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Most people have back pain at some time in their lives. According to the Nuprin Pain Report, over half of the U.S. adult population suffers from backaches each year. For 15% of adults, back pain is a major health problem in which pain is experienced for more than 100 days in a given year. Back pain has also been ranked as one of the primary causes of days lost from work, and as one of the primary reasons for seeing physicians.

Women tend to report low back pain more often than men. The occurrence of low back pain increases with age and decreases with educational level. The prevalence of low back pain appears to be highest among the separated, divorced, and widowed; it is lower among married people and people who have never married. People who do heavy physical work are more likely to experience low back pain. However, low back pain can occur regardless of occupation or employment status.

For the many people who experience mild back pain, the pain episode usually ends on its own without the need for special medical intervention. Even among those who seek medical attention, most back pain episodes improve within a few months regardless of the treatment. Nevertheless, a significant number of people experience recurrent episodes of back pain, and a significant number develop persistent, chronic pain that endures beyond six months. Their problem interferes with work, with sleep, and with usual daily routines.


Frequently, a specific cause of low back pain in an individual person cannot be pinpointed. A variety of diseases and disorders can cause low back pain. Trauma to the lower back associated with a falling, lifting, or twisting injury is one of the most common causes of low back pain. These injuries from trauma can cause muscle strains or compression fractures of the vertebrae (bones making up the spinal column) of the back.

Mechanical causes of low back pain include poor muscle tone, chronic strain from poor posture, and curvature of the spine. Degenerative disorders such as a herniated or slipped disc and osteoarthritis are also common causes of low back pain.

Osteoporosis is sometimes a cause of low back pain in older women. In osteoporosis, the hormonal changes of menopause result in a decrease in bone density or a thinning of the bones of the lumbar spine (low back). Other less common causes of low back pain are tumors of the lumbar spine, congenital disorders such as misalignment of the vertebrae, and infections. Since low back pain is a complex phenomenon, the exact cause is not always clear. Although surgery and/or conservative treatments such as bed rest, physical therapy, and medications sometimes help, these treatments do not always result in a cure for pain. Many patients continue to experience persistent low back pain despite repeated medical interventions.

Lifestyle Consequences

When pain persists beyond several months, it is referred to as chronic pain. Chronic pain often has a significant impact on many areas of a person’s life. Activity is usually affected. Some individuals become unable to work and spend significant amounts of time reclining on the bed or the couch. They may decrease their involvement in social and recreational activities. Changes in mood are also common. Some people report feeling “down” or depressed, anxious, irritable, frustrated, and angry. Bodily responses that may occur as a result of pain include disrupted sleep patterns, reduced energy level, and decreased muscle tone and strength. Because the impact of low back pain on the affected individual can be extreme, his or her family members can also experience lifestyle changes.

Behavior Therapy Treatment Approaches

There are several goals in the treatment of chronic low back pain through behavior therapy methods. The first goal is to help the person understand the factors that may increase pain, suffering, and disability. These factors can include muscle tension, overactivity or underactivity, and psychological stress. The second goal is to teach the person new skills to control muscle tension, change activity patterns, and reduce psychological problems and stress.


  • Relaxation and Biofeedback Training. In order to learn to relax certain muscle groups such as the muscles of the low back, both relaxation exercises and biofeedback strategies are used. In progressive muscle relaxation, the individual is taught how to relax major muscle groups. In biofeedback, sensors are attached to the skin over muscle groups such as those of the low back, and feedback, in the form of a tone or light, is provided to the individual about his or her muscle activity. For example, a person with higher than normal muscle tension in low back muscles might hear a pulsating tone of increasing pitch until he or she is able to relax and thereby lower the pitch. Because learning to relax through biofeedback and relaxation training is like learning any new skill (e.g., learning to play a musical instrument), several sessions are usually necessary, and practice at home with relaxation training is beneficial for many people with chronic low back pain.

  • Changing Activity Patterns Through Goal Setting. People with low back pain commonly overextend themselves and overdo activity. This results in increased pain, which in turn causes the person to rest and avoid activity for several days. Over time, some people with low back pain become extremely inactive and avoid other people and activities that used to be pleasurable. A common goal for behavior therapy is to help the person change maladaptive activity patterns. A first step is often to help the person learn to pace activity. The person is taught to gradually increase activity and become involved again in recreational and social activities. This is usually done by having the person set reasonable goals for pleasant activities that can be accomplished if broken down into small steps. Physical therapy is very often part of the treatment program, and the behavior therapist and physical therapist work closely in the treatment program.

  • Cognitive Coping Skills. Individuals with chronic low back pain often have a number of negative thoughts. Typical thoughts may include: “I will never get better” “Nobody understands my pain” “I can’t do anything anymore and therefore am useless” The person may or may not be aware of these thoughts. Negative thoughts can lead to anxiety, depression, and increased pain. The aim of cognitive coping. skills training is to help the person recognize these thoughts, examine them objectively, and replace negative thoughts with more positive and realistic coping thoughts, such as, “There are still many things I can do” and “gI have coped with pain before, so I can do it again.” Other cognitive strategies include imagery (mentally focusing on a pleasant, relaxing scene) and distraction.

  • Inpatient Pain Programs. Many behavior therapy techniques can be implemented on an outpatient basis. For some people with chronic low back pain, however, an inpatient pain program is useful. Inpatient pain programs take a comprehensive approach to the assessment and treatment of an individual’s pain problem. The person is usually seen by a number of medical specialists as well as by clinical psychologists. The goal is to provide several types of treatment to the person in an environment that is designed to help the individual change behavior. Inpatient programs may involve medication adjustment (when appropriate), physical therapy, biofeedback, pain management groups, and individual therapy. Nursing staff are usually specially trained to help the patients apply the new skills they learn in day-to-day activities. Members of the treatment team meet regularly to review each patient’s progress and coordinate treatment goals. Family members are often included in various parts of the program. Research studies have shown that inpatient pain programs can help patients reduce pain, increase activity levels, decrease medication use, and improve their emotional adjustment to the pain problem.

What is Cognitive Behavior Therapy?