The effectiveness of Cognitive Behavioral Therapy (CBT) with general

exercises versus general exercises alone in the management of chronic

low back pain

Muhammad Khan*, Saeed Akhter, Rabail Rani Soomro and Syed Shahzad Ali
Department of Physiotherapy, Institute of Physical Medicine & Rehabilitation, Dow University of Health Sciences, Karachi, Pakistan

Abstract: To evaluate the effectiveness of Cognitive Behavioural Therapy (CBT) along with General exercises and
General exercises alone in chronic low back pain. Total 54 patients with chronic low back pain who fulfilled inclusion
criteria were recruited from Physiotherapy, Department of Alain Poly Clinic Karachi and Institute of Physical Medicine
& Rehabilitation Dow University of Health Sciences Karachi. Selected patients were equally divided and randomly
assigned into two groups with simple randomisation method. The Cognitive Behavioural Therapy (CBT) and General
exercises group received Operant model of CBT and General Exercises whereas General exercises group received
General exercises only. Both groups received a home exercise program as well. Patients in both groups received 3
treatment sessions per week for 12 consecutive weeks. Clinical assessment was performed using Visual Analogue Scale
(VAS) and Ronald Morris Disability Questionnaire at baseline and after 12 weeks. Both study groups showed
statistically significant improvements in both outcomes measures p =0.000. However, mean improvements in post
intervention VAS score and Ronald Morris score was better in CBT and exercises group as compared to General exercise
group. In conclusion, both interventions are effective in treating chronic low back pain however; CBT & General
exercises are clinically more effective than General exercises alone.

Keywords: Cognitive Behavioural Therapy, exercises, low back pain, psychological interventions.

INTRODUCTION interaction may produce unwanted outcomes, which

includes higher pain intensity, pain-related disability, and
Low-back pain is a major musculoskeletal complain utilization of health care resources (Goossens et al, 1998).
which not only put economical burden but also cause Vlaeyen & Crombez (1999) proposed a bio psychosocial
disability in large populations around the world. Chronic model called Fear avoidance model. The model proposed
low-back pain (CLBP) is a major cause of medical two types of opposing behaviours called confrontation
expenses, work absenteeism, and disability (Koes 2006). and avoidance. As indicated by the name confrontation is
Many interventions has been applied in the management an adaptive behaviour response to resolve the problem.
of Chronic Low Back Pain (CLBP) includes medication, The avoidance is a catastrophic cognition leading to
manipulation, exercise, heat and cold, electrophysical chronicity, disuse, de-conditioning and depression (Wand
agents and Cognitive behavioural therapy (CBT). & O’Connell, 2008). It is not clear what causes
Cognitive behavioral therapy (CBT) for pain management catastrophic beliefs however altered proprioception has
is based upon a cognitive behavioral model of pain. This been documented by some authors (Keefe et al 2005).
model highlights that pain is a complex experience which Operant CBT model consist of behavioural graded
is not only caused by its underlying pathophysiology, but activity training (Sanders, 1996). Back strengthening
also by an individuals' cognitions, and behaviour (Keefe exercises, aerobic training and cognitive behavioural
al et, 1986). The cognitive-behavioural model suggested treatment (CBT) are beneficial modes of treatment when
that functional limitations result from maladaptive beliefs applied in combination. But the effectiveness of
and avoidance behaviours that are maintained by learning strengthening and aerobic training versus other active
processes (Vlaeyen et al, 1995). Tissue injury or treatments produced inconclusive evidence. (vanTudler,
pathology is a common cause of pain; other psychosocial 2000). However, individually designed stretching and
factors cannot be ignored in understanding pain and strengthening programs, improves pain and function
disability. Pain is both sensory and emotional experience (Hayden et al, 2005). Johnsen et al. (2007) randomised
and tissue damage is not a necessity to initiate pain controlled trial did not show any significant effects of
(Vlayen et al, 1999). additional CBT as compared to GP usual care. In another
high quality Randomized controlled trial Hay et al. (2005)
According to CBT theory, inappropriate cognitions and compared the role of usual physiotherapy with a brief
poor pain coping behaviours may interact with biological pain-management programme based on CBT approach
factors and social, environmental consequences. This and did not show any significant difference between both
groups. In addition Smeets et al. (2006) did not report any
*Corresponding author: e-mail: mohdkhan50@[Link]
Pak. J. Pharm. Sci., Vol.27, No.4(Suppl), July 2014, pp.1113-1116 1113
The effectiveness of cognitive behavioral therapy (CBT) with general exercises versus general exercises

significant difference between CBT, active physiotherapy, score from 0 as no pain and 10 is the worse pain patient
combination of CBT and active physiotherapy or waiting can get. The RDQ is a health status measure designed to
list in chronic non-specific low back pain. These studies be completed by patients to assess physical disability due
used various models of CBT intervention without much tolow back pain. It consist of 24 sentences which
explanation of the CBT activities while some used fear of describes patient status and patient have to tic a sentence
avoidance model. Therefore the aim of this study was to best suits their condition and add up all tics for some of
compare the effectiveness of CBT consisted of operant disability score.
behavioural graded activity training (Sanders, 1996) with
general exercises versus general exercise alone in the SPSS version 16 was used for data analysis. T-test was
management of chronic low back pain. used to reveal the effects of treatments within the groups.
Wilcoxon signed rank test was used to compare group A
METHODS and group B for their pre and post treatment effects with
level of significance P-value less than 0.05 considered
This randomised controlled trial was conducted at Alain significant.
Poly Clinic Karachi &Institute of Physical Medicine &
Rehabilitation Dow University of Health Sciences RESULTS
Karachi between January, 2012 and April, 2012. Patients
who were diagnosed with chronic non-specific low back This study included 54 patients 27 patients in CBT and
pain were selected. Both males and females’ patients’ age general exercise group A and 27 patients in general
25-45 years who had MRI of the lumbar spine to exclude exercises group B. There was no drop out in both groups.
any underlying pathology, back pain for more than 3 Age of the participants ranges between 29 and 50 years
months till 2 yearsand had no associated medical with mean age 39.61±5.3 years. Gender distribution were
conditions were included. Exclusion criteria was back (n=25) 46% males and (n=29) 54% were females.
pain for less than 3 months Patients, history of back Statistically there was no significant difference between
surgery, inflammatory arthritis, tumours, spinal or hip two groups with P-value =0.000 for both groups.
fractures, pregnancy, lumbar radiculopathy and severe However, clinically CBT & General exercise group A
cardiopulmonary disease affecting exercise tolerance. The showed better results as compared to general exercise
calculated sample size was 54 subjects, 27 each group group B. In group A, mean VAS score reduced to 2.66±
which was calculatedwith independent population group 1.39 post interventions which was 6.51±1.34 on base line.
formula repeated measure analysis of variance with power Ronald Morris score also reduced to 5.33±2.67 post
of test 99% and confidence interval 99%. interventions, which was 13.77±2.53 on base line. In
General exercise group mean VAS score reduced to 5.25
After taken written consent computer based simple ±1.19 post interventions, which was 7.03±1.25 on base
randomisation technique was used to assign subjects into line. Ronald Morris score also reduced to 9.88 ±1.84 post
2 groups. Group ‘A’ received CBT aimed to guide interventions which was 12.92±2.09 on base line.
patients to achieve their daily life goals. CBT consisted of
operant behavioural graded activity and problem solving DISCUSSION
training. In graded activity the physical therapist focused
on gradual increase or pacing of activities which were The results of the trial showed that participants in both
important and relevant for individual patients with CBT with general exercises and general exercises both
instruction to modify dysfunctional beliefs and general groups made significant improvements in pain scale and
exercises consisting of rolling, bridging, knee to chest, RDQ (P-value=0.000). However CBT group showed
hamstring stretching (each exercise 20 repetitions) and better results in mean pre and post intervention score on
cycling plus treadmill each exercise for 10 minutes with both measures VAS and Ronald Morris Disability
resistance and speed adjusted to patient individual needs. Questionnaire as compared to general exercises group.
Group ‘B’ only received general exercise protocol same The results of Johnsenet al. (2007) study support the
as group A. All the exercises in both groups were carried notion that CBT and active exercise have produced
out under the supervision of physical therapist and the additional benefit but overall there was no significant
patients were instructed to carry out same exercises at difference between the two groups in pain and disability
home 2 times per day and at least 5 times a week. The measures. All subjects in this study were given
duration of the intervention was for 12 weeks, 3 sessions educational pack contained advise on pain and activity,
a week for each group. Patients were blind to the study pacing, goal setting, posture and when to see their GP.
where as treating therapists received brief training for The intervention group received an additional 6 weeks
application of CBT. Pre and post intervention data was intervention based on CBT. In addition, subjects in the
collected by using Visual Analogue Scale (VAS) and Johnsen et al. (2007) study were followed for a longer
Ronald Morris Disability Questionnaire (RDQ). The VAS period of time (12 months) and more frequently, which
is a 0 to 10 point subjective scale and the patient have to may have influenced the outcomes.
1114 Pak. J. Pharm. Sci., Vol.27, No.4(Suppl), July 2014, pp.1113-1116
 Muhammad Khan et al

Table 1: evaluation of vas and ronald morris scores CBT & general exercise group and general exercise group.
Mean ±SD
Intervention group Parameters P-value
Baseline 12 Weeks
Visual Analogue Scale (VAS) 6.51 ±1.34 2.66±1.39
CBT & General Exercise Group 0.000
Ronald Morris Disability Questionnaire 13.77±2.53 5.33±2.67
Visual Analogue Scale (VAS) 7.03 ±1.25 5.25±1.19
General Exercise Group 0.000
Ronald Morris Disability Questionnaire 12.92±2.09 9.88±1.84
P-values were obtained employing Wilcoxon signed rank test. (*P-value ≤ 0.05 isconsidered as significant.
The first limitation of the study was that it was not a training. This makes it difficult to replicate studies on
double-blinded trial and the Physical Therapists were CBT due to variations in the skills of clinicians applying
given only brief training for application of CBT and the treatment. The present study and Johnsen et al. (2007)
sample size was also low. Secondly no psychological study attempted to address this issue and provided brief
measure was used to measure participant’s stress and training to the clinicians applying CBT intervention. In
depression level to establish whether higher scores would Johnsen et al. (2007) study the treating physiotherapists
be a cause of poor outcome despite CBT intervention. The received a brief 2 days CBT training however, Jellema et
results of present study suggest that reduction of pain in al. (2005) have reported that brief training is ineffective
VAS is associated with positive change in function in for carrying out psychological assessment in low back
CLBP patients in both treatment groups. These findings pain patients. The author concluded that it is important to
are in agreement with Moffet et al. (2006) study reported recognise fear of pain or movement during initial
that active exercises consisting of McKenzie techniques assessment and treatment and the clinician must receive
and CBT treatments are clinically effective in the appropriate training before applying CBT in clinical
management of CLBP. However, McKenzie showed practice.
slightly better results in as compared to CBT intervention.
This study used multiple outcome measures measuring Cognitive-behaviour therapy produced positive changes
pain, disability, anxiety and depression, which increase in disability and pain intensity. This can be explained by
the validity of the results while present study did not the fact that CBT is based on changing patient’s
measure anxiety and depression. Secondly Moffet et al. perception, enhance empowerment and teach coping
(2006) study included high disability score patients while strategies. CBT focus on motor processing and helps
in present study baseline disability score was low hence patients to distract their memory from pain experience by
still produced better results. This could be explained by using pacing based activities and return to previous
the fact that both general exercises and McKenzie normal activity level (Strong et al, 2002). Poor coping
protocol decrease fear-of-movement and fear-avoidance- strategies, self-efficacy and fear-avoidance has been
beliefs by encouraging active participation of the patient. highlighted as a strong predictor of disability in low back
Furthermore the general exercise group had higher pain (Mannion et al, 2001). Psychological stress disrupts
compliance as compared to CBT group, which could have Central Nervous System performance and alters motor
impact on the results. control this can cause avoidance and inhibit motor control
to process appropriate coping strategies (Moseley and
There is evidence that de-conditioning play a role in Hodges 2004). In contrast adapting positive behaviours
chronic pain disability (Hazard et al, 1989). It is possible such as activities, pacing and distraction improve motor
that participants who received general exercise with CBT processing and produce descending inhibitory effect to
may have improved their endurance, leading to better control pain (Zusman, 2002).
functional outcome in disability score. In the present
study measurement of aerobic fitness was not considered CONCLUSION
despite aerobic exercise like cycling and treadmill was a
part of general exercise. It would be interesting to This study found that both CBT with General exercises
establish whether changes in aerobic fitness are associated and General exercises alone significantly reduced pain
with better function outcome among persons with chronic intensity and disability in patients with chronic low back
low back pain. pain. Furthermore, subjects treated with CBT & Exercises
There are several issues that need to be addressed in the showed an additional clinical benefit as compared to
study of CBT interventions. First, in clinical settings, General Exercises only. Hence, CBT & Exercises could
interventions are individually tailored according to be a better option in clinical practice.
assessment finding of a patient, thus making it is difficult REFERENCES
to make treatment protocols for clinical trials. Most
importantly performing psychological assessment and Goossens MEJ, Rutten-Van Molken MPM, Kole-Snijders
treatment by application of CBT is a skill required special AMJ, Vlaeyen JWS, Van Breukelen G and Leidl R
Pak. J. Pharm. Sci., Vol.27, No.4(Suppl), July 2014, pp.1113-1116 1115
The effectiveness of cognitive behavioral therapy (CBT) with general exercises versus general exercises

(1998). Health economic assessment of behavioural Gatchel RJ and Turk DC. New York, The Guilford
rehabilitation in chronic low back pain: A randomised press.
clinical trial. Health Econ, 7: 39-51. Smeets RJ, Vlaeyen JW, Hidding A, Kester AD, van der
Hayden JA, van Tulder MW and Tomlinson G (2005). Heijden GJ, van Geel AC, Knottnerus JA. (2006).
Systematic review: strategies for using exercise therapy Active rehabilitation for chronic low back pain:
to improve outcomes in chronic low back pain. Ann. Cognitive-behavioral, physical, or both? first direct
Intern Med., 142: 776-785. post-treatment results from a randomized controlled
HayE M, Mullis R, Lewis M, Vohora K, Main CJ and trial. BMC musculoskelet disord, 20(7): 5.
Watson P et al. (2005). Comparison of physical Strong J and Patric D (2002). Pain: A textbook for
treatments versus a brief pain-management program for Therapists. Edinburgh, Churchill Livingstone.
back pain in primary care: A randomised clinical trial vanTulder M, Malmivaara A, Esmail R and Koes B
in physiotherapy practice. The lancet, 365(9476): (2000). Exercise therapy for low back pain. A
2024-2030. systematic review within the framework of the
Hazard RG, Fenwick JW, Kalish SM, Redmond J, Reeves Cochrane collaboration back Review Group. Spine, 25:
V, Reid S, Frymoyer JW (1989). Functional restoration 2784-2796.
with behavioral support: A one-year prospective study Vlaeyen JWS and C rombez G (1999). Fear of
of patients with chronic low back pain. Spine, 14: 157- movement/(re) injury, avoidance and pain disability in
161. chronic low back pain patients. Man ther, 4(4): 187-
Jellema P, van der Windt DA, van der Horst HE, Twisk 195.
JW, Stalman WA and Bouter LM (2005). Should Vlaeyen JWS, Kole-Snijders AM, Boeren RG and van
treatment of (sub) acute low back pain be aimed at Eek H (1995). Fear of movement/(re) injury in chronic
psychosocial prognostic factors? Cluster randomised low back pain and its relation to behavioral
clinical trial in general practice. BMJ., 331(7508): 84. performance. Pain, 62: 363-372.
Johnson RE, Jones GT, Wiles NJ, Chaddock C and Potter Wand B and O'Connell NE (2008). Chronic non-specific
RG Roberts C et al. (2007). Active exercise, education, low back pain sub-groups or a single mechanism?
and cognitive behavioral therapy for persistent BMC Musculoskel Disord, 9: 11.
disabling low back pain: A randomized controlled trial. Zusman M (2002). Forebrain-mediated sensitisation of
Spine, 32(15): 1578-1585. central pain pathways: ‘non-specific' pain and a new
Keefe FJ and Gil KM (1986) Behavioral concepts in the image for MT. Man ther, 7(2): 80-88.
analysis of chronic pain syndromes. J Consul Clin
Psychol, 54: 776-783.
Keefe FJ, Nicholas M, Vlaeye J (2005). Psychological
Assessment and Management of Pain. In Pain An
Updated Review Edited by: Justins D. IASP Press.
Koes BW, van Tulder MW and Thomas S (2006).
Diagnosis and treatment of low back pain. BMJ,
332(7555): 1430-1434.
Mannion A.F, Junge A, Taimela S, Müntener M, Lorenzo
K and Dvorak J (2001). Active therapy for chronic low
back pain: Part 3. factors influencing self-rated
disability and its change following therapy. Spine,
26(8): 920-929.
Moffett JK, Jackson DA, Gardiner ED, Torgerson DJ,
Coulton S, Eaton S, Mooney MP, Pickering C, Green
AJ, Walker LG, May S, Young S. (2006). Randomized
trial of two physiotherapy interventions for primary
care neck and back pain patients: 'McKenzie' vs brief
physiotherapy pain management. Rheumatology,
45(12): 1514-1521.
Moseley GL, Nicholas MK and Hodges PW (2004). Does
anti-cipation of back pain predispose to back trouble?
Brain, 127(10): 2339-2347.
Sanders SH (1996). Operant conditioning with chronic
pain: Back to basics. In Psychological approaches to
pain management Apractitioner's handbook Edited by:

1116 Pak. J. Pharm. Sci., Vol.27, No.4(Suppl), July 2014, pp.1113-1116