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Cochrane Database of Systematic Reviews Review - Intervention

Multidisciplinary biopsychosocial rehabilitation for chronic low back pain

Authors' declarations of interest

Version published: 02 September 2014 Version history

https://doi.org/10.1002/14651858.CD000963.pub3
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Abstract

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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.

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.

PICOs

Population
Intervention
Comparison
Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

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 multidisciplinary 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.

Authors' conclusions

Implications for practice

Choosing an MBR intervention over usual care or a physical treatment 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 compared to physical treatment. However, given the moderate size of these effects and the potentially high cost of an intensive intervention, in terms of both the monetary and time burden, the decision to refer to MBR requires some consideration. While our subgroup 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 recommend assessment and treatment of physical and psychosocial factors and referral to appropriately trained clinicians for management 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 clinically 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, inconvenience 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 investigate 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 research 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, incorporation 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 companies must be addressed.

Summary of findings

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Summary of findings for the main comparison. Multidisciplinary compared to usual care for chronic low back pain

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 disabled.
Follow‐up: median 12 mth

# The baseline for the most representative
study is 11.4 out of 24

The mean disability long term in the MBR groups was
0.23 standard deviations lower
(0.4 to 0.06 lower)

722
(6 studies)

⊕⊕⊕⊝
moderate1

This is a small effect that may be clinically relevant in this patient group

Assumed risk*

Usual care

Corresponding risk

MBR

Relative effect
(95% CI)

Work long term
Proportion working
Follow‐up: median 12 mth

744 per 1000

751 per 1000
(679 to 810)

OR 1.04
(0.73 to 1.47)

1360
(7 studies)

⊕⊕⊕⊝
moderate1

This difference is not statistically or clinically relevant

Adverse events

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 (Von Korff 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 studies

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Summary of findings 2. Multidisciplinary compared to physical treatment for chronic low back pain

Multidisciplinary compared to physical treatment for chronic low back pain

Patient or population: Patients with chronic low back pain
Intervention: Multidisciplinary Biopsychosocial Rehabilitation
Comparison: Physical treatment

Outcomes

Baseline

Comparative effect (95% CI)

No. of participants
(studies)

Quality of the evidence
(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.
Follow‐up: median 12 mth

# The baseline for the most representative study is 4.5 out of 10

The mean pain long term in the MBR groups was
0.51 standard deviations lower
(1.04 lower to 0.01 higher)

872
(9 studies)

⊕⊕⊝⊝
low1,2

This is a moderate effect that is probably clinically relevant in this patient group

Disability long term
Various
Follow‐up: median 12 mth

# The baseline for the most representative study is 51 out of 100 on the Daily Activities subscale of the Dallas Questionnaire; 0 equals no disability and 100 is seriously disabled

The mean disability long term in the MBR groups was
0.68 standard deviations lower
(1.19 to 0.16 lower)

1169
(10 studies)

⊕⊕⊝⊝
low1,2

This is a moderate effect that is probably clinically relevant in this patient group

Assumed risk*

Physical treatment

Corresponding risk

MBR

Relative effect
(95% CI)

Work long term
Proportion working

Follow‐up: median 12 mth

659 per 1000

783 per 1000
(729 to 830)

OR 1.87
(1.39 to 2.53)

1006
(8 studies)

⊕⊕⊕⊝
moderate1

This is a moderate effect that is probably clinically relevant in this patient group

Adverse events

not estimable

not estimable

not estimable

0

No evidence

#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 studies
2 Substantial heterogeneity, I2 > 60%

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Summary of findings 3. Multidisciplinary compared to surgery for chronic low back pain

Multidisciplinary compared to surgery for chronic low back pain

Patient or population: Patients with chronic low back pain
Intervention: Multidisciplinary Biopsychosocial Rehabilitation
Comparison: Surgery

Outcomes

Baseline

Comparative effects (95% CI)

No. of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Pain long term
SF‐36 Pain subscale; where 100 equals pain‐free
Follow‐up: median 24 mth

# The baseline for the
most representative
study is 28.6 out of 100

The mean pain long term in the MBR groups was
0.25 standard deviations higher
(0.04 lower to 0.53 higher)

385
(2 studies)

⊕⊕⊝⊝
low1,2

This difference is not statistically or clinically relevant

Disability long term
Oswestry; 100‐point scale where 0 equals no disability and 100 is seriously disabled.
Follow‐up: median 24 mth

# The baseline for the most representative
study is 46.5 out of 100

The mean disability long term in the MBR groups was
0.25 standard deviations higher
(0.08 lower to 0.57 higher)

423
(2 studies)

⊕⊕⊝⊝
low1,3

This difference is not statistically or clinically relevant

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

This difference is not statistically or clinically relevant

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

#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 studies
2 Total sample size < 400
3 Substantial heterogeneity, I2 > 60%

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Summary of findings 4. Multidisciplinary compared to wait list for chronic low back pain

Multidisciplinary compared to wait list for chronic low back pain

Patient or population: Patients with chronic low back pain
Intervention: Multidisciplinary Biopsychosocial Rehabilitation
Comparison: Wait list

Outcomes

Assumed risk

Comparative effects (95% CI)

No. of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Pain long term

0‐100 Visual scale, where 0 equals no pain at all and 100 is the worst pain imaginable

# The baseline for the
most representative
study is 51.02 out of 100

not estimable

0

No evidence

Only short‐term results available for this comparison

Disability long term

Mostly Roland Morris 24‐point scale where 0 equals no disability at all and 24 is seriously disabled

# The baseline for the
most representative
study is 13.96 out of 24

not estimable

0

No evidence

Only short‐term results available for this comparison

Assumed risk

Wait List

Corresponding risk

MBR

Relative effect
(95% CI)

Work long term

not estimable

not estimable

not estimable

0

No evidence

Adverse events

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

Background

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 disability (Vos 2012). There is also a substantial societal burden, with costs attributable to healthcare services and to loss of work productivity running into the billions of dollars annually in many western countries (Maetzal 2002). Lifetime prevalence rates are high, approaching 70% to 80% according to some studies, and a significant 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 contention (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 educational 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 programs 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 multidisciplinary treatments on subacute back pain, however they identified only two studies that met their inclusion criteria. The previous version 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 biopsychosocial 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 biopsychosocial rehabilitation includes elements aimed at improving back‐related physical dysfunction as well as addressing psychological 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 participation 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 investment of substantial staffing and financial resources by the heathcare system. The indirect costs burden employers, insurance companies and patients as well. The value of MBR has often been questioned because data are lacking regarding its effectiveness and cost‐effectiveness (Smeets 2009). While two meta‐analyses on the effectiveness 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.

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.

Methods

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 patients 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. Trials that recruited patients with spinal pain at any level were included if > 75% of participants had LBP. Trials including participants 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 degeneration 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 component (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 professional 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, physiotherapists, social workers, occupational therapists and exercise therapists.

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 biopsychosocial 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 review 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 represent 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 between group differences were not synthesised.

Types of outcome measures

Patient‐centred outcomes formed the principle target for this review. 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 primary 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 published 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 relevant to the topic and studies included in this review. Citation tracking of included RCTs was also conducted using Science Citation Index. All articles included in the previous version of this review (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 independently by two authors (SK, AA) and disagreements were resolved 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 analysed 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 standard 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 methods, 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 Handbook for 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 calculating the pooled mean difference (MD) when the same instrument was used to measure outcomes, or the standardised mean difference (SMD) when different instruments were used. The uncertainty 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 comparability 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 Cochrane Handbook 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 for Systematic Reviews of Interventions), and graded down for precision where there were less than a total of 400 participants in the comparison (Guyatt 2011).

Subgroup analysis and investigation of heterogeneity

We conducted pre‐planned subgroup analyses based on the following 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.

Results

Description of studies

Results of the search

The electronic searches yielded a total of 6168 potentially eligible 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.

Study flow diagram.

Included studies

Most of the included studies were conducted in Europe (33 studies), 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 studies 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 insufficient 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 intervention 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, inclusion 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 different 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.

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.

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 assessors 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 compliance 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.

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

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

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

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

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.

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.

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.

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.

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.

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.

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.

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.

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.

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 Table 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 intensity. 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.

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.

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.

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.

Forest plot of comparison: 2 Multidisciplinary versus physical treatment, outcome: 2.4 Disability short term.

Figure 20
Forest plot of comparison: 2 Multidisciplinary versus physical treatment, outcome: 2.6 Disability long term.

Forest plot of comparison: 2 Multidisciplinary versus physical treatment, outcome: 2.6 Disability long term.

Figure 21
Forest plot of comparison: 2 Multidisciplinary versus physical treatment, outcome: 2.5 Disability medium term.

Forest plot of comparison: 2 Multidisciplinary versus physical treatment, outcome: 2.5 Disability 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.

Forest plot of comparison: 2 Multidisciplinary versus physical treatment, outcome: 2.7 Work short term.

Figure 23
Forest plot of comparison: 2 Multidisciplinary versus physical treatment, outcome: 2.8 Work medium term.

Forest plot of comparison: 2 Multidisciplinary versus physical treatment, outcome: 2.8 Work medium term.

Figure 24
Forest plot of comparison: 2 Multidisciplinary versus physical treatment, outcome: 2.9 Work long term.

Forest plot of comparison: 2 Multidisciplinary versus physical treatment, outcome: 2.9 Work 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 Table 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 instances 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. Statistical 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 second 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 overestimation 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 substantially larger than those for low intensity. Given these circumstances, the influence of baseline symptom intensity on the effect of MBR versus physical rehabilitation was unclear.

The low intensity interventions had substantially larger effect estimates 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 between 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 between MBR and surgery for pain (SMD of 0.25) (Figure 25), disability (SMD of 0.25) (Figure 26) or work; the quality of the evidence was low (summary of findings Table 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.

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.

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.

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 difference of 0.49 (SMD) (Figure 29) in the short term. These estimates 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.

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.

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 interventions. 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.

Discussion

Summary of main results

We set out to conduct an updated review on the impact of multidisciplinary 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 decreased pain and disability to a moderate degree but had little to no effect on work outcomes. When compared with physical rehabilitation, 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 programs.

Several factors need to be taken into account when interpreting our findings to formulate recommendations regarding clinical implementation. 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 symptom 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 included 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. Comparable 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 comparisons of MBR with surgery or waiting list controls. From each comparison a pooled estimate was generated for pain and disability at one time point. There was low quality evidence of no significant 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 of evidence

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 baseline 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 comprehensive 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).

Quality of the evidence

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 subjective 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 evident 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 further 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 interpretation of the biopsychosocial model and reflective of the different 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 treatment; differences in the settings; differences in the balance of the interventions in terms of focus on physical, psychological and social 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 control interventions. By using a random‐effects model for generating 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 recommended 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 other studies or reviews

Guzman 2006 reviewed the literature up to 1998 and found that intensive MBR programs had important effects on disability outcomes and small effects on pain. Evidence regarding work outcomes 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 conducted a systematic review of studies involving people with subacute or chronic LBP and included three studies with chronic LBP, all are in this review. Their meta‐analysis showed no effect on return to work for MBR interventions in the chronic LBP studies. It is somewhat surprising that the present review showed no impact 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 interventions 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 involved 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, employers 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 influence on the effect size. Individual RCTs conducted by Rose 1997 and Skouen 2002 reported no substantial differences in effect between 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.

Study flow diagram.
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Figure 1

Study flow diagram.

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Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

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

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Forest plot of comparison: 2 Multidisciplinary versus physical treatment, outcome: 2.2 Pain medium term.

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

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

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

Forest plot of comparison: 2 Multidisciplinary versus physical treatment, outcome: 2.4 Disability short term.

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Forest plot of comparison: 2 Multidisciplinary versus physical treatment, outcome: 2.6 Disability long term.
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Figure 20

Forest plot of comparison: 2 Multidisciplinary versus physical treatment, outcome: 2.6 Disability long term.

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Forest plot of comparison: 2 Multidisciplinary versus physical treatment, outcome: 2.5 Disability medium term.
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Figure 21

Forest plot of comparison: 2 Multidisciplinary versus physical treatment, outcome: 2.5 Disability medium term.

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

Forest plot of comparison: 2 Multidisciplinary versus physical treatment, outcome: 2.7 Work short term.

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Forest plot of comparison: 2 Multidisciplinary versus physical treatment, outcome: 2.8 Work medium term.
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Figure 23

Forest plot of comparison: 2 Multidisciplinary versus physical treatment, outcome: 2.8 Work medium term.

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Forest plot of comparison: 2 Multidisciplinary versus physical treatment, outcome: 2.9 Work long term.
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Figure 24

Forest plot of comparison: 2 Multidisciplinary versus physical treatment, outcome: 2.9 Work long term.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Comparison 2 MBR versus physical treatment, Outcome 19 Self‐efficacy short term.

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

Comparison 2 MBR versus physical treatment, Outcome 20 Self‐efficacy medium term.

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

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

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

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

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

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

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

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

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

Comparison 3 MBR versus surgery, Outcome 3 Work long term.

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

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

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

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

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

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

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

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

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

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

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

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

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

Comparison 5 MBR versus usual care, sensitivity and subgroup analyses, Outcome 1 Pain short term ‐ all studies.

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

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

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

Comparison 5 MBR versus usual care, sensitivity and subgroup analyses, Outcome 3 Pain medium term ‐ all studies.

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

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

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

Comparison 5 MBR versus usual care, sensitivity and subgroup analyses, Outcome 5 Pain long term ‐ all studies.

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

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

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

Comparison 5 MBR versus usual care, sensitivity and subgroup analyses, Outcome 7 Disability short term ‐ all analyses.

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

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

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

Comparison 5 MBR versus usual care, sensitivity and subgroup analyses, Outcome 9 Disability medium term ‐ all studies.

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

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

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

Comparison 5 MBR versus usual care, sensitivity and subgroup analyses, Outcome 11 Disability long term ‐ all studies.

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

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

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

Comparison 5 MBR versus usual care, sensitivity and subgroup analyses, Outcome 13 Work short term ‐ all studies.

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

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

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

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

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

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

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

Comparison 5 MBR versus usual care, sensitivity and subgroup analyses, Outcome 17 Work long term ‐ all studies.

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

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

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

Comparison 6 MBR versus physical treatment, sensitivity and subgroup analyses, Outcome 1 Pain short term ‐ all studies.

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

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

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

Comparison 6 MBR versus physical treatment, sensitivity and subgroup analyses, Outcome 3 Pain medium term ‐ all studies.

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

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

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

Comparison 6 MBR versus physical treatment, sensitivity and subgroup analyses, Outcome 5 Pain long term ‐ all studies.

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

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

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

Comparison 6 MBR versus physical treatment, sensitivity and subgroup analyses, Outcome 7 Disability short term ‐ all studies.

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

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

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Comparison 6 MBR versus physical treatment, sensitivity and subgroup analyses, Outcome 9 Disability medium term ‐ all studies.
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Analysis 6.9

Comparison 6 MBR versus physical treatment, sensitivity and subgroup analyses, Outcome 9 Disability medium term ‐ all studies.

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Comparison 6 MBR versus physical treatment, sensitivity and subgroup analyses, Outcome 10 Disability medium term ‐ sensitivity and subgroup analyses.
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Analysis 6.10

Comparison 6 MBR versus physical treatment, sensitivity and subgroup analyses, Outcome 10 Disability medium term ‐ sensitivity and subgroup analyses.

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Comparison 6 MBR versus physical treatment, sensitivity and subgroup analyses, Outcome 11 Disability long term ‐ all studies.
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Analysis 6.11

Comparison 6 MBR versus physical treatment, sensitivity and subgroup analyses, Outcome 11 Disability long term ‐ all studies.

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Comparison 6 MBR versus physical treatment, sensitivity and subgroup analyses, Outcome 12 Disability long term ‐ sensitivity and subgroup analyses.
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Analysis 6.12

Comparison 6 MBR versus physical treatment, sensitivity and subgroup analyses, Outcome 12 Disability long term ‐ sensitivity and subgroup analyses.

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

Comparison 6 MBR versus physical treatment, sensitivity and subgroup analyses, Outcome 13 Work short term ‐ all studies.

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

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

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Comparison 6 MBR versus physical treatment, sensitivity and subgroup analyses, Outcome 15 Work medium term ‐ all studies.
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Analysis 6.15

Comparison 6 MBR versus physical treatment, sensitivity and subgroup analyses, Outcome 15 Work medium term ‐ all studies.

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

Comparison 6 MBR versus physical treatment, sensitivity and subgroup analyses, Outcome 16 Work medium term ‐ sensitivity and subgroup analyses.

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Comparison 6 MBR versus physical treatment, sensitivity and subgroup analyses, Outcome 17 Work long term ‐ all studies.
Figures and Tables -
Analysis 6.17

Comparison 6 MBR versus physical treatment, sensitivity and subgroup analyses, Outcome 17 Work long term ‐ all studies.

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Comparison 6 MBR versus physical treatment, sensitivity and subgroup analyses, Outcome 18 Work long term ‐ sensitivity and subgroup analyses.
Figures and Tables -
Analysis 6.18

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

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Summary of findings for the main comparison. Multidisciplinary compared to usual care for chronic low back pain

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 disabled.
Follow‐up: median 12 mth

# The baseline for the most representative
study is 11.4 out of 24

The mean disability long term in the MBR groups was
0.23 standard deviations lower
(0.4 to 0.06 lower)

722
(6 studies)

⊕⊕⊕⊝
moderate1

This is a small effect that may be clinically relevant in this patient group

Assumed risk*

Usual care

Corresponding risk

MBR

Relative effect
(95% CI)

Work long term
Proportion working
Follow‐up: median 12 mth

744 per 1000

751 per 1000
(679 to 810)

OR 1.04
(0.73 to 1.47)

1360
(7 studies)

⊕⊕⊕⊝
moderate1

This difference is not statistically or clinically relevant

Adverse events

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 (Von Korff 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 studies

Figures and Tables -
Summary of findings for the main comparison. Multidisciplinary compared to usual care for chronic low back pain
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Summary of findings 2. Multidisciplinary compared to physical treatment for chronic low back pain

Multidisciplinary compared to physical treatment for chronic low back pain

Patient or population: Patients with chronic low back pain
Intervention: Multidisciplinary Biopsychosocial Rehabilitation
Comparison: Physical treatment

Outcomes

Baseline

Comparative effect (95% CI)

No. of participants
(studies)

Quality of the evidence
(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.
Follow‐up: median 12 mth

# The baseline for the most representative study is 4.5 out of 10

The mean pain long term in the MBR groups was
0.51 standard deviations lower
(1.04 lower to 0.01 higher)

872
(9 studies)

⊕⊕⊝⊝
low1,2

This is a moderate effect that is probably clinically relevant in this patient group

Disability long term
Various
Follow‐up: median 12 mth

# The baseline for the most representative study is 51 out of 100 on the Daily Activities subscale of the Dallas Questionnaire; 0 equals no disability and 100 is seriously disabled

The mean disability long term in the MBR groups was
0.68 standard deviations lower
(1.19 to 0.16 lower)

1169
(10 studies)

⊕⊕⊝⊝
low1,2

This is a moderate effect that is probably clinically relevant in this patient group

Assumed risk*

Physical treatment

Corresponding risk

MBR

Relative effect
(95% CI)

Work long term
Proportion working

Follow‐up: median 12 mth

659 per 1000

783 per 1000
(729 to 830)

OR 1.87
(1.39 to 2.53)

1006
(8 studies)

⊕⊕⊕⊝
moderate1

This is a moderate effect that is probably clinically relevant in this patient group

Adverse events

not estimable

not estimable

not estimable

0

No evidence

#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 studies
2 Substantial heterogeneity, I2 > 60%

Figures and Tables -
Summary of findings 2. Multidisciplinary compared to physical treatment for chronic low back pain
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Summary of findings 3. Multidisciplinary compared to surgery for chronic low back pain

Multidisciplinary compared to surgery for chronic low back pain

Patient or population: Patients with chronic low back pain
Intervention: Multidisciplinary Biopsychosocial Rehabilitation
Comparison: Surgery

Outcomes

Baseline

Comparative effects (95% CI)

No. of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Pain long term
SF‐36 Pain subscale; where 100 equals pain‐free
Follow‐up: median 24 mth

# The baseline for the
most representative
study is 28.6 out of 100

The mean pain long term in the MBR groups was
0.25 standard deviations higher
(0.04 lower to 0.53 higher)

385
(2 studies)

⊕⊕⊝⊝
low1,2

This difference is not statistically or clinically relevant

Disability long term
Oswestry; 100‐point scale where 0 equals no disability and 100 is seriously disabled.
Follow‐up: median 24 mth

# The baseline for the most representative
study is 46.5 out of 100

The mean disability long term in the MBR groups was
0.25 standard deviations higher
(0.08 lower to 0.57 higher)

423
(2 studies)

⊕⊕⊝⊝
low1,3

This difference is not statistically or clinically relevant

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

This difference is not statistically or clinically relevant

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

#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 studies
2 Total sample size < 400
3 Substantial heterogeneity, I2 > 60%

Figures and Tables -
Summary of findings 3. Multidisciplinary compared to surgery for chronic low back pain
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Summary of findings 4. Multidisciplinary compared to wait list for chronic low back pain

Multidisciplinary compared to wait list for chronic low back pain

Patient or population: Patients with chronic low back pain
Intervention: Multidisciplinary Biopsychosocial Rehabilitation
Comparison: Wait list

Outcomes

Assumed risk

Comparative effects (95% CI)

No. of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Pain long term

0‐100 Visual scale, where 0 equals no pain at all and 100 is the worst pain imaginable

# The baseline for the
most representative
study is 51.02 out of 100

not estimable

0

No evidence

Only short‐term results available for this comparison

Disability long term

Mostly Roland Morris 24‐point scale where 0 equals no disability at all and 24 is seriously disabled

# The baseline for the
most representative
study is 13.96 out of 24

not estimable

0

No evidence

Only short‐term results available for this comparison

Assumed risk

Wait List

Corresponding risk

MBR

Relative effect
(95% CI)

Work long term

not estimable

not estimable

not estimable

0

No evidence

Adverse events

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

Figures and Tables -
Summary of findings 4. Multidisciplinary compared to wait list for chronic low back pain
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Comparison 1. MBR versus usual care

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Back pain short term Show forest plot

9

879

Std. Mean Difference (IV, Random, 95% CI)

‐0.55 [‐0.83, ‐0.28]

2 Back pain medium term Show forest plot

6

740

Std. Mean Difference (IV, Random, 95% CI)

‐0.60 [‐0.85, ‐0.34]

3 Back pain long term Show forest plot

7

821

Std. Mean Difference (IV, Random, 95% CI)

‐0.21 [‐0.37, ‐0.04]

4 Disability short term Show forest plot

9

939

Std. Mean Difference (IV, Random, 95% CI)

‐0.41 [‐0.62, ‐0.19]

5 Disability medium term Show forest plot

6

786

Std. Mean Difference (IV, Random, 95% CI)

‐0.43 [‐0.66, ‐0.19]

6 Disability long term Show forest plot

6

722

Std. Mean Difference (IV, Random, 95% CI)

‐0.23 [‐0.40, ‐0.06]

7 Work short term Show forest plot

2

373

Odds Ratio (M‐H, Random, 95% CI)

1.07 [0.60, 1.90]

8 Work medium term Show forest plot

3

457

Odds Ratio (M‐H, Random, 95% CI)

1.60 [0.52, 4.91]

9 Work long term Show forest plot

7

1360

Odds Ratio (M‐H, Random, 95% CI)

1.04 [0.73, 1.47]

10 QoL SF36 PCS short term Show forest plot

2

144

Mean Difference (IV, Random, 95% CI)

13.45 [‐9.07, 35.96]

11 QoL SF36 MCS short term Show forest plot

2

144

Mean Difference (IV, Random, 95% CI)

15.25 [2.05, 28.44]

12 QoL SF36 PCS medium term Show forest plot

2

144

Mean Difference (IV, Random, 95% CI)

7.41 [‐4.99, 19.81]

13 QoL SF36 MCS medium term Show forest plot

2

144

Mean Difference (IV, Random, 95% CI)

7.59 [1.69, 13.49]

14 Catastrophising short term Show forest plot

2

99

Std. Mean Difference (IV, Random, 95% CI)

‐0.43 [‐0.83, ‐0.03]

15 Catastrophising long term Show forest plot

2

127

Std. Mean Difference (IV, Random, 95% CI)

‐0.40 [‐0.76, ‐0.05]

16 Fear avoidance short term Show forest plot

2

253

Std. Mean Difference (IV, Random, 95% CI)

‐0.69 [‐1.52, 0.14]

17 Fear avoidance long term Show forest plot

3

371

Std. Mean Difference (IV, Random, 95% CI)

‐0.29 [‐0.49, ‐0.08]
Figures and Tables -
Comparison 1. MBR versus usual care
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Comparison 2. MBR versus physical treatment

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Pain short term Show forest plot

12

1661

Std. Mean Difference (IV, Random, 95% CI)

‐0.30 [‐0.54, ‐0.06]

2 Pain medium term Show forest plot

9

531

Std. Mean Difference (IV, Random, 95% CI)

‐0.28 [‐0.54, ‐0.02]

3 Pain long term Show forest plot

9

872

Std. Mean Difference (IV, Random, 95% CI)

‐0.51 [‐1.04, 0.01]

4 Disability short term Show forest plot

13

1878

Std. Mean Difference (IV, Random, 95% CI)

‐0.39 [‐0.68, ‐0.10]

5 Disability medium term Show forest plot

9

511

Std. Mean Difference (IV, Random, 95% CI)

‐0.21 [‐0.48, 0.06]

6 Disability long term Show forest plot

10

1169

Std. Mean Difference (IV, Random, 95% CI)

‐0.68 [‐1.19, ‐0.16]

7 Work short term Show forest plot

3

379

Odds Ratio (M‐H, Random, 95% CI)

1.60 [0.92, 2.78]

8 Work medium term Show forest plot

3

221

Odds Ratio (M‐H, Random, 95% CI)

2.14 [1.12, 4.10]

9 Work long term Show forest plot

8

1006

Odds Ratio (M‐H, Random, 95% CI)

1.87 [1.39, 2.53]

10 QoL short term Show forest plot

3

568

Std. Mean Difference (IV, Random, 95% CI)

‐0.04 [‐0.34, 0.26]

11 Quality of Life medium term Show forest plot

2

342

Std. Mean Difference (IV, Random, 95% CI)

0.20 [‐0.12, 0.51]

12 Healthcare visits long term Show forest plot

2

226

Std. Mean Difference (IV, Random, 95% CI)

‐0.06 [‐0.32, 0.20]

13 Depression short term Show forest plot

7

911

Std. Mean Difference (IV, Random, 95% CI)

0.05 [‐0.12, 0.22]

14 Depression medium term Show forest plot

7

411

Std. Mean Difference (IV, Random, 95% CI)

‐0.16 [‐0.42, 0.09]

15 Depression long term Show forest plot

5

506

Std. Mean Difference (IV, Random, 95% CI)

‐0.05 [‐0.40, 0.30]

16 Coping short term Show forest plot

3

282

Std. Mean Difference (IV, Random, 95% CI)

0.22 [‐0.02, 0.45]

17 Coping medium term Show forest plot

2

40

Std. Mean Difference (IV, Random, 95% CI)

1.09 [0.31, 1.87]

18 Coping long term Show forest plot

2

262

Std. Mean Difference (IV, Random, 95% CI)

0.30 [0.06, 0.54]

19 Self‐efficacy short term Show forest plot

3

432

Std. Mean Difference (IV, Random, 95% CI)

0.27 [‐0.08, 0.61]

20 Self‐efficacy medium term Show forest plot

2

58

Std. Mean Difference (IV, Random, 95% CI)

0.26 [‐0.40, 0.92]

21 Anxiety short term Show forest plot

2

377

Std. Mean Difference (IV, Random, 95% CI)

‐0.10 [‐0.67, 0.47]

22 Anxiety medium term Show forest plot

2

51

Std. Mean Difference (IV, Random, 95% CI)

‐0.40 [‐1.80, 1.00]
Figures and Tables -
Comparison 2. MBR versus physical treatment
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Comparison 3. MBR versus surgery

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Pain long term Show forest plot

2

385

Std. Mean Difference (IV, Random, 95% CI)

‐0.25 [‐0.53, 0.04]

2 Disability long term Show forest plot

2

423

Std. Mean Difference (IV, Random, 95% CI)

0.25 [‐0.08, 0.57]

3 Work long term Show forest plot

1

133

Odds Ratio (M‐H, Random, 95% CI)

0.67 [0.31, 1.45]

4 Adverse events/complications Show forest plot

2

385

Odds Ratio (M‐H, Fixed, 95% CI)

28.25 [3.77, 211.93]

5 QoL SF36 PCS long term Show forest plot

2

385

Std. Mean Difference (IV, Random, 95% CI)

‐0.28 [‐0.70, 0.14]

6 QoL SF36 MCS long term Show forest plot

2

385

Std. Mean Difference (IV, Random, 95% CI)

‐0.03 [‐0.25, 0.19]
Figures and Tables -
Comparison 3. MBR versus surgery
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Comparison 4. MBR versus wait list

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Pain short term Show forest plot

3

213

Std. Mean Difference (IV, Random, 95% CI)

‐0.73 [‐1.22, ‐0.24]

2 Disability short term Show forest plot

3

213

Std. Mean Difference (IV, Random, 95% CI)

‐0.49 [‐0.76, ‐0.22]

3 Depression short term Show forest plot

3

213

Std. Mean Difference (IV, Random, 95% CI)

‐0.21 [‐0.59, 0.18]
Figures and Tables -
Comparison 4. MBR versus wait list
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Comparison 5. MBR versus usual care, sensitivity and subgroup analyses

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Pain short term ‐ all studies Show forest plot

9

879

Std. Mean Difference (IV, Random, 95% CI)

‐0.55 [‐0.83, ‐0.28]

2 Pain short term ‐ sensitivity and subgroup analyses Show forest plot

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

4

431

Std. Mean Difference (IV, Fixed, 95% CI)

‐0.71 [‐0.91, ‐0.51]

2.3 High baseline symptom intensity (>60% on pain & disability scales)

1

122

Std. Mean Difference (IV, Fixed, 95% CI)

‐0.66 [‐1.03, ‐0.30]

2.4 Low baseline symptom intensity (<60% on pain & disability scales)

8

757

Std. Mean Difference (IV, Fixed, 95% CI)

‐0.44 [‐0.59, ‐0.30]

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)

6

477

Std. Mean Difference (IV, Fixed, 95% CI)

‐0.42 [‐0.61, ‐0.24]

3 Pain medium term ‐ all studies Show forest plot

6

740

Std. Mean Difference (IV, Random, 95% CI)

‐0.60 [‐0.85, ‐0.34]

4 Pain medium term ‐ sensitivity and subgroup analyses Show forest plot

6

Std. Mean Difference (IV, Random, 95% CI)

Subtotals only

4.1 High quality 1 ‐ 6 or more Risk of Bias items

2

306

Std. Mean Difference (IV, Random, 95% CI)

‐0.49 [‐0.72, ‐0.26]

4.2 High quality 2 ‐ Concealed allocation

4

426

Std. Mean Difference (IV, Random, 95% CI)

‐0.73 [‐1.07, ‐0.39]

4.3 High baseline symptom intensity (>60% on pain & disability scales)

1

118

Std. Mean Difference (IV, Random, 95% CI)

‐0.49 [‐0.86, ‐0.12]

4.4 Low baseline symptom intensity (<60% on pain & disability scales)

5

622

Std. Mean Difference (IV, Random, 95% CI)

‐0.64 [‐0.96, ‐0.32]

4.5 High intervention intensity (>100 hours, daily contact)

1

94

Std. Mean Difference (IV, Random, 95% CI)

‐0.57 [‐0.98, ‐0.15]

4.6 Low intervention intensity (<30 hours, non‐daily contact)

4

458

Std. Mean Difference (IV, Random, 95% CI)

‐0.68 [‐1.12, ‐0.25]

5 Pain long term ‐ all studies Show forest plot

7

821

Std. Mean Difference (IV, Random, 95% CI)

‐0.21 [‐0.37, ‐0.04]

6 Pain long term ‐ sensitivity and subgroup analyses Show forest plot

7

Std. Mean Difference (IV, Random, 95% CI)

Subtotals only

6.1 High quality 1 ‐ 6 or more Risk of Bias items

2

142

Std. Mean Difference (IV, Random, 95% CI)

‐0.14 [‐0.47, 0.19]

6.2 High quality 2 ‐ Concealed allocation

2

236

Std. Mean Difference (IV, Random, 95% CI)

‐0.18 [‐0.45, 0.09]

6.3 High baseline symptom intensity (>60% on pain & disability scales)

1

119

Std. Mean Difference (IV, Random, 95% CI)

‐0.11 [‐0.47, 0.24]

6.4 Low baseline symptom intensity (<60% on pain & disability scales)

6

702

Std. Mean Difference (IV, Random, 95% CI)

‐0.23 [‐0.42, ‐0.03]

6.5 High intervention intensity (>100 hours, daily contact)

2

216

Std. Mean Difference (IV, Random, 95% CI)

‐0.24 [‐0.52, 0.04]

6.6 Low intervention intensity (<30 hours, non‐daily contact)

4

447

Std. Mean Difference (IV, Random, 95% CI)

‐0.31 [‐0.50, ‐0.12]

7 Disability short term ‐ all analyses Show forest plot

9

939

Std. Mean Difference (IV, Random, 95% CI)

‐0.41 [‐0.62, ‐0.19]

8 Disability short term ‐ sensitivity and subgroup analyses Show forest plot

9

Std. Mean Difference (IV, Random, 95% CI)

Subtotals only

8.1 High quality 1 ‐ 6 more or Risk of Bias items

4

485

Std. Mean Difference (IV, Random, 95% CI)

‐0.31 [‐0.71, 0.08]

8.2 High quality 2 ‐ Concealed allocation

5

582

Std. Mean Difference (IV, Random, 95% CI)

‐0.55 [‐0.80, ‐0.30]

8.3 High baseline symptom intensity (>60% on pain & disability scales)

1

122

Std. Mean Difference (IV, Random, 95% CI)

‐0.79 [‐1.16, ‐0.42]

8.4 Low baseline symptom intensity (<60% on pain & disability scales)

8

817

Std. Mean Difference (IV, Random, 95% CI)

‐0.35 [‐0.56, ‐0.13]

8.5 High intervention intensity (>100 hours, daily contact)

0

0

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

8.6 Low intervention intensity (<30 hours, non‐daily contact)

7

599

Std. Mean Difference (IV, Random, 95% CI)

‐0.43 [‐0.75, ‐0.11]

9 Disability medium term ‐ all studies Show forest plot

6

786

Std. Mean Difference (IV, Random, 95% CI)

‐0.43 [‐0.66, ‐0.19]

10 Disability medium term ‐ sensitivity and subgroup analyses Show forest plot

6

Std. Mean Difference (IV, Random, 95% CI)

Subtotals only

10.1 High quality 1 ‐ 6 or more Risk of Bias items

3

446

Std. Mean Difference (IV, Random, 95% CI)

‐0.38 [‐0.63, ‐0.12]

10.2 High quality 2 ‐ Concealed allocation

5

566

Std. Mean Difference (IV, Random, 95% CI)

‐0.50 [‐0.76, ‐0.25]

10.3 High baseline symptom intensity (>60% on pain & disability scales)

1

118

Std. Mean Difference (IV, Random, 95% CI)

‐0.67 [‐1.04, ‐0.30]

10.4 Low baseline symptom intensity (<60% on pain & disability scales)

5

668

Std. Mean Difference (IV, Random, 95% CI)

‐0.37 [‐0.62, ‐0.13]

10.5 High intervention intensity (>100 hours, daily contact)

0

0

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

10.6 Low intervention intensity (<30 hours, non‐daily contact)

4

458

Std. Mean Difference (IV, Random, 95% CI)

‐0.56 [‐0.95, ‐0.18]

11 Disability long term ‐ all studies Show forest plot

6

722

Std. Mean Difference (IV, Random, 95% CI)

‐0.23 [‐0.40, ‐0.06]

12 Disability long term ‐ sensitivity and subgroup analyses Show forest plot

6

Std. Mean Difference (IV, Random, 95% CI)

Subtotals only

12.1 High quality 1 ‐ 6 or more Risk of Bias items

2

142

Std. Mean Difference (IV, Random, 95% CI)

‐0.45 [‐0.78, ‐0.11]

12.2 High quality 2 ‐ Concealed allocation

2

236

Std. Mean Difference (IV, Random, 95% CI)

‐0.50 [‐0.77, ‐0.23]

12.3 High baseline symptom intensity (>60% on pain & disability scales)

1

119

Std. Mean Difference (IV, Random, 95% CI)

‐0.49 [‐0.85, ‐0.12]

12.4 Low baseline symptom intensity (<60% on pain & disability scales)

5

603

Std. Mean Difference (IV, Random, 95% CI)

‐0.17 [‐0.34, ‐0.01]

12.5 High intervention intensity (>100 hours, daily contact)

1

117

Std. Mean Difference (IV, Random, 95% CI)

‐0.52 [‐0.92, ‐0.13]

12.6 Low intervention intensity (<30 hours, non‐daily contact)

4

447

Std. Mean Difference (IV, Random, 95% CI)

‐0.22 [‐0.41, ‐0.03]

13 Work short term ‐ all studies Show forest plot

2

373

Odds Ratio (M‐H, Fixed, 95% CI)

1.07 [0.60, 1.90]

14 Work short term ‐ sensitivity and subgroup analyses Show forest plot

2

Odds Ratio (M‐H, Random, 95% CI)

Subtotals only

14.1 High quality 1 ‐ 6 or more Risk of Bias items

0

0

Odds Ratio (M‐H, Random, 95% CI)

0.0 [0.0, 0.0]

14.2 High quality 2 ‐ Concealed allocation

1

143

Odds Ratio (M‐H, Random, 95% CI)

1.14 [0.58, 2.24]

14.3 High baseline symptom intensity (>60% on pain & disability scales)

0

0

Odds Ratio (M‐H, Random, 95% CI)

0.0 [0.0, 0.0]

14.4 Low baseline symptom intensity (<60% on pain & disability scales)

1

230

Odds Ratio (M‐H, Random, 95% CI)

0.91 [0.31, 2.69]

14.5 High intervention volume (>100 hours, daily contact)

1

143

Odds Ratio (M‐H, Random, 95% CI)

1.14 [0.58, 2.24]

14.6 Low intervention volume (<30 hours, non‐daily contact)

1

230

Odds Ratio (M‐H, Random, 95% CI)

0.91 [0.31, 2.69]

15 Work medium term all studies Show forest plot

3

457

Odds Ratio (M‐H, Random, 95% CI)

1.60 [0.52, 4.91]

16 Work medium term ‐ sensitivity and subgroup analyses Show forest plot

3

Odds Ratio (M‐H, Random, 95% CI)

Subtotals only

16.1 High quality 1 ‐ 6 or more Risk of Bias items

0

0

Odds Ratio (M‐H, Random, 95% CI)

0.0 [0.0, 0.0]

16.2 High quality 2 ‐ Concealed allocation

1

143

Odds Ratio (M‐H, Random, 95% CI)

1.66 [0.84, 3.26]

16.3 High baseline symptom intensity (>60% on pain & disability scales)

0

0

Odds Ratio (M‐H, Random, 95% CI)

0.0 [0.0, 0.0]

16.4 Low baseline symptom intensity (<60% on pain & disability scales)

2

314

Odds Ratio (M‐H, Random, 95% CI)

1.51 [0.17, 13.75]

16.5 High intervention volume (>100 hours, daily contact)

2

237

Odds Ratio (M‐H, Random, 95% CI)

2.64 [0.99, 7.04]

16.6 Low intervention volume (<30 hours, non‐daily contact)

1

220

Odds Ratio (M‐H, Random, 95% CI)

0.48 [0.16, 1.44]

17 Work long term ‐ all studies Show forest plot

7

1360

Odds Ratio (M‐H, Random, 95% CI)

1.04 [0.73, 1.47]

18 Work long term ‐ sensitivity and subgroup analyses Show forest plot

7

Odds Ratio (M‐H, Random, 95% CI)

Subtotals only

18.1 High quality 1 ‐ 6 or more Risk of Bias items

0

0

Odds Ratio (M‐H, Random, 95% CI)

0.0 [0.0, 0.0]

18.2 High quality 2 ‐ Concealed allocation

2

260

Odds Ratio (M‐H, Random, 95% CI)

1.10 [0.39, 3.11]

18.3 High baseline symptom intensity (>60% on pain & disability scales)

0

0

Odds Ratio (M‐H, Random, 95% CI)

0.0 [0.0, 0.0]

18.4 Low baseline symptom intensity (<60% on pain & disability scales)

5

675

Odds Ratio (M‐H, Random, 95% CI)

0.86 [0.54, 1.36]

18.5 High intervention volume (>100 hours, daily contact)

4

901

Odds Ratio (M‐H, Random, 95% CI)

1.09 [0.76, 1.58]

18.6 Low intervention volume (<30 hours, non‐daily contact)

2

301

Odds Ratio (M‐H, Random, 95% CI)

1.11 [0.20, 6.22]
Figures and Tables -
Comparison 5. MBR versus usual care, sensitivity and subgroup analyses
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Comparison 6. MBR versus physical treatment, sensitivity and subgroup analyses

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Pain short term ‐ all studies Show forest plot

11

1352

Std. Mean Difference (IV, Random, 95% CI)

‐0.29 [‐0.57, ‐0.01]

2 Pain short term ‐ sensitivity and subgroup analyses Show forest plot

11

Std. Mean Difference (IV, Random, 95% CI)

Subtotals only

2.1 High quality 1 ‐ 6 or more Risk of Bias items

6

860

Std. Mean Difference (IV, Random, 95% CI)

‐0.41 [‐0.85, 0.03]

2.2 High quality 2 ‐ Concealed allocation

10

1313

Std. Mean Difference (IV, Random, 95% CI)

‐0.29 [‐0.59, ‐0.00]

2.3 High baseline symptom intensity (>60% on pain & disability scales)

2

453

Std. Mean Difference (IV, Random, 95% CI)

‐1.06 [‐2.86, 0.74]

2.4 Low baseline symptom intensity (<60% on pain & disability scales)

9

899

Std. Mean Difference (IV, Random, 95% CI)

‐0.13 [‐0.26, 0.00]

2.5 High intervention intensity 1 (>100 hours, daily contact)

4

856

Std. Mean Difference (IV, Random, 95% CI)

‐0.11 [‐0.24, 0.02]

2.6 Low intervention intensity 1 (<30 hours, non‐daily contact)

5

219

Std. Mean Difference (IV, Random, 95% CI)

‐0.51 [‐1.44, 0.41]

3 Pain medium term ‐ all studies Show forest plot

9

531

Std. Mean Difference (IV, Random, 95% CI)

‐0.28 [‐0.54, ‐0.02]

4 Pain medium term ‐ sensitivity and subgroup analyses Show forest plot

9

Std. Mean Difference (IV, Random, 95% CI)

Subtotals only

4.1 High quality 1 ‐ 6 or more Risk of Bias items

2

223

Std. Mean Difference (IV, Random, 95% CI)

0.02 [‐0.24, 0.29]

4.2 High quality 2 ‐ Concealed allocation

5

308

Std. Mean Difference (IV, Random, 95% CI)

‐0.25 [‐0.69, 0.19]

4.3 High baseline symptom intensity (>60% on pain & disability scales)

0

0

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

4.4 Low baseline symptom intensity (<60% on pain & disability scales)

9

531

Std. Mean Difference (IV, Random, 95% CI)

‐0.28 [‐0.54, ‐0.02]

4.5 High intervention intensity 1 (>100 hours, daily contact)

3

273

Std. Mean Difference (IV, Random, 95% CI)

‐0.32 [‐0.68, 0.04]

4.6 Low intervention intensity 1 (<30 hours, non‐daily contact)

5

154

Std. Mean Difference (IV, Random, 95% CI)

‐0.39 [‐0.88, 0.10]

5 Pain long term ‐ all studies Show forest plot

9

872

Std. Mean Difference (IV, Random, 95% CI)

‐0.51 [‐1.04, 0.01]

6 Pain long term ‐ sensitivity and subgroup analyses Show forest plot

9

Std. Mean Difference (IV, Random, 95% CI)

Subtotals only

6.1 High quality 1 ‐ 6 or more Risk of Bias items

5

655

Std. Mean Difference (IV, Random, 95% CI)

‐0.66 [‐1.50, 0.17]

6.2 High quality 2 ‐ Concealed allocation

6

675

Std. Mean Difference (IV, Random, 95% CI)

‐0.65 [‐1.41, 0.10]

6.3 High baseline symptom intensity (>60% on pain & disability scales)

1

90

Std. Mean Difference (IV, Random, 95% CI)

‐3.41 [‐4.07, ‐2.76]

6.4 Low baseline symptom intensity (<60% on pain & disability scales)

8

782

Std. Mean Difference (IV, Random, 95% CI)

‐0.15 [‐0.37, 0.06]

6.5 High intervention intensity 1 (>100 hours, daily contact)

5

628

Std. Mean Difference (IV, Random, 95% CI)

‐0.23 [‐0.45, ‐0.01]

6.6 Low intervention intensity 1 (<30 hours, non‐daily contact)

3

140

Std. Mean Difference (IV, Random, 95% CI)

‐1.25 [‐3.64, 1.13]

7 Disability short term ‐ all studies Show forest plot

13

1878

Std. Mean Difference (IV, Random, 95% CI)

‐0.39 [‐0.68, ‐0.10]

8 Disability short term ‐ sensitivity and subgroup analyses Show forest plot

13

Std. Mean Difference (IV, Random, 95% CI)

Subtotals only

8.1 High quality 1 ‐ 6 or more Risk of Bias items

5

691

Std. Mean Difference (IV, Random, 95% CI)

‐0.56 [‐1.27, 0.15]

8.2 High quality 2 ‐ Concealed allocation

10

1244

Std. Mean Difference (IV, Random, 95% CI)

‐0.43 [‐0.84, ‐0.02]

8.3 High baseline symptom intensity (>60% on pain & disability scales)

2

453

Std. Mean Difference (IV, Random, 95% CI)

‐1.25 [‐4.18, 1.69]

8.4 Low baseline symptom intensity (<60% on pain & disability scales)

11

1425

Std. Mean Difference (IV, Random, 95% CI)

‐0.23 [‐0.36, ‐0.11]

8.5 High intervention intensity 1 (>100 hours, daily contact)

7

1552

Std. Mean Difference (IV, Random, 95% CI)

‐0.16 [‐0.38, 0.06]

8.6 Low intervention intensity 1 (<30 hours, non‐daily contact)

5

219

Std. Mean Difference (IV, Random, 95% CI)

‐0.87 [‐1.93, 0.19]

9 Disability medium term ‐ all studies Show forest plot

9

511

Std. Mean Difference (IV, Random, 95% CI)

‐0.21 [‐0.48, 0.06]

10 Disability medium term ‐ sensitivity and subgroup analyses Show forest plot

9

Std. Mean Difference (IV, Random, 95% CI)

Subtotals only

10.1 High quality 1 ‐ 6 or more Risk of Bias items

2

219

Std. Mean Difference (IV, Random, 95% CI)

0.11 [‐0.15, 0.38]

10.2 High quality 2 ‐ Concealed allocation

6

359

Std. Mean Difference (IV, Random, 95% CI)

‐0.35 [‐0.75, 0.05]

10.3 High baseline symptom intensity (>60% on pain & disability scales)

0

0

Std. Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

10.4 Low baseline symptom intensity (<60% on pain & disability scales)

9

560

Std. Mean Difference (IV, Random, 95% CI)

‐0.14 [‐0.39, 0.11]

10.5 High intervention intensity 1 (>100 hours, daily contact)

3

302

Std. Mean Difference (IV, Random, 95% CI)

0.07 [‐0.16, 0.29]

10.6 Low intervention intensity 1 (<30 hours, non‐daily contact)

5

154

Std. Mean Difference (IV, Random, 95% CI)

‐0.46 [‐0.95, 0.03]

11 Disability long term ‐ all studies Show forest plot

10

1169

Std. Mean Difference (IV, Random, 95% CI)

‐0.68 [‐1.19, ‐0.16]

12 Disability long term ‐ sensitivity and subgroup analyses Show forest plot

10

Std. Mean Difference (IV, Random, 95% CI)

Subtotals only

12.1 High quality 1 ‐ 6 or more Risk of Bias items

5

656

Std. Mean Difference (IV, Random, 95% CI)

‐0.97 [‐1.98, 0.05]

12.2 High quality 2 ‐ Concealed allocation

8

852

Std. Mean Difference (IV, Random, 95% CI)

‐0.85 [‐1.54, ‐0.16]

12.3 High baseline symptom intensity (>60% on pain & disability scale)

1

90

Std. Mean Difference (IV, Random, 95% CI)

‐5.32 [‐6.21, ‐4.42]

12.4 Low baseline symptom intensity (<60% on pain & disability scale)

9

1079

Std. Mean Difference (IV, Random, 95% CI)

‐0.18 [‐0.38, 0.03]

12.5 High intervention intensity 1 (>100 hours, daily contact)

5

823

Std. Mean Difference (IV, Random, 95% CI)

‐0.18 [‐0.42, 0.07]

12.6 Low intervention intensity 1 (<30 hours, non‐daily contact)

3

140

Std. Mean Difference (IV, Random, 95% CI)

‐2.24 [‐5.48, 1.00]

13 Work short term ‐ all studies Show forest plot

3

379

Odds Ratio (M‐H, Random, 95% CI)

1.60 [0.92, 2.78]

14 Work short term ‐ sensitivity and subgroup analyses Show forest plot

3

Odds Ratio (M‐H, Random, 95% CI)

Subtotals only

14.1 High quality 1 ‐ 6 or more Risk of bias items

2

304

Odds Ratio (M‐H, Random, 95% CI)

1.76 [0.82, 3.76]

14.2 High quality 2 ‐ Concealed allocation

2

304

Odds Ratio (M‐H, Random, 95% CI)

1.76 [0.82, 3.76]

14.3 High baseline symptom intensity (>60% on pain & disability scales)

0

0

Odds Ratio (M‐H, Random, 95% CI)

0.0 [0.0, 0.0]

14.4 Low baseline symptom intensity (<60% on pain & disability scales)

3

379

Odds Ratio (M‐H, Random, 95% CI)

1.60 [0.92, 2.78]

14.5 High intervention volume (>100 hours, daily contact)

2

207

Odds Ratio (M‐H, Random, 95% CI)

1.10 [0.55, 2.20]

14.6 Low intervention volume (<30 hours, non‐daily contact)

0

0

Odds Ratio (M‐H, Random, 95% CI)

0.0 [0.0, 0.0]

15 Work medium term ‐ all studies Show forest plot

3

221

Odds Ratio (M‐H, Random, 95% CI)

2.14 [1.12, 4.10]

16 Work medium term ‐ sensitivity and subgroup analyses Show forest plot

3

Odds Ratio (M‐H, Random, 95% CI)

Subtotals only

16.1 High quality 1 ‐ 6 or more Risk of Bias items

0

0

Odds Ratio (M‐H, Random, 95% CI)

0.0 [0.0, 0.0]

16.2 High quality 2 ‐ Concealed allocation

1

67

Odds Ratio (M‐H, Random, 95% CI)

1.21 [0.39, 3.76]

16.3 High baseline symptom intensity (>60% on pain & disability scales)

0

0

Odds Ratio (M‐H, Random, 95% CI)

0.0 [0.0, 0.0]

16.4 Low baseline symptom intensity (<60% on pain & disability scales)

3

221

Odds Ratio (M‐H, Random, 95% CI)

2.14 [1.12, 4.10]

16.5 High intervention volume (>100 hours, daily contact)

3

221

Odds Ratio (M‐H, Random, 95% CI)

2.14 [1.12, 4.10]

16.6 Low intervention volume (<30 hours, non‐daily contact)

0

0

Odds Ratio (M‐H, Random, 95% CI)

0.0 [0.0, 0.0]

17 Work long term ‐ all studies Show forest plot

8

1006

Odds Ratio (M‐H, Random, 95% CI)

1.87 [1.39, 2.53]

18 Work long term ‐ sensitivity and subgroup analyses Show forest plot

8

Odds Ratio (M‐H, Random, 95% CI)

Subtotals only

18.1 High quality 1 ‐ 6 or more Risk of Bias items

3

385

Odds Ratio (M‐H, Random, 95% CI)

1.83 [1.16, 2.87]

18.2 High quality 2 ‐ Concealed allocation

5

551

Odds Ratio (M‐H, Random, 95% CI)

1.83 [1.26, 2.67]

18.3 High baseline symptom intensity (>60% on pain & disability scales)

0

0

Odds Ratio (M‐H, Random, 95% CI)

0.0 [0.0, 0.0]

18.4 Low baseline symptom intensity (<60% on pain & disability scales)

8

1006

Odds Ratio (M‐H, Random, 95% CI)

1.87 [1.39, 2.53]

18.5 High intervention volume (>100 hours, daily contact)

6

741

Odds Ratio (M‐H, Random, 95% CI)

1.71 [1.13, 2.60]

18.6 Low intervention volume (<30 hours, non‐daily contact)

0

0

Odds Ratio (M‐H, Random, 95% CI)

0.0 [0.0, 0.0]
Figures and Tables -
Comparison 6. MBR versus physical treatment, sensitivity and subgroup analyses
Navigate to table in Review