Back to the basics: Cognitive-Behavioral Therapy and Psychosocial Factors in Low Back Pain
In New Zealand, the national accident insurer, Accident Compensation Corporation, has been reviewing its pain management service contracts. The latest message from both the Government and ACC is the need to reduce costs (not that I’ve ever heard anyone say ‘let’s go for broke, let’s spend all we can!’) and one way to do this is to look at how to reduce the risk of long-term disability associated with chronic pain. So, in their pursuit of ways to do this, ACC has consulted with providers and reviewed opinions about services provided to claimants under the various pain services contracts and come up with some pretty sensible options.

Some of the findings from examining current services simply do not surprise me – amongst two of the most common services, pain interventions (ie nerve blocks and infusions etc), and ‘functional reactivation’ programmes (ie let’s get fit in a gym), the providers rarely use a biopsychosocial model – apparently, these services are provided within a biomedical model, and those factors that are so well known to complicate recovery are simply not addressed. Now I’ve mentioned before in this blog that some interventional doctors actually believe that if they can abolish the pain the person’s problems will simply disappear and they’ll return to normal – and this is an opinion that now ACC is fully aware of, and hopefully will reconsider! The evidence from empirical studies just does not support the idea that pain and disability are linked in a nice tidy causal relationship. In fact, for a really lovely illustration of this in another health condition, angina, by Gill Furze, I think you’ll enjoy it.

So, from my somewhat cursory reading of the recommendations from ACC, it looks like a ‘stepped care’ approach is being adopted.  In this, ‘low risk’ people are provided with fairly simply input – advice from a GP, maybe a DVD or pamphlet advising people that it’s OK to move, that returning to work is good, and to simply get on with it.  ‘Medium risk’ people are provided with ‘reactivation’ but with some attention to psychosocial factors, and a comprehensive pain assessment is less likely to be on the cards for them.  Finally, ‘high risk’ people will be able to access ‘the whole works’ including comprehensive pain assessment, multidisciplinary and interdisciplinary pain management, and with a strong emphasis on attending to the psychosocial factors that are known to influence recovery.  Good ideas. With one catch – how ‘risk’ is identified is not yet clear.

In New Zealand we’ve used the Orebro Musculoskeletal Screening Questionnaire in some form since 1997 or so.  Unfortunately, this wonderful tool is often either not interpreted, or the ‘warning signs’ are not addressed, and for some people, a high score can almost be a flag for a case manager to be especially punitive in terms of ‘lets get this person back to work any way we can’ rather than using it as an indication that this person requires more support.  If this tool is used to screen for risk, and used well – then there could be some excellent results, and hopefully ‘low risk’ people won’t be over-serviced, while ‘high risk’ people will receive that help that they need.  But it will need case managers and other service providers to really come to grips with what the biopsychosocial model actually is, and how to truly address psychosocial factors in a systematic way.

How this plays out will be interesting.  Currently a claimant could see several providers concurrently: perhaps a doctor who is completing medical certificates, the physiotherapist providing the ‘reactivation’, an occupational therapist helping with return to work, and maybe an independent psychologist providing ‘CBT’ for pain.  If each of these providers has a slightly different understanding of the risk factors influencing disability in chronic pain, the poor claimant is going to be very confused.

For example, the doctor may be aware of the person’s home situation and certify fitness for work based on his or her knowledge of the overall ‘stress’ level of the person in context.  Without good understanding of how pain can influence function, the doctor could suggest ‘no heavy lifting’ – but fail to indicate how heavy ‘heavy’ is, whether this applies all day every day, whether there is a difference between lifting from the ground or above the head etc.  And the rationale for ‘no heavy lifting’ is fairly limited – what ‘damage’ will actually occur? or is the doctor responding to the person’s distress about ‘having to lift’ and experiencing pain?

The physiotherapist could be focusing on fitness generally, and asking the person to complete a full gym routine, maybe with some ‘core stability’ thrown in for good measure.  If the person is still fearful about his or her pain (because the doctor has said ‘no heavy lifting’), while completing the gym programme may actually be avoiding specific movements like bending because of this.  And be extremely fit – but not actually doing anything at home!  And you canbe very sure that this happens.  A lot.

The occupational therapist, with a really good ‘ergonomic’ approach, may recommend all sorts of wonderful gadgets, seating and break down the work tasks to ones the person ‘can do’, but the actual tasks the person does is really being established on the basis of what the doctor said about ‘no heavy lifting’.  The person feels pressured because there are lots of other movements that increase pain, apart from ‘heavy lifting’ (what about sitting? or twisting? or going up stairs?) but ‘has’ to do these movements because the doctor didn’t say they were ‘banned’, and there really are not that many tasks at work that the person can do!

And finally the psychologist, who is aware that the person isn’t sleeping, is feeling quite anxious and doesn’t have effective communication skills, works on these – but fails to address the confusion that the person has about what this pain actually means.

These situations are so common as to be the norm.  And while each provider is possibly working to ‘clinical standards’, the models they’re using don’t dovetail, and the person’s real concerns are not identified – and worse, the person gets caught in the middle between all these rather earnest providers who are actually talking past each other!

Now it’s not my plan here to lobby for any specific approach – I think plurality and choice is great in pain management.  But – and you knew there would be a but – there does need to be excellent communication and agreement amongst the providers and the claimant/person as to

  1. what the problems are
  2. what the hypothesised relationships between various factors are
  3. a consistent approach to managing specific beliefs and behaviours

Oh and it does need to be evidence-based.  That means ‘favourite’ treatments that individuals like to do (like acupuncture, pilates, adaptive gadgets and even CBT or mindfulness) need to be justified not only from the literature, but also in terms of how they ‘fit’ for this person in this situation at this time.  That means outcomes need to be measured.

I’m still not convinced that primary care, even secondary care, clinicians talk to each other enough in the same language.  If ACC wants to ‘risk profile’ patients, maybe it also needs to ‘risk profile’ providers.  And maybe providers could be given some further training (maybe even training through a tertiary institute like University of Otago’s postgraduate papers in Musculoskeletal Medicine, Pain, Pain Management etc?!), even psychologists who currently don’t receive any specific training in a cognitive behavioural approach in pain management.

Read this paper – it’s an oldie but a goodie.  Even though some of the recommendations have now moved on, the fundamentals remain.  Psychosocial factors continue to be the most important predictor of disability, and need to be managed from the outset.  After all, people with chronic pain had acute pain in the beginning!

Pincus T, Vlaeyen JW, Kendall NA, Von Korff MR, Kalauokalani DA, & Reis S (2002). Cognitive-behavioral therapy and psychosocial factors in low back pain: directions for the future. Spine, 27 (5) PMID: 11880850


  1. Great article. It clearly illustrates many of the problems faced in general pain rehabilitation. There were a couple of issues that your comments raised for me, and which I think might be best stated more bluntly. That is, most of the “providers” involved in rehabilitation know very little of the literature in this area. And this is reflected in their practice which can serve to actually increase disability by providing excessive “support” (time off work, limited activity and so on) rather than fostering independence. Also, that the bio-psycho-social model is generally really just the bio model. The actual full model is given a lot of lip service, but is not really comprehended by most medical practitioners, and that filters down to nurses, OTs, physios, and (though it pains me to say it) psychologists who all follow suit. As a result it is just business as usual. The most recent NZ Pain Society Conference was a prime example. Everyone warmly welcomed, even applauded the call for greater understanding of how pain is explained, how it is comprehend by patients, how important wider social or psychological factors are, but no one pointed out the obvious. We have know this for nearly 40 years. And, this information is presented again and again every few years. The research demonstrates increasingly sophisticated ways of measuring these issues, however our treatments do not change significantly. That to me is shocking, and an indictment on those engaged in rehabilitation and rehabilitation medicine.

    1. Hi Jim
      I could have put it more bluntly – and will in the future. I can’t believe how few psychologists actually study pain management at postgraduate level – I’ve had about four do the papers I teach. Many many more physiotherapists, occupational therapists and nurses – even social workers – but ACC still doesn’t recognise social workers as having any role in pain management! And the medical people who continue to believe that psychosocial factors only influence people when pain persists – and if the pain is removed then the psychosocial factors no longer apply. As if!
      Work with me on this for the 2011 NZ Pain Society Conference and maybe we can drive some change down into practice… sigh… After teaching for nearly 10 years and working in pain management singing the same song for 20 I start to wonder whether I’m beating my head against a brick wall. But the evidence is SO compelling that to ignore it is simply unethical, and I won’t do that.
      Thanks for dropping in – hope to see more of you!

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