Multimodal pain management and cognitive behavioral therapy for chronic back pain

Cognitive behavioral therapy involves things like learning how to get rid of harmful worries and thoughts. This can help you to cope better with the pain, which helps to reduce it. The pain sometimes makes people avoid doing things that would actually be good for them, like exercise or enjoyable activities with friends. Then they might end up in a vicious circle of fear and reduced activity, which makes the problem even worse. In behavioral therapy, you learn strategies to break out of the vicious circle, which can help you in the long term too. It is also a suitable treatment approach if the back problems are associated with a mental illness such as depression. People who have psychotherapy to treat chronic back pain are advised to combine it with other effective treatments, such as exercise therapy.

In Germany, behavioral therapy is usually provided by psychotherapists. If chronic low back pain causes considerable suffering or is accompanied by another condition like depression, public health insurers may cover the costs of behavioral therapy. But it can take some time to get a psychotherapy appointment for the management of pain in Germany.

There are more than 20 studies on the effect of cognitive behavioral therapy on chronic back pain. They found that cognitive behavioral therapy can't make chronic low back pain go away completely. But it can relieve the pain and make it easier to cope with. One good-quality study showed that cognitive behavioral therapy led to a noticeable improvement in 1 to 2 out of 10 people, and the symptoms were still better months after the therapy had ended. Cognitive behavioral therapy seems to work particularly well when it is combined with exercise therapy or used as part of multimodal pain management.

There are now internet-based treatment programs that use cognitive behavioral therapy to treat chronic pain. They are usually apps or browser-based applications. Some of them have been recognized as "DiGAs" (digital health applications). DiGAs are assessed and certified by Germany’s Federal Institute for Drugs and Medical Devices (BfArM). This means they meet certain requirements to do with data privacy and content quality. If DiGAs are prescribed by a doctor, public health insurers in Germany cover the costs.

You will find a list of all DiGAs for the treatment of back pain and chronic pain on the BfArM website (in German). The list contains additional information on the content of each app and how to use it.

If you have private health insurance, it is best to ask your health insurance provider whether they will cover the costs of the DiGA.

Multimodal pain management is provided by specialists from various areas of expertise, such as doctors, physical therapists and psychologists. The treatment involves a combination of exercise, patient education, relaxation techniques and (if needed) medication. Psychotherapists show patients strategies to help them cope with chronic pain and stress. This is either done in groups or in one-on-one sessions. Multimodal pain management is offered as part of pain therapy or rehabilitation programs. It has been proven to help in the treatment of chronic back pain – even over longer periods of time.

In Germany, multimodal pain management programs are mainly offered by pain centers and psychosomatic medicine departments in hospitals, as well as rehabilitation centers with a focus on rheumatology, orthopedics and psychosomatic medicine. You generally stay there the whole time (stationary treatment) or go there during the day and sleep at home. The programs last at least seven days, but they usually last two to four weeks.

This multimodal treatment approach is considered if other treatments haven’t helped enough and the symptoms are having a great impact on your quality of life or ability to function in everyday life. The treatment can be prescribed by a practice-based doctor such as a family doctor, orthopedist or pain specialist.