Use of cognitive behavioural therapy with usual physical therapy intervention for individuals who are unemployed secondary to chronic low back pain: A case series.

Background: Low back pain (LBP) is a leading cause of work absence and may influence the development of fear-avoidance behaviours. The purpose of this case series was to examine the use of cognitive behavioural therapy (CBT) with physical therapy (PT) for the treatment of fear-avoidance behaviours in patients with chronic LBP who are disabled or in a period of work absence. Case description: Four patients with high-irritability chronic LBP who were considered as being on work absence or disability were treated in outpatient PT clinics. The intervention consisted of fundamental CBT concepts utilized in combination with a traditional PT intervention. Outcomes: Patients were treated until the achievement of functional goals and normalized movement patterns. Pain, disability and function were measured via a numerical pain rating scale, the Oswestry Disability Index and Focus on Therapeutic Outcomes. All patients achieved the minimally clinically important difference for these measures. Fear-avoidance behaviours decreased, as observed by an average 15-point change in Fear-Avoidance Behaviour Questionnaire (Physical Activity) outcomes. Patients on work absence returned to work. Discussion: This case series describes the use of CBT in combination with a traditional PT intervention for the treatment of high-irritability, fear-avoidant individuals who are on disability or in a period of work absence. The results indicated that CBT may be a useful and feasible adjunct to PT and may positively influence a return to work. Further studies are needed to determine effectiveness, including randomized controlled trials.