Evaluation of Cognitive Behavioral Therapy on Improving Pain, Fear Avoidance, and Self-Efficacy in Patients with Chronic Low Back Pain: A Systematic Review and Meta-Analysis

Abstract

Background: Cognitive-behavioral therapy (CBT) is commonly adopted in pain management programs for patients with chronic low back pain (CLBP). However, the benefits of CBT are still unclear.

Objectives: This review investigated the effectiveness of CBT on pain, disability, fear avoidance, and self-efficacy in patients with CLBP.

Methods: Databases including PubMed, EMBASE, Web of Science, Cochrane Library, and PsycINFO were searched. RCTs examining the effects of CBT in adults with CLBP were included. The data about the outcome of pain, disability, fear avoidance, and self-efficacy were retained. Subgroup analysis about the effects of CBT on posttreatment was conducted according to CBT versus control groups (waiting list/usual care, active therapy) and concurrent CBT versus CBT alone. A random-effects model was used, and statistical heterogeneity was explored.

Results: 22 articles were included. The results indicated that CBT was superior to other therapies in improving disability (SMD -0.44, 95% CI -0.71 to -0.17, P < 0.05), pain (SMD -0.32, 95% CI -0.57 to -0.06, P < 0.05), fear avoidance (SMD -1.24, 95% CI -2.25 to -0.23, P < 0.05), and self-efficacy (SMD 0.27, 95% CI 0.15 to 0.40, P < 0.05) after intervention. No different effect was observed between CBT and other therapies in all the follow-up terms. Subgroup analysis suggested that CBT in conjunction with other interventions was in favor of other interventions alone to reduce pain and disability (P < 0.05).

Conclusion: CBT is beneficial in patients with CLBP for improving pain, disability, fear avoidance, and self-efficacy in CLBP patients. Further study is recommended to investigate the long-term benefits of CBT. This meta-analysis is registered with Prospero (registration number CRD42021224837).

Figure 1

An illustration of the flow at each stage of the study.

Figure 2

Risk of bias of the included studies. Most studies were low risk in the selection bias, while the performance and detected bias were high risks.

Figure 3

Pain intensity immediately after intervention and during the follow-up period. Compared with other therapies, the overall effect of CBT on pain outcome immediately after intervention was significant (P < 0.05). All the follow-up periods failed to show statistical significance.

Figure 4

Disability levels immediately after intervention and during the follow-up period. Compared with other therapies, the overall effect of CBT on disability outcome immediately after intervention was significant (P < 0.05). All the follow-up periods failed to show statistical significance.

Figure 5

Self-efficacy and fear avoidance after intervention. The overall effect of CBT on self-efficacy and fear avoidance after intervention was in favor of other therapies (P < 0.05).

Figure 6

The outcome of the pain of different control subgroups. Combined CBT with other therapies showed a greater overall effect than other therapies alone (P < 0.05).

Figure 7

The outcome of disability of different control subgroups. Compared with the waiting list or usual care, the overall effect of CBT on improving disability showed statistical significance (P < 0.05). Combining CBT with other therapies showed a greater overall effect than other therapies alone (P < 0.05).