"Physical therapy is not a subspecialty of the medical profession and physical therapists are not medical doctors; we are a separate profession that provides a unique service that physicians are unable and untrained to provide."

Letter to the AMA from the APTA, Dec 2009

Monday, January 2, 2012

Cognitive Behavior Therapy Over the Telephone Effective for Chronic Widespread Pain

Physical therapists who treat chronic pain patients may be interested in this new randomized controlled trial of 442 patients comparing cognitive behavioral therapy (CBT) and an exercise program over 6 months.

As background information, the researchers described why alternatives to pharmacologic management, such as CBT and exercise, are necessary:
"In the United States, mean per-patient costs, including the following:

  • pain and non-pain-related medication,
  • physician consultations, 
  • tests and procedures, 
  • and emergency department visits 

...in the six months following a new diagnosis of fibromyalgia were $3,481"
The researchers compared telephone-delivered cognitive behavioral therapy (TCBT), graded exercise, combined intervention, or treatment as usual (control group). The results are shown in this chart:
Rate of Positive Outcomes
Time FrameControl groupTCBT groupExercise groupCombined Exercise and TCBT
6 months (end of intervention)8.1%29.9%34.8%37.2%
9 month follow-up8.3%32.6%24.2%37.1%

Cognitive Behavior Therapy...
"...represent a management strategy that puts patients firmly in charge.  
The skills learned in CBT, for example, are available after hours and over long weekends and do not require monthly refills
Moreover, because CBT can be administered by telephone, this intervention is convenient and can be made available to a wide range of patients."
The implications for physical therapists practicing in "traditional" settings with standard techniques and interventions are these:
  1. Notice the deterioration of exercise-only 9-month outcomes - we know this to be true since most patients don't stick with their exercises once they start feeling better.
  2. The TCBT group treatment were delivered over the telephone - this new delivery method is a threat to our traditional, clinic or hospital-based delivery and payment structure.

  3. Presumably, similar technologies such as the following:
  • Voice Over-Internet-Protocol (VOiP, or Skype),
  • Simple Message Syndication (SMS, or text),
  • social networks or
  • old-fashioned e-mail
...could work just as effectively.

I'd be curious to hear about therapist treating chronic pain patients using Cognitive Behavioral Therapy. I would like to learn some of these techniques.

I believe behavior-based interventions using non-traditional delivery methods represent the future for our profession.


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Tim Richardson, PT owns a private practice at Medical Arts Rehabilitation, Inc in Palmetto, Florida. The clinic website is at MedicalArtsRehab.com.

Bulletproof Expert Systems: Clinical Decision Support for Physical Therapists in the Outpatient Setting is a manager's workbook with stories, checklists, charts, graphs, tables, and templates describing how you can use paper-based or computerized tools to improve your clinic's Medicare compliance, process adherence and patient outcomes.

Tim has implemented a computerized Clinical Decision Support (CDS) system in his clinic since 2006 that serves as a Reminder, Alerting, Prompting and Predicting CDS using evidence-based tests and measures.

Tim can be reached at
TimRichPT@BulletproofPT.com .

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