Background: Chronic low back pain (CLBP) is a leading cause of disability and contributes to long-term opioid prescriptions and spinal surgery. Psychosocial factors - including depression, anxiety, and chronic stress - amplify pain intensity, increase opioid reliance, and predict poorer functional recovery and higher postoperative complications. Multidisciplinary rehabilitation combining exercise or physiotherapy with psychological approaches such as cognitive behavioral therapy (CBT) is recommended; however, the independent and additive effects of CBT on pain, opioid use, and subsequent surgical rates remain uncertain. Methods: We conducted a focused literature review using PubMed and Embase, including randomized controlled trials, meta-analyses, systematic reviews, and large cohort studies evaluating CBT-based interventions delivered alone or combined with rehabilitation in adults with CLBP. Outcomes included pain intensity, functional measures, opioid use or taper success, and rates of spinal surgery. High-quality RCTs and recent pragmatic trials were prioritized.
Results: Evidence shows that psychological interventions combined with physiotherapy or exercise produce moderate improvements in pain and function. Long-term outcomes remain heterogeneous due to variability in intervention delivery and patient populations. Pragmatic trials yield mixed but generally favorable results, with some showing reduced pain and improved function versus usual care. Emerging data suggest CBT and mindfulness-based therapies reduce self-reported pain and are associated with decreased opioid dosing at 6–12 months. Direct evidence linking CBT to reduced spinal surgery rates remains limited. Conclusions: CBT is a low-risk, clinically meaningful adjunct that improves pain, function, and opioid stewardship in CLBP. Its greatest value lies in targeting maladaptive pain behaviors and central sensitization, key drivers of chronic pain and treatment resistance. Integrating CBT early in care pathways has the potential to reduce progression to high-risk interventions, including long-term opioid therapy and potentially surgery. Future studies should standardize interventions and evaluate long-term outcomes, particularly surgical utilization, to better define CBT’s role in altering disease trajectory.
Results: Evidence shows that psychological interventions combined with physiotherapy or exercise produce moderate improvements in pain and function. Long-term outcomes remain heterogeneous due to variability in intervention delivery and patient populations. Pragmatic trials yield mixed but generally favorable results, with some showing reduced pain and improved function versus usual care. Emerging data suggest CBT and mindfulness-based therapies reduce self-reported pain and are associated with decreased opioid dosing at 6–12 months. Direct evidence linking CBT to reduced spinal surgery rates remains limited. Conclusions: CBT is a low-risk, clinically meaningful adjunct that improves pain, function, and opioid stewardship in CLBP. Its greatest value lies in targeting maladaptive pain behaviors and central sensitization, key drivers of chronic pain and treatment resistance. Integrating CBT early in care pathways has the potential to reduce progression to high-risk interventions, including long-term opioid therapy and potentially surgery. Future studies should standardize interventions and evaluate long-term outcomes, particularly surgical utilization, to better define CBT’s role in altering disease trajectory.