Multimodal pain management and cognitive behavioral therapy

Photo of a patient at a psychotherapy session

Low back pain that doesn't go away or keeps returning despite treatment can be very distressing. One way to cope with it is to learn to manage the pain better – for example, using cognitive behavioral therapy or multimodal pain management.

Cognitive behavioral therapy (CBT) is one of the most effective treatments for chronic low back pain. It involves things like getting rid of harmful fears and thoughts. This can help you cope better with the pain, which helps to reduce it.

One example of these fears is the widespread belief that certain activities could damage your back. In the long term it is actually more harmful to rest – exercise can help to strengthen your muscles and prevent pain. If you're in pain, it's not always easy to stay or become physically active again. It is important to set realistic goals, and neither focus too much on the pain nor suppress it.

Cognitive behavioral therapy can help here. During this psychological treatment, you learn to recognize negative thoughts that lead to harmful behavior. You then try to change those thoughts. Examples include:

  • “I have to be really careful, or else I'll damage my back even more and the pain will never go away."
  • “I'd better stay at home because of my back pain, otherwise it will only get worse."

Thought patterns like these can cause unnecessary anxiety, making you become inactive and withdraw from social activities. But this may lead to other problems over time, and make the pain even worse.

How effective is cognitive behavioral therapy?

Cognitive behavioral therapy has been scientifically proven to relieve chronic low back pain and to reduce the perceived disabling effects of the pain. One good study showed that – compared to conventional conservative treatment – cognitive behavioral therapy was able to noticeably improve symptoms in an additional 1 to 2 out of 10 people. Studies suggest that this positive effect may last over the long term too.

Even though cognitive behavioral therapy can't make chronic low back pain go away completely, it can relieve the pain and make it easier to cope with. Relaxation techniques are often used as part of the CBT treatment as well.

When are the costs of CBT covered?

If chronic low back pain causes considerable suffering or is accompanied by another condition like , statutory health insurers in Germany may cover the costs of behavioral therapy.

But it can take quite some time to get an appointment for psychological treatment for the management of pain in Germany.

Multimodal pain management

Multimodal pain management is provided by specialists from various areas of expertise, such as doctors, physiotherapists and psychologists. The treatment involves a combination of exercise, patient education, relaxation techniques and medication. Psychotherapists show patients psychological strategies that help them cope with chronic pain and stress at work or home. This is either done in groups or one-on-one sessions. Multimodal pain management is offered as part of standard pain therapy or rehabilitation programs.

Multimodal pain management can reduce back pain in the long term, too. Because cognitive behavioral therapy has also been shown to be helpful in the long term, it should be included in multimodal pain management programs.

These programs are mainly offered by pain centers, psychosomatic medicine departments in hospitals, and rehabilitation centers with a focus on rheumatology, orthopedics and psychosomatic medicine. In some programs you may stay at the hospital or center the whole time, and in others you may have some or all of the treatments as an outpatient. 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 the person’s quality of life or ability to function in everyday life. The treatment can be prescribed by a practice-based doctor, for instance a family doctor, orthopedist or pain specialist. People generally have to wait about three months before they get a place in a multimodal pain management program.

Chou R, Deyo R, Friedly J et al. Noninvasive Treatments for Low Back Pain. (AHRQ Comparative Effectiveness Reviews; No. 169). 2016.

Chou R, Deyo R, Friedly J et al. Nonpharmacologic Therapies for Low Back Pain: A Systematic Review for an American College of Physicians Clinical Practice Guideline. Ann Intern Med 2017; 166(7): 493-505.

Lamb SE, Lall R, Hansen Z et al. A multicentred randomised controlled trial of a primary care-based cognitive behavioural programme for low back pain. The Back Skills Training (BeST) trial. Health Technol Assess 2010; 14(41): 1-253, iii-iv.

Skelly AC, Chou R, Dettori JR et al. Noninvasive Nonpharmacological Treatment for Chronic Pain: A Systematic Review Update. (AHRQ Comparative Effectiveness Reviews; No. 227). 2020.

Williams AC, Fisher E, Hearn L et al. Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database Syst Rev 2020; (8): CD007407.

IQWiG health information is written with the aim of helping people understand the advantages and disadvantages of the main treatment options and health care services.

Because IQWiG is a German institute, some of the information provided here is specific to the German health care system. The suitability of any of the described options in an individual case can be determined by talking to a doctor. can provide support for talks with doctors and other medical professionals, but cannot replace them. We do not offer individual consultations.

Our information is based on the results of good-quality studies. It is written by a team of health care professionals, scientists and editors, and reviewed by external experts. You can find a detailed description of how our health information is produced and updated in our methods.

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Please note that we do not provide individual advice on matters of health. You can read about where to find help and support in Germany in our information “How can I find self-help groups and information centers?

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Updated on December 5, 2022

Next planned update: 2025


Institute for Quality and Efficiency in Health Care (IQWiG, Germany)

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