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Spotlight on Research: cognitive factors in pain management

In the third in our series we look at the importance of targeting cognitive factors in the treatment of pain. Reports by Colleen Shannon

Anatomy of a study There is now a sizeable base of evidence confirming the importance of cognitive factors, such as catastrophising, in pain management and in chronic low back pain. Studies have shown there is a strong relationship between certain cognitive factors and levels of pain and disability, and have pointed to the efficacy of physiotherapy-led interventions in addressing pain management. Now, a clinic-based research team looking at interactive behavioural modification therapy (a physiotherapist-led intervention underpinned by cognitive behavioural principles) has taken work on the role of cognitive factors one step further. The researchers not only investigated whether a physiotherapy-based intervention aiming to modify cognitive factors was effective, they also looked at whether there were changes in cognitive factors, and, significantly, they investigated whether there was any link between the cognitive processes (the pre- to post-treatment change in cognitive factors) and changes in pain, disability and depression. Finally, they then examined whether changes in some cognitive factors were related more strongly to improvements in pain and disability: this is important because it potentially guides the focus of treatment. Researchers studied 137 patients with CLBP who had been referred to the hospital’s Work Back to Life rehabilitation programme, which incorporates behaviour modification principles. To use resources effectively, patients are only referred to the programme if they have psychosocial risk factors such as fear of movement and reinjury, catastrophising and avoidance behaviour.  Patients worked in a group and participated in five sessions of three and a half hours, over a period of six weeks. Two physiotherapists led each session. Components of the intervention included graded exercise, education, problem solving and progressive goal setting.  Patients showed significant favourable changes in a range of cognitive factors: fear of movement/(re)injury; catastrophising; depression; functional self-efficacy; perceptions of control over pain, and perceptions of their ability to decrease pain. The researchers then examined the relationship between cognitive processes and changes in pain intensity, disability and depression. Pre- to post-treatment changes in cognitive factors explained an additional 22 per cent, 17 per cent and 15 per cent of the variances in changes in pain intensity, disability and depression, respectively, after controlling for other important factors. Further examination of the associations showed increases in functional self efficacy were strongly related to reductions in pain intensity. Reductions in fear of movement and increases in self efficacy were strongly related to reductions in disability, while increases in functional self efficacy and reductions in catastrophising were both strongly related to reductions in depression. The authors concluded that some changes in cognitive factors were strongly related to treatment outcome within a physiotherapy treatment context. They noted that, in particular, reductions in fear of movement and catastrophising, and increases in functional self-efficacy emerged as strong predictors of treatment outcomes. They suggest it is important to target these cognitive factors when treating CLBP patients. What does it tell us? This piece of research is significant because it highlights that physiotherapists can lead interventions that modify cognitive factors and can be effective in managing pain. This is a key finding for physiotherapists that supports guideline recommendations to take account of the psychosocial barriers to recovery (yellow flags) when planning and carrying out physiotherapy for people with back pain. The draft guidelines from the National Institute for Health and Clinical Excellence recommend multidisciplinary rehabilitation for people with ongoing psychological distress. But if a physiotherapy programme can reduce psychological distress then this is surely a more cost-effective option. We need to emphasise this to managers and commissioners when implementing the NICE guidelines locally. We might do this using the patient reported outcome measures used in this study. In England, following Lord Darzi’s Next Stage Review report, PROMs have high status in the NHS.  This trial also has definite implications for physiotherapy, in that practitioners should be considering if and how to incorporate cognitive behavioural approaches into their treatment options and acquiring the competence required to undertake the role. Once competent, this will fall within an individual’s scope of physiotherapy practice. This piece of research has implications for the management of long-term conditions and vocational rehabilitation, helping people back to work. The researchers, while describing the working demographics of the group, do not report on the changes the intervention had on the working capacity or functional ability to work of the group. The opportunity for physiotherapists to take a greater role in addressing chronic low back pain is highlighted by the positive conclusions of this report. However, cost effectiveness and measurable outcomes demonstrating successful remaining in, or returning to, work are also required to influence commissioners. Anne Jackson, CSP research and development adviser, and Léonie Dawson, CSP professional adviser Fact file Research: Examining the changes emerging in cognitive factors following a physiotherapist-led intervention for chronic low back pain. Lead investigator: Steve Woby, research therapist, physiotherapy department, Pennine Acute Hospitals trust, and honorary research fellow, Manchester Metropolitan University and University of Manchester. Publication: Woby SR et al. ‘Outcome following a physiotherapist-led intervention for chronic low back pain: the important role of cognitive processes.’ Physiotherapy (2008), 94: 115. To view this paper visit www.csp.org.uk In the clinic Peter Gladwell, clinical specialist physiotherapist in the pain management service at North Bristol trust, has used a cognitive behavioural approach with his own patients for a decade so he is glad to see further evidence that it works. He was particularly interested to see improvements in physical functioning were underpinned by reductions in the patients’ levels of fear. As a clinician, Mr Gladwell has long been sensitive to the relationship between the mind and body. ‘We are particularly interested in the boundaries between physiotherapy and psychology,’ he says. ‘A number of us have worked alongside psychologists and have realised how close the two professions can be at times, while also trying to recognise the differences.’ Looking at this paper, he finds himself asking: ‘How can we do our jobs as physiotherapists without taking into account thoughts and feelings?’ The research affirms ‘everything is joined up in rehabilitation’, he adds. ‘We can’t separate the physical benefits people gain through physical exercise and goal setting from the effect of that on their mood and their confidence.’ In addition to the results reported, he would be interested to hear what patients thought of their experiences during the study. Reflections on research Steve Woby, research therapist at Pennine Acute Hospitals trust, has a unique position in a unique department. Management is keen to see research integrated into everyday work, with clinicians not only applying evidence-based principles but also discovering them.   The programme has very practical drivers, such as reducing waiting lists and using budgets effectively. ‘If you can produce good research in your department, then that should improve efficiency in your department,’ Dr Woby says. By training, Dr Woby is not a physiotherapist but a sports scientist, with specialised knowledge of exercise. The back pain research has been running for about seven years, and Dr Woby was brought in midway to provide an unbiased view from outside the profession. ‘People get quite anxious when we talk about cognitive factors,’ he says. ‘This is not cognitive behavioural therapy. What we are doing is just addressing some of the factors that we know influence rehabilitation. It’s having the confidence to challenge patients and expose them to certain types of activity.’ Some physiotherapists remain sceptical, he adds, and favour more hands-on interventions such as massage and manipulation. ‘Some people will say, they don’t treat them, all they do is talk them better. We find that quite frustrating because it is a treatment and it is quite an important skill,’ says Dr Woby. ‘This type of treatment relies exclusively on communication.’ The next step for the back pain research is to tease out the parts of the intervention that are creating the most clinical benefit. Dr Woby would have preferred a randomised controlled trial to answer this question from the outset. However, denying benefits of the therapy to a control group was ruled out on ethical grounds. A crossover design might have overcome that problem, he reflects. The researchers settled for a design that would provide some useful answers with available resources. The team is also investigating a similar cognitive approach to chronic fatigue syndrome. ‘Conventional physiotherapy interventions don’t really work for CFS, so we developed a similar intervention, and we’ve just finished evaluating that,’he says. The data indicate psychological factors are extremely important within chronic fatigue syndrome. Ultimately, Dr Woby would like to see this type of intervention used more widely in the NHS, provided it is targeted at the patients most likely to benefit. ‘The idea should be to give the patients the skills to manage the condition themselves, to empower the patients. That can take time, you can’t just do it in one or two sessions.’  He acknowledges it might seem an expensive intervention because of the clinician time required. However, he believes if the right patients are targeted and a group approach is taken, such interventions could prove cost effective in the long term because once problems are truly resolved, patients will not need recurrent treatment. The psychologist’s Perspective Kevin Lucas is a senior lecturer in psychology applied to healthcare and teaches psychology to physiotherapy and podiatry students at the University of Brighton.  Looking at this paper, he would like to know more about the characteristics of the participating physiotherapists. In particular, Dr Lucas thinks their training, experience and attitudes to cognitive behavioural interventions would have influenced the outcomes. Overall, he sees it as a positive study with an important message: cognitive behavioural approaches in the hands of physiotherapists can indeed work. In general, he believes any healthcare professional can give cognitive behavioural interventions within the care they offer, provided they can meet two conditions. First, the professional needs ‘sufficient emotional intelligence to be able to respond appropriately to what patients say’. Dr Lucas tries to persuade his students that developing this skill is just as important as learning anatomy. Second, there is a need for standardised training in cognitive behavioural interventions. This would not only ensure quality but would also make it easier to assess the effectiveness of the intervention more systematically. While this study focused on patients with psychosocial risk factors, Dr Lucas is keen to remind physiotherapists these elements are at work with any person experiencing illness or pain. ‘All practising physiotherapists recognise psychosocial factors have an important role to play in the outcome of their treatment,’ he says. ‘I think what few physiotherapists realise is the magnitude of that effect.’ Research into practice If you would like to put these and other findings on cognitive approaches to work in your own practice, here are some tips Observe the therapy in action – see for yourself what is involved. Find another team applying cognitive principles and ask if you can shadow them Taining will increase your confidence in delivering cognitive based interventions. It will also raise clinical standards and ensure consistency of care Recognise it’s not for everyone. Try some of the assessment and outcome measure tools used in the study that look at cognitive factors Try using components of the programme, such as progressive goal setting, with individual patients would these outcome measures be useful for other patients, not just those with back pain? The pain expert ‘In recent times, physiotherapy for back pain has been very much biomechanically focused – very much focused on the physical treatment,’ according to Denis Martin, head of the centre for rehabilitation sciences, University of Teesside. This study affirms the importance of cognitive factors as well. In Dr Martin’s view, there is now sufficient evidence from many good quality studies to suggest considering cognitive factors should be a standard approach in physiotherapy for people with chronic pain. Dr Martin, who is chair of the Pain Association Scotland, comments this study also shows physiotherapists are entirely capable of addressing the cognitive and behavioural aspects of care for their patients. ‘Some people get put off when they hear the term cognitive behaviour therapy and they think that’s only for the psychologists.’ However, he has ‘no qualms about thinking that the application of these principles should be common. They should be core skills.’ ‘This study has reinforced the idea that applying cognitive behavioural principles ought really to be within the comfort zone of physiotherapists. That doesn’t mean physical techniques have to be abandoned.’ Nor do physiotherapists have to worry about adhering to ‘pure, rigid cognitive behavioural therapy’, he adds. ‘It’s perfectly acceptable to take those principles and incorporate them within the type of physiotherapy described in this paper.’ Further reading Woby SR et al. ‘Self-efficacy mediates the relation between pain-related fear and outcome in chronic low back pain patients’, European Journal of Pain (2007), 11: 711 Main C, Sullivan M, Watson P. Pain Management: practical applications of the biopsychosical perspective in clinical and occcupational settings (2007), Churchill Livingstone. Mercer C et al. Clinical Guidelines for the Physiotherapy Management of Persistent Low Back Pain (2006), CSP. CSP. Scope of Practice 2008. Practice and development information paper PD001. www.csp.org.uk/publications NICE.Low Back Pain. www.nice.org.uk/guidance/index.jsp? action=download&o=42250DoH. High Quality Care for All. NHS Next Stage Review final report, 2008. www.dh.gov.uk/en/Publicationsandstatistics/ Publications/PublicationsPolicyAndGuidance/DH_85825

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