- Chronic back pain impacts millions of Americans.
- New research revealed that combining cognitive behavioral therapy (CBT) with tailored exercises could significantly support pain management.
- CBT is designed to change the way individuals thought processes, focus, and attitudes.
- The new findings highlight the importance of individualized treatment plans in treating chronic pain.
An ailment that can strike at any time, chronic back pain is one of the leading causes of disability. It contributes to everything from sleepless nights and depression to missed work and reduced income.
Painkillers and rest are two popular approaches taken to ease its symptoms. However, new research from Goethe University Frankfurt has revealed that combining tailored exercises with cognitive behavioral therapy (CBT) might be an optimal approach to treating chronic back pain.
The study analyzed data from 58 randomized control trials comprising over 10,000 individuals with chronic lower back pain. The researchers looked at the efficacy of three different treatment approaches, including standard exercise, individualized, and individualized care with CBT.
Standard exercise treatments comprise activities such as Pilates, while individualized care involves tailored exercises created with a medical professional, such as a physiotherapist. CBT, meanwhile, is a talking therapy designed to alter a person’s thoughts and behaviors.
Individualized care was found to be 38% more effective at reducing pain than standard exercise treatments, as it focuses more on the patient, their pain, and their needs.
However, when researchers looked at the impact of CBT and individualized care combined — known as a ‘multimodal approach’ — the benefits were remarkable: 84% higher than standard treatment alone.
Dr. Johannes Fleckenstein, from the Institute of Sports Sciences at Goethe University Frankfurt and co-author of the research, revealed the benefits were optimal in the shorter term (three months or less).
However, he noted, “at one year, effects can still be observed — [they are just] smaller. Pain and disability are still reduced compared to the initial level.”
One reason improvements may have declined? The data didn’t allow the researchers to see whether participants adhered to treatment — and consistency is critical.
“I am sure that effects are stronger in groups where a minimum level of counseling is obtained through the year or in patients that continued with CBT training,” Fleckenstein hypothesized.
Before diving into CBT, let’s look at what chronic back pain involves.
“Back pain is one of the most common reasons why Americans over the age of 45 seek medical care,” Dr. Ronald Tolchin, medical director of the Spine Center at Baptist Health Miami Neuroscience Institute, told Healthline.
Pain is deemed ‘chronic’ if it persists for three months or longer, and it can impact all ages.
“Some issues are from long-term wear and tear and can affect older individuals or people with old injuries,” explained Dr. Ai Mukai, a board certified physiatrist at Texas Orthopedics, Sports and Rehabilitation Associates.
“Meanwhile, others are more commonly seen in young individuals (like pars fractures),” she noted.
According to Tolchin and Mukai, factors contributing to chronic back pain include:
- Muscle pain through poor posture or straining
- Joint pain, such as from arthritis or inflammation
- Sacroiliac joint (a pelvic joint) pain
- Spinal disc issues
- Sedentary lifestyle
- Being overweight
- Types of cancer
As for the main symptoms? These are:
- Pain in the back
- Weakness in the leg(s)
- Difficulty moving
“Mood disorders, like depression and anxiety, sleep disturbances, and stress can also impact the chronicity and perception of pain,” stated Mukai. And this is where CBT comes in.
“In CBT, you’ll work with a therapist to identify unhelpful thoughts and behaviors and replace them with balanced thoughts and healthy behaviors,” Dr. Whitley Lassen, clinical director of mental health services at digital care app K Health, told Healthline.
Numerous types of talk therapies are available, such as psychoanalysis, which delves into unconscious thoughts and feelings as a route for self-improvement.
In comparison, “CBT is not such an extended process” and doesn’t focus on “the introspective journey,” explained Laurie Singer, a board certified behavior analyst and founder of Laurie Singer Behavioral Services.
Instead, “it’s a swift, satisfactory correction of a single issue, or multiple combined issues, that have taken control of a life,” she added.
Many studies have previously shown how CBT alone can improve back pain perception.
For example, an analysis of individuals with chronic back pain saw CBT reduces pain-related catastrophizing thoughts (when someone assumes that the worst will happen) and improves attitudes. Meanwhile, individuals in another study experienced a significant decrease in pain and fear-avoidance beliefs following CBT.
“CBT for pain management works in several different ways,” Clare Flaxen, CBT therapist and mindset mentor, told Healthline. But how?
First, Lassen explained it’s important to understand that “CBT can’t change your pain.”
Instead, she continued, it can aid in transforming “unhelpful or negative thinking patterns related to pain [and] your reaction to it.”
The study researchers noted that, following CBT, participants became less afraid to move around. So how did CBT lead to this outcome?
“If you are saying to yourself, ‘I can’t cope with the pain,’ that unhelpful thought may intensify emotions like fear,” explained Lassen.
But, with CBT, you can “change your thought from ‘I can’t cope with the pain’ to a more balanced thought like, ‘I had pain before and survived. I can cope with this,” she continued. This change in attitude ultimately alters your overall reaction to the pain.
Another tool CBT provides is a distraction. Being highly aware and fearful of pain puts you at greater risk of feeling and registering it, shared Dr. Peggy Loo, a licensed psychologist, and director at Manhattan Therapy Collective.
CBT teaches you to focus on more positive thoughts instead, helping us to “completely forget about pain because our attention is somewhere else.”
Because the mind and body are intrinsically related, CBT can assist on a physiological level.
“By reducing stress and distress, you’re able to calm your stress responses down,” Flaxen explained. “Which, in turn, can reduce the amount of pain experienced.”
Trying to suppress or ignore feelings and worries can actually make them more prominent.
CBT enables you to recognize that you’re in charge of your thoughts and “focus on goals and positive actions,” stated Flaxen. “It’s an empowering process.”
Indeed, the researchers found that, following the multimodal approach, study participants could acknowledge that pain needn’t render them helpless.
While CBT can ultimately aid pain management, Loo highlighted that the therapy “is not an alternative to sound medical care.”
She continued: “I’d recommend that a CBT therapist work closely with a person’s physician to differentiate what falls under the category of pain management and what may require further medical intervention.”
Therapy varies between an individual, their concerns, and their goals. In the new study, the researchers did not analyze particular discussion points or approaches taken by therapists.
However, Flaxen revealed that typical elements of a CBT session include:
- If you’re a new patient, the therapist will obtain an outline of your pain experience and brief medical history.
- Then, guided questions “take you through the different processes of understanding your thoughts, emotions, and behaviors.”
- The therapist will assist you in recognizing and changing unhelpful thought patterns. For example, you may be asked to describe how you felt physically and emotionally during a pain flare-up.
- You’ll then be asked to identify negative thought processes, such as generalization (‘If I’m in pain today, it’ll be bad all week’) and catastrophizing (‘This pain will never end’).
- From there, you’ll collaboratively “come up with alternative ways of thinking about the situation and actions that could be taken to create different, more positive outcomes.” After the session, it’s time to test these out.
- “You can also expect support for managing emotions, learning pain management techniques (such as pacing or progressive muscle relaxation), and increasing activities that bring pleasure and enjoyment.”
While CBT can aid in aspects of pain management, “like any approach, it’s not going to be effective for everyone,” Flaxen said.
CBT doesn’t change the root cause of pain but rather the thinking around it. As such, some cases might require more extensive measures — for example, surgery to deal with a slipped disc.
As to whether CBT might benefit you, experts say a lot of its success is due to commitment and disposition.
“An individual must be willing to do the work involved in CBT. There needs to be a willingness to create and execute a plan of action,” stated Singer. “There is no magic wand with CBT. It requires a personal commitment.”
Engaging in CBT for a certain length of time is also critical, as this therapy is “not an overnight fix,” Flaxen explained. “For chronic pain management, people usually have 5-20 sessions.”
- Poor language/communication skills
- Low emotional value judgment
- The tendency of medical dependency
- Excessive focus on searching for pain
- Fantasy/distortion of actual experience
To get started, Loo recommended searching CBT therapist directories — such as the Association for Behavioral and Cognitive Therapies website.
Directories allow you to search by specialties, meaning you can specifically look for therapists who deal with pain. “Health psychologists often focus on the intersection of mental and physical health, so chronic pain falls into their wheelhouse,” noted Loo.
To ensure a therapist is a right fit for your needs, Singer suggested “asking if they’ve worked with anyone [with] similar symptoms and what their type of therapy entails.”
She added that it’s OK to speak honestly to a prospective therapist and that you should pay attention to your gut feeling.
New research indicated that a combined, individualized therapy approach — combining CBT and physiotherapy exercises — can significantly reduce chronic back pain.
Fleckenstein stated the findings highlight the importance of individualized therapy in managing chronic back pain and the value of incorporating CBT into treatment plans.
“Our data shows [individualized care] to be justified; patients will perceive larger benefits,” he said. “Our analysis…should encourage stakeholders and decision-makers to prioritize individualized multimodal pain therapy.”