Operationalisation of a biopsychosocial approach for the non-pharmacological management of patients with chronic musculoskeletal pain in low- and middle-income countries: A systematic review

Background
Chronic musculoskeletal pain is a major health concern. The biopsychosocial approach is an evidence-based approach recommended for managing chronic musculoskeletal pain. However, the evidence for this approach is largely reported from high-income countries; therefore, it is important to ascertain how biopsychosocial approaches are operationalised in low- and middle-income countries to inform practice.

Aim
To examine the evidence for the operationalization of biopsychosocial interventions in managing patients with chronic musculoskeletal pain in low-and middle-income countries.

Methods
The search included studies published in English from 2008 to September 2019 in: Cochrane library, OVID, CINAHL, Scopus, PUBMED, Web of Science, and SportDiscus. Randomised and non-randomised trials using a biopsychosocial intervention were considered. The review team developed a search strategy; two independent reviewers screened and assessed results for quality.

Results
Sixteen studies were included (n = 996) with mainly low back pain populations (n = 11 studies). Others were osteoarthritis (n = 1) and other musculoskeletal pain (n = 4). The majority (n = 12) of studies attained fair to poor quality, three had good quality, one scored excellent quality. Interventions applied biopsychosocial principles such as cognitive functional therapy, and graded activity, delivered by healthcare professionals such as physiotherapists and doctors. However, most results provided insufficient information regarding healthcare professionals' capacity to deliver interventions, lack of information regarding intervention delivery and training of healthcare professionals.

Conclusions
The results highlight the potential for delivering biopsychosocial interventions in low- and middle-income countries; however, future research should consider robust methodological approaches with clear details to achieve high-quality trials.