CI) 158 184 100.0 % 0.20 [ -0.12, 0.51 ]




-100 -50 0 50 100




Analysis 2.12. Comparison 2 MBR versus physical treatment, Outcome 12 Healthcare visits long term.



Outcome: 12 Healthcare visits long term


Std.Mean

Difference Weight

Std.Mean

Difference


Kaapa 2006 59 5.8 (9.9) 60 5.4 (8.2) 52.8 % 0.04 [ -0.32, 0.40 ]

Smeets 2006/2008 55 4.39 (4.11) 52 5.42 (7.01) 47.2 % -0.18 [ -0.56, 0.20 ]

Total (95% CI) 114 112 100.0 % -0.06 [ -0.32, 0.20 ]




-2 -1 0 1 2




Analysis 2.13. Comparison 2 MBR versus physical treatment, Outcome 13 Depression short term.



Outcome: 13 Depression short term


Std.Mean

Difference Weight

Std.Mean

Difference


Kaapa 2006 59 5.5 (5.5) 61 5.7 (5.2) 16.0 % -0.04 [ -0.40, 0.32 ]

Mangels 2009 111 7.2 (7.8) 131 7.8 (7.8) 25.3 % -0.08 [ -0.33, 0.18 ]

Nicholas 1991 9 11.56 (5.5) 11 15.57 (5) 3.1 % -0.73 [ -1.65, 0.18 ]

Nicholas 1992 10 14.69 (6.2) 10 16.44 (10.39) 3.4 % -0.20 [ -1.08, 0.68 ]

Schweikert 2006 170 10.6 (6.8) 193 9 (6.8) 31.3 % 0.23 [ 0.03, 0.44 ]

Smeets 2006/2008 55 9.07 (6.53) 52 7.69 (6.26) 14.6 % 0.21 [ -0.17, 0.59 ]

Turner 1990 18 7.36 (5.89) 21 7.38 (4.57) 6.3 % 0.00 [ -0.63, 0.63 ]

Total (95% CI) 432 479 100.0 % 0.05 [ -0.12, 0.22 ]




-2 -1 0 1 2




Analysis 2.14. Comparison 2 MBR versus physical treatment, Outcome 14 Depression medium term.



Outcome: 14 Depression medium term


Std.Mean

Difference Weight

Std.Mean

Difference


Coole 2013 19 6.58 (4.93) 19 5.53 (4.53) 11.8 % 0.22 [ -0.42, 0.86 ]

Jousset 2004 42 12.7 (7.2) 41 13.4 (6.4) 19.8 % -0.10 [ -0.53, 0.33 ]

Kaapa 2006 58 5.7 (4.6) 57 5.8 (5.7) 23.5 % -0.02 [ -0.38, 0.35 ]

Nicholas 1991 9 8.14 (5.77) 11 19.17 (8.78) 5.6 % -1.39 [ -2.40, -0.39 ]

Nicholas 1992 10 14.44 (5.98) 10 18.5 (9.26) 6.9 % -0.50 [ -1.39, 0.39 ]

Smeets 2006/2008 53 7.75 (6) 51 8.04 (6.64) 22.4 % -0.05 [ -0.43, 0.34 ]

Turner 1990 14 5.89 (8.29) 17 9.29 (8.3) 9.9 % -0.40 [ -1.11, 0.32 ]

Total (95% CI) 205 206 100.0 % -0.16 [ -0.42, 0.09 ]




-2 -1 0 1 2




Analysis 2.15. Comparison 2 MBR versus physical treatment, Outcome 15 Depression long term.



Outcome: 15 Depression long term


Std.Mean

Difference Weight

Std.Mean

Difference


Kaapa 2006 53 6.6 (5.8) 54 5 (4) 24.2 % 0.32 [ -0.06, 0.70 ]

Mangels 2009 111 10.7 (8.8) 131 11.4 (8.2) 28.9 % -0.08 [ -0.34, 0.17 ]

Nicholas 1991 9 8 (5.93) 11 17.6 (6.09) 8.6 % -1.53 [ -2.55, -0.50 ]

Smeets 2006/2008 55 7.64 (6.42) 52 7.2 (6.22) 24.3 % 0.07 [ -0.31, 0.45 ]

Turner 1990 14 10 (7.57) 16 9.31 (7.73) 14.0 % 0.09 [ -0.63, 0.81 ]

Total (95% CI) 242 264 100.0 % -0.05 [ -0.40, 0.30 ]




-2 -1 0 1 2




Analysis 2.16. Comparison 2 MBR versus physical treatment, Outcome 16 Coping short term.



Outcome: 16 Coping short term


Std.Mean

Difference Weight

Std.Mean

Difference


Mangels 2009 111 18.5 (3.8) 131 17.8 (4.3) 86.3 % 0.17 [ -0.08, 0.42 ]

Nicholas 1991 9 49.22 (21.87) 11 32.29 (38.97) 6.9 % 0.50 [ -0.40, 1.40 ]

Nicholas 1992 10 49.33 (36.47) 10 29.56 (32.14) 6.9 % 0.55 [ -0.35, 1.45 ]

Total (95% CI) 130 152 100.0 % 0.22 [ -0.02, 0.45 ]




-2 -1 0 1 2


Analysis 2.17. Comparison 2 MBR versus physical treatment, Outcome 17 Coping medium term.



Outcome: 17 Coping medium term


Std.Mean

Difference Weight

Std.Mean

Difference


Nicholas 1991 9 59.43 (27.67) 11 37.17 (30.69) 54.2 % 0.73 [ -0.19, 1.64 ]

Nicholas 1992 10 64.89 (22.85) 10 23.75 (28.62) 45.8 % 1.52 [ 0.50, 2.54 ]

Total (95% CI) 19 21 100.0 % 1.09 [ 0.31, 1.87 ]




-2 -1 0 1 2




Analysis 2.18. Comparison 2 MBR versus physical treatment, Outcome 18 Coping long term.



Outcome: 18 Coping long term


Std.Mean

Difference Weight

Std.Mean

Difference


Mangels 2009 111 17.8 (5.1) 131 16.4 (4.8) 92.6 % 0.28 [ 0.03, 0.54 ]

Nicholas 1991 9 57 (30.97) 11 43 (21.36) 7.4 % 0.51 [ -0.38, 1.41 ]

Total (95% CI) 120 142 100.0 % 0.30 [ 0.06, 0.54 ]




-2 -1 0 1 2




Analysis 2.19. Comparison 2 MBR versus physical treatment, Outcome 19 Self-efficacy short term.



Outcome: 19 Self-efficacy short term


Std.Mean

Difference Weight

Std.Mean

Difference


Kool 2007 85 117 (45) 85 95 (45) 41.6 % 0.49 [ 0.18, 0.79 ]

Mangels 2009 111 45.1 (10.8) 131 44.6 (9.7) 46.4 % 0.05 [ -0.20, 0.30 ]

Nicholas 1992 10 30.78 (10.53) 10 25.89 (16.84) 12.1 % 0.33 [ -0.55, 1.22 ]

Total (95% CI) 206 226 100.0 % 0.27 [ -0.08, 0.61 ]




-2 -1 0 1 2


Analysis 2.20. Comparison 2 MBR versus physical treatment, Outcome 20 Self-efficacy medium term.



Outcome: 20 Self-efficacy medium term


Std.Mean

Difference Weight

Std.Mean

Difference


Coole 2013 19 39.53 (15.82) 19 39.66 (13.69) 61.5 % -0.01 [ -0.64, 0.63 ]

Nicholas 1992 10 32.78 (14.03) 10 22 (16.19) 38.5 % 0.68 [ -0.23, 1.59 ]

Total (95% CI) 29 29 100.0 % 0.26 [ -0.40, 0.92 ]




-2 -1 0 1 2




Analysis 2.21. Comparison 2 MBR versus physical treatment, Outcome 21 Anxiety short term.



Outcome: 21 Anxiety short term


Std.Mean

Difference Weight

Std.Mean

Difference


Nicholas 1991 9 40.67 (9.66) 11 46.57 (9.75) 26.9 % -0.58 [ -1.49, 0.32 ]

Schweikert 2006 165 41.9 (10.2) 192 41.1 (10.2) 73.1 % 0.08 [ -0.13, 0.29 ]

Total (95% CI) 174 203 100.0 % -0.10 [ -0.67, 0.47 ]




-100 -50 0 50 100




Analysis 2.22. Comparison 2 MBR versus physical treatment, Outcome 22 Anxiety medium term.



Outcome: 22 Anxiety medium term


Std.Mean

Difference Weight

Std.Mean

Difference


Coole 2013 19 8.42 (4.52) 19 7.47 (3.92) 56.9 % 0.22 [ -0.42, 0.86 ]

Nicholas 1991 7 37.57 (12.92) 6 54 (12.03) 43.1 % -1.22 [ -2.45, 0.01 ]

Total (95% CI) 26 25 100.0 % -0.40 [ -1.80, 1.00 ]




-2 -1 0 1 2


Analysis 3.1. Comparison 3 MBR versus surgery, Outcome 1 Pain long term.


Comparison: 3 MBR versus surgery

Outcome: 1 Pain long term

Study or subgroup Experimental Control

Std.Mean

Difference Weight

Std.Mean

Difference


Fairbank 2005 131 44.9 (25.1) 115 48.1 (26.4) 57.6 % -0.12 [ -0.37, 0.13 ]

Hellum 2011 66 44.4 (23) 73 55.5 (29.1) 42.4 % -0.42 [ -0.76, -0.08 ]

Total (95% CI) 197 188 100.0 % -0.25 [ -0.53, 0.04 ]




-2 -1 0 1 2

Favours Surgery Favours Multidis



Analysis 3.2. Comparison 3 MBR versus surgery, Outcome 2 Disability long term.





Std.Mean

Difference Weight

Std.Mean

Difference


Fairbank 2005 146 36.1 (20.6) 138 34 (21.1) 56.8 % 0.10 [ -0.13, 0.33 ]

Hellum 2011 66 26.7 (14.5) 73 19.8 (16.7) 43.2 % 0.44 [ 0.10, 0.77 ]

Total (95% CI) 212 211 100.0 % 0.25 [ -0.08, 0.57 ]




-2 -1 0 1 2

Favours Multidis Favours Surgery



Analysis 3.3. Comparison 3 MBR versus surgery, Outcome 3 Work long term.




Study or subgroup Multidisciplinary Surgery Odds Ratio Weight Odds Ratio

n/N n/N

M-H,Random,95%

CI

M-H,Random,95%

CI

Hellum 2011 15/65 21/68 100.0 % 0.67 [ 0.31, 1.45 ]

Total (95% CI) 65 68 100.0 % 0.67 [ 0.31, 1.45 ]

Total events: 15 (Multidisciplinary), 21 (Surgery)

Heterogeneity: not applicable



0.01 0.1 1 10 100


Analysis 3.4. Comparison 3 MBR versus surgery, Outcome 4 Adverse events/complications.



Outcome: 4 Adverse events/complications

Study or subgroup Experimental Control Odds Ratio Weight Odds Ratio

n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI

Fairbank 2005 19/131 0/115 51.4 % 40.04 [ 2.39, 671.14 ]

Hellum 2011 6/66 0/73 48.6 % 15.79 [ 0.87, 286.03 ]

Total (95% CI) 197 188 100.0 % 28.25 [ 3.77, 211.93 ]

Total events: 25 (Experimental), 0 (Control)

Heterogeneity: Chi2 = 0.21, df = 1 (P = 0.64); I2 =0.0%



0.01 0.1 1 10 100




Analysis 3.5. Comparison 3 MBR versus surgery, Outcome 5 QoL SF36 PCS long term.



Outcome: 5 QoL SF36 PCS long term


Std.Mean

Difference Weight

Std.Mean

Difference


Fairbank 2005 131 27.6 (14.6) 115 28.8 (14.9) 53.7 % -0.08 [ -0.33, 0.17 ]

Hellum 2011 66 37.7 (10.1) 73 43.3 (11.7) 46.3 % -0.51 [ -0.85, -0.17 ]

Total (95% CI) 197 188 100.0 % -0.28 [ -0.70, 0.14 ]




-2 -1 0 1 2


Analysis 3.6. Comparison 3 MBR versus surgery, Outcome 6 QoL SF36 MCS long term.



Outcome: 6 QoL SF36 MCS long term


Std.Mean

Difference Weight

Std.Mean

Difference


Fairbank 2005 131 48.1 (12.6) 115 47.4 (12.2) 62.2 % 0.06 [ -0.19, 0.31 ]

Hellum 2011 66 48.6 (12.8) 73 50.7 (11.6) 37.8 % -0.17 [ -0.50, 0.16 ]

Total (95% CI) 197 188 100.0 % -0.03 [ -0.25, 0.19 ]




-2 -1 0 1 2




Analysis 4.1. Comparison 4 MBR versus wait list, Outcome 1 Pain short term.


Comparison: 4 MBR versus wait list

Outcome: 1 Pain short term


Std.Mean

Difference Weight

Std.Mean

Difference


Jackel 1990 33 3.7 (1.7) 38 5.9 (1.9) 33.5 % -1.20 [ -1.71, -0.69 ]

Smeets 2006/2008 55 42.31 (25.56) 50 53.35 (22.6) 39.6 % -0.45 [ -0.84, -0.06 ]

Turner 1990 18 14.78 (11.44) 19 20.95 (10.62) 26.9 % -0.55 [ -1.21, 0.11 ]

Total (95% CI) 106 107 100.0 % -0.73 [ -1.22, -0.24 ]




-2 -1 0 1 2

Favours Multidis Favours Wait list



Analysis 4.2. Comparison 4 MBR versus wait list, Outcome 2 Disability short term.





Std.Mean

Difference Weight

Std.Mean

Difference


Jackel 1990 33 -8.6 (1.3) 38 -7.7 (1.8) 33.0 % -0.56 [ -1.04, -0.08 ]

Smeets 2006/2008 55 11.4 (5.25) 50 13.88 (4.78) 49.4 % -0.49 [ -0.88, -0.10 ]

Turner 1990 18 3.63 (2.98) 19 5.37 (5.93) 17.6 % -0.36 [ -1.01, 0.29 ]

Total (95% CI) 106 107 100.0 % -0.49 [ -0.76, -0.22 ]




-2 -1 0 1 2




Analysis 4.3. Comparison 4 MBR versus wait list, Outcome 3 Depression short term.



Outcome: 3 Depression short term


Std.Mean

Difference Weight

Std.Mean

Difference


Jackel 1990 33 1.9 (1.4) 38 3 (2.2) 34.2 % -0.58 [ -1.06, -0.10 ]

Smeets 2006/2008 55 9.07 (6.53) 50 9.42 (7.81) 42.1 % -0.05 [ -0.43, 0.33 ]

Turner 1990 18 7.36 (5.89) 19 7.03 (5.02) 23.7 % 0.06 [ -0.59, 0.70 ]

Total (95% CI) 106 107 100.0 % -0.21 [ -0.59, 0.18 ]




-2 -1 0 1 2




Analysis 5.1. Comparison 5 MBR versus usual care, sensitivity and subgroup analyses, Outcome 1 Pain short

term - all studies.


Comparison: 5 MBR versus usual care, sensitivity and subgroup analyses

Outcome: 1 Pain short term - all studies

Study or subgroup Multidisciplinary Usual care

Std.Mean

Difference Weight

Std.Mean

Difference


Abbassi 2012 12 2.6 (2) 11 3.2 (1.6) 6.8 % -0.32 [ -1.14, 0.51 ]

Basler 1997 36 4.08 (2.11) 40 4.18 (1.37) 11.7 % -0.06 [ -0.51, 0.39 ]

Lambeek 2010 60 3.89 (2.54) 62 5.52 (2.35) 13.1 % -0.66 [ -1.03, -0.30 ]

Moix 2003 13 14.5 (3.2) 15 14.9 (3.2) 7.7 % -0.12 [ -0.86, 0.62 ]

Morone 2011 41 4.5 (2.3) 29 7.6 (2.1) 10.5 % -1.38 [ -1.91, -0.85 ]

Morone 2012 25 5 (2.2) 25 8 (2.2) 9.2 % -1.34 [ -1.96, -0.72 ]

Tavafian 2008 44 -71.5 (16.2) 47 -56.6 (30) 12.2 % -0.61 [ -1.03, -0.19 ]

Tavafian 2011 92 -65.82 (22.56) 97 -56.35 (23.62) 14.3 % -0.41 [ -0.70, -0.12 ]

Von Korff 2005 110 4.9 (2) 120 5.3 (1.9) 14.7 % -0.20 [ -0.46, 0.05 ]

Total (95% CI) 433 446 100.0 % -0.55 [ -0.83, -0.28 ]




-2 -1 0 1 2




Analysis 5.2. Comparison 5 MBR versus usual care, sensitivity and subgroup analyses, Outcome 2 Pain short

term - sensitivity and subgroup analyses.



Outcome: 2 Pain short term - sensitivity and subgroup analyses

Study or subgroup Experimental Usual care

Std.Mean

Difference Weight

Std.Mean

Difference

N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

1 High quality 1 - 6 or more Risk of Bias items

Abbassi 2012 12 2.6 (2) 11 3.2 (1.6) 7.0 % -0.32 [ -1.14, 0.51 ]

Lambeek 2010 60 3.89 (2.54) 62 5.52 (2.35) 35.7 % -0.66 [ -1.03, -0.30 ]

Tavafian 2011 92 -65.82 (22.56) 97 -56.35 (23.62) 57.3 % -0.41 [ -0.70, -0.12 ]

Subtotal (95% CI) 164 170 100.0 % -0.49 [ -0.71, -0.27 ]



2 High quality 2 - Concealed allocation

Lambeek 2010 60 3.89 (2.54) 62 5.52 (2.35) 29.2 % -0.66 [ -1.03, -0.30 ]

Morone 2011 41 4.5 (2.3) 29 7.6 (2.1) 13.8 % -1.38 [ -1.91, -0.85 ]

Morone 2012 25 5 (2.2) 25 8 (2.2) 10.2 % -1.34 [ -1.96, -0.72 ]

Tavafian 2011 92 -65.82 (22.56) 97 -56.35 (23.62) 46.8 % -0.41 [ -0.70, -0.12 ]

Subtotal (95% CI) 218 213 100.0 % -0.71 [ -0.91, -0.51 ]

Heterogeneity: Chi2 = 14.44, df = 3 (P = 0.002); I2 =79%


3 High baseline symptom intensity (>60% on pain % disability scales)

Lambeek 2010 60 3.89 (2.54) 62 5.52 (2.35) 100.0 % -0.66 [ -1.03, -0.30 ]

Subtotal (95% CI) 60 62 100.0 % -0.66 [ -1.03, -0.30 ]



4 Low baseline symptom intensity (<60% on pain % disability scales)

Abbassi 2012 12 2.6 (2) 11 3.2 (1.6) 3.1 % -0.32 [ -1.14, 0.51 ]

Basler 1997 36 4.08 (2.11) 40 4.18 (1.37) 10.5 % -0.06 [ -0.51, 0.39 ]

Moix 2003 13 14.5 (3.2) 15 14.9 (3.2) 3.9 % -0.12 [ -0.86, 0.62 ]

Morone 2011 41 4.5 (2.3) 29 7.6 (2.1) 7.6 % -1.38 [ -1.91, -0.85 ]

Morone 2012 25 5 (2.2) 25 8 (2.2) 5.6 % -1.34 [ -1.96, -0.72 ]

Tavafian 2008 44 -71.5 (16.2) 47 -56.6 (30) 12.0 % -0.61 [ -1.03, -0.19 ]

Tavafian 2011 92 -65.82 (22.56) 97 -56.35 (23.62) 25.7 % -0.41 [ -0.70, -0.12 ]

-2 -1 0 1 2


(Continued . . . )



(. . . Continued)


Std.Mean

Difference Weight

Std.Mean

Difference

N Mean(SD) N Mean(SD) IV,Fixed,95% CI IV,Fixed,95% CI

Von Korff 2005 110 4.9 (2) 120 5.3 (1.9) 31.7 % -0.20 [ -0.46, 0.05 ]

Subtotal (95% CI) 373 384 100.0 % -0.44 [ -0.59, -0.30 ]



5 High intervention intensity (>100 hours, daily contact)

Subtotal (95% CI) 0 0 Not estimable


Test for overall effect: not applicable

6 Low intervention intensity (<100 hours, non-daily contact)

Abbassi 2012 12 2.6 (2) 11 3.2 (1.6) 5.0 % -0.32 [ -1.14, 0.51 ]

Basler 1997 36 4.08 (2.11) 40 4.18 (1.37) 16.9 % -0.06 [ -0.51, 0.39 ]

Moix 2003 13 14.5 (3.2) 15 14.9 (3.2) 6.2 % -0.12 [ -0.86, 0.62 ]

Morone 2011 41 4.5 (2.3) 29 7.6 (2.1) 12.1 % -1.38 [ -1.91, -0.85 ]

Morone 2012 25 5 (2.2) 25 8 (2.2) 8.9 % -1.34 [ -1.96, -0.72 ]

Von Korff 2005 110 4.9 (2) 120 5.3 (1.9) 50.8 % -0.20 [ -0.46, 0.05 ]

Subtotal (95% CI) 237 240 100.0 % -0.42 [ -0.61, -0.24 ]



Test for subgroup differences: Chi2 = 6.35, df = 4 (P = 0.17), I2 =37%

-2 -1 0 1 2




Analysis 5.3. Comparison 5 MBR versus usual care, sensitivity and subgroup analyses, Outcome 3 Pain

medium term - all studies.



Outcome: 3 Pain medium term - all studies


Std.Mean

Difference Weight

Std.Mean

Difference


Bendix ’A’ 1996/1998 45 5.7 (2.1) 49 6.9 (2.1) 16.2 % -0.57 [ -0.98, -0.15 ]

Lambeek 2010 58 3.61 (2.59) 60 4.84 (2.41) 17.7 % -0.49 [ -0.86, -0.12 ]

Morone 2011 41 4.4 (2.5) 29 6.5 (1.9) 13.5 % -0.91 [ -1.41, -0.41 ]

Morone 2012 25 4 (2.2) 25 7 (2.2) 10.7 % -1.34 [ -1.96, -0.72 ]

Tavafian 2011 92 -72.34 (22.77) 96 -60.27 (25.82) 20.5 % -0.49 [ -0.78, -0.20 ]

Von Korff 2005 110 4.2 (2) 110 4.7 (2.2) 21.4 % -0.24 [ -0.50, 0.03 ]

Total (95% CI) 371 369 100.0 % -0.60 [ -0.85, -0.34 ]




-2 -1 0 1 2




Analysis 5.4. Comparison 5 MBR versus usual care, sensitivity and subgroup analyses, Outcome 4 Pain

medium term - sensitivity and subgroup analyses.



Outcome: 4 Pain medium term - sensitivity and subgroup analyses


Std.Mean

Difference Weight

Std.Mean

Difference



Lambeek 2010 58 3.61 (2.59) 60 4.84 (2.41) 38.6 % -0.49 [ -0.86, -0.12 ]

Tavafian 2011 92 -72.34 (22.77) 96 -60.27 (25.82) 61.4 % -0.49 [ -0.78, -0.20 ]

Subtotal (95% CI) 150 156 100.0 % -0.49 [ -0.72, -0.26 ]




Lambeek 2010 58 3.61 (2.59) 60 4.84 (2.41) 28.3 % -0.49 [ -0.86, -0.12 ]

Morone 2011 41 4.4 (2.5) 29 6.5 (1.9) 22.0 % -0.91 [ -1.41, -0.41 ]

Morone 2012 25 4 (2.2) 25 7 (2.2) 17.5 % -1.34 [ -1.96, -0.72 ]

Tavafian 2011 92 -72.34 (22.77) 96 -60.27 (25.82) 32.2 % -0.49 [ -0.78, -0.20 ]

Subtotal (95% CI) 216 210 100.0 % -0.73 [ -1.07, -0.39 ]




Lambeek 2010 58 3.61 (2.59) 60 4.84 (2.41) 100.0 % -0.49 [ -0.86, -0.12 ]

Subtotal (95% CI) 58 60 100.0 % -0.49 [ -0.86, -0.12 ]




Bendix ’A’ 1996/1998 45 5.7 (2.1) 49 6.9 (2.1) 19.9 % -0.57 [ -0.98, -0.15 ]

Morone 2011 41 4.4 (2.5) 29 6.5 (1.9) 17.2 % -0.91 [ -1.41, -0.41 ]

Morone 2012 25 4 (2.2) 25 7 (2.2) 14.1 % -1.34 [ -1.96, -0.72 ]

Tavafian 2011 92 -72.34 (22.77) 96 -60.27 (25.82) 24.0 % -0.49 [ -0.78, -0.20 ]

Von Korff 2005 110 4.2 (2) 110 4.7 (2.2) 24.8 % -0.24 [ -0.50, 0.03 ]

Subtotal (95% CI) 313 309 100.0 % -0.64 [ -0.96, -0.32 ]




-2 -1 0 1 2


(Continued . . . )



(. . . Continued)


Std.Mean

Difference Weight

Std.Mean

Difference


Bendix ’A’ 1996/1998 45 5.7 (2.1) 49 6.9 (2.1) 100.0 % -0.57 [ -0.98, -0.15 ]

Subtotal (95% CI) 45 49 100.0 % -0.57 [ -0.98, -0.15 ]




Lambeek 2010 58 3.61 (2.59) 60 4.84 (2.41) 27.0 % -0.49 [ -0.86, -0.12 ]

Morone 2011 41 4.4 (2.5) 29 6.5 (1.9) 23.2 % -0.91 [ -1.41, -0.41 ]

Morone 2012 25 4 (2.2) 25 7 (2.2) 20.0 % -1.34 [ -1.96, -0.72 ]

Von Korff 2005 110 4.2 (2) 110 4.7 (2.2) 29.7 % -0.24 [ -0.50, 0.03 ]

Subtotal (95% CI) 234 224 100.0 % -0.68 [ -1.12, -0.25 ]



Test for subgroup differences: Chi2 = 1.95, df = 5 (P = 0.86), I2 =0.0%

-2 -1 0 1 2




Analysis 5.5. Comparison 5 MBR versus usual care, sensitivity and subgroup analyses, Outcome 5 Pain long

term - all studies.



Outcome: 5 Pain long term - all studies


Std.Mean

Difference Weight

Std.Mean

Difference


Abbassi 2012 12 3.7 (2.5) 11 4.3 (1.4) 3.7 % -0.28 [ -1.10, 0.54 ]

Bendix ’A’ 1996/1998 50 6 (2.2) 49 6.5 (2.2) 13.3 % -0.23 [ -0.62, 0.17 ]

Lambeek 2010 59 4.16 (2.68) 60 4.47 (2.68) 15.4 % -0.11 [ -0.47, 0.24 ]

Linton 2005 61 2.9 (2) 47 4.1 (2.6) 13.8 % -0.52 [ -0.91, -0.14 ]

Lukinmaa 1989 86 47.3 (20.5) 72 44.6 (20.5) 18.7 % 0.13 [ -0.18, 0.44 ]

Strand 2001 81 37.2 (20.5) 36 42.5 (20.5) 13.4 % -0.26 [ -0.65, 0.14 ]

Von Korff 2005 99 4 (2.3) 98 4.7 (2.1) 21.6 % -0.32 [ -0.60, -0.04 ]

Total (95% CI) 448 373 100.0 % -0.21 [ -0.37, -0.04 ]




-2 -1 0 1 2




Analysis 5.6. Comparison 5 MBR versus usual care, sensitivity and subgroup analyses, Outcome 6 Pain long

term - sensitivity and subgroup analyses.



Outcome: 6 Pain long term - sensitivity and subgroup analyses


Std.Mean

Difference Weight

Std.Mean

Difference



Abbassi 2012 12 3.7 (2.5) 11 4.3 (1.4) 16.0 % -0.28 [ -1.10, 0.54 ]

Lambeek 2010 59 4.16 (2.68) 60 4.47 (2.68) 84.0 % -0.11 [ -0.47, 0.24 ]

Subtotal (95% CI) 71 71 100.0 % -0.14 [ -0.47, 0.19 ]




Lambeek 2010 59 4.16 (2.68) 60 4.47 (2.68) 54.5 % -0.11 [ -0.47, 0.24 ]

Strand 2001 81 37.2 (20.5) 36 42.5 (20.5) 45.5 % -0.26 [ -0.65, 0.14 ]

Subtotal (95% CI) 140 96 100.0 % -0.18 [ -0.45, 0.09 ]




Lambeek 2010 59 4.16 (2.68) 60 4.47 (2.68) 100.0 % -0.11 [ -0.47, 0.24 ]

Subtotal (95% CI) 59 60 100.0 % -0.11 [ -0.47, 0.24 ]




Abbassi 2012 12 3.7 (2.5) 11 4.3 (1.4) 5.0 % -0.28 [ -1.10, 0.54 ]

Bendix ’A’ 1996/1998 50 6 (2.2) 49 6.5 (2.2) 16.2 % -0.23 [ -0.62, 0.17 ]

Linton 2005 61 2.9 (2) 47 4.1 (2.6) 16.7 % -0.52 [ -0.91, -0.14 ]

Lukinmaa 1989 86 47.3 (20.5) 72 44.6 (20.5) 21.6 % 0.13 [ -0.18, 0.44 ]

Strand 2001 81 37.2 (20.5) 36 42.5 (20.5) 16.3 % -0.26 [ -0.65, 0.14 ]

Von Korff 2005 99 4 (2.3) 98 4.7 (2.1) 24.2 % -0.32 [ -0.60, -0.04 ]

Subtotal (95% CI) 389 313 100.0 % -0.23 [ -0.42, -0.03 ]




Bendix ’A’ 1996/1998 50 6 (2.2) 49 6.5 (2.2) 49.8 % -0.23 [ -0.62, 0.17 ]

-2 -1 0 1 2


(Continued . . . )



(. . . Continued)


Std.Mean

Difference Weight

Std.Mean

Difference


Strand 2001 81 37.2 (20.5) 36 42.5 (20.5) 50.2 % -0.26 [ -0.65, 0.14 ]

Subtotal (95% CI) 131 85 100.0 % -0.24 [ -0.52, 0.04 ]




Abbassi 2012 12 3.7 (2.5) 11 4.3 (1.4) 5.2 % -0.28 [ -1.10, 0.54 ]

Lambeek 2010 59 4.16 (2.68) 60 4.47 (2.68) 27.1 % -0.11 [ -0.47, 0.24 ]

Linton 2005 61 2.9 (2) 47 4.1 (2.6) 23.4 % -0.52 [ -0.91, -0.14 ]

Von Korff 2005 99 4 (2.3) 98 4.7 (2.1) 44.3 % -0.32 [ -0.60, -0.04 ]

Subtotal (95% CI) 231 216 100.0 % -0.31 [ -0.50, -0.12 ]




-2 -1 0 1 2




Analysis 5.7. Comparison 5 MBR versus usual care, sensitivity and subgroup analyses, Outcome 7 Disability

short term - all analyses.



Outcome: 7 Disability short term - all analyses


Std.Mean

Difference Weight

Std.Mean

Difference


Abbassi 2012 12 6.2 (4.4) 11 3.2 (3.2) 5.0 % 0.75 [ -0.11, 1.60 ]

Basler 1997 36 1.63 (0.87) 40 1.84 (0.62) 11.1 % -0.28 [ -0.73, 0.17 ]

Lambeek 2010 60 8.8 (5.58) 62 13.16 (5.39) 13.2 % -0.79 [ -1.16, -0.42 ]

Moix 2003 13 14.7 (4.4) 15 16.8 (3.4) 5.9 % -0.52 [ -1.28, 0.23 ]

Morone 2011 41 18 (12.9) 29 25.8 (14.1) 10.3 % -0.58 [ -1.06, -0.09 ]

Morone 2012 25 12 (13.5) 25 26 (13.5) 8.3 % -1.02 [ -1.61, -0.43 ]

Tavafian 2011 92 9.01 (5.71) 97 10.56 (5.78) 15.5 % -0.27 [ -0.56, 0.02 ]


Von Korff 2005 110 10.2 (6.3) 120 11.5 (5.8) 16.3 % -0.21 [ -0.47, 0.05 ]

Total (95% CI) 461 478 100.0 % -0.41 [ -0.62, -0.19 ]




-2 -1 0 1 2





short term - sensitivity and subgroup analyses.



Outcome: 8 Disability short term - sensitivity and subgroup analyses


Std.Mean

Difference Weight

Std.Mean

Difference


1 High quality 1 - 6 more or Risk of Bias items

Abbassi 2012 12 6.2 (4.4) 11 3.2 (3.2) 13.5 % 0.75 [ -0.11, 1.60 ]

Lambeek 2010 60 8.8 (5.58) 62 13.16 (5.39) 27.4 % -0.79 [ -1.16, -0.42 ]

Tavafian 2011 92 9.01 (5.71) 97 10.56 (5.78) 30.2 % -0.27 [ -0.56, 0.02 ]


Subtotal (95% CI) 236 249 100.0 % -0.31 [ -0.71, 0.08 ]




Lambeek 2010 60 8.8 (5.58) 62 13.16 (5.39) 21.4 % -0.79 [ -1.16, -0.42 ]

Morone 2011 41 18 (12.9) 29 25.8 (14.1) 16.0 % -0.58 [ -1.06, -0.09 ]

Morone 2012 25 12 (13.5) 25 26 (13.5) 12.4 % -1.02 [ -1.61, -0.43 ]

Tavafian 2011 92 9.01 (5.71) 97 10.56 (5.78) 26.2 % -0.27 [ -0.56, 0.02 ]


Subtotal (95% CI) 290 292 100.0 % -0.55 [ -0.80, -0.30 ]




Lambeek 2010 60 8.8 (5.58) 62 13.16 (5.39) 100.0 % -0.79 [ -1.16, -0.42 ]

Subtotal (95% CI) 60 62 100.0 % -0.79 [ -1.16, -0.42 ]




Abbassi 2012 12 6.2 (4.4) 11 3.2 (3.2) 5.1 % 0.75 [ -0.11, 1.60 ]

Basler 1997 36 1.63 (0.87) 40 1.84 (0.62) 12.5 % -0.28 [ -0.73, 0.17 ]

Moix 2003 13 14.7 (4.4) 15 16.8 (3.4) 6.2 % -0.52 [ -1.28, 0.23 ]

Morone 2011 41 18 (12.9) 29 25.8 (14.1) 11.5 % -0.58 [ -1.06, -0.09 ]

Morone 2012 25 12 (13.5) 25 26 (13.5) 8.9 % -1.02 [ -1.61, -0.43 ]

-2 -1 0 1 2


(Continued . . . )



(. . . Continued)


Std.Mean

Difference Weight

Std.Mean

Difference


Tavafian 2011 92 9.01 (5.71) 97 10.56 (5.78) 18.7 % -0.27 [ -0.56, 0.02 ]


Von Korff 2005 110 10.2 (6.3) 120 11.5 (5.8) 19.9 % -0.21 [ -0.47, 0.05 ]

Subtotal (95% CI) 401 416 100.0 % -0.35 [ -0.56, -0.13 ]








Abbassi 2012 12 6.2 (4.4) 11 3.2 (3.2) 8.7 % 0.75 [ -0.11, 1.60 ]

Basler 1997 36 1.63 (0.87) 40 1.84 (0.62) 15.8 % -0.28 [ -0.73, 0.17 ]

Lambeek 2010 60 8.8 (5.58) 62 13.16 (5.39) 17.7 % -0.79 [ -1.16, -0.42 ]

Moix 2003 13 14.7 (4.4) 15 16.8 (3.4) 10.0 % -0.52 [ -1.28, 0.23 ]

Morone 2011 41 18 (12.9) 29 25.8 (14.1) 15.0 % -0.58 [ -1.06, -0.09 ]

Morone 2012 25 12 (13.5) 25 26 (13.5) 12.8 % -1.02 [ -1.61, -0.43 ]

Von Korff 2005 110 10.2 (6.3) 120 11.5 (5.8) 20.1 % -0.21 [ -0.47, 0.05 ]

Subtotal (95% CI) 297 302 100.0 % -0.43 [ -0.75, -0.11 ]




-2 -1 0 1 2





medium term - all studies.



Outcome: 9 Disability medium term - all studies


Std.Mean

Difference Weight

Std.Mean

Difference


Lambeek 2010 58 7.94 (5.99) 60 11.88 (5.76) 16.9 % -0.67 [ -1.04, -0.30 ]

Morone 2011 41 16.8 (14.2) 29 26 (16.1) 12.9 % -0.61 [ -1.09, -0.12 ]

Morone 2012 25 10 (15.2) 25 26 (15.2) 10.1 % -1.04 [ -1.63, -0.44 ]

Tavafian 2011 92 7.03 (5.49) 96 8.8 (5.68) 20.3 % -0.32 [ -0.60, -0.03 ]


Von Korff 2005 110 9.2 (6.6) 110 10.1 (6.4) 21.4 % -0.14 [ -0.40, 0.13 ]

Total (95% CI) 394 392 100.0 % -0.43 [ -0.66, -0.19 ]




-2 -1 0 1 2




Analysis 5.10. Comparison 5 MBR versus usual care, sensitivity and subgroup analyses, Outcome 10

Disability medium term - sensitivity and subgroup analyses.



Outcome: 10 Disability medium term - sensitivity and subgroup analyses


Std.Mean

Difference Weight

Std.Mean

Difference



Lambeek 2010 58 7.94 (5.99) 60 11.88 (5.76) 28.9 % -0.67 [ -1.04, -0.30 ]

Tavafian 2011 92 7.03 (5.49) 96 8.8 (5.68) 38.2 % -0.32 [ -0.60, -0.03 ]


Subtotal (95% CI) 218 228 100.0 % -0.38 [ -0.63, -0.12 ]




Lambeek 2010 58 7.94 (5.99) 60 11.88 (5.76) 21.5 % -0.67 [ -1.04, -0.30 ]

Morone 2011 41 16.8 (14.2) 29 26 (16.1) 16.2 % -0.61 [ -1.09, -0.12 ]

Morone 2012 25 10 (15.2) 25 26 (15.2) 12.6 % -1.04 [ -1.63, -0.44 ]

Tavafian 2011 92 7.03 (5.49) 96 8.8 (5.68) 26.2 % -0.32 [ -0.60, -0.03 ]


Subtotal (95% CI) 284 282 100.0 % -0.50 [ -0.76, -0.25 ]




Lambeek 2010 58 7.94 (5.99) 60 11.88 (5.76) 100.0 % -0.67 [ -1.04, -0.30 ]

Subtotal (95% CI) 58 60 100.0 % -0.67 [ -1.04, -0.30 ]




Morone 2011 41 16.8 (14.2) 29 26 (16.1) 15.2 % -0.61 [ -1.09, -0.12 ]

Morone 2012 25 10 (15.2) 25 26 (15.2) 11.8 % -1.04 [ -1.63, -0.44 ]

Tavafian 2011 92 7.03 (5.49) 96 8.8 (5.68) 24.7 % -0.32 [ -0.60, -0.03 ]


Von Korff 2005 110 9.2 (6.6) 110 10.1 (6.4) 26.0 % -0.14 [ -0.40, 0.13 ]

Subtotal (95% CI) 336 332 100.0 % -0.37 [ -0.62, -0.13 ]

-2 -1 0 1 2


(Continued . . . )



(. . . Continued)


Std.Mean

Difference Weight

Std.Mean

Difference









Lambeek 2010 58 7.94 (5.99) 60 11.88 (5.76) 27.0 % -0.67 [ -1.04, -0.30 ]

Morone 2011 41 16.8 (14.2) 29 26 (16.1) 22.9 % -0.61 [ -1.09, -0.12 ]

Morone 2012 25 10 (15.2) 25 26 (15.2) 19.4 % -1.04 [ -1.63, -0.44 ]

Von Korff 2005 110 9.2 (6.6) 110 10.1 (6.4) 30.7 % -0.14 [ -0.40, 0.13 ]

Subtotal (95% CI) 234 224 100.0 % -0.56 [ -0.95, -0.18 ]




-2 -1 0 1 2





Disability long term - all studies.



Outcome: 11 Disability long term - all studies


Std.Mean

Difference Weight

Std.Mean

Difference


Abbassi 2012 12 8.8 (5.9) 11 10.4 (6.2) 4.0 % -0.26 [ -1.08, 0.57 ]

Lambeek 2010 59 7.49 (6.15) 60 10.58 (6.5) 17.3 % -0.49 [ -0.85, -0.12 ]

Linton 2005 61 3.4 (4) 47 4 (4.7) 16.1 % -0.14 [ -0.52, 0.24 ]

Lukinmaa 1989 86 8 (5.7) 72 8.3 (5.7) 21.9 % -0.05 [ -0.37, 0.26 ]

Strand 2001 81 42 (12.9) 36 48.8 (12.9) 14.9 % -0.52 [ -0.92, -0.13 ]

Von Korff 2005 99 8.4 (7) 98 9.1 (6.3) 25.8 % -0.10 [ -0.38, 0.17 ]

Total (95% CI) 398 324 100.0 % -0.23 [ -0.40, -0.06 ]




-2 -1 0 1 2





Disability long term - sensitivity and subgroup analyses.



Outcome: 12 Disability long term - sensitivity and subgroup analyses


Std.Mean

Difference Weight

Std.Mean

Difference



Abbassi 2012 12 8.8 (5.9) 11 10.4 (6.2) 16.4 % -0.26 [ -1.08, 0.57 ]

Lambeek 2010 59 7.49 (6.15) 60 10.58 (6.5) 83.6 % -0.49 [ -0.85, -0.12 ]

Subtotal (95% CI) 71 71 100.0 % -0.45 [ -0.78, -0.11 ]




Lambeek 2010 59 7.49 (6.15) 60 10.58 (6.5) 54.4 % -0.49 [ -0.85, -0.12 ]

Strand 2001 81 42 (12.9) 36 48.8 (12.9) 45.6 % -0.52 [ -0.92, -0.13 ]

Subtotal (95% CI) 140 96 100.0 % -0.50 [ -0.77, -0.23 ]




Lambeek 2010 59 7.49 (6.15) 60 10.58 (6.5) 100.0 % -0.49 [ -0.85, -0.12 ]

Subtotal (95% CI) 59 60 100.0 % -0.49 [ -0.85, -0.12 ]




Abbassi 2012 12 8.8 (5.9) 11 10.4 (6.2) 3.9 % -0.26 [ -1.08, 0.57 ]

Linton 2005 61 3.4 (4) 47 4 (4.7) 18.3 % -0.14 [ -0.52, 0.24 ]

Lukinmaa 1989 86 8 (5.7) 72 8.3 (5.7) 27.1 % -0.05 [ -0.37, 0.26 ]

Strand 2001 81 42 (12.9) 36 48.8 (12.9) 16.7 % -0.52 [ -0.92, -0.13 ]

Von Korff 2005 99 8.4 (7) 98 9.1 (6.3) 34.0 % -0.10 [ -0.38, 0.17 ]

Subtotal (95% CI) 339 264 100.0 % -0.17 [ -0.34, -0.01 ]




Strand 2001 81 42 (12.9) 36 48.8 (12.9) 100.0 % -0.52 [ -0.92, -0.13 ]

Subtotal (95% CI) 81 36 100.0 % -0.52 [ -0.92, -0.13 ]

-2 -1 0 1 2


(Continued . . . )



(. . . Continued)


Std.Mean

Difference Weight

Std.Mean

Difference





Abbassi 2012 12 8.8 (5.9) 11 10.4 (6.2) 5.2 % -0.26 [ -1.08, 0.57 ]

Lambeek 2010 59 7.49 (6.15) 60 10.58 (6.5) 26.2 % -0.49 [ -0.85, -0.12 ]

Linton 2005 61 3.4 (4) 47 4 (4.7) 24.0 % -0.14 [ -0.52, 0.24 ]

Von Korff 2005 99 8.4 (7) 98 9.1 (6.3) 44.6 % -0.10 [ -0.38, 0.17 ]

Subtotal (95% CI) 231 216 100.0 % -0.22 [ -0.41, -0.03 ]




-2 -1 0 1 2


Analysis 5.13. Comparison 5 MBR versus usual care, sensitivity and subgroup analyses, Outcome 13 Work

short term - all studies.



Outcome: 13 Work short term - all studies

Study or subgroup Experimental Usual care Odds Ratio Weight Odds Ratio

n/N n/N M-H,Fixed,95% CI M-H,Fixed,95% CI

Skouen 2002 25/57 35/86 69.5 % 1.14 [ 0.58, 2.24 ]

Von Korff 2005 103/110 113/120 30.5 % 0.91 [ 0.31, 2.69 ]

Total (95% CI) 167 206 100.0 % 1.07 [ 0.60, 1.90 ]

Total events: 128 (Experimental), 148 (Usual care)




0.2 0.5 1 2 5





short term - sensitivity and subgroup analyses.



Outcome: 14 Work short term - sensitivity and subgroup analyses

Study or subgroup Multidisciplinary Usual care Odds Ratio Weight Odds Ratio

n/N n/N

M-H,Random,95%

CI

M-H,Random,95%

CI



Total events: 0 (Multidisciplinary), 0 (Usual care)




Skouen 2002 25/57 35/86 100.0 % 1.14 [ 0.58, 2.24 ]

Subtotal (95% CI) 57 86 100.0 % 1.14 [ 0.58, 2.24 ]










Von Korff 2005 103/110 113/120 100.0 % 0.91 [ 0.31, 2.69 ]

Subtotal (95% CI) 110 120 100.0 % 0.91 [ 0.31, 2.69 ]




5 High intervention volume (>100 hours, daily contact)

Skouen 2002 25/57 35/86 100.0 % 1.14 [ 0.58, 2.24 ]

Subtotal (95% CI) 57 86 100.0 % 1.14 [ 0.58, 2.24 ]




0.2 0.5 1 2 5


(Continued . . . )



(. . . Continued)Study or subgroup Multidisciplinary Usual care Odds Ratio Weight Odds Ratio

n/N n/N

M-H,Random,95%

CI

M-H,Random,95%

CI

6 Low intervention volume (<30 hours, non-daily contact)

Von Korff 2005 103/110 113/120 100.0 % 0.91 [ 0.31, 2.69 ]

Subtotal (95% CI) 110 120 100.0 % 0.91 [ 0.31, 2.69 ]





0.2 0.5 1 2 5



medium term all studies.



Outcome: 15 Work medium term all studies


n/N n/N

M-H,Random,95%

CI

M-H,Random,95%

CI

Bendix ’A’ 1996/1998 29/45 14/49 33.6 % 4.53 [ 1.90, 10.81 ]

Skouen 2002 33/57 39/86 36.5 % 1.66 [ 0.84, 3.26 ]

Von Korff 2005 100/110 105/110 29.8 % 0.48 [ 0.16, 1.44 ]

Total (95% CI) 212 245 100.0 % 1.60 [ 0.52, 4.91 ]





0.1 0.2 0.5 1 2 5 10





medium term - sensitivity and subgroup analyses.



Outcome: 16 Work medium term - sensitivity and subgroup analyses


n/N n/N

M-H,Random,95%

CI

M-H,Random,95%

CI







Skouen 2002 33/57 39/86 100.0 % 1.66 [ 0.84, 3.26 ]

Subtotal (95% CI) 57 86 100.0 % 1.66 [ 0.84, 3.26 ]










Bendix ’A’ 1996/1998 29/45 14/49 51.2 % 4.53 [ 1.90, 10.81 ]

Von Korff 2005 100/110 105/110 48.8 % 0.48 [ 0.16, 1.44 ]

Subtotal (95% CI) 155 159 100.0 % 1.51 [ 0.17, 13.75 ]





Bendix ’A’ 1996/1998 29/45 14/49 46.1 % 4.53 [ 1.90, 10.81 ]

Skouen 2002 33/57 39/86 53.9 % 1.66 [ 0.84, 3.26 ]

Subtotal (95% CI) 102 135 100.0 % 2.64 [ 0.99, 7.04 ]





Von Korff 2005 100/110 105/110 100.0 % 0.48 [ 0.16, 1.44 ]

0.1 0.2 0.5 1 2 5 10


(Continued . . . )



(. . . Continued)


n/N n/N

M-H,Random,95%

CI

M-H,Random,95%

CI

Subtotal (95% CI) 110 110 100.0 % 0.48 [ 0.16, 1.44 ]





0.1 0.2 0.5 1 2 5 10



long term - all studies.



Outcome: 17 Work long term - all studies


n/N n/N

M-H,Random,95%

CI

M-H,Random,95%

CI

Bendix ’A’ 1996/1998 26/50 25/49 13.8 % 1.04 [ 0.47, 2.29 ]

Linton 2005 57/61 36/43 6.2 % 2.77 [ 0.76, 10.14 ]

Lukinmaa 1989 70/86 61/72 12.6 % 0.79 [ 0.34, 1.83 ]

Mitchell 1994 214/271 211/271 28.9 % 1.07 [ 0.71, 1.61 ]

Skouen 2002 35/57 40/86 16.8 % 1.83 [ 0.93, 3.62 ]

Strand 2001 38/81 21/36 13.7 % 0.63 [ 0.29, 1.40 ]

Von Korff 2005 89/99 93/98 8.1 % 0.48 [ 0.16, 1.46 ]

Total (95% CI) 705 655 100.0 % 1.04 [ 0.73, 1.47 ]





0.1 0.2 0.5 1 2 5 10





long term - sensitivity and subgroup analyses.



Outcome: 18 Work long term - sensitivity and subgroup analyses


n/N n/N

M-H,Random,95%

CI

M-H,Random,95%

CI







Skouen 2002 35/57 40/86 51.9 % 1.83 [ 0.93, 3.62 ]

Strand 2001 38/81 21/36 48.1 % 0.63 [ 0.29, 1.40 ]

Subtotal (95% CI) 138 122 100.0 % 1.10 [ 0.39, 3.11 ]










Bendix ’A’ 1996/1998 26/50 25/49 25.5 % 1.04 [ 0.47, 2.29 ]

Linton 2005 57/61 36/43 11.3 % 2.77 [ 0.76, 10.14 ]

Lukinmaa 1989 70/86 61/72 23.2 % 0.79 [ 0.34, 1.83 ]

Strand 2001 38/81 21/36 25.3 % 0.63 [ 0.29, 1.40 ]

Von Korff 2005 89/99 93/98 14.8 % 0.48 [ 0.16, 1.46 ]

Subtotal (95% CI) 377 298 100.0 % 0.86 [ 0.54, 1.36 ]



0.1 0.2 0.5 1 2 5 10


(Continued . . . )



(. . . Continued)Study or subgroup Multidisciplinary Usual care Odds Ratio Weight Odds Ratio

n/N n/N

M-H,Random,95%

CI

M-H,Random,95%

CI



Bendix ’A’ 1996/1998 26/50 25/49 17.6 % 1.04 [ 0.47, 2.29 ]

Mitchell 1994 214/271 211/271 43.0 % 1.07 [ 0.71, 1.61 ]

Skouen 2002 35/57 40/86 22.1 % 1.83 [ 0.93, 3.62 ]

Strand 2001 38/81 21/36 17.4 % 0.63 [ 0.29, 1.40 ]

Subtotal (95% CI) 459 442 100.0 % 1.09 [ 0.76, 1.58 ]





Linton 2005 57/61 36/43 48.1 % 2.77 [ 0.76, 10.14 ]

Von Korff 2005 89/99 93/98 51.9 % 0.48 [ 0.16, 1.46 ]

Subtotal (95% CI) 160 141 100.0 % 1.11 [ 0.20, 6.22 ]





0.1 0.2 0.5 1 2 5 10




Analysis 6.1. Comparison 6 MBR versus physical treatment, sensitivity and subgroup analyses, Outcome 1

Pain short term - all studies.


Comparison: 6 MBR versus physical treatment, sensitivity and subgroup analyses

Outcome: 1 Pain short term - all studies

Study or subgroup Multidisciplinary Physical

Std.Mean

Difference Weight

Std.Mean

Difference


Kaapa 2006 59 3.3 (2.5) 61 3.4 (2.4) 10.3 % -0.04 [ -0.40, 0.32 ]

Kool 2007 85 5.85 (2.3) 85 6.59 (2.2) 10.9 % -0.33 [ -0.63, -0.02 ]

Mangels 2009 111 15.9 (5.3) 131 16.4 (5.8) 11.3 % -0.09 [ -0.34, 0.16 ]

Monticone 2013 45 2.69 (0.97) 45 4.96 (1.27) 8.8 % -1.99 [ -2.50, -1.48 ]

Morone 2012 25 5 (2.2) 25 5 (2.2) 8.3 % 0.0 [ -0.55, 0.55 ]

Nicholas 1991 9 2.73 (0.6) 11 3.16 (0.66) 5.3 % -0.65 [ -1.56, 0.26 ]

Nicholas 1992 10 3.07 (0.79) 10 2.72 (0.77) 5.4 % 0.43 [ -0.46, 1.32 ]

Roche 2007/2011 67 2.8 (2.1) 64 3 (2.1) 10.5 % -0.09 [ -0.44, 0.25 ]

Schweikert 2006 170 5.5 (1.3) 193 5.7 (1.3) 11.7 % -0.15 [ -0.36, 0.05 ]

Smeets 2006/2008 55 42.31 (25.56) 52 44.63 (28.86) 10.1 % -0.08 [ -0.46, 0.29 ]

Turner 1990 18 14.78 (11.44) 21 17.52 (10.2) 7.5 % -0.25 [ -0.88, 0.38 ]

Total (95% CI) 654 698 100.0 % -0.29 [ -0.57, -0.01 ]




-2 -1 0 1 2





Pain short term - sensitivity and subgroup analyses.



Outcome: 2 Pain short term - sensitivity and subgroup analyses


Std.Mean

Difference Weight

Std.Mean

Difference



Kaapa 2006 59 3.3 (2.5) 61 3.4 (2.4) 16.7 % -0.04 [ -0.40, 0.32 ]

Kool 2007 85 5.85 (2.3) 85 6.59 (2.2) 17.3 % -0.33 [ -0.63, -0.02 ]

Mangels 2009 111 15.9 (5.3) 131 16.4 (5.8) 17.7 % -0.09 [ -0.34, 0.16 ]

Monticone 2013 45 2.69 (0.97) 45 4.96 (1.27) 15.0 % -1.99 [ -2.50, -1.48 ]

Roche 2007/2011 67 2.8 (2.1) 64 3 (2.1) 16.9 % -0.09 [ -0.44, 0.25 ]

Smeets 2006/2008 55 42.31 (25.56) 52 44.63 (28.86) 16.5 % -0.08 [ -0.46, 0.29 ]

Subtotal (95% CI) 422 438 100.0 % -0.41 [ -0.85, 0.03 ]




Kaapa 2006 59 3.3 (2.5) 61 3.4 (2.4) 11.1 % -0.04 [ -0.40, 0.32 ]

Kool 2007 85 5.85 (2.3) 85 6.59 (2.2) 11.7 % -0.33 [ -0.63, -0.02 ]

Mangels 2009 111 15.9 (5.3) 131 16.4 (5.8) 12.1 % -0.09 [ -0.34, 0.16 ]

Monticone 2013 45 2.69 (0.97) 45 4.96 (1.27) 9.5 % -1.99 [ -2.50, -1.48 ]

Morone 2012 25 5 (2.2) 25 5 (2.2) 9.0 % 0.0 [ -0.55, 0.55 ]

Nicholas 1991 9 2.73 (0.6) 11 3.16 (0.66) 5.9 % -0.65 [ -1.56, 0.26 ]

Nicholas 1992 10 3.07 (0.79) 10 2.72 (0.77) 6.0 % 0.43 [ -0.46, 1.32 ]

Roche 2007/2011 67 2.8 (2.1) 64 3 (2.1) 11.3 % -0.09 [ -0.44, 0.25 ]

Schweikert 2006 170 5.5 (1.3) 193 5.7 (1.3) 12.5 % -0.15 [ -0.36, 0.05 ]

Smeets 2006/2008 55 42.31 (25.56) 52 44.63 (28.86) 10.9 % -0.08 [ -0.46, 0.29 ]

Subtotal (95% CI) 636 677 100.0 % -0.29 [ -0.59, 0.00 ]




Monticone 2013 45 2.69 (0.97) 45 4.96 (1.27) 49.2 % -1.99 [ -2.50, -1.48 ]

Schweikert 2006 170 5.5 (1.3) 193 5.7 (1.3) 50.8 % -0.15 [ -0.36, 0.05 ]

-2 -1 0 1 2


(Continued . . . )



(. . . Continued)


Std.Mean

Difference Weight

Std.Mean

Difference


Subtotal (95% CI) 215 238 100.0 % -1.06 [ -2.86, 0.74 ]




Kaapa 2006 59 3.3 (2.5) 61 3.4 (2.4) 13.4 % -0.04 [ -0.40, 0.32 ]

Kool 2007 85 5.85 (2.3) 85 6.59 (2.2) 18.8 % -0.33 [ -0.63, -0.02 ]

Mangels 2009 111 15.9 (5.3) 131 16.4 (5.8) 26.9 % -0.09 [ -0.34, 0.16 ]

Morone 2012 25 5 (2.2) 25 5 (2.2) 5.6 % 0.0 [ -0.55, 0.55 ]

Nicholas 1991 9 2.73 (0.6) 11 3.16 (0.66) 2.1 % -0.65 [ -1.56, 0.26 ]

Nicholas 1992 10 3.07 (0.79) 10 2.72 (0.77) 2.2 % 0.43 [ -0.46, 1.32 ]

Roche 2007/2011 67 2.8 (2.1) 64 3 (2.1) 14.7 % -0.09 [ -0.44, 0.25 ]

Smeets 2006/2008 55 42.31 (25.56) 52 44.63 (28.86) 12.0 % -0.08 [ -0.46, 0.29 ]

Turner 1990 18 14.78 (11.44) 21 17.52 (10.2) 4.3 % -0.25 [ -0.88, 0.38 ]

Subtotal (95% CI) 439 460 100.0 % -0.13 [ -0.26, 0.00 ]



5 High intervention intensity 1 (>100 hours, daily contact)

Kaapa 2006 59 3.3 (2.5) 61 3.4 (2.4) 14.1 % -0.04 [ -0.40, 0.32 ]

Mangels 2009 111 15.9 (5.3) 131 16.4 (5.8) 28.2 % -0.09 [ -0.34, 0.16 ]

Roche 2007/2011 67 2.8 (2.1) 64 3 (2.1) 15.4 % -0.09 [ -0.44, 0.25 ]

Schweikert 2006 170 5.5 (1.3) 193 5.7 (1.3) 42.3 % -0.15 [ -0.36, 0.05 ]

Subtotal (95% CI) 407 449 100.0 % -0.11 [ -0.24, 0.02 ]



6 Low intervention intensity 1 (<30 hours, non-daily contact)

Monticone 2013 45 2.69 (0.97) 45 4.96 (1.27) 21.2 % -1.99 [ -2.50, -1.48 ]

Morone 2012 25 5 (2.2) 25 5 (2.2) 21.0 % 0.0 [ -0.55, 0.55 ]

Nicholas 1991 9 2.73 (0.6) 11 3.16 (0.66) 18.6 % -0.65 [ -1.56, 0.26 ]

Nicholas 1992 10 3.07 (0.79) 10 2.72 (0.77) 18.7 % 0.43 [ -0.46, 1.32 ]

Turner 1990 18 14.78 (11.44) 21 17.52 (10.2) 20.5 % -0.25 [ -0.88, 0.38 ]

Subtotal (95% CI) 107 112 100.0 % -0.51 [ -1.44, 0.41 ]




-2 -1 0 1 2





Pain medium term - all studies.



Outcome: 3 Pain medium term - all studies


Std.Mean

Difference Weight

Std.Mean

Difference


Bendix ’B’ 1995/1998 40 2.7 (2.5) 31 4.4 (2.5) 13.1 % -0.67 [ -1.16, -0.19 ]

Coole 2013 19 5.19 (1.87) 19 5.33 (2.18) 9.9 % -0.07 [ -0.70, 0.57 ]

Jousset 2004 42 3.1 (2.5) 41 4 (2.8) 14.3 % -0.34 [ -0.77, 0.10 ]

Kaapa 2006 59 3.3 (2.5) 60 3.4 (2.5) 16.3 % -0.04 [ -0.40, 0.32 ]

Morone 2012 20 4 (2.2) 25 5 (2.2) 10.7 % -0.45 [ -1.04, 0.15 ]

Nicholas 1991 9 1.87 (0.73) 11 3.18 (0.72) 4.8 % -1.73 [ -2.80, -0.67 ]

Nicholas 1992 10 2.89 (0.64) 10 2.75 (1.11) 6.5 % 0.15 [ -0.73, 1.03 ]

Smeets 2006/2008 53 49.53 (22.24) 51 47.14 (27.3) 15.6 % 0.10 [ -0.29, 0.48 ]

Turner 1990 14 13.29 (9.15) 17 15.65 (9.15) 8.7 % -0.25 [ -0.96, 0.46 ]

Total (95% CI) 266 265 100.0 % -0.28 [ -0.54, -0.02 ]




-2 -1 0 1 2





Pain medium term - sensitivity and subgroup analyses.



Outcome: 4 Pain medium term - sensitivity and subgroup analyses


Std.Mean

Difference Weight

Std.Mean

Difference



Kaapa 2006 59 3.3 (2.5) 60 3.4 (2.5) 53.4 % -0.04 [ -0.40, 0.32 ]

Smeets 2006/2008 53 49.53 (22.24) 51 47.14 (27.3) 46.6 % 0.10 [ -0.29, 0.48 ]

Subtotal (95% CI) 112 111 100.0 % 0.02 [ -0.24, 0.29 ]




Kaapa 2006 59 3.3 (2.5) 60 3.4 (2.5) 27.3 % -0.04 [ -0.40, 0.32 ]

Morone 2012 20 4 (2.2) 25 5 (2.2) 20.6 % -0.45 [ -1.04, 0.15 ]

Nicholas 1991 9 1.87 (0.73) 11 3.18 (0.72) 11.2 % -1.73 [ -2.80, -0.67 ]

Nicholas 1992 10 2.89 (0.64) 10 2.75 (1.11) 14.2 % 0.15 [ -0.73, 1.03 ]

Smeets 2006/2008 53 49.53 (22.24) 51 47.14 (27.3) 26.6 % 0.10 [ -0.29, 0.48 ]

Subtotal (95% CI) 151 157 100.0 % -0.25 [ -0.69, 0.19 ]








Bendix ’B’ 1995/1998 40 2.7 (2.5) 31 4.4 (2.5) 13.1 % -0.67 [ -1.16, -0.19 ]

Coole 2013 19 5.19 (1.87) 19 5.33 (2.18) 9.9 % -0.07 [ -0.70, 0.57 ]

Jousset 2004 42 3.1 (2.5) 41 4 (2.8) 14.3 % -0.34 [ -0.77, 0.10 ]

Kaapa 2006 59 3.3 (2.5) 60 3.4 (2.5) 16.3 % -0.04 [ -0.40, 0.32 ]

Morone 2012 20 4 (2.2) 25 5 (2.2) 10.7 % -0.45 [ -1.04, 0.15 ]

Nicholas 1991 9 1.87 (0.73) 11 3.18 (0.72) 4.8 % -1.73 [ -2.80, -0.67 ]

Nicholas 1992 10 2.89 (0.64) 10 2.75 (1.11) 6.5 % 0.15 [ -0.73, 1.03 ]

Smeets 2006/2008 53 49.53 (22.24) 51 47.14 (27.3) 15.6 % 0.10 [ -0.29, 0.48 ]

-2 -1 0 1 2


(Continued . . . )



(. . . Continued)


Std.Mean

Difference Weight

Std.Mean

Difference


Turner 1990 14 13.29 (9.15) 17 15.65 (9.15) 8.7 % -0.25 [ -0.96, 0.46 ]

Subtotal (95% CI) 266 265 100.0 % -0.28 [ -0.54, -0.02 ]




Bendix ’B’ 1995/1998 40 2.7 (2.5) 31 4.4 (2.5) 29.2 % -0.67 [ -1.16, -0.19 ]

Jousset 2004 42 3.1 (2.5) 41 4 (2.8) 32.5 % -0.34 [ -0.77, 0.10 ]

Kaapa 2006 59 3.3 (2.5) 60 3.4 (2.5) 38.2 % -0.04 [ -0.40, 0.32 ]

Subtotal (95% CI) 141 132 100.0 % -0.32 [ -0.68, 0.04 ]




Coole 2013 19 5.19 (1.87) 19 5.33 (2.18) 23.3 % -0.07 [ -0.70, 0.57 ]

Morone 2012 20 4 (2.2) 25 5 (2.2) 24.5 % -0.45 [ -1.04, 0.15 ]

Nicholas 1991 9 1.87 (0.73) 11 3.18 (0.72) 13.7 % -1.73 [ -2.80, -0.67 ]

Nicholas 1992 10 2.89 (0.64) 10 2.75 (1.11) 17.2 % 0.15 [ -0.73, 1.03 ]

Turner 1990 14 13.29 (9.15) 17 15.65 (9.15) 21.3 % -0.25 [ -0.96, 0.46 ]

Subtotal (95% CI) 72 82 100.0 % -0.39 [ -0.88, 0.10 ]




-2 -1 0 1 2





Pain long term - all studies.



Outcome: 5 Pain long term - all studies


Std.Mean

Difference Weight

Std.Mean

Difference


Bendix ’B’ 1995/1998 38 3.3 (2.6) 31 5.3 (2.6) 11.3 % -0.76 [ -1.25, -0.27 ]

Bendix ’C’ 2000 48 5.1 (2.6) 50 5.7 (2.6) 11.7 % -0.23 [ -0.63, 0.17 ]

Kaapa 2006 53 3.6 (2.7) 54 3.4 (2.5) 11.7 % 0.08 [ -0.30, 0.46 ]

Mangels 2009 111 16.3 (5.7) 131 17.3 (6.1) 12.1 % -0.17 [ -0.42, 0.08 ]

Monticone 2013 45 1.38 (1.07) 45 5.33 (1.22) 10.5 % -3.41 [ -4.07, -2.76 ]

Nicholas 1991 9 2.66 (1.06) 11 3.22 (0.69) 9.1 % -0.61 [ -1.52, 0.29 ]

Roche 2007/2011 64 2.9 (2.4) 48 3.5 (2.3) 11.8 % -0.25 [ -0.63, 0.12 ]

Smeets 2006/2008 53 52.87 (24.47) 51 47.24 (27.53) 11.7 % 0.21 [ -0.17, 0.60 ]

Turner 1990 14 18.21 (13.31) 16 14.94 (7.86) 10.1 % 0.30 [ -0.43, 1.02 ]

Total (95% CI) 435 437 100.0 % -0.51 [ -1.04, 0.01 ]




-2 -1 0 1 2

Favours Multidis Favours Physical




Pain long term - sensitivity and subgroup analyses.



Outcome: 6 Pain long term - sensitivity and subgroup analyses


Std.Mean

Difference Weight

Std.Mean

Difference



Kaapa 2006 53 3.6 (2.7) 54 3.4 (2.5) 20.2 % 0.08 [ -0.30, 0.46 ]

Mangels 2009 111 16.3 (5.7) 131 17.3 (6.1) 20.7 % -0.17 [ -0.42, 0.08 ]

Monticone 2013 45 1.38 (1.07) 45 5.33 (1.22) 18.7 % -3.41 [ -4.07, -2.76 ]

Roche 2007/2011 64 2.9 (2.4) 48 3.5 (2.3) 20.2 % -0.25 [ -0.63, 0.12 ]

Smeets 2006/2008 53 52.87 (24.47) 51 47.24 (27.53) 20.2 % 0.21 [ -0.17, 0.60 ]

Subtotal (95% CI) 326 329 100.0 % -0.66 [ -1.50, 0.17 ]




Kaapa 2006 53 3.6 (2.7) 54 3.4 (2.5) 17.3 % 0.08 [ -0.30, 0.46 ]

Mangels 2009 111 16.3 (5.7) 131 17.3 (6.1) 17.8 % -0.17 [ -0.42, 0.08 ]

Monticone 2013 45 1.38 (1.07) 45 5.33 (1.22) 15.9 % -3.41 [ -4.07, -2.76 ]

Nicholas 1991 9 2.66 (1.06) 11 3.22 (0.69) 14.3 % -0.61 [ -1.52, 0.29 ]

Roche 2007/2011 64 2.9 (2.4) 48 3.5 (2.3) 17.3 % -0.25 [ -0.63, 0.12 ]

Smeets 2006/2008 53 52.87 (24.47) 51 47.24 (27.53) 17.3 % 0.21 [ -0.17, 0.60 ]

Subtotal (95% CI) 335 340 100.0 % -0.65 [ -1.41, 0.10 ]




Monticone 2013 45 1.38 (1.07) 45 5.33 (1.22) 100.0 % -3.41 [ -4.07, -2.76 ]

Subtotal (95% CI) 45 45 100.0 % -3.41 [ -4.07, -2.76 ]




Bendix ’B’ 1995/1998 38 3.3 (2.6) 31 5.3 (2.6) 11.1 % -0.76 [ -1.25, -0.27 ]

Bendix ’C’ 2000 48 5.1 (2.6) 50 5.7 (2.6) 14.0 % -0.23 [ -0.63, 0.17 ]

Kaapa 2006 53 3.6 (2.7) 54 3.4 (2.5) 14.7 % 0.08 [ -0.30, 0.46 ]

-2 -1 0 1 2


(Continued . . . )



(. . . Continued)


Std.Mean

Difference Weight

Std.Mean

Difference


Mangels 2009 111 16.3 (5.7) 131 17.3 (6.1) 19.8 % -0.17 [ -0.42, 0.08 ]

Nicholas 1991 9 2.66 (1.06) 11 3.22 (0.69) 4.6 % -0.61 [ -1.52, 0.29 ]

Roche 2007/2011 64 2.9 (2.4) 48 3.5 (2.3) 14.8 % -0.25 [ -0.63, 0.12 ]

Smeets 2006/2008 53 52.87 (24.47) 51 47.24 (27.53) 14.4 % 0.21 [ -0.17, 0.60 ]

Turner 1990 14 18.21 (13.31) 16 14.94 (7.86) 6.6 % 0.30 [ -0.43, 1.02 ]

Subtotal (95% CI) 390 392 100.0 % -0.15 [ -0.37, 0.06 ]




Bendix ’B’ 1995/1998 38 3.3 (2.6) 31 5.3 (2.6) 13.9 % -0.76 [ -1.25, -0.27 ]

Bendix ’C’ 2000 48 5.1 (2.6) 50 5.7 (2.6) 18.4 % -0.23 [ -0.63, 0.17 ]

Kaapa 2006 53 3.6 (2.7) 54 3.4 (2.5) 19.4 % 0.08 [ -0.30, 0.46 ]

Mangels 2009 111 16.3 (5.7) 131 17.3 (6.1) 28.6 % -0.17 [ -0.42, 0.08 ]

Roche 2007/2011 64 2.9 (2.4) 48 3.5 (2.3) 19.6 % -0.25 [ -0.63, 0.12 ]

Subtotal (95% CI) 314 314 100.0 % -0.23 [ -0.45, -0.01 ]




Monticone 2013 45 1.38 (1.07) 45 5.33 (1.22) 33.6 % -3.41 [ -4.07, -2.76 ]

Nicholas 1991 9 2.66 (1.06) 11 3.22 (0.69) 32.9 % -0.61 [ -1.52, 0.29 ]

Turner 1990 14 18.21 (13.31) 16 14.94 (7.86) 33.5 % 0.30 [ -0.43, 1.02 ]

Subtotal (95% CI) 68 72 100.0 % -1.25 [ -3.64, 1.13 ]




-2 -1 0 1 2





Disability short term - all studies.



Outcome: 7 Disability short term - all studies


Std.Mean

Difference Weight

Std.Mean

Difference


Alaranta 1994 147 27.9 (22.1) 139 35.3 (20.6) 9.0 % -0.35 [ -0.58, -0.11 ]

Harkapaa 1989 156 14 (7.9) 153 16.5 (7.9) 9.1 % -0.32 [ -0.54, -0.09 ]

Henchoz 2010 56 25.7 (15.8) 44 35 (12.3) 8.1 % -0.64 [ -1.05, -0.24 ]

Kaapa 2006 59 20.9 (10.1) 61 21.6 (11.4) 8.4 % -0.06 [ -0.42, 0.29 ]

Mangels 2009 111 21.7 (13.3) 131 21 (13.3) 8.9 % 0.05 [ -0.20, 0.31 ]

Monticone 2013 45 5.04 (2.04) 45 11.04 (2.27) 6.9 % -2.76 [ -3.34, -2.17 ]

Morone 2012 25 12 (10.7) 25 16 (10.7) 7.1 % -0.37 [ -0.93, 0.19 ]

Nicholas 1991 9 19.26 (9.79) 11 21.96 (4.59) 5.1 % -0.35 [ -1.24, 0.54 ]

Nicholas 1992 10 18.81 (10.97) 10 26.08 (16.14) 5.1 % -0.50 [ -1.40, 0.39 ]

Roche 2007/2011 68 30.3 (23.3) 64 33.8 (23.3) 8.5 % -0.15 [ -0.49, 0.19 ]

Schweikert 2006 169 73.2 (18.8) 194 68.7 (18.8) 9.1 % 0.24 [ 0.03, 0.45 ]

Smeets 2006/2008 55 11.4 (5.25) 52 11.9 (5.9) 8.2 % -0.09 [ -0.47, 0.29 ]

Turner 1990 18 3.63 (2.98) 21 5.49 (7.79) 6.6 % -0.30 [ -0.93, 0.33 ]

Total (95% CI) 928 950 100.0 % -0.39 [ -0.68, -0.10 ]




-4 -2 0 2 4





Disability short term - sensitivity and subgroup analyses.



Outcome: 8 Disability short term - sensitivity and subgroup analyses


Std.Mean

Difference Weight

Std.Mean

Difference



Kaapa 2006 59 20.9 (10.1) 61 21.6 (11.4) 20.2 % -0.06 [ -0.42, 0.29 ]

Mangels 2009 111 21.7 (13.3) 131 21 (13.3) 20.8 % 0.05 [ -0.20, 0.31 ]

Monticone 2013 45 5.04 (2.04) 45 11.04 (2.27) 18.6 % -2.76 [ -3.34, -2.17 ]

Roche 2007/2011 68 30.3 (23.3) 64 33.8 (23.3) 20.3 % -0.15 [ -0.49, 0.19 ]

Smeets 2006/2008 55 11.4 (5.25) 52 11.9 (5.9) 20.1 % -0.09 [ -0.47, 0.29 ]

Subtotal (95% CI) 338 353 100.0 % -0.56 [ -1.27, 0.15 ]




Henchoz 2010 56 25.7 (15.8) 44 35 (12.3) 10.6 % -0.64 [ -1.05, -0.24 ]

Kaapa 2006 59 20.9 (10.1) 61 21.6 (11.4) 10.8 % -0.06 [ -0.42, 0.29 ]

Mangels 2009 111 21.7 (13.3) 131 21 (13.3) 11.3 % 0.05 [ -0.20, 0.31 ]

Monticone 2013 45 5.04 (2.04) 45 11.04 (2.27) 9.5 % -2.76 [ -3.34, -2.17 ]

Morone 2012 25 12 (10.7) 25 16 (10.7) 9.7 % -0.37 [ -0.93, 0.19 ]

Nicholas 1991 9 19.26 (9.79) 11 21.96 (4.59) 7.6 % -0.35 [ -1.24, 0.54 ]

Nicholas 1992 10 18.81 (10.97) 10 26.08 (16.14) 7.6 % -0.50 [ -1.40, 0.39 ]

Roche 2007/2011 68 30.3 (23.3) 64 33.8 (23.3) 10.9 % -0.15 [ -0.49, 0.19 ]

Schweikert 2006 169 73.2 (18.8) 194 68.7 (18.8) 11.4 % 0.24 [ 0.03, 0.45 ]

Smeets 2006/2008 55 11.4 (5.25) 52 11.9 (5.9) 10.7 % -0.09 [ -0.47, 0.29 ]

Subtotal (95% CI) 607 637 100.0 % -0.43 [ -0.84, -0.02 ]




Monticone 2013 45 5.04 (2.04) 45 11.04 (2.27) 49.6 % -2.76 [ -3.34, -2.17 ]

Schweikert 2006 169 73.2 (18.8) 194 68.7 (18.8) 50.4 % 0.24 [ 0.03, 0.45 ]

Subtotal (95% CI) 214 239 100.0 % -1.25 [ -4.18, 1.69 ]

-4 -2 0 2 4


(Continued . . . )



(. . . Continued)


Std.Mean

Difference Weight

Std.Mean

Difference





Alaranta 1994 147 27.9 (22.1) 139 35.3 (20.6) 17.6 % -0.35 [ -0.58, -0.11 ]

Harkapaa 1989 156 14 (7.9) 153 16.5 (7.9) 18.5 % -0.32 [ -0.54, -0.09 ]

Henchoz 2010 56 25.7 (15.8) 44 35 (12.3) 7.8 % -0.64 [ -1.05, -0.24 ]

Kaapa 2006 59 20.9 (10.1) 61 21.6 (11.4) 9.5 % -0.06 [ -0.42, 0.29 ]

Mangels 2009 111 21.7 (13.3) 131 21 (13.3) 15.9 % 0.05 [ -0.20, 0.31 ]

Morone 2012 25 12 (10.7) 25 16 (10.7) 4.4 % -0.37 [ -0.93, 0.19 ]

Nicholas 1991 9 19.26 (9.79) 11 21.96 (4.59) 1.9 % -0.35 [ -1.24, 0.54 ]

Nicholas 1992 10 18.81 (10.97) 10 26.08 (16.14) 1.8 % -0.50 [ -1.40, 0.39 ]

Roche 2007/2011 68 30.3 (23.3) 64 33.8 (23.3) 10.3 % -0.15 [ -0.49, 0.19 ]

Smeets 2006/2008 55 11.4 (5.25) 52 11.9 (5.9) 8.7 % -0.09 [ -0.47, 0.29 ]

Turner 1990 18 3.63 (2.98) 21 5.49 (7.79) 3.5 % -0.30 [ -0.93, 0.33 ]

Subtotal (95% CI) 714 711 100.0 % -0.23 [ -0.36, -0.11 ]




Alaranta 1994 147 27.9 (22.1) 139 35.3 (20.6) 15.7 % -0.35 [ -0.58, -0.11 ]

Harkapaa 1989 156 14 (7.9) 153 16.5 (7.9) 15.9 % -0.32 [ -0.54, -0.09 ]

Henchoz 2010 56 25.7 (15.8) 44 35 (12.3) 11.5 % -0.64 [ -1.05, -0.24 ]

Kaapa 2006 59 20.9 (10.1) 61 21.6 (11.4) 12.6 % -0.06 [ -0.42, 0.29 ]

Mangels 2009 111 21.7 (13.3) 131 21 (13.3) 15.2 % 0.05 [ -0.20, 0.31 ]

Roche 2007/2011 68 30.3 (23.3) 64 33.8 (23.3) 13.0 % -0.15 [ -0.49, 0.19 ]

Schweikert 2006 169 73.2 (18.8) 194 68.7 (18.8) 16.3 % 0.24 [ 0.03, 0.45 ]

Subtotal (95% CI) 766 786 100.0 % -0.16 [ -0.38, 0.06 ]




Monticone 2013 45 5.04 (2.04) 45 11.04 (2.27) 20.7 % -2.76 [ -3.34, -2.17 ]

Morone 2012 25 12 (10.7) 25 16 (10.7) 20.8 % -0.37 [ -0.93, 0.19 ]

Nicholas 1991 9 19.26 (9.79) 11 21.96 (4.59) 19.1 % -0.35 [ -1.24, 0.54 ]

Nicholas 1992 10 18.81 (10.97) 10 26.08 (16.14) 19.1 % -0.50 [ -1.40, 0.39 ]

Turner 1990 18 3.63 (2.98) 21 5.49 (7.79) 20.4 % -0.30 [ -0.93, 0.33 ]

-4 -2 0 2 4


(Continued . . . )



(. . . Continued)


Std.Mean

Difference Weight

Std.Mean

Difference


Subtotal (95% CI) 107 112 100.0 % -0.87 [ -1.93, 0.19 ]




-4 -2 0 2 4



Disability medium term - all studies.



Outcome: 9 Disability medium term - all studies


Std.Mean

Difference Weight

Std.Mean

Difference


Coole 2013 19 8.79 (6.76) 19 7.32 (6.06) 10.1 % 0.22 [ -0.41, 0.86 ]

Henchoz 2010 34 28.6 (18.4) 21 35.4 (15) 11.8 % -0.39 [ -0.94, 0.16 ]

Jousset 2004 42 22 (16) 41 22.9 (17.7) 14.6 % -0.05 [ -0.48, 0.38 ]

Kaapa 2006 58 20.4 (11.6) 57 18 (11.5) 16.2 % 0.21 [ -0.16, 0.57 ]

Morone 2012 20 10 (11.6) 25 20 (11.6) 10.5 % -0.85 [ -1.46, -0.23 ]

Nicholas 1991 9 15.44 (14.12) 11 29.78 (8.76) 5.7 % -1.20 [ -2.17, -0.23 ]

Nicholas 1992 10 18.3 (11.18) 10 25.31 (14.34) 6.5 % -0.52 [ -1.42, 0.37 ]

Smeets 2006/2008 53 11.34 (5.66) 51 11.29 (6.15) 15.7 % 0.01 [ -0.38, 0.39 ]

Turner 1990 14 4.51 (4.68) 17 6.25 (10.08) 8.9 % -0.21 [ -0.92, 0.50 ]

Total (95% CI) 259 252 100.0 % -0.21 [ -0.48, 0.06 ]




-2 -1 0 1 2




Analysis 6.10. Comparison 6 MBR versus physical treatment, sensitivity and subgroup analyses, Outcome

10 Disability medium term - sensitivity and subgroup analyses.



Outcome: 10 Disability medium term - sensitivity and subgroup analyses


Std.Mean

Difference Weight

Std.Mean

Difference



Kaapa 2006 58 20.4 (11.6) 57 18 (11.5) 52.4 % 0.21 [ -0.16, 0.57 ]

Smeets 2006/2008 53 11.34 (5.66) 51 11.29 (6.15) 47.6 % 0.01 [ -0.38, 0.39 ]

Subtotal (95% CI) 111 108 100.0 % 0.11 [ -0.15, 0.38 ]




Henchoz 2010 34 28.6 (18.4) 21 35.4 (15) 17.9 % -0.39 [ -0.94, 0.16 ]

Kaapa 2006 58 20.4 (11.6) 57 18 (11.5) 22.1 % 0.21 [ -0.16, 0.57 ]

Morone 2012 20 10 (11.6) 25 20 (11.6) 16.5 % -0.85 [ -1.46, -0.23 ]

Nicholas 1991 9 15.44 (14.12) 11 29.78 (8.76) 10.4 % -1.20 [ -2.17, -0.23 ]

Nicholas 1992 10 18.3 (11.18) 10 25.31 (14.34) 11.5 % -0.52 [ -1.42, 0.37 ]

Smeets 2006/2008 53 11.34 (5.66) 51 11.29 (6.15) 21.7 % 0.01 [ -0.38, 0.39 ]

Subtotal (95% CI) 184 175 100.0 % -0.35 [ -0.75, 0.05 ]








Coole 2013 19 8.79 (6.76) 19 7.32 (6.06) 9.4 % 0.22 [ -0.41, 0.86 ]

Henchoz 2010 53 11.34 (5.66) 51 11.29 (6.15) 15.5 % 0.01 [ -0.38, 0.39 ]

-2 -1 0 1 2


(Continued . . . )



(. . . Continued)


Std.Mean

Difference Weight

Std.Mean

Difference


Jousset 2004 42 22 (16) 41 22.9 (17.7) 14.2 % -0.05 [ -0.48, 0.38 ]

Kaapa 2006 58 20.4 (11.6) 57 18 (11.5) 16.1 % 0.21 [ -0.16, 0.57 ]

Morone 2012 20 10 (11.6) 25 20 (11.6) 9.9 % -0.85 [ -1.46, -0.23 ]

Nicholas 1991 9 15.44 (14.12) 11 29.78 (8.76) 5.2 % -1.20 [ -2.17, -0.23 ]

Nicholas 1992 10 18.3 (11.18) 10 25.31 (14.34) 5.9 % -0.52 [ -1.42, 0.37 ]

Smeets 2006/2008 53 11.34 (5.66) 51 11.29 (6.15) 15.5 % 0.01 [ -0.38, 0.39 ]

Turner 1990 14 4.51 (4.68) 17 6.25 (10.08) 8.2 % -0.21 [ -0.92, 0.50 ]

Subtotal (95% CI) 278 282 100.0 % -0.14 [ -0.39, 0.11 ]




Henchoz 2010 53 11.34 (5.66) 51 11.29 (6.15) 34.5 % 0.01 [ -0.38, 0.39 ]

Jousset 2004 42 22 (16) 41 22.9 (17.7) 27.5 % -0.05 [ -0.48, 0.38 ]

Kaapa 2006 58 20.4 (11.6) 57 18 (11.5) 38.0 % 0.21 [ -0.16, 0.57 ]

Subtotal (95% CI) 153 149 100.0 % 0.07 [ -0.16, 0.29 ]




Coole 2013 19 8.79 (6.76) 19 7.32 (6.06) 23.1 % 0.22 [ -0.41, 0.86 ]

Morone 2012 20 10 (11.6) 25 20 (11.6) 23.8 % -0.85 [ -1.46, -0.23 ]

Nicholas 1991 9 15.44 (14.12) 11 29.78 (8.76) 15.2 % -1.20 [ -2.17, -0.23 ]

Nicholas 1992 10 18.3 (11.18) 10 25.31 (14.34) 16.8 % -0.52 [ -1.42, 0.37 ]

Turner 1990 14 4.51 (4.68) 17 6.25 (10.08) 21.2 % -0.21 [ -0.92, 0.50 ]

Subtotal (95% CI) 72 82 100.0 % -0.46 [ -0.95, 0.03 ]




-2 -1 0 1 2





11 Disability long term - all studies.



Outcome: 11 Disability long term - all studies


Std.Mean

Difference Weight

Std.Mean

Difference


Alaranta 1994 149 29.4 (23.5) 138 35.5 (24.8) 11.0 % -0.25 [ -0.48, -0.02 ]

Henchoz 2010 49 26.2 (18) 25 38 (18.4) 10.2 % -0.64 [ -1.14, -0.15 ]

Kaapa 2006 53 18.9 (12.2) 54 18.5 (12.4) 10.6 % 0.03 [ -0.35, 0.41 ]

Mangels 2009 111 22.6 (16) 131 20.6 (13.5) 11.0 % 0.14 [ -0.12, 0.39 ]

Monticone 2013 45 1.31 (1.59) 45 11 (2) 8.4 % -5.32 [ -6.21, -4.42 ]

Nicholas 1991 9 12.8 (8.62) 11 25.18 (8.08) 7.9 % -1.42 [ -2.43, -0.42 ]

Roche 2007/2011 64 31.4 (22.9) 49 39.1 (21.9) 10.6 % -0.34 [ -0.72, 0.03 ]

Smeets 2006/2008 53 11.75 (5.81) 51 10.94 (5.66) 10.6 % 0.14 [ -0.24, 0.53 ]

Streibelt 2009 55 27.7 (16.5) 47 31.1 (16.5) 10.6 % -0.20 [ -0.59, 0.19 ]

Turner 1990 14 4.75 (3.4) 16 4.73 (7.85) 9.2 % 0.00 [ -0.71, 0.72 ]

Total (95% CI) 602 567 100.0 % -0.68 [ -1.19, -0.16 ]




-2 -1 0 1 2





12 Disability long term - sensitivity and subgroup analyses.



Outcome: 12 Disability long term - sensitivity and subgroup analyses


Std.Mean

Difference Weight

Std.Mean

Difference



Kaapa 2006 53 18.9 (12.2) 54 18.5 (12.4) 20.4 % 0.03 [ -0.35, 0.41 ]

Mangels 2009 111 22.6 (16) 131 20.6 (13.5) 20.7 % 0.14 [ -0.12, 0.39 ]

Monticone 2013 45 1.31 (1.59) 45 11 (2) 18.0 % -5.32 [ -6.21, -4.42 ]

Roche 2007/2011 64 31.4 (22.9) 49 39.1 (21.9) 20.4 % -0.34 [ -0.72, 0.03 ]

Smeets 2006/2008 53 11.75 (5.81) 51 10.94 (5.66) 20.4 % 0.14 [ -0.24, 0.53 ]

Subtotal (95% CI) 326 330 100.0 % -0.97 [ -1.98, 0.05 ]




Henchoz 2010 49 26.2 (18) 25 38 (18.4) 12.7 % -0.64 [ -1.14, -0.15 ]

Kaapa 2006 53 18.9 (12.2) 54 18.5 (12.4) 13.1 % 0.03 [ -0.35, 0.41 ]

Mangels 2009 111 22.6 (16) 131 20.6 (13.5) 13.4 % 0.14 [ -0.12, 0.39 ]

Monticone 2013 45 1.31 (1.59) 45 11 (2) 11.1 % -5.32 [ -6.21, -4.42 ]

Nicholas 1991 9 12.8 (8.62) 11 25.18 (8.08) 10.5 % -1.42 [ -2.43, -0.42 ]

Roche 2007/2011 64 31.4 (22.9) 49 39.1 (21.9) 13.1 % -0.34 [ -0.72, 0.03 ]

Smeets 2006/2008 53 11.75 (5.81) 51 10.94 (5.66) 13.1 % 0.14 [ -0.24, 0.53 ]

Streibelt 2009 55 27.7 (16.5) 47 31.1 (16.5) 13.1 % -0.20 [ -0.59, 0.19 ]

Subtotal (95% CI) 439 413 100.0 % -0.85 [ -1.54, -0.16 ]



3 High baseline symptom intensity (>60% on pain % disability scale)

Monticone 2013 45 1.31 (1.59) 45 11 (2) 100.0 % -5.32 [ -6.21, -4.42 ]

Subtotal (95% CI) 45 45 100.0 % -5.32 [ -6.21, -4.42 ]



4 Low baseline symptom intensity (<60% on pain % disability scale)

Alaranta 1994 149 29.4 (23.5) 138 35.5 (24.8) 16.4 % -0.25 [ -0.48, -0.02 ]

-2 -1 0 1 2


(Continued . . . )



(. . . Continued)


Std.Mean

Difference Weight

Std.Mean

Difference


Henchoz 2010 49 26.2 (18) 25 38 (18.4) 9.5 % -0.64 [ -1.14, -0.15 ]

Kaapa 2006 53 18.9 (12.2) 54 18.5 (12.4) 12.3 % 0.03 [ -0.35, 0.41 ]

Mangels 2009 111 22.6 (16) 131 20.6 (13.5) 15.8 % 0.14 [ -0.12, 0.39 ]

Nicholas 1991 9 12.8 (8.62) 11 25.18 (8.08) 3.5 % -1.42 [ -2.43, -0.42 ]

Roche 2007/2011 64 31.4 (22.9) 49 39.1 (21.9) 12.4 % -0.34 [ -0.72, 0.03 ]

Smeets 2006/2008 53 11.75 (5.81) 51 10.94 (5.66) 12.1 % 0.14 [ -0.24, 0.53 ]

Streibelt 2009 55 27.7 (16.5) 47 31.1 (16.5) 12.0 % -0.20 [ -0.59, 0.19 ]

Turner 1990 14 4.75 (3.4) 16 4.73 (7.85) 6.0 % 0.00 [ -0.71, 0.72 ]

Subtotal (95% CI) 557 522 100.0 % -0.18 [ -0.38, 0.03 ]




Alaranta 1994 149 29.4 (23.5) 138 35.5 (24.8) 25.1 % -0.25 [ -0.48, -0.02 ]

Henchoz 2010 49 26.2 (18) 25 38 (18.4) 14.1 % -0.64 [ -1.14, -0.15 ]

Kaapa 2006 53 18.9 (12.2) 54 18.5 (12.4) 18.3 % 0.03 [ -0.35, 0.41 ]

Mangels 2009 111 22.6 (16) 131 20.6 (13.5) 24.1 % 0.14 [ -0.12, 0.39 ]

Roche 2007/2011 64 31.4 (22.9) 49 39.1 (21.9) 18.5 % -0.34 [ -0.72, 0.03 ]

Subtotal (95% CI) 426 397 100.0 % -0.18 [ -0.42, 0.07 ]




Monticone 2013 45 1.31 (1.59) 45 11 (2) 33.3 % -5.32 [ -6.21, -4.42 ]

Nicholas 1991 9 12.8 (8.62) 11 25.18 (8.08) 33.1 % -1.42 [ -2.43, -0.42 ]

Turner 1990 14 4.75 (3.4) 16 4.73 (7.85) 33.6 % 0.00 [ -0.71, 0.72 ]

Subtotal (95% CI) 68 72 100.0 % -2.24 [ -5.48, 1.00 ]




-2 -1 0 1 2





13 Work short term - all studies.



Outcome: 13 Work short term - all studies

Study or subgroup Multidisciplinary Physical Odds Ratio Weight Odds Ratio

n/N n/N

M-H,Random,95%

CI

M-H,Random,95%

CI

Jousset 2004 27/39 24/36 26.2 % 1.13 [ 0.43, 2.97 ]

Kool 2007 40/86 23/86 48.7 % 2.38 [ 1.26, 4.51 ]

Roche 2007/2011 59/68 55/64 25.2 % 1.07 [ 0.40, 2.90 ]

Total (95% CI) 193 186 100.0 % 1.60 [ 0.92, 2.78 ]

Total events: 126 (Multidisciplinary), 102 (Physical)




0.2 0.5 1 2 5





14 Work short term - sensitivity and subgroup analyses.



Outcome: 14 Work short term - sensitivity and subgroup analyses


n/N n/N

M-H,Random,95%

CI

M-H,Random,95%

CI

1 High quality 1 - 6 or more Risk of bias items

Kool 2007 40/86 23/86 61.9 % 2.38 [ 1.26, 4.51 ]

Roche 2007/2011 59/68 55/64 38.1 % 1.07 [ 0.40, 2.90 ]

Subtotal (95% CI) 154 150 100.0 % 1.76 [ 0.82, 3.76 ]





Kool 2007 40/86 23/86 61.9 % 2.38 [ 1.26, 4.51 ]

Roche 2007/2011 59/68 55/64 38.1 % 1.07 [ 0.40, 2.90 ]

Subtotal (95% CI) 154 150 100.0 % 1.76 [ 0.82, 3.76 ]










Jousset 2004 27/39 24/36 26.2 % 1.13 [ 0.43, 2.97 ]

Kool 2007 40/86 23/86 48.7 % 2.38 [ 1.26, 4.51 ]

Roche 2007/2011 59/68 55/64 25.2 % 1.07 [ 0.40, 2.90 ]

Subtotal (95% CI) 193 186 100.0 % 1.60 [ 0.92, 2.78 ]





Jousset 2004 27/39 24/36 51.2 % 1.13 [ 0.43, 2.97 ]

Roche 2007/2011 59/68 55/64 48.8 % 1.07 [ 0.40, 2.90 ]

0.2 0.5 1 2 5


(Continued . . . )



(. . . Continued)Study or subgroup Multidisciplinary Physical Odds Ratio Weight Odds Ratio

n/N n/N

M-H,Random,95%

CI

M-H,Random,95%

CI

Subtotal (95% CI) 107 100 100.0 % 1.10 [ 0.55, 2.20 ]










0.2 0.5 1 2 5



15 Work medium term - all studies.



Outcome: 15 Work medium term - all studies


n/N n/N

M-H,Random,95%

CI

M-H,Random,95%

CI

Bendix ’B’ 1995/1998 30/40 15/31 41.9 % 3.20 [ 1.17, 8.73 ]

Henchoz 2010 31/40 20/27 32.7 % 1.21 [ 0.39, 3.76 ]

Jousset 2004 38/42 33/41 25.5 % 2.30 [ 0.64, 8.35 ]

Total (95% CI) 122 99 100.0 % 2.14 [ 1.12, 4.10 ]





0.2 0.5 1 2 5





16 Work medium term - sensitivity and subgroup analyses.



Outcome: 16 Work medium term - sensitivity and subgroup analyses


n/N n/N

M-H,Random,95%

CI

M-H,Random,95%

CI







Henchoz 2010 31/40 20/27 100.0 % 1.21 [ 0.39, 3.76 ]

Subtotal (95% CI) 40 27 100.0 % 1.21 [ 0.39, 3.76 ]










Bendix ’B’ 1995/1998 30/40 15/31 41.9 % 3.20 [ 1.17, 8.73 ]

Henchoz 2010 31/40 20/27 32.7 % 1.21 [ 0.39, 3.76 ]

Jousset 2004 38/42 33/41 25.5 % 2.30 [ 0.64, 8.35 ]

Subtotal (95% CI) 122 99 100.0 % 2.14 [ 1.12, 4.10 ]





Bendix ’B’ 1995/1998 30/40 15/31 41.9 % 3.20 [ 1.17, 8.73 ]

Henchoz 2010 31/40 20/27 32.7 % 1.21 [ 0.39, 3.76 ]

Jousset 2004 38/42 33/41 25.5 % 2.30 [ 0.64, 8.35 ]

Subtotal (95% CI) 122 99 100.0 % 2.14 [ 1.12, 4.10 ]

0.2 0.5 1 2 5


(Continued . . . )




n/N n/N

M-H,Random,95%

CI

M-H,Random,95%

CI










0.2 0.5 1 2 5



17 Work long term - all studies.



Outcome: 17 Work long term - all studies


n/N n/N

M-H,Random,95%

CI

M-H,Random,95%

CI

Alaranta 1994 134/149 116/138 18.3 % 1.69 [ 0.84, 3.42 ]

Bendix ’B’ 1995/1998 34/38 18/31 5.7 % 6.14 [ 1.75, 21.60 ]

Bendix ’C’ 2000 36/48 35/51 11.6 % 1.37 [ 0.57, 3.31 ]

Henchoz 2010 31/40 21/27 6.6 % 0.98 [ 0.30, 3.18 ]

Kaapa 2006 33/53 30/54 15.1 % 1.32 [ 0.61, 2.86 ]

Kool 2007 49/82 35/84 23.6 % 2.08 [ 1.12, 3.86 ]

Roche 2007/2011 60/64 41/48 5.4 % 2.56 [ 0.70, 9.31 ]

Streibelt 2009 35/54 19/45 13.6 % 2.52 [ 1.12, 5.69 ]

0.2 0.5 1 2 5


(Continued . . . )




n/N n/N

M-H,Random,95%

CI

M-H,Random,95%

CI

Total (95% CI) 528 478 100.0 % 1.87 [ 1.39, 2.53 ]





0.2 0.5 1 2 5



18 Work long term - sensitivity and subgroup analyses.



Outcome: 18 Work long term - sensitivity and subgroup analyses


n/N n/N

M-H,Random,95%

CI

M-H,Random,95%

CI


Kaapa 2006 33/53 30/54 34.3 % 1.32 [ 0.61, 2.86 ]

Kool 2007 49/82 35/84 53.4 % 2.08 [ 1.12, 3.86 ]

Roche 2007/2011 60/64 41/48 12.3 % 2.56 [ 0.70, 9.31 ]

Subtotal (95% CI) 199 186 100.0 % 1.83 [ 1.16, 2.87 ]





Henchoz 2010 31/40 21/27 10.2 % 0.98 [ 0.30, 3.18 ]

Kaapa 2006 33/53 30/54 23.5 % 1.32 [ 0.61, 2.86 ]

Kool 2007 49/82 35/84 36.6 % 2.08 [ 1.12, 3.86 ]

Roche 2007/2011 60/64 41/48 8.4 % 2.56 [ 0.70, 9.31 ]

0.2 0.5 1 2 5


(Continued . . . )




n/N n/N

M-H,Random,95%

CI

M-H,Random,95%

CI

Streibelt 2009 35/54 19/45 21.2 % 2.52 [ 1.12, 5.69 ]

Subtotal (95% CI) 293 258 100.0 % 1.83 [ 1.26, 2.67 ]










Alaranta 1994 134/149 116/138 18.3 % 1.69 [ 0.84, 3.42 ]

Bendix ’B’ 1995/1998 34/38 18/31 5.7 % 6.14 [ 1.75, 21.60 ]

Bendix ’C’ 2000 36/48 35/51 11.6 % 1.37 [ 0.57, 3.31 ]

Henchoz 2010 31/40 21/27 6.6 % 0.98 [ 0.30, 3.18 ]

Kaapa 2006 33/53 30/54 15.1 % 1.32 [ 0.61, 2.86 ]

Kool 2007 49/82 35/84 23.6 % 2.08 [ 1.12, 3.86 ]

Roche 2007/2011 60/64 41/48 5.4 % 2.56 [ 0.70, 9.31 ]

Streibelt 2009 35/54 19/45 13.6 % 2.52 [ 1.12, 5.69 ]

Subtotal (95% CI) 528 478 100.0 % 1.87 [ 1.39, 2.53 ]





Alaranta 1994 134/149 116/138 26.9 % 1.69 [ 0.84, 3.42 ]

Bendix ’B’ 1995/1998 34/38 18/31 10.1 % 6.14 [ 1.75, 21.60 ]

Bendix ’C’ 2000 36/48 35/51 18.7 % 1.37 [ 0.57, 3.31 ]

Henchoz 2010 31/40 21/27 11.4 % 0.98 [ 0.30, 3.18 ]

Kaapa 2006 33/53 30/54 23.2 % 1.32 [ 0.61, 2.86 ]

Roche 2007/2011 60/64 41/48 9.6 % 2.56 [ 0.70, 9.31 ]

Subtotal (95% CI) 392 349 100.0 % 1.71 [ 1.13, 2.60 ]








0.2 0.5 1 2 5


(Continued . . . )




n/N n/N

M-H,Random,95%

CI

M-H,Random,95%

CI



0.2 0.5 1 2 5


A P P E N D I C E S

Appendix 1. Search strategies

MEDLINE

Ovid MEDLINE(R) <1946 to January Week 4 2014>, Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations <January 30,

2014>

1. randomized controlled trial.pt.

2. controlled clinical trial.pt.

3. randomized.ab.

4. placebo.ab,ti.

5. drug therapy.fs.

6. randomly.ab,ti.

7. trial.ab,ti.

8. groups.ab,ti.

9. or/1-8

10. (animals not (humans and animals)).sh.

11. 9 not 10

12. multidisciplinar$.mp.

13. interdisciplinar$.mp.

14. multiprofessional$.mp.

15. multimodal$.mp.

16. exp Patient Care Team/

17. exp Patient Care Management/

18. exp Patient Education/

19. exp Social Support/

20. exp Social Environment/

21. exp Pain Clinics/

22. (pain clinic$ or pain center$ or pain service$ or pain relief unit$ or pain centr$).mp.

23. exp Social Work/

24. exp Occupational Therapy/

25. exp Rehabilitation/ or exp Rehabilitation Centers/ or exp Rehabilitation, Vocational/

26. exp Treatment Outcome/



27. exp Behavior Therapy/

28. “Recovery of Function”/

29. functional restoration.mp.

30. *Pain/rh

31. or/12-30

32. exp Arthritis, Rheumatoid/

33. exp Neoplasms/

34. exp Musculoskeletal Diseases/cn, su [Congenital, Surgery]

35. exp Central Nervous System/

36. exp Central Nervous System Diseases/

37. exp Dentistry/

38. exp Tooth Diseases/

39. or/32-38

40. dorsalgia.ti,ab.

41. exp Back Pain/

42. backache.ti,ab.

43. (lumbar adj pain).ti,ab.

44. coccyx.ti,ab.

45. coccydynia.ti,ab.

46. sciatica.ti,ab.

47. sciatica/

48. spondylosis.ti,ab.

49. lumbago.ti,ab.

50. exp low back pain/

51. or/40-50

52. 51 and 11 and 31

53. 52 not 39

EMBASE

Embase <1980 to 2014 Week 10>

1. Clinical Article/

2. exp Clinical Study/

3. Clinical Trial/

4. Controlled Study/

5. Randomized Controlled Trial/

6. Major Clinical Study/

7. Double Blind Procedure/

8. Multicenter Study/

9. Single Blind Procedure/

10. Phase 3 Clinical Trial/

11. Phase 4 Clinical Trial/

12. crossover procedure/

13. placebo/

14. or/1-13

15. allocat$.mp.

16. assign$.mp.

17. blind$.mp.

18. (clinic$ adj25 (study or trial)).mp.

19. compar$.mp.

20. control$.mp.

21. cross?over.mp.

22. factorial$.mp.



23. follow?up.mp.

24. placebo$.mp.

25. prospectiv$.mp.

26. random$.mp.

27. ((singl$ or doubl$ or trebl$ or tripl$) adj25 (blind$ or mask$)).mp.

28. trial.mp.

29. (versus or vs).mp.

30. or/15-29

31. 14 or 30

32. exp animals/ or exp invertebrate/ or animal experiment/ or animal model/ or animal tissue/ or animal cell/ or nonhuman/

33. human/ or normal human/ or human cell/

34. 32 and 33

35. 32 not 34

36. 31 not 35

37. multidisciplinar$.mp.

38. interdisciplinar$.mp.

39. multiprofessional$.mp.

40. multimodal$.mp.

41. patient care team.mp.

42. exp Patient Care/

43. patient care management.mp.

44. exp Patient Education/

45. exp Social Support/

46. exp Social Environment/

47. exp Pain Clinic/

48. (pain clinic$ or pain center$ or pain service$ or pain relief unit$ or pain centre$).mp.

49. exp Occupational Therapy/

50. exp Social Work/

51. exp Vocational Rehabilitation/

52. exp Rehabilitation Center/

53. rehabilitation clinic$.mp.

54. exp REHABILITATION/

55. exp Treatment Outcome/

56. behavior therapy.mp. or exp Behavior Therapy/

57. or/37-56

58. exp Rheumatoid Arthritis/

59. exp NEOPLASM/

60. exp Musculoskeletal Disease/cn, su [Congenital Disorder, Surgery]

61. exp Central Nervous System/

62. exp Central Nervous System Disease/

63. exp Tooth Disease/

64. exp Musculoskeletal System Inflammation/

65. exp Musculoskeletal System Malformation/

66. exp HEADACHE/

67. exp Osteoarthritis/

68. or/58-67

69. 36 and 57

70. 69 not 68

71. dorsalgia.mp.

72. back pain.mp.

73. exp BACKACHE/

74. (lumbar adj pain).mp.

75. coccyx.mp.



76. coccydynia.mp.

77. sciatica.mp.

78. exp ISCHIALGIA/

79. spondylosis.mp.

80. lumbago.mp.

81. exp Low Back Pain/

82. or/71-81

83. 70 and 82

CENTRAL

#1 MeSH descriptor: [Back Pain] explode all trees

#2 dorsalgia

#3 backache

#4 MeSH descriptor: [Low Back Pain] explode all trees

#5 lumbar next pain OR coccyx OR coccydynia OR sciatica OR spondylosis

#6 MeSH descriptor: [Spine] explode all trees

#7 MeSH descriptor: [Spinal Diseases] explode all trees

#8 lumbago OR discitis OR disc near degeneration OR disc near prolapse OR disc near herniation

#9 spinal fusion

#10 spinal neoplasms

#11 facet near joints

#12 MeSH descriptor: [Intervertebral Disk] explode all trees

#13 postlaminectomy

#14 arachnoiditis

#15 failed near back

#16 MeSH descriptor: [Cauda Equina] explode all trees

#17 lumbar near vertebra*

#18 spinal near stenosis

#19 slipped near (disc* or disk*)

#20 degenerat* near (disc* or disk*)

#21 stenosis near (spine or root or spinal)

#22 displace* near (disc* or disk*)

#23 prolap* near (disc* or disk*)

#24 MeSH descriptor: [Sciatic Neuropathy] explode all trees

#25 sciatic*

#26 back disorder*

#27 back near pain

#28 #1 or #2 or #3 or #4 or #5 or #6 or #7 or #8 or #9 or #10 or #11 or #12 or #13 or #14 or #15 or #16 or #17 or #18 or #19 or #

20 or #21 or #22 or #23 or #24 or #25 or #26 or #27

#29 MeSH descriptor: [Patient Care Team] this term only

#30 MeSH descriptor: [Patient Care Management] explode all trees

#31 MeSH descriptor: [Comprehensive Health Care] explode all trees

#32 MeSH descriptor: [Pain Clinics] explode all trees

#33 multidisciplinary

#34 interdisciplinary

#35 multiprofessional

#36 multi-professional

#37 multimodal

#38 multi-modal

#39 pain clinic

#40 functional restoration

#41 biopsychosocial



#42 MeSH descriptor: [Patient Education as Topic] explode all trees

#43 MeSH descriptor: [Social Support] explode all trees

#44 MeSH descriptor: [Social Environment] explode all trees

#45 (pain clinic* or pain center* or pain service* or pain relief unit* or pain centr*)

#46 MeSH descriptor: [Social Work] explode all trees

#47 MeSH descriptor: [Occupational Therapy] explode all trees

#48 MeSH descriptor: [Rehabilitation, Vocational] explode all trees

#49 MeSH descriptor: [Rehabilitation Centers] explode all trees

#50 #29 or #30 or #31 or #32 or #33 or #34 or #35 or #36 or #37 or #38 or #39 or #40 or #41 or #42 or #43 or #44 or #45 or #46

or #47 or #48 or #49

#51 #28 and #50, in Trials

CINAHL

S86 S85 NOT S84

S85 S49 and S76

S84 S77 or S78 or S79 or S80 or S81 or S82 or S83

S83 (MH “Tooth Diseases+”)

S82 (MH “Dentistry+”)

S81 (MH “Central Nervous System Diseases+”)

S80 (MH “Central Nervous System+”)

S79 (MH “Musculoskeletal Diseases/FG/SU”)

S78 (MH “Neoplasms+”)

S77 (MH “Arthritis, Rheumatoid+”)

S76 S50 or S51 or S52 or S53 or S54 or S55 or S56 or S57 or S58

or S59 or S60 or S61 or S62 or S63 or S64 or S65 or S66 or S67 or S68

or S69 or S70 or S71 or S72 or S73 or S74 or S75

S75 (MH “Behavior Therapy+”)

S74 (MH “Treatment Outcomes+”)

S73 “rehabilitation clinic*”

S72 (MH “Rehabilitation Centers+”)

S71 (MH “Rehabilitation+”)

S70 (MH “Rehabilitation, Vocational+”)

S69 (MH “Occupational Therapy+”)

S68 (MH “Social Work+”)

S67 “pain relief unit*” 5

S66 “pain service*” 161

S65 “pain centre*” 21

S64 “pain center*” 141

S63 (MH “Pain Clinics”) 368

S62 (MH “Social Environment+”) 24,968

S61 (MH “Support, Psychosocial+”) 36,808

S60 (MH “Patient Education”) 37,325

S59 “patient care management” 81

S58 (MH “Patient Centered Care”) 11,891

S57 “patient care team” 63

S56 (MH “Combined Modality Therapy+”) 16,090

S55 “multimodal” 1,509

S54 multiprofessional 561

S53 (MH “Collaboration”)

S52 “interdisciplinary”

S51 “multidisciplinary”

S50 (MH “Multidisciplinary Care Team+”)



S49 S28 and S48

S48 S35 or S43 or S47

S47 S44 or S45 or S46

S46 “lumbago”

S45 (MH “Spondylolisthesis”) OR (MH “Spondylolysis”)

S44 (MH “Thoracic Vertebrae”)

S43 S36 or S37 or S38 or S39 or S40 or S41 or S42

S42 lumbar N2 vertebra

S41 (MH “Lumbar Vertebrae”)

S40 “coccydynia”

S39 “coccyx”

S38 “sciatica”

S37 (MH “Sciatica”)

S36 (MH “Coccyx”)

S35 S29 or S30 or S31 or S32 or S33 or S34

S34 lumbar N5 pain

S33 lumbar W1 pain

S32 “backache”

S31 (MH “Low Back Pain”)

S30 (MH “Back Pain+”)

S29 “dorsalgia”

S28 S26 NOT S27

S27 (MH “Animals”)

S26 S7 or S12 or S19 or S25

S25 S20 or S21 or S22 or S23 or S24

S24 volunteer*

S23 prospectiv*

S22 control*

S21 followup stud*

S20 follow-up stud*


S18 (MH “Prospective Studies+”)

S17 (MH “Evaluation Research+”)

S16 (MH “Comparative Studies”)

S15 latin square

S14 (MH “Study Design+”)

S13 (MH “Random Sample”)

S12 S8 or S9 or S10 or S11

S11 random*

S10 placebo*

S9 (MH “Placebos”)

S8 (MH “Placebo Effect”)


S6 triple-blind

S5 single-blind

S4 double-blind

S3 clinical W3 trial

S2 “randomi?ed controlled trial*”

S1 (MH “Clinical Trials+”)

PsycINFO

PsycINFO <2002 to January Week 3 2014>



1. clinical trials/

2. controlled trial.mp.

3. RCT.mp.

4. (Random* adj3 trial).mp.

5. (clin* adj3 trial).mp.

6. (sing* adj2 blind*).mp.

7. (doub* adj2 blind*).mp.

8. placebo.mp. or exp Placebo/

9. latin square.mp.

10. (random* adj2 assign*).mp.

11. prospective studies/

12. (prospective adj stud*).mp.

13. (comparative adj stud*).mp.

14. treatment effectiveness evaluation/

15. treatment effectiveness evaluation/

16. (evaluation adj stud*).mp.

17. exp Posttreatment Followup/

18. follow?up stud*.mp.

19. or/1-18

20. back pain/

21. lumbar spinal cord/

22. (low adj back adj pain).mp.

23. (back adj pain).mp.

24. spinal column/

25. (lumbar adj2 vertebra*).mp.

26. coccyx.mp.

27. sciatica.mp.

28. lumbago.mp.

29. dorsalgia.mp.

30. back disorder*.mp.

31. “back (anatomy)”/

32. ((disc or disk) adj degenerat*).mp.

33. ((disc or disk) adj herniat*).mp.

34. ((disc or disk) adj prolapse*).mp.

35. (failed adj back).mp.

36. or/20-35

37. 19 and 36

38. interdisciplinary treatment approach/

39. multimodal treatment approach/

40. multidisciplinary.mp.

41. patient care team.mp.

42. patient care management.mp.

43. client education/

44. Patient Education.mp.

45. social support/

46. Social Environments/

47. biopsychosocial approach/

48. pain clinic.mp.

49. pain center.mp.

50. pain centre.mp.

51. social casework/

52. exp case management/

53. occupational therapy/



54. rehabilitation centers/

55. exp vocational rehabilitation/

56. interdisciplinary.mp.

57. multiprofessional.mp.

58. or/38-57

59. 37 and 58

W H A T ’ S N E W

Last assessed as up-to-date: 1 January 2014.

Date Event Description

21 May 2014 New search has been performed Inclusion of 31 new RCTs since the previous version, this

enabled performance of several meta-analyses rather than

narrative descriptions of results only. Updated methods in-

cluded up-to-date risk of bias assessment and summary syn-

thesis of quality of evidence using the GRADE system

21 May 2014 New citation required and conclusions have changed The broad conclusions are in agreement with the previous

version in that MBR is effective compared to usual care and

non-MBR interventions for chronic LBP. This review pro-

vides quantification of the mean effect size and does not con-

firm the finding that more intensive interventions resulted

in larger effects. It is unlikely that conducting further RCTs

comparing MBR to usual care or physical treatments will

change our estimate of the effect of these interventions

H I S T O R Y

Protocol first published: Issue 3, 2000

Review first published: Issue 1, 2002

Date Event Description

24 June 2008 Amended Converted to new review format

3 February 2006 Amended Feb 3/06 - contact author informed that review will be

tagged as ’withdrawn’ in this month’s submission. It will

be re-instated once the update has been submitted and

approved for publication. Literature search last done in

1998. VEP

30 October 2001 New citation required and conclusions have changed Substantive amendment



C O N T R I B U T I O N S O F A U T H O R S

SK, MvT, RO, JG and RS planned the review and developed the protocol. SK, AA and AC screened titles and abstracts, SK and AA

performed the RoB assessments. SK and AC conducted the handsearches and extracted and checked the data. SK wrote the initial draft

of the manuscript and all authors critically reviewed successive drafts.

D E C L A R A T I O N S O F I N T E R E S T

MvT was involved in the conduct of one of the included studies (Lambeek 2010), and RS was involved in one of the included studies

(Smeets 2006/2008). They were not involved in the risk of bias assessment or data extraction.

S O U R C E S O F S U P P O R T

Internal sources

• National Health and Medical Research Council, Australia.

Fellowship for SK

External sources

• No sources of support supplied

D I F F E R E N C E S B E T W E E N P R O T O C O L A N D R E V I E W

Small changes were made to the inclusion criteria between this review and the previous version. This involved clarifying that interventions

must be delivered by a truly multidisciplinary team of practitioners with different clinical backgrounds relevant to the portion of the

intervention they delivered. The sensitivity and subgroup analyses described in the ’Methods’ section were devised after publication of

the previous version of the review but before commencement of searches for this review.

I N D E X T E R M S

Medical Subject Headings (MeSH)

Back Pain [psychology; ∗rehabilitation]; Chronic Disease; Occupational Therapy [methods]; Psychotherapy; Randomized Controlled

Trials as Topic; Social Support

MeSH check words

Humans



cochrane database of systematic reviews (reviews) || multidisciplinary biopsychosocial...

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