I have heard many discussions about scopes of practice: the main concern as far as I can see is of people who are trained to work mainly with the body perhaps stepping out of scope to work with thoughts, beliefs, and emotions. There are risks from stepping too far away from what you’re trained to do, I acknowledge this, though I think health professionals who see people are probably exerting greater influence over thoughts, beliefs and emotions than many of us acknowledge. And given that’s the case, I think it’s only ethical to learn to craft that influence in ways that are positive rather than inadvertently doing harm because of ignorance.
When I read about a post-surgical rehabilitation approach for people who had spine surgery, I was immediately interested and not because of the surgery! This study compared “cognitive-behavioural based physical therapy” with an education programme six weeks after laminectomy for a lumbar degenerative condition. People were included in the study if they reported high fear of movement using the Tampa Scale for Kinesiophobia. Assessments were completed before treatment, after treatment and at a 3 month follow-up, and included the Brief Pain Inventory, Oswestry Disability Index, SF-12, and three performance tests (5-chair stand, timed up and go, and 10 metre walk).
There was no discussion about the physical rehabilitation, but the CBT and education sessions were conducted by phone and participants also received a workbook to take home and follow. Sessions took 30 minutes, except the first session which was for one hour. The main components of the programme are reported as education on the mind-body connection, activity levels, graded activity plan (graded hierarchy) and weekly activity and walking goals. A cognitive or behavioural strategy was introduced in each session, with the therapist helping patients identify enjoyable activities, replace negative thinking with positive thoughts, find a balance between rest and activity, and manage setbacks by recognising high-risk situations and negative thoughts.
The education sessions included the usual contents delivered by a physiotherapist, and featured biomechanics, daily exercise, and ways to promote healing. Information on stress reduction, sleep hygiene, energy management, communicating with health providers and preventing future injury were also provided.
What did they find?
Firstly, only 68% of those eligible for the study agreed to take part, which in itself is interesting. A number of other factors influenced the total number of people entered into the programme – not being treated for a degenerative lumbar condition, not having high enough scores on the TSK were the main reasons. Dropout rates for both programmes were quite low – 7 – 5%, and both programmes had good follow-up outcomes (not too many people missed the follow-up).
Now here’s a thing: 91% of participants also received clinic-based physiotherapy during the treatment phase (roughly 8 visits), and right up until the three-month follow-up (about 6 – 7 visits). No real difference between the groups here.
What did differ was the long-term improvement in the cognitive behavioural group – in terms of back and leg pain, pain interference and disability. The education group still improved in their leg pain and disability, but back pain and pain interference stayed the same. Similarly, the CBT group continued to improve on measures of physical and mental health over time, while the education group’s physical scores improved but mental health scores stayed pretty much the same. The CBT group’s scores improved more than the education group on almost all the measures including the physical performance tests.
What does this mean?
Well, interestingly, the authors of this study suggest that they obtained large and clinically relevant changes because of the specific focus they had on decreasing barriers to functional activity and walking rather than focusing solely on resolving pain symptoms. I think this is very interesting indeed. Although this study used physiotherapists, the clinician was naive to using CBT and was trained specifically for this study. Participants received concurrent physiotherapy in a clinic – the CBT (and education sessions) were additional to what was delivered in the clinic setting. To me the results suggest that the occupational therapy focus on creating opportunities for people to do more within their own environment might be a potent tool in post-operative rehabilitation.
Once again, it also suggests that the professional discipline of the clinician delivering a CBT approach is far less important than the fact that the CBT approach is tailored to the concerns of the patient, and that the treatment targets factors within the real-world context.
Important points to note: these patients were selected on the basis of high levels of pain-related fear and avoidance. I don’t think the outcomes would be nearly as fabulous in a general or undifferentiated group. This approach, while relatively inexpensive to implement, is an added cost – though if we look at the effect on patient outcomes, I would argue that the financial cost is far outweighed by the positive human results.
Finally, I think this study also shows that addressing thoughts, beliefs and emotions is a part of what every health professional should be doing: it’s unethical not to learn to do this well.
Archer KR, Devin CJ, Vanston SW, Koyama T, Phillips S, George SZ, McGirt ML, Spengler DM, Aaronson OS, Cheng JS, Wegener ST, Cognitive-behavioral based physical therapy
for patients with chronic pain undergoing lumbar spine surgery: a randomized controlled trial, Journal of Pain (2015), doi: 10.1016/j.jpain.2015.09.013.
HealthSkills Blog 
Hi Bronnie. Very interesting study and as usual it raises a lot of questions. It would be interesting (if possible) to have done a long term follow up on the 32% who didn’t want to participate and presumably did nothing and compare their long term outcome to the intervention groups. Also, you made what seems complicated more simple I think when you distilled it down to what I read as “patient centred care”. There does seem to be a slant in practice to “practitioner centred care” I.e. You do what we tell you to do. Such as patient X needs hydrotherapy or must do Pilates etc. Humans are obviously complex and it’s not always simple but as you say with patient centred care and a bit of listening some of your answers are sitting right there in front of you. Thanks for the blog.
I agree that looking at the longterm follow-up of those who didn’t join the study would be a great idea. I think patient-centred care is a bit broad for what this CBT approach is about, though.
To me it’s definitely about the lens through which we see the problem. If the problem is thought to be tissues that need time to recover, then functional restoration through exercise is the treatment. If we think of people as people, then we need to go beyond our conceptualisation of the problem and learn to stand in the shoes of the person we see – I’m not sure that this is always so easy! For example, an orthopaedic surgeon told me last week that physiotherapy for osteoarthritis in the knee is “a waste of time” and “useless”. To him, the factor of interest was limited to the degree of degenerative change present in the knee – so of course there’s no change from any kind of treatment, pretty much. But we know that the main impact of OA knee is on confidence to mobilise and to do the everyday things people want to do – and when confidence is gone because of a painful knee that the person doesn’t believe he or she can rely on, then we know that disability, falls, immobility and the need for further care is increased.
BUT if the orthopaedic surgeon doesn’t factor these aspects in, or thinks they won’t respond because “of course” the problem lies in the joint, then you can bet these things just won’t get considered. And I’ll bet the orthopaedic surgeon believes he is doing “patient-centred care”!
I think the strength of a cognitive behavioural approach is that it provides a structure and a lens through which any health professional can begin to understand and influence the things most relevant to an individual person. The thing with calls for patient-centred care is that so often there is not framework for people to use to help break the factors down and guide treatment. And I think it’s critical to look beyond the CBT therapy and into the approach itself – the approach that says people actively process what’s happening to them, act on their beliefs and emotions, and respond to anyone who takes the time to hear what their main concern is. The issue to date is that it’s often been seen as the preserve of psychologists rather than extending beyond and into allied health professionals’ practice. Hence there’s a proliferation of psychological approaches to disability – and this is not always (a) accepted by patients, and in the case of people like the orthopaedic surgeon I mentioned, other professionals (b) costly – occupational therapists, physiotherapists, osteopaths etc are less expensive than psychologists (c) means those people who need the specialist expertise of a psychologist may not get this because psychologists are doing the relatively easier work of providing “education” and coping strategies to people who have less severe problems. I’m not suggesting that psychologists shouldn’t see people in rehabilitation settings, but I do think it’s worth carefully reviewing whether other health professionals might not use a cognitive behavioural approach just as effectively as those with exclusively psychological training.
Thanks for taking the time to comment – and yes, I agree that “you need to have X treatment” doesn’t address those unique factors that are relevant to each individual.
The benefits of CBT extend beyond rehab outcomes. Check out Janet Bezner’s article in PTJ from last month. She makes a great point that PT’s need to be part of the solution for health promotion in response to the WHO’s efforts to reduce global effects of non communicable diseases. We are not trained in counseling skills and CBT lends itself well in helping to guide that process. There are a number of studies from other health professionals that show CBT reduces inflammation after surgery and reduce infection. The mind body connection is important and needs to be a prime focus for patient centered care.
I agree that all health professionals need to be involved in communicating strategies people can use to develop greater awareness of the contributions they can make to their health. I haven’t seen studies looking at reduced infection etc, but I know that increased self efficacy means people are more confident they can do things, and as a result reduce their tendency towards experiencing depression and demoralisation. People listening to and talking to people – that’s the magic ingredient!
As I mentioned on Twitter. CBT refers to the replacing negative thinking with positive thinking which in my view is impossible. Acceptance of negative thoughts and how you respond to these thoughts appears to be more logical than substituting them with positive ideals. Certainly allied health would be far more effective if we could utilise CBT techniques not just for chronic pain but all pain, as pain is always has an emotional context. I tend to use ACT principles but also use therapeutic neurophysiology education as a way of reducing anxiety, fear and catastrophisation. It doesn’t really matter what approach we use as long as we can induce top down sensitisation effect which will lead to less pain and increased function.
Carl, that’s exactly why I indicated so clearly that this is a CBT approach based on the principles I listed – not that challenging/changing thinking patterns is the key, but that good information and knowing what you want to do and why (values) along with strategies to manage distress (or experiential avoidance) is influential. I think “TNE” is pretty much what I’ve been doing in chronic pain management for 30 years now – giving good explanations for what we know about pain and thus reducing the threat response (to use modern jargon). All pain is a contextual experience, made of up a whole bunch of things including biological, psychological and most importantly to me, social contributing factors. That’s why I keep harping on about extending the current application of CBT approaches outside the clinic confines and into the real, messy, difficult and ever-changing social world. Thanks for taking the time to comment – I haven’t been on Twitter today, but I will certainly take a look!