Effects of cognitive behavioral therapy combined with physical therapy on improving outcomes in chronic low back pain

Abstract

[Purpose] This study aimed to investigate the effect of cognitive behavioral therapy (CBT) combined with physical therapy on improving outcomes in chronic low back pain (CLBP). [Participants and Methods] Participants were divided into two groups: Group A (31 participants) received CBT combined with physical therapy, and Group B (32 participants) received only physical therapy. Outcome measures at baseline and post-treatment were assessed using the Numeric Pain Rating Scale (NPRS), Oswestry Disability Index, Tampa Scale for Kinesiophobia, Pain Self-Efficacy Questionnaire, and Depression Anxiety Stress Scale-21. [Results] After 12 weeks of intervention, the pain relief effect, as measured using the NPRS, indicated that Group A experienced a reduction of 79.0% compared with the pretreatment period, whereas Group B showed a decrease of 58.0% during the same timeframe. However, Group A demonstrated a more significant improvement than did Group B. Additionally, enhancements in self-confidence during daily activities, reduction in motor avoidance, and overall psychological well-being were all more pronounced in Group A than in Group B. [Conclusion] Both groups demonstrated improvement following treatment; however, CBT combined with physical therapy resulted in greater enhancements in pain relief, psychological status, kinesiophobia, and daily functioning in patients with CLBP compared with that via physical therapy alone after 12 weeks of intervention.

INTRODUCTION

Low back pain is a common condition that affects motor function and daily activities and is one of the leading causes of disability worldwide¹⁾. Within 1 year, approximately 20.0–56.0% of adults experience low back pain, and most individuals experience it at some point in their lives. In the United Kingdom, the management and treatment of low back pain alone account for direct annual costs of approximately £2.8 billion annually²⁾. According to another study, approximately 10.0–15.0% of patients with acute low back pain progress to chronic low back pain (CLBP)³⁾. In clinical practice in Vietnam, low back pain is significantly common and is the leading reason why patients seek care at specialized, general internal medicine, and family medicine clinics⁴⁾. A cross-sectional study evaluating the prevalence and pain management in 48 of 63 provinces and cities, involving 12,136 individuals seeking medical care for pain, found that 27.7% of these individuals reported experiencing low back pain, making it the second most common pain location after headaches⁴⁾.

A widely accepted hypothesis suggests that CLBP results from the complex interplay of various factors, including biological, psychological, and social influences⁵⁾. Conditions, such as depression, stress, anxiety, and fear of movement, have been identified as contributing factors that increase the risk of persistent lower back pain and are associated with higher rates of functional impairment and disability in individuals with CLBP^6,7,8).

After experiencing pain, many individuals tend to develop a fear of movement, believing that physical activity exacerbates their pain. As a result, their daily activities and physical movements are limited. Consequently, their physical health declines, and they withdraw from engaging in meaningful and enjoyable life events. This leads to increased feelings of distress, self-disappointment, negative thinking, and helplessness. In turn, these negative emotions contribute to heightened pain, reinforcing the fear of movement, which further solidifies the pathological cycle and leads to greater disability owing to ineffective coping strategies.

Current management of CLBP focuses mainly on medication, physical therapy, acupuncture, and other treatments. However, pain still recurs, intervention is not comprehensive, and long-term effects are limited.

Cognitive behavioral interventions for chronic pain primarily aim to improve patients’ self-management skills, thereby helping to break and positively change the cycle of pain. This approach is based on the core principle that thoughts, actions, and emotions are closely interconnected and influence health-related issues. Changing negative thoughts, ineffective behaviors, and unhealthy emotions can help manage chronic pain⁹⁾.

Cognitive behavioral therapy (CBT) treats chronic pain using the following strategies: re-education and modification of distorted beliefs, emotions, and thoughts about pain; applying relaxation exercises, developing plans, and using pain-coping techniques; encouraging increased physical activity and participation in healthy and enjoyable activities; and enhancing patients’ ability to self-manage pain¹⁰⁾.

Physical therapy for patients with CLBP includes methods, such as manual therapy, therapeutic exercises, modalities (heat, transcutaneous electrical nerve stimulation), and traction therapy, with the aim of pain relief, muscle relaxation, and increased body muscle strength. There is limited research and clinical practice regarding Cognitive Behavioral Therapy (CBT) for patients with chronic low back pain in Vietnam. This study aimed to evaluate the effectiveness of CBT combined with physical therapy in patients with CLBP, exploring its potential as a culturally adapted approach in Vietnam.

PARTICIPANTS AND METHODS

This was a prospective controlled study. Data were collected from patients diagnosed with CLBP who were treated at the Department of Rehabilitation, Hanoi Medical University Hospital, Vietnam, between October 2022 and December 2023.

The following patients were included in this study: (1) patients ≥18 years diagnosed with CLBP, with disease progression lasting >12 weeks; (2) patients receiving outpatient treatment requiring ≥5 sessions; and (3) participants who complied with the treatment protocol and agreed to participate in this study. The exclusion criteria were as follows: (1) lumbar pain requiring surgery, (2) severe osteoporosis or malignancy, (3) cognitive disorders, and (4) concomitant medical conditions that prevented patients from complying with the exercise program. This study was approved by the Research Proposal Committee of Hanoi Medical University, under decision No. 3958/QĐ-ĐHYHN, dated September 26, 2022. The study process and objectives were explained to each participant. All the patients provided written informed consent to participate in this study.

Sample size calculation, based on a similar study by Vibe Fersum et al. and using the formula for controlled intervention studies, resulted in 26 patients per group¹¹⁾. Sixty-three patients were selected. Group A (n=32) received physical therapy according to a regular program (exercises for patients with low back pain combined with physical therapy). Group B (31 patients) received the same intervention as the control group combined with CBT.

This was a controlled prospective study. The participants were randomly assigned in a 1:1 ratio to either the intervention or control group. The participants were first paired based on similar characteristics; then, within each pair, randomization was used to assign one participant to the intervention group and the other to the control group.

Step 1: Selection of patients and assigning them to study groups

The patients with CLBP were admitted, examined, and diagnosed. Information was collected and assessed, records were made, and intervention plans were made. Patients who met the selection criteria were assigned to one of the two groups.

Step 2: Intervention

Group A: Physical therapy intervention was implemented according to the regular program.

Group B: Regular physical therapy combined with CBT was implemented. The clinical physician in the rehabilitation department is responsible for conducting Cognitive Behavioral Therapy (CBT) interventions for patients. The CBT program consisted of six sessions, each corresponding to a different stage (Fig. 1).

Fig. 1.

Flowchart of the study design.

CLBP: chronic low back pain.

Cognitive behavioral intervention sessions were conducted in parallel with physical therapy training sessions in a 1:1 format. Each intervention session lasted for approximately 2 h. Each intervention session followed a general structure that included the introduction of the module and confirmation of the agenda; inquiries about mood, symptoms, and discussion of relevant findings; review of material from the previous module, including home practice activities, addressing any questions; introduction of new content and clarification of any questions; discussion of new home practice assignments; and conclusion and wrap-up of the module.

The details of the module were as follows:

Module 1. Education and goal setting: chronic pain education, effects of pain, and goal identification and utilizing the Specific, Measurable, Achievable, Realistic, and Timely (SMART) criteria to establish short- and long-term goals.

Module 2. Activities and Pacing: distinguishing hurt vs. harm and incorporating pleasant activities.

Module 3. Relaxation training: education on relaxation techniques and creating a tracking system to monitor relaxation frequency and depth over time.

Module 4. Cognitive coping: recognizing and modifying unhelpful thoughts that negatively influence the pain experience, exploring the relationship between thoughts and pain, and identifying pain-related thoughts.

Module 5. The pain action plan: reviewing progress, emphasizing notable improvements in function or mood during treatment, anticipating potential obstacles, and developing coping strategies to identify pain triggers and appropriate responses, action planning using Weekly Activity logs, and setting future short- and long-term goals using the SMART goal setting framework.

Module 6. Review, adjustment, and maintenance: reviewing tasks and skills applied by the patient; assessing adherence, progress, and areas requiring adjustment to enhance success; evaluating the overall process and effectiveness of cognitive behavioral interventions in daily living; reinforcing the ongoing application and maintenance of CBT techniques; and session wrap-up and evaluation, documentation, analysis, and comparison of results and characteristics across groups.

The measurement tools used in this study included the following: The Numerical Pain Rating Scale (NPRS) is used to assess pain intensity in patients with CLBP; the Oswestry Disability Index (ODI), after scoring, is converted into a percentage reflecting the level of disability in individuals with CLBP, as shown in daily living activities; the Tampa Scale of Kinesiophobia (TSK) allows for the evaluation of an individual’s fear of movement or reinjury after experiencing pain; the Pain Self-Efficacy Questionnaire (PSEQ) is a self-report tool used to assess the confidence level of individuals with chronic pain, such as those with CLBP, in performing various activities; and the Depression Anxiety Stress Scale-21 (DASS-21) is a self-report questionnaire reflecting the severity of psychological conditions, including depression, anxiety, and stress.

A p-value <0.05 was considered statistically significant. Binary logistic regression was used to examine the relationship between variables using the χ² test and Student paired and unpaired t-tests employed for analysis. Data were analyzed using the IBM SPSS Statistics 20 software.

RESULTS

Sixty-three patients were eligible for this study, with Group A consisting of 31 patients and Group B consisting of 32 patients. The sex distributions were 5:10 males and 26:22 females in Groups A and B, respectively. Along with this, 8:5 samples with ages ≤30 years, 17:21 samples with ages 31–60 years, and 6:6 samples with ages >60 years were observed in Groups A and B, respectively. There were no statistically significant differences in patient age and sex between the two groups, according to the χ² test results (Table 1).

Table 1. General characteristics of the participants.

Variables		Group A (Intervention group) (n=31)	Group B (Control group) (n=32)
Age range (years), n (%)	≤30	8 (25.8)	5 (15.6)
	31–60	17 (54.8)	21 (65.6)
	>60	6 (19.4)	6 (18.8)
Sex, n (%)	Male	5 (16.1)	10 (31.2)
	Female	26 (83.9)	22 (68.8)

Table 2 shows the statistical analysis of all outcome measures, the significant pre- and post-treatment values within groups, and post-treatment values between groups. The results of this study revealed that Group A significantly outperformed Group B in terms of pain, psychological status, kinesiophobia, and daily functioning in patients with CLBP (Table 2).

Table 2. Comparison of NRPS, ODI, PSEQ, TSK, and DASS-21 findings between groups.

Variables		Group A (Intervention group)		Group B (Control group)
		Week 0	Week 12	Week 0	Week 12
NPRS		5.52 ± 1.18	1.16 ± 0.89**	4.97 ± 1.23	2.09 ± 1.12
ODI		46.12 ± 16.06	24.48 ± 8.04*	39.08 ± 12.73	30.84 ± 14.02
PSEQ		30.58 ± 4.15	49.19 ± 5.36**	34.13 ± 7.51	33.66 ± 7.69
TSK		45.77 ± 5.95	22.52 ± 3.08**	45.66 ± 4.97	42.16 ± 0.90
DASS-21	Anxiety	10.45 ± 4.97	4.61 ± 3.38**	8.56 ± 4.96	7.88 ± 4.34
	Stress	13.65 ± 5.53	4.52 ± 4.10*	9.53 ± 6.36	7.63 ± 6.33
	Depression	9.10 ± 4.64	4.16 ± 3.83**	6.94 ± 4.50	7.56 ± 6.06

Statistical significance of multiple comparisons: *p<0.05, **p<0.01.

NPRS: Numeric Pain Rating Scale; ODI: Oswestry Disability Index; PSEQ: Pain Self-Efficacy Questionnaire; TSK: Tampa Scale for Kinesiophobia; DASS-21: Depression Anxiety Stress Scale 21.

DISCUSSION

This study found that the prevalence of CLBP was the highest in individuals in their 30s, with a higher incidence observed in women than in men. Similarly, Jones et al.¹²⁾ reported that the mean age of their participants was 47 (interquartile range, 38–56) years. The increased prevalence of CLBP in individuals aged 30–60 years may be attributed to occupational factors, as this is the working-age range, where physical activities or postures in the workplace cause excessive strain on the lower back, combined with degenerative processes that typically occur after the age of 30 years.

This study showed an improvement in NPRS post-treatment scores in both groups after 12 weeks of intervention. The pain relief effect in Group A was nearly double that of Group B. The combination of CBT intervention and a basic physical therapy program results in better pain reduction in patients with CLBP than in those receiving only conventional physical therapy, as demonstrated by Lamb et al¹³⁾. Furthermore, Monticone et al. conducted a more extensive study lasting up to 3 years, with the final assessment point at 24 months, and the pain reduction efficacy of the intervention group remained higher than that of the control group (p<0.001)¹¹⁾. Pain is often the primary issue driving individuals to seek medical consultation and treatment. Improving pain management is particularly important in patients with chronic pain. After the healing process, biological factors within the body are typically repaired and pain issues may be addressed. However, if pain persists in a manner disproportionate to the injury, psychological and social factors may contribute to the ongoing pain. CBT intervenes in the chronic pain cycle by breaking pathological loops. The pain reduction achieved comes from addressing underlying psychological and social issues.

Avoidance of physical activity and restriction of physical exertion in patients with CLBP over an extended period lead to negative effects on the musculoskeletal and cardiovascular systems, thereby exacerbating pain¹⁴⁾. In a study by Bunzli et al., a group of participants achieved pain reduction and reported that by understanding their lower back pain, they felt less fear and had a better sense of control over the pain and their responses to pain became more positive. CBT offers patients relevant information to enhance their understanding of their condition. Once patients gain a clearer understanding, they experience reduced anxiety and fear related to unwarranted threats posed by pain, leading to changes in their emotional responses and pain-related behaviors. Achieving this understanding requires a structured approach that includes providing a clear explanation and an accurate diagnosis, elucidating symptoms, and addressing misconceptions and erroneous beliefs about pain. Additionally, CBT incorporates coping strategies designed to equip patients with tools to effectively manage their condition. When individuals acquire these coping mechanisms and recognize the consequences of their prior maladaptive behaviors, they gradually regain the ability to engage in enjoyable and meaningful activities, thereby improving their overall quality of life¹⁵⁾. We observed that the improvement in pain was the result of physical enhancement through activity and cognitive improvement.

Our findings suggest that CBT has a significant effect on disability (ODI), pain self-efficacy (PSEQ), fear avoidance behavior (TSK), and psychological issues related to central sensitivity, which are neglected by conventional physiotherapy.

CLBP can lead to limitations in the ability to perform daily activities, resulting in functional disability and affecting quality of life. This is because the initial pain potentially increases when standing, sitting, or moving, leading to reduced participation in activities. Reinforcement of the belief that limiting movement can prevent pain exacerbation causes individuals to engage in fewer activities. They tend to avoid daily tasks, thereby increasing their levels of disability.

A vicious cycle occurs in which avoidance behaviors lead to physical disability and an increase in negative emotions, which in turn exacerbate the intensity and duration of pain, and vice versa. Psychological factors, such as depression, anxiety, kinesiophobia, and low self-confidence, in coping with pain are associated with an increased risk of symptom escalation in patients with CLBP^{6, 7, 16)}. La Touche et al. examined the relationship between psychological variables, lumbar spine range of motion, and pain intensity in patients with CLBP in a cross-sectional study. The results showed that patients with low self-confidence tended to experience increased pain when performing heavy-lifting tasks¹⁷⁾. Individuals with low self-confidence may worry that lifting heavy objects will cause harm or pain. When anxiety and fear persist, the body may react by tensing the muscles and creating unnecessary strain, leading to an increase in pain. Alternatively, a lack of confidence in engaging in activities may create a cycle that results in physical decline, muscle weakness, and the lifting of heavy objects, exacerbating pain. Therefore, we agree with the perspective that fear avoidance is characterized by avoidance behaviors, reduced participation in daily activities, diminished involvement in enjoyable and meaningful tasks, and lack of self-confidence in performing activities, all of which predict worse pain outcomes¹⁸⁾.

The disability status due to lower back pain in Group A patients showed a more significant improvement than that in Group B patients after 12 weeks of intervention. Physical therapy methods, such as exercise and stretching, not only help reduce pain but also enhance mobility and improve muscle strength, flexibility, and the ability to perform daily activities independently. However, for patients with chronic pain, pain persists despite undergoing various treatment methods, indicating that interventions targeting only physical biological factors are insufficient. If not addressed, psychological factors may limit the effectiveness of the treatment. The combination of CBT can help patients change their negative thoughts about their abilities, reduce feelings of inadequacy and anxiety when performing activities, and foster positive changes in cognition and psychology, thereby improving the overall effectiveness of lower back pain treatment.

Educating patients on how to modify their incorrect fears and encouraging the adoption of appropriate behaviors fostered early positive attitudes toward perceived disability. As patients adjusted their beliefs about the possibility of engaging in activities despite pain, they became more comfortable with their usual tasks, which, in turn, enhanced their positive attitudes toward exercise and improved their physical performance. Increased engagement in daily activities led them to recognize their ability to accomplish these tasks, and participating in meaningful activities contributed to an improved mood and greater happiness. It is likely that the key factor in these changes was psychological intervention, which may have cognitively reshaped the patients’ subjective perceptions of disability.

The PSEQ is used to assess the effectiveness of self-management in pain reduction and reflects an individual’s belief in his/her ability to perform, organize, and complete specific tasks to achieve a goal. The positive changes observed in Group A compared with Group B are believed to be attributable to CBT. For patients with irrational fear, adjusting their attitudes and encouraging behaviors while enhancing appropriate positive cognition will help patients with CLBP engage in activities despite experiencing pain. This approach enables them to feel more comfortable with daily tasks, improves their physical health, and develops more positive attitudes toward activities. As they participated more in daily activities, they recognized their ability to complete these tasks, thereby improving their mood and increasing their overall sense of well-being.

A comprehensive approach to chronic pain is the biopsychosocial model, which emphasizes that an individual’s condition should be evaluated from a biological perspective and psychological and social factors¹⁹⁾. Misconceptions and beliefs can influence a patient’s mood, behavior, and psychological state, and these factors have been studied and shown to be strongly correlated with the persistence of chronic pain²⁰⁾. Previous studies have demonstrated a correlation between chronic pain and psychological issues, indicating that individuals with chronic pain are more likely to experience anxiety and depression. Conversely, those with psychological distress are at a higher risk of developing chronic pain²¹⁾. The relationship between chronic pain and psychological distress is complex and proportional, with each factor potentially influencing and exacerbating the other²²⁾.

CBT is one of the most widely used psychological approaches to manage chronic pain²³⁾. Various forms of CBT are employed not only to treat chronic pain but also to address related conditions, such as anxiety and depression^{24, 25)}. The effectiveness of this intervention on stress, depression, and anxiety in our study was consistent with the findings of a previous study by Nicholas et al²⁶⁾.

In conclusion, the findings of this study indicate that both groups demonstrated improvement following treatment. However, physical therapy combined with CBT results in greater enhancements in pain relief, psychological status, kinesiophobia, and daily functioning in patients with CLBP than physical therapy alone after 12 weeks of intervention.

Funding

No funding was received.

Conflict of interest

The authors declare no conflict of interest.