The Influence of Cognitive Behavioral Therapy on Pain, Quality of Life, and Depression in Patients Receiving Physical Therapy for Chronic Low Back Pain: A Systematic Review

PM R. 2019 Feb;11(2):167-176. doi: 10.1016/j.pmrj.2018.09.029. Epub 2019 Feb 11.


Objective: The purpose of this systematic review was to investigate the effect of adding the cognitive behavioral treatment (CBT) component to routine physical therapy (PT) on pain and depression reduction, improvement in quality of life, and enhanced function in patients with chronic low back pain (CLBP). TYPE: Systematic review.

Literature survey: Google Scholar, PubMed, Ovid, ScienceDirect, ProQuest, Scopus, Cochrane Library, and Embase electronic databases were explored for the key terms of "behavioral (or behavioural) treatment" OR "behavior (behaviour) treatment" OR "behavior (behaviour) therapy" OR "cognitive behavior (or behaviour) treatment" OR "cognitive treatment" OR "cognitive therapy" OR "operant behavior (or behaviour) treatment" OR "respondent behavior (or behaviour) treatment" AND "physical therapy" OR "physiotherapy" OR "exercise therapy" OR "electrotherapy" OR "electrical therapy" OR "manual therapy" OR "myofascial therapy" OR "rehabilitation" AND "low back pain" OR "lower back pain" OR "back pain" OR "chronic back pain" OR "chronic lower back pain", with no limitation on language, through January 2018.

Methodology: All randomized controlled trials that statistically compared the effectiveness of CBT + PT and PT were included for quality analysis. Studies were rated by high to poor quality, using Hailey's classification, based on their design and performance.

Synthesis: Of the 10 included studies, 7 were rated as high quality and 3 as good quality. Although CBT + PT was found to be superior to PT for pain, disability, quality of life, and functional capacity variables in some of the included studies, no extra benefit from CBT was documented in other investigations. The included studies also failed to show any advantage of CBT + PT over PT in reducing depression, and PT was even found to be superior to CBT + PT in one high-quality study.

Conclusions: Although appearing to be advantageous by reducing pain and disability and enhancing functional capacity and quality of life, CBT effects on depression cannot be teased out from the effects of PT.

Level of evidence: I.

Publication types

  • Systematic Review

MeSH terms

  • Chronic Pain / complications
  • Chronic Pain / psychology*
  • Chronic Pain / rehabilitation
  • Cognitive Behavioral Therapy / methods*
  • Depression / etiology*
  • Depression / rehabilitation
  • Humans
  • Low Back Pain / complications
  • Low Back Pain / psychology*
  • Low Back Pain / rehabilitation
  • Physical Therapy Modalities*
  • Quality of Life*