Let's talk about back pain
Published on 01 April 2011
Can talking about back pain help people to manage it? One man with severe chronic back pain certainly thinks so, and now Arthritis Research UK is running a pilot study which could provide scientific proof and lead to a full-scale clinical trial.
When his pain specialist suggested that Barry Bell went on an intensive “contextual cognitive behavioural therapy” course, the former soldier was deeply sceptical.
An ex-Royal Engineer with 12 years of service, he had suffered from severe back pain and sciatica since a tour of duty during the first Gulf War, when he developed prolapses in several discs in different parts of the spine.
The former rugby referee had become a virtual recluse, rarely leaving the house except to attend medical appointments; his confidence at rock bottom.
Barry’s back pain had meant he had to leave the armed forces, and although he had managed to find another job, he was taking so much time off undergoing numerous operations to repair his damaged discs, that he eventually gave up work at the age of 37.
“The pain affected my whole life”
“I was very moody and had a tendency to a very quick temper because of the pain – I was also very depressed, although didn’t realise it at the time,” says Barry, now 45, from Forfar, near Dundee. “The pain was so bad I couldn’t stand up or sit down; it was like red hot needles jabbing into my leg, without relief, for 24 hours a day. Every time I moved there was a searing pain. It affected my whole life.
“When my pain specialist suggested going on this talking course in Bath last year I said to him: ‘If all the operations I’ve had didn’t fix the problem, how will talking about it fix it?’ I didn’t really understand it,” says Barry. “Of course, he quickly told me that it wouldn’t fix my pain, but would help me handle it – he was very clear about that.”
Barry agreed to attend the three week intensive contextual cognitive behavioural therapy (CCBT) course run by psychologists Dr Lance McCracken and Miles Thomson at the Royal National Hospital for Rheumatic Diseases in Bath, along with ten other people with a number of different conditions but a shared experience of severe, chronic pain. He admits that at the beginning he was still only 70 per cent convinced that he would get anything out of it and the first couple of days didn’t go well.
“As a group we were shown a clock face and asked to divide it up into hours, to show what we did in a normal day,” explains Barry. “I had been getting up in the morning, going into the living room, getting up and sitting down and trying to get comfortable, and so my clock face was completely empty. There was nothing on it, because I hadn’t done anything. I just stormed out of the class and wanted to go home, because at that moment I realised that that’s all my life was about – nothing.”
“I learned how to get back into the human race”
However, after that moment of epiphany, Barry realised he had to commit himself to the course and started to get his head around the concept of “mindfulness”. He explains: “You empty your body and mind and concentrate all your attention on feeling your toes moving, for example; you visualise them, and then you focus on the tingling, and then the sciatic pain, visualising that too, and every time you do it the pain eases a bit.”
Combining the mindfulness technique with some gentle gym work and exercise, Barry found he was able to get over his fear of walking down a busy street. He’d previously been too afraid of people bumping into him and causing him intense pain. He also organised a trip to watch a rugby match with other patients whilst in Bath and enjoyed a couple of pints after the game; something that would have been unthinkable previously. “I learned how to get back into the human race. I had sat in the house feeling sorry for myself for a long time, but the Bath team taught us to question ourselves and to re-train our minds – a bit like you’d re-train a puppy!”
Barry wanted to achieve two objectives from his time on the course: to have the confidence to go out for a meal – he’d stopped doing this because of his inability to grip cutlery properly and resulting self-consciousness – and to go out for walks with his partner Trudi, her daughters and their dog. He’s since managed both, with flying colours.
“Since I’ve been back from the course I’ve gone for loads of walks and the within two days of being home, me and Trudi and the girls went for a slap-up meal. It was so good to tuck into that steak – without dropping my fork!
“There’s no stopping me now”
“I used to make excuses for not doing things but I don’t anymore and I’m a lot happier in myself. To go from the stage I was at to the stage I’m at now is like night and day. I still have pain, I still get weary, but there’s no stopping me now. I proved to myself in Bath that I could do it, that you can change your mental attitude to pain; that it doesn’t have to stop you doing things.”
Recently Barry popped into his local rugby club for the first time in a long while. “Everyone looked at me and said: ’we thought you were dead!’ Then it was like I’d never been away. The course has given me my confidence back, and I have to take my hat off to the Bath team; I’ve got a wee bit of life back. I’d highly recommend it to anyone in severe pain, although it’s not for everyone – I know one of the girls on my course didn’t get much out of it. You have to be really committed.”
CCBT and the Arthritis Research UK pilot study
With funding of more than £320,000, study leaders psychologists Dr Tamar Pincus from the Royal Holloway, University of London, and Dr Lance McCracken, from the Royal National Hospital for Rheumatic Diseases in Bath, are aiming to recruit 92 people with severe back pain to test the effectiveness of CCBT compared to physiotherapy in a pilot project. CCBT is slightly different to the more traditional CBT, focusing on acceptance and uses methods of “mindfulness.” CBT has been the subject of clinical trials in the past, but Dr Pincus believes that this current approach is the most rigorous.
“In several trials the CBT was not delivered by a trained psychologist, but a physiotherapist with a weekend’s training. We will be using clinical psychologists with three years experience of pain,” she says. “The other key thing is that we’re selecting patients very specifically – people we know have a real psychological need. Not everyone with chronic back pain needs this sort of approach.” CCBT primarily aims to help those whose chronic back pain has led them to withdraw from society and normal life, people who are known as “fear avoidant”, such as Barry.
“We have to find out if it makes a difference”
CCBT will be tested against an equally rigorously designed physiotherapy regime. “We have one of the best physios in the country, Alison McGregor, training up our physios, to deliver a really good programme that includes some cardiovascular work, some education – everything but pure psychology,” adds Dr Pincus. “We could be setting ourselves up for a fall by making our control arm so robust, but otherwise we will never find out if CCBT works, and, as a scientist, I want to see a definite and significant result. We really have to find out if it makes a difference as the government is spending a great deal of money in developing CBT.”
“Step by step they slowly change their behaviour patterns”
Patients having CCBT as part of the pilot will have up to eight individual, intensive one-to-one sessions with a psychologist, in a process designed to promote change in both the way they think about their pain, and in their behavior.
Lance McCracken explains how it works: “One of the techniques we use is called mindfulness. This means paying more careful attention to our experiences. It includes watching and noticing things – thoughts and sensations, and adopting an accepting and observing attitude towards pain for example, so that its impact reduces. The process of being more conscious, more aware and more focused on what is going on around you means you’re less controlled by influences that can lead to inactivity or failure and less overwhelmed by pain.”
Patients having CCBT choose what their goals are and identify the obstacles standing in their way – such as confusion, fear, pain and fatigue; and step by step slowly change their behaviour patterns.
It can sound too good to be true but Dr McCracken points out that three previous studies on the effectiveness of CCBT reported that participants reduced their visits to the GP by 40 per cent, that one in three people took fewer painkillers, and three times as many people were in work or training after the course than at the start.
“These are the most severely disabled chronic pain sufferers in the country, but this treatment frees them from their struggling and allows them to focus on things that are more important and positive,” he adds.
The pilot study will show if the team’s trial methodology is sound and feasible, and if the treatment is acceptable and credible. If so, the team will then aim to develop a multi-centre trial that will also look at both effectiveness and cost effectiveness.