A Cognitive Behavioral Therapy Program for Spinal Pain

Steven J. Linton

LEARNING OBJECTIVES

After reading this chapter, you should be able to:

Understand how psychological factors can interfere with recovery from acute spinal pain syndromes.
Understand how cognitions, emotions, and behaviors influence self-management.
Understand how “screening” may be performed to identify patients who risk developing chronic pain problems.
Understand how a series of cognitive behavioral classes can be used with patients with chronic pain.

“We currently have the knowledge and the tools to provide early interventions that prevent the development of chronic pain.

–MICHAEL NICHOLAS

Introduction

This chapter deals with early interventions that may prevent the development of long-term work disability caused by back pain problems. Although psychological factors are known to be related to the development of chronic pain, the implementation of an approach that includes such factors has been hampered by a lack of clearly described programs. Among the successful psychological approaches to pain is cognitive behaviorally oriented interventions.¹^,²^,³ However, the cognitive behavioral approach does not refer to one specific intervention, but rather to a class of intervention strategies.⁴ These may vary considerably and include methods to engage clients (e.g., goal setting, motivational interviewing), relaxation (e.g., applied relaxation), cognitive restructuring, fear reduction, coping strategies, activity training (e.g., graded activity), stress management, problem solving, and assertiveness training. Furthermore, because many healthcare professionals have limited education in psychology, the details of how and why these interventions are used may be unclear. As a result, the purpose of this chapter is to describe a cognitive behavioral group intervention program designed for early implementation.

There is good reason to consider a cognitive behavioral approach for patients at risk for long-term disability. Basically, if psychological variables catalyze the development of persistent disability, then using cognitive behavioral interventions is logical and should have great value. In fact, such programs have demonstrated their value in treating chronic back pain problems.³^,⁵^,⁶ Through the years, it has become apparent that early interventions might be more effective and actually prevent persistent disability from developing. The setting has varied, but these programs are often used in conjunction with other treatments, including manipulation and physical therapy.

Let us briefly examine some programs to underscore their potential as well as the variety of content. In one program, van den Hout and associates⁷ studied the effects of teaching problem-solving skills to participants off work less than 6 months for back pain. Subjects were randomized to a group receiving graded activity training and education or to a group receiving graded activity and problem solving. The long-term results indicated that those receiving problem-solving skills training were significantly more successful at returning to work. This indicates, then, that the specific technique of problem solving was quite helpful in preventing long-term disability. Using a similar design, Marhold and coworkers⁸ examined the effects of teaching specific return-to-work skills. They reasoned that one problem for those off work might be a lack of skills concerning how to actually return to work. Participants off work an average of 3 months were randomized to a treatment as usual control group or a cognitive behavioral group that included specific return-to-work skills training such as making contact with the employer, overcoming barriers, and coping with anticipated increased pain. Results demonstrated that participants in the cognitive behavioral therapy (CBT) program had significantly less absenteeism at the 1-year follow-up than did the treatment as usual control group.

Although most programs are limited to one facility, a community-based program designed to prevent pain disability has recently been tested in Canada.⁹ Here again, the intervention is specific to certain risk factors. In fact, individuals were selected for treatment if they were off work for back pain and had elevated scores on risk factors addressed by the intervention program. The program systematically works with goal-directed activity training and in minimizing psychological barriers to return to work. This program specifically focuses on reducing catastrophizing, fear, and avoidance. Although the study did not have a randomized design, the results were encouraging because 65% returned to work as compared to an 18% base rate of return. A similar program focusing on early identification of psychosocial factors and psychologically informed intervention has shown clear effects in Australia.¹⁰^,¹¹

In a trial in England, patients seeking care for low back pain were first screened and classified into subgroups on the basis of their level of risk.¹²^,¹³ Those with low risk were provided with “conservative” care, whereas those with medium risk received treatment focusing on function and those with high risk received psychologically informed treatment. Results showed that the stratification worked and treatment allocated accordingly produced larger improvements than standard care.

In our own work, we have used a cognitive behavioral group therapy as secondary prevention and evaluated it in several studies.⁸^,¹⁴^,¹⁵ In the most recent evaluation, we selected participants with short-term back pain in a primary care setting who had risk profiles on a screening instrument and then provided the cognitive behavioral group intervention designed to address these risk factors.¹⁶ These participants (n = 185) were randomly assignment to a standardized, guideline-based, treatment as usual group, or a cognitive behavioral group (alone), or the combination of a cognitive behavioral group and physical therapy (assessment plus exercise). The results showed that for
work absenteeism, the two groups receiving cognitive behavioral interventions had fewer days off work for back pain during the 12-month follow-up than did the guideline-based treatment as usual group. The risk for developing long-term sick disability leave was more than 5-fold higher in the guideline-based treatment as usual group than in the other two groups receiving the cognitive behavioral intervention. Thus, there is some evidence that using a psychologically oriented intervention may help prevent future disability.

Because few lucid descriptions of cognitive behavioral interventions for early prevention exist, let us now turn to a more detailed description of the cognitive behavioral group intervention. The description begins with a closer look at the psychological risk factors that such interventions are designed to deal with. This is important because the intervention is only provided for patients with relatively high levels of psychological risk factors. That is, it is offered to patients “at risk” for disability.

Psychological Risk Factors Deserve Psychological Interventions

Psychological factors are powerful risk factors linked to the development of persistent disability (see Chapter 8). Even though psychological factors are often found to be potent risk factors, treatments may nevertheless be medical in nature. Consequently, patients displaying such psychological risk factors seem to deserve an intervention that addresses these.¹⁷ Let us examine this idea more closely.

Although many factors may be related to the development of disability, psychological factors appear to be particularly relevant. Other chapters (see Chapters 9, 13 and 38) in this book cogently show that a host of factors are related to the development of persistent pain and disability. These involve medical or biologic factors, such as ischias pain, and sensitization, in addition to a previous history of treatment.¹⁸ Furthermore, the work environment is important in terms of physical work.¹⁹^,²⁰ and in terms of psychosocial factors such as stress, control, and demands.²¹^,²² Social factors akin to educational level, income, race, and family situation are complex, but certainly may also influence the development of a pain problem.¹⁸^,²³ However, psychological factors have been found to have a clear relationship to the development of persistent pain.⁶^,²⁴^,²⁵^,²⁶^,²⁷^,²⁸^,²⁹^,³⁰ Moreover, psychological factors are integrally related to the transition from acute to chronic pain.³⁰^,³¹ Thus, psychological factors seem to be of great importance for understanding the development of chronic disability.

There is considerable logic in providing psychologically oriented interventions for a problem characterized by psychological aspects.³² For example, providing a psychological intervention would help to match the treatment to the patient’s unique needs. Further, the identification of psychological factors might provide guides for defining intervention targets and barriers to recovery. Finally, the identification of psychological factors might also enhance the development of interventions by providing insight into the mechanisms that are maintaining the problem. For example, if depressed mood were identified, appropriate measures might be taken.

Although it would seem logical to use psychologically oriented interventions, this seldom happens in the current healthcare system (see Chapters 3 and 13). For a variety of reasons, most healthcare units fail to identify psychosocial factors let alone implement an early psychologically oriented intervention.³³^,³⁴ Consider the fact that although psychological factors are often present, it is still common to only provide medical treatments.³⁵^,³⁶ This appears to be related to an approach of providing “more of the same” if a treatment is not successful. In other words, as the problem progresses toward chronic disability, there is a tendency to prescribe more of the same therapies tried early on. Consequently, the “dose” of the treatment is increased rather than viewing the progression as a risk situation that needs to be tackled in an alternative way. However, if psychological factors are catalyzing the problem toward chronicity, these treatments may be ineffective because they do not address the problem. Unfortunately, before the clinician realizes that this “normal” treatment is not successful, the problem may well be on the way to a persistent disability. To be successful, then, changes in the system of healthcare may need to be taken to implement an alternative that can address psychological aspects of the problem.

Only gold members can continue reading. Log In or Register to continue