Cognitive-behavioral Techniques in the Treatment of Chronic Low Back Pain J. Monroe Laborde, MD, MS, New Orleans, La [J South Orthop Assoc 7(2):81-85, 1998. © 1998 Southern Orthopaedic Association] Abstract Review of the literature reveals chronic low back pain has not responded well to conventional medical treatment with medication and surgery. The addition of cognitive-behavioral approaches to complement conventional medicine seems to improve the results and lessens pain in this group of patients. Introduction Chronic low back pain is common, expensive, and has been difficult to manage by conventional medical and surgical treatment.[1-8] Many reports have been written on the subject, but there is still a lack of general agreement about how to best treat this widespread problem. Extensive literature reviews on chronic back pain have not eliminated this disagreement, even though the reviews were done by panels of experts.[1,2,6,9] There are no scientific (controlled, randomized) studies showing that any treatment is of significant benefit in chronic back pain patients.[1] The high rates of success (up to 90%) of placebo treatments for pain (including sham surgery) are as great as any conventional treatments and emphasize the necessity of scientific studies.[10-17] The treatment of chronic back pain is more art than science. Surgery has not been successful in patients with chronic back pain.[1,5-7,18-26] Medication has not solved the problem; addiction to narcotics is a common result.[6,7,27-30] In fact, patients with chronic pain will benefit from weaning off narcotic pain medication.[6,20,31] Pain is both a physical and psychologic event.[1,2,4,7,8,32-39] Emotional trauma (such as childhood abuse) frequently precedes the injury in patients who have chronic back pain.[40-43] Psychologic factors (stress) may cause pain by increasing local muscle tension, which becomes painful LA 70115. because of the accumulation of waste products in the muscle.[7,32,36-38,44] The longer the pain lasts after an injury, the more the psychologic factors predominate and the more psychologic modalities should be used in treatment.[1,7,32-35,45] Failure to appreciate and treat the psychologic component of chronic pain too commonly leads to repeated and failed surgery.[22,27,32,46] Alternative medical approaches to reduce psychologic distress (stress reduction) are now being used for chronic pain. They can be effective, yet safer and less expensive than surgery.[7] Alternative medical approaches used along with conventional medicine is known as holistic or complementary medicine. Holistic medicine treats the whole person -- body, mind, and spirit -- to attain optimal health. The National Institutes of Health acknowledges that behavioral and relaxation interventions such as meditation, hypnosis, biofeedback, and cognitive-behavioral therapy are often used to treat chronic pain and that available data support their effectiveness.[47] Other authors agree with this conclusion.[6,8,31,34,39,48-53] In addition, group therapy and support groups have been found to be helpful and cost-effective.[1,6,39,52,54-56] Medical 57 and surgical 58 specialists have recommended cognitive-behavioral techniques as a helpful adjunct to their clinical practices. Turner 52 recommended these techniques be used in primary care settings. The cognitive-behavioral techniques these authors used included support groups, stress reduction, relaxation, and changing maladaptive beliefs and behaviors. In my general orthopaedic surgery practice, I was treating a significant number of patients with chronic pain. Most of these patients had had persistent back pain for years after failed surgery; most were depressed, on Workers' Compensation, and had already attended pain clinics. My experience in treating chronic back pain with conventional medical techniques of medication, surgery, physical therapy, exercise, etc, was frustrating because the results were too often poor. Drawing from this group of patients, I decided to begin a chronic pain support group. In this report, I describe a group of patients with chronic pain treated with a combination of cognitive-behavioral approaches and conventional medicine by a treating orthopaedic surgeon. Methods The "back" support group meets every other week and receives lectures on stress reduction and coping skills for chronic pain management. Techniques discussed include relaxation strategies, meditation, self-hypnosis, guided imagery, and cognitive-behavioral therapy.[8,59] Each coping skill is reinforced with actual practice. Additional time provides a discussion of the patients' feelings about their pain and stress and encourages peer support. One hour of each 2-hour session is devoted to group discussion, using self-help and pain reduction by modifying beliefs that amplify pain. Sessions are concluded with a combination of relaxation and affirmation techniques designed to counter negative or ing attitudes. The group is optional. Patients who did not have indications for surgery but who had had severe back pain for more than 6 months, despite treatment with medication and exercise, were invited to the chronic pain support group. Seventy-five patients were invited, and 24 attended one or more meetings. Eleven of the 24 attended 10 or more meetings in the first 3 years. Eight of the 11 attended 10 or more in the second and third year. Three from the first year were lost to follow-up, but all eight from the second and third years were reviewed. This review was an anonymous written evaluation using a 0 to 10 subjective rating system to compare how patients felt before starting the group and after attending the group at least 10 times. Zero signified no pain or stress and 10 the most severe pain or stress. Subjective improvement was measured by the percentage change in numerical ratings for the patient. The eight patients' percentages were then averaged to obtain the average improvement for the group. Results Of the eight patients, five were women and three men. Four patients had had spinal surgery before attending the group. The average age was 58 years (range, 41 to 75 years). No patient thought his condition worsened during participation in the group. The review revealed a decrease in stress level on an average of 54%. Pain level decreased an average of 47%. Ability to cope with pain rose an average of 73%. Activity level increased an average of 47%. Overall quality of life rating increased an average of 61%. Frequency of office visits decreased an average of 37%. Overall rating of program averaged 8.8 on a scale of 1 to 10. There were no complications attributable to this treatment. Discussion The patients are encouraged to assume some responsibility for coping with their problems. They are taught techniques with which they can control pain themselves. The group's goal is not elimination of pain but instead a reduction in suffering and improvement in the quality of life. One main problem of patients who have chronic pain is passivity, resulting from feelings of hopelessness and helplessness. While all such patients are invited to attend the chronic pain group meetings, many do not attend any meetings or attend only a few. This has resulted in a small number of patients available for after treatment review, despite the fact that there are no out-of-pocket medical costs to the patients for attending the group. Conclusions based on the results of this study should be made cautiously and data considered preliminary because of the small group size, lack of controls, and subjective nature of evaluation. The results do, however, agree with other literature[9,49-51,54] and suggest that this approach can be helpful, with a low risk of complications. The patients who attended only a few meetings did not have enough group exposure to benefit; however, if they had stayed they still may not have benefited, which would have worsened the study results. Rose et al 39 reported 64% attrition from their cognitive behavioral program for rehabilitation of patients with chronic low back pain. They found such an attrition rate typical in this group of patients. They also concluded the attrition did not affect the results, since patients who take part in an intervention are not different from the ones who do not. My own satisfaction with the group has been high for several reasons. In addition to the subjective benefits to the patients described in the results, I no longer have to tell patients with chronic pain that there is nothing more I can do for them and they need to see someone else. I get fewer requests for narcotic pain medication. The patients are also appreciative of my efforts to help them with methods besides conventional orthopaedic treatment. Because of the apparent success of this approach on preliminary retrospective review, a prospective study is planned on a larger number of patients. Definitive testing (eg, Dallas Pain Questionnaire) would be done on all patients before their attendance at any meetings and after completion of 5, 10, and 20 meetings. A more reliable evaluation of the benefit of this treatment will then be available. Conclusion The desperate patient with chronic back pain who does not have a correctable or clear physical cause for the pain represents a difficult dilemma for a spine surgeon. The situation is especially hard when the patients insist something has to be done because they cannot stand the pain and when medication, passage of time, and surgery have failed. Cognitive-behavioral approaches by the treating physician in the group setting appear to be a useful adjunctive treatment for the patient with chronic back pain. From the Departments of Orthopaedic Surgery and Biomedical Engineering, Tulane University, New Orleans, La. Reprint requests to J. Monroe Laborde, MD, MS, 3525 Prytania St, Suite 402, New Orleans, LA 70115. References Back Pain in the Workplace: Management of Disability in Nonspecific Conditions. Fordyce WE (ed). 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