Cognitive-behavioral-based physical therapy to improve surgical spine outcomes: a case series

Abstract

Background and purpose: Fear of movement is a risk factor for poor postoperative outcomes in patients following spine surgery. The purposes of this case series were: (1) to describe the effects of a cognitive-behavioral-based physical therapy (CBPT) intervention in patients with high fear of movement following lumbar spine surgery and (2) to assess the feasibility of physical therapists delivering cognitive-behavioral techniques over the telephone.

Case description: Eight patients who underwent surgery for a lumbar degenerative condition completed the 6-session CBPT intervention. The intervention included empirically supported behavioral self-management, problem solving, and cognitive restructuring and relaxation strategies and was conducted in person and then weekly over the phone. Patient-reported outcomes of pain and disability were assessed at baseline (6 weeks after surgery), postintervention (3 months after surgery), and at follow-up (6 months after surgery). Performance-based outcomes were tested at baseline and postintervention. The outcome measures were the Brief Pain Inventory, Oswestry Disability Index, 5-Chair Stand Test, and 10-Meter Walk Test.

Outcomes: Seven of the patients demonstrated a clinically significant reduction in pain, and all 8 of the patients had a clinically significant reduction in disability at 6-month follow-up. Improvement on the performance-based tests also was noted postintervention, with 5 patients demonstrating clinically meaningful change on the 10-Meter Walk Test.

Discussion: The findings suggest that physical therapists can feasibly implement cognitive-behavioral skills over the telephone and may positively affect outcomes after spine surgery. However, a randomized clinical trial is needed to confirm the results of this case series and the efficacy of the CBPT intervention. Clinical implications include broadening the availability of well-accepted cognitive-behavioral strategies by expanding implementation to physical therapists and through a telephone delivery model.

Figures

Figure 1.

Changes over time in outcomes for fear of movement, pain catastrophizing, depression, and pain self-efficacy: (A) Tampa Scale for Kinesiophobia (TSK), (B) Pain Catastrophizing Scale (PCS), (C) 9-item Patient Health Questionnaire (PHQ-9), and (D) Pain Self-Efficacy Questionnaire (PSEQ). P1-P8=patients 1–8.

Figure 2.

Changes over time in outcomes for pain and disability: (A) Brief Pain Inventory: pain intensity (BPI: Intensity), (B) Brief Pain Inventory: pain interference (BPI: Interference), (C) Oswestry Disability Index (ODI). P1–P8=patients 1–8.

Figure 3.

Changes over time in outcomes for performance-based function: (A) 5-Chair Stand Test, (B) 10-Meter Walk Test at comfortable pace, (C) 10-Meter Walk Test at fast pace. P1–P8=patients 1–8.

Appendix.

Summary of the Cognitive-Behavioral-Based Physical Therapy Intervention by Session