Education and advice within a cognitive-behavioural approach
During the past two or three decades, however, there has been increasing recognition of the importance of cognitive factors and this has been reflected in the design of a range of research studies, particularly in the treatment of low back pain, which have included a focus to a greater or lesser extent on the modification of beliefs and behaviour, in the context of early intervention. Clearly all therapeutic encounters incorporate, at least to some extent, a focus on cognitions and behaviour, but CBT differs in that the explicit focus of intervention is on the modification of thoughts and behaviour, rather than medical or biomechanical abnormality. The psychosocial component within the cognitive-behavioural approach (CBA) is offered within a framework of reactivation and therefore should be viewed more as ‘psychologically informed physiotherapy’ rather than psychotherapy per se.
Specific evaluations of educational interventions in LBP
An early randomized controlled trial (RCT) of The Back Book versus a traditional biomedical booklet (Burton et al. 1999) demonstrated a significant shift in inevitability of back problems with reduction of fear of physical activity in highly fearful LBP patients. Both Von Korff et al. (1998) and Moore et al. (2000) reduced back-related worries and fear-avoidance beliefs worry in RCTs of an educational approach that focused on self-management. Albaladejo et al. (2010), in a primary care RCT, found that the additional of a short education programme on active management to usual care led to a small but consistent improvement in disability, pain, and quality of life. In another RCT conducted in Spain, Kovacs et al. (2010) found in a group of institutionalized elderly subjects that The Back Book and a 20-min group talk improved disability 6 months later.
In the context of early interventions (usually in terms of secondary prevention) the derivation of simpler psychosocial interventions than ‘full-blown CBT’, containing a specific but narrower focus on pain- or disability-specific cognitions and behaviour, in patients with less entrenched disability, has offered an alternative to ‘traditional’ physiotherapy, based on manipulation or mobilization. Linton and Andersson (2000) conducted an interesting RCT compared a CBT programme of six 2-hour sessions with the Symonds et al. (1995) pamphlet (referenced above) and a conventional packet of ‘biomedical’ material. Although the CBT programme was more effective in reducing future sickness absence, all three groups improved in pain, fear-avoidance and catastro- phizing. In such ‘patient-centred’ approaches, the role of education and advice is fundamental.