Cognitive-behavioral factors in the management of chronic low back pain: Conceptualization and evidence of treatment efficacy

The biomedical and psychogenic models of chronic pain view chronic low back pain (CLBP) in terms too extreme to account for the many factors that contribute to its development and maintenance. A cognitive-behavioral model depicts CLBP not merely in terms of sensory information or psychiatric disturbance, but in terms of well-validated principles that govern perception and behavior. Evidence from correlation, prospective, and experimental studies shows that CLBP can be explained in large measure by 1) the manner in which noxious stimuli are attended to and interpreted; 2) the degree to which certain behaviors become conditioned stimuli for fear responses; and 3) how environmental contingencies increase and decrease the frequency of maladaptive and adaptive behaviors. From this basic research, interventions have been designed to alter maladaptive cognitions and problematic behavioral contingencies. These appear quite effective in alleviating pain, decreasing disability, and lifting mood; more effective perhaps than standard medical management. Although further work is still needed, the case for a cognitive-behavioral model for the conceptualization of CLBP is strong and grows stronger with emerging research.