Abstract
Background:
Correcting false cognitions and establishing preventive behaviors in patients with chronic low-back pain can improve self-efficacy and self-discovery of these patients against the physical and psychological consequences of chronic back pain through reinforcing thoughts and constructive behaviors.Objectives:
This study aimed to investigate the effectiveness of cognitive-behavioral training in self-efficacy, self-discovery, and pain perception of patients with chronic low-back pain.Methods:
Based on a quasi-experimental design, 40 patients with chronic low-back were selected through purposive sampling and assigned into two groups of intervention (n = 20) and control (n = 20). After administering the pain self-efficacy (PSE) scale, the self-discovery scale (SDS), and the pain perception questionnaire (MPQ) to both groups, the intervention group received the cognitive-behavioral training while the control group did not receive the intervention. The post-test was performed on both groups and the data were analyzed using SPSS.Results:
The scores of pain self-efficacy and self-discovery (self-awareness and acceptance, commitment and attraction, transcendence and development, and personal growth) were higher in the intervention group than in the control group (P < 0.01). The highest increase with an effect size of 0.514 was related to the self-awareness and acceptance subscale. In addition, the pain assessment perception was the only reduced subscale among the other dimensions of pain perception (P < 0.01).Conclusions:
Psychosocial complementary therapies can provide patients suffering from chronic pain with better physical and mental conditions to have a higher quality of life.Keywords
Cognitive-Behavioral Training Pain Perception Pain Self-Efficacy Self-Discovery
1. Background
Chronic low-back pain is one of the most common types of pain (1). In patients with chronic low-back pain, the objective measurement of physical activity is not necessarily related to the fear of movement (2). Complete relief from pain, sometimes, is not possible and therefore, learning to live with pain is essential. Psychological factors play an important role in converting acute pain to chronic pain and explaining the severity of pain and pain-related problems (3). The belief that pain is a disaster and the formation of avoidance-fear behavioral patterns can ultimately lead to helplessness pain responses (1). Cognitive-behavioral training, with a focus on avoidance beliefs and behaviors, can play an important role in pain management. The long-term physiological interventions without any psychological intervention may not be very effective in pain self-management. On the other hand, the effect of cognitive-behavioral training is more stable on the self-management of pain (4). High levels of self-efficacy can reduce distracting physical information by reducing anxiety, physiological exacerbations, and negative physical senses (5). Therefore, pain self-efficacy can reduce the effect of pain on crucial everyday activities by increasing efforts to cope effectively with pain (6).
In adaptation to chronic pain, it is necessary to overcome the gaps between social roles and personal identities (7). The frequent presence of pain-related symptoms can form a fragile (8), fearful, and humiliated person, and may be associated with the experience of negative emotions, identity confusion (9), and more avoidable behaviors in everyday life (10). Based on humanistic views, the degree of perception destruction that an individual has of “self” (11) can engage the person in a continuous defense against attacks to “self” and against self-blame, due to the discrepancy between the “real self” and the “ideal self” (12, 13). As cognitive bias increases, the pattern of “self-pain enmeshment and pain increases (13) to the extent that the physician occasionally becomes pessimistic about the patient’s treatment process (14). Under these circumstances, self-discovery can help patients to achieve a more productive life despite their pain and limitations. Self-discovery is defined as prosperity and realization of self, accurate recognition of abilities, and effort to realize them, and is based on the dimensions of self-awareness and acceptance, commitment and attraction, transcendence and development, and personal growth (15). Integrated medicine, besides focusing on the regaining of more normal physical conditions, emphasizes the importance of patients’ unique ability and desire for adaptation and continuous promotion of his well-being (16).
2. Objectives
This study aimed to examine the effectiveness of cognitive-behavioral training in pain self-efficacy, self-discovery, and perception in patients with chronic low-back pain.
3. Methods
In this quasi-experimental study, 40 patients were purposefully selected from among 100 patients diagnosed with chronic low-back pain referring to the pain clinic of Rasoul-e-Akram affiliated to Iran University of Medical Sciences. They were divided into an intervention group (n = 20) and a control group (n = 20). The patients’ selection criteria included consent to participate in the study, no history of similar training, appropriate physical conditions for attending the training sessions, and having the pain for more than three months. Cognitive-behavioral intervention for chronic pain was designed based on the general cognitive-behavioral (17) and special chronic pain (18, 19) packages and administered in eight two-hour sessions. Patients in the intervention and control groups were asked to complete the pain self-efficacy (PSE) scale, the self-discovery scale (SDS), and the pain perception questionnaire (MPQ) as the pretest. Then, the training was performed on the intervention group and the control group continued the routine medical treatment. Finally, the questionnaires were completed again by both groups as the post-test.
PSE is a six-item scale each scored from 0 to 10 to assess the sense of trust in patients with chronic pain in some activities related to disease control (20). SDS is a 33-item questionnaire each scored 0 - 4 on four dimensions of self-awareness and acceptance, commitment and attraction, transcendence and development, and personal growth (total self-discovery) (21). The MPQ is a 20-item questionnaire with the dimensions of pain sensory perception, affective perception, and pain assessment perception (22). The validity and reliability of these tools were proven by previous similar studies in Iran.
3.1. Implementation
The protocol designed for eight two-hour sessions (Table 1) was performed for the intervention group. The cognitive-behavioral training sessions for chronic pain are presented in Table 1.
Cognitive-Behavioral Training Sessions for Chronic Pain
| Session | Outlines | Time, min | Subtitles |
|---|---|---|---|
| 1 | Principles of cognitive-behavioral training and pre-test | 120 | Relationship between thoughts, feelings, and behaviors; the need for psychological training along with drug use |
| 2 | Training of guided mastery | 120 | Patterning, activation (encouragement and planning of daily activities to avoid passivity) |
| 3 | Exposure to avoidance and elimination of safe behaviors | 120 | Training of visual exposure |
| 4 | Stress reduction methods | 120 | Training of rapid relaxation and diaphragmatic breathing |
| 5 | Training of problem-solving | 120 | Exploring efficient problem-solving methods |
| 6 | Training of profit and loss analysis | 120 | How to complete the profit and loss analysis table |
| 7 | Application of dual criteria method | 120 | Learning how to think about different options for a problem |
| 8 | Summary, conclusion, and post-test | 120 | Reviewing the achievements of the sessions in relation to the experienced situations |
3.2. Statistical Analysis
Descriptive statistics such as mean and standard deviation and inferential statistics as multivariate and univariate covariance analysis were used in the present study.
4. Results
In the experimental group, the post-test scores of the self-discovery dimensions increased compared to the pretest scores, but no considerable change was observed in the scores of the control group. The reduction in the score of pain perception in the experimental group was not very significant when compared to the control group score. However, the post-test score of pain self-efficacy significantly increased in the experimental group when compared to the control group. Table 2 presents the pre-test and post-test mean scores and standard deviations of self-discovery, pain perception, and pain self-efficacy.
The Mean ± SD of Self-Discovery, Pain Perception, and Pain Self-Efficacy in Pre-Test and Post-Testa
| Components | Intervention Group | Control Group | ||
|---|---|---|---|---|
| Pre-Test | Post-Test | Pre-Test | Post-Test | |
| 1- Self-awareness and acceptance | 85.33 ± 5.6 | 39 ± 3.9 | 31.30 ± 6.8 | 31.35 ± 6.5 |
| 2- Commitment and attraction | 27.45 ± 5.8 | 31.70 ± 4.8 | 28.20 ± 5 | 28.25 ± 5.4 |
| 3- Transcendence and development | 24.30 ± 4 | 28.25 ± 3.6 | 21.70 ± 3.9 | 22.45 ± 4.3 |
| 4- Personal growth | 26.25 ± 4.6 | 30.60 ± 3.8 | 25.20 ± 5.3 | 25.70 ± 5.5 |
| 5- Total (self-discovery) | 111.85 ± 16.4 | 129.55 ± 13.9 | 106.55 ± 21.8 | 107.90 ± 18.4 |
| 6- Pain sensory perception | 17.10 ± 5.9 | 9.95 ± 3.3 | 13.65 ± 6.9 | 9.15 ± 5.8 |
| 7- Pain affective perception | 7.95 ± 2.7 | 4.10 ± 2 | 8 ± 2.5 | 4.30 ± 1.8 |
| 8- Pain assessment perception | 24.05 ± 7.9 | 14.40 ± 4.9 | 25.35 ± 8.4 | 17.85 ± 5.3 |
| 9- Total (pain perception) | 49.10 ± 14.2 | 28.45 ± 8.7 | 47 ± 15.7 | 31.30 ± 11.4 |
| 10- Pain self-efficacy | 10.95 ± 7.18 | 16 ± 5.7 | 11.5 ± 7.86 | 12.65 ± 7.5 |
Univariate covariance analysis indicated a higher pain self-efficacy score in the intervention group than in the control group (P < 0.01) and 40% of increased pain self-efficacy was related to the effect of cognitive-behavioral training (Table 3).
A Summary of ANOVA Test for Inter-Group Factors to Examine the Effect of Cognitive-Behavioral Training on Pain Self-Efficacy
| Change Source | Sum of Squares | Degree of Freedom | Mean of Squares | F Ratio | Significance Level | Effect Size |
|---|---|---|---|---|---|---|
| Covariance | 1492 | 1 | 1492 | 257.3 | 0.001 | 0.874 |
| Group | 144.8 | 1 | 144.8 | 25 | 0.001 | 0.403 |
| Error | 214.6 | 37 | 5.8 | |||
| Total | 19927 | 40 |
Multivariate covariance analysis indicated that the total score of self-discovery and the scores of the components (self-awareness and acceptance, commitment and attraction, transcendence and development, and personal growth) were significantly higher in the intervention group than in the control group (P < 0.01). The highest effect size was related to the self-awareness and acceptance component (0.514) (Table 4).
Factor Covariance Analysis to Compare Post-Test scores of Self-Discovery Components
| Change Source/Variable | Sum of Squares | Degree of Freedom | Mean of Squares | F Ratio | Significance Level | Effect Size |
|---|---|---|---|---|---|---|
| Group | ||||||
| Self-awareness and acceptance | 260.1 | 1 | 260.1 | 40.3 | 0.001 | 0.514 |
| Commitment and attraction | 176.4 | 1 | 176.4 | 13.2 | 0.001 | 0.257 |
| Transcendence and development | 102.4 | 1 | 102.4 | 9.9 | 0.003 | 0.207 |
| Personal growth | 148.2 | 1 | 148.2 | 20.9 | 0.001 | 0.355 |
| Total | 3515.6 | 1 | 3515.6 | 847 | 0.001 | |
| Error | ||||||
| Self-awareness and acceptance | 245.5 | 38 | 6.5 | |||
| Commitment and attraction | 508.7 | 38 | 13.4 | |||
| Transcendence and development | 392.7 | 38 | 10.3 | |||
| Personal growth | 269.6 | 38 | 7.09 | |||
| Total | 2796.4 | 38 | 73.6 | |||
| Total | ||||||
| Self-awareness and acceptance | 776 | 40 | ||||
| Commitment and attraction | 870 | 40 | ||||
| Transcendence and development | 716 | 40 | ||||
| Personal growth | 653 | 40 | ||||
| Total | 11811 | 40 |
Among the dimensions of pain perception, only the score of pain assessment perception was lower in the intervention group than in the control group (P < 0.01) and 35.7% of the reduction in the pain assessment perception score was related to the effect of cognitive-behavioral training (Table 5).
Factor Covariance Analysis to Examine the Effect of Cognitive-Behavioral Training on Pain Perception
| Change Source/Variable | Sum of Squares | Degree of Freedom | Mean of Squares | F | Significance Level | Effect Size |
|---|---|---|---|---|---|---|
| Group | ||||||
| Pain sensory perception | 19.9 | 1 | 19.9 | 5.9 | 0.21 | 0.144 |
| Pain affective perception | 0.304 | 1 | 0.304 | 0.22 | 0.65 | 0.006 |
| Pain assessment perception | 98.8 | 1 | 98.8 | 19.4 | 0.001 | 0.357 |
| Error | ||||||
| Pain sensory perception | 118.4 | 35 | 3.4 | |||
| Pain affective perception | 49.2 | 35 | 1.4 | |||
| Pain assessment perception | 178.2 | 35 | 5.09 | |||
| Total | ||||||
| Pain sensory perception | 449.6 | 40 | ||||
| Pain affective perception | 842 | 40 | ||||
| Pain assessment perception | 11507 | 40 |
5. Discussion
The reported symptoms in people suffering from specific low-back pain (with specific medical causes like blows or osteoporosis) and non-specific low-back pain (without specific medical causes) (23) do not match the data obtained from clinical examinations (24). Perceived fear-avoidance beliefs, catastrophic thinking, and perceived disability make the symptoms more severe than they really are. Therefore, psychological interventions in both groups with specific and non-specific chronic low-back pain (CLBP) can be useful (7, 25).
The first finding of the current study suggesting that cognitive behavioral education (CBE) increases pain self-efficacy in the experimental group is in line with some previous studies (26, 27) that indicated the role this approach in increasing the efficacy, active coping strategies, and psychological flexibility in people with CLBP. In explaining this finding, we can point to the impressionability of the individual’s cognitive evaluations in the area of bodily information, attention diversion from potentially threatening bodily information, increased resistance against disturbing bodily information, changes in explanation and interpretation of body sensations and hence, increased pain self-efficacy (8). The second finding also suggests that awareness and acceptance, commitment and absorption, transcendence and advancement, and personal growth, as the dimensions of self-discovery, increased in the experimental group. This finding conforms to a study that emphasized the role of self-discovery and the ability to distinguish between the “self” and the body; the study also indicated that the pain-related thoughts and feelings played a very important role in pain self-management education and enhanced self-compassion in patients with CLBP (28). Increased self-awareness and self-acceptance in patients is also in agreement with a previous study that indicated the role of CBE in increasing mindfulness in patients with chronic pain (29). In explaining this finding, we can point to the role CBE in reducing the avoidance strategies, decreasing the disparity between the actual and the ideal self of the patient (30) and therefore, enhancing self-awareness and self-acceptance.
As the second self-discovery dimension, commitment and absorption also increased in the experimental group. This finding conforms to a survey in which CBE positively influenced active coping with the problem, solving the programmed problem, reevaluating the problem, and accepting responsibility for the problem (31).
In fact, the lack of complete success in daily living activities prevents the increased entanglement of the “self” and pain, and the individual experiences greater commitment and attraction to the personal life through accepting pain as a life event and by refusing to focus excessively on the body as a painful object (13).
In the present study, education increased transcendence and advancement as the third self-discovery dimension in the experimental group. This finding agrees with a study that investigated the effects of CBE on developing newer capabilities and skills for adapting to conditions. We can explain this finding through the effect of CBE on reevaluating the new goals and concentrating on behaviors to reach these goals, thus enabling CLBP patients to experience less damage to their self-concept, transcendence, and advancement (32).
As the last self-discovery dimension, personal growth increased in the experimental group. This finding is in agreement with studies of the effect of CBE on increasing self-direction, the incentive to collect information regarding oneself, self-confidence, time spent for oneself, and concentration on treatment quality in patients with CLBP (33). In fact, CBE can prepare the ground for personal growth in patients by influencing information processing, acceptance of facts, and continuous learning and self-sufficiency (15, 34).
The last finding of the present study suggests that education had a positive effect on reducing pain assessment perception among the other dimensions of pain assessment.
Studies conforming to the present study (35-37) also emphasized the effect of CBE on reducing the pain assessment perception. It seems that approaches like neurofeedback and emotion-focused approach together with CBE are appropriate complements for influencing the sensory and affective perception of pain.
By employing the educational aspect of CBE as a distinctive feature, the present study indicated that CBE was more effective on CLBP compared to cognitive-behavioral treatment in patients who did not necessarily belong to the upper social classes. It also increased physical performance, reduced pain level, and even decreased depression in this group of people (38). Moreover, most domestic studies have not examined the processes centered on “self” to even influence the cognitive and affective aspects of CLBP, while recent research in other countries on CLBP places greater emphasis on reconstructing processes centered on “self” (39).
5.1. Conclusions
Based on the fear-avoidance model, fear of movement in patients with CLBP can increase their inefficiency in coping with pain and pain severity (39). Furthermore, losing the feelings of control, self-determination, and identity of the “self” as an efficient human being creates the feeling in a person with CLBP that his whole life is under attack. Therefore, psychological interventions like CBE for chronic pain can enhance self-rediscovery in people, along with increasing pain self-efficacy and reducing pain perception. The impossibility of studying the stability of the effects of CBE and the fact that patients with various types of low back pain (specific, non-specific, persistent chronic, and recurrent) were not separately assessed to compare the results were among the limitations of the study. Research in other areas related to pain can be useful.
Acknowledgements
References
-
1.
Taub CJ, Sturgeon JA, Johnson KA, Mackey SC, Darnall BD. Effects of a pain catastrophizing induction on sensory testing in women with chronic low back pain: A pilot study. Pain Res Manag. 2017;2017:7892494. [PubMed ID: 28348505]. [PubMed Central ID: PMC5350337]. https://doi.org/10.1155/2017/7892494.
-
2.
Carvalho FA, Maher CG, Franco MR, Morelhao PK, Oliveira CB, Silva FG, et al. Fear of movement is not associated with objective and subjective physical activity levels in chronic nonspecific low back pain. Arch Phys Med Rehabil. 2017;98(1):96-104. [PubMed ID: 27713076]. https://doi.org/10.1016/j.apmr.2016.09.115.
-
3.
Wertli MM, Rasmussen-Barr E, Held U, Weiser S, Bachmann LM, Brunner F. Fear-avoidance beliefs-a moderator of treatment efficacy in patients with low back pain: A systematic review. Spine J. 2014;14(11):2658-78. [PubMed ID: 24614254]. https://doi.org/10.1016/j.spinee.2014.02.033.
-
4.
Du S, Hu L, Dong J, Xu G, Chen X, Jin S, et al. Self-management program for chronic low back pain: A systematic review and meta-analysis. Patient Educ Couns. 2017;100(1):37-49. [PubMed ID: 27554077]. https://doi.org/10.1016/j.pec.2016.07.029.
-
5.
Sardá J, Nicholas MK, Pimenta CAM, Asghari A. Pain-related self-efficacy beliefs in a Brazilian chronic pain patient sample: A psychometric analysis. Stress Health. 2007;23(3):185-90. https://doi.org/10.1002/smi.1135.
-
6.
Vergara F, Rosa J, Orozco C, Bertiller E, Gallardo MA, Bravo M, et al. Evaluation of learned helplessness, self-efficacy and disease activity, functional capacity and pain in Argentinian patients with rheumatoid arthritis. Scand J Rheumatol. 2017;46(1):17-21. [PubMed ID: 27095187]. https://doi.org/10.3109/03009742.2016.1155643.
-
7.
Kwok SS, Chan EC, Chen PP, Lo BC. The "self" in pain: The role of psychological inflexibility in chronic pain adjustment. J Behav Med. 2016;39(5):908-15. [PubMed ID: 27278752]. https://doi.org/10.1007/s10865-016-9750-x.
-
8.
Van Ryckeghem DM, De Houwer J, Van Bockstaele B, Van Damme S, De Schryver M, Crombez G. Implicit associations between pain and self-schema in patients with chronic pain. Pain. 2013;154(12):2700-6. [PubMed ID: 23932910]. https://doi.org/10.1016/j.pain.2013.07.055.
-
9.
Reme SE. Positive affect could reduce the impact of pain. Scand J Pain. 2017;14:89-90. [PubMed ID: 28850442]. https://doi.org/10.1016/j.sjpain.2016.11.002.
-
10.
Huijnen IP, Kindermans HP, Seelen HA, Peters ML, Smeets RJ, Serroyen J, et al. Effects of self-discrepancies on activity-related behaviour: Explaining disability and quality of life in patients with chronic low back pain. Pain. 2011;152(9):2165-72. [PubMed ID: 21723039]. https://doi.org/10.1016/j.pain.2011.05.028.
-
11.
Dorka R. Resilience and personal growth: A potential resource for therapeutic programmes in people with congenital heart disease. Eur J Cardiovasc Nurs. 2017;16(4):270-1. [PubMed ID: 28071940]. https://doi.org/10.1177/1474515116687223.
-
12.
Sutherland R, Morley S. Self-pain enmeshment: Future possible selves, sociotropy, autonomy and adjustment to chronic pain. Pain. 2008;137(2):366-77. [PubMed ID: 17977661]. https://doi.org/10.1016/j.pain.2007.09.023.
-
13.
Morley S, Davies C, Barton S. Possible selves in chronic pain: Self-pain enmeshment, adjustment and acceptance. Pain. 2005;115(1-2):84-94. [PubMed ID: 15836972]. https://doi.org/10.1016/j.pain.2005.02.021.
-
14.
Rudich Z, Lerman SF, Gurevich B, Weksler N, Shahar G. Patients' self-criticism is a stronger predictor of physician's evaluation of prognosis than pain diagnosis or severity in chronic pain patients. J Pain. 2008;9(3):210-6. [PubMed ID: 18055267]. https://doi.org/10.1016/j.jpain.2007.10.013.
-
15.
Morley S. Psychology of pain. Br J Anaesth. 2008;101(1):25-31. [PubMed ID: 18511440]. https://doi.org/10.1093/bja/aen123.
-
16.
Perlman A. Helping people to self-actualize: Revising the role and goal of our healthcare system. Explore (NY). 2017;13(1):6-8. [PubMed ID: 27890519]. https://doi.org/10.1016/j.explore.2016.10.009.
-
17.
Ghahari S. Behavioral therapy techniques. 1th ed. Tehran: Ghatreh; 2013.
-
18.
Cosio D. Replication of a cognitive behavioral therapy for chronic pain group protocol by therapists in training. Postgrad Med. 2015;127(2):242-50. [PubMed ID: 25597391]. https://doi.org/10.1080/00325481.2015.1000230.
-
19.
Johnson MH, Kazantzis N. Cognitive behavioral therapy for chronic pain: Strategies for the successful use of homework assignments. J Ration Emot Cogn Behav Ther. 2004;22(3):189-218. https://doi.org/10.1023/b:jore.0000047307.90472.56.
-
20.
Rezaei S, Afsharnejad T, Moosavi V, Yousefzadeh S, Soltani R. [Validation of the Persian version of pain self-efficacy scale: A psychometric chronic low back pain patient]. J Fundam Ment Health. 2012;13(4):328-45. Persian.
-
21.
Akbari Balootbangan A, Rezaei AM. [Construction and validation to self-discovery scale (SDS) based on different theories of personality in students]. J Clin Psychol. 2014;6(3):55-68. Persian.
-
22.
Tanhaei Z, Fathi Ashtiani A, Amini M, Vahedi H, Shaghaghi F. [Validation of the revised short-form Mc Gill pain questionnaire]. Govaresh J. 2012;17(2):91-6. Persian.
-
23.
Huysmans E, Ickmans K, Van Dyck D, Nijs J, Gidron Y, Roussel N, et al. Association between symptoms of central sensitization and cognitive behavioral factors in people with chronic nonspecific low back pain: A cross-sectional study. J Manipulative Physiol Ther. 2018;41(2):92-101. [PubMed ID: 29329739]. https://doi.org/10.1016/j.jmpt.2017.08.007.
-
24.
Stensland M, Sanders S. Living a life full of pain: Older pain clinic patients' experience of living with chronic low back pain. Qual Health Res. 2018;28(9):1434-48. [PubMed ID: 29598770]. https://doi.org/10.1177/1049732318765712.
-
25.
Ogunlana MO, Odole AC, Adejumo A, Olagbegi OM, Williams OO. Augmenting conventional treatment of non-specific low back pain with progressive goal attainment programme. Phys Ther Rev. 2018;23(2):133-43. https://doi.org/10.1080/10833196.2018.1454034.
-
26.
Chuen Chan SL. Pain self-efficacy, socially prescribed perfectionism and coping strategies in older adults with chronic pain. University of Regina; 2009.
-
27.
Glombiewski JA, Holzapfel S, Riecke J, Vlaeyen JWS, de Jong J, Lemmer G, et al. Exposure and CBT for chronic back pain: An RCT on differential efficacy and optimal length of treatment. J Consult Clin Psychol. 2018;86(6):533-45. [PubMed ID: 29781651]. https://doi.org/10.1037/ccp0000298.
-
28.
Devan H, Hale L, Hempel D, Saipe B, Perry MA. What works and does not work in a self-management intervention for people with chronic pain? Qualitative systematic review and meta-synthesis. Phys Ther. 2018;98(5):381-97. [PubMed ID: 29669089]. https://doi.org/10.1093/ptj/pzy029.
-
29.
Ghasemi M, Hatami M, Hasani J. The effectiveness of combination of cognitive behavior therapy and cognitive emotion regulation strategies on mindfulness, resiliency and quality of life in patients with chronic pain. Health Psychol. 2016;5(18):69-86.
-
30.
Guck TP, Burke RV, Rainville C, Hill-Taylor D, Wallace DP. A brief primary care intervention to reduce fear of movement in chronic low back pain patients. Transl Behav Med. 2015;5(1):113-21. [PubMed ID: 25729460]. [PubMed Central ID: PMC4332907]. https://doi.org/10.1007/s13142-014-0292-x.
-
31.
Golchin N, Janbozorgi M, Alipour A, Agah-Heris M. [The efficacy of cognitive behavioral therapy on using coping strategies and decreasing pain among females with chronic back pain]. J Fundamentals Ment Health. 2011;13(2):160-9. Persian. https://doi.org/10.22038/JFMH.2011.1016.
-
32.
Tang NKY. Cognitive behavioural therapy in pain and psychological disorders: Towards a hybrid future. Prog Neuropsychopharmacol Biol Psychiatry. 2018;87(Pt B):281-9. [PubMed ID: 28284902]. https://doi.org/10.1016/j.pnpbp.2017.02.023.
-
33.
King KP. A journey with chronic pain: Self-directed learning as survival. New Horiz Adult Educ Hum Resour Dev. 2014;26(2):5-18. https://doi.org/10.1002/nha3.20059.
-
34.
Stensland ML, Sanders S. "It has changed my whole life": The systemic implications of chronic low back pain among older adults. J Gerontol Soc Work. 2018;61(2):129-50. [PubMed ID: 29336694]. https://doi.org/10.1080/01634372.2018.1427169.
-
35.
Abdolghaderi M, Kafee M, Saberi A, Aryapouran S. [The effectiveness of mindfulness-based cognitive therapy (MBCT) and cognitive behavior therapy (CBT) on decreasing pain, depression and anxiety of patients with chronic low back pain]. J Shahid Sadoughi Univ Med Sci. 2014;21(6):795-807. Persian.
-
36.
Janbozorgi M, Golchin N, Alipour A, Agah Heris M. [The effectiveness of group cognitive-behavior therapy on decreasing severity of pain and psychological distressamong women with chronic back pain]. Iran J Psychiatry Clin Psychol. 2013;19(2):102-8. Persian.
-
37.
Hamid N, Ramezan Sa'atchi L, Mehrabizadeh Honarmand M. [The effect of cognitive behavioral therapy on the pain severity and mental health of female patients with chronic low back pain visiting specialized clinics in Tehran]. Clin Psychol. 2013;10(3):95-113. Persian.
-
38.
Thorn BE, Eyer JC, Van Dyke BP, Torres CA, Burns JW, Kim M, et al. Literacy-adapted cognitive behavioral therapy versus education for chronic pain at low-income clinics: A randomized controlled trial. Ann Intern Med. 2018;168(7):471-80. [PubMed ID: 29482213]. https://doi.org/10.7326/M17-0972.
-
39.
Hazeldine-Baker CE, Salkovskis PM, Osborn M, Gauntlett-Gilbert J. Understanding the link between feelings of mental defeat, self-efficacy and the experience of chronic pain. Br J Pain. 2018;12(2):87-94. [PubMed ID: 29796260]. [PubMed Central ID: PMC5958515]. https://doi.org/10.1177/2049463718759131.