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

Sherriff, Bronwyn; Clark, Carol; Killingback, Clare; Newell, Dave


Bronwyn Sherriff

Carol Clark

Dave Newell


Background and objective
Chronic low back pain is pervasive, societally impactful, and current treatments only provide moderate relief. Exploring whether therapeutic elements, either unrecognised or perceived as implicit within clinical encounters, are acknowledged and deliberately targeted may improve treatment efficacy. Contextual factors (specifically, patient’s and practitioner’s beliefs/characteristics; patient-practitioner relationships; the therapeutic setting/environment; and treatment characteristics) could be important, but there is limited evidence regarding their influence. This research aims to review the impact of interventions modifying contextual factors during conservative care on patient’s pain and physical functioning.
Databases and data treatment
Four electronic databases (Medline, CINAHL, PsycINFO and AMED) were searched from 2009 until 15th February 2022, using tailored search strategies, and resulted in 3476 unique citations. After initial screening, 170 full-text records were potentially eligible and assessed against the inclusion–exclusion criteria. Thereafter, studies were assessed for methodological quality using a modified Downs and Black scale, data extracted, and synthesised using a narrative approach.
Twenty-one primary studies (N = 3075 participants), were included in this review. Eight studies reported significant improvements in pain intensity, and seven in physical functioning, in favour of the contextual factor intervention(s). Notable contextual factors included: addressing maladaptive illness beliefs; verbal suggestions to influence symptom change expectations; visual or physical cues to suggest pain-relieving treatment properties; and positive communication such as empathy to enhance the therapeutic alliance.
This review identified influential contextual factors which may augment conservative chronic low back pain care. The heterogeneity of interventions suggests modifying more than one contextual factor may be more impactful on patients’ clinical outcomes, although these findings require judicious interpretation.


Sherriff, B., Clark, C., Killingback, C., & Newell, D. (2022). Impact of contextual factors on patient outcomes following conservative low back pain treatment: systematic review. Chiropractic & manual therapies, 30(1), Article 20.

Journal Article Type Article
Acceptance Date Apr 11, 2022
Online Publication Date Apr 21, 2022
Publication Date 2022-12
Deposit Date Apr 28, 2022
Publicly Available Date Oct 27, 2022
Journal Chiropractic & Manual Therapies
Print ISSN 2045-709X
Publisher Springer Verlag
Peer Reviewed Peer Reviewed
Volume 30
Issue 1
Article Number 20
Keywords Contextual factors; Placebo effect; Chronic low back pain; Illness beliefs; Communication; Verbal suggestion; Physician–patient relations; Empathy; Therapeutic alliance
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Copyright Statement
© The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which<br /> permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the<br /> original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or<br /> other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line<br /> to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory<br /> regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this<br /> licence, visit 0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons. org/publicdomain/zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

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