Exposure and cognitive‐behavioural therapy for chronic back pain: An RCT on treatment processes

Abstract

Background To improve treatment outcomes, it is essential to understand the processes involved in therapeutic change. The aim of this study was to investigate the processes involved in treatment of individuals with chronic lower back pain (CLBP) and high fear‐avoidance. Graded in vivo exposure (Exposure), a specific treatment, and cognitive‐behavioural therapy (CBT), a general treatment, were compared. Methods Our study used data from a three‐arm randomized controlled trial. The sample comprised 61 CLBP patients (pain duration >3 months; sufficient level of fear‐avoidance). Assessments of session‐by‐session processes were done weekly for a maximum 14 weeks. The primary outcome, functional disability, was assessed at pre‐treatment, post‐treatment and 6‐months follow‐up. First, two‐level models were used to test for treatment‐related similarities and differences in the changes in session‐by‐session measures (i.e., common and unique treatment processes respectively). Second, we analysed treatment processes as predictors of treatment outcome. Results Contrary to our expectations, we found no evidence of unique treatment processes. Our results indicate that Exposure and CBT share some treatment processes. Specifically, patients reported a reduction in fear of movement and improvements in their ability to relax, to distract themselves, to manage their pain, to confront feared movements, to be active and to enjoy things despite their pain. Changes in fear of movement, relaxation, distraction, confrontation, activity and pain‐related self‐efficacy were also related to disability reduction. Conclusions Despite conceptual differences, Exposure and CBT may share common treatment processes. Future research needs to address, however, whether these processes need to be targeted directly or can be supported indirectly. Significance We identified several treatment processes (e.g., reduction of fear of movement, enhancement of self‐efficacy), which were associated with disability reduction during the management of chronic pain and fear‐avoidance. These processes appeared to be equally important for Exposure and CBT. Practitioners should optimize these processes to improve their patients’ functioning.

What Works? Processes of Change in a Transdiagnostic Exposure Treatment for Patients With Chronic Pain and Emotional Problems

“…These findings are in line with studies showing that improved catastrophizing and painacceptance mediate effects on pain interference in similar cognitive-behavioral treatments focusing on exposure, values and pain-coping [26][27][28] . In addition, these results add to the increasing empirical support for the theoretical assumption that pain interference, catastrophizing, inactivity and lack of reinforcement are important factors in the development and maintenance of depression in the context of chronic pain 8,68,69 .…”

“…Improvement on measures regarding pain-related dysregulation (such as: the Pain Catastrophizing Scale, PCS 26 ; the Tampa Scale of Kinesiophobia, TSK 27 ; and the Chronic Pain Acceptance Questionnaire, CPAQ 28 ) have been shown to mediate effects on pain interference and disability in both CBT treatments and physical therapy for patients with chronic pain [26][27][28] , and reductions in emotion dysregulation (including several measures of difficulties in emotion regulation, rumination, and experiential avoidance) have been shown to correlate with effects on emotional problems such as depressive symptoms in multiple psychological treatments for psychiatric disorders 14 .…”

The association between believing staying active is beneficial and achieving a clinically relevant functional improvement after 52 weeks: a prospective cohort study of patients with chronic low back pain in secondary care

“…A previous study has found moderate evidence that health care professionals with a biomedical orientation or elevated fear-avoidance beliefs themselves are more likely to advise patients to limit physical activities [29], which in turn can affect patients' outcomes [42]. Consequently, there is a future need for interventions aimed at addressing clinicians' beliefs about LBP and the benefits of staying active, with a focus on building clinical skills to optimise reassurance [43]. This may enable healthcare professionals to identify and effectively address factors such as fear-avoidance, self-efficacy, catastrophising, and recovery expectations [9,10] that may importantly influence LBP recovery.…”

The Good, the Bad, and the Ugly—Chances, Challenges, and Clinical Implications of Avoidance Research in Psychosomatic Medicine

“…The principles of learning theory and the key role of avoidance are increasingly recognized within biopsychosocial disease models and have been successfully translated into extinctionbased interventions in various psychiatric and psychosomatic conditions. Inspired by their wide application in anxiety disorders (30,32,36,77), exposure therapy has been established as an integral part of multimodal interventions for disorders characterized by disturbed interoception (78), including chronic pain (38,54,79,80), disorders of the gut-brain axis, particularly irritable bowel syndrome (IBS) (48,(81)(82)(83)(84), but also for body image disturbances and eating disorders (85)(86)(87)(88), substance abuse and addiction (89)(90)(91).…”