Cover Image

Rumination-Focused Cognitive-Behavioral Therapy for Chronic Low Back Pain: A Randomized Controlled Trial

Ali Soleymani, Abbas Masjedi Arani, Seyed Ahmad Raeissadat, Mohammad Hassan Davazdahemami
Background: Chronic pain remains or reappears for more than 3 to 6 months, and it is influencing 20% of the global population. The pain catastrophizing affects pain intensity and psychological conditions of patients with chronic pain. Rumination-focused cognitive-behavioral therapy (RFCBT) targets rumination as the key component of pain catastrophizing. The aim of this study was to determine the effectiveness of RFCBT on depression, anxiety, and pain severity of individuals with chronic low back pain (LBP). Materials and Methods: In a randomized controlled trial, 30 patients aged between 20-55 years with diagnosed chronic LBP were chosen by convenience sampling and randomly allocated into intervention and control groups. All patients used their prescribed medications for pain management, but the intervention group received 12 weekly sessions of RFCBT, which was manualized psychotherapy to change unconstructive rumination to constructive rumination. Depression Anxiety and Stress scale-21 and chronic pain grade questionnaire were administered as pre-tests and re-administered after 3 and 6 months as post-test and follow-up assessments, respectively. Results: RFCBT significantly reduced depression (F1=23.01, P=0.001), anxiety (F1=25.7, P=0.001) and pain severity (F1=7.17, P=0.012) in patients with chronic LBP. Conclusion: RFCBT may offer benefits for treating patients with chronic low back pain when added to their usual pharmacological treatment. This benefit may be the result of targeting rumination as the key element of pain catastrophizing. [GMJ.2020;9:e1722]
Rumination; Low Back Pain; Depression; Anxiety

Jackson TP, Stabile VS, McQueen KK. The global burden of chronic pain. ASA Newsl. 2014;78(6):24-27. Available from: (accessed 24 Sept 2019).

Treede R-D, Rief W, Barke A, Aziz Q, Bennett MI, Benoliel R, et al. A classification of chronic pain for ICD-11. Pain. 2015;156(6):1003-1007.

PMid:25844555 PMCid:PMC4450869

Soo H, Burney S, Basten C. The role of rumination in affective distress in people with chronic physical illness: A review of the literature and theoretical formulation. J Health Psychol. 2009;14(7):956-966.


Oliveira DS, Vélia Ferreira Mendonça L, Sofia Monteiro Sampaio R, de Castro-Lopes MPD, Ribeiro de Azevedo LF. The Impact of Anxiety and Depression on the Outcomes of Chronic Low Back Pain Multidisciplinary Pain Management: A Multicenter Prospective Cohort Study in Pain Clinics with One-Year Follow-up. Pain Med. 2018;20(4):736-764.


Sturgeon JA. Psychological therapies for the management of chronic pain. Psychol Res Behav Manag. 2014;7:115-124.

PMid:24748826 PMCid:PMC3986332

Severeijns R, Vlaeyen JW, van den Hout MA, Weber WE. Pain catastrophizing predicts pain intensity, disability, and psychological distress independent of the level of physical impairment. Clin J Pain. 2001;17(2):165-172.


Quartana PJ, Campbell CM, Edwards RR. Pain catastrophizing: a critical review. Expert Rev Neurother. 2009;9(5):745-758.

PMid:19402782 PMCid:PMC2696024

Schütze R, Rees C, Smith A, Slater H, Campbell JM, O'Sullivan P. How can we best reduce pain catastrophizing in adults with chronic noncancer pain: A systematic review and meta-analysis. J Pain. 2018;19(3):233-256.


Sullivan MJ, Bishop SR, Pivik J. The pain catastrophizing scale: development and validation. Psychol Assess. 1995;7(4):524-532.

Ogunlana MO, Odole AC, Adejumo A, Odunaiya N. Catastrophising, pain, and disability in patients with nonspecific low back pain. Hong Kong Physiother J. 2015;33(2):73-79.

PMid:30930571 PMCid:PMC6385129

Van Damme S, Crombez G, Bijttebier P, Goubert L, Van Houdenhove B. A confirmatory factor analysis of the Pain Catastrophizing Scale: invariant factor structure across clinical and non-clinical populations. Pain. 2002;96(3):319-324.

Sansone RA, Sansone LA. Rumination: relationships with physical health. Innov Clin Neurosci. 2012;9(2):29-34. (Accessed 15 Sept. 2019, at

Watkins ER, Mullan E, Wingrove J, Rimes K, Steiner H, Bathurst N, et al. Rumination-focused cognitive-behavioural therapy for residual depression: Phase II randomised controlled trial. Br J Psychiatry. 2011;199(4):317-322.


Hvenegaard M, Moeller SB, Poulsen S, Gondan M, Grafton B, Austin SF, et al. Group rumination-focused cognitive-behavioural therapy (CBT) v. group CBT for depression: phase II trial. Psychol Med. 2019:1-9.


Cook L, Mostazir M, Watkins E. Reducing Stress and Preventing Depression (RESPOND): Randomized Controlled Trial of Web-Based Rumination-Focused Cognitive Behavioral Therapy for High-Ruminating University Students. J Med Internet Res. 2019;21(5):e11349.

PMid:31094331 PMCid:PMC6536298

Lovibond PF, Lovibond SH. The structure of negative emotional states: Comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories. Behav Res Ther. 1995;33(3):335-343.

Antony MM, Bieling PJ, Cox BJ, Enns MW, Swinson RP. Psychometric properties of the 42-item and 21-item versions of the Depression Anxiety Stress Scales in clinical groups and a community sample. Psychol Assess. 1998;10(2):176-181.

Smith BH, Penny KI, Purves AM, Munro C, Wilson B, Grimshaw J, et al. The Chronic Pain Grade questionnaire: validation and reliability in postal research. Pain. 1997;71(2):141-147.

Hawker GA, Mian S, Kendzerska T, French M. Measures of adult pain: Visual analog scale for pain (vas pain), numeric rating scale for pain (nrs pain), mcgill pain questionnaire (mpq), short‐form mcgill pain questionnaire (sf‐mpq), chronic pain grade scale (cpgs), short form‐36 bodily pain scale (sf‐36 bps), and measure of intermittent and constant osteoarthritis pain (icoap). Arthritis Care Res. 2011;63(S11): S240-S252.


Von Korff M, Ormel J, Keefe FJ, Dworkin SF. Grading the severity of chronic pain. Pain. 1992;50(2):133-149. h

Watkins ER. Rumination-focused cognitive-behavioral therapy for depression. 2nd ed. New York: Guilford Press; 2018.

Smeets RJ, Vlaeyen JW, Kester AD, Knottnerus JA. Reduction of pain catastrophizing mediates the outcome of both physical and cognitive-behavioral treatment in chronic low back pain. J Pain. 2006;7(4):261-271.



  • There are currently no refbacks.