Determining the Effects of Multimodal Manual Therapy Alone and MMT along with Cognitive Behavioral Therapy on Keele STarT Back Screening Tool in Patients of Chronic Low Back Pain

Authors

  • Muhammad Mahmood Alam Lincoln University College, Wisma Lincoln, No. 12-18, Jalan SS 6/12, 47301 Petaling Jaya, Selangor Darul Ehsan, Malaysia
  • Suriyakala Perumal Chandran 1Lincoln University College, Wisma Lincoln, No. 12-18, Jalan SS 6/12, 47301 Petaling Jaya, Selangor Darul Ehsan, Malaysia
  • Saiem Alam Farooq Hospital, Asif Block Allama Iqbal Town, Lahore, 54000, Pakistan
  • Athar Mansoor University of Cambridge, The Old Schools, Trinity Ln, Cambridge CB2 1TN, United Kingdom

DOI:

https://doi.org/10.31674/mjmr.2026.v010i01.005

Abstract

Background: Low back pain (LBP) impacts 619 million individuals worldwide, leading to disability, decreased productivity, and significant economic costs. Addressing chronic low back pain (CLBP), which encompasses physical, psychological, and social dimensions, demands an integrated treatment strategy. Research indicates that combining Cognitive Behavioral Therapy (CBT) with Multimodal Manual Therapy (MMT) offers notable effectiveness. Randomized Controlled Trial (RCT). Methods: The study involved two groups: Group A, received MMT exclusively, and Group B, underwent a combination of CBT and MMT. Participants were closely matched by age and gender. Keele STarT Back Screening Tool (SBST) scores were recorded both before and after treatment to assess the risk of persistent disability, with statistical analyses performed to evaluate the effectiveness of the interventions within each group and between the groups. Results: The demographic analysis confirmed that both groups were well-matched, reducing the potential for bias in treatment outcomes. Pre-treatment SBST scores showed no significant difference between Group A and Group B. However, post-treatment, Group B exhibited significantly lower SBST scores than Group A, with a mean difference of 1.59. While both groups demonstrated significant improvements from pre- to post-treatment, the reduction was more pronounced in the CBT & MMT group. Conclusion: Combining CBT with MMT was more effective in lowering SBST scores, indicating a reduced risk of persistent disability compared to MMT alone. These findings emphasize the importance of integrating CBT with manual therapies for CLBP, reinforcing the value of a biopsychosocial approach that addresses both physical and psychological components in treatment planning.

Keywords:

Chronic Low Back Pain, Cognitive Behavioral Therapy, Keele STarT Back Screening Tool;, Multimodal Manual Therapy

Downloads

Download data is not yet available.

References

Airaksinen, O., Brox, J. I., Cedraschi, C., Hildebrandt, J., Klaber-Moffett, J., Kovacs, F., ... & COST B13 Working Group on Guidelines for Chronic Low Back Pain. (2006). European guidelines for the management of chronic nonspecific low back pain. European Spine Journal, 15(Suppl 2), s192. https://doi.org/10.1007/s00586-006-1072-1

Bannon, S., Greenberg, J., Mace, R. A., Locascio, J. J., & Vranceanu, A. M. (2021). The role of social isolation in physical and emotional outcomes among patients with chronic pain. General Hospital Psychiatry, 69, 50-54. https://doi.org/10.1016/j.genhosppsych.2021.01.009

Beck, J. S. (2020). Cognitive behavior therapy: Basics and beyond (3rd ed.). Guilford Publications.

Buchbinder, R., van Tulder, M., Öberg, B., Costa, L. M., Woolf, A., Schoene, M., ... & Turner, J. A. (2018). Low back pain: a call for action. The Lancet, 391(10137), 2384-2388. https://doi.org/10.1016/S0140-6736(18)30488-4

Campbell, P., Foster, N. E., Thomas, E., & Dunn, K. M. (2013). Prognostic indicators of low back pain in primary care: five-year prospective study. The Journal of Pain, 14(8), 873-883. https://doi.org/10.1016/j.jpain.2013.03.013

Chehadi, O., Rusu, A. C., Konietzny, K., Schulz, E., Köster, O., Schmidt‐Wilcke, T., & Hasenbring, M. (2018). Brain structural alterations associated with dysfunctional cognitive control of pain in patients with low back pain. European Journal of Pain, 22(4), 745-755. https://doi.org/10.1002/ejp.1159

Chen, Y., Campbell, P., Strauss, V. Y., Foster, N. E., Jordan, K. P., & Dunn, K. M. (2018). Trajectories and predictors of the long-term course of low back pain: cohort study with 5-year follow-up. Pain, 159(2), 252-260. https://doi.org/10.1097/j.pain.0000000000001091

Cho, N. H., Jung, Y. O., Lim, S. H., Chung, C. K., & Kim, H. A. (2012). The prevalence and risk factors of low back pain in rural community residents of Korea. Spine, 37(24), 2001-2010. https://doi.org/10.1097/BRS.0b013e31825d233c

Chou, R., Loeser, J. D., Owens, D. K., Rosenquist, R. W., Atlas, S. J., Baisden, J., ... & American Pain Society Low Back Pain Guideline Panel. (2009). Interventional therapies, surgery, and interdisciplinary rehabilitation for low back pain: an evidence-based clinical practice guideline from the American Pain Society. Spine, 34(10), 1066-1077. https://doi.org/10.1097/BRS.0b013e3181a1390d

Devasahayam, A. J., Lim, C. K. S., Goh, M. R., You, J. P. L., & Pua, P. Y. (2014). Delivering a back school programme with a cognitive behavioural modification: a randomised pilot trial on patients with chronic nonspecific low back pain and functional disability. Proceedings of Singapore Healthcare, 23(3), 218-225. https://doi.org/10.1177/201010581402300309

Duncan, B. B., Magliano, D. J., & Boyko, E. J. (2025). IDF diabetes atlas 11th edition 2025: global prevalence and projections for 2050. Nephrology Dialysis Transplantation, gfaf177. https://doi.org/10.1093/ndt/gfaf177

Falla, D., Lewis, J., McCarthy, C., Cook, C. E., & Sterling, M. (Eds.). (2024). Grieve's Modern Musculoskeletal Physiotherapy E-Book: Grieve's Modern Musculoskeletal Physiotherapy E-Book. Elsevier Health Sciences.

Ferreira, M. L., Katie de Luca, Haile, L. M., Steinmetz, J. D., Culbreth, G. T., Cross, M., Kopec, J. A., Ferreira, P. H., Blyth, F. M., Buchbinder, R., Hartvigsen, J., Wu, A.-M., Saeid Safiri, Woolf, A., Collins, G. S., Ong, K. L., Stein Emil Vollset, Smith, A. E., Cruz, J. A., & Kai Glenn Fukutaki. (2023). Global, regional, and national burden of low back pain, 1990–2020, its attributable risk factors, and projections to 2050: a systematic analysis of the Global Burden of Disease Study 2021. The Lancet Rheumatology, 5(6), e316–e329. https://doi.org/10.1016/s2665-9913(23)00098-x

Freburger, J. K., Holmes, G. M., Agans, R. P., Jackman, A. M., Darter, J. D., Wallace, A. S., ... & Carey, T. S. (2009). The rising prevalence of chronic low back pain. Archives of Internal Medicine, 169(3), 251-258. https://doi.org/10.1001/archinternmed.2008.543

Hodges, P. W., & Tucker, K. (2011). Moving differently in pain: a new theory to explain the adaptation to pain. Pain, 152(3), S90-S98. https://doi.org/10.1016/j.pain.2010.10.020

Kamper, S. J., Apeldoorn, A. T., Chiarotto, A., Smeets, R. J., Ostelo, R. W., Guzman, J., & van Tulder, M. W. (2014). Multidisciplinary biopsychosocial rehabilitation for chronic low back pain. Cochrane Database of Systematic Reviews, (9). https://doi.org/10.1002/14651858.CD000963.pub3

Kazantzis, N., & Miller, A. R. (2022). A comprehensive model of homework in cognitive behavior therapy. Cognitive Therapy and Research, 46(1), 247-257.

https://doi.org/10.1007/s10608-021-10247-z

Morley, S. (2011). Efficacy and effectiveness of cognitive behaviour therapy for chronic pain: progress and some challenges. Pain, 152(3), S99-S106. https://doi.org/10.1016/j.pain.2010.10.042

Morley, S., Williams, A., & Eccleston, C. (2013). Examining the evidence about psychological treatments for chronic pain: time for a paradigm shift?. Pain, 154(10), 1929-1931. https://doi.org/10.1016/j.pain.2013.05.049

Murphy, J. L., Cordova, M. J., & Dedert, E. A. (2022). Cognitive behavioral therapy for chronic pain in veterans: Evidence for clinical effectiveness in a model program. Psychological Services, 19(1), 95. https://psycnet.apa.org/doi/10.1037/ser0000506

Rabey, M., Slater, H., O'Sullivan, P., Beales, D., & Smith, A. (2015). Somatosensory nociceptive characteristics differentiate subgroups in people with chronic low back pain: A cluster analysis. Pain, 156(10), 1874-1884. https://doi.org/10.1097/j.pain.0000000000000244

Reme, S. E., Eriksen, H. R., & Ursin, H. (2008). Cognitive activation theory of stress—how are individual experiences mediated into biological systems?. Scandinavian Journal of Work, Environment & Health, (6), 177-183. https://www.sjweh.fi/article/1265

Tomás‐Rodríguez, M. I., Asensio‐García, M. D. R., García, R. N., Delicado‐Miralles, M., Sánchez, S. H., & Segura‐Heras, J. V. (2024). Short‐and medium‐term effects of a single session of pain neuroscience education on pain and psychological factors in patients with chronic low back pain. A single‐blind randomized clinical trial. European Journal of Pain, 28(10), 1841-1854. https://doi.org/10.1002/ejp.4700

Vallury, K. D., Jones, M., & Oosterbroek, C. (2015). Computerized cognitive behavior therapy for anxiety and depression in rural areas: a systematic review. Journal of Medical Internet Research, 17(6), e139. https://doi.org/10.2196/jmir.4145

Downloads

Published

08-01-2026

How to Cite

Alam, M. M., Chandran, S. P., Alam, S., & Mansoor, A. (2026). Determining the Effects of Multimodal Manual Therapy Alone and MMT along with Cognitive Behavioral Therapy on Keele STarT Back Screening Tool in Patients of Chronic Low Back Pain. Malaysian Journal of Medical Research (MJMR), 10(1), 50-58. https://doi.org/10.31674/mjmr.2026.v010i01.005

Issue

Vol. 10 No. 1 (2026): Malaysian Journal of Medical Research (MJMR)

Section

Articles

License

Copyright (c) 2026 Malaysian Journal of Medical Research (MJMR)

Creative Commons License

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

Metrics