Chiropractic + Naturopathic Doctor

Research review: Behavioural therapy and back pain

Dr. Shawn   

Features Research

Biofeedback: Defined as “the process of gaining greater awareness of many physiological functions primarily using instruments that provide information on the activity of those same systems

Study title: Behavioural therapy approaches for the management of low back pain: An up-to-date systematic review
Authors: Vitoula K, Venneri A, Varrassi G et al.
Publication Information: Pain and Therapy 2018; 7(1): 1-12. doi: 10.1007/s40122-018-0099-4.

Background Information:

Low back pain (LBP) is one of the most common reasons for seeking medical treatment. It is often categorized by its temporal evolution, which is generally defined as follows: acute (lasting less than four weeks), subacute (lasting between four and 12 weeks) and chronic (lasting greater than 12 weeks) (1, 2). This temporal classification is important, as chronic pain may relate to prolonged, impaired quality of life due to psychological symptoms, in addition to physical symptoms, requiring adaptive interventions (3). 


The objective of this review was to summarize strategies and evaluate the evidence regarding the effectiveness of behavioural approaches in the management of patients with LBP.

Pertinent Results:


Biofeedback is defined as: ‘the process of gaining greater awareness of many physiological functions primarily using instruments that provide information on the activity of those same systems, with a goal of being able to manipulate them at will.’ As a relaxation technique aimed at educating patients to alter autonomic functions that are not normally under voluntary control (such as blood pressure, heart rate etc.), it has been found to be useful in reducing paraspinal muscle tension in patients with chronic LBP (4). Unfortunately, in a study of electromyography (EMG) biofeedback in patients with LBP, a direct analgesic effect was not found (5). 

Cognitive Behavioral Therapy: 

Cognitive behavioral therapy (CBT) is comprised of four components: 1) the patient’s understanding of pain and pain perception; 2) the use of active coping skills; 3) maintenance of pain-coping strategies; and 4) problem-solving skills that enable patients to deal with pain and challenging situations (6). CBT aims to assist patients in the development of adaptive thought patterns, as it is believed that the patient’s thoughts and beliefs about their symptoms will influence their behaviors (7). In patients with chronic LBP, a link between negative beliefs and increased pain perception has been demonstrated (8). 

Graded activity/graded exposure CBT strategies aim to increase an individual’s tolerance of activity (9). Individual sessions show similar effectiveness to physiotherapy (10) and motor control exercises (11), while group sessions have demonstrated significant improvements in pain intensity (12). These strategies have also been demonstrated to be a successful method of restoring occupational function and facilitating return to work in patients with subacute LBP (13). 

Individual sessions of CBT have often been studied as a component of a multidisciplinary approach, however the evidence is unclear, as some studies demonstrated a significant improvement in pain intensity when CBT was included (14, 15), while others did not (16-21). As a stand-alone therapy in a patient population of candidates for spinal surgery, those who received CBT demonstrated less fear avoidance at 12 months than the patients who underwent spinal fusion (22), and these findings were confirmed at the four-year follow up (23). It is likely the heterogeneity in patient populations, interventions and co-interventions is responsible for the disparity of these results. It is important to note that neither telephone-based (24) nor videotapes (25) were found to be effective forms of adjunctive therapy. 

Group sessions of CBT demonstrated similarly unclear results. In a study comparing multidisciplinary care (including CBT strategies) to traditional exercises, multidisciplinary care was found to be superior in reducing pain and kinesiophobia, de-catastrophizing and enhancing quality of life, and the effects lasted for two years following the intervention (26). Outpatient CBT sessions focused on negative reinforcement of pain behaviors reduced pain intensity for up to 12 months, particularly when combined with aerobic exercise (27). 

In a population of patients with the potential for acute, severe pain following surgery, preoperative CBT was found to facilitate mobility and reduce the need for rescue painkillers in the acute post-surgical phase (28). CBT may also be a beneficial intervention for patients with acute LBP, as it may prevent chronicity in these patients (29). CBT may also improve the quality of sleep (30) and decrease pain perception in patients with depression and anxiety (31). 

Mindfulness-Based Stress Reduction: 

Mindfulness has been described as “non-elaborative, non-judgmental, moment-to-moment awareness” (32). Mindfulness-based stress reduction (MBSR) includes meditation, yoga and body scan (sequential focus on different parts of the body) (32). These therapies are considered feasible, acceptable and safe for patients with LBP (33, 34). In addition to usual care, MBSR may result in improvements in pain and functional limitations in patients with LBP (35, 36). This form of treatment certainly warrants more research. 

Acceptance and Commitment Therapy: 

Acceptance and commitment therapy teaches patients how to accept unpleasant sensations and thoughts, without attempting to avoid or change them (37). The intention is not to reduce pain, rather to teach patients to accept the pain and let go of ineffective pain control strategies (37). This approach, as with some of the others discussed here, takes some time and requires further research. At the time of publication for this review, a study was underway in a population of patients with CLBP (38).

Clinical Application & Conclusions:

This review outlined behavioral strategies that may assist clinicians in treating patients with LBP. These therapies appear to be most effective in altering pain perception and regaining functionality. While the evidence is unclear, it appears that the addition of CBT to multidisciplinary care is the most effective way to incorporate behavioral strategies within the biopsychosocial model (most clinicians wouldn’t use this sort of thing as the sole intervention, so this makes sense!). Future research regarding specific interventions and outcomes (pain intensity, pain acceptance, reduction of medication use, disability and quality of life) will assist clinicians in personalizing therapeutic approaches based on patient-specific needs.

Study Methods:

  • A systematic literature search was conducted on PubMed using two Medical Subject Headings: ‘low back pain’ and ‘behavioral therapy’.
  • Articles had to meet the following criteria: original research, study human adult subjects, publication in English primarily focused on the effectiveness of behavioral therapy, and involve patients with LBP to be included.
  • Critical appraisal, data extraction and data synthesis were unfortunately not disclosed.

Study Strengths / Weaknesses:

  • This review provided a helpful summary of various behavioral strategies that may be used in the treatment of patients with LBP.
  • As CBT was the most widely researched strategy, findings were divided into method of use (individual session, group sessions, telephone/video) to assist clinicians in determining the most effective manner to utilize CBT with patients.


  • The primary limitation of this study is the lack of appropriate methodology. Without discussion of critical appraisal, these results must be interpreted with a great deal of caution, though they do provide an interesting overview of the literature regarding behavioral therapy for LBP.
  • Given the varied methodologies of the included studies, specifics regarding interventions cannot be gleaned from this review.
  • The paucity of research relating to most behavioral interventions limits the utility of the results and conclusions, but existing work is helpful for informing and stimulating future research.

Additional References:

  1. Koes BW, van Tulder MW, Thomas S. Diagnosis and treatment of low back pain. BMJ 2006; 332(7555): 1430–1434.
  2. Meucci RD, Fassa AG, Faria NM. Prevalence of chronic low back pain: systematic review. Rev Saude Publ 2015; 49.
  3. Zis P, Daskalaki A, Bountouni I et al. Depression and chronic pain in the elderly: links and management challenges. Clin Interv Aging 2017; 21(12): 709–20.
  4. Nouwen A. EMG biofeedback used to reduce standing levels of paraspinal muscle tension in chronic low back pain. Pain 1983; 17(4): 353–360.
  5. Bush C, Ditto B, Feuerstein M. A controlled evaluation of paraspinal EMG biofeedback in the treatment of chronic low back pain. Health Psychol 1985; 4(4): 307–321.
  6. Fordyce WE, Mosby CV. Behavioral methods for chronic pain and illness. Pain 1977; 3(3): 291–292.
  7. Moore JE. Chronic low back pain and psychosocial issues. Phys Med Rehabil Clin N Am 2010; 21(4): 801–815.
  8. Walsh DA, Radcliffe JC. Pain beliefs and perceived physical disability of patients with chronic low back pain. Pain 2002; 97(1–2): 23–31.
  9. Macedo LG, Smeets RJ, Maher CG et al. Graded activity and graded exposure for persistent nonspecific low back pain: a systematic review. Phys Ther 2010; 90(6): 860–879.
  10. Magalhaes MO, Muzi LH, Comachio J et al. The short-term effects of graded activity versus physiotherapy in patients with chronic low back pain: a randomized controlled trial. Man Ther 2015; 20(4): 603–609.
  11. Macedo LG, Latimer J, Maher CG, Hodges PW, et al. Effect of motor control exercises versus graded activity in patients with chronic nonspecific low back pain: a randomized controlled trial. Phys Ther 2012; 92(3): 363–77.
  12. Ogston JB, Crowell RD, Konowalchuk BK. Graded group exercise and fear avoidance behavior modification in the treatment of chronic low back pain. J Back Musculoskelet Rehabil 2016; 29(4): 673–84.
  13. Ogston JB, Crowell RD, Konowalchuk BK. Graded group exercise and fear avoidance behavior modification in the treatment of chronic low back pain. J Back Musculoskelet Rehabil 2016; 29(4): 673–684.
  14. Lindstrom I, Ohlund C, Eek C et al. Mobility, strength, and fitness after a graded activity program for patients with subacute low back pain. A randomized prospective clinical study with a behavioral therapy approach. Spine 1992; 17(6): 641–652.
  15. Khan M, Akhter S, Soomro RR et al. The effectiveness of Cognitive Behavioral Therapy (CBT) with general exercises versus general exercises alone in the management of chronic low back pain. Pak J Pharm Sci 2014; 27(4 Suppl): 1113–1116.
  16. Monticone M, Ferrante S, Rocca B et al. Effect of a long-lasting multidisciplinary program on disability and fear-avoidance behaviors in patients with chronic low back pain: results of a randomized controlled trial. Clin J Pain 2013; 29(11): 929–938.
  17. Barone Gibbs B, Hergenroeder AL, Perdomo SJ et al. Reducing sedentary behaviour to decrease chronic low back pain: the stand back randomised trial. Occup Environ Med 2018.
  18. Reme SE, Tveito TH, Harris A et al. Cognitive interventions and nutritional supplements (The CINS Trial): a randomized controlled, multicenter trial comparing a brief intervention with additional cognitive behavioral therapy, seal oil, and soy oil for sick-listed low back pain patients. Spine 2016; 41(20): 1557–1564.
  19. Guck TP, Burke RV, Rainville C et al. A brief primary care intervention to reduce fear of movement in chronic low back pain patients. Transl Behav Med 2015; 5(1): 113–21.
  20. Monticone M, Ambrosini E, Rocca B et al. A multidisciplinary rehabilitation programme improves disability, kinesiophobia and walking ability in subjects with chronic low back pain: results of a randomised controlled pilot study. Eur Spine J 2014; 23(10): 2105–2113.
  21. Lang E, Liebig K, Kastner S et al. Multidisciplinary rehabilitation versus usual care for chronic low back pain in the community: effects on quality of life. Spine J 2003; 3(4): 270–306.
  22. Brox JI, Sørensen R, Friis A et al. Randomized clinical trial of lumbar instrumented fusion and cognitive intervention and exercises in patients with chronic low back pain and disc degeneration. Spine 2003; 28(17): 1913–1921.
  23. Brox JI, Nygaard ØP, Holm I et al. Four-year follow-up of surgical versus non-surgical therapy for chronic low back pain. Ann Rheum Dis 2010; 69(9): 1643–1648.
  24. Rutledge T, Atkinson JH, Chircop-Rollick T et al. Randomized controlled trial of telephone-delivered cognitive behavioral therapy versus supportive care for chronic back pain. Clin J Pain 2017.
  25. Newcomer KL, Vickers Douglas KS, Shelerud RA et al. Is a videotape to change beliefs and behaviors superior to a standard videotape in acute low back pain? A randomized controlled trial. Spine J 2008; 8(6): 940–947.
  26. Monticone M, Ambrosini E, Rocca B et al. Group-based task-oriented exercises aimed at managing kinesiophobia improved disability in chronic low back pain. Eur J Pain 2016; 20(4): 541–551.
  27. Turner JA, Clancy S, McQuade KJ et al. Effectiveness of behavioral therapy for chronic low back pain: a component analysis. J Consult Clin Psychol 1990; 58(5): 573–9.
  28. Rolving N, Nielsen CV, Christensen FB et al. Preoperative cognitivebehavioral intervention improves in-hospital mobilisation and analgesic use for lumbar spinal fusion patients. BMC Musculoskelet Disord 2016; 20(17): 217.
  29. Hasenbring M, Ulrich HW, Hartmann M et al. The efficacy of a risk factor-based cognitive behavioral intervention and electromyographic biofeedback in patients with acute sciatic pain. An attempt to prevent chronicity. Spine 1999; 24(23): 2525–2535.
  30. Manber R, Edinger JD, Gress JL et al. Cognitive behavioral therapy for insomnia enhances depression outcome in patients with comorbid major depressive disorder and insomnia. Sleep 2008; 31(4): 489–495.
  31. Smeets RJ, Vlaeyen JW, Kester AD et al. Reduction of pain catastrophizing mediates the outcome of both physical and cognitive- behavioral treatment in chronic low back pain. J Pain 2006; 7(4): 261–271.
  32. Bishop SR, Lau M, Shapiro S et al. Mindfulness meditation and cognitive behavioral therapy intervention reduces pain severity and sensitivity in opioid-treated chronic low back pain: pilot findings from a randomized controlled trial. Pain Med 2016; 17(10): 1865–1881.
  33. Zgierska AE, Burzinski CA, Cox J et al. Mindfulness meditation-based intervention is feasible, acceptable, and safe for chronic low back pain requiring long-term daily opioid therapy. J Altern Complement Med 2016; 22(8): 610–620.
  34. Cherkin DC, Anderson ML, Sherman KJ et al. Two-year follow- up of a randomized clinical trial of mindfulness-based stress reduction vs cognitive behavioral therapy or usual care for chronic low back pain. JAMA 2017; 317(6): 642–644.
  35. Cherkin DC, Sherman KJ, Balderson BH et al. Effect of mindfulness-based stress reduction vs cognitive behavioral therapy or usual care on back pain and functional limitations in adults with chronic low back pain: a randomized clinical trial. JAMA 2016; 315(12): 1240–1249.
  36. Dahl J, Wilson KG, Nilsson A. Acceptance and commitment therapy and the treatment of persons at risk for long-term disability resulting from stress and pain symptoms: a preliminary randomized trial. Behav Ther 2004; 35: 785–801.
  37. Godfrey E, Galea Holmes M, Wileman V et al. Physiotherapy informed by Acceptance and Commitment Therapy (PACT): protocol for a randomised controlled trial of PACT versus usual physiotherapy care for adults with chronic low back pain. BMJ Open 2016; 6(6): e011548.

Dr. Shawn Thistle is a practising chiropractor, educator, international speaker, knowledge-transfer leader, evidence-based health care advocate, entrepreneur and medicolegal consultant. He founded RRS Education in 2006 and currently acts as the company’s CEO. RRS Education helps chiropractors and other manual medicine clinicians around the world integrate research into patient care via weekly research reviews, online courses and seminars.

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