Cognitive-Behavioral Physical Therapy

Despite surgical advances, up to 40% of patients continue to have chronic pain and
functional disability after lumbar spine surgery. Our own data demonstrate that high fear of
movement is a risk factor for increased pain and disability in this patient population.
Cognitive-behavioral therapy (CBT) and physical therapy (PT) interventions targeting fear of
movement have proven effective for decreasing persistent pain and functional disability in
patients with chronic low back pain. However, the efficacy of a combined CBT and PT approach
has not been well demonstrated in a surgical spine population. Therefore, we propose to
conduct a two-group randomized controlled trial (RCT) to gather preliminary evidence on the
efficacy of a brief cognitive-behavioral based PT (CBPT) intervention in patients at-risk
for poor outcomes following lumbar spine surgery for degenerative conditions. We hypothesize
that incorporating cognitive and behavioral strategies into postoperative standard of care
PT will improve self-reported pain and disability and observed physical function, through
reductions in fear of movement and pain catastrophizing (i.e., tendency to magnify pain
sensations). This pilot study plans to recruit 80 patients with high postoperative fear of
movement or pain catastrophizing. These eligible at-risk patients will be randomized to one
of the two groups: (1) standard PT treatment + CBPT or (2) standard PT treatment + weekly
phone calls to control for attention. The CBPT program consists of 1 in person and 5
telephone sessions and is based on well-accepted and effective CBT strategies. These
strategies focus on relaxation, problem-solving training, cognitive restructuring, and
behavioral self management. Primary outcomes include self-reported pain and disability as
measured by the Brief Pain Inventory and the Oswestry Disability Index. Secondary outcomes
consist of observed physical function as measured by performance-based tests of gait speed,
balance, repeated chair stands, and mobility (Short Physical Performance Battery, Timed Up
and Go). Outcome data will be collected at baseline (6 weeks after surgery), after treatment
(3 months after surgery), and at 6 months following surgery. The proposed two-group RCT will
provide estimates of effect sizes and sample sizes associated with the CBPT intervention and
data on feasible recruitment and retention goals and the mechanisms through which the CBPT
intervention affects long-term outcomes. This informative pilot data will guide a
multicenter, three-group clinical trial to further validate the CBPT intervention. Our
long-term objective is to broaden the availability of effective CBT strategies by expanding
the implementation from traditional providers, psychologists, to a group of providers,
physical therapists, who routinely interact with a large population of patients with
musculoskeletal pain.

English speaking adults of both sexes and all races scheduled for lumbar spine surgery for
a degenerative condition (spinal stenosis, spondylosis with or without myelopathy, and
spondylolisthesis) will be considered for study participation.

Inclusion criteria will include the following:

1. Radiographic evidence of lumbar spinal stenosis secondary to degenerative changes;

2. Surgical treatment using laminectomy with or without arthrodesis (i.e., fusion);

3. Presence of back and/or lower extremity pain > 6 months;

4. No history of neurological movement disorder;

5. No presence of psychotic disease; and

6. TSK score > 39 or Pain Catastrophizing Scale (PCS) score > 20

Exclusion criteria will include the following:

1. Patients having microsurgical techniques as the primary procedure, such as an
isolated laminotomy or microdiscectomy (individuals having these minimally invasive
surgical techniques tend to have a less severe case of lumbar degeneration and a
shorter recovery time than individuals having arthrodesis or laminectomy without
arthrodesis);

2. Patients having surgery for spinal deformity as the primary indication (patients with
spinal deformity as the primary spinal disorder tend to have a different recovery
trajectory compared to the inclusion population); and

3. Patients having surgery secondary to pseudarthrosis, trauma, infection, or tumor.