A Cognitive Behavioral Therapy Program for Spinal Pain

A Cognitive Behavioral Therapy Program for Spinal Pain

Steven J. Linton


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.

Apr 17, 2020 | Posted by in PHYSICAL MEDICINE & REHABILITATION | Comments Off on A Cognitive Behavioral Therapy Program for Spinal Pain

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