Can cognitive behavioural therapy help spinal surgery patients return to work and daily life?


By Nanna Rolving

Each year, thousands of chronic low back pain patients undergo lumbar spinal fusion surgery, and the rates have been increasing over the past two decades1,2. Despite a high level of a technical success in the form of radiographic fusion, there is still a need to improve and regain patients’ habitual functional level and quality of life after surgery3,4. Furthermore, studies suggest that return to work rates are relatively low5,6. Psychological traits, such as fear-avoidance belief and catastrophic thinking, have become increasingly accepted as potentially important determinants of patient-related outcomes following spinal surgery7–9. In particular, characteristics such as maladaptive coping strategies, fear-avoidance beliefs and catastrophic thinking seem to be predictive of worse outcomes regarding pain, function and quality of life. These psychological traits seem susceptible to change through the application of cognitive-behavioural therapy (CBT)7,10,11, which, in short, is defined as a psychotherapeutic approach aiming to solve problems concerning dysfunctional cognitions and behaviours through a goal-oriented, systematic procedure. The use of CBT has empirical support in chronic pain populations, with randomised controlled trials documenting a positive effect on catastrophising and fear of movement10,12. However, CBT, or elements thereof, have been used in only few studies in the spinal surgery population, suggesting a positive effect on pain, disability and return to work13,14. Another factor found to influence the postoperative outcome in several fields of surgery is the timing of the rehabilitation effort, with superior outcomes resulting from interventions initiated prior to surgery15,16.

Aim of our study

Based on this knowledge, we found it relevant to investigate whether a preoperative rehabilitation strategy using a cognitive behavioural approach could improve short- and long-term outcomes, compared with standard care, in a study population of patients undergoing lumbar spinal fusion due to degenerative disorders. Furthermore, we wished to undertake a cost-effectiveness and cost-utility analysis with the aim of evaluating whether CBT is cost-effective.

Brief description of the study design

The study is a prospective randomised clinical trial with one year follow-up. Altogether, 96 patients (age 18–64 years) undergoing lumbar spinal fusion due to degenerative disease or spondylolisthesis grade I–II between October 2011 and June 2013 were enrolled in the study. A detailed description of the study design and the cognitive behavioural intervention has been published recently in BMC Musculoskeletal Disorders17.

Three studies have been planned for publication, elucidating the following hypothesis—adding a preoperative CBT intervention to the standard treatment for patients undergoing lumbar spinal fusion will: reduce postoperative pain and analgesic intake, facilitate earlier mobilisation, and decrease the length of hospitalisation following lumbar spinal fusion surgery (study one); have a positive effect on the patients’ level of function and quality of life (ie. reduce time to return to work and improve their ability to cope with pain (study two); and be cost-effective in a socioeconomic perspective (study three).


We expect the results for study one to be ready for publication in the near future. The data for study two and three will be analysed during the autumn of 2014, and hopefully results will be ready for publication before the end of 2014.


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2. Rajaee et al. Spine 2012; 37: 67–76

3. Bentsen et al. J Clin Nurs 2008; 17: 2061–69

4. Robinson et al. Acta Orthop 2013; 84: 7–11

5. Oestergaard et al. Spine 2012; 37: 1803–09

6. Soegaard et al. Eur Spine J 2007; 16: 657–68

7. Khan et al. American Journal of Surgery 2011; 201: 122–31

8. Papaioannou et al. Pain Med 2009; 10: 1452–59

9. Celestin et al. Pain Med (USA) 2009; 10: 639–53

10. Hoffman et al. Health Psychology 2007; 26: 1–9

11. Thorn et al. Health Psychology 2007; 26: 10–12

12. Kerns et al. J Clin Psychol 2006; 62: 1327–31

13. Abbott et al. Spine 2010; 35: 848–57

14. Christensen et al. Spine 2003; 28: 2561–69

15. Louw et al. Physiotherapy Theory and Practice 2013; 29: 175–94

16. Nielsen et al. Clin Rehabil 2010; 24:137–48

17. Rolving et al. BMC Musculoskelet Disord 2014. In press


Nanna Rolving, Fysioterapi-og Ergoterapiafdelingen, Aarhus Universitshospital, Denmark