PAIN+ CPN

OBJECTIVE: To evaluate the effectiveness of combined biopsychosocial interventions compared with usual care, waiting-list controls, and active unimodal interventions in reducing pain and functional disability in adults with chronic low back pain (LBP), and to explore the consistency of effects across different intervention structures.

DATA SOURCES: A systematic search was conducted in PubMed/MEDLINE, Embase, Scopus, Web of Science, Cochrane Central Register of Controlled Trials, CINAHL, Physiotherapy Evidence Database, LILACS, and SciELO from inception to November 2025, including clinical trial registries.

STUDY SELECTION: Randomized controlled trials including adults (=18y) with nonspecific chronic LBP (=12wk). Interventions combined =2 components: exercise therapy, pain education, or psychological strategies.

DATA EXTRACTION: Two independent reviewers performed study selection, data extraction, and risk of bias assessment. Certainty of evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation.

DATA SYNTHESIS: Random-effects meta-analyses (Hedges g) included 28 randomized controlled trials (n=2521 participants). Interventions significantly reduced pain at short term (standardized mean difference [SMD]=-0.60; 95% CI, -0.81 to -0.38) and medium term (SMD=-0.49; 95% CI, -0.84 to -0.13), and disability at short term (SMD=-0.74; 95% CI, -1.03 to -0.46) and medium term (SMD=-0.45; 95% CI, -0.84 to -0.05). Kinesiophobia decreased in the short term but not in the medium term. Heterogeneity ranged from moderate to high (I²=66.8%-89.4%). Evidence certainty was moderate for most pain and disability outcomes and low for medium term kinesiophobia. No significant differences were found between integrated and structured interventions.

CONCLUSIONS: Combined biopsychosocial interventions reduce pain and disability in chronic LBP, particularly in the short term. The observed effects were generally small to moderate in magnitude and should be interpreted considering the variability of outcome measures and comparator interventions across studies. These findings support multimodal approaches, especially for patients with greater psychosocial complexity, while reinforcing the need for individualized treatment strategies.

Physician rater

High heterogeneity.

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