Cognitive behavioral treatment for low back pain: Case study and commentary

Objective: To review principles of behavioral management of nonspecific low back pain. Methods: Case presentation and review of the literature. Results: Low back pain is a common musculoskeletal disorder characterized by symptoms of pain, ache, and stiffness in the lumbosacral spine. The majority of those with back pain are classified as having nonspecific low back pain. The main features of guideline-based primary care for acute nonspecific back pain are provision of information and assurance about the condition and encouragement to maintain normal daily activity and work, in conjunction with simple analgesia. If recovery is slow or incomplete by 4 to 6 weeks, further assessment is required to check that specific pathology has not been missed and to identify possible psychosocial barriers. For patients with heightened psychosocial features at the subacute or chronic stage, cognitive behavioral treatment is recommended, with more intensive and multidisciplinary programs required for more disabled or complex cases. Cognitive behavioral management involves individualized advice and reassurance, activity upgrading using pacing, rationalization of medication, cognitive restructuring, and management of psychological distress and associated problems such as sleep disturbance. The patient is taught skills to gradually return to normal activity and work, even if symptoms have not fully resolved, and to utilize helpful coping strategies to manage the condition and prevent relapses. Conclusion: Early identification of those who require cognitive behavioral treatment is critical to prevent persistent disabling chronic pain.