Here is an interview that I did for Strength Physio on the physiotherapy management of on-going pain. Click here for a link to the interview on the Strength Physio site.
Using the CB approach in physiotherapy management of on-going pain
How would you describe CBT/What is it?
CBT has its origins in cognitive and behavioural therapies and now refers to any therapy that incorporates interventions to target unhelpful thoughts or beliefs and any intervention that targets unhelpful behaviours. But more commonly these days it refers to an approach that incorporates both. Essentially, the CBT model explains the relationship between thoughts, feelings and behaviour. It’s not the event that is important but the thoughts we have about it that produces feelings which drive behaviour. Sometimes the behaviour has the effect of then reinforcing the belief. So, it’s not what is actually happening in someone’s back that is important when looking at prognosis, but the thoughts they are having about it, e.g. ‘I have a weak back’ and ‘I should protect my back’, which makes them feel worried – the emotion – which then drives them to avoid certain movements or activities, leading to deconditioning and a sensitised pain system, i.e. a back that keeps on hurting and maybe even gets worse, which reinforces the thoughts of ‘I have a weak back’ etc.
What are the physiological processes that take place in chronic pain?
Have you got a few days….! I think the easiest thing to say here is that our pain system is truly wondrous and thankfully very efficient at protecting us. But like any system, it doesn’t always do what is helpful and, like my husband, it’s not always right. In chronic pain the original cause of the pain has usually shrunk into the background, or even disappeared, and now the cause of the pain is a malfunctioning pain system. I like to think of it like an overprotective parent that is screaming like a banshee as soon as little Jonny even contemplates climbing on the sofa. For anyone that is interested in learning more, I would direct them to literature like the Topical Issues in Pain series of books and the Neuro-Orthopaedic-Institute courses. And if you can wait a short while, there will be a series of books being published that I know will be awesome without having a read a word yet. Louis Gifford penned 5 or so books before he passed away recently. They have been proof read by his mate Mick Thacker who has described them as a ‘masterpiece’ and will be published shortly. I can’t tell you how much I’m looking forward to it.
What type of patients are best indicated in the use of CBT?
All the guidelines and research are pointing to those patients with a high risk of poor outcome. The key risk factors are the psychosocial ones, such as catastrophisation, low mood/anxiety, and work factors. Unfortunately the research suggests that we are not that good at intuitively knowing who is at risk so we need help in learning how to ask the right questions in addition to using screening tools such as the StarTBack tool or the CSQ24.
What are the techniques used in CBT as it relates to physio?
There are lots of techniques that slot nicely into physio practice, especially the ones about self-management such as pacing, and baseline setting. I find the hardest techniques for physio’s to master are the skills of questioning. This is where you use questions to guide the patient to challenge their own ways of thinking or behaving.
How do these techniques help people with pain from a physiological point of view?
Good question but tricky to answer quickly. I suppose the easiest way to think about it is from a threat perspective. You want the pain system of the person suffering with chronic pain not to freak out whenever it receives normal input. We have to remember that pain is an output. I.e. it is created by the brain in response to incoming information based on everything it’s ever heard, seen, learnt etc. So if we can change the brain’s experience of the world, we’ll change its outputs. We need to teach it that pain does not always equal harm, especially in chronic pain, through good reassurance and education. Maybe we can outwit the brain by doing things differently so that we don’t trigger pain memories – sometimes called pain tags. If we can desensitise the pain system by graded activity that doesn’t trigger a pain response and allows the tissues to become stronger and more flexible then the brain won’t be so interested in focussing on them. The physiology of chronic pain is fascinating and the experimental studies done on manipulating pain outputs are starting to give us great insights into how many of our tried and tested physio techniques actually work, as well as insights into why CBT approaches are supported empirically.
Can you use manual/exercise therapy alongside CBT or does this contradict some of CBT’s messages (especially manual techniques)
Yes. But no but. In general I’d like to say yes but it depends so much on how much time you have with the patient, what are the key problems etc. And, it depends how you set up the intervention. So, Mrs Smith, I know you are very concerned that you have something out of place in your back. Don’t worry, everything is fine but I’m just going to press on your back to help you with your pain…. It’s terrifyingly easy to say one thing and for your patient to hear something different. One way to get round this is to think about what we are saying but also to ask the patient to summarise what we’ve said. My typical patter is; So Mrs Smith, I apologise, I have been doing this job far too long and without realising I start talking jargon and confuse the heck out of my patients, so can I just check with you what you think I just said about why you have knee pain? And what we’re going to do about it? I think in this way we can check whether we are contradicting ourselves by saying one thing and doing another.
What is the evidence base for this form of treatment with physio patients?
The main trials are the Back Skills Training Trial, which I was the clinical lead on, and the StartBack trial along with quite a few other smaller trials. Expect to see CBT based treatments to feature strongly in the next NICE guidelines on the management of low back pain.
Where can people find out more about CBT/good books etc?
I think joining the Physiotherapy Pain Association is a good start as they are the group that have been advocating physio’s to use CBT approaches for a very long time. There is a good CBT book called ‘Overcoming Chronic Pain’ by Cole, MacDonald, Carus, and Howden-Leach. The British Association of Behavioural and Cognitive Therapies have a directory of CBT courses and therapists for anyone interested.
Are there courses that you would recommend in this area?
The courses for physio’s are few and far between. I would encourage people to seek feedback from colleagues that may have been on any CB courses and keep your eyes on Frontline. It goes without saying that my course is hands down the best course, ever.
Anything else from your point of view that you feel is important to mention with regards to CBT?
Well, I’m now a glass of wine into writing these responses so there are probably lots of important things. I suppose the main thing to say is that just telling someone they need to get some exercise isn’t ‘physiotherapy’, and equally, just talking to your patients isn’t ‘CBT’. However, from the research I’ve done so far, physiotherapists are pretty good at learning the CB model and implementing some of the techniques to complement what they do on a day to day basis.
What are your 5 top tips to remember when using CBT with patients?
These tips may not make sense unless you’ve had some CB training but here goes anyway; 1) Be nosey/curious. What do your patients really think is going on and what does that look like to them, what does that mean for the future, what do they think needs to be done. 2) Be gentle. If you are challenging someone’s way of thinking or acting then be aware that you might be wrong, but even if you are not it is a scary time for the patient to contemplate doing things differently. 3) It is not your job to change someone’s mind, just to raise the possibility of another way of thinking/behaving. The rest is up to them. 4) Be guided by a good grounding in physiology/pain science when using CBT techniques. Seek support. Talk through cases with colleagues that love this stuff. This will also help you gain some feedback in case you are going into a hole without a shovel to dig yourself out.