Investigation of relationship between cognitive flexibility and emotional regulation and pain severity in chronic low back pain patients

Objective: In this study, we aimed to investigate the relationship of cognitive flexibility and emotion regulation skills with pain severity in patients admitted to the physical therapy and rehabilitation outpatient clinic due to chronic mechanical low back pain. Materials and Methods: The study sample included 38 patients with chronic mechanical low back pain who met the inclusion criteria and admitted to the Abant Izzet Baysal University Physical Therapy and Rehabilitation outpatient clinic between 01.06.2025 and 01.09.2025, along with 38 healthy controls. The participants were administered a sociodemographic data form, the Visual Analog Scale (VAS) to assess pain severity, algometric measurements, the Roland Morris Disability Questionnaire to evaluate pain-related disability, and the Brief Illness Perception Questionnaire. Additionally, the Structured Clinical Interview for DSM-5 (SCID-5) was conducted to identify comorbidities. To measure objective cognitive flexibility, neurocognitive tests—including the Trail Making Test (TMT), Wisconsin Card Sorting Test (WCST), and the Stroop Test—were administered, along with the Cognitive Flexibility Inventory (CFI) as a self-report measure. Symptoms related to emotion regulation were evaluated using the Perth Emotion Regulation Competency Inventory (PERCI) and the Difficulties in Emotion Regulation Scale–Short Form (DERS-16). Furthermore, quality of life was assessed using the WHOQOL-BREF (World Health Organization Quality of Life Scale, Short Form), and levels of anxiety and depression were measured with the Beck Depression Inventory (BDI) and the Beck Anxiety Inventory (BAI). Results: The patient and healthy control groups displayed similar distributions in age, gender, and education level (p > .05). No statistically significant differences were observed between the groups in neurocognitive test performances measuring objective cognitive flexibility (WCST, Stroop, TMT), or in emotion regulation difficulty (DERS-16) and emotion regulation competency (PERCI) scores. In contrast, subjective cognitive flexibility (CFI) scores were significantly lower in the patient group compared to the control group. No between-group differences were found in BDI or BAI scores. In the correlation analyses, pain severity (VAS, algometer) was found to be unrelated to cognitive and emotional variables, while subjective (CFI) and objective measures of cognitive flexibility generally did not demonstrate significant correlations with each other. Additionally, cognitive flexibility and emotion regulation variables were associated with quality of life, whereas WCST and TMT performances were not related to quality of life. Conclusion: This study reveals that executive functions and cognitive capacity are preserved in patients with chronic mechanical low back pain, but the patients' beliefs regarding their own flexibility (subjective cognitive flexibility) are impaired. Patients' functioning, illness perception, and quality of life are related to subjective cognitive flexibility, competence in managing negative emotions, attention control, and the capacity to act despite emotional distress, rather than the severity of pain. These findings indicate that chronic low back pain is not solely a physical condition; rather, the individual's perception of the disease, emotion regulation capacity, and subjective cognitive processes play a significant role in the pain experience and functioning. Therefore, it is concluded that holistic and multidisciplinary approaches targeting psychological processes are needed in the evaluation and treatment of chronic low back pain. Keywords: Emotion Regulation, Cognitive Flexibility, Chronic Low Back Pain