Abstract
Background and Purpose Fear of movement is a risk factor for poor postoperative outcomes in patients following spine surgery. The purposes of this case series were: (1) to describe the effects of a cognitive-behavioral–based physical therapy (CBPT) intervention in patients with high fear of movement following lumbar spine surgery and (2) to assess the feasibility of physical therapists delivering cognitive-behavioral techniques over the telephone.
Case Description Eight patients who underwent surgery for a lumbar degenerative condition completed the 6-session CBPT intervention. The intervention included empirically supported behavioral self-management, problem solving, and cognitive restructuring and relaxation strategies and was conducted in person and then weekly over the phone. Patient-reported outcomes of pain and disability were assessed at baseline (6 weeks after surgery), postintervention (3 months after surgery), and at follow-up (6 months after surgery). Performance-based outcomes were tested at baseline and postintervention. The outcome measures were the Brief Pain Inventory, Oswestry Disability Index, 5-Chair Stand Test, and 10-Meter Walk Test.
Outcomes Seven of the patients demonstrated a clinically significant reduction in pain, and all 8 of the patients had a clinically significant reduction in disability at 6-month follow-up. Improvement on the performance-based tests also was noted postintervention, with 5 patients demonstrating clinically meaningful change on the 10-Meter Walk Test.
Discussion The findings suggest that physical therapists can feasibly implement cognitive-behavioral skills over the telephone and may positively affect outcomes after spine surgery. However, a randomized clinical trial is needed to confirm the results of this case series and the efficacy of the CBPT intervention. Clinical implications include broadening the availability of well-accepted cognitive-behavioral strategies by expanding implementation to physical therapists and through a telephone delivery model.
The United States has the highest rate of lumbar spine surgery in the world, with rates increasing more than 200% in the last decade.1 Medicare spends more than $1 billion annually on lumbar spine surgery, and fusion procedures account for almost half of total spending.1 Despite surgical advances, individuals after surgery for degenerative lumbar spine disease continue to have poorer physical and psychosocial functioning compared with the general US population, and up to 40% have residual chronic pain and functional disability.2 Our work and that of other researchers3,4 has shown fear of movement to be a significant predictor of increased pain and disability after lumbar spine surgery.
Cognitive-behavioral therapy (CBT) has strong empirical support, with randomized controlled trials documenting a positive influence on fear of movement in chronic pain populations.5 Subsequently, initial studies have begun to explore incorporating cognitive and behavioral strategies into physical therapy for patients with back and neck pain. Sullivan et al6 targeted fear of movement and pain catastrophizing with a 10-week activity-based psychosocial physical therapy intervention and found a higher return-to-work rate at 12-month follow-up. George et al7 found a decrease in self-reported disability at 6-month follow-up with a 6-session behavioral physical therapy intervention in participants with elevated fear-avoidance beliefs.
To date, only 2 studies, to our knowledge, have investigated a cognitive-behavioral approach to physical therapy in patients following spine surgery. Randomized controlled trials by Christensen et al8 and Abbott et al9 showed significantly reduced leg pain and improved function with an 8-week group behavioral physical therapy intervention and decreased disability with a 3-session psychomotor therapy program, respectively, at 2 years following lumbar fusion. Overall, preliminary evidence suggests that physical therapist–delivered cognitive and behavioral interventions targeting psychosocial risk factors have the potential to yield significant reductions in pain and disability.
The primary purpose of this case series was to describe the effects of a cognitive-behavioral–based physical therapy (CBPT) intervention in patients with high fear of movement following lumbar spine surgery for degenerative conditions. The CBPT intervention was designed to address fear of movement through behavior self-management and cognitive restructuring techniques in order to increase physical activity. Innovative aspects of the CBPT intervention include a risk-factor–targeted approach for improving outcomes and a telephone-based delivery model. Due to the novelty of physical therapists delivering a broad range of cognitive and behavioral strategies over the telephone, the feasibility of the CBPT intervention was assessed to inform a randomized controlled trial.
Patient History and Review of Symptoms
The case series included adult patients undergoing surgery for a lumbar degenerative condition between February and April 2011 at an academic medical center. Degenerative conditions included spinal stenosis, spondylosis, and spondylolisthesis. Patients had to be at least 21 years of age; English speaking; undergoing laminectomy with arthrodesis; participating in postoperative physical therapy; have back or lower extremity pain for greater than 6 months; have no medical history of schizophrenia or other psychotic disorder; have high fear of movement; and have a stable address and access to a telephone, indicating the ability to participate in the study. Patients having microsurgical techniques (eg, microdiskectomy) as the primary procedure, surgery for spinal deformity as the primary indication, or surgery for pseudarthrosis, trauma, infection, or tumor were excluded. In addition, patients could not have surgery covered by a workers' compensation claim.
Fifteen patients provided informed consent prior to surgery. The patients were screened for high fear of movement using a validated questionnaire (Tampa Scale for Kinesiophobia). Eight patients had scores greater than 394 and remained eligible for the study intervention. An intake assessment was completed that gathered data on demographic and health characteristics.
Examination
A baseline assessment occurred at a standard 6-week postoperative clinic visit before initiation of the CBPT intervention. The patients were asked questions with regard to age, sex, education, marital status, insurance, smoking status, comorbidities, height and weight, and previous spinal surgery. A battery of self-report instruments measured fear of movement, pain catastrophizing, depressive symptoms, pain self-efficacy, pain intensity and interference, and disability. Patients also completed 3 performance-based tests. After the CBPT intervention (3 months after surgery), the patients completed the same battery of self-report instruments and performance-based tests. Performance tests were conducted in the clinic, but patients were given the questionnaires to complete at home and send in by mail. A self-report follow-up assessment administered by mail also was conducted at 6 months following surgery. Patients who did not return their follow-up questionnaires within 1 week of receipt through clinic contact or mail were contacted by telephone to complete the assessment.
Outcome Measures
Fear of Movement
The 17-item Tampa Scale for Kinesiophobia (TSK) was used to measure fear of movement.10 A total score can range from 17 to 68. Respondents are asked to rate each item, 4 being negatively worded and reverse-scored, on a 4-point Likert scale with scoring alternatives ranging from “strongly disagree” to “strongly agree.” A decrease of 4 or more points on the TSK is considered a clinically relevant reduction.11 The TSK has good internal consistency and test-retest reliability in patients with chronic pain.10
Pain Catastrophizing
The 13-item Pain Catastrophizing Scale (PCS)12 assessed catastrophic thinking associated with pain. Respondents rate items on a 5-point scale with the end points “not at all” and “all the time.” A total score ranges from 0 to 52, and a score greater than 24 differentiates between “catastrophizers” and “noncatastrophizers.”12 Pain Catastrophizing Scale scores have been found to be associated with pain, self-reported disability, negative affect, and pain-related fear.12
Depressive Symptoms
The 9-Item Patient Health Questionnaire (PHQ-9)13 assessed depressive symptoms. Each item has 4 possible answers to quantify how often a patient has had a particular depressive symptom: “not at all,” “several days,” “more than half the days,” and “nearly every day.” A total score ranges from 0 to 27. A score of 10 or greater is the most commonly recommended cutoff point for a “clinically significant” depressive symptom. Compared with independent diagnoses made by mental health professionals, the PHQ-9 has been found both sensitive (0.75) and specific (0.90) for the diagnosis of major depression.13
Pain Self-efficacy
The 10-item Pain Self-Efficacy Questionnaire (PSEQ)14 measures the strength and generality of a person's belief in his or her ability to accomplish a range of activities despite pain. Respondents rate how confident they are on a 7-point scale from “not at all confident” to “completely confident.” Scores range from 0 to 60, with a score greater than 40 indicating high pain self-efficacy. The PSEQ has been found to have excellent internal consistency, good test-retest reliability, and construct validity through correlations with depression, anxiety, coping strategies, and pain ratings in patients with chronic pain.14
Pain Intensity and Interference
The Brief Pain Inventory (BPI)15 measured pain intensity and interference with daily activity. The pain intensity subscale assesses current, worst, least, and average pain, and the interference subscale assesses general activity, mood, walking ability, normal work, relations with other people, sleep, and enjoyment of life. Both subscales use a rating scale with 0 representing “no pain or does not interfere” and 10 representing “pain as bad as you can imagine or completely interferes.” Scores of 5 or greater indicate moderate to severe pain intensity and interference. The BPI has proved both reliable and valid in both surgical patients and patients with chronic low back pain.15 Published values of minimum clinically important difference (MCID) for pain range from 1.2 to 2.1 after lumbar spine surgery.16
Disability
The 10-item Oswestry Disability Index (ODI)17 assessed the impact of lumbar spinal disorders on daily living. Ratings for each item are from 0 (high functioning) to 5 (low functioning). Total scores are divided by the total possible score and multiplied by 100 to create a percentage of disability. Scores on the ODI above 40% classify individuals as having severe disability. The ODI has demonstrated good test-retest reliability, internal consistency, and validity, with moderately high correlations with the Medical Outcomes Study 36-Item Short-Form Health Survey questionnaire (SF-36) and various condition-specific disability measures.17 The MCID for the ODI has been found to range from 11 to 12.8 in patients undergoing lumbar spine surgery.16,18
Performance-Based Function
The 5-Chair Stand Test19 was used to assess lower extremity strength. Patients were instructed to fold their arms across their chest and stand up from and sit down on a standard chair. If able to perform one time successfully, patients were asked to stand up and sit down 5 times as fast as possible starting in the sitting position and stopping after the fifth rise. Performance on the 5-Chair Stand Test was measured in seconds. The 5-Chair Stand Test has demonstrated good test-retest reliability and validity, with significant correlations with other measures of physical performance and self-reported disability.19
The 10-Meter Walk Test was used to assess gait speed.20 Patients were given a 2-m warm-up distance preceding the 10-m distance and 2 m beyond the 10 m to continue walking. The time that it took to traverse the 10 m at a comfortable pace and a fast pace were recorded. Two trials were conducted at each pace, with a brief rest as needed by the patient between trials. Measurements for both trials were averaged for each respective walking speed. Excellent interrater and intrarater reliability and good test-retest reliability for self-paced timed walking speed tests using a stopwatch have been reported.21 Validity for walking speed tests has been determined by significant correlations with measures of function and mortality in older adults.20,21 The MCID for the 10-Meter Walk Test at a comfortable pace has been estimated to be 0.16 m/s, and a meaningful change in older adults has been documented at 0.10 m/s.22
Feasibility
One physical therapist with 4 years of experience treating patients with chronic and postsurgical low back pain and no prior experience delivering cognitive-behavioral strategies participated in a training program. Formal training included 2 sessions with a clinical psychologist. Feasibility of the training was determined through a written test after the first 2-day session and a skills test after the second 1-day session (ie, scores needed to be >85).
Feasibility of the intervention was monitored through a therapist checklist that was completed at the end of each session to determine whether specific CBPT strategies were delivered and patient exit interviews that gathered data on satisfaction with the program and specific components. All sessions were audiotaped and reviewed by a clinical psychologist and research personnel to evaluate adherence to the CBPT manual and specific CBT competencies. These competencies23 were: (1) setting clear, measurable, and achievable goals; (2) problem solving obstacles to goal achievement; (3) leaving responsibility for recovery with the patient; and (4) affirming positive behaviors and goal achievement.
Intervention
The CBPT intervention is a structured, manual-based program that was designed to complement and be integrated into postoperative physical therapy to improve surgical spine outcomes through decreases in fear of movement and increases in physical activity. Patients received weekly sessions with a study physical therapist for 6 weeks. The first session was conducted in person during a clinic visit at 6 weeks following surgery, and the remaining sessions were delivered over the telephone. All sessions were 30 minutes in length, except the first session, which was about 1 hour. In addition to the CBPT intervention, all patients were referred for outpatient physical therapy close to their home for 12 sessions. Outpatient physical therapy included a range of therapeutic modalities and exercises as determined by the treating surgeon and therapist. Patient adherence to the physical therapy script of 12 sessions was documented by the study physical therapist during weekly CBPT intervention contact.
The CBPT program focuses on empirically supported behavioral self-management, problem solving, cognitive restructuring, and relaxation training (Appendix).24–26 The main components of the program include a graded activity plan (ie, a comprehensive list of activities ordered from least to most difficult based on fear or pain) and weekly activity and walking goals (see video). Goals are rated by patients on a scale from 0 to 10 (completely confident), and scores of 8 or greater indicate a realistic goal. A cognitive or behavioral strategy is introduced in each session, with the therapist helping patients identify enjoyable activities (ie, distraction), replace negative thinking with positive thoughts, find the right balance between rest and activity, and manage setbacks by recognizing high-risk situations and negative thoughts.
Outcomes
All 8 patients completed the 6-session intervention and the 3-month (postintervention) and 6-month follow-up assessments. The demographic and clinical characteristics of the patients are presented in Table 1.
Baseline Demographic and Clinical Characteristics of Patients Following Lumbar Spine Surgerya
With regard to feasibility, the therapist passed the written and skills tests with scores greater than 90. Therapist checklists demonstrated that at least 90% of the CBPT components were delivered during each session. Exit interviews showed 100% of the patients were very satisfied with the program and that they found the most benefit from the graded activity plan, goal setting, positive statements, and pain management plan. Review of audiotapes also demonstrated that the therapist covered greater than 90% of the CBPT techniques and greater than 85% of CBT competencies in each session, which indicated adequate knowledge of the CBPT intervention.
All patients decreased their scores on the TSK, PCS, and PHQ-9 at 3 months (postintervention) and 6 months after lumbar spine surgery (Tab. 2). Patients 1, 3, 4, 5, 6, and 7 at 3-month follow-up and all patients at 6-month follow-up demonstrated a clinically relevant reduction in fear of movement (Fig. 1A). Patients 1, 5, 6, and 7 were identified as “catastrophizers” at baseline (ie, PCS score >24) and had the largest decreases in PCS scores at 6-month follow-up (Fig. 1B). Clinically relevant depressive symptoms (ie, PHQ-9 score ≥10) were noted at baseline for patients 1, 3, 5, 6, and 7, and all of these patients reported none or minimal symptoms by 6-month follow-up (Fig. 1C). Patient 2 demonstrated minimal symptoms at 3 months and 6 months, and patient 8 reported minimal symptoms only at 6-month follow-up. Patient 4 reported no depressive symptoms at both 3 and 6 months following surgery. Large increases in pain self-efficacy were noted (Fig. 1D), with all patients reporting high pain self-efficacy at 6-month follow-up (ie, PSEQ score >40).14
Individual Outcomes for Patients at 6 Weeks (Baseline), 3 Months (Postintervention), and 6 Months After Lumbar Spine Surgerya
Changes over time in outcomes for fear of movement, pain catastrophizing, depression, and pain self-efficacy: (A) Tampa Scale for Kinesiophobia (TSK), (B) Pain Catastrophizing Scale (PCS), (C) 9-item Patient Health Questionnaire (PHQ-9), and (D) Pain Self-Efficacy Questionnaire (PSEQ). P1-P8=patients 1–8.
Patients 1, 3, 4, and 6 demonstrated moderate pain intensity at baseline, with BPI scores greater than 5, and patients 2, 5, 7, and 8 reported mild pain intensity at baseline (Tab. 2). All 8 patients decreased their BPI pain intensity scores from baseline to 3-month assessment and from 3-month assessment to 6-month follow-up. Patients 1, 3, 4, 6, and 7 exceeded the MCID for pain at the 3-month assessment (Fig. 2A). Patients 3, 7, and 8 reported no pain at 6 months following lumbar spine surgery. For pain interference, patients 1, 5, 6, and 7 reported severe interference, with BPI scores of 7 or greater, patients 3 and 4 reported moderate interference, and patients 2 and 8 reported mild interference at baseline (Tab. 2). Six of the 8 patients exceeded MCID for pain at the 3-month assessment, with 3 of these patients reporting no pain interference at 6 months following surgery (Fig. 2B). All 8 patients had severe disability at baseline (Tab. 2), and 7 of the 8 patients decreased their ODI scores to moderate disability (ie, ODI score=21–40) by 3 months (postintervention). Patient 8 reported minimal disability at 6-month follow-up, and the remaining 7 patients demonstrated moderate disability, with ODI scores between 22 and 32 (Fig. 2C). All patients exceeded the MCID for the ODI at 6 months.
Changes over time in outcomes for pain and disability: (A) Brief Pain Inventory: pain intensity (BPI: Intensity), (B) Brief Pain Inventory: pain interference (BPI: Interference), (C) Oswestry Disability Index (ODI). P1–P8=patients 1–8.
The 8 patients decreased their time on the 5-Chair Stand Test and increased their distance on the 10-Meter Walk Test at 3 months following surgery (Tab. 2). Patient 4 had the lowest time on the 5-Chair Stand Test and maintained the lowest time at the 3-month assessment (Fig. 3A). Patients 1 and 5 had the lowest comfortable pace baseline scores and maintained the lowest scores at follow-up (Fig. 3B), and patients 2 and 8 exceeded the MCID for the 10-Meter Walk Test at a comfortable pace. For the fast pace, large increases in distance were noted for patients 2, 5, and 8 (Fig. 3C), and 5 patients exceeded a meaningful change at 3 months.
Changes over time in outcomes for performance-based function: (A) 5-Chair Stand Test, (B) 10-Meter Walk Test at comfortable pace, (C) 10-Meter Walk Test at fast pace. P1–P8=patients 1–8.
Discussion
Prior studies have demonstrated the importance of psychosocial risk factors to persistent pain and disability in patients with low back pain who undergo spinal surgery.3,4 Subsequently, rehabilitation research has begun to investigate the use and effectiveness of CBT strategies delivered by physical therapists.6–9 The purpose of this case series was to assess the feasibility and describe the effects of a telephone-delivered CBPT intervention on fear of movement, pain, disability, and performance-based function, as well as pain catastrophizing, depressive symptoms, and pain self-efficacy, in patients following lumbar spine surgery. The feasibility results demonstrated that physical therapists can learn and successfully implement cognitive-behavioral techniques over the telephone following structured training by a clinical psychologist. Furthermore, all 8 patients in this case series demonstrated a decrease in fear of movement, pain catastrophizing, depressive symptoms, pain, and disability and an increase in pain self-efficacy following the CBPT intervention and at 6-month follow-up. Decreases in time and increases in distance during the performance-based tests also were noted from baseline to 3 months following surgery (treatment completion).
The results of this case series appear consistent with the findings of Sullivan et al6 and George and colleagues7 in suggesting that identifying patients at-risk for poor outcomes and applying a targeted rehabilitation approach may lead to meaningful reductions in psychosocial risk factors as well as pain and disability outcomes. The findings also support work by Abbott et al,9 who demonstrated that a combined cognitive-behavioral and motor learning rehabilitation intervention significantly improved functional disability in patients undergoing lumbar spinal fusion surgery.
Reductions of pain and disability appear clinically relevant, with 7 of the 8 patients exceeding published values of MCID for pain intensity (1.2–2.1) and all patients exceeding MCID for the ODI (11–12.8) at 6-month follow-up.16,18 Decreases in both pain and disability may have been due to the CBPT intervention's focus on decreasing barriers to functional activity and walking rather than focusing solely on pain symptoms. All CBPT sessions included patient-tailored activity and walking goals and problem solving, which also may have had a direct result on improvement for the walking tests, with 5 patients demonstrating clinically meaningful change (in meters per second).22 It is important to note that improvements occurred in all patients for both patient-reported and objective outcomes, especially as low correlations have been reported between these 2 types of measures.27
Specific changes in fear of movement and pain catastrophizing for all patients appear similar to or larger than TSK and PCS change scores obtained following behavioral physical therapy interventions in patients with back pain24 and following lumbar disk surgery.28 Changes for all patients were consistent with the physical therapist–delivered Progressive Goal Attainment Program, an activity-based psychosocial intervention, in patients following whiplash injury.6 In addition, change in fear of movement scores appear clinically relevant based on prior work demonstrating that fear of movement is stable following lumbar spine surgery in the absence of a psychological intervention.4
Patients had larger-than-expected gains in pain self-efficacy following the CBPT intervention. All 8 patients had PSEQ scores greater than 50 at the 6-month follow-up and scores greater than 40 have been found to be associated with maintenance of functional gains.15 Turner et al29 demonstrated the importance of self-efficacy to decreased disability and improved functioning in chronic pain populations, and their findings suggest that increasing a patient's self-efficacy may provide additional benefit beyond decreasing fear of movement and pain catastrophizing.
Several limitations should be considered when interpreting our findings. First, we used a case series design, and statistical testing was not performed; thus, our findings may be attributed to chance. Second, we are unable to determine whether improvement in outcomes was a direct result of the CBPT intervention or due to other factors such as the participation in physical therapy, benefits of surgery, or impact of greater attention from study personnel. Our next step is to assess the efficacy of the CBPT intervention in a randomized clinical trial to compare a CBPT group with an attention-control group. Third, patient assessment occurred at completion of the CBPT intervention and again 3 months later, and longer follow-up is needed to assess maintenance of treatment gains. Finally, all patients were white, which limits the generalizability of our findings.
Overall, our case series findings suggest that physical therapists can feasibly implement cognitive-behavioral skills over the telephone and may positively affect psychosocial factors, pain, and disability after spine surgery. However, a randomized clinical trial is needed to confirm the results of this case series and the efficacy of the CBPT intervention. Clinical implications of this study and future work in this area include the opportunity to broaden the availability of well-accepted and effective CBT strategies by expanding implementation from traditional providers (psychologists) to physical therapists30 and through a telephone delivery model. Screening for psychosocial risk factors and incorporating cognitive-behavioral techniques into postoperative rehabilitation may have the potential to improve outcomes in patients undergoing lumbar spine surgery.
Appendix.
Summary of the Cognitive-Behavioral-Based Physical Therapy Intervention by Session
Footnotes
Dr Archer, Dr Devin, Dr McGirt, Dr Aaronson, Dr Cheng, and Dr Wegener provided concept/idea/project design. Dr Archer, Dr Devin, Dr McGirt, and Dr Wegener provided writing. Dr Archer, Ms Abraham, and Dr Aaronson provided data collection and fund procurement. Dr Archer provided data analysis. Dr Archer and Ms Abraham provided project management. Dr Motzny, Dr Devin, Dr Aaronson, and Dr Cheng provided patients. Dr Motzny, Dr Yaffe, Dr Seebach, Dr Devin, Dr Spengler, Dr McGirt, Dr Aaronson, Dr Cheng, and Dr Wegener provided consultation (including review of manuscript before submission).
This publication was made possible by a grant from the American Physical Therapy Association, Orthopedic Section, and Vanderbilt Clinical and Translational Science Award grant UL1 RR024975-01 from the National Center for Research Resources/National Institutes of Health.
- Received October 15, 2012.
- Accepted April 11, 2013.
- © 2013 American Physical Therapy Association
References
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