Chronic Pain Management Series – Behavioural Treatment?

This is part 3 of a series on Persisting Pain, a topic of interest to many of my patients in Ascot (Bracknell) and Kensington West London, where my patients with chronic pain live.  Part One explores what chronic pain is, and Part two introduces the idea of non-hands work such as behavioural therapies to help with chronic pain.

In addition to their expertise in manual therapies and exercise rehabilitation, some specialised therapists use psychotherapy approaches such as CBT and ACT are experts at addressing multiple aspects of pain. These therapists adopt pain management strategies by combining both traditional movement-based physical therapy and modern-day psychosocial principles. Sometimes, the answer to a complex problem such as chronic pain is to broaden the horizon of your treatments. To heal the body, you may need to heal the thoughts and behaviours around the body and pain as well.

Behavioural Cognitive Therapy and Acceptance & Commitment Therapy

Unlike conventional forms of physical therapy, CBT and ACT sessions involve more verbal interactions and communication. During these sessions, an experienced physiotherapist will combine CBT and/or ACT approaches with their pre-existing knowledge of movement and the human body. When comparing these powerful therapies, they both present with similar intentions but differing philosophies. Oftentimes these therapies will be used as part of the rehabilitation side of a session, complete with homework.

Behavioural Cognitive Therapy (BCT)

BCT works on the basis that chronic pain is in part based on your perception of your current circumstances. To help clarify the role of BCT, the Fear-Avoidance Model below will highlight the two routes an individual may navigate in response to an injury. 

Route A (on the right-hand side): When faced with an injury or pain, you will acknowledge these disturbances and continue to function as per usual until recovery. 

Route B (on the left-hand side): When faced with an injury or pain, these feelings of fear may become overwhelming. Additionally, misinformation such as misleading online resources or even inaccurate medical advice can exacerbate an impending sense of stress and fear. Unfortunately, these negative emotions can result in behaviours and actions that exacerbate our pain and disability.

An example of how cognitive factors affect chronic pain

For example, you suffer a small bout of low back pain, and your doctor informs you that bending forward will make it ‘worse.‘ What might happen is that you become fearful and avoid bending forward at all costs. The more that you avoid, the less flexible and weaker your body becomes. Ultimately, you reach a point where every time you move in a certain way, you will anticipate pain, making it more likely to consistently feel pain. 

Image 2. Fear-avoidance model which details the 2 paths of acute injury recovery. Source. 

CBT aims to help mitigate your chronic pain by changing your negative emotions and behaviours. Initially, your therapist will learn more about your pain and background. By working together, you will begin to understand why you are experiencing pain and performing certain maladaptive behaviours. To combat these problems, pain-management strategies, such as empowering to change your mindset and developing positive coping mechanisms.

CBT is an established psychological process which has been used for the last 50-60 years to manage chronic conditions, such as:

• Chronic pain
• Post-traumatic stress disorder
• Anxiety
• Depression
• Eating disorders

Additionally, research has supported the use of CBT for managing chronic pain conditions such as low back or recurrent joint pain. In a massive 2012 study which screened over 266 research articles, the authors concluded that physiotherapist-lead CBT has a “positive impact on obstacles to recovery from [chronic] low back pain such a catastrophising and fear-avoidance beliefs.”  

Acceptance and Commitment Therapy (ACT)

Acceptance and Commitment Therapy (ACT) also aims to decrease your pain but within a contrasting approach. Chronic pain extends beyond the physical limitations dictated by your pain. It can also affect other parts of your life. You might begin to organise yourself around your pain – such as “what you can do” and “who you can see”.  This shifts your values to avoiding pain from all the other things you care about. Perhaps you’ve avoided running because of your back pain. Or maybe you’ve stopped attending your dance lessons because you’re embarrassed by your impediments. Pain can take over your life and leave you feeling powerless, and make your world feel smaller.

 How does Acceptance and Commitment Therapy work?

By working with an ACT trained therapist, the eventual goal is to accept your pain and commit to self-motivated behaviours based on your values rather than avoiding pain. There are two significant components regarding ACT, this includes:

• The Acceptance Phase: Similar to CBT, you will be made aware of the difficulties you have faced and become open to how your experiences may have affected you. 
• The Commitment Phase: Unlike CBT, instead of trying to change your current outlook, you will be able to accept your difficulties and experiences. You will be empowered to acknowledge the pain you have suffered and to see how you can choose positive and helpful behaviours. 

Although the concept of ACT in physiotherapy is more novel than CBT, it is an effective treatment of persisting pain. In a novel randomised controlled trial published in 2019, ACT showed potential for “significantly improved participants’ back pain disability.” Like the outcomes of CBT, both therapies present viable and effective options for chronic low back pain. 

In the next Part of this series, I’ll show you a case study of how these strategies are applied in a real life situation.  If you want some help with longer term pain, and live near the Ascot osteopathy clinic or the osteopathy clinic I run on Mondays in Kensington, please reach out and contact me.