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Table 5 Summary of Contextual Factor intervention types and their influence on patient outcomes

From: Impact of contextual factors on patient outcomes following conservative low back pain treatment: systematic review

Ref no. (year) & Design No. of CFs Which CFs? (frequency) How CFs manipulated during the intervention? Influence on cLBP outcome(s) Compared to active treatment Effect size(s)
[36] (2013) RCT 1 Patient’s beliefs (1) Cognitive Behavioural Approach – reframing back pain, explaining biopsychosocial pain mechanisms, changing maladaptive (i.e., fear-avoidant) movement using, goal setting, graded activity, and reflective communication Significant improvement (pain intensity & physical functioning) Superior Unreported
[37] (2014)
RCT
(2 × 2)
2 Patient-practitioner relationship (1) Therapeutic Alliance – interactions enhanced through verbal behaviours, active listening, tone of voice, non-verbal behaviours (i.e., eye contact, touch), and empathy Clinically meaningful improvement (pain intensity) Superior to limited TA Sham + TA > Sham
d = 1.73
Active + TA > Active
d = 1.36
   Treatment characteristics (1) Sham vs Active Treatment – both patients and practitioners could not visually discriminate between sham or active IFC   Superior to Sham IFC Active + TA > Sham + TA
d = 1.0
Active > Sham
d = 0.89
[38] (2022)
RCT
1 Patient’s beliefs (2) Cognitive-Behavioural and Affective Approach—aims to shift patients’ beliefs about the causes and threat value of pain, focuses on reframing pain sensations through a lens of safety, addressing emotional threats and enhancing positive feelings and sensations through exposure to feared movements and evidence to provide reassurance Clinically meaningful improvement (pain intensity)
Improvement (physical functioning)
Superior Pain Intensity
g =  − 1.75
Physical Functioning
g =  − 1.70
[39] (2019)
RCT
2 Patient’s beliefs (3) Implicit Cognitive Approach – Verbal suggestions to positively influence patient’s symptom change expectations introduced by principal investigator wearing a white coat. Social learning – News report video (German subtitles/dubbing) regarding patients’ experiences of OLP to infer it is a legitimate/credible treatment approach Improvement (pain intensity & physical functioning) Superior Pain Intensity
d = –0.44
Physical Functioning
d = –0.45
   Treatment characteristics (2) Response Expectancy – physical cues (i.e., typical, labelled medicine bottle and capsules) to connote pain-relieving treatment properties    
[40] (2016)
RCT
2 Patient’s beliefs (4) Implicit Cognitive Approach – Verbal suggestion to positively influence patient’s symptom change expectations using a warm and supportive communication style. Social learning – video of a news report regarding patients’ experiences of OLP to infer it is a legitimate/credible treatment approach Much Improved (pain intensity & physical functioning) Superior Pain Intensity
g = 0.76
Physical Functioning
g = 0.74
   Treatment characteristics (3) Response Expectancy – physical cues (i.e., typical, labelled medicine bottle and capsules) to connote pain-relieving treatment properties    
[42] (2010)
RCT
2 Patient’s beliefs (5) Explicit Cognitive Strategy – Pain neuro-biology education (PNE) targeted misconceptions about the mechanisms of pain experiences (1 × 2.5 h) Significant improvement
(pain intensity only)
PNE Superior to PNE plus Exercise Unreported
Note: Patients attending group exercise classes interacted with non-trial staff/patients which may have undermined the PNE
   Patient-practitioner relationship (2) Additional Interactions – group-based physical exercise classes open to the general community (via NHS)    
[45] (2017)
RCT
(2 × 2)
2 Patient’s beliefs (6) Implicit Cognitive Approach – Truthful [or Deceptive] verbal suggestions to influence patient’s symptom change expectations: “this solution is neutral, a placebo [an opioid], it has no effect [reduces pain and improves physical capacity]”) Significant improvement (pain intensity & physical functioning) Superior to truthful verbal suggestions Pain Intensity
With CC: d = 1.83
No CC: d = 0.83
Physical Functioning:
With CC: d = − 0.92
No CC: d = − 0.59
   Treatment characteristics (4) Response Expectancy – visual and physical cues to connote pain-relieving treatment properties (i.e., bottles labelled as “Opioid Klinische Prüfung” (i.e., Opioid Clinical Trial). Classical Conditioning (CC) – 6 × experimental pain stimuli    
[46] (2019)
RCT
(2 × 2)
2 Patient’s beliefs (7) Implicit Cognitive Approach – Deceptive verbal suggestions to influence patient’s symptom change expectations: “…a new and very powerful transdermal infusion which reduces clinical back pain and improves functional capacity.”) Significant improvement (pain intensity & physical functioning) Superior to Natural History group Pain Intensity
Sham Only: η2 = 0.56
Placebo Cond: η2 = 0.38
Nocebo Cond: η2 = 0.21
Physical Functioning:
Sham Only: η2 = 0.27
Placebo Cond: η2 = 0.15
Nocebo Cond: η2 = 0.20
   Treatment characteristics (5) Response Expectancy – visual and physical cues to connote pain-relieving treatment properties (patch was labelled as “Taroxin – hydromorphone, 1 mL = 10 mg, so patients believed it was a potent analgesic”), could see its application using mirrors and felt a damp sensation too. Classical Conditioning (CC) – use of experimental pain stimuli to positively (PC) or negatively (NC) influence pain perceptions    
[44] (2021)
RCT
2 Patient’s beliefs (8) Explicit Cognitive Strategy – Patient education (ED) relating to return to daily activities, advice on coping with pain, a clear explanation of signs and symptoms as recommended by treatment guidelines (2 × 1-h) Improvement (pain intensity & physical functioning) Equivalent (ED + TA ~ ED only)
Superior to No ED group
Pain Intensity (1-year)
Unreported
Physical Functioning
(see Table 4)
Unreported
   Patient-practitioner relationship (3) Therapeutic Alliance – In one group (ED + TA) the therapist aimed to enhance TA and empathy by emphasising a warm and caring reception, showing interest in the patient, asking about the patient’s condition in an interested manner, and demonstrating interest in the current complaint etc    
[35] (2011)
RCT
3 Patient’s beliefs (9) Cognitive-Behavioural and Affective Approach – including motivation enhancing factors such as proxy efficacy, treatment expectancy, and goal setting (MET) Significant improvement (pain intensity & physical functioning) Equivalent Not Applicable
   Patient-practitioner relationship (4) Therapeutic Alliance – use of motivational interviewing to develop working alliance    
   Treatment characteristics (6) Dummy MET (Motivational Enhancement Treatment) – general communication skills, but deliberately avoided adopting MET-based counselling skills    
[43] (2020)
RCT
2 Patient’s beliefs (10) Implicit Cognitive Approach – Verbal suggestion to positively influence patient’s symptom change expectations (1-h session) Significant improvement (physical functioning (RMDQ) only) Equivalent Not Applicable
   Treatment characteristics (7) Response Expectancy – physical cues (i.e., typical, medicine bottle and capsules) to connote pain-relieving treatment properties    
[41] (2017)
RCT (Cluster)
2 Patient’s beliefs (11) Explicit Cognitive Approach – ensure patients understand their LBP and the relationship to physical activity; addressing fear-avoidance beliefs Improvement (pain intensity & physical functioning) Equivalent Note: Sex moderated the effect. Women in the intervention arm improved (i.e., 4.94 RMDQ points lower) compared to women in the control arm
   Patient-practitioner relationship (5) Improved Communication – enhance physiotherapists’ communication skills using the ‘5A’ framework (i.e., ask, advise, agree, assist, arrange)    
[47] (2017)
CCT
2 Patient’s beliefs (12) Cognitive-Behavioural and Affective Approach – address low motivation/self-efficacy for physical activity using behaviour change principles, graded activity to target fear-avoidance beliefs/behaviour, and educational messages informed by effective reassurance Improvement (pain intensity & physical functioning) Equivalent at post-treatment
Superior at follow-up*
*Physical Functioning
d = 0.54
   Patient-practitioner relationship (6) Therapeutic Alliance – building the relationship with an emphasis on communicating empathy and active listening    
[48] (2012)
CCT
1 Patient’s beliefs (13) Explicit Cognitive Strategy – Educational intervention covering beliefs about medicines, rehabilitation, and individualised information to address unhelpful illness perceptions Significant improvement (pain intensity & physical functioning) Equivalent Note: Control-arm involved in-patient multidisciplinary rehabilitation
[49] (2018)
CCT
2 Patient-practitioner relationship (7) Additional Interactions – one weekly group-based physical therapy session (i.e., extra time/attention) Significant improvement (pain intensity & physical functioning) Equivalent Not Applicable
   Treatment Setting (1) Environment – one group participated in physical therapy at home only whilst the other also attended weekly classes at a rehabilitation facility    
[50] (2015)
Quasi-exp
1 Patient’s beliefs (14) Cognitive Behavioural Approach – reframing back pain, explaining biopsychosocial pain mechanisms, changing maladaptive (i.e., fear-avoidant) movement using goal setting, graded activity, and reflective communication Significant improvement (pain intensity & physical functioning) Not Applicable Pain Intensity
d = 0.65
Physical Functioning
d = 0.85
[51] (2017)
Quasi-exp
1 Patient’s beliefs (15) Explicit Cognitive Strategy – Pain neuro-biology aimed at re-educating older patients on the relationship between LBP and normal aging processes Significant improvement (pain intensity & physical functioning) Not Applicable Pain Intensity
r = 0.45
Physical Functioning
partial η2 = 0.54
[54] (2011)
Obs. Cohort
1 Patient’s beliefs (16) Explicit Cognitive Strategy – Using the Socratic dialogue technique to investigate and restructure patient’s maladaptive or unhelpful illness perceptions Significant improvement (physical functioning) Not Applicable r2 = 3.9%
An increase in patient’s rational problem-solving skills was associated with improved physical functioning outcomes
No direct manipulation of CFs       
[52] (2013)
Obs. Cohort
1 Patient-practitioner relationship (8) Measuring Communication Skills – patient information, perceived involvement in care, trust, satisfaction, and aspects of their communication behaviour during multimodal orthopaedic pain rehabilitation involving educational, psychotherapeutic, social, and occupation-related therapy Significant improvement (pain intensity & physical functioning) Not Applicable Pain Intensity
Post: d = 0.60
Follow-up: d = 0.48
Physical Functioning
Post: d = 0.53
Follow-up: d = 0.48
[53] (2013)
Obs. Cohort
1 Patient-practitioner relationship (9) Measuring Therapeutic Alliance – sense of collaboration, warmth, and support between the patient and therapist. Includes agreement on (a) goals, (b) treatment, and (c) the affective or emotional bond Significant improvement (pain intensity & physical functioning) Not Applicable One unit increase in TA reduced pain intensity by 0.044 units
One unit increase in TA reduced disability by 0.113 units
[55] (2019)
Obs. Cohort
1 Patient’s beliefs (17) Measuring relationships between patients’ Competence Perceptions and Motivation for undertaking physical therapy and whether patient motivations mediate the relationship between Competence Perceptions (CP) and pain and disability. Competence Perceptions refers to the patient’s beliefs regarding their ability, efficacy, and proficiency to meet rehabilitation demands. Along a continuum, amotivation represents the least self-determined type whereas autonomous motivation is the most self-determined Significant associations (pain intensity & physical functioning) Not Applicable Note: Higher CP levels were associated with lower pain and disability at post-treatment
Amotivation was the only significant mediator
CP negatively predicted amotivation, which in turn positively predicted greater pain and disability