Behavioral therapy approaches for the management of low back pain: an up-to-date systematic review
Open accessAbstract
Low back pain is one of the most common causes for seeking medical treatment and it is estimated that one in two people will experience low back pain at some point during their lifetimes. Management of low back pain includes pharmacological and non-pharmacological approaches. Non-pharmaceutical treatments include interventions such as acupuncture, spinal manipulation, and psychotherapy. The latter is especially important as patients who suffer from low back pain often have impaired quality of life and also suffer from depression. Depressive symptoms can appear because back pain limits patients' ability to work and engage in their usual social activities. The aim of this systematic review was to overview the behavioral approaches that can be used in the management of patients with low back pain. Approaches such as electromyography (EMG) biofeedback, cognitive behavioral therapy, and mindfulness-based stress reduction are discussed as non-pharmacological options in the management of low back pain.
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A large proportion of the reviews (N=15) reported the distress-related outcomes of interventions employing a variety of psychological strategies including acceptance and commitment therapy, cognitive-behavioural therapy (CBT), behavioural therapy, goal setting and self-management strategies.
“A large proportion of the reviews (N=15) reported the distress-related outcomes of interventions employing a variety of psychological strategies including acceptance and commitment therapy, cognitive–behavioural therapy (CBT), behavioural therapy, goal setting and self-management strategies.3444 50 62 6472 75 82”
From Impact of healthcare interventions on distress following acute musculoskeletal/orthopaedic injury: A scoping review of systematic reviews (2024) · cites this paper as [44]
The Results sections on Cognitive Behavioral Therapy and Third Wave Approaches discuss CBT, ACT, and distress-related concerns such as depression, anxiety, and pain catastrophizing in low back pain. But the review says studies of ACT in low back pain are lacking, so it does not report ACT distress outcomes; the passages also do not establish goal-setting or self-management outcomes. The count of 15 reviews is the citing authors’ aggregate, not a count this individual review can establish. (LLM, conf=0.86)
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A controlled evaluation of paraspinal EMG biofeedback in the treatment of chronic low back pain.
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“paraspinal muscle tension in patients with chronic low back pain [44]; however studies of EMG-biofeedback in LBP have not provided robust data supporting a direct analgesic effect [45].”
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“Other Forms of CBT Neither telephone-based CBT [12] nor the use of a cognitive behavioral videotape, as an adjunct to treatment, was found to be superior to standard care in the management of LBP [33].”
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“It has been shown that patients’ expectations [32, 34] and patients’ preferences for the type treatment [35] influence the outcome in patients with chronic LBP.”
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“Currently, a randomized controlled trial of physiotherapy informed by acceptance and commitment therapy (PACT) versus usual physiotherapy for adults with chronic LBP is underway [72].”
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“In an observational study of patients with chronic LBP, group sessions of graded activity showed significant improvement in pain intensity [16].”
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“Other Forms of CBT Neither telephone-based CBT [12] nor the use of a cognitive behavioral videotape, as an adjunct to treatment, was found to be superior to standard care in the management of LBP [33].”
MethodZwingmann, J., Eberbach, H., Strohm, P. C., Südkamp, N. P., Lauritsen, J. L., & Schmal, H. (2019) · BMC Musculoskeletal Disorders · doi:10.1186/s12891-019-2583-3 · Cited by 16 · see citing works
A brief primary care intervention to reduce fear of movement in chronic low back pain patients
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“Some studies report significantly greater improvements in mean pain intensity when CBT was used [28, 29]; however in other studies, the multidisciplinary approach had no significant impact on pain management [10, 18, 26, 27, 37, 46].”
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Pain Coping but Not Readiness to Change Is Associated With Pretreatment Pain-related Functioning
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Flagged first, then by citations
Research works printed but not linked: 2
- [57]Walsh DA Radcliffe JC Pain beliefs and perceived physical disability of patients with chronic low back pain Pain 2002 97 1–2 23 31 10.1016/S0304-3959(01)00426-2 12031776 · DOI
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Low Back Pain, a Comprehensive Review: Pathophysiology, Diagnosis, and Treatment
Urits, I., Burshtein, A. L., Sharma, M., Testa, L. C., Gold, P. A., Orhurhu, V., Viswanath, O., Jones, M. R., Sidransky, M. A., Spektor, B., et al. (2019) · Current Pain and Headache Reports · doi:10.1007/s11916-019-0757-1 · Cited by 628 · see citing works
Ho, E. K.-Y., Chen, L., Simic, M., Ashton-James, C. E., Comachio, J., Wang, D. X. M., Hayden, J. A., Ferreira, M. L., & Ferreira, P. H. (2022) · BMJ · doi:10.1136/bmj-2021-067718 · Cited by 220 · see citing works
Acupuncture and Neural Mechanism in the Management of Low Back Pain—An Update
Lim, T.-K., Ma, Y., Berger, F., & Litscher, G. (2018) · Medicines · doi:10.3390/medicines5030063 · Cited by 138 · see citing works
Vadalà, G., Russo, F., Salvatore, S. D., Cortina, G., Albo, E., Papalia, R., & Denaro, V. (2020) · Journal of Clinical Medicine · doi:10.3390/jcm9041023 · Cited by 89 · see citing works
Hybrid Approach to Treatment Tailoring for Low Back Pain: A Proposed Model of Care
Hodges, P. W. (2019) · Journal of Orthopaedic and Sports Physical Therapy · doi:10.2519/jospt.2019.8774 · Cited by 76 · see citing works
Limakatso, K., & Parker, R. (2021) · PM&R · doi:10.1002/pmrj.12556 · Cited by 67 · see citing works
Barbari, V., Storari, L., Ciuro, A., & Testa, M. (2019) · Patient Education and Counseling · doi:10.1016/j.pec.2019.11.031 · Cited by 66 · see citing works
Zhang, J., Liu, T.-F., Shan, H., Wan, Z.-Y., Wang, Z., Viswanath, O., Paladini, A., Varrassi, G., & Wang, H. (2021) · Pain and Therapy · doi:10.1007/s40122-021-00293-6 · Cited by 64 · see citing works
Non-Pharmacological Management of Painful Peripheral Neuropathies: A Systematic Review
Liampas, A., Rekatsina, M., Vadalouca, A., Paladini, A., Varrassi, G., & Zis, P. (2020) · Advances in Therapy · doi:10.1007/s12325-020-01462-3 · Cited by 59 · see citing works
Baumeister, H., Paganini, S., Sander, L. B., Lin, J., Schlicker, S., Terhorst, Y., Moshagen, M., Bengel, J., Lehr, D., & Ebert, D. D. (2021) · Psychotherapy and Psychosomatics · doi:10.1159/000511881 · Cited by 55 · see citing works
Gatzinsky, K. P., Eldabe, S. S., Deneuville, J.-P., Duyvendak, W., Naïditch, N., Buyten, J. V., & Rigoard, P. (2019) · Pain Research and Management · doi:10.1155/2019/8184592 · Cited by 37 · see citing works
“-ere is, however, growing evidence showing that a structured, mixed rehabilitative approach [35] combining pain education [36, 37], behavioral approach [38], and patient-centered exercise programs aiming to gradually expose the patient to fearful or painful movement to improve function [39] seems more effective than t…”
BackgroundCommon Clinical Practice for Low Back Pain Treatment: A Modified Delphi Study
Varrassi, G., Moretti, B., Pace, M. C., Evangelista, P., & Iolascon, G. (2021) · Pain and Therapy · doi:10.1007/s40122-021-00249-w · Cited by 35 · see citing works
Can Acupuncture Improve Chronic Spinal Pain? A Systematic Review and Meta-Analysis
Huang, J.-F., Zheng, X.-Q., Chen, D., Lin, J., Zhou, W.-X., Wang, H., Qin, Z., & Wu, A. (2020) · Global Spine Journal · doi:10.1177/2192568220962440 · Cited by 31 · see citing works
O'Connell, N. E., Moore, A., Stewart, G. B., Fisher, E., Hearn, L., Eccleston, C., Wewege, M. A., & Williams, A. C. D. C. (2023) · Journal of Pain · doi:10.1016/j.jpain.2023.07.003 · Cited by 26 · see citing works
Meloncelli, S., Germani, G., Urti, I., Divizia, M., Rosciano, M., Puntillo, F., Paladini, A., & Varrassi, G. (2020) · Therapeutic Advances in Musculoskeletal Disease · doi:10.1177/1759720x20958979 · Cited by 27 · see citing works
Grabli, F. E., Quesque, F., Borg, C., Witthöft, M., Michael, G. A., Lucas, C., Pasquier, F., Lebouvier, T., & Bertoux, M. (2021) · Pain Management · doi:10.2217/pmt-2021-0090 · Cited by 22 · see citing works
Chang, J. R., Cheung, Y. K., Sharma, S., Li, S. X., Tao, R. R., Lee, J. L. C., Sun, E. R., Pinto, S. M., Zhou, Z., Fong, H. H. K., et al. (2023) · Sleep Medicine Reviews · doi:10.1016/j.smrv.2023.101867 · Cited by 18 · see citing works
Ho, E. K., Ferreira, M. L., Chen, L., Simić, M., Ashton-James, C. E., Comachio, J., Hayden, J. A., & Ferreira, P. H. (2020) · BMJ Open · doi:10.1136/bmjopen-2019-034996 · Cited by 15 · see citing works
Polich, G. R., Gray, S., Tran, D., Morales-Quezada, L., & Glenn, M. B. (2020) · Brain Injury · doi:10.1080/02699052.2020.1802781 · Cited by 14 · see citing works
Psychological Aspects and Quality of Life in Chronic Pain
Zis, P., Varrassi, G., Vadalouka, A., & Paladini, A. (2019) · Pain Research and Management · doi:10.1155/2019/8346161 · Cited by 15 · see citing works
Kinesiotherapy in chronic back pain and combined tension type headache
Александровна, Г. А., & Golovacheva, V. A. (2023) · Russian neurological Journal · doi:10.30629/2658-7947-2023-28-3-61-68 · Cited by 14 · see citing works
Haslam, C., Bertschy, K., Cruwys, T., Griffin, J., & Johnson, D. B. (2022) · Disability and Rehabilitation · doi:10.1080/09638288.2022.2057602 · Cited by 14 · see citing works
Psychological methods in the treatment of chronic nonspecific low back pain
Golovacheva, V. A., Александровна, Г. А., & Fateeva, T. G. (2019) · Neurology neuropsychiatry Psychosomatics · doi:10.14412/2074-2711-2019-2s-25-32 · Cited by 14 · see citing works
Leung, T., Low, M. K., Yao, P. C., & Pinho‐Gomes, A. (2025) · PLoS ONE · doi:10.1371/journal.pone.0325122 · Cited by 13 · see citing works
“The “third wave” integrates other concepts such as metacognition, mindfulness, acceptance, personal values and goals into CBT [4,17].”
Zinovyeva, O. E., & Александровна, Г. А. (2023) · Meditsinskiy sovet = Medical Council · doi:10.21518/2079-701x-2022-16-23-78-85 · Cited by 10 · see citing works
Greenberger, H. M., Andreopoulos, E., Peters, A., & Pande, R. L. (2019) · Pain Practice · doi:10.1111/papr.12867 · Cited by 9 · see citing works
Lee, H.-Y., Cho, M. K., Kim, N.-K., Lee, S.-Y., Gong, N.-G., & Hyun, E. (2021) · Evidence-based Complementary and Alternative Medicine · doi:10.1155/2021/5535857 · Cited by 9 · see citing works
“A multidisciplinary approach is imperative for treating LBP effectively [3], which should ideally include a combination of pharmacological and nonpharmacological treatments that result in functional recovery of muscles and tendons [4, 5].”
BackgroundSim, A., McNeilage, A. G., Gholamrezaei, A., Rebbeck, T., & Ashton-James, C. (2024) · BMJ Open · doi:10.1136/bmjopen-2024-085778 · Cited by 8 · see citing works
“The total duration of interventions ranged from 1 week to 12 months.”
BackgroundPoolman, E. Y., Vorstermans, L., Donker, M. H., Bijker, L., Coppieters, M. W., Cuijpers, P. J., Scholten-Peeters, G. G. M., & de Wit, L. M. (2024) · Internet Interventions · doi:10.1016/j.invent.2024.100731 · Cited by 7 · see citing works
“Recommended interventions for psychologically-informed care are pain education and behavioural activation (Mazzucchelli and Da Silva, 2016; Tegner et al., 2018; Vitoula et al., 2018).”
BackgroundAkinrolie, O., Abioke, U. B., Kolawole, F. O., Askin, N., Anieto, E. M., Itua, S. A., Akin, O. G., Eromosele, B., Idowu, O. A., & Fawole, H. O. (2025) · Musculoskeletal Care · doi:10.1002/msc.70048 · Cited by 8 · see citing works
Zheng, F., Liu, S., Yin, Q., Zheng, Y., Yang, J., Huang, H., Chen, L., Wang, Y., Chen, X., & Wang, C. (2024) · Journal of Psychosomatic Research · doi:10.1016/j.jpsychores.2024.111678 · Cited by 6 · see citing works
Lutsch, A., Baumeister, H., Paganini, S., Sander, L., Terhorst, Y., & Domhardt, M. (2023) · Behaviour Research and Therapy · doi:10.1016/j.brat.2023.104369 · Cited by 5 · see citing works
Bishop, L. D., Rosenberg-Yunger, Z. R. S., & Dattani, S. (2021) · Canadian Pharmacists Journal / Revue des Pharmaciens du Canada · doi:10.1177/17151635211034530 · Cited by 4 · see citing works
“Improved access to nonpharmacologic options for patients may also lead to greater success with pain management and opioid deprescribing.(14,36,37) Our study highlighted some system inconsistencies resulting in inequalities related to patients’ ability to access care.”
Ussing, K., Smith, A. J., & O’Sullivan, P. (2024) · Scandinavian Journal of Pain · doi:10.1515/sjpain-2024-0040 · Cited by 3 · see citing works
Alipour, F., Norouzi, A., Reskati, M. H., & Hosseini, S. H. (2020) · Iranian Journal of Psychiatry and Behavioral Sciences · doi:10.5812/ijpbs.102509 · Cited by 3 · see citing works
Pain and postgraduate medicine
Varrassi, G. (2020) · Postgraduate Medicine · doi:10.1080/00325481.2020.1816693 · Cited by 3 · see citing works
“The concept of multi-modal pharmacological analgesia is increasingly clear [24,25], as it is suggested the necessity of combining pharmacological treatment with other possible therapies to ameliorate the final results [26–28].”
Keyaerts, S., Szymanski, M., Godderis, L., Abeele, V. V., & Daenen, L. (2025) · JMIR Formative Research · doi:10.2196/67886 · Cited by 2 · see citing works
“The fourth module focused on stress management and resilience training, including self-regulation, problem-solving, and goal-setting techniques [33,38,39].”
Acupuncture – Basic Research and Clinical Application
Litscher, G. (2018) · MDPI eBooks · doi:10.3390/books978-3-03897-235-8 · Cited by 2 · see citing works
Delasas, G. E., Delgado, N. M., Mojica, I. K., Ragasa, S., Dones, V. C., & Manlapaz, D. (2025) · JBI Evidence Synthesis · doi:10.11124/jbies-23-00480 · Cited by 4 · see citing works
Liew, B. X. W., Ford, J. J., Briganti, G., & Hahne, A. J. (2022) · PLoS ONE · doi:10.1371/journal.pone.0263574 · Cited by 1 · see citing works
“cognitive behavioural therapy) [55] and multi-disciplinary Fig 3.”
BackgroundLi, X., Yin, X., Feng, H., Liao, W., Zhao, J., Su, W., Fan, Z., & Wu, S. (2023) · Frontiers in Neuroscience · doi:10.3389/fnins.2023.1106051 · Cited by 1 · see citing works
“Currently, for the management of patients with non-specific low back pain, pharmacological (non-steroidal anti-inflammatory drugs, weak opioids, and muscle relaxants) and non-pharmacological (exercise therapy, spinal manipulation, psychotherapy, and physiotherapy) treatments are recommended by guidelines (Vitoula et a…”
BackgroundНіканоров, О. К., Kormiltsev, V., Zharova, I., Lazareva, O. B., & Kravchuk, L. D. (2019) · Current issues in pharmacy and medicine science and practice · doi:10.14739/2409-2932.2019.3.184249
“The biopsychosocial approach to constructing com plex rehabilitation programs for the thematic contingent (A. B. Danilov, 2012; K. Vitoula et al., 2018) is also sub stantiated [6,7].”
MethodPsychosocial Impact of Chronic Back Pain: Patient and Societal Perspectives
Rampersaud, Y. R. (2019) · Springer eBooks · doi:10.1007/978-3-319-33037-2_135-1
EFFECTS OF COGNITIVE BEHAVIORAL THERAPY (CBT) AND MEDITATION IN CHRONIC LOW BACK PAIN
Bora, M., & Ranade Parag, S. (2020) · International Journal of Clinical and Biomedical Research · doi:10.31878/ijcbr.2020.64.02
“Therefore, the modification of patients’ beliefs about the nature and treatment of their pain may be associated with improvements in patients’ perceptions of the level of their disability [13].”
BackgroundPsychosocial Impact of Chronic Back Pain: Patient and Societal Perspectives
Rampersaud, Y. R. (2021) · Springer eBooks · doi:10.1007/978-3-319-44424-6_135
Acupuncture as complementary treatment for lower back pain
Jastrzębska, I., Kołodziej, M., & Piecewicz‐Szczęsna, H. (2022) · Journal of Education Health and Sport · doi:10.12775/jehs.2022.12.08.017
“When the cause of the CLBP is known, the disorder is termed as a specific chronic low back pain[14].”
BackgroundMeloncelli, S., Divizia, M., Rekatsina, M., & Varrassi, G. (2023) · Springer eBooks · doi:10.1007/978-981-19-7761-9_44
Noor, N., & Afredi, S. R. (2023) · Cambridge University Press eBooks · doi:10.1017/9781108979849.016
Bijker, L., Scholten-Peeters, G. G. M., Donker, M. H., Coppieters, M. W., Cuijpers, P. J., Busink, V., Poolman, E. Y., & de Wit, L. M. (2024) · Musculoskeletal Science and Practice · doi:10.1016/j.msksp.2024.103121
The Impact of Behavioral Interventions on Spine Care
Brush, P. L., Opara, O. A., Lee, Y., Narayanan, R., Sumughan, S., Eichbaum, Y. K., & Vacarro, A. R. (2024) · Contemporary Spine Surgery · doi:10.1097/01.css.0001096052.52365.c8
Principios de manejo del dolor crónico
Guillemet, G. (2025) · EMC - Kinesiterapia - Medicina Física · doi:10.1016/s1293-2965(25)50348-1
Principi di gestione di un dolore cronico
Guillemet, G. (2025) · EMC - Medicina Riabilitativa · doi:10.1016/s1283-078x(25)50365-6
Decoding the Complexity of Pain in Older Adults
da Silva, T. M. H. R. (2025) · IGI Global eBooks · doi:10.4018/979-8-3693-9501-1.ch009
da Silva, T. M. H. R. (2025) · IGI Global eBooks · doi:10.4018/979-8-3693-6432-1.ch008
An overview of current and emerging strategies for phantom limb pain
Cascella, M., Simone, M. D., Vittori, A., Fasolino, S., & İaconetta, G. (2026) · Expert Review of Neurotherapeutics · doi:10.1080/14737175.2026.2709803
“Its inclusion likely reflects its well-established efficacy in other chronic pain conditions and its alignment with the neuromatrix model of pain, addressing cognitive, emotional, and behavioral contributors such as depression, catastrophizing, and maladaptive coping [72–74].”
High-fidelity simulation improves acute pain management competency in final-year medical students
Moria, H. A. (2026) · Frontiers in Medicine · doi:10.3389/fmed.2026.1907025
“Epidural analgesia is widely used for severe postoperative pain and may improve pulmonary outcomes (12), while peripheral nerve blocks, such as femoral nerve block and adductor canal block, are frequently used in orthopedic surgery to reduce opioid requirements and improve analgesia (13).”
Koshti, S. H., Soni, A., Champaneri, H., Bhangale, D., Agrawal, A., & Dubey, S. (2026) · Cureus · doi:10.7759/cureus.117483
- Authors
- Vitoula, K., Venneri, A., Varrassi, G., Paladini, A., Sykioti, P., Adewusi, J., & Zis, P.
- Affiliations
- KAT General Hospital of Attica (GR)
- University of Sheffield (GB)
- University of L'Aquila (IT)
- Central and North West London NHS Foundation Trust (GB)
- Sheffield Teaching Hospitals NHS Foundation Trust (GB)
- Corresponding author
- Zis, Panagiotis
- ORCID
- Venue
- Pain and Therapy
- Published
- 2018-05-16
- Volume
- 7
- Issue
- 1
- Pages
- 1-12
- ISSN
- 2193-651X (ISSN-L)
- 2193-8237
- PMC
- PMC5993685
- OpenAlex
- W2804254863
- Cited by
- 60
- References
- 74
- Citations by year
- 2026: 3 · 2025: 8 · 2024: 6 · 2023: 8 · 2022: 4 · 2021: 9 · 2020: 11 · 2019: 9 · 2018: 2
- FWCI
- 0.90
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- Pain and Therapy (publishedVersion, cc-by-nc)
- Europe PMC (PubMed Central) (publishedVersion, cc-by-nc)
- PubMed Central (publishedVersion, cc-by-nc)
- PubMed (publishedVersion)
- White Rose Research Online (University of Leeds, The University of Sheffield, University of York) (acceptedVersion)
- Archivio Istituzionale della Ricerca - Università degli Studi dell Aquila (submittedVersion, cc-by-nc)
- Funders
- Ryder Briggs Neuroscience Research Fund
- National Institute for Health and Care Research
- NIHR Sheffield Biomedical Research Centre
- Topics
- Health Sciences › Medicine › Pharmacology › Musculoskeletal pain and rehabilitation
- Health Sciences › Medicine › Anesthesiology and Pain Medicine › Pain Management and Treatment
- Health Sciences › Medicine › Physiology › Pain Mechanisms and Treatments
- Keywords
- low back pain, behavior therapy, non-pharmacological treatment, cognitive behavioral therapy, mindfulness-based stress reduction, EMG biofeedback, depression, quality of life, psychotherapy
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