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Cognitive Behaviour Therapy (CBT) & Back Pain

The problem of low back pain.

Low back pain is common, affecting around a third of adults in the UK each year. The treatment of all types of back pain cost the NHS over £1 billion a year in 2000. Back pain related time off work and productivity losses cost the economy at least £3.5 billion per year.

Current low back treatment.

A number of drug and non-drug treatment options for pain relief are available but don’t usually cure the problem, which leaves around 62 per cent of people still having back pain a year after the first episode. The most recent NICE guidelines which were published in 2016 recommend a combined approach of psychological therapies and exercise (with or without manual therapy). This presents a challenge in terms of access and understanding of what is meant by psychological therapies

What is CBT?

CBT is a form of psychological therapy drawn from evidence-based models. Focusing on your thoughts makes up the cognitive part of CBT. Focusing on your actions are the behavioural part.

First, your therapist helps you recognize the negative feelings and thoughts that occur when you have back pain. Then your therapist teaches you how to change those into helpful thoughts and healthy actions. Changing your thoughts from negative to positive can help you manage your pain.

How does it work?

It is believed that changing your thoughts about pain can change how your body responds to pain. Healthy thinking makes you feel better, and feeling better reduces pain.

You may not be able to stop physical pain from happening. But, with practice, you can control how your mind manages the pain. An example is changing a negative thought, such as "I cannot do anything anymore," to a more positive thought, such as "I dealt with this before and I can do it again."

A therapist using CBT will help you learn to:

  • ·         Identify negative thoughts
  • ·         Stop negative thoughts
  • ·         Practice using positive thoughts
  • ·         Develop healthy thinking
  • ·         Setting goals;
  • ·         Working out your baseline for activities;
  • ·         Using pacing;
  • ·         Increasing activity gradually using graded activity;
  • ·         Problem solving and breaking down tasks/activities;
  • ·         Using relaxation.


CBT can also teach you to become more active. This is important because regular, low-impact exercise, such as walking and swimming, can help reduce back pain over the long run. For CBT to help reduce pain, your treatment goals need to be realistic and your treatment should be done in small steps.

Where to access CBT.

Cognitive behavioural interventions for low back pain are not routinely offered by the NHS but can be an option for people with chronic treatment-resistant pain.

There is currently a lack of capacity in the NHS to provide cognitive behavioural therapy for mental health conditions so, if the same practitioners were used, a significant increase in capacity would be needed to extend provision to the large number of people with persistent low back pain.

Pain management programmes can support patients with a high level of complexity but these services will never cope with the diverse nature of demands of patients who struggle with low back pain. Furthermore this intensity of treatment is not required by all. 

Physiotherapists are well placed to deliver cognitive behavioural approaches for patients with lower levels of complexity in their presentation.