19 Cognitive Therapy for Symptomatic Disc Degeneration

Factors predicting which acute pain patients will become chronic pain sufferers have been identified. In a working population, the fear of reinjury or increased pain and an expectation of nonrecovery were predictive of non-recovery of work-related back pain at 6 months after the initial injury.1

In a simplistic model, one may expect the extent of injury to be related to the severity of pain, and the severity of pain to the degree of disability. This is not necessarily the case with chronic back pain. Some patients report pain or disability of severity greater than one may anticipate based on the degree of tissue injury that can be identified. In the past, this was often attributed to the patient being a malingerer and faking or exaggerating symptoms to get disability and/or sympathy and attention. In reality, the problem is often not malingering but is behaviorally based. There may be a cycle of a nonsevere injury, the patient responding by being fearful of movement, decreasing activity, general deconditioning, and possibly increased pain sensitivity. With brain imaging, primarily functional magnetic resonance imaging (MRI), there is now strong evidence that pain, including chronic back pain, is associated with structural and/or functional changes in the human brain.^2–5 Among the changes are decreased size of portions of the brain. Such studies support that there are physiological differences present among chronic pain sufferers. The clinical implications for these findings have not yet been identified, but the studies do provide evidence of the strong impact of ongoing pain and that there is more to chronic back pain than what can be identified by radiographic images of the spine or the behavior of malingering.

Behavioral Factors Associated with Chronic Back Pain

Waddell et al⁶ introduced the fear-avoidance concept in back pain patients. The work was based on the idea that pain is only one contributor to the patient’s functional level. They found that fear-avoidance contributed to disability beyond pain severity. The term kinesophobia (fear of movement) was later coined. Waddell and colleagues’ work suggested the concept that the fear of pain may be as limiting, if not more so, than the actual pain being experienced. This sets the stage for the potential role of cognitive therapy for back pain. Fear-avoidance behavior suggests that patients select their activity, or lack thereof, based on their fear of pain rather than on the actual experience of pain itself. This behavior severely limits the patient’s life. Due to the fear of pain, they do not engage in physical activity, which leads to overall deconditioning. Additionally, they will not participate in active rehabilitation for their pain, which greatly reduces their chances of recovery from their back problems. These patients tend to cope with their pain in a passive rather than active fashion and have a negative outlook concerning the outcome of treatment.

There have been numerous studies performed during the last two decades that support the existence of a strong psychological and behavioral component to back pain. In a large population-based study, it was found that catastrophizing and kinesophobia, identified by the administration of a questionnaire, was associated with significantly greater risk of developing back pain and related disability.7

Woby et al⁸ investigated factors related to pain and disability in patients attending physical therapy for the treatment of chronic low back pain (LBP). They found that after adjusting for demographic variables, cognitive factors accounted for an additional 30% of the variance in pain intensity. Additionally, cognitive factors accounted for 32% of the variance in disability after adjusting for demographic variable and pain intensity. Functional self-efficacy was strongly related to both pain and disability. In another study by the same authors, it was found that reductions in fear-avoidance of activity and increased perceived pain control were significantly related to lower levels of disability, even after the effects of pain intensity, age, and gender were accounted for.⁹ This work reinforces the differentiation of the severity of disability related to pain intensity from pain beliefs.

In a study involving a large population of workers, it was reported that pain intensity was significantly related to function and social disability.¹⁰ Regression analyses revealed that fear of reinjury associated with movement added significantly to the predictive value of the models for function and disability beyond the variance explained by pain intensity. These results supported that fear of further injury and pain is significantly related to function and cannot be accounted for by pain intensity.

Cognitive Therapy

When working with back pain patients, cognitive therapy involves dealing with beliefs, fears, expectations, self-efficacy, coping skills, and other issues related to how the patients interpret and deal with their symptoms. Understanding these issues and developing a strategy to teach the patient how to address them forms the basis of cognitive therapy. One of the basic premises of cognitive therapy in relation to the treatment of back pain is primarily built around the concept of the patient’s behavior being greatly affected by the fear of pain and not just the experience of pain itself. Although two patients may have similar pain complaints and similar MRI scans of a disc problem, they may deal with the problem very differently. Much of how they deal with it may be shaped by past experiences and personality. To some patients the pain and abnormal images may be interpreted as a significant debilitating problem that creates high levels of fear, anxiety, and helplessness. Other patients may acknowledge the abnormal disc as a problem but are willing to accept it and actively engage in rehabilitation to address it, while altering their routine only as dictated by the actual pain level and advice from care providers. For the group of patients who do not cope well with the injury, there is a major place for education and support—thus the role for cognitive intervention. It is extremely important for patients to understand that activity is good, even after an injury. Traditionally, most people thought that when an injury occurred, the best thing to do was to not use the injured body part for a while. This may have reduced pain due to the lack of tissue loading or movement and allowed healing. Then a gradual return to activity follows as pain, inflammation, and swelling subside. This model is appropriate for many injuries such as sprains and strains. However, patients need to understand that extended lack of activity is detrimental—not moderate activity. In a comprehensive review involving acute, subacute, and chronic back pain patients, Rainville et al found that there was no evidence to support that exercise is related to increased back pain or disability.¹¹ In fact, just the opposite was true. Exercise was related to increased flexibility and strength, decreased pain, and negative behavior and beliefs about pain. Arming patents with this type of information through education is one of the basic concepts of cognitive therapy; that is, to change the patient’s concepts of how to deal with pain. Rather than intentionally avoiding activity and feeling helpless, they can feel confident and empowered to take on an active role in dealing with their pain, and by doing so they can engage in activities without increasing symptoms.

One of the questions that may arise is whether cognitive factors can be altered in pain patients, particularly considering these factors may have been developed over the course of years and are part of the patient’s personality. It has been found that cognitive factors can be changed with education and rehabilitation in back pain patients.^12,13 The changes in cognitive factors were also associated with significant improvement in function. Moseley¹² reported a significant relationship between cognitive changes after intervention and the physical measures of straight leg raise and forward bending and attributed the results primarily to changes in the patients’ beliefs that pain suggested tissue damage and, in turn, this reduced catastrophizing.

Considering the strong impact of psychological factors in back pain, it is logical to think that cognitive intervention should be a part of the treatment. By teaching patients that they can function and be active without significantly increasing pain or causing significant injury to themselves, their confidence increases, the fear of additional pain or injury subsides, and overall function and well-being are enhanced. One of the roles of cognitive intervention may be in improving patient participation in exercise therapy. Among a group of subacute back pain patients, it was reported that adding a cognitive-behavioral component to an exercise program enhanced self-efficacy and other parameters as well as improving the frequency of exercise long-term.14 However, there was no difference in pain intensity.

Linton et al¹⁵ compared the results of minimal care, minimal care with cognitive intervention, and cognitive intervention with physical therapy in the treatment of back or neck pain. They found that the addition of cognitive therapy significantly improved outcomes in terms of reduced health care visits, work absenteeism, and taking long-term sick leave disability. The addition of physical therapy to the cognitive intervention did not further improve the results of cognitive intervention. This same group of patients was assessed 5 years later.¹⁶ At the long-term follow-up the cognitive intervention group had less pain and better overall quality of life and health than did the minimal care group. There was no difference in health care utilization, but in the cognitive group, costs related to lost work and disability were only one third of that in the minimal care group. These studies demonstrate that the benefits of cognitive intervention in the treatment of back and neck pain are significantly maintained long term.

Issues Involved with Diagnosing Symptomatic Disc Degeneration

One of the issues of great importance when addressing the role of any intervention, including cognitive therapy, in the treatment of symptomatic disc degeneration is the diagnostic accuracy. Disc degeneration is a naturally occurring phenomenon. However, degeneration as an occurrence of natural history should not be confused with that which is related to injury or premature changes in the intervertebral disc, which is the target of treatment when painful. It is unknown how many people have painful disc degeneration or the percentage of back pain for which it is responsible. The primary diagnostic tool to identify painful disc degeneration is discography. This is an invasive procedure and is typically not performed until after the patient has failed nonoperative attempts to gain symptom relief. Therefore, the percentage of patients with disc-related pain that resolves with nonoperative care is elusive. Trying to diagnose discrelated pain without discography is not supported in the literature. Although dehydrated discs may be seen on MRI, there is no means by which to determine if such changes are related to symptoms. The false-positive rate of MRI in showing disc degeneration in asymptomatic subjects has been reported to be as high as 85% in a population that was age, gender, and occupation matched to a back pain population.¹⁷ Such studies verify the importance of the pain provocation portion of the discographic assessment. One must also keep in mind, however, that not all discograms are equal; that is, the technique and interpretation employed by the discographer may have a significant impact on the results of the evaluation.

Discography results are also impacted by psychological factors. With respect to disc-related pain, a strong relationship was found between the hypochondriasis and hysteria scales of the MMPI (Minnesota Multiphasic Personality Inventory) and the number of levels at which discographic injection of contrast into a normal disc provoked pain.¹⁸ The influence of psychological factors on discography has been described by others as well.¹⁹ When confirming the diagnosis of lumbar disc-related pain, the benefit of pressure-controlled manometric injection has been reported.²⁰ The relationship of this discographic technique to treatment outcome has been described.²¹ Together these works suggest that psychological factors play a significant role in diagnostic discography. However, performing and interpreting the evaluation based on a precise protocol including pressure-controlled manometry will typically provide reliable results in at least 90% of patients.²²

Impact of Psychological Factors on Surgery

In a group of patients undergoing discectomy, it was found that imaging studies correlated with surgical findings; however, psychological factors were more strongly related to surgical outcome than were imaging studies.²³ This was a very strong finding and although published almost 20 years ago, the role of presurgical psychological testing is still underappreciated. A surgeon would not perform spine surgery without an MRI or computed tomography (CT); nonetheless, although psychological factors are more strongly related to outcome, it remains acceptable in some practices to not perform formal psychological screening on a routine basis. Den Boer et al²⁴ reported that increased levels of cognitive-behavioral factors, such as fear of movement, passive coping skills, and negative expectations, identified preoperatively were related to greater pain and disability at postoperative follow-up. Block et al have described a presurgical screening tool that has been used on a variety of lumbar and cervical surgical candidates, including those with painful disc degeneration, that had a predictive value of 82% based on clinical outcome.25,26 The screening instrument was developed based on a comprehensive review of the literature on factors related to surgical outcome.

Literature Review of Studies of Cognitive Therapy for the Treatment of Symptomatic Disc Degeneration

There has been very little investigation on the nonoperative treatment of symptomatic disc degeneration, particularly that confirmed by discography. One of the difficulties with this type of study is that a patient is typically not considered a candidate for discography, due to the invasive nature of the procedure, until they have already failed nonoperative care. Thus, the diagnosis of painful disc degeneration is usually verified after failure of nonoperative treatment. It may be unlikely that patients would be willing to participate in a study providing them with a course of treatment that they have already failed prior to the discogram.

Cognitive Therapy in Conjunction with Nonoperative Treatment

Fairbank et al²⁷ described a study comparing results of fusion to comprehensive nonoperative care incorporating a cognitive component. They found that the fusion group had significantly greater improvement in Oswestry scores; however, they commented that it was only at the threshold of reaching clinical relevance. The authors also noted that in this group of patients who were considered possible surgical candidates, 72% were able to avoid surgery during 24-month follow-up after participation in a cognitive-based nonoperative treatment program. However, the patient population included in the study was not well described (~10% spondylolisthesis, 8% postlaminectomy, and 81% described only as chronic LBP).

In the prospective randomized study by Brox et al²⁸ surgery was compared with nonoperative treatment. They found no difference in outcomes between the two treatment groups. However, although the authors commented that the patients were being treated for chronic LBP and disc degeneration, how the diagnosis of disc degeneration was formulated was not clear. The only inclusion criterion dealing with the determination of disc degeneration was “degeneration at L4-L5 and/or L5-S1 (spondylosis) on plain radiographs” and there was also a comment that all patients had plain radiographs, CT, and/or MRI. There is no evidence that painful disc degeneration can be accurately diagnosed from plain radiographs. As stated earlier, MRI has been found to have a high false-positive rate for disc degeneration.¹⁷ Although this study found that nonoperative care and instrumented surgery produced similar results, the context of these findings with respect to painful disc degeneration remains to be verified. Brox et al performed a study comparing lumbar fusion to cognitive intervention and exercise in a group of patients who had previously undergone surgery for disc herniation.²⁹ The nonoperative treatment group received a lecture emphasizing that ordinary activity would not harm their back and were encouraged to use their spines. This was followed by three daily exercise sessions for 3 weeks. There was no difference in the outcomes of the two treatments, with ~50% of patients in both groups having a successful result. In the cognitive group, their mean Oswestry scores improved significantly from 45 to 32. Further study was done in this group of patients with respect to muscle area and muscle performance.³⁰ Patients in the cognitive therapy and exercise group increased muscle strength and density. This change was maintained at 12-month follow-up, which led the authors to suggest that the patients had overcome psychological inhibitors and became, as well as remained, more active. In the fusion group, muscle density decreased and function did not increase. This may be due to the muscle damage done during operative intervention and/or lack of structured physical rehabilitation following the surgery.

One significant methodologic factor arises in all studies comparing surgery with nonoperative care. That is, one of the primary indications for elective surgery is a failure of nonoperative treatment. In the randomized studies, should the patients really be considered surgical candidates if adequate attempts of nonoperative care have not been undertaken, such as the treatments delivered in the control group? Or are these patients repeating nonoperative treatment that did not produce the desired result the first time?

Cognitive Therapy in Conjunction with Surgical Treatment

One area yet to be investigated adequately is that of combining cognitive therapy with surgical intervention for symptomatic disc degeneration. The results of fusion in patients with painful disc degeneration are good but seem to have stabilized over the past several years despite the development of materials such as bone morphogenetic protein that increases the rate of bony fusion.^31–33 Some surgeons, although not many, refer patients for formal psychological screening before surgical intervention, but this is not a widely standardized practice. Even with the screening, some patients may have had improved surgical results if they had received cognitive support along with surgical intervention. Ostelo et al reported that patients with some ongoing pain following first-time disc surgery randomized to a behavioral activity group did not have better results than did patients receiving usual care.34 However, it must be noted that the behavioral therapy was provided by physical therapists who had received training in this area only for purposes of executing the study. Their understanding of behavioral therapy and skills in delivering such may not have been adequate or at the same level as a trained psychologist with experience in working with back pain patients.

Summary

There is strong and consistent evidence that psychological factors play a significant role in back pain patients. This may play a role in evaluating patients with any tests that require activity or interpretation from patients such as functional physical testing or discography. Despite the literature, it is doubtful that most back pain patients receive adequate education and treatment involving cognitive intervention. There have been several studies reporting on the clinical results of cognitive intervention in chronic back pain patients, with favorable results. More recently, randomized trials comparing nonoperative treatment, including cognitive therapy, to surgical intervention have been conducted. The results have generally been supportive of surgery; however, not overwhelmingly so. Some of these studies do not provide an adequate description of the diagnostic evaluation of the patients enrolled including psychological evaluation. Also, some of these studies indicate that patients were treated for discogenic pain; however, the diagnostic work-up did not include discography and thus the diagnosis of painful disc degeneration was not verified. Therefore, the results of such studies cannot be used to evaluate the role of cognitive therapy for disc-related pain. To perform such a study adequately may be difficult. Typically, discography is not indicated until nonoperative treatment has failed and surgery is being considered. The willingness of patients to forgo surgery for more nonoperative treatment, in the form of a cognitive program with physical activity, is questionable.

The role of cognitive intervention specifically for the treatment of disc-related pain has yet to be defined. Considering that many of the studies evaluating this treatment included a mix of chronic back pain patients, however, it is likely that there were several disc pain patients involved. Another consideration is the role of cognitive intervention combined with surgery. Although surgery can address the tissue-based source of the patient’s pain, it cannot address the patient’s beliefs about pain that result in undesirable behavior such as fear-avoidance beliefs deterring patients from engaging in physical activity. It appears reasonable that outcome may be optimized by evaluating surgical patients, identifying those with a significant psychological component to dealing with their pain and providing a formal cognitive therapy-based postoperative active rehabilitation program.

References

1. Turner JA, Franklin G, Fulton-Kehoe D, et al. Worker recovery expectations and fear-avoidance predict work disability in a population-based workers’ compensation back pain sample. Spine 2006; 31:682–689

2. Apkarian AV, Sosa Y, Sonty S, et al. Chronic back pain is associated with decreased prefrontal and thalamic gray matter density. J Neurosci 2004;24:10410–10415

3. Giesecke T, Gracely RH, Grant MA, et al. Evidence of augmented central pain processing in idiopathic chronic low back pain. Arthritis Rheum 2004;50:613–623

4. Schmidt-Wilcke T, Leinisch E, Ganssbauer S, et al. Affective components and intensity of pain correlate with structural differences in gray matter in chronic back pain patients. Pain 2006; 125:89–97

5. Baliki MN, Chialvo DR, Geha PY, et al. Chronic pain and the emotional brain: specific brain activity associated with spontaneous fluctuations of intensity of chronic back pain. J Neurosci 2006;26: 12165–12173

6. Waddell G, Newton M, Henderson I, Somerville D, Main CJA. Fear-Avoidance Beliefs Questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability. Pain 1993;52:157–168

7. Picavet HS, Vlaeyen JW, Schouten JS. Pain catastrophizing and kinesiophobia: predictors of chronic low back pain. Am J Epidemiol 2002;156:1028–1034

8. Woby SR, Roach NK, Urmston M, Watson PJ. The relation between cognitive factors and levels of pain and disability in chronic low back pain patients presenting for physiotherapy. Eur J Pain 2007; 11:869–877

9. Woby SR, Watson PJ, Roach NK, Urmston M. Are changes in fear-avoidance beliefs, catastrophizing, and appraisals of control, predictive of changes in chronic low back pain and disability? Eur J Pain 2004;8:201–210

10. Gheldof EL, Vinck J, Van den Bussche E, et al. Pain and pain-related fear are associated with functional and social disability in an occupational setting: evidence of mediation by pain-related fear. Eur J Pain 2006;10:513–525

11. Rainville J, Hartigan C, Martinez E, et al. Exercise as a treatment for chronic low back pain. Spine J 2004;4:106–115

12. Moseley GL. Evidence for a direct relationship between cognitive and physical change during an education intervention in people with chronic low back pain. Eur J Pain 2004;8:39–45

13. Walsh DA, Radcliffe JC. Pain beliefs and perceived physical disability of patients with chronic low back pain. Pain 2002;97:23–31

14. Gohner W, Schlicht W. Preventing chronic back pain: evaluation of a theory-based cognitive-behavioural training programme for patients with subacute back pain. Patient Educ Couns 2006; 64:87–95

15. Linton SJ, Boersma K, Jansson M, Svard L, Botvalde M. The effects of cognitive-behavioral and physical therapy preventive interventions on pain-related sick leave: a randomized controlled trial. Clin J Pain 2005;21:109–119

16. Linton SJ, Nordin E. A 5-year follow-up evaluation of the health and economic consequences of an early cognitive behavioral intervention for back pain: a randomized, controlled trial. Spine 2006;31:853–858

17. Boos N, Rieder R, Schade V, et al. 1995 Volvo Award in Clinical Sciences. The diagnostic accuracy of magnetic resonance imaging, work perception, and psychosocial factors in identifying symptomatic disc herniations. Spine 1995;20:2613–2625

18. Block AR, Vanharanta H, Ohnmeiss DD, Guyer RD. Discographic pain report: influence of psychological factors. Spine 1996;21: 334–338

19. Carragee EJ, Tanner CM, Khurana S, et al. The rates of false-positive lumbar discography in select patients without low back symptoms. Spine 2000;25:1373–1380

20. Derby R, Kim BJ, Lee SH, et al. Comparison of discographic findings in asymptomatic subject discs and the negative discs of chronic LBP patients: can discography distinguish asymptomatic discs among morphologically abnormal discs? Spine J 2005;5:389–394

21. Derby R, Howard MW, Grant JM, et al. The ability of pressure-controlled discography to predict surgical and nonsurgical outcomes. Spine 1999;24:364–371

22. Derby R, Lee SH, Kim BJ, et al. Pressure-controlled lumbar discography in volunteers without low back symptoms. Pain Med 2005; 6:213–221

23. Spengler DM, Ouellette EA, Battie M, Zeh J. Elective discectomy for herniation of a lumbar disc: additional experience with an objective method. J Bone Joint Surg Am 1990;72:230–237

24. den Boer JJ, Oostendorp RA, Beems T, Munneke M, Evers AW. Continued disability and pain after lumbar disc surgery: the role of cognitive-behavioral factors. Pain 2006;123:45–52

25. Block AR, Ohnmeiss DD, Guyer RD, Rashbaum RF, Hochschuler SH. The use of presurgical psychological screening to predict the outcome of spine surgery. Spine J 2001;1:274–282

26. Block AR, Gatchel RJ, Deardorff WW, Guyer RD. The Psychology of Spine Surgery. Washington, D.C.: American Psychological Association; 2003

27. Fairbank J, Frost H, Wilson-MacDonald J, et al. Randomised controlled trial to compare surgical stabilisation of the lumbar spine with an intensive rehabilitation programme for patients with chronic low back pain: the MRC spine stabilisation trial. BMJ 2005;330:1233

28. Brox JI, Sorensen R, Friis A, et al. Randomized clinical trial of lumbar instrumented fusion and cognitive intervention and exercises in patients with chronic low back pain and disc degeneration. Spine 2003;28:1913–1921

29. Brox JI, Reikeras O, Nygaard O, et al. Lumbar instrumented fusion compared with cognitive intervention and exercises in patients with chronic back pain after previous surgery for disc herniation: a prospective randomized controlled study. Pain 2006;122:145–155

30. Keller A, Brox JI, Gunderson R, et al. Trunk muscle strength, cross-sectional area, and density in patients with chronic low back pain randomized to lumbar fusion or cognitive intervention and exercises. Spine 2004;29:3–8

31. Dimar JR, Glassman SD, Burkus KJ, Carreon LY. Clinical outcomes and fusion success at 2 years of single-level instrumented posterolateral fusions with recombinant human bone morphogenetic protein-2/ compression resistant matrix versus iliac crest bone graft. Spine 2006;31:2534–2539

32. Haid RW Jr, Branch CL Jr, Alexander JT, Burkus JK. Posterior lumbar interbody fusion using recombinant human bone morphogenetic protein type 2 with cylindrical interbody cages. Spine J 2004; 4:527–538

33. Burkus JK, Sandhu HS, Gornet MF, Longley MC. Use of rhBMP-2 in combination with structural cortical allografts: clinical and radiographic outcomes in anterior lumbar spinal surgery. J Bone Joint Surg Am 2005;87:1205–1212

34. Ostelo RW, de Vet HC, Waddell G, et al. Rehabilitation following first-time lumbar disc surgery: a systematic review within the framework of the Cochrane collaboration. Spine 2003;28:209–218

Related posts:

Biomechanics of the Lumbar Intervertebral Disc The Role of Education and Back Schools Presurgical Psychological Screening The Mechanisms of Pain from Intervertebral Discs Percutaneous Decompression Spinal Fusion: Posterior Approaches

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