The Inclusion of CBT in Physiotherapy Education

Original Editor - Ernest Chao, Florence Cook, Aoife Doyle, Martin Lanfear, Corey Hafner as part of the QMU Current and Emerging Roles in Physiotherapy Practice Project

Top Contributors - Ernest Chao, Corey Hafner, Aoife Doyle, Martin Lanfear, Florence Cook, Kim Jackson, Admin, 127.0.0.1 and Evan Thomas  

<uLearning Outcomes:<u

1. Critically appraise the importance of CBT in physiotherapy practice for the benefits of new physiotherapy graduate.
2. Formulate an appropriate CBT in-service that enhances the ability of graduate physiotherapists to address the psychosocial aspects with regards to patients in various settings

Part 1: Theory

COREY

History of Cognitive Behavioural Therapy (CBT) 
In the early 1960s psychoanalyst professor, Aaron Beck developed cognitive therapy after investigating the psychoanalytic concepts of depression.  He discovered that depressed patients spontaneously experienced automatic negative thoughts. These negative thoughts fell into three categories: negative thoughts about themselves, the world, and the future. After spending some time with these patients Beck recognized that these automatic negative thoughts were highly related to the individual’s emotions. Beck started to notice rapid improvements amongst these individuals after helping these patients identify, evaluate and respond to their maladaptive thinking and behaviour patterns. Although in order to see the efficacy of this form of cognitive therapy, a randomized controlled study was conducted looking at the effects of this form of treatment in depressed patients. Results showed cognitive therapy to be as effects as imipramine, a pharmacological antidepressant. These findings were a huge milestone, as further research went on to show that even though therapy must be tailored specifically to the individual there is certain principles that underlie the use of cognitive behavioural therapy amongst patients.

What is CBT?
Cognitive behavioural therapy stems from the cognitive model of psychopathology.  This theory looks at how individual’s perceptions and thoughts about situations influence their emotional, behavioural and physiological reactions. For example when individuals are stressed their thoughts tend to be distorted and dysfunctional, if individuals learn to identify and address these thoughts, correcting them, there stress tends to decrease and they will be able to behave more functionally. INSERT DIAGRAM
Cognitive Behavioural therapy teaches individuals to confront their irrational thoughts, in a more realistic and adaptive manner so that they experience improvements in their emotional state and behaviour. CBT can include a number a cognitive and behavioural techniques including self-instructions (i.e. imagery, distraction, motivational self-talk) the use of relaxation and biofeedback strategies and adaptive coping strategies (ie. minimizing self-defeating thoughts) all aiming to change an individual’s maladaptive thoughts and behaviour.  INSERT YOUTUBE VIDEO. The use of CBT is multifaceted and can be adapted to a diverse set of populations with various disorders and problems. For each patient CBT uses a different formula, through adjustments to the length and techniques used in treatment in order to adapt to the patients specific needs.

 

6 phases of CBT (PAIN: churchill)
- 1. Assessment
o Conversation with patients and their families
o Includes a series of self-reported measures to identify the degree of psychosocial impairment and determines the most appropriate course of action
- 2. Reconceptualization (“cognitive” portion of CBT)
o Seeks to help patients to challenge and question the rationality of their maladaptive thoughts (i.e. I am a failure in life because I am in pain”)
- 3. Skills acquisition
o Teaches patients how to deal with obstacles in their day to day lives and how to avoid falling into the patient of automatic thoughts
- 4. Skills consolidation and application training
o Patient are given homework in an attempt to help reinforce the skills that they have acquired during the skill acquisition phase
- 5. Generalization and maintenance
o The therapist and patients discuss the future, and how the patients are going to cope once they have left treatment
- 6. Post-treatment assessment follow-up
o Participate in the post treatment assessments and follow-up phases for the therapist to monitor and evaluate patients application of CBT to their live INSERT DIAGRAM

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Where Does CBT Fit into Physiotherapy Practice

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There is empirical evidence that Cognitive Behavioural Therapy (CBT) is effective in improving problems such as anxiety, depression, post-traumatic stress disorder, eating disorders and chronic pain.  In the United Kingdom, the National Institute for Health and Clinical Excellence (NICE) recommends CBT as the treatment of choice for a number of mental health difficulties previously mentioned (London Bridge Physiotherapy).

INSERT BOX OF CONDITIONS 

The therapeutic alliance between the patient and the therapist is an important aspect of the CBT and involves a collaborative approach from the therapist and active participation from the patient.   CBT is widely applicable across situations and beyond the initial problem for which the patient may seek treatment, though it has been specialized and adapted for use within a number of specific disorders ranging from depression, anxiety, and insomnia, to substance abuse and psychosis. CBT has also become increasingly popular for a wide variety of chronic pain conditions, particularly for chronic LBP. 
CBT treatments show the following benefits over wait-list control: reduced pain,  anxiety, avoidance, back-related worry, catastrophizing, depression, disability, disabling attitudes and beliefs, stress, health-related quality of life (for females only), pain control, pain self-efficacy,  perceived ability to function, physical health-related qual¬ity of life, quality of life in general, and social support.  It has also demonstrated effects on occupational and eco¬nomic outcomes in terms of cost-effectiveness, health care visits, and reduction in sick days/work days lost and return to work (Sveinsdottir et al. 2012).

ERNEST Selection of patient population

There is a growing body of evidence behind the effectiveness of cognitive behavioural therapy (CBT) for physiotherapy producing significant improvements for patients with back pain (van Tulder et al. 2000), chronic pain (Morley et al. 1999) and fibromyalgia (Rossy et al. 1999) with regards to function, pain experience and coping strategies. Despite this, there exists a patient population that is less likely to respond to CBT as a treatment (Vlaeyen, 2005). In addition, some research has shown that a CBT approach is no more effective at reducing pain levels as traditional interventions (Eccleston et al 2009). Perhaps a more systematic approach to matching the treatment to certain patient populations and filtering CBT to those who are more likely to respond positively to treatment is the approach required for CBT.
The Keele STarT Back Screening Tool (SBST) (see Appendix 1) is designed to address the mismatch. The SBST categorizes patients with low back pain into three subgroups based on their prognosis (low risk of chronicity, medium risk with physical obstacles to recovery, and high risk with psychological obstacles to recovery) (See Appendix 2) (Keele website). The practice of physiotherapy revolves around patient centered care. The choice of a physiotherapist utilizing CBT as an intervention stems from prior CBT training, therapist intuition and determining from a tool such as the SBST, whether there would be a mismatch between whether a patient will need and respond well to CBT. The SBST is valid and repeatable, and consists of 9 items which include: referred pain, co-morbid pain, disability, bothersomeness, catastrophizing, fear avoidance, anxiety and depression. The latter 5 items combine to form a subscore relating to psychosocial factors that indicates appropriateness for CBT as an intervention (Hill et al. 2008). The SBST is currently being adapted to musculoskeletal conditions, with trials occurring in the NHS 24 in Scotland (Keele website).
Targeting patient subgroups that are most likely to be receptive to CBT can help improve outcomes and reduce costs. A trial of SBST conducted by Hill et al. 2011 demonstrated increased health benefits along with reduced cost of health care. The trial revealed that with the SBST and trained therapists to deliver targeted interventions for each of the three subgroups of patients, there was a direct mean savings of £34.39 per patient and an indirect productivity of £675 per patient when compared with patients receiving best current care. Pain-related productivity and societal losses can manifest with an increase in sick leave days and number of health care visits for back pain. A randomized control trial conducted by Linton et al. 2005 found that CBT in addition to physiotherapy reduced the mean number of health care visits due to pain from 6 to 1, and reduced the percentage on sick leave from 9-14% to 2-5% when comparing groups that received minimal treatment and CBT. This type of evidence suggests that with therapeutic interventions that take into account the biopsychosocial model of patient care, there is a possibility to reduce disability and reduce the cost of care.
The evidence in the literature is indicative of the effectiveness of CBT when directed at the correct patient populations. Current practices are implementing CBT as an approach. Tools like the SBST need to be used in conjunction with sound clinical reasoning in a patient centered approach to target those who are likely to benefit from it. With adapted versions of the SBST to encompass other musculoskeletal conditions being trialed with the NHS 24 currently, newly trained physiotherapists would benefit from CBT training to effectively utilize this new information gained from patients in practice. Physiotherapists are evidenced-based practitioners and there exists not only a need for further training to incorporate CBT principles, but a desire to expand knowledge on CBT principles from practicing physiotherapists as well (Podcast, 2012

EXAMPLES OF THESE VARIOUS PT CASES (ACUTE AND CHRONIC)

With regard to MSK pain issues, there has been an increase in the demand for interventions that may prevent the development of persistent pain problems.  To date few studies have examined the specific effects of psychological preventative interventions despite some early efforts showing promise.  In 1997, Waddell at el. reviewed 10 trials of early interventions for acute back pain.  These programmes dealt with fear and anxiety which is often associated with acute pain.  Von Korff et al. (1998) also found that a cognitive-behavioural programme for patients with acute back pain significantly reduced worry and disability at follow-up – therefore preventative measures may be viable.  In 2001, a RCT was published which aimed to investigate the preventative effects of a CBT group intervention for people reporting neck or back pain (Linton and Ryberg. 2001).  The participants had experienced four or more episodes of relatively intense spinal pain during the past year but had not been out of work more than 30 days.  As a result the aim was to prevent a non-patient population developing a more serious pain problem and entering a chronic stage.  The experimental group participated in a six-session structured programme where the individuals met in groups of 6-10 people once a week for two hours.  The CBT group showed the most stable improvements over the control group with a better result for sick leave reducing the risk of sick leave greater than 2 weeks by more than threefold.  The CBT group also reported a decrease in fear avoidance and an increase in the number of pain-free days concluding early preventative measure may be helpful.
In addition to the physical pain experienced by patients, musculoskeletal disorders are one of the most commonly reported work-related illnesses (Jones et al. 2003).  There is now general agreement among the various occupational health guidelines for management of MSDs which encompasses the identification of psychosocial obstacles to recovery, provision of advice that MSDs are self-limiting conditions and that remaining at work or an early return to work (RTW) should be encourages and supported.  A study was conducted in 2006 in a large pharmaceutical company in the UK.  Occupational health nurses were trained to deliver an intervention to workers taking absence due to various MSDs including low back pain and upper limb disorders.  This training package included education about pain and pain mechanisms, tackling negative beliefs and attitudes and reinforcing the importance of keeping active and early RTW (McCluskey et al. 2006).  Results showed a decrease in absence days in one particular site compared to the control site where workers were seen by the OHN on RTW.  In summary this study adds to emerging evidence that absence from work can also be reduced by providing information and support to employees. 

As previously mentioned, CBT can also play a role in the treatment of various mental health conditions.  A study was published in 2002 (Lewis et al) which aimed to test the effectiveness of added CBT in accelerating remission from acute psychotic symptoms in early
schizophrenia.   A 5-week CBT programme plus routine care was compared with supportive counselling plus routine care and routine care alone in a multi-centre trial randomising 315 people with DSM-IV schizophrenia and related disorders in their first (83%) or second acute admission.  Linear regression over 70 days showed predicted trends towards faster improvement in the CBT group concluding that CBT shows transient advantages over routine care alone or supportive counselling in speeding remission from acute symptoms in early Schizophrenia. 

MARTIN (CBT IN MDT AND FAMILY)
Cognitive behaviour therapy can also be used away from the therapist-patient relationship. Some areas where CBT can be applied by an AHP include:
• Supporting families of those with both chronic and acute conditions:
o Reassurance to family member of those affected by both chronic and acute conditions is essential in the treatment and recovery of the patient [9].
o Programs designed to include families in the care of relatives with chronic conditions can be implemented, particularly in the chronic/terminal setting. Such programs can guide family members in setting goals for supporting patient self-care behaviours, train families in supportive communication techniques and give families tools and infrastructure to assist in monitoring clinical symptoms and medications [10].
o For those with career threatening injuries e.g. professional athletes or manual working, coping with potential loss of income can be extremely stressful for both themselves and their families.
In order to get families on board in a supportive role, there often needs to be a change in cognition. Unrealistic and irrational thoughts regarding their loved ones prognosis may be detrimental to the treatment process, therefore where possible such beliefs should be addressed to reduce the potential of any maladaptive behaviours [11]. For those with acute conditions that may result in loss of earnings or concept of self, CBT may help to prevent anxiety and cognitive distortion e.g. catastrophizing as well as increased adherence to rehabilitation protocol [12].
• To work effectively other members of the Multidisciplinary Team (MDT), particularly in challenging settings e.g. palliative care, oncology, pediatrics:
o When those working in palliative care settings have been interviewed with regards to work place stressors more were related to difficulty with colleagues, work environment, and occupational role than with interaction with patients and their families [7].
o Seeking support from colleagues is often preferred and more accessible then official support models in place for those working in health provision areas with high stress [8].
With an insight into the cognitive and behavioural components of our own actions we can develop higher self-monitoring traits along with increased empathy, this in turn may lead to further understanding of fellow professionals within the MDT thus enabling us to defuse any potentially volatile situations. Furthermore, many of the environments in which Physiotherapist’s skills are required a highly stressful and emotional. As a result we may be required to engage in supportive behaviour and cognitive reason with colleagues.

• To ensure an optimum personal mental health for AHP’s:
o The Health and Safety Executive (HSE) recognizes that there are many factors in the workplace that contribute to strains on NHS professional’s mental health. These include: excessive demands, lack of control, lack of support, poor working relationships, role ambiguity, organizational change [1].
o The 2009 Boorman Review reported that the NHS 10 million working days annually due to sickness costing the NHS an estimated £555million, with mental health along with muscular skeletal issues being the primary cause. Combined they are also the leading cause of health-related early retirement in the NHS [2].
o The Work Foundation estimates that presenteeism due to poor mental health leads to a loss of working time nearly 1.5 times that caused by sickness absence due to mental health in the United Kingdom [3].
By having an understanding of ones own cognitive, allied health professionals may be able to overcomes the inherent stresses of their jobs. It has been documented that self-directed CBT can reduce an individual’s own stress, anxiety, depression and cognitive dissonance [4][5]. As CBT incorporates the introspection of thought process from Cognitive Therapy and the goal of behavioural change from Behavioural Therapy, CBT can be a useful tool for Physiotherapists in their own development as a competent and holistic professional [6]. The resultant increased insight into their thoughts and ability to rationalize those that are irrational in nature may lead to a reduction in mental health issue in those that work on the NHS, resulting in a decrease in work days lost.

Part 2: Case Studies 

Sample case studies where CBT can be beneficial

Principles to CBT treatment
- Therapeutic Alliance
o Essential that the patient views therapy as teamwork
o Important for the therapist to provide empathy, warmth and genuine regard, through listening and understanding the patients true feelings
o Providing a realistic outlook
o Ensuring the patient understands and agrees with types of therapy
o Active participation from the patient, encouraging the patient to take an active role in her recovery, providing therapy homework
- Goals
o Elicit SMART goals from the start to ensure the patient understands what they are working towards
- Educate
o The therapist should aim to teach the patient skills and techniques of how to be their own therapist
- Time Limited
o Patients are usually treated for 6-14 sessions, the therapist aims to provide relief, resolve the patients most pressing problem and teach them skills to avoid relapse
- Structured therapy
o In order to maximize efficiency and effective each session should be structured
- Various techniques
o CBT uses various techniques to change in order to cater to the individuals needs
- Identify, evaluate and respond
o Patients can have hundreds of automatic thoughts everyday but it is important that the therapist teaches the patient how to identify the key cognitions and how to respond

Case 1: Eager/hyperactive patient and Chronic engraved behaviour

Subjective examination:
A 38 year old plumber presents with an 18 month history of low back pain. He’s had a sore back “on and off” for the past 10 years (about 2-3 episodes a year). These previous episodes would usually resolve within a week or so. However, over the last 18 months, the pain has become constant and he is finding it much, much harder to work because of it. His main problems at work are bending down, working in cramped places (e.g. under sinks), carrying his tools and driving for longer than half an hour. His only (partial) relief is a long, hot bath at the end of the day – it doesn’t help the pain much, it just helps him to relax. He’s self-employed and has a family to support, so he tends to “push on” to get the work done but towards the end of the day, he says he’s “good for nothing except lying on the sofa”. He also spends a lot of the weekend resting to try and recuperate/prepare for the week ahead. His GP has prescribed various painkillers over the last year, none of which have helped much. His GP told him he doesn’t need an XR, a scan or surgery. He attended physiotherapy a year ago where he was given exercises to do and manipulation but none of this helped. He found the exercises very painful to do and so he stopped them because they weren’t helping anyway.

Physical examination:
All active movements of the lumbar spine reduced to about ¾ of normal range. Neurological examination is normal. Palpation of the lumbar spine reveals pain and tenderness at all levels. SLR was 70 bilaterally.

Possible strategies to employ:

Pacing strategies
- At work
- With exercises
Education re: Boom/bust model
Pain management techniques

Case 2: Acute MSK condition

Subjective examination:
A 26-year-old professional rugby player reports coming off his first right ACL-repair. 8 months prior he had his first traumatic injury in a game, when a player tackled his right knee forcing it into valgus. He heard an immediate “pop” and had pain with immediate swelling and immediately went to A&E. An MRI revealed a triad injury of the right knee (ACL rupture, MCL tear, medial meniscal tear). He has had an arthroscopy 4 days following the incident. Since then, he reports he has received daily physiotherapy, but has not returned to rugby since he reports ongoing weakness in his right knee, and feels very fearful of re-injury and returning to the full contact nature of the sport.

Physical examination:
No swelling, locking, crepitus, giving way
All ligaments of knee intact
Full ROM, full strength
McMurrays test negative

Possible strategies to employ:
Graded exposure
 progressively increase the amount full sprints and cutting movements
- non-contact in training
- controlled contact in training
- gradually increasing minutes played in actual game
Thought re-evaluation
- re-model maladaptive/fear avoidance behaviors
- problem solving

Case 3: Palliative care

Subjective examination:
45 year old woman with end stage lung cancer, lives at home with husband and 12 year old daughter. Patient has been managing personal ADLs until recently but is struggling with fatigue and nausea resulting in declining motivation. She has recently been diagnosed with depression but does not wish to take medication for this because she feels she ‘is already taking enough pills’. She has started to decline physiotherapy sessions because she ‘doesn’t see the point’. As a result her exercise tolerance is declining quickly, she has a low compliance and motivation.
Husband feels he will be unable cope with the role of primary caregiver and the inevitability of single parenthood through bereavement. Upon seeing the loss of a close family unit the MDT are struggling to maintain their professional composure.

Possible strategies to employ:
• Thought remodelling to aid patients acceptance of situation along with an understanding of the value of maximizing remaining quality of life for her and her family.
• Realising the Stages of Grief (Kubler-Ross) that the husband may be presently at, allow time for acceptance of the situation him to adopt his new role.
• Provide support to colleagues and self through open lines of communication and introspection to highlight irrational thoughts regarding loss.

Case 4: Problems with Adherence

Subjective examination
Domiciliary visit to a 62-year-old male with Chronic Obstructive Pulmonary Disease continues to smoke 30 cigarettes a day as he has done for the last 45 years. He sees no reason to give up smoking at this stage as feels he’s “beyond help”. He reports shortness of breath and increase work of breathing with difficulty climbing stairs and walking distances greater than 5m (MRC score 5). As a result he remains house bound through fear of exacerbation of his breathlessness, though has yet to experience episodes that would confirm this fear. Patient finds it difficult to cough up secretions, has been taught Active Cycle of Breathing but does not feel confident that it works therefore doesn’t comply with prescribed technique.

Physical examination:
Auscultation – Widespread wheeze, prolonged expiration, fine crackles right base
Cough – weak, secretions small amount thick yellow
ABG – (2L O2) H+57, PaCO2 6.8Kpa, HCO3 37 mmol/L, PaO2 8.0 Kpa
SaO2 92% on RA
CXR- consolidation on right base

Possible strategies to employ:
• Remodeling of beliefs towards ACBT and smoking
• Education regarding smoking
• Thought monitoring to examine the grounds on which he bases his reluctance to exercise

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Recent Related Research (from Pubmed)

 Part 3: Incorporating CBT Education into CurricuChallenges in the Current Education System Challenges section (Foster and Delitto 2011):

Entry-Level physiotherapy training
- Prioritizes anatomical/musculoskeletal/biomechanical/biomedical over biopsychosocial model
o treating disease and injury
o strength, movement, modalities, function, balance
o Limited interprofessional education
- Some education within biopsychosocial realm of physiotherapeutic management. However, lacks depth and focus and how to assess and manage psychosocial factors. Most time spent on biomedical assessment and treatment of MSK conditions (i.e. at times education into modalities that are lacking evidence/underpinning)
- Lacks consolidation of above psychosocial education and application into practice to fully reinforce those principles

Current physiotherapy practice
- Physiotherapy culture and practice instills traditional anatomical/biomechanical/biomedical models
- Focus of CPD continues to enforce models above, minimal CPD workshops with psychosocial approach
- Patients’ expectations of their conditions and physiotherapy – hands-on treatment, scans to determine problem
o Openness to physiotherapy management of psychosocial factors
- Lacking the knowledge and know how on how to assess and manage psychosocial factors
- Increasing pressures on waiting times/access to physiotherapy services
o Decreasing amount of funding/limited resources
o Increased reliance on PTA, technical staff (telephone assessment NHS24)
o Insufficient time/treatment sessions to help address psychosocial issues

References

References will automatically be added here, see adding references tutorial.