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Zhang J, Jiang N, Xu H, et al. Efficacy of cognitive functional therapy in patients with low back pain: A systematic review and meta-analysis. Int J Nurs Stud. 2024 Mar;151:104679. doi: 10.1016/j.ijnurstu.2023.104679. Epub 2023 Dec 28. (Systematic review)
Abstract

BACKGROUND: Low back pain is a major public health problem worldwide, and there exists evidence that cognitive functional therapy may help improve patients' health condition. However, the utilization of cognitive functional therapy for low back pain is limited, and its clinical efficacy remains unclear.

OBJECTIVES: To determine the efficacy of cognitive functional therapy in the management of disability, pain intensity, and fear-avoidance beliefs in low back pain patients.

DESIGN: Systematic review and meta-analysis.

METHOD: A comprehensive study search of Pubmed, Web of Science, Medline, CINAHL, Embase, PsycINFO, and the Cochrane Library databases was conducted from their inception to August 14th, 2023. Two researchers independently conducted the literature search and data extraction. All statistical analysis was performed using Stata Version 17.0.

RESULTS: A total of eight randomized controlled trials were included. In the short-term, cognitive functional therapy significantly improved disability (7 studies, SMD?=?-1.05, 95?% CI?=?-1.74 to -0.35, I2?=?95.37?%, GRADE?=?very low), pain intensity (7 studies, SMD?=?-1.02, 95?% CI?=?-1.89 to -0.15, I2?=?97.21?%, GRADE?=?very low), and fear-avoidance beliefs (4 studies, SMD?=?-0.89, 95?% CI?=?-1.30 to -0.47, I2?=?82.49?%, GRADE?=?very low). In the medium-term, cognitive functional therapy also significantly improved disability (3 studies, SMD?=?-0.48, 95?% CI?=?-0.82 to -0.14, I2?=?77.97?%, GRADE?=?very low), pain intensity (3 studies, SMD?=?-0.34, 95?% CI?=?-0.58 to -0.10, I2?=?55.55?%, GRADE?=?very low), and fear-avoidance beliefs (2 studies, SMD?=?-0.62, 95?% CI?=?-1.19 to -0.04, I2?=?88.24?%, GRADE?=?very low). In the long-term, cognitive functional therapy significantly improved disability (4 studies, SMD?=?-0.54, 95?% CI?=?-0.95 to -0.13, I2?=?85.87?%, GRADE?=?very low) and fear-avoidance beliefs (3 studies, SMD?=?-0.76, 95?% CI?=?-1.17 to -0.34, I2?=?80.34?%, GRADE?=?very low).

CONCLUSION: Cognitive functional therapy might be effective in reducing disability and fear-avoidance beliefs at any of short-, medium- and long-term follow-ups, and reducing pain at short- and medium-term follow-ups. No definitive conclusions can be drawn about the impact of cognitive functional therapy on low back pain patients due to the very low certainty evidence base. Additional rigorous randomized controlled trials are needed to further confirm these findings.

REGISTRATION NUMBER: CRD42022287123 (PROSPERO).

Ratings
Discipline Area Score
Psychologist 6 / 7
Physician 5 / 7
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  Back Pain   Chronic Low Back Pain
Comments from MORE raters

Physician rater

This paper focuses on a therapeutic approach to low-back pain that often does not respond well to other interventions. It shows benefit despite some limitations, so I believe it is useful for psychiatrists.

Psychologist rater

As a psychologist with a specialty in pain management and teaching students, I think it very important that the current evidence explicated in this meta-analysis should be interpreted and applied with caution. I agree with the authors who suggest that additional rigorous randomized controlled trials with larger samples are needed in the future to confirm the efficacy of cognitive functional therapy in low back pain patients. I also agree that there should be a focus on the mechanism of cognitive functional therapy. Finally, the authors' findings highlight the importance of cognitive functional therapy for patients with low back pain, indicating that medical institutions should increasingly focus on the comprehensive management of the entire biopsychosocial range.
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