Break the cycle of fear and disability

Breaking the Cycle of Fear and Disability

Spinal surgery is on the rise. The annual number of laminectomy and spinal fusion surgeries increased from 1998 to 2008 by 11% and 137% (!) respectively, even though the benefit of spinal surgery for some patients is questionable at best.

Three randomized controlled trials (RCTs) found no evidence for the superiority of lumbar fusion at 11-year follow-up. Compared to the general population, people who have had lumbar spine surgery continue to have poorer physical and mental health, and as much as 40% of individuals after lumbar spine surgery have persistent pain and disability (Atlas et al., 2005; Jansson et al., 2009).

Despite advancements in medical technology, surgery is not more effective than physical therapy for lumbar spinal stenosis (Delitto et al., 2015). But it would be remiss of us in the physical therapy profession to pat ourselves on the backs and declare victory. We need to ask ourselves why physical therapy is at least as good as surgery, if not better, at treating low back pain.

In light of evidence that low back pain is “a multidimensional disorder,” our approach in treating low back pain should be multidimensional, too. Peter O’Sullivan et al. (2016) recently published a strong plea for our health care system to embrace a “cultural shift”:

There is growing evidence that the management of low back pain needs a paradigm shift. This perspective considers low back pain (after screening for red flags) as a protective mechanism that emerges in response to perceived threats from multiple domains in the individual context. In this context, negative societal beliefs and fear about the meaning of low back pain can escalate pain and lead to unhelpful behavioral responses, leaving patients distressed and disabled. (p. 935)

The above argument is consistent with the fear-avoidance model of pain (see Figure; Leeuw et al., 2007), which argues that pain in combination with pain-related fear can lead to avoidance, disability, and even more pain. This cycle repeats indefinitely until the person confronts their pain-related fear. After confronting fear, the person can increase their activity, increase their fitness, and reduce their risk of future disability. They break the cycle.

Fear-Avoidance Model
Figure. The Fear-Avoidance Model, from Physiopedia. See Leeuw et al. (2007).

It shouldn’t be surprising that multidimensional approaches such as classification-based cognitive functional therapy (CB-CFT) yield better outcomes than traditional physical interventions (Vibe Fersum et al., 2013). Evidence for psychologically-informed physical therapy practice is puzzling, but newer approaches such as CB-CFT and the STarT Back stratification are promising.

Kristin Archer et al. (2016) are among the latest to find superior outcomes in patients receiving multidimensional rehabilitation, this time in patients receiving spinal surgery for chronic low back pain. Eighty-six patients were assigned to one of two educational treatments after undergoing laminectomy with or without arthrodesis for a chronic degenerative lumbar condition. Both treatments consisted of six sessions of 30 minutes in length, except for a 60-minute initial session. For both groups, the first session was completed in person, with the remaining five sessions delivered over the phone.

The control group focused on postoperative recovery and included discussion about proper biomechanics after surgery, the benefits of exercise, sleep hygiene, stress reduction, and strategies for preventing future injury. The second treatment, called Changing Behavior through Physical Therapy (CBPT), is a cognitive-behavioral-based approach that focuses on both decreasing fear of movement and increasing self-efficacy in order to reduce pain and disability. Sessions in the CBPT program “focused on empirically supported behavioral self-management, problem solving, cognitive restructuring, and relaxation training” (p. 80). You can read more about the CBPT intervention in Archer et al. (2013).

Six months after surgery, the CBPT group demonstrated several benefits compared to the control group. Those receiving CBPT scored lower on the Brief Pain Inventory and on the Oswestry Disability Index, and CBPT even showed improvement on performance-based tests such as the 5-Chair Stand and TUG tests. For the CBPT group, the changes were greater than the minimal clinically important difference for all measures, with effect sizes ranging from .41 to .79.

To me, this study is another drop in the bucket of evidence supporting biopsychosocial approaches to low back pain. What is more, the authors show a potential mechanism suggesting why a multidimensional approach to pain could outperform surgery alone — by decreasing the fear of movement. Indeed, those receiving cognitive-behavioral-based physical therapy education showed a reduction in movement-related fear and an increase in pain self-efficacy compared to the control group.

It’s time for us as a society to ask whether we should treat the multidimensional condition of low back pain with something as spectacularly unidimensional as surgery alone. But we can’t stop there. Are we really succeeding in promoting multidimensional approaches in physical therapy? Are we really using patient-centered care that values the uniqueness of every person?

As Archer, O’Sullivan, and others show us, we must move our profession toward the biopsychosocial model — not just in theory, but also in practice.

Only then can we break the cycle.