Effectiveness of Combined Biopsychosocial Interventions for Chronic Low Back Pain: A Systematic Review and Meta-analysis of Randomized Controlled Trials.

Abstract

To evaluate the effectiveness of combined biopsychosocial interventions compared with usual care, waiting-list controls, and active unimodal interventions in reducing pain and functional disability in adults with chronic low back pain, and to explore the consistency of effects across different intervention structures. A systematic search was conducted in PubMed/MEDLINE, Embase, Scopus, Web of Science, CENTRAL, CINAHL, PEDro, LILACS, and SciELO from inception to November 2025, including clinical trial registries. Randomized controlled trials including adults (≥18 years) with nonspecific chronic low back pain (≥12 weeks). Interventions combined at least two components: exercise therapy, pain education, or psychological strategies. Two independent reviewers performed study selection, data extraction, and risk of bias assessment (RoB 2). Certainty of evidence was evaluated using GRADE. Random-effects meta-analyses (Hedges g) included 28 randomized controlled trials (n = 2,521 participants). Interventions significantly reduced pain at short-term (SMD = -0.60; 95% CI: -0.81 to -0.38) and medium-term (SMD = -0.49; 95% CI: -0.84 to -0.13), and disability at short-term (SMD = -0.74; 95% CI: -1.03 to -0.46) and medium-term (SMD = -0.45; 95% CI: -0.84 to -0.05). Kinesiophobia decreased at short-term but not at medium-term. Heterogeneity ranged from moderate to high (I² = 66.8%-89.4%). Evidence certainty was moderate for most pain and disability outcomes and low for medium-term kinesiophobia. No significant differences were found between integrated and structured interventions. Combined biopsychosocial interventions reduce pain and disability in chronic low back pain, particularly in the short term. The observed effects were generally small to moderate in magnitude and should be interpreted considering the variability of outcome measures and comparator interventions across studies. These findings support multimodal approaches, especially for patients with greater psychosocial complexity, while reinforcing the need for individualized treatment strategies.