Abstract
[Purpose] This study investigated the effectiveness of psychologically informed practice (PIP) combined with progressive exposure techniques in managing fear, pain, disability, depression, and anxiety among patients with chronic low back pain. It also examined the need for customized psychological interventions for these patients. [Participants and Methods] Nineteen patients with chronic low back pain participated in this study. The experimental group (n=9) received progressive exposure-based PIP combined with physical therapy, while the control group (n=10) received only physical therapy. The primary evaluation measures were fear (Tampa Scale for Kinesiophobia), perceived harmfulness (Photo Series of Daily Activities), pain (visual analogue scale), disability (Oswestry Disability Index), depression (Beck Depression Inventory), and anxiety (Beck Anxiety Inventory). Changes in these measures before and after the intervention were compared. [Results] The experimental group exhibited significant decreases in fear, pain, disability, and depression, with significant between-group differences observed for pain and depression. No significant change in anxiety was noted. [Conclusion] PIP combined with progressive exposure effectively reduced fear, pain, disability, and depression in patients with chronic low back pain, underscoring the importance of integrating psychological factors into treatment. Multidisciplinary approaches may improve long-term treatment outcomes and quality of life.
Keywords: Chronic low back pain, Psychologically informed treatment, Biopsychosocial model
INTRODUCTION
Low back pain is a prevalent chronic pain condition that imposes a significant social burden worldwide. More than 85% of patients with low back pain are diagnosed with non-specific low back pain (NSLBP), a condition for which the cause is difficult to identify1). NSLBP is influenced by a complex interplay of psychological factors—including depression, anxiety, self-efficacy, and prior pain education—and social factors such as activity level, economic burden, and quality of life2). Thus, a multidimensional approach based on the biopsychosocial (BPS) model is essential3). This model conceptualizes disease as the result of interactions among biological, psychological, and social factors3). Chronic pain conditions, including low back pain, are closely linked to psychological factors such as depression, anxiety, and fear4,5,6), all of which significantly influence pain persistence and disability levels7). Specifically, patients with high levels of fear tend to overestimate pain and are more likely to experience declines in physical function7). Hence, interventions that modify pain perception and enhance psychological stability are important. Cognitive behavioral therapy is an effective method for addressing psychological issues by targeting the interplay between cognition and behavior8). Psychologically informed physical therapy (PIP), a psychological intervention, has been recommended as a non-pharmacological pain management strategy since 20119), and has been demonstrated to reduce disability and pain in patients with low back pain10, 11). It is particularly effective in patients with high levels of fear12).
Graded exposure, a core component of PIP, alleviates patients’ fear by gradually introducing them to increasingly challenging movements13). Conversational techniques help build trust and enhance psychological stability14, 15). Nonetheless, the BPS model and associated psychological techniques are underutilized in clinical practice.
The purpose of this study was to evaluate the effectiveness of PIP in patients with chronic low back pain and to underscore the need for tailored psychological interventions that address individual psychological factors.
PARTICIPANTS AND METHODS
This study included 19 patients with chronic low back pain (control group: 10, experimental group: 9) from two hospitals in Cheonan and Ansan, Republic of Korea. The study was approved by Dankook University’s IRB (DKU 2024-10-032-010). The purpose and methods were explained to all participants, and written informed consent was obtained.
Initially, 28 individuals were selected based on predefined inclusion and exclusion criteria. One person with a history of hip replacement surgery and eight individuals who could not participate due to scheduling conflicts or lack of willingness were excluded. Participants were randomly assigned to the control group, which received only physical therapy, or the experimental group, which received both physical therapy and PIP. All participants underwent thermal therapy, ultrasound, and transcutaneous electrical nerve stimulation (TENS) for 45 minutes per session across five sessions over two weeks. The experimental group also received PIP for 30 minutes per session.
The inclusion criteria were a diagnosis of chronic low back pain lasting at least 6 months, with normal neurological examinations (i.e., no abnormalities in lower extremity muscle strength, sensory deficits, incontinence, or a positive straight leg raising test). Patients with spondylolisthesis or spondylolysis, who were at risk of the condition worsening during the intervention, were excluded.
The Tampa Scale for Kinesiophobia (TSK) was used to assess fear of movement and re-injury based on the fear-avoidance model. The Photo Series of Daily Activities (PHODA) evaluated patients’ perceived harmfulness of daily activities; for efficiency, the PHODA-Short Electronic Version (PHODA-SeV)—a condensed version of the original 100-photo series—was employed. Pain intensity was measured using the Visual Analogue Scale (VAS), scored from 0 (no pain) to 10 (very severe pain). The Oswestry Disability Index (ODI), a 10-item questionnaire, assessed physical function and pain; scores are expressed as percentages (0–20%: mild disability; 21–40%: moderate disability; 41–60%: severe disability; 81–100%: bedridden). The Beck Depression Inventory (BDI), a 21-item self-report measure, assessed depressive symptoms, with scores ranging from 0 to 63 and categorized as non-depressed (0–9), mild depression (10–15), moderate depression (16–23), and severe depression (≥24). The Beck Anxiety Inventory (BAI), also a 21-item questionnaire, evaluated anxiety symptoms over the past week on a scale of 0–3, with scores classified as no anxiety (0–21), moderate anxiety (22–31), and severe anxiety (≥32).
To increase participant adherence, a reminder text was sent one day before each intervention session. All interventions were performed by the same therapist. Baseline assessments (TSK, PHODA, VAS, ODI, BDI, and BAI) were completed at the first visit, and the same assessments were repeated after the two-week intervention period.
The control group received standard physiotherapy for chronic low back pain, which included heat therapy, ultrasound therapy (1 MHz, 1.5 W/cm2 for 5 minutes), and TENS (100 Hz for 20 minutes). The experimental group received additional PIP sessions. The PIP intervention comprised five 30-minute sessions over two weeks, employing two main techniques. The conversational technique addressed patients’ misconceptions regarding the causes of pain and alleviated their fears; discussions were tailored to TSK items rated as “3=agree” or “4=strongly agree”. Patients were informed that pathological changes do not always result in pain and that pain is a subjective experience. The progressive exposure technique identified five fear-inducing activities via the PHODA and gradually exposed patients to increasingly challenging tasks. Sessions were individualized based on each patient’s condition, ensuring that pain levels did not exceed a VAS score of 5. Treatment began with low-intensity movements, progressed to more complex movements, and the progression speed was adjusted according to each patient’s pain and fear levels.
Data analysis was performed using SPSS version 25.0. The Shapiro–Wilk test indicated that the main outcome variables did not follow a normal distribution; therefore, nonparametric methods were used. Within-group differences in TSK, pain, ODI, depression, and anxiety scores before and after the intervention were evaluated using the Wilcoxon signed-rank test, while the Mann–Whitney U test was employed to compare changes between groups. Statistical significance was set at α=0.05.
RESULTS
The general characteristics of the participants are summarized in Table 1.
Table 1. General characteristics of the participants (Unit: score).
| Variables | Control group (n=10) | Experimental group (n=9) |
| Gender (M/F) | 1/9 | 3/6 |
| Age (years) | 54.10 ± 15.08 | 40.44 ± 16.74 |
| TSK | 31.40 ± 8.77 | 34.55 ± 8.09 |
| VAS | 4.50 ± 2.36 | 4.44 ± 1.42 |
| ODI | 32.87 ± 19.78 | 25.38 ± 9.43 |
| BDI | 34.30 ± 8.75 | 21.33 ± 20.24 |
| BAI | 13.70 ± 12.15 | 11.66 ± 7.46 |
Values are presented as mean ± standard deviation; M: male; F: Female; TSK: Tampa scale for kinesiophobia; VAS: visual analogue scale; ODI: oswestry disability index; BDI: Beck depression inventory; BAI: Beck anxiety inventory.
Fear scores measured by the TSK decreased slightly in the control group (from 31.40 ± 8.77 to 30.30 ± 10.62, p>0.05) and significantly in the experimental group (from 34.55 ± 8.09 to 28.66 ± 5.67, p<0.05); however, the between-group difference was not statistically significant (p>0.05). Analysis of the PHODA-SeV showed that the experimental group rated previously feared activities (e.g., bending, lifting) as less harmful after the intervention, with photo selections shifting toward the “not harmful at all” category. In contrast, the control group showed little or no change. Pain scores, as measured by the VAS, decreased significantly in the experimental group (from 4.44 ± 1.42 to 2.33 ± 1.41, p<0.01) with a significant difference between groups (p<0.01), whereas the control group showed a non-significant reduction (from 4.50 ± 2.36 to 4.10 ± 2.07, p>0.05). Disability scores, assessed by the ODI, decreased significantly in the experimental group (from 25.38 ± 9.43 to 16.64 ± 5.46, p<0.05) but not in the control group (from 32.87 ± 19.78 to 29.27 ± 18.48, p>0.05), with no significant difference between groups (p>0.05) (Table 2). Regarding depression scores, the control group exhibited a slight, non-significant increase (from 34.30 ± 8.75 to 35.20 ± 12.90, p>0.05), whereas the experimental group demonstrated a significant decrease (from 21.33 ± 20.24 to 13.33 ± 13.05, p<0.05) with a significant difference between groups (p<0.05). For anxiety scores, the control group experienced a slight, non-significant decrease (from 13.70 ± 12.15 to 13.00 ± 11.76, p>0.05), and the experimental group showed a non-significant reduction (from 11.66 ± 7.46 to 8.33 ± 7.50, p>0.05). No significant between-group differences were observed for anxiety (p>0.05) (Table 3).
Table 2. Changes related to kinesiophobia, pain, and disability scores (Unit: score).
| Variables | Group | Pre | Post | Mean change | p-value |
| TSK | Control | 31.40 ± 8.77 | 30.30 ± 10.62 | 1.1 ± 1.85 | 0.61 |
| Experimental | 34.55 ± 8.09 | 28.66 ± 5.67 | 5.88 ± 2.41* | 0.03* | |
| Between-group | 0.20 | ||||
| VAS | Control | 4.50 ± 2.36 | 4.10 ± 2.07 | 0.4 ± 0.28 | 0.33 |
| Experimental | 4.44 ± 1.42 | 2.33 ± 1.41 | 2.11 ± 0.00* | 0.00* | |
| Between-group | 0.00* | ||||
| ODI | Control | 32.87 ± 19.78 | 29.27 ± 18.48 | 3.6 ± 1.29 | 0.22 |
| Experimental | 25.38 ± 9.43 | 16.64 ± 5.46 | 8.81 ± 4.02* | 0.01* | |
| Between-group | 0.23 | ||||
Values are presented as mean ± standard deviation; TSK: Tampa scale for kinesiophobia; VAS: visual analogue scale; ODI: Oswestry disability index; *p<0.05 (Wilcoxon signed-rank test); Between-group significance refers to group comparison using the Mann–Whitney U test: Significant between-group differences were found for VAS (p<0.05).
Table 3. Pre- and Post-intervention comparison of BDI and BAI scores (Unit: score).
| Variables | Group | Pre | Post | Mean change | p-value |
| BDI | Control | 34.30 ± 8.75 | 35.20 ± 12.90 | 0.9 ± 4.15 | 0.57 |
| Experimental | 21.33 ± 20.24 | 13.33 ± 13.05 | 8.0 ± 7.18* | 0.02* | |
| Between-group | 0.01* | ||||
| BAI | Control | 13.70 ± 12.15 | 13.00 ± 11.76 | 0.69 ± 0.39 | 0.48 |
| Experimental | 11.66 ± 7.46 | 8.33 ± 7.50 | 3.33 ± 0.03 | 0.08 | |
| Between-group | 0.12 | ||||
BDI: Beck depression inventory; BAI: Beck anxiety inventory; *p<0.05 (Wilcoxon signed-rank test); Between-group significance refers to group comparison using the Mann–Whitney U test: Significant between-group differences were found for BDI (p<0.05).
DISCUSSION
This study evaluated the effects of PIP combined with progressive exposure techniques on fear, pain, disability, depression, and anxiety in patients with chronic low back pain lasting more than six months. The results demonstrated significant reductions in fear (TSK), pain, disability, and depression in the experimental group, underscoring the value of combining psychological and physical interventions for effective chronic pain management16).
The observed reduction in fear aligns with previous research linking fear to physical stiffness and limited movement in chronic low back pain16). Patients with higher levels of fear tended to exhibit excessive muscle tension and slower movements, contributing to increased stiffness and delayed recovery17). Through conversational techniques, patients were reassured and learned to perceive pain as a subjective experience, thereby enhancing their confidence and promoting more natural movement. Gradual exposure to feared activities further reduced fear and improved mobility. Previous studies have reported that patients remain more active and experience less fear despite the presence of pain18). This combined intervention emphasizes the interrelationship between fear, pain, and disability in chronic pain management.
Pain reduction in the experimental group was clinically significant, with a mean reduction exceeding two points—a change considered meaningful19). Patients began to reframe pain as a protective mechanism, reducing its intensity and frequency20). Furthermore, disability significantly decreased as patients expanded their range of physical activities and corrected misconceptions about pain, leading to improved function and mobility21). The study also indicated that patients came to interpret sudden pain as a “positive protective signal” rather than a cause for fear or concern22). The observed reduction in depression suggests that alleviating pain and fear can enhance social participation and support mental health4). However, the reduction in anxiety was not statistically significant, possibly due to the short duration of the intervention; previous studies suggest that longer interventions (up to 1 year) yield more pronounced effects23). The control group exhibited only limited changes, consistent with evidence that physical therapy alone does not address the multifaceted causes of chronic low back pain24). Moreover, analysis of the PHODA-SeV revealed a reduced perception of harmfulness and fear in the experimental group, demonstrating that combining the TSK and PHODA-SeV provides a comprehensive evaluation of fear. These findings indicate that the intervention not only alleviated activity-related fear but also modified patients’ perceptions of harm, thereby increasing their confidence in movement.
This study further highlights the importance of the therapeutic relationship and patient-centered care in improving treatment outcomes. Pain education and effective communication were essential in fostering positive perceptions and encouraging active patient participation, thereby supporting an integrated treatment model25).
Despite its strengths, the study has several limitations. The small sample size and short intervention period limit the generalizability of the findings and preclude evaluation of long-term effects or the individual contributions of PIP and graded exposure techniques. Future research should involve larger, more diverse populations, extend the duration of the intervention, and assess the sustainability of effects over three months or longer. Additionally, the development and validation of multidisciplinary programs are necessary for broader clinical application.
In conclusion, this study emphasizes the importance of integrating psychological and physical approaches in managing chronic low back pain. It demonstrates the potential of PIP combined with progressive exposure to reduce pain, fear, disability, and depression, and advocates for the broader adoption of these methods in clinical practice.
Conflict of interest
The author declares no conflicts of interest.
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