Physical, psychological or combined interventions: what’s best for treating pain?

Non-specific chronic spinal pain (NSCSP), particularly low back pain (LBP) and neck pain (NP), are common and costly musculoskeletal disorders. NSCSP can be associated with physical factors (e.g. stiff postures and movement patterns) and behavioural/psychological factors (e.g. fear, beliefs, stress, depression, sleep problems, physical inactivity). As a result, conservative interventions can be broadly categorised into physical, psychological or combined interventions. Physical interventions usually aim to improve physical capacity (e.g. exercise, manual therapy, ergonomics). Behavioural and/or psychologically informed interventions aim to improve behaviours, cognitions or mood (e.g. relaxation and cognitive behavioural therapy). Combined interventions aim to improve physical and behavioural/psychological factors contributing to patients’ pain (e.g multidisciplinary (MDT) programmes).


This systematic review and meta-analysis included 24 RCTs that compared the effectiveness of physical, behavioural/psychological and combined interventions. Five studies compared physical and behavioural/psychologically informed interventions. 20 studies compared physical and combined interventions. Only one study compared a behavioural/psychologically informed intervention to a combined intervention.


No statistically significant differences were found for pain and disability between

  • physical and behavioural/psychologically informed interventions
  • behavioural/psychologically informed and combined interventions

While a small statistically significant difference was found for both pain and disability between the physical and combined interventions, favouring the combined intervention, this difference was small.


This review highlights that current conservative interventions for NSCSP result in similar, small improvements in pain and disability. Choosing the most cost-efficient and feasible may be reasonable, based on the evidence to date. All the interventions in this review were safe, and helpful in the short-term. Combined treatments (e.g MDT rehabilitation) might not be possible to provide to all patients. Furthermore, combined treatments may not adequately target all the important factors in people with NSCSP (e.g sleep).  Further work is needed to investigate whether tailoring rehabilitation to the needs of individual patients, which has been examined in RCTs for LBP (e.g here and here) can enhance outcomes in NSCSP.



About Mary O’Keeffe

Personal info: Mary O’Keeffe (@MaryOKeeffe1990) is just about to complete the fourth (and final) year of her PhD in the University of Limerick, Ireland. Mary’s PhD research is examining whether tailoring multidimensional rehabilitation to the individual chronic LBP patient enhances effectiveness, and is worth the additional time (and costs!) involved. Her supervisors are Dr Kieran O’Sullivan and Dr Norelee Kennedy from UL and Prof Peter O’Sullivan from Curtin University, Perth. Mary’s PhD research is funded by the Irish Research Council.

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