Literature Review

The study aimed to compare the effectiveness of cognitive-behavioral group treatment, incorporating
relaxation training, with a control condition in 20 outpatients suffering from chronic low back pain. Both
groups received the same physiotherapy back-education and exercise program, with the control condition
addressing therapist attention in cognitive-behavioral treatment. Results indicated that the combined
psychological treatment and physiotherapy showed significantly greater improvement post-treatment in
measures such as other-rated functional impairment, active coping strategies, self-efficacy beliefs, and
medication use compared to the attention-control and physiotherapy condition. These differences were
sustained at the 6-month follow-up, particularly in the use of active coping strategies and, to a lesser
extent, in self-efficacy beliefs and other-rated functional impairment.

Nicholas, M. K., Wilson, P. H., & Goyen, J. (1992). Comparison of cognitive-behavioral group treatment
and an alternative non-psychological treatment for chronic low back pain. Pain, 48(3), 339-347.

This systematic review aimed to assess the effectiveness of combining cognitive-behavioral

therapy (CBT) with exercise versus exercise alone in managing non-specific chronic low back
pain (NSCLBP). The study conducted an electronic search of multiple databases and utilized
PRISMA guidelines for screening studies. Data extraction followed Cochrane Handbook of
Systematic Reviews guidelines, and risk of bias assessment used Cochrane Back Review Group
recommendations. Meta-analysis of four studies (n = 406 participants) revealed no significant
difference between groups in short-term, medium-term, or long-term outcomes for both pain and
disability. The findings suggest moderate-level evidence that adding CBT to exercise does not
improve pain and disability outcomes compared to exercise alone, but both interventions
demonstrate favorable results.

Kwesi Ampiah, P., Hendrick, P., & Gonzalez Macias, E. (2018). Comparative effectiveness of cognitive
behavioural therapy combined with exercise versus exercise in the management of non-specific chronic
low back pain: A systematic review with meta-analysis.

This study investigated the effectiveness of different treatments for non-specific chronic low
back pain, considering the deconditioning model, cognitive-behavioral model, and
biopsychosocial model. A randomized controlled trial in three rehabilitation centers compared
Active Physical Treatment (APT), Cognitive-Behavioral Treatment (CBT), Combined Treatment
(CT) of APT and CBT, and a Waiting List (WL) control group. Out of 223 patients, 212 were
analyzed using intention-to-treat. After a 10-week intervention, all three active treatments (APT,
CBT, CT) showed significant reductions in functional limitations, patient's main complaints, and
pain intensity compared to the WL. Self-rated treatment effectiveness and satisfaction were
higher in the active treatments. Physical performance improved in APT and CT but not in CBT.
No clinically relevant differences were found between CT and APT or between CT and CBT. In
conclusion, all three active treatments were effective compared to no treatment, with no
significant differences between combined and single-component treatments.
Smeets, R. J., Vlaeyen, J. W., Hidding, A., Kester, A. D., van der Heijden, G. J., van Geel, A. C., &
Knottnerus, J. A. (2006). Active rehabilitation for chronic low back pain: cognitive-behavioral, physical,
or both? First direct post-treatment results from a randomized controlled trial [ISRCTN22714229]. BMC
Musculoskeletal disorders, 7, 1-16.

This study employed a systematic review and network meta-analysis to assess the current
treatment options for chronic low back pain (LBP) based on randomized controlled trials
(RCTs). The objective was to compare the effectiveness of different treatments using a mixed-
treatment comparison (MTC).

Twelve RCTs were included, covering various comparisons such as total disk replacement
(TDR) versus fusion, TDR versus exercise and cognitive-behavioral therapy (CBT), fusion
versus exercise and CBT, and fusion versus physical therapy (PT). The analysis focused on
outcomes like ODI change scores, VAS back pain scores, additional surgeries, and
complications.

The MTC analysis revealed that all four treatments (TDR, fusion, exercise with CBT, and PT)
provided some benefit to patients with chronic LBP. According to the analysis, TDR appeared to
be the most effective treatment, while PT was considered the least effective. The study
emphasizes that the findings are based on a limited number of RCT studies and do not endorse a
one-size-fits-all treatment modality for all patients with chronic LBP.

Rihn, J. A., Radcliff, K., Norvell, D. C., Eastlack, R., Phillips, F. M., Berland, D., ... & Vaccaro, A. R.
(2017). Comparative effectiveness of treatments for chronic low back pain. Clinical Spine Surgery, 30(5),
204-225.

This study aims to present a narrative review of the role of cognitive-behavioral therapy (CBT)
in managing chronic nonspecific back pain. A literature search up to July 2012 was conducted
using PubMed and PsycINFO. The search criteria included terms related to CBT, chronic or low
back pain, and randomized controlled trials (RCTs). Results were based on RCTs and reviews of
RCTs, where interventions included both cognitive and behavioral components.

Out of 108 studies identified, 46 were included in the analysis. Categorized interventions
compared CBT to wait-list controls/treatment as usual, physical treatments/exercise,
information/education, biofeedback, operant behavioral treatment, lumbar spinal fusion surgery,
and relaxation training. The findings indicate that CBT is a beneficial treatment for chronic back
pain across various relevant variables, particularly when compared to wait-list controls/treatment
as usual. However, results for comparisons with other treatments were mixed and inconclusive.

In conclusion, the review suggests that CBT is effective in improving cognitive, behavioral, and
physical variables associated with chronic nonspecific back pain, especially when compared to
standard treatments. However, the evidence is less clear when compared to various other
interventions. The study proposes that future directions in chronic back pain management may
involve multidisciplinary and transdisciplinary interventions integrating CBT with other
approaches, tailored to specific circumstances and stakeholders. The authors emphasize the need
for future intervention studies to precisely define the use of cognitive-behavioral elements for
meaningful comparisons.

Sveinsdottir, V., Eriksen, H. R., & Reme, S. E. (2012). Assessing the role of cognitive behavioral therapy
in the management of chronic nonspecific back pain. Journal of pain research, 371-380.

This randomized controlled trial aimed to assess the effectiveness, cost-effectiveness, and impact
of patient preference on outcomes for individuals with persistent disabling low back pain (LBP).
Conducted in nine family medical practices in East Cheshire, UK, the study involved patients
aged 18 to 65 with LBP persisting after 3 months. Participants were randomized into two arms:
one receiving a 6-week group program of exercise and education with a cognitive behavioral
therapy (CBT) approach, and the other receiving an educational booklet and audio-cassette.
Primary outcome measures were pain (Visual Analogue Scale) and disability (Roland and Morris
Disability Scale).

Results, based on 196 subjects completing a 12-month follow-up, showed that the intervention
had a small and nonsignificant effect on reducing pain (-3.6 mm) and disability (-0.6 score). The
intervention's cost was relatively low, with an incremental cost-effectiveness ratio of £5000 (U.S.
$8650) per quality-adjusted life year. Notably, patients who expressed a preference for the
intervention demonstrated clinically important reductions in pain and disability. The study
concludes that the program has modest effects over a 1-year period, emphasizing the need for
further investigation into how patient preference for treatment influences outcomes.

Johnson, R. E., Jones, G. T., Wiles, N. J., Chaddock, C., Potter, R. G., Roberts, C., ... & Macfarlane, G. J.
(2007). Active exercise, education, and cognitive behavioral therapy for persistent disabling low back
pain: a randomized controlled trial.

This study aimed to assess the effectiveness of Cognitive Behavioural Therapy (CBT) combined
with General exercises compared to General exercises alone in treating chronic low back pain.
Fifty-four eligible patients were recruited from Alain Poly Clinic Karachi and Institute of
Physical Medicine & Rehabilitation Dow University of Health Sciences Karachi. The patients
were randomly divided into two groups: one receiving CBT and General exercises, and the other
receiving General exercises only, with both groups following a home exercise program. Both
groups received three treatment sessions per week for 12 consecutive weeks. Clinical assessment
using Visual Analogue Scale (VAS) and Ronald Morris Disability Questionnaire was conducted
at baseline and after 12 weeks.

Both study groups demonstrated statistically significant improvements in both outcome measures
(p = 0.000). However, the group receiving CBT and exercises showed better mean improvements
in post-intervention VAS score and Ronald Morris score compared to the General exercises
alone group. In conclusion, the study suggests that both interventions are effective in treating
chronic low back pain; however, the combination of CBT and General exercises appears to be
clinically more effective than General exercises alone.

Khan, M., Akhter, S., Soomro, R. R., & Ali, S. S. (2014). The effectiveness of Cognitive Behavioral
Therapy (CBT) with general exercises versus general exercises alone in the management of chronic low
back pain. Pakistan journal of pharmaceutical sciences, 27(4 SI), 1113-1117.

This randomized controlled clinical trial aimed to investigate the effectiveness of cognitive
behavior group therapy for back pain (CBT-BP) in improving pain tolerance, reducing disability,
and addressing somatization in individuals with chronic back pain. Fifty-three participants
received six sessions of CBT-BP, while 50 participants in the control group underwent
unspecific occupational therapy sessions. All patients underwent a 21-day multimodal orthopedic
rehabilitation program.

Results indicated a significant improvement over time in various measures, including the
Symptom Checklist (SCL-90), Rating of Health Locus of Control Attributions, Fear Avoidance
Beliefs Questionnaire (FABQS), and Visual Analogue Pain Scale (VAS-pain) for both groups.
However, the intervention group showed superior improvement in VAS-pain and FABQS
compared to the control group, while no significant differences were observed in the SCL. The
findings suggest that cognitive behavior group therapy has a specific treatment effect beyond the
benefits of a multimodal inpatient care program, directly altering the experience of pain and
contributing to the evidence base for this mode of treatment.

Linden, M., Scherbe, S., & Cicholas, B. (2014). Randomized controlled trial on the effectiveness of
cognitive behavior group therapy in chronic back pain patients. Journal of Back and Musculoskeletal
Rehabilitation, 27(4), 563-568.

The primary aim of this systematic review was to identify and examine randomized controlled
trials (RCTs) that investigated the application of cognitive-behavior therapy-based (CBT)
treatments for acute/sub-acute low back pain (LBP). A secondary objective was to analyze the
methodological characteristics of the included studies and identify theory-based treatment
strategies relevant for physiotherapists. The systematic literature search across four databases
resulted in the inclusion of eight studies. The review highlighted that half of the studies had a
high risk of bias, and various methodological domains, including treatment design and outcome
measures, exhibited variability. Graded activity, an operant treatment approach grounded in
operant conditioning principles, emerged as a CBT-based strategy with a clear theoretical
foundation applicable to physiotherapy practice. The conclusion emphasizes the potential
integration of operant conditioning in ambulant physiotherapy, presenting it as a promising CBT-
based strategy for preventing chronic low back pain.
Brunner, E., De Herdt, A., Minguet, P., Baldew, S. S., & Probst, M. (2013). Can cognitive behavioural
therapy based strategies be integrated into physiotherapy for the prevention of chronic low back pain? A
systematic review. Disability and rehabilitation, 35(1), 1-10.

This study compared three types of treatments for chronic musculoskeletal pain, focusing on 57
patients with chronic back pain and 21 patients with temporomandibular pain and dysfunction.
The treatments included electromyographic (EMG) biofeedback, cognitive-behavioral therapy,
and conservative medical treatment. Posttreatment improvements were observed in all three
groups, with the biofeedback group showing the most significant change. However, at the 6- and
24-month follow-up, only the biofeedback group maintained significant reductions in various
pain-related measures and an increase in active coping self-statements. The study suggests that
patients with musculoskeletal pain and few physical disabilities may benefit the most from short-
term EMG biofeedback treatment. Chronicity and treatment-specific variables were found to
predict treatment outcomes, and therapist and somatic pathology extent influenced attrition rates.
Overall, the results highlight the potential effectiveness of EMG biofeedback in managing
chronic musculoskeletal pain.

Flor, H., & Birbaumer, N. (1993). Comparison of the efficacy of electromyographic biofeedback,
cognitive-behavioral therapy, and conservative medical interventions in the treatment of chronic
musculoskeletal pain. Journal of Consulting and Clinical Psychology, 61(4), 653.

This single-blind randomized controlled trial aimed to compare the effectiveness of a

biobehavioral approach alone versus a combination of biobehavioral therapy with orthopedic
manual physical therapy in patients diagnosed with nonspecific chronic low back pain. Fifty
patients were randomly assigned to either group, with both receiving eight sessions over a period
of one month, consisting of two sessions per week. Somatosensory, physical, and psychological
variables were assessed at baseline, and during the first and third months after treatment
initiation.

Results showed that both treatment approaches were effective, with significant improvements in
all variables over time in both groups. However, there were no significant differences between
the two groups in terms of pain intensity or frequency, although notable intragroup differences
were observed at one- and three-month follow-ups. Secondary variables also did not exhibit
significant differences between the groups during the same follow-up period.

In conclusion, the study suggests that adding orthopedic manual physical therapy did not
enhance the effects of a biobehavioral therapy-based treatment in the short or medium term.
However, the results should be interpreted with caution, indicating the need for further
investigation and consideration of potential limitations.

Grande-Alonso, M., Suso-Martí, L., Cuenca-Martínez, F., Pardo-Montero, J., Gil-Martínez, A., & La
Touche, R. (2019). Physiotherapy based on a biobehavioral approach with or without orthopedic manual
physical therapy in the treatment of nonspecific chronic low back pain: a randomized controlled trial.
Pain Medicine, 20(12), 2571-2587.

This study aimed to assess the impact of cognitive-behavioral (CB) approaches on disability,
pain, quality of life, and work disability in patients with low back pain (LBP) across various
durations and age groups. A systematic search of nine databases was conducted, covering
randomized controlled trials (RCTs) up to November 2014. Two independent reviewers assessed
trial quality and extracted data. Standardized mean differences (SMD) and 95% confidence
intervals were calculated for individual trials, and pooled effect sizes were determined using a
random-effects model for two comparisons: CB versus no treatment (including wait-list and
usual care) and CB versus other guideline-based active treatment.

The review included 23 studies with a total of 3359 participants, primarily focusing on patients
with persistent LBP (>6 weeks). At long-term follow-up, CB interventions showed significant
improvements in disability and pain compared to no treatment (wait-list/usual care) and other
guideline-based active treatments. The pooled effect sizes favored CB interventions in terms of
disability and pain. Despite variations in methodological quality and intervention factors, the
study identified lower-intensity, cost-effective CB interventions that proved effective. In
conclusion, CB interventions demonstrate long-term benefits in pain, disability, and quality of
life for patients with LBP across different durations and age groups when compared to no
treatment or other guideline-based active treatments.

Richmond, H., Hall, A. M., Copsey, B., Hansen, Z., Williamson, E., Hoxey-Thomas, N., ... & Lamb, S. E.
(2015). The effectiveness of cognitive behavioural treatment for non-specific low back pain: a systematic
review and meta-analysis. PloS one, 10(8), e0134192.

This observational cohort study aimed to compare the effectiveness of physical therapy (PT)
with an interdisciplinary treatment approach in patients with chronic low back pain (CLBP).
Chronic low back pain is a costly and potentially disabling condition, and while PT, cognitive-
behavioral therapy, and interdisciplinary pain programs (IPPs) have shown superiority over usual
care, it remains unclear which approach is more effective.

The study involved 117 adult patients who completed an IPP for individuals with ≥3 months of
back pain and 214 adult patients with similar characteristics who completed PT. The primary
outcome measure was the Modified Low Back Pain Disability Questionnaire (MDQ). Additional
measures included various patient-reported outcomes. Patients from the IPP were matched to a
historical control group of PT patients using propensity score matching.

The results showed that patients in the IPP demonstrated significantly greater improvement in
MDQ scores compared to PT patients upon completion of treatment. A higher proportion of IPP
patients reached the clinically meaningful change threshold (≥10 point reduction) compared to
PT patients. Additionally, IPP patients showed statistically and clinically significant
improvement in social role satisfaction, fatigue, and sleep disturbance.
In conclusion, patients with CLBP in an IPP exhibited greater functional improvements
compared to similar patients participating in PT.

Davin, S., Lapin, B., Mijatovic, D., Fox, R., Benzel, E., Stilphen, M., ... & Katzan, I. L. (2019).
Comparative effectiveness of an interdisciplinary pain program for chronic low back pain, compared to
physical therapy alone. Spine, 44(24), 1715-1722.

The purpose of this study was to determine the effectiveness of physiotherapist-led cognitive-
behavioral (CB) interventions for low back pain (LBP) and to assess if these interventions were
described sufficiently for replication.
The researchers identified and analyzed five randomized controlled trials (RCTs) involving 1390
participants, comparing CB interventions led by physiotherapists with education and/or exercise
interventions. The outcomes assessed included disability, pain, and quality of life, utilizing the
GRADE approach. Additionally, the reporting quality of interventions was evaluated using the
Template for Intervention Description and Replication.
The findings revealed high-quality evidence that CB interventions led by physiotherapists had a
greater effect on reducing disability and pain compared to education and/or exercise
interventions. However, there was moderate-quality evidence of little difference in quality of
life. While sufficient information was provided on dose, setting, and provider, details regarding
intervention content and procedural information were lacking. The studies reported the type of
CB components used but provided limited detail on their operationalization. Additionally,
accessibility to treatment manuals, patient materials, and provider training was found to be
deficient.
In conclusion, the study suggests that with additional training, physiotherapists can effectively
deliver CB interventions for LBP. However, successful translation and implementation may be
hindered without proper training or resources. The researchers recommend that future studies
improve the reporting of procedural information, provide relevant materials, and offer accessible
training for providers.

Hall, A., Richmond, H., Copsey, B., Hansen, Z., Williamson, E., Jones, G., ... & Lamb, S. (2018).
Physiotherapist-delivered cognitive-behavioural interventions are effective for low back pain, but can
they be replicated in clinical practice? A systematic review. Disability and rehabilitation, 40(1), 1-9.

The study aimed to assess the effectiveness of group-based physiotherapy-led behavioral

psychological interventions (GPBPIs) for pain relief in adults with chronic low back pain
(CLBP). Thirteen randomized controlled trials published between 1998 and 2013 were reviewed,
and a meta-analysis was conducted following Cochrane Handbook guidelines.

The meta-analysis considered short-term (<6 months), intermediate-term (≥6 and <12 months),
and longer-term (≥12 months) effects of GPBPIs. The results indicated that long-term follow-up
evaluations showed significant and large effect sizes (standardized mean difference = −0.25,
95% confidence interval = −0.39 to −0.11, I2 = 38%, P < 0.01). Subgroup analysis revealed that
patients in the GPBPIs group experienced greater short-, intermediate-, and long-term pain
reduction compared to those in the waiting list or usual care group. When compared with other
active treatments, GPBPIs demonstrated a small but significant long-term reduction in pain for
patients with CLBP (standardized mean difference = −0.18, 95% confidence interval = −0.35 to
−0.01, I2 = 32%, P = 0.04).

In conclusion, the study suggests that GPBPIs may be a viable intervention for alleviating pain
intensity in individuals with chronic low back pain, particularly in the long term.

Zhang, Q., Jiang, S., Young, L., & Li, F. (2019). The effectiveness of group-based physiotherapy-led
behavioral psychological interventions on adults with chronic low back pain: a systematic review and
meta-analysis. American Journal of Physical Medicine & Rehabilitation, 98(3), 215-225.

The systematic review aimed to assess the effectiveness of advice/education compared to

exercise and/or manual therapy in managing chronic non-specific low back pain (NSLBP),
considering randomized controlled trials (RCTs). The study searched multiple databases and
included four RCTs involving 483 participants.

The results, based on low-risk bias studies, showed that two studies found a statistically
significant improvement in pain and functional capacities in the exercise group at short-term
follow-up (3 months), while one study favored the advice group, and another found no
significant difference between groups. Heterogeneity was identified in intervention nature,
outcome measures, treatment duration and frequency, and follow-up periods.

In conclusion, the evidence suggests low-quality evidence that exercise is not more effective than
advice/education for chronic NSLBP patients at short-term follow-up. The study highlights the
lack of high-quality research in this area and emphasizes the need for rigorous research to
compare the effectiveness of guideline-recommended interventions for chronic NSLBP.

Otoo, S. K. W., Hendrick, P., & Ribeiro, D. C. (2015). The comparative effectiveness of
advice/education compared to active physiotherapy (manual therapy and exercise) in the
management of chronic non-specific low back pain. Physical Therapy Reviews, 20(1), 16-26.

This randomized controlled trial aimed to compare the efficacy of classification-based cognitive
functional therapy (CB-CFT) with traditional manual therapy and exercise for non-specific
chronic low back pain (NSCLBP). The study included 121 patients aged 18-65, diagnosed with
NSCLBP for more than three months, and with specific inclusion criteria related to disability and
pain intensity. Linear mixed models were used for group differences in treatment effects.

Results showed that the CB-CFT group exhibited significantly superior outcomes compared to
the manual therapy and exercise group, both statistically (p < 0.001) and clinically. At the 12-
month follow-up, the CB-CFT group demonstrated a substantial improvement in Oswestry
Disability Index (13.7 points) and pain intensity (3.2 points), while the manual therapy and
exercise group showed lesser improvements (5.5 points and 1.5 points, respectively).
In conclusion, CB-CFT proved to be more effective in improving outcomes for NSCLBP
compared to traditional manual therapy and exercise.

Vibe Fersum, K., O'Sullivan, P., Skouen, J. S., Smith, A., & Kvåle, A. (2013). Efficacy of classification‐
based cognitive functional therapy in patients with non‐specific chronic low back pain: A randomized
controlled trial. European journal of pain, 17(6), 916-928.

This randomized controlled trial aimed to assess the efficacy of a cognitive-behavioral–based

physical therapy (CBPT) program in improving outcomes for patients undergoing lumbar spine
surgery. The study included 86 adults undergoing laminectomy with or without arthrodesis for
lumbar degenerative conditions, with preoperative screening for high fear of movement using the
Tampa Scale for Kinesiophobia.

Randomization to either CBPT or an education program occurred at 6 weeks post-surgery.

Assessments were conducted before treatment, post-treatment, and at a 3-month follow-up.
Primary outcomes included pain and disability measured by the Brief Pain Inventory and
Oswestry Disability Index. Secondary outcomes covered general health (SF-12) and
performance-based tests (5-Chair Stand, Timed Up and Go, 10-Meter Walk).

Multivariable linear regression analyses revealed that CBPT participants exhibited significantly
greater decreases in pain and disability, along with increases in general health and physical
performance compared to the education group at the 3-month follow-up. The findings suggest
that a targeted CBPT program may lead to substantial and clinically meaningful improvements in
postoperative outcomes, making it a potential evidence-based recommendation for patients at
risk for poor recovery after spine surgery.

Archer, K. R., Devin, C. J., Vanston, S. W., Koyama, T., Phillips, S. E., George, S. Z., ... & Wegener, S.
T. (2016). Cognitive-behavioral–based physical therapy for patients with chronic pain undergoing lumbar
spine surgery: a randomized controlled trial. The Journal of Pain, 17(1), 76-89.

This review aimed to investigate the effectiveness of cognitive-behavioral therapy (CBT) in

managing chronic low back pain (CLBP). Twenty-two articles were included in the analysis, and
the results suggested that CBT was superior to other therapies in improving disability, pain, fear
avoidance, and self-efficacy after intervention. No significant difference was observed between
CBT and other therapies in follow-up terms. Subgroup analysis indicated that CBT in
conjunction with other interventions was more effective in reducing pain and disability compared
to other interventions alone. The conclusion drawn from the meta-analysis is that CBT is
beneficial for improving pain, disability, fear avoidance, and self-efficacy in patients with CLBP.
The study recommends further research to investigate the long-term benefits of CBT in this
context.
Yang, J., Lo, W. L. A., Zheng, F., Cheng, X., Yu, Q., & Wang, C. (2022). Evaluation of cognitive
behavioral therapy on improving pain, fear avoidance, and self-efficacy in patients with chronic low back
pain: a systematic review and meta-analysis. Pain Research and Management, 2022.