The Development of a Cognitive Reassurance Training Program

Identifying strategies to favorably alter unhelpful cognitions of patients with recent onset
low back pain is a research priority and could help curb the transition from acute to chronic
low back pain; lessening the need for prolonged and costly management. Current evidence
suggests that psychological factors, including maladaptive pain beliefs and avoidant
behaviors and expectations for recovery, are associated with poor outcomes in patients with
low back pain. Recently, considerable attention has been given to training non-psychologists
to provide psychologically based interventions for patients with low back pian. A recent
review of interventions that included psychological approaches noted that all of the trials
that failed to show benefit included delivery of the intervention by non-psychologists.
Authors suggest that increasing the effort in selecting, training, supervising and assessing
the competence of the practitioners delivering the treatment could improve results.

Low back pain comprises approximately 50% of the caseload of outpatient physical therapists
physical therapists making physical therapists ideally positioned to manage the unhelpful
cognitions of patients with low back pain. However, physical therapists often feel unprepared
when managing the cognitive factors associated with low back pain. The purpose of this
project is to develop and assess the effectiveness of a training program for physical
therapists that focuses on cognitive reassurance; a novel cognitive intervention for patients
with low back pain.

Cognitive reassurance is a communication approach in which maladaptive beliefs and
expectations are identified. Tailored explanations for the patient's conditions are then
provided, possible prognosis and treatment are discussed, and clarifications are offered. With
adequate training, physical therapists could utilize cognitive reassurance to promote
patients' understanding of his/her condition and modify maladaptive low back pain-related
beliefs and expectations.

The proposed pilot study will use a pre-post design to examine the impact of cognitive
reassurance training on the low back pain beliefs and skills in physical therapists and
physical therapist assistants. Following the training the investigators will recruit patients
who have scheduled an evaluation for low back pain with the physical therapists who attended
the training. Patient data will be collected at baseline before the evaluation and follow up
data at 2, 4 and 8 weeks.

The specific aims are: 1) Evaluate the feasibility of a cognitive reassurance training
program for physical therapists that focuses on modifying physical therapists' beliefs and
improving physical therapists' skill in the application of cognitive reassurance for patients
with acute/subacute low back pain. 2) Evaluate the application of cognitive reassurance by
physical therapists to patients with acute/sub-acute low back pain. 3) Examine the
association between physical therapist application of cognitive reassurance and short-term
changes in the patient's low back pain beliefs and expectations (low back pain beliefs,
self-efficacy, pain catastrophizing, fear-avoidance).

Therapist inclusion criteria:

- University of Utah Health Care physical therapists and physical therapist assistants

- Employed at least 20 hours a week

- Licensed in the state of Utah

Therapist exclusion criteria:

Patient inclusion criteria

- Primary reason for scheduling an evaluation with a physical therapist is low back pain
(defined as symptoms of pain and/or numbness between the 12th rib and buttocks with or
without referral in to one or both legs

- Current episode of low back pain ≤ 12 weeks duration

- Age 18-64

- Ability to read and speak English

Patient exclusion criteria

- Report being referred to physical therapy for specific low back pathology (e.g.
fracture)

- Any lumbar surgery in the past 6 months

- Current pregnancy