CBT based strategies, physiotherapy and low back pain

Goldfish jumps out of bowl

We Musculoskeletal Elves are always keen to promote the use of psychosocial interventions by healthcare professionals in the management and prevention of chronic low back pain (LBP). However, the content as well as the treatment theory of psychosocial interventions, such as cognitive behavioural therapy (CBT), remains vague.

The CBT concept for chronic LBP has been distinguished into three different treatment approaches: operant, cognitive, and respondent treatment (Henschke et al, 2010), but the lack of clarity as to which approach should be followed makes the clinical decision making process with regard to targeting adequate treatments for a patient difficult.

Therefore, it was with interest that a systematic review by Brunner et al (2013) was sourced that detected randomised controlled trials investigating cognitive behaviour therapy-based (CBT) treatments applied in acute/sub-acute low back pain (LBP). The review’s secondary purpose was to analyse the methodological properties of detected trials, and finally to find theory based treatment strategies that are applicable for physiotherapists.

Here’s what they did

Articles were included if they fulfilled all of the following criteria: randomised controlled trial (RCT); non-specific LBP lasting for less than 12 weeks; reporting results from one or more outcome measures in the domains of pain symptom, back-pain related function, general well-being, disability, and patient satisfaction; published between January 1992 and September 2011. Risk of bias was assessed using the 12 criteria for internal validity recommended by the Cochrane Back Review Group (Furlan et al 2009).

Here’s what they found

The search strategies on databases identified 426 records, and one additional record was additionally identified through citation tracking. Following the removal of duplicated records, 266 were screened for eligibility by reading title and abstract, and 120 full texts were read for the final control of eligibility. Eight studies met all criteria and were included in the systematic review, which suffered partially from high risk of bias.

This study concludes that physiotherapists and other healthcare professionals should deliver CBT-based treatment strategies, not just clinical psychologists.

The authors concluded

Of the different types of CBT strategies, operant conditioning can be integrated into physiotherapy practice and is a promising CBT-based strategy for the prevention of chronic LBP.

The authors suggested the following implications for rehabilitation:

  • Physiotherapist can integrate operant treatment approaches into their standard pain management for acute/sub-acute LBP.
  • Graded activity, based on operant conditioning, is a promising treatment approach for the prevention of chronic LBP.
  • Health care providers, other than only clinical psychologists, should deliver CBT- based treatment strategies, which aim to decrease pain behaviour by reinforcing exercise behaviour and active coping strategies.

The Musculoskeletal Elf’s view

The Musculoskeletal ElfWhat is positive from this review is the fact that it supports the use of CBT based treatment strategies that can be delivered by physiotherapists and other healthcare professionals. What has not been established is the optimal treatment frequency and intensity. The authors suggest that approximately 26 sessions might be appropriate, which in the current economic climate would be difficult for most physiotherapists to justify. Furthermore, there still remains a significant training need for most clinical practitioners in order for them to be suitably up-skilled.

With what CBT based strategies are you most familiar? Do you feel suitably trained to deliver them? If not, what further training might you need to up-skill yourself?

Send us your views on this blog and become part of the ever expanding Musculoskeletal Elf community.


Henschke N, Ostelo RW, van Tulder MW, Vlaeyen JW, Morley S, Assendelft WJ, Main CJ. Behavioural treatment for chronic low-back pain. Cochrane Database Systematic Reviews. 2010; 7: CD002014. [PubMed abstract]

Furlan AD, Pennick V, Bombardier C, van Tulder M; Editorial Board, Cochrane Back Review Group. 2009 updated method guidelines for systematic reviews in the Cochrane Back Review Group. Spine 2009;34:1929–1941. [PubMed abstract]

Brunner, Emanuel, et al. “Can cognitive behavioural therapy based strategies be integrated into physiotherapy for the prevention of chronic low back pain? A systematic review.” Disability and Rehabilitation January 2013, Vol. 35, No. 1 , Pages 1-10 (doi:10.3109/09638288.2012.683848) [PubMed abstract]

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