Rated #1

Medical News

Evidence-informed management of chronic low back pain with cognitive behavioral therapy

The major goal of cognitive behavioral therapy (CBT) is to replace maladaptive patient coping skills, cognitions, emotions, and behaviors with more adaptive ones. From a biopsychosocial perspective, CBT alone does not address all of the important variables potentially contributing to chronic low back pain (CLBP) (eg, biological factors) but may improve care for patients with psychological comorbidities. The addition of even a very brief schedule of CBT to usual care from primary care physicians has been shown to reduce pain and anxiety, though such effects may not last over time [1,2]. CBT is often a component of multidisciplinary pain programs and patients sometimes find it difficult to perceive the utility of CBT as the sole treatment for CLBP [3]. Use of the term CBT varies widely and may be used to denote self-instructions (eg, distraction, imagery, motivational self-talk), relaxation and/or biofeedback, development of adaptive coping strategies (eg, minimizing negative or self-defeating thoughts), changing maladaptive beliefs about pain, and goal setting. Patients referred for CBT may be exposed to varying selections of these strategies, specifically tailored to their needs.

To date, the literature indicates that CBT is an effective component in the overall treatment of CLBP. As noted earlier, the biopscyhosocial approach to chronic pain management has moved away from the outdated view that monotherapy is the best approach to achieve overall therapeutic improvement. Multiple factors- biological, psychological, and social-must be simultaneously addressed and CBT serves an effective role in dealing with the psychosocial component of CLBP. However, it needs to be combined with other therapeutic components, such as physical therapy to deal with physical deconditioning issues.

Currently, though, there are no studies directly addressing what combination of components for what type of chronic pain syndrome provide the best therapeutic outcomes. This is a challenge for future clinical research. For example, a recent study by Molloy et al. evaluated whether a combination of CBT and a spinal implantable device was effective in the treatment of a cohort of chronic pain patients (75% of whom had CLBP). Results demonstrated that this combined approach produced significant improvements in disability, affective distress, self-efficacy, and catastrophizing at long-term follow-up. Previously, this cohort of patients showed suboptimal response to either of these treatment components when administered alone.

Although there were some methodological issues associated with the above study, it does illustrate the growing perceived need to conduct "component-type" analyses of comprehensive pain management programs to dissect the relative contributions of the various components. This will further advance the heuristic value of a biopshycosocial approach to chronic pain management.

By Robert J. Gatchel, Kathryn H. Rollings.