In recent years, chronic low back pain (CLBP) has been one of the most common and recurring musculoskeletal problems leading patients to seek healthcare.  It has been extensively studied to understand the confounding variables and barriers that affect people’s recovery rates. Over the years, numerous studies have examined the role of psychological issues in the development and maintenance of chronic low back pain . Research during this time has shown increasingly negative perceptions of pain and fear of exercising or re-injury. Important in the etiology of chronic low back pain .
It has therefore been suggested that the mechanistic structure is not always at the root of chronic low back pain, but that it has a greater psychological connection. A biopsychosocial model was introduced to emphasize the importance of psychobehavioral and social factors Contributes to the development and continuation of CLBP.  Clinicians identify psychological factors as yellow flags.
Markers in physical therapy are markers of risk factors for musculoskeletal diseases and disorders. Yellow flags indicate psychosocial factors (depression, anxiety, etc.) and the patient’s perception of their condition. The concept has attracted attention and debate Several guidelines were incorporated in the early management of CLBP. Some researchers believe that the impact of yellow flags in clinical practice is unclear.  There are many psychosocial and environmental risk factors for disability. Psychological risk factors may include fear Invalid beliefs related to pain or injury Invalid beliefs related to recovery and the patient’s distressed emotions (eg, depression and anxiety). Alternatively, social and environmental risk factors include a person’s cognitive support from work and family and healthcare facility.
When performing a yellow flag assessment, the following should be confirmed:
Attitudes/Beliefs – What does the patient think the problem is, do they have a positive or negative attitude towards pain and potential treatment? Behavior – Has the patient changed their behavior about pain? Did they reduce activity or compensate for certain movements. Early Signs of catastrophizing and fear avoidance? Compensation – are they awaiting a claim due to a potential accident? Is this adding unnecessary stress to their lives? .Diagnosis/Treatment – Did the language used have an impact on the patient’s mind? have they ever Has the pain been treated before, are there conflicting diagnoses? This can lead patients to overthink problems leading to catastrophizing and fearful avoidance. Emotional – Does the patient have any underlying emotional issues that could lead to an increased likelihood of chronic pain? Gather detailed background information on their psychological history. Family – How did the patient’s family respond to their injury? Are they under-supported or over-supported, both of which can affect the patient’s concept of pain work – are they currently off work? Financial problems may arise? What do patients think about their work environment?
Another psychological problem associated with CLBP is catastrophizing. This is outlined by the fear avoidance model (shown below).
Fear is an emotional response to a specific identifiable and immediate threat, such as a dangerous injury . Fear may protect individuals from obstructive hazards because it triggers defensive behaviors associated with the fight-or-flight response . These avoidance behaviors can Helps with fear of pain and was introduced by Lethem in 1983.
Fearful avoidance behaviors manifest as a person’s negative beliefs and built-in expectations that engaging in physical activity will lead to increased pain and suffering.  According to Vlaeyen and Linton (2000), pain avoidance behavior provides a good example of How an individual’s cognitive errors (eg, fearful-pain avoidance beliefs) combine with an individual’s negative perception of pain to have a substantial negative impact on pain and further limit an individual’s movement and disability. 
The fear-avoidance model aims to identify and explain why chronic low back pain problems and associated disabilities develop in people with low back pain episodes . For patients with CLBP, they can avoid any back impact exercises to try to avoid further pain and injury. However, for people with CLBP, prolonged physical abstinence can lead to disability and depressive symptoms.  Additionally, clinicians can utilize the Fear Avoidance Beliefs Questionnaire (FABQ) to assess how physical activity and work affect Patient’s low back pain from the patient’s point of view. 
This model suggests that a person experiencing pain will experience one of two different pathways (Figure 1).
Fig.1 Fear Avoidance Model 
This suggests that when pain/injury occurs, people are on the path to continue to be independent without having negative thoughts about what they are suffering, thus leading them to accept that they have this sympathy that will eventually add up for faster recovery pain. In contrast, a loop can If the pain is misinterpreted in a catastrophic way, treatment begins. Negative expectations contribute to pain catastrophization, which is a good predictor of pain and disability in CLBP patients.  It has been recognized that these thoughts lead to pain-related fears and associated Safety-seeking behaviors such as avoidance. However, due to disuse and disability, this can cause the pain to get worse and enter a chronic phase. This, in turn, can lower the threshold at which people experience pain.
Cognitive Behavioral Therapy (CBT)
Cognitive behavioral therapy (CBT) is an approach that can help manage problems by changing the way patients think and behave. It is not designed to eliminate any problems, but to help manage them in a positive manner  . According to Monticone et al. (2013) CBT is classified as psychological Used in the management of chronic pain conditions. This is often combined with other physical modalities and forms of exercise.  The aim of CBT is to integrate behavioral and cognitive factors that arise in the patient’s experience of pain.  This approach focuses on the Individual social functioning quality of life and overall physical functioning.  It draws on a number of principles to help patients redefine their concept of pain and allow space to transform perceptions of negative and threatening thoughts into something understandable. therapist will work From this established personal purpose and goals, possible realistic treatment plans are developed to help patients achieve their goals and overcome cognitive and behavioral problems they may experience along the way. 
CBT was created to change the way an individual perceives it challenges pain-related beliefs, thereby affecting the patient’s perception. The treatment process is divided into several parts (for example: behavior change implementation and cognitive restoration). 
The Six Phases of CBT
CBT involves six phases: 1. Assessment (assessment of patient information through self-reported questions and observations) 2. Reconceptualization (patient will need to keep a self-reported diary to help the patient address negative and/or Manipulating Thoughts) 3. Skill Acquisition and Reinforcement (the therapist will use cognitive and behavioral techniques to educate the patient on challenges that affect their daily life, this may include problem solving and relaxation skills) 4. Skill Consolidation and Application (Patients are given tasks to help them reinforce the skills they have learned to process thoughts) 5. Generalization and Sustainment (Patients’ practice of tasks and skills will be reviewed and they will be assessed for their progress in order to successfully improving their coping skills) and 6. Post-Treatment and Follow-up (the therapist will thoroughly review the patient’s progress and the patient’s ability to apply CBT in activities of daily living). 
Behavioral therapy (BT) was developed independently in three countries in the 1950s: South Africa, the United States, and the United Kingdom . It was further developed in the 1970s by Dr. Aaron Beck into Cognitive Therapy (CT), primarily for people with depression, anxiety and eating disorders  [twenty one]. However, the main evidence today focuses on CBT following the merger of BT and CT in the late 1980s .
Fig.2 – Breakdown of CBT theory
Figure 3 – Factors Involved in the Cognitive Behavioral Therapy Model
This CBT model was first recognized by Aaron Beck and Christine Padesky in the 1970s .
How it is used:
- Negative thoughts (e.g. my back pain is out of control –> negative emotions (e.g. depression and anger) and maladaptive health behaviors (e.g. skipping therapy) –> reinforce the negative cycle.
If a negative thought can be changed or better understood, it can break the cycle of negativity. This can be addressed through education and approaches to symptom management .
The biopsychosocial model is a conceptual model that suggests that not only biological but also psychological and social factors should be considered when understanding a person’s medical condition . It is often used for chronic pain, thinking that pain is a A psychophysiological behavioral pattern that cannot be individually classified as biopsychological or social factors. It has been suggested that physical therapy should be combined with psychotherapy to address all the components that make up the chronic pain experience. The figure below shows a Example of this model.
Figure 4 – Diagram of the biopsychosocial model. 
Principles of Cognitive Behavioral Therapy
CBT has 3 basic principles :
- How people perceive their situation affects how they feel and behave.
- Problematic thought patterns can address things like depression, anxiety, and self-defeating behaviors.
- People can learn to recognize distorted thinking, change their perspective, take constructive action, and feel better.
Advantages and Disadvantages
Table showing CBT advantages and disadvantages Disadvantages The highly structured nature of CBT means that it can be provided in different formats, including group self-help books and computer programs. A holistic approach to the patient’s condition is not used. learned skills Going through CBT is useful practical and helpful. These strategies can be incorporated into everyday life and facilitate the management of future stress and difficulties. Due to the structured nature of CBT, it may not be suitable for people with more complex mental health needs or studies difficulties.CBT can be sustained over the long term requiring patient commitment. A therapist can help and advise them, but it may fail without the patient’s cooperation.
Outcome measures of CBT vary according to their intended use. Certain outcome measures will be used to:
- Patient Thought’s and Beliefs
Examples of outcome measures are as follows:
- Roland Morris Disability Questionnaire
- Pain Anxiety Symptom Scale (PASS) – The Pain Anxiety Symptom Scale (PASS) is used to assess a patient’s “fear of pain.” It is intended to provide a means of “fear of pain” during exaggerated or persistent pain behaviors . it was created because of anxiety The reaction can lead to avoidance behavior, which in turn leads to chronic pain. The Pain Anxiety Symptom Inventory was classified as having a high level of validity when used in clinical practice .
- Chronic Pain Acceptance Questionnaire – The Chronic Pain Acceptance Questionnaire is a 20-item scale with two components; activity participation and pain willingness. Activity Engagement measures patient engagement with activities, regardless of pain Willingness is assessed for relative lack of attempts to control or avoid pain . This outcome measure has been found to have good reliability .
Figure 5 Words from experienced clinicians
Cognitive Therapy (CT)
Cognitive therapy was developed and pioneered by Dr. Aaron Beck in the 1960s. During this period, it was used as an information processing model to understand and treat psychopathological conditions.
Cognitive Therapy – The Theory
Cognitive therapy (CT), mentioned above, is part of the overall CBT model and an approach to chronic pain. This process shows that distorted or dysfunctional thinking affects the patient’s emotions and mental beliefs, which has been found to coincide with chronic pain   。
This treatment involves identifying and replacing misrepresented thoughts and beliefs that the patient may be feeling. Cognitive therapy is a type of problem-solving therapy based on the principle that how we perceive situations influences how we feel about them .
The effectiveness of CT has shown positive results in depression and anxiety disorders. In addition to these psychological benefits, it has also provided positive outcomes in certain medical issues, including chronic fatigue syndrome and other chronic pain disorders .
Fig.6 Concept of Cognitive Therapy
Principles of CT
Patients learn the 5 principles of CT in each session:
- Difference Between Thoughts and Feelings
- Be aware of the ways thoughts can affect feelings that can be harmful and harmful.
- Learn about thoughts that seem to happen automatically without even realizing how they can affect emotions.
- A critical assessment of whether these automatic assumptions are accurate.
- Develop the skill of independent attention to interrupt and correct these thoughts .
Impact of CT on Chronic Low Back Pain – The Evidence
There is limited evidence for the effect of cognitive therapy on chronic low back pain . The table below provides a breakdown of CT randomized controlled trials for chronic low back pain.
Behavioural Therapy (BT)
Behavioral therapy (BT) was developed in the 1950s. It was originally used to treat psychological problems such as depression, but has more recently been used to treat other conditions such as CLBP.
Behavior therapy is divided into two areas – operant therapy and response therapy. Both components of behavioral therapy focus on changing harmful behaviors to healthier and positive ones .
Operant Therapy (OT)
Operant therapy is based on the principles of operant conditioning first proposed by Skinner (1953) in his book Science and Human Behavior. Fordyce (1976) first applied the operant behavioral model to CLBP in his book A Behavioral Approach to Chronic Pain and Disease .
OT – The Theory
Operant behavior therapy or operant conditioning proposes that an individual’s learned pain behaviors can be reinforced by external factors  . These external factors are positive reinforcement of pain behaviors used by patients, which can be detrimental to their long-term health. These factors often include dependence on pain medication and unfavorable concerns about excessive rest by family health care providers. Therefore, operant behavior therapy looks at removing these harmful positive reinforcements and replacing them with healthier behaviors. Operational behavior Technique usually involves using increased levels of exercise and working towards goals set by the patient and clinician. This approach can also help by involving the patient’s family and friends to maintain and monitor changes back to healthier behaviors. every goal is The patient was actively supported by all involved staff and personnel .
Uses in Clinical Practice
Surgical therapy is used in a variety of clinical settings . Manipulative therapy is primarily used to treat psychological problems such as depression and anxiety. It is also used as part of a multidisciplinary approach to treat long-term conditions such as CLBP and fibromyalgia ; . Tim et al. (2007) studied the effects of operant behavior therapy in 125 patients with fibromyalgia. After 12 months of follow-up, the results showed that 53.5% of patients in the surgical treatment group had significantly improved pain intensity.
Respondent Therapy (RT) – The Theory
Response therapy is a type of behavioral therapy designed to alter the body’s physiological response to pain by reducing muscle tension . The response model described by Gentry and Bernal (1977)  assumes that physical injury results in a pain-stress cycle.
Figure 7 Diagram representing the pain-stress cycle in a simplified manner.
This cycle is seen as both a cause and a consequence of muscle tension . It notes that while avoiding exercise can be used to reduce pain, the resulting loss of mobility may increase tension, which can further exacerbate pain. Response therapy aims to break this cycle using RELAXATION Progressive Relaxation Applies relaxation and electromyography (EMG) feedback. These methods are used to reduce muscle tension, reduce anxiety, and thus reduce subsequent pain  .
Techniques for RT
Progressive relaxation is a technique for learning to monitor and control muscle tension . It was developed by American physician Edmund Jacobson in the early 1920s. The technique involves learning by consciously monitoring the tension in each specific muscle group of the body. Create tension in each group. Notice the contrast between tension and relaxation as you release this tension. Note that these are not considered exercises or hypnosis.
The Applied Relaxation program, developed in Sweden by psychologist Lars-Goran Öst, is an adaptation of Jacobson’s progressive relaxation technique. It extends progressive relaxation but involves trying to relax faster in different situations .
EMG feedback in response therapy is used as a reference point for patients to objectify their muscle relaxation techniques . It uses multiple surface electrodes to detect muscle action potentials, providing appropriate feedback on the state of muscle contraction.
Evidence for RT
Several studies compared response therapy using progressive relaxation with placebo   . The results showed that the favorable effect of active treatment was not statistically significant, as waitlist control also showed improvement.
Four studies have identified EMG feedback therapy versus placebo ; ; ; ). These studies showed a slight advantage in the outcome of the intervention, but did not produce significant results.
Evidence of effectiveness against other forms of treatment
One study compared response therapy with self-hypnosis . It concluded that neither intervention was superior to the other due to insignificant effects compared with placebo.
Evidence of effectiveness of response therapy in addition to other treatments
One study compared the combination of response therapy with EMG feedback and physical therapy with physical therapy alone . Significant differences were noted for the combined intervention after 6 weeks and 6 months for post-pain management.
Cognitive and behavioral therapy for CLBP – the evidence
One study  compared cognitive therapy with operant therapy. Both groups also received physical therapy and education in back pain management in the form of an exercise program. Significant improvements in general functional status were reported in the surgical treatment group, but the same results were not found for pain intensity. As a systematic review by Middlekoop et al., the quality of this study has been questioned. (2011)  reported that the study was at high risk of bias.
Two studies   compared cognitive therapy with response therapy in the form of progressive relaxation training. Only one of these studies  reported long-term pain and disability. These results were not statistically significant between the groups. Review by Middelkoop et al. (2011) also found that these studies were at high risk of bias.
Cognitive behavioral therapy for chronic low back pain – the evidence
Previous research has shown that CBT is an effective form of treatment for chronic low back pain (CLBP