Shawn Thistle 2019-02-03 22:41:42
Behavioural therapy and back pain
STUDY TITLE: Behavioural therapy approaches for the management of low back pain: An up-to-date systematic review
AUTHORS: Vitoula K, Venneri A, Varrassi G et al.
PUBLICATION INFORMATION: Pain and Therapy 2018; 7(1): 1-12. doi: 10.1007/ s40122-018-0099-4.
Biofeedback: Defined as “the process of gaining greater awareness of many physiological functions primarily using instruments that provide information on the activity of those same systems, with a goal of being able to manipulate them at will.” As a relaxation technique aimed at educating patients to alter autonomic functions that are not normally under voluntary control (such as blood pressure, heart rate etc.), it has been found to be useful in reducing paraspinal muscle tension in patients with chronic LBP. Unfortunately, in a study of electromyography (EMG) biofeedback in patients with LBP, a direct analgesic effect was not found.
Cognitive Behavioural Therapy: CBT is comprised of four components: 1) the patient’s understanding of pain and pain perception; 2) the use of active coping skills; 3) maintenance of pain-coping strategies; and 4) problem- solving skills that enable patients to deal with pain and challenging situations. CBT aims to assist patients in the development of adaptive thought patterns, as it is believed that the patient’s thoughts and beliefs about their symptoms will influence their behaviours. Graded activity/ graded exposure CBT strategies aim to increase an individual’s tolerance of activity. Individual sessions show similar effectiveness to physiotherapy and motor control exercises, while group sessions have demonstrated significant improvements in pain intensity. These strategies have also been demonstrated to be a successful method of restoring occupational function and facilitating return to work in patients with subacute LBP.
Individual sessions of CBT have often been studied as a component of a multidisciplinary approach, however the evidence is unclear. As a stand-alone therapy in a patient population of candidates for spinal surgery, those who received CBT demonstrated less fear avoidance at 12 months than the patients who underwent spinal fusion, and these findings were confirmed at the four-year follow up. It is likely the heterogeneity in patient populations, interventions and co-interventions is responsible for the disparity of these results. Neither telephone-based nor videotapes were found to be effective forms of adjunctive therapy.
Group sessions of CBT demonstrated similarly unclear results. In a population of patients with the potential for acute, severe pain following surgery, preoperative CBT was found to facilitate mobility and reduce the need for rescue painkillers in the acute post-surgical phase. CBT may also be a beneficial intervention for patients with acute LBP, as it may prevent chronicity in these patients. CBT may also improve the quality of sleep and decrease pain perception in patients with depression and anxiety.
Mindfulness-Based Stress Reduction (MBSR): Mindfulness has been described as “non-elaborative, non-judgmental, moment-to-moment awareness.” MBSR includes meditation, yoga and body scan (sequential focus on different parts of the body). These therapies are considered feasible, acceptable and safe for patients with LBP. In addition to usual care, MBSR may result in improvements in pain and functional limitations in patients with LBP.
Acceptance and Commitment Therapy: This teaches patients how to accept unpleasant sensations and thoughts, without attempting to avoid or change them. The intention is not to reduce pain, rather to teach patients to accept the pain and let go of ineffective pain control strategies. This approach, as with some of the others discussed here, takes some time and requires further research.
Applications, conclusions This review outlined behavioural strategies that may assist clinicians in treating patients with LBP. These therapies appear to be most effective in altering pain perception and regaining functionality. While the evidence is unclear, it appears that the addition of CBT to multidisciplinary care is the most effective way to incorporate behavioural strategies within the biopsychosocial model. Future research regarding specific interventions and outcomes (pain intensity, pain acceptance, reduction of medication use, disability and quality of life) will assist clinicians in personalizing therapeutic approaches based on patient-specific needs.
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