ORIGINAL RESEARCH ARTICLE

The Effectiveness of Group-Based Physiotherapy-Led

Behavioral Psychological Interventions on Adults With
Chronic Low Back Pain
A Systematic Review and Meta-Analysis
Qi Zhang, PhD student, Shujun Jiang, PhD, Lufei Young, PhD, and Feng Li, PhD

Abstract: Group-based physiotherapy-led behavioral psychological interventions (GPBPIs) are an emerging treatment for chronic low back pain,
but the efficacy of these interventions is uncertain. A review of relevant randomized controlled trials and a meta-analysis was conducted to
evaluate the effectiveness of GPBPIs on pain relief in adults with chronic low back pain. Literature databases, Google Scholar, bibliographies,
Downloaded from http://journals.lww.com/ajpmr by BhDMf5ePHKbH4TTImqenVBZZxeh5YHRL6fZHrmKBxx9QNmGL7YTZ6tg4AUlJ69U896uFpFyKv8Q= on 09/01/2020

and other relevant sources were searched. Thirteen intervention studies (13) published from 1998 to 2013 were included. The meta-analysis
was conducted using RevMan software in accordance with the Cochrane Handbook for Systematic Reviews of Interventions. In reviewing
the short- (<6 mos), intermediate- (≥6 and <12 mos), and longer-term (≥12 mos) effects of GPBPIs, long-term follow-up evaluations showed
large and significant effect sizes (standardized mean difference = −0.25, 95% confidence interval = −0.39 to −0.11, I2 = 38%, P < 0.01). Sub-
group analysis indicated that patients from GPBPIs group had the greater short-, intermediate-, and long-term pain reduction than patients on
waiting listing or usual care group. Compared with other active treatments, GPBPIs showed a small but significant long-term pain reduction in
patients with chronic low back pain (standardized mean difference = −0.18, 95% confidence interval = −0.35 to −0.01, I2 = 32%, P = 0.04). In
general, GPBPIs may be an acceptable intervention to relieve pain intensity.
Key Words: Low Back Pain, Physiotherapy, Psychological, Meta-analysis
(Am J Phys Med Rehabil 2019;98:215–225)

hronic low back pain (CLBP) is defined as a discomfort
C localized between the costal margins and inferior gluteal
folds, with or without accompanying leg pain, and persists for
at least 12 wks.1,2 Chronic low back pain is the most frequently
reported pain in working-age people3 and a major socioeco-
nomic public health issue worldwide. The European Guidelines
for the Management of Chronic Low Back Pain report a lifetime
incidence of low back pain in adults as high as 84%, and in 85%
of these patients,1 the condition is considered chronic. Along
with physical damage, people with CLBP frequently experience
psychological impairment, which results in symptomatic re-
sponses including emotional disturbances and depression, as well
as deleterious effects on work, recreational, and social life.4,5
Many efforts have been made to find effective treatments
for this multidimensional disorder. However, it remains difficult
to treat.1,6,7 Many interventions, including specific exercises,
spinal manipulation, and education, are reportedly effective
From the College of Nursing, Jilin University, Changchun, China (QZ, FL); Binzhou
Medical University, Yantai, China (SJ); and College of Nursing, Augusta Uni-
versity, Augusta, Georgia (LY).
All correspondence should be addressed to: Feng Li, PhD, College of Nursing, Jilin
University, Changchun 130021, Jilin Province, China.
This research did not receive any specific grant from funding agencies in the public,
commercial, or not-for-profit sectors.
Financial disclosure statements have been obtained, and no conflicts of interest have
been reported by the authors or by any individuals in control of the content of
this article.
Supplemental digital content is available for this article. Direct URL citations appear
in the printed text and are provided in the HTML and PDF versions of this article
on the journal’s Web site (www.ajpmr.com).
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0894-9115
DOI: 10.1097/PHM.0000000000001053
in the short term to ameliorate pain and other physical functions,
but the long-term effects are unclear.8 Although international
clinical guidelines for CLBP recommend the use of multidisci-
plinary holistic approaches, including mind body-soul healing,
supervised physical exercises, and cognitive-behavioral thera-
pies (Fig. S1, Supplemental Digital Content 1, http://links.lww.
com/PHM/A676),1,9–12 specific and detailed recommendations
are few. Behavioral psychological (BP) intervention, as one of
the mind-body-soul therapies, integrates behavioral, educational
and psychotherapeutic principles designed to promote healthy
lifestyle and enhance self-management skills through counseling,
support, interaction, or instruction.13–15 At present, community-
or group-based BP interventions have been applied in pain relief
in adult patients with CLBP,10 weight loss, and other physical
activity settings.16 Physiotherapist are trained to manage mus-
culoskeletal pain by using BP interventions, cognitive behav-
ioral therapies, and other exercises.17
Considering the increase in the number of group-based BP
interventions provided by physiotherapists (GPBPIs) for peo-
ple with CLBP in primary care, decision-makers should be in-
formed of the need for systematic reviews to determine the
overall effectiveness of these interventions. To the best of our
knowledge, there is no published meta-analysis on the effec-
tiveness of GPBPIs for CLBP. Available reviews only included
trials evaluating cognitive behavioral treatment for nonspecific
low back pain. Furthermore, no previous study has reviewed
the efficacy of interventions provided by a single profession
among healthcare providers. The absence of a separate evaluation
of professional healthcare deliverers has contributed to a gap in
knowledge concerning the effectiveness of the interventions.18

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Zhang et al. Volume 98, Number 3, March 2019

Therefore, the present systematic review and meta-analysis only
includes randomized clinical trials (RCTs) provided by phys-
iotherapists to investigate the effectiveness of GPBPIs on pain
relief in adult patients with CLBP. These results were then
compared with control interventions such as treatment as
usual, no treatment, and patients on a waiting list.
METHODS
Search Strategy
We searched the following databases from their inception to
February 2018, with no language restrictions, to gather relevant
RCTs: PubMed, Web of Science, Cochrane Library, EMBASE,
Ovid Medline, PsycINFO, Physiotherapy Evidence Database,
Chinese Biomedical Literature Database, China National Knowl-
edge Infrastructure, and Google Scholar. The search consisted of
a combination of free text words and MeSH terms using Boolean
operators. The following combination of key words and opera-
tors was used: (“Back Pain” OR “Low Back Pain” OR “Lumbar
near Pain” OR “Dorsalgia” OR “backache” OR “Back disorder”)
AND [“Chronic Disease *” OR “Chronic Disease” OR “Chronic
Pain” OR “Musculoskeletal Pain”] AND [“Exercise” OR
“Movement Techniques” OR “Exercise Therapy” OR “Physical
Fitness” OR “Physical Endurance” OR “Rehabilitation” OR

TABLE 1. Inclusion/exclusion criteria and intervention definition

Variable Inclusion Description Exclusion Description

Study design Only RCTs published in full text • Qualitative study.
peer-reviewed journals. • Case report.
• Nonrandomized controlled trial.
• Multiple case-cohort study.
Population • Studies including adult participants with a clinical • Trials involved participants with specific low
diagnosis of nonspecific CLBP (We defined pain back pain caused by pathologies (such as modic
duration as >3 mos). changes, ankylosing, radicular pain, stenosis,
• Over the age of 18 (males and females). spondylolisthesis, disc herniation).
• Patients with previous spinal surgery longer • “Red flag” disorders (such as fractures, infection,
than 6 mos were eligible. or spinal cord compression).
• Recruited women experiencing back pain
during pregnancy.
Intervention • RCTs were included if they evaluated the effects • Interventions using physiotherapy or BP techniques,
of GPBPIs on CLBP. Because there is no specific but not both, were also excluded.
definition of GPBPIs, we developed a working • Interventions delivered by healthcare professionals
definition for inclusion in this study. with unrelated professional backgrounds, with the
(1) We defined GPBPIs as involving a physiotherapy exception physiotherapists, were excluded.
component and one or both of a behavioral or a
psychological component.
(2) Delivered in a group format.
(3) Delivered by physiotherapist.
(4) Delivery method (such as face-to-face methods
or remote delivery—i.e., online or phone) was
not restricted.
• Education sessions, back exercise school, and exercise
therapy were defined as a psychological and/or
behavioral component if it used specific techniques and
rehabilitation approaches to change both cognition and
behavior. In cases where treatments were the main
focus of the intervention, the cognitive and psychological
aspects (such as relaxation, thoughts, fear, stress, and
beliefs) was deemed to be the psychological components.
If an intervention consisted of a wide range of components,
educational leaflets or treatment sessions consisting of a
large psychological component, without physical aspects
such as exercise, it was deemed inadequate to be
defined as GPBPIs.
Comparisons We categorized control interventions into two branches: Comparisons with
• No treatment • Surgery.
No prescribed treatment was provided, including • Percutaneous procedures.
UC and WL. • Pharmacology.
• AT.
Outcomes The primary outcome was pain.
• If more than one outcome scale was used to assess pain,
VAS was prioritized, rather than NRS or other measurements.
NRS, numerical rating scale.

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Volume 98, Number 3, March 2019
“Rehab*” OR “exercise*” OR “groups”] OR [“Self Care” OR
“Patient Education” OR “Disease Management” OR “Cognitive
Therapy” OR “Behavior Therapy” OR “Adaptation” OR “Psy-
chological” OR “physical” OR “motion” OR “fitness” OR
“therap*”] AND [“controlled clinical trial” OR “randomized
controlled trial” OR “trial” OR “randomly” OR “randomized”].
The databases were searched for relevant systematic re-
views and meta-analyses. Titles, abstracts, key words, and ref-
erence lists were scanned to refine the search terms. If the
abstracts met the inclusion criteria, the full-text article was
downloaded. In addition, the reference lists of all included
studies were screened to identify potentially studies that had
not been identified by previous search methods. This study
conforms to all PRISMA guidelines and reports the required
information accordingly (see Checklist, Supplemental Digital
Content 2, http://links.lww.com/PHM/A677).
Inclusion Criteria
Studies were included in the review if they were RCTs that
evaluated the effects of GPBPIs on CLBP in adults of any age,
irrespective of sex. Pain intensity was the primary outcome
consideration of the present study. Inclusion criteria were ap-
plied (Table 1).
Data Extraction and Assessment of Risk of Bias
All literature search results were screened and assessed by
two independent reviewers. Disagreement and uncertainties
FIGURE 1. Flow chart identification, selection and inclusion of the studies.
© 2018 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
Chronic Low Back Pain
were resolved by discussion and advice from a third reviewer
was sought. One author entered extracted data into Excel soft-
ware, and these were checked by the other author for accuracy.
Extraction of information included the following: study char-
acteristics, patient demographics, type of intervention, baseline
and follow-up outcomes, and methodological quality. Data on
effect size that could not be obtained directly were reanalyzed
when possible. The risk of bias was assessed using procedures
and criteria based on the Cochrane Collaboration Risk of Bias
Assessment Tool (Higgins and Green, 2011) for selection, at-
trition, performance, reporting, and detection biases.19
Data Analysis
The meta-analysis was performed using RevMan Version
5.1 software.20 Because continuous data were from different
scales, we calculated effect sizes by using the standardized
mean difference (SMD) based on sample size with 95% confi-
dence intervals (CIs) for each study.21 A two-sided P value of
less than 0.05 was considered statistically significant.
For the expected heterogeneity, all meta-analyses were
performed using a more conservative random-effects model.22
Heterogeneity was assessed from statistical, methodological,
and clinical perspectives. When the source of heterogeneity
could not be determined, descriptive analysis was used. Statis-
tical heterogeneity was assessed both graphically and statisti-
cally. Funnel plots were generated when the number of trials
was 10 or more, and symmetry could be assessed by visual
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Zhang et al. Volume 98, Number 3, March 2019

inspection.23 We quantified statistical heterogeneity by using
the χ2 test and the I2 statistic (interpreted as follows: 0%–
40% not important; 30%–60% moderate; 50%–90% substan-
tial; 75%–100% high).24 However, when heterogeneity was
likely present but underestimated (or undetected), one possible
solution was to arbitrarily assume unobserved heterogeneity in
moderate to large levels and then to test the sensitivity.25 Sen-
sitivity analyses was performed to investigate whether the risk
of bias had an influence on effect estimates, and subgroup anal-
yses were conducted according to different control interven-
tions and follow-up times.
The studies assessed pain intensity at various follow-up
times, and outcomes were split into the following three periods:
short term (<6 mos), intermediate term (≥6 and <12 mos), and
long term (≥12 mos). Of particular interest were long-term out-
comes, together with a comparison to wait list and usual care
(WL/UC).
Scholar and relevant bibliographies (Fig. 1). After removal of
387 duplicates, another 272 were excluded for irrelevancy. A
further 489 articles were excluded after screening and assessment
of the titles and abstracts. Finally, the full text of 111 potentially
relevant records was investigated. Of the records identified in
the database search, we found one additional RCT26 from the ref-
erence list, an article by Tavafian et al.,27 making a total of 112
studies for consideration. Of these 112 studies, 56 were excluded
because they were not RCTs, and 33 did not meet the participant
inclusion criteria. Other reasons for exclusion, delivered by an
unrelated healthcare professional,28–31 did not involve GPBPIs
or CLBP,32–36 nonvalidated standard for assessing pain and
included patients with subacute back pain (pain duration was
between 7 days and 7 wks),37 comparisons with percutaneous
procedures,27 primary outcome was quality of life,38 and one
did not report outcome data.39 In the end, 13 articles were in-
cluded in the present meta-analysis.26,40–51

RESULTS Main Features of Included RCTs

All of the included 13 studies were published in English
Search Results (Table S1, Supplemental Digital Content 3, http://links.lww.
Identified through the initial literature search were 1236 com/PHM/A678) between May 1998 and April 2013. Sample
records, with 23 additional records identified through Google sizes ranged from 52 to 348 patients. Two (2) came from

TABLE 2. Patient characteristics

Mean Sample
Age, y Size, n Completed, n (%)
First Author [Ref.] Population Women, % I C Duration of Pain I C I C
Albaladejo 40
Primary care physicians 67.2 51.0 52.5 ≥3 mos 100 109 100 (100) 109 (100)
Cecchi41 Outpatient rehabilitation 66.7 57.9 60.5 Nonspecific LBP, often 70 70 68 (97) 68 (97)
patients with chronic, always, ≥6 mos
nonspecific LBP
Critchley42 Patients ≥18 yrs 60.7 44.0 45.0 ≥12 wks 69 71 47 (68) 59 (83)
Dufour43 Patients 18–60 yrs 56.3 41.2 40.6 ≥12 wks 142 144 83 (58) 91 (63)
Fersum44 Patients 18–65 yrs 51.1 41.0 42.9 ≥3 mos 51 43 49 (96) 39 (90)
Ferreira45 Patients 18–80 yrs 68.1 54.8 51.9 ≥3 mos 80 80 73 (91) 65 (81)
Friedrich46 Physical therapy outpatients 50.5 43.3 44.9 LBP in the last 6 mos 44 49 34 (77) 35 (71)
before the initial
visit, with the
current episode
lasting ≥2 mos
Hunter47 Primary care and a university 62.7 42.4 43.2 >3 mos 28 24 24 (86) 20 (83)
population between 18
and 65 yrs
Johnson48 Patients 18–65 yrs 59.8 47.3 48.5 ≥3 mos 116 118 102 (88) 94 (80)
Kaapa26 Employed patients 22–57 yrs 100 46 46.5 Daily or nearly daily 64 66 49 (77) 46 (70)
LBP with or without
sciatica during
the preceding year
Niemisto49 Students, temporary housewives 53.9 37.3 36.7 ≥3 mos 102 102 96 (94) 100 (98)
Sherman50 College-educated employed 66.3 42 44 Two-thirds of 35 36 32 (91) 34 (94)
white women 40–50 yrs participants
lasted >1 yrs
Van Der Roer51 18–65 yrs, inability to resume 51.8 41.5 42.0 Nonspecific LBP 60 54 55 (92) 47 (87)
daily activities in previous >12 wks
3 wks
C, control group; I, intervention group; LBP, low back pain; NA, not available; PR, postrehabilitation.

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Volume 98, Number 3, March 2019 Chronic Low Back Pain

TABLE 3. Review of the empirical group

First Author
[Ref.] Delivery Model Description Duration Outcome Intervals
40
Albaladejo PT, physician Education & physiotherapy; usual GP care, 270 mins; 6 sessions on consecutive B, 3, 6 mos
group education on active LBP management days, for 1 wk
& group physiotherapy; usual treatment for
CLBP by primary care physician (advice,
medication, potential request for diagnostic
procedures, or potential referral to orthopedic
surgery, neurosurgery, rheumatology, or pain
units); back book, postural hygiene book
& group talk on active management of LBP;
group sessions on relaxation techniques,
stretching, active core exercises adapted to
ability, encouragement to practice at home
Cecchi41 PT only Back school; booklet with educational 15 sessions  60 mins = 900 mins; B, 3, 6, 12 mos
information on anatomy & biomechanics, 5 sessions/wk for 3 wks
postures, ergonomics & advice to stay active;
information & group discussions on back
physiology & pathology with reassurance
& education in ergonomics; relaxation
techniques, postural & respiratory group
exercises; customized back exercises
Critchley42 PT, PT assistant Back pain education; group general 8 sessions  90 mins = 720 mins B, 6, 12, 18 mos
strengthening, stretching & light aerobic
exercises & CBT & SM education
Dufour43 PT, OT Group-based MDT biopsychosocial 36 sessions  120 mins = 4320 mins B, 3, 6, 12, 24 mos
rehabilitation; aerobic training & strengthening (72 hrs) for 12 wks
exercises; biweekly lessons on anatomy,
postural techniques & pain management by
a PT; back care & lifting techniques by an OT
Fersum44 3 PT CB-CFT intervention: a cognitive education 1 session = 30–45 mins; 1 session/2 B, 3, 12 mos
& specific movement exercises & functional to 3 wks; 12 wks
integration & group physical activity program
Ferreira45 PT only Exercise, education & CBT; 11 group sessions, 12 sessions of 60 mins = 720 mins B, 8 wks, 6 & 12 mos
1 individual session; strengthening & stretching for 8 wks
exercises; exercises for cardiovascular fitness
based on back-to-fitness short relaxation session;
brief educational message provided as a “tip of
the day”; PTs applied principles of CBT
Friedrich46 8 PT Group education; exercise; motivation program; 10 sessions  25 mins = 250 mins; B, 3.5 wks, 4, 12 mos
extensive counseling & information strategies; 2 to 3 session/wk; 4 wks
reinforcement techniques
Hunter47 2 PT Exercise & education; core strengthening, 12 wks; 6 sessions  60 mins = B, 8 & 13 wks, 6 mos
flexibility, cardiovascular exercise; period of 360 mins for first 6 wks, followed
relaxation; back exercise book to reinforce the by 6-wk unsupervised exercise
message to remain active & develop coping
strategies; program is underpinned by CBT
principles; PTs used CBT principles to identify
& combat illness behaviors & address fear
avoidance of physical activity
Johnson48 2 PT Exercise, education & CBT; educational pack 8  120 mins = 960 mins; 8 sessions B, 3, 9, 15 mos
with advice on pain, activity, pacing, goal for 6 wks
setting, stress, posture & body mechanics;
guidelines for sleep hygiene, beds & sleeping,
flare-up plans; when to see your GP. Group
sessions of exercise; practical activity;
cognitive behavior approach
(Continued on next page)

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Zhang et al. Volume 98, Number 3, March 2019

TABLE 3. (Continued)

First Author
[Ref.] Delivery Model Description Duration Outcome Intervals
26
Kaapa 1 PT, 2 OT, 1 MDT group rehabilitation; cognitive-behavior 5 d, 6 hrs/d, home training; 2 wks, B, PR, & 6, 12, 24 mos
psychologist, 1 stress management & applied relaxation 4 hrs twice/wk 5 wks = 4200 mins
physician sessions; coping skills; back exercise school (70 hrs)
education including occupational intervention
(anatomy, muscles & the spine, & AT methods
of the back disorders); customized physical
exercise program
Niemisto49 PT, physician, Group education; exercise; educational booklet; 4 sessions  60 mins = 240 mins, B, 5 & 12 mos
nurse specific instructions based on the clinical 4 wks; 5-mo follow-up exercise
evaluation; muscle energy technique
& stabilizing exercises
Sherman50 PT only Exercise & SM education on proper body 12 sessions  75 mins = 900 mins; B, 6 wks, 3, 6.5 mos
mechanics; benefits of exercise & realistic 1/wk for 12 wks
goal setting; overcoming common barriers
to developing an exercise routine; aerobic
& strengthening exercises that emphasized
leg, hip, abdominal, & back muscles
Van Der Roer51 PT only Intensive group training; exercise therapy, back 30 sessions (10  30 mins + 20  6, 13, 26, 52 wks
school & behavior principles; 10 individual 90 mins = 35 hrs); 6 sessions for
sessions consisting of physical examination, 3 wks, then 2/wk for 8 wks
determining baseline levels, setting goals;
20 group sessions according to operant
conditioning behavior principles based on
the baseline level of functional ability
B, baseline; CBT, cognitive-behavioral therapy; GP, general practitioner; LBP, low back pain; MDT, multidisciplinary team; NSAID, nonsteroidal anti-
inflammatory; OT, occupational therapist; PT, physiotherapist; SM, self-management; CB-CFT, classification-based cognitive functional therapy.

Finland, two (2) from United Kingdom, and two (2) were con-
ducted in the United States. The remaining studies originated
in Australia, Norway, the Netherlands, Italy, Spanish, Denmark,
and Ireland.
The average age of the participants was between 37 and
59 yrs (Table 2). Sex percentages for individual studies involv-
ing patients with CLBP are displayed (Fig. S2, Supplemental
Digital Content 4, http://links.lww.com/PHM/A679). The stud-
ies included different types of exercise interventions (Table 3).
The duration of the exercise programs ranged from 4 to
12 wks, and the frequency of classes varied from 1 to 5 sessions
per week. In addition to pain and disability, other instruments
were used to measure outcomes (Table 4).
Risk of Bias
Regarding the methodological quality of the 13 included
studies, all used randomization to assign study populations
(Table 1), and the risk of bias was based on the Cochrane Sys-
tematic Reviews of Interventions (Fig. S3, Supplemental Digital
Content 5, http://links.lww.com/PHM/A680). Random sequence
generation was by computer-generated random software in four
trials42,47,48,50 and serially numbered opaque envelopes for al-
location concealment in seven trials.26,40,44,45,49–51 Given the
nature of the intervention, it was not feasible to blind partici-
pants and therapists in these trials. Only the outcome assessors
and statisticians could be blinded. However, five trials reported
double blinding.26,40,44–46 Nevertheless, blinding was not clearly
reported in all of the studies. The reasons for participant
withdrawals and dropouts were also given in all these trials.
The shape of the funnel plot was inspected and found to be
roughly symmetrical (Fig. S4, Supplemental Digital Content
6, http://links.lww.com/PHM/A681).
Meta-Analysis Results
Thirteen studies with 13 comparison groups were evaluated
for the effects of GPBPIs relative to that of other interventions
(both WL/UC and active treatment [AT]) for pain relief in
CLBP at three terms. Meta-analysis did not find a significant
difference in pain improvements in the short-term (SMD = −0.31,
95% CI = −0.62 to 0.00, I2 = 88%, P = 0.05) and intermediate-
term evaluations (SMD = −0.42, 95% CI = −0.95 to 0.11,
I2 = 96%, P = 0.12). Long-term follow-up evaluations showed
large and significant effect sizes in favor of GPBPIs (SMD =
−0.25, 95% CI = −0.39 to −0.11, I2 = 38%, P < 0.01). However,
considerable heterogeneity was observed in the short- and
intermediate-term comparisons, so subgroup analysis was per-
formed to compare GPBPIs with different control interventions
(WL/UC or AT) at these three terms (Fig. 2).
Group-Based Physiotherapy-Led Behavioral
Psychological Interventions vs. AT
In the short term, heterogeneity analyses revealed substan-
tial heterogeneity across the studies (SMD = −0.18, 95% CI =
−0.48 to 0.11, I2 = 79%, P = 0.22). This could have been a
result of differences in ethnicity and exercise time. However,
again meta-analysis did not find a significant difference

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Volume 98, Number 3, March 2019 Chronic Low Back Pain

TABLE 4. Instruments used to measure outcomes

First Author [Ref.] Functional Outcomes Other Outcome Measures

40
Albaladejo Pain (VAS); referred pain (VAS) Disability (RMDQ); coping strategies questionnaire;
HRQOL (SF-12); satisfaction with care (Likert);
referred pain (Likert); disability (Likert); pain
evolution (Likert)
Cecchi41 Pain (RMDS) Disability (RMDQ); CLBP recurrence; CLBP-related
use of drugs; further treatment for CLBP
Critchley42 Pain intensity (NRS) Disability (RMDQ); QOL (EQ5D)
Dufour43 Pain (VAS) Disability (RMDQ); HRQOL (SF36)
Fersum44 Pain intensity (NRS) Disability (ODI)
Ferreira45 Pain (VAS) Disability (RMDQ); function (Patient-Specific
Functional Scale); perceived effect of treatment
(global perceived effect)
Friedrich46 Pain intensity (101-point NRS) Disability (low back outcome score), physical impairment
(modified Waddell score, fingertip-to-floor distance,
abdominal muscle strength), working ability, motivation,
& compliance.
Hunter47 Pain (VAS); rating pain bothersomeness (VAS) Disability (ODI); QOL (EQ5D); International Physical
Activity Questionnaire, daily diary, back beliefs
questionnaire; holistic complementary & alternative
health questionnaire; general SE scale; medication
intake; fear-avoidance beliefs questionnaire
Johnson48 Pain (VAS) Disability (RMDQ); heath status/HRQOL (EQ5D)
Kaapa26 Sciatic pain (NRS) Back disability (ODI); sick leave due to CLBP; DEPS;
self-efficacy regarding working ability after 2 yrs (NRS)
General well-being after rehab (Likert scale); healthcare
utilization due to CLBP (visits to HCPs)
Niemisto49 Pain (VAS) Back-specific disability (ODI) degree of mental depression
(DEPS); health-related quality of life (15D-HRQOL),
20 d on sick leave, costs of healthcare consumption
& productivity costs.
Sherman50 Rating bothersomeness of pain (NRS) Disability (RMDS); HRQOL (SF-36); degree of restricted
activity (3 questions); medication use
Van Der Roer51 Pain intensity (NRS) Disability (RMDQ); global perceived effect (6-pt scale);
work absenteeism (short-form health & labor
questionnaire); fear of movement/reinjury; pain SE
questionnaire; pain coping (Pain Coping Inventory)
15D-HRQOL, 15-Dimensional Quality-of-Life Instrument; DEPS, Depression Scale; EQ5D, European Quality of Life 5-Dimensions; HCP, healthcare profes-
sional; HRQOL, health-related quality of life; NRS, numerical rating scale; ODI, Oswestry Disability Index; RMDQ, Roland-Morris Disability Questionnaire;
RMDS, Roland-Morris Disability Score; SE, self-efficacy; VAS, visual analog scale.

between the two groups in the intermediate term (SMD =
0.02, 95% CI = −0.10 to 0.15, I2 = 0%, P = 0.71). This indicated
that there was insufficient evidence to affirm that GPBPIs in the
short term and intermediate term can reduce pain perceived by
patients with CLBP compared with patients in the AT groups.
The pooled results of the studies showed a small but significant
reduction in CLBP in favor of the group receiving GPBPIs in
the long term (SMD = −0.18, 95% CI = −0.35 to −0.01,
I2 = 32%, P = 0.04) (Fig. 3).
Group-Based Physiotherapy-Led Behavioral
Psychological Interventions vs. WL/UC
Although the intervention and control groups were compa-
rable in CLBP reduction, the heterogeneity test indicated a small
degree of heterogeneity at three terms. The results showed a sig-
nificant difference between the two groups in favor of GPBPIs
for reduction in pain at the short term (SMD = −0.33, 95%
CI = −0.50 to −0.15, I2 = 0%, P < 0.001), intermediate term
(SMD = −0.33, 95% CI = −0.48 to −0.18, I2 = 0%,
P < 0.001), and long term (SMD = −0.34, 95% CI = −0.52 to
−0.16, I2 = 0%, P < 0.001). The aggregated results suggest that
GPBPIs were associated with a reduction in pain in patients with
CLBP compared with usual care and waiting list (SMD = −0.33,
95% CI = −0.43 to −0.23, I2 = 0%, P < 0.001) (Fig. 4).
Adverse Events
Of the 13 included studies, only 4 evaluated the occur-
rence of adverse events and provided this information in the ar-
ticles.43,47,49,51 Two of these studies reported that no adverse
events occurred.49,51 Another two studies reported minor
adverse events,43,47 but none of the serious events were related
to the treatment intervention. Dufour et al.43 reported that one

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Zhang et al.
FIGURE 2. Forest plots of effects of GPBPIs (total) for people with CLBP.
patient experienced a concussion caused by a fall during a ball
game session. The authors of another study reported a number
of adverse events in the control groups, such as pain (14%),
redness (2%), and minor bleeding (1%).47
DISCUSSION
Summary
The current study is the first systematic review complete
with meta-analysis to compare the effects of GPBPIs with
other forms of interventions. Altogether, the primary findings
show that group-based behavioral interventions covering sev-
eral domains of the biopsychosocial model and delivered by
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Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
Volume 98, Number 3, March 2019
physiotherapists are more effective than both usual care and
other treatments in decreasing pain in patients with CLBP in
the long term. However, it is important to note the heterogene-
ity within this comparison, because substantial variation may
exist in the clinic approach delivered by the physiotherapist.
More specifically, the component intensity and the training ex-
perience of the physiotherapist in interventions that incorpo-
rates more than one physiotherapy may lead to this variation
in GPBPIs. When subgroup analysis was performed, the pres-
ent meta-analysis suggests moderate effect sizes in favor of
GPBPIs when compared with no treatment arm in the three
terms. However, there was insufficient evidence to support
the clinical effectiveness of GPBPIs compared with other active
therapies in the short and intermediate term. The physiotherapists'
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Volume 98, Number 3, March 2019
FIGURE 3. Forest plots of effects of GPBPIs vs. AT for people with CLBP.
skills must be taken into account in the application of these
interventions, because the physiotherapist can encourage self-
care and provide patients with adequate supervision and advice,
which may help improve patient compliance and consequently
improve the effectiveness of the interventions. Providing regular
face-to-face individualized training and teaching psychological
skills for physiotherapist will help ensure the quality of the inter-
vention and promote psychological flexibility. As for chronic
pain, more attention should be focused on the long-term effects
of the interventions.
Strengths and Limitations
The results of this meta-analysis need to be interpreted
with caution for a number of reasons. The severity and duration
of CLBP varied among the studies, as well as the methods,
frequency, and duration of GPBPIs sessions. In addition,
conclusions based on this meta-analysis are limited by the
considerable variation among the studies and in the tools
used for measuring study outcomes. Other factors that var-
ied among these studies were intergroup member support,
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Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
Chronic Low Back Pain
relationship dynamics, communication skills, timing of the
intervention with respect to primary CLBP treatment, and
determination in achieving timed goals. In addition, because
the primary outcome measures (i.e., pain) in this review
were on subjective self-report scales, and data assessors
were the patients themselves, the risk of bias was high.
Future Work
The included studies also reported their results over a wide
range of time intervals, ranging from 3.5 wks (Friedrich et al.46)
to 24 mos (Kaapa et al.26 and Dufour et al.43). Future interven-
tion studies need to consider the influence of these designs over
subsequent years. Future work might recruit patients within a
particular age group or in various settings (e.g., community,
home care, acute care) to examine the effects of such interven-
tions. In addition, to minimize the margin of error and increase
the precision of results, future studies should adopt designs
with appropriate statistics and adequate sample size. Popula-
tions at specific stages of CLBP should be targeted. Our meta-
analysis provides justification for future studies of the benefits
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Zhang et al.
FIGURE 4. Forest plots of effects of GPBPIs vs. WL/UC for people with CLBP.
of GPBPIs in the treatment of CLBP in various populations at
different ages, in hospital or in community settings, although
further evidence of the cost-effectiveness is needed. The benefits
of GPBPIs may be extended to a larger populations of patients
(e.g., acute and chronic, in pregnant and postpartum women)
with back pain. However, these costly and time-consuming
hospital-based programs can only be offered to a minority of pa-
tients, so caregivers must pay attention to include more hospital-
independent programs in GPBPIs to treat a larger number of
patients more effectively and at a lower cost.
CONCLUSIONS
The present meta-analysis suggests that GPBPIs have a
long-term beneficial effect on pain relief in comparison with
no treatment and other ATs for patients with CLBP. However,
there was insufficient evidence to affirm that GPBPIs pro-
grams should be offered routinely to patients diagnosed with
CLBP. In general, it may be an acceptable intervention to re-
lieve pain intensity.
ACKNOWLEDGMENTS
The authors thank all the reviewers for their assistance
and support.
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