CBT Approach to Chronic Low Back Pain

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Introduction

This page is designed to outline and review existing literature on the different types of Cognitive Behavioural Therapy (CBT). Additionally, literature comparing the different types of therapy has been analysed with relation to Physiotherapy.

Background 

CBT is a method that can help manage problems by changing the way patients would think and behave. It is not designed to remove any problems but help manage them in a positive manner (Beck, 1995; NHS Choices, 2012).

Behaviour therapy (BT) was developed in the 1950’s independently in three countries: South Africa, USA and England (Öst, 2008). It was further developed to Cognitive Therapy (CT) in the 1970’s by Aaron Beck with its main application on people with depression, anxiety and eating disorders (Beck, 1995; Hayes, 2004). However the main evidence today is focusses on Cognitive Behavioural Therapy (CBT), after the merging of BT and CT in the late 80’s (Roth and Fonagy, 2005).

Principles of Cognitive Behavioural Therapy

There are 3 basic principles of CBT (Butler, 2010):
• How people think about their situations influences how they feel and what they do.
• Problems like depression, anxiety and self-defeating behaviour can be broken down by problematic thought patterns.
• People can learn to identify distorted thinking, change their outlook, take constructive action, and feel better.

Advantages and Disadvantages 

Table showing the advantages and disadvantages of CBT

Advantages	Disadvantages
The highly structured nature of CBT means it can be provided in different formats, including in groups, self-help books and computer programs.	Does not use a holistic approach to patient’s situation.
Skills learnt through CBT are useful, practical and helpful strategies that can be incorporated into daily lifestyle and benefit the management with future stresses and difficulties.	Due to the structured nature of CBT, it may not be suitable for people with more complex mental health needs or learning difficulties.
	Commitment is required from the patient. A therapist can help and advise them, but may be unsuccessful without co-operation from the patient.

Behavioural Therapy

Operant Therapy - The Theory

Operant Therapy

Operant therapy is based on the Operant Conditioning principles first proposed by Skinner in 1953 in his book Science and Human Behaviour. The Operant behavioural model was first applied to CLBP by Fordyce W E in 1976 in his book Behavioural Methods for Chronic pain and Illness (Henschke et al., 2010).

What is Operant Behavioural Therapy

Operant Behavioural Therapy or Operant Conditioning proposes that pain behaviours learnt by an individual can be reinforced by external factors (Henschke et al., 2010) (Shinohara et al., 2013). The external factors are damaging positive reinforcements of the pain behaviours used by the patient that can be detrimental to the long term health of the patient. These factors often include detrimental attention from family, medical personnel, dependency on pain medication and excessive rest. Therefore operant behavioural therapy looks at removing these damaging positive reinforcements and replacing them with more healthy behaviour. Operant behavioural techniques often involve the use of increased exercise levels and work to meet targets set by the patient and clinician. This method can also be helped by incorporating the family and friends of the patient to maintain and monitor the change back to more healthy behaviours. With each goal that is achieved the patient is positively reinforced by all staff and personnel, involved (Henschke et al., 2010).

Uses in Clinical Practice

Operant Therapy is used in a variety of clinical settings (Shinohara et al., 2013). Operant therapy is primarily used to treat psychological issues such as depression and anxiety. Operant therapy has also been used as part of a Multi-disciplinary approach to treating long term conditions such as CLBP and Fibromyalgia (Thieme et al., 2007; Henschke et al., 2010). Thieme et al. (2007) looked at the effects of Operant Behaviour therapy on 125 Fibromyalgia patients after a 12 month Follow up which showed that 53.5% of patients in the operant therapy group had meaningful improvements in pain intensity.

Respondant Therapy - The Theory

What is Respondent Therapy?

Respondent therapy is an approach to behavioural therapy with aims to modify the body’s physiological response to pain, by reducing muscular tension (Henschke et al., 2010). The respondent model as described by Gentry and Bernal (1977) theorises that physical damage can lead to a pain-tension cycle.

This cycle is viewed as a cause and a result of muscular tension (Turk 1984). It states that whilst avoidance of movement may be used to reduce pain, the resulting decreased mobility may increase the tension and thus pain furthermore. Respondent therapy aims to disrupt this cycle using methods such as relaxation, progressive relaxation, applied relaxation and Electromyographic (EMG) feedback. These methods are used to reduce the muscular tension, relieving anxiety and thus the subsequent pain (Turk 1984; Vlaeyen 1995).

Techniques for Respondent Therapy

Progressive relaxation is a technique for learning to monitor and control the state of muscular tension (Jacobsen, 1929). It was developed by American physician Edmund Jacobson in the early 1920s. The technique involves learning to monitor tension in each specific muscle group in the body by deliberately inducing tension in each group. Upon releasing this tension, attention is paid to the contrast between tension and relaxation. It is to be noted that these are not considered to be exercises or hypnotism.

The “Applied Relaxation” protocol developed in Sweden by the psychologist Lars-Goran Öst developed from Jacobson’s progressive relaxation technique. It expands on progressive relaxation but involves attempting to relax more quickly and in various scenarios (Öst, 1987).

EMG feedback, in respondent therapy, is used as a point of reference for a patient, to objectify their muscle relaxation techniques (Nouwen, 1983). It uses several surface electrodes to detect the action potentials of muscles giving appropriate feedback as to the state of muscle contraction.

Evidence for Respondent Therapy

Several studies have compared respondent therapy using progressive relaxation to a placebo (Stuckey et al., 1986; Turner 1982; Turner et al., 1993). Results showed favourable effects of the treatment but not significantly as the waiting list control also showed improvements.

Four studies have identified respondent therapy with EMG feedback against a placebo (Bush et al., 1985; Newton-John et al., 1995; Nouwen, 1983; Stuckey et al., 1986). These studies showed slightly favourable results but producing no significant results.

Evidence of effectiveness against other forms of therapy

One study compared respondent therapy against self-hypnosis (McCauley et al., 1983), concluding that neither intervention were superior to the other, given its non-significant results as compared to a placebo.

Evidence of effectiveness of respondent therapy in addition to other treatments

One study compared a combination of respondent therapy with EMG feedback and physiotherapy with physiotherapy alone (Magnusson et al., 2008). Significant differences noted in favour of the combination for pain post-treatment, after 6 weeks and 6 months.

References

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