REP 8: MAKE BACK PAIN EXERCISES MORE CEREBRAL
“I heard the biopsychosocial model is the new thing…formulating treatments that consider, physical, psychological and social factors. If it’s so great, how come some fancy-pants physio hasn’t come up with exercises that involve using one’s head?” Fortunately, there is such a fancy-pants physio: Dr. Peter O’Sullivan has created an exercise approach for managing low back pain that explicitly integrates cognitions. It’s called Classification-based Cognitive Functional Training (CB-CFT).
The big idea
In this short blog post (accompanied with videos and lively discussion) on the bodyinmind.orgwebsite, Dr. Peter O’Sullivan discusses an exercise prescription and clinical reasoning approach for physical therapists (PT) that explicitly integrates thoughts. Now, if you believe how one thinks about pain is important for overcoming pain, this approach will interest you.
PTs are adept at evaluating physical impairments that result from, or contribute to, back pain. For example, it is sensible to come to the conclusion that a spondylolisthesis may be a culprit for Sally’s back pain. But what about Sally’s fears, stress, and lack of confidence associated with movement? We know some of this goes away by ‘fixing’ the patho-anatomy. We also know for many people that the fix does not always fix pain and disability. O’Sullivan’s approach is patient-centered and examines how beliefs and fears influence movement. Despite the individualized approach, they were able to publish a compelling RCT (provided at the end of O’Sullivan’s blog post) which demonstrated that this behavioral approach was superior (better improvement in pain intensity and self-reported physical function) to manual therapy and exercise.
So is Dr. Fancy Pants putting forward a new fad that will likely fade?
My take on things…
Using education to reduce fears about movement can have physical effects.
‘They’ say we need to treat the whole person (if you do not know who ‘they’ are, here ‘they’ are). If ‘they’ are correct, this involves considering physical, psychological and social factors in the experience of pain. Despite our physical focus, the truth is there is a boat load of evidence for PTs using cognitive strategies to positively influence movement. For example, in this oldy but goody, pain neurophysiology education in patients with chronic low back pain improved range of motion as measured by the straight leg raise test. I know, I know, the dura mater surrounds the brain too…. Seriously though, using education to reduce fears about movement can have physical effects.
Back to Sally: of course we need to consider her patho-anatomy. But do you believe thoughts and feelings can be as relevant to patho-anatomy? This concept can be a stretch for some, but I believe O’Sullivan’s approach brings the relevance of psychological factors in line with physical factors. Importantly, his approach moves beyond vague recommendations to practice in a biopsychosocial way, toward tangible recommendations on how PTs can use careful listening, pain education, and graded movement to promote self-efficacy and overcome fear avoidant beliefs about movement and activity.
I don’t believe special training is needed here. The skills to be more holistic in our approach are there. What Dr. O’Sullivan is proposing (in my opinion) is to use our communication skills to understand all the factors that influence one’s pain and movement. With some in-depth discussion, sufferers may identify for you their fears, worries, and maladaptive thoughts which could be relevant for their movement. Through careful and reassuring education, and helping people see the relevance of stress, worry, etc, to their pain and movement, PTs can be more holistic in their approach.
Is your interest piqued? I’ve put together a couple more resources on integrating principles of cognitive-behavioural theory with physical therapy that you may want to check out:
Moseley GL and Butler DS. The Explain Pain Handbook: Protectometer.
Linton SJ, Shaw WS. Impact of psychological factors in the experience of pain. Phys Ther 2011;91:700-11. (Open access)
Notice, I did not at any point above suggest that we directly treat psychological effects of pain or psychological morbidity. Instead, by facilitating relaxed movement, and consequently, improved function and self-efficacy, psychological effects can be positively impacted, indirectly.
The idea of more explicitly practicing within a biopsychosocial framework is not going away, so I really want to hear from you – what do you think about PTs being more cerebral in prescribing exercises for LBP? What are your concerns or hesitations?
About Geoff Bostick
I obtained my BSc in Physical Therapy (PT) from the University of Saskatchewan in 2001, Diploma of Advanced Manual and Manipulative PT in 2005 and PhD from the University of Alberta (UofA) in 2012. My clinical and research interests fall broadly in the field of pain science. Specifically, I am interested in the role of neuropathic pain in osteoarthritis, assessment and management of complex pain and pain assessment in marginalized groups. I am currently working as an Assistant Professor in the Department of PT and Adjunct Assistant Professor in the Department of Anaesthesiology and Pain Medicine at the UofA. I also offer a student-led physiotherapy chronic pain program for the UofA Multidisciplinary Pain Clinic. I am currently involved in the executive for the Pain Sciences Division.
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