Vol. 89, No. 5, May 2009, pp. 470-472
DOI: 10.2522/ptj.20080163.ic
Research Reports |
Invited Commentary
KA Sluka, PT, PhD, is Professor, Physical Therapy and Rehabilitation Science, University of Iowa, Iowa City, IA 52242 (USA).
DC Turk, PhD, is Professor, Department of Anesthesiology, University of Washington, Seattle, Washington.
Address all correspondence to Dr Sluka at: kathleen-sluka{at}uiowa.edu
"Cognitive-behavioral therapy" (CBT) has become a generic term that includes a range of cognitive and behavioral techniques such as cognitive restructuring, problem solving, communication skills training, and operant conditioning (ie, contingent reward for activity and withdrawal of positive reinforcement for avoidance and withdrawal of activity). The survey article by Beissner and colleagues1 describes the current usage of cognitive and behavioral techniques in physical therapist management of older adults with chronic pain that would be considered part of a CBT program, such as pleasurable activity scheduling and activity pacing. However, CBT is much more than a set of techniques, and it is easy to become seduced by the details of the techniques and lose sight of the conceptual perspective and objectives for which the techniques are being used.2
The cognitive-behavioral perspective is predicated on a set of assumptions about people. Specifically: (1) patients are active processors of information and not passive reactors; (2) thoughts (eg, appraisals, expectancies, beliefs) can elicit and influence mood, affect physiological processes, have social consequences, and serve as an impetus for behavior; conversely, mood, physiology, environmental factors, and behavior can influence the nature and content of thought processes; (3) behavior is reciprocally determined by both the individual and environmental factors; (4) patients can learn more adaptive ways of thinking, feeling, and behaving; and (5) patients should be active collaborative agents in changing their thoughts, feelings, behavior, and physiology.
The cognitive-behavioral perspective can be incorporated into interactions with patients by a variety of clinicians, including physical therapists. This will assist patients in making positive changes in their thought processes and changes in maladaptive pain behaviors (inactivity) to well behaviors (exercise). The various cognitive and behavioral techniques are less important than the set of principles outlined. The techniques themselves are all designed to help patients self-manage their symptoms and their lives. The objectives and the change in behavior being targeted are the essential components; how the changes in behavior are brought about, the techniques, much less so. The assumptions underlying the cognitive-behavioral perspective are helpful in guiding interactions between any health care provider and his or her patients and are not the specific purview of psychologists.
To summarize, CBT has 4 key components that can be adapted for use in physical therapist practice: (1) education, (2) skills acquisition, (3) skills consolidation, and (4) generalization and maintenance.2,3 The educational component focuses on helping patients identify and challenge their maladaptive beliefs and expectations about activity, their abilities, and their negative expectations about the future. It also attempts to manage pain by making patients aware of the role that thoughts and emotions play in potentiating and maintaining stress and physical symptoms (ie, cognitive restructuring). Cognitive restructuring includes identifying and challenging maladaptive thoughts, feelings, and behaviors; introduction and practice of coping thoughts and behaviors; shifting from self-defeating to coping thoughts; and practice of positive thoughts including home practice and follow-up.
The main goal of the education component is to shift the patient's repertoire from well-established, habitual, and automatic, but ineffective, responses toward systematic problem solving, control of affect, or disengagement from self-defeating situations. For example, as a physical therapist, it is important to examine and challenge the patient's perception about exercise and physical activity: the erroneous and often-inhibiting thought that "hurt" is equivalent to "harm" and, therefore, if exercise hurts, it should be avoided to prevent damage. Physical therapists should emphasize that in patients with chronic pain, exercise and physical activity will not make the injury worse, but rather, if continued regularly, will increase flexibility, endurance, and strength and eventually decrease pain, as well as improve the ability to perform other activities. Avoidance of activity or premature termination will prevent patients from obtaining corrective feedback. That is, they may not learn that they, indeed, can perform activities that they may have feared, without further damage and with improvements in functioning.
Skills acquisition and consolidation help people learn and practice new pain management behaviors through a variety of techniques that include relaxation, problem solving, distraction methods, activity pacing, and communication. Psychologists utilize a variety of methods to teach these pain management behaviors: education, didactic instruction, Socratic questioning, observational learning, and role playing. The overall goal of the skills acquisition and consolidation components is to teach the patient self-management strategies using various techniques. Importantly, patients learn from observing outcomes of their own efforts and those of others. Often CBT is carried out in a group context where the psychologist can use the support of other patients and have patients interact with each other to assist in providing alternative ways of thinking and behaving. In such groups, patients can observe others making improvements without aversive consequences that may have been anticipated by the patients. Observational learning is thus a valuable tool that can easily be incorporated into physical therapist practice through group exercise therapy, where patients view others with similar physical limitations performing exercises that might be threatening without anticipated negative consequences. As a physical therapist, the use of activity pacing also is common and consistent with the therapist's understanding of exercise and functional activities. Thus, incorporating cognitive and behavioral techniques into physical therapist practice can easily be accomplished and serve to enhance standard physical therapy treatments.
Finally, generalization and maintenance are geared toward consolidating skills and preventing relapse. Importantly, psychologists utilize homework in CBT to solidify the skills learned. Initially, patients have been taught and have practiced self-management skills within the therapeutic environment. After this, it is essential that the patients practice their skills in the home environment, where the therapist is not present to guide and support them. Difficulties that arise when the skills are attempted at home are important topics for discussion and to teach further problem solving, including flare management. In this phase, psychologists assist patients to anticipate future problems and high-risk situations so that they can think about and practice the behavioral responses that may be necessary for adaptive coping. This is a critical phase for long-term success of the patients in managing their pain. In terms of physical therapist practice, implementation of behaviors long-term, especially with exercise, is quite difficult. Understanding and emphasizing home programs of exercise for the patient, outside the clinical setting, is an important factor. This may require encouraging participation in a local gym, setting up home exercise equipment, or assisting with setting up a daily exercise routine with the patient. Thus, translating the principles taught in the clinic to a continued successful program will take guidance from the therapist to strategize and adapt to the home program.
There is good evidence, from randomized controlled trials and systematic reviews, that the cognitive-behavioral perspective, when integrated within a comprehensive rehabilitation program, reduces pain and disability and restores function in people with chronic pain.4–7 We have only highlighted some aspects of CBT, but it should be obvious that the approach is much more complex then simply teaching patients a set of skills such as pleasurable activity scheduling and activity pacing. Considerable clinical sensitivity and expertise are required to develop an integrated program for patients with chronic pain. (For detailed treatments of CBT as a perspective and techniques applied to chronic pain, see Turk8 and Turk and Meichenbaum.9)
Although understanding the principles of CBT for the management of pain and incorporating these into physical therapy interactions with patients are important, it is equally important to recognize when to refer a patient to a psychologist specializing in pain management. Some cognitive and behavioral techniques (eg, activity pacing, relaxation exercises) can be incorporated into physical therapist practice, whereas some techniques (eg, cognitive restructuring, communications skills training) require specialized training in CBT and remain outside the domain of physical therapist practice. Many patients with chronic pain would benefit from psychological interventions; thus, patients in need of specific CBT skills training should be referred to a psychologist specializing in pain management. Furthermore, those individuals who are in most critical need of referral for psychological interventions include those with a high level of fear of pain and reinjury, those with a high level of catastrophizing (negative thoughts about themselves, their abilities, and the future), those with a strong affective (emotional) component to their pain, and those with suspected underlying psychological diseases (eg, anxiety, depression). Adequate treatment of these variables may require multiple psychological approaches and, when used in combination with physical therapy approaches in a team environment, will result in an enhanced efficacy of treatment.
- Beissner K, Henderson CR Jr, Papaleontiou M, et al. Physical therapists’ use of cognitive-behavioral therapy for older adults with chronic pain: a nationwide survey. Phys Ther. 2009;89:456–469.
[Abstract/Free Full Text] - Turk DC. Cognitive-behavioral approach to the treatment of chronic pain patients. Reg Anesth Pain Med. 2003;28:573–579.[CrossRef][Web of Science][Medline]
- Turk DC, Wilson HD, Psychological approaches in pain management. In: Sluka KA, ed. Mechanisms and Management of Pain for the Physical Therapist. Seattle, WA: IASP Press. In press.
- Guzman J, Esmail R, Karjalinen K, et al. Multidisciplinary rehabilitation for chronic low back pain: systematic review. Br Med J. 2001;322:1511–1516.
[Abstract/Free Full Text] - McCracken LM, Turk DC. Behavioral and cognitive-behavioral treatment for chronic pain: outcome, predictors of outcome, and treatment process. Spine. 2002;27:2564–2573.[CrossRef][Web of Science][Medline]
- Morley S, Eccleston C, Williams A. Systematic review and meta-analysis of randomized controlled trials of cognitive behaviour therapy and behaviour therapy for chronic pain in adults, excluding headache. Pain. 1999;80:1–13.[CrossRef][Web of Science][Medline]
- Friedrich M, Gittler G, Arendasy M, Friedrich KM. Long-term effect of a combined exercise and motivational program on the level of disability of patients with chronic low back pain. Spine. 2005;30:995–1000.[CrossRef][Web of Science][Medline]
- Turk DC. A cognitive-behavioral perspective on the treatment of chronic pain patients. In: Turk DC, Gatchel RJ. eds. Psychological Approaches to Pain Management: A Practitioner's Handbook. New York, NY: Guilford Press; 2002:138–158.
- Turk DC, Meichenbaum D, Geneat M. Pain and Behavioral Medicine: A Cognitive-Behavioral Perspective. New York, NY: Guilford Press; 1983.
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  K. Beissner and M. Reid Author Response Physical Therapy, May 1, 2009; 89(5): 472 - 473. [Full Text] [PDF]
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