Comparing physical and behavior therapy for chronic low back pain on physical abilities, psychological distress, and patients' perceptions

Complicating factors associated with mild traumatic brain injury: impact on pain and posttraumatic stress disorder treatment

The nature of combat in Iraq and Afghanistan has resulted in high rates of comorbidity among chronic pain, posttraumatic stress disorder (PTSD), and mild traumatic brain injury (mTBI) in Veterans of Operations Enduring Freedom and Iraqi Freedom (OEF/OIF). Although separate evidence-based psychological treatments have been developed for chronic pain and PTSD, far less is known about how to approach treatment when these conditions co-occur, and especially when they co-occur with mTBI. To provide the best care possible for OEF/OIF Veterans, clinicians need to have a clearer understanding of how to identify these conditions, ways in which these conditions may interact with one another, and ways in which existing evidence-based treatments can be modified to meet the needs of individuals with mTBI. The purpose of the present paper is to review the comorbidity of pain, PTSD, and mTBI in OEF/OIF Veterans, and provide recommendations to clinicians who provide care to Veterans with these conditions. First, we will begin with an overview of the presentation, symptomatology, and treatment of chronic pain and PTSD. The challenges associated with mTBI in OEF/OIF Veterans will be reported and data will be presented on the comorbidity among all three of these conditions in OEF/OIF Veterans. Second, we will present recommendations for providing psychological treatment for chronic pain and PTSD when comorbid with mTBI. Finally, the paper concludes with a discussion of the need for a multidisciplinary treatment approach, as well as a call for continued research to further refine existing treatments for these conditions.

The role of classification of chronic low back pain

STUDY DESIGN

Systematic review.

OBJECTIVE

To describe the various ways chronic low back pain (CLBP) is classified, to determine if the classification systems are reliable and to assess whether classification-specific interventions have been shown to be effective in treating CLBP.

SUMMARY OF BACKGROUND DATA

A classification system by which individual patients with CLBP could be identified and directed to an effective treatment protocol would be beneficial. Those systems that direct treatment have the greatest potential influence on patient outcomes.

METHODS

A systematic search was conducted in MEDLINE and the Cochrane Collaboration Library for English language literature published through January 2011. We included articles that specifically described a clinical classification system for CLBP, reported on the reliability of a classification system, or evaluated the effectiveness of classification-specific interventions.

RESULTS

A total of 60 articles were initially reviewed. We identified 28 classification systems that met inclusion criteria: 16 diagnostic systems, 7 prognostic systems, and 5 treatment-based systems. In addition, we found 10 randomized controlled trials of CLBP treatment from which we compared inclusion and exclusion criteria. Treatment-based systems were all directed at nonoperative management. Four of the 5 treatment-based systems underwent reliability testing and were found to have interobserver agreement of 70% to 100%. Reliability increased with training and familiarity with a given classification. As the number of subgroups within a classification increased, interobserver agreement decreased. Function and pain were similar between patients treated with the McKenzie classification system and those treated with dynamic strengthening training after 8 months of follow-up in one randomized controlled trial. One prospective cohort study reported better pain and function using the Canadian Back Institute Classification system than with standard rehabilitation. An analysis of the admission criteria to recent randomized studies with either nonoperative care or another surgical intervention provided a methodology for refining criteria to be met by patients considering surgery.

CONCLUSION

There currently are many classification systems for CLBP; some that are descriptive, some prognostic, and some that attempt to direct treatment. We recommend that no one classification system be adopted for all purposes. We further recommend that future efforts in developing a classification system focus on one that helps to direct both surgical and nonsurgical treatments.

CLINICAL RECOMMENDATIONS

There currently are many classification systems for CLBP; some that are descriptive, some prognostic, and some that attempt to direct treatment. We recommend that no one classification system be adopted for all purposes. We further recommend that future efforts in developing a classification system focus on one that helps to direct both surgical and nonsurgical treatments.

Graded activity and graded exposure for persistent nonspecific low back pain: a systematic review

BACKGROUND

Graded activity and graded exposure are increasingly being used in the management of persistent low back pain; however, their effectiveness remains poorly understood.

PURPOSE

The aim of this study was to systematically review randomized controlled trials that evaluated the effectiveness of graded activity or graded exposure for persistent (>6 weeks in duration or recurrent) low back pain.

DATA SOURCES

Trials were electronically searched and rated for quality by use of the PEDro scale (values of 0-10).

STUDY SELECTION

Randomized controlled trials of graded activity or graded exposure that included pain, disability, global perceived effect, or work status outcomes were included in the study.

DATA EXTRACTION

Outcomes were converted to a scale from 0 to 100. Trials were pooled with software used for preparing and maintaining Cochrane reviews.

RESULTS

are presented as weighted mean differences with 95% confidence intervals.

DATA SYNTHESIS

Fifteen trials with 1,654 patients were included. The trials had a median quality score of 6 (range=3-9). Pooled effects from 6 trials comparing graded activity with a minimal intervention or no treatment favored graded activity, with 4 contrasts being statistically significant: mean values (95% confidence intervals) for pain in the short term, pain in the intermediate term, disability in the short term, and disability in the intermediate term were -6.2 (-9.4 to -3.0), -5.5 (-9.9 to -1.0), -6.5 (-10.1 to -3.0), and -3.9 (-7.4 to -0.4), respectively. None of the pooled effects from 6 trials comparing graded activity with another form of exercise, from 4 trials comparing graded activity with graded exposure, and from 2 trials comparing graded exposure with a waiting list were statistically significant.

LIMITATIONS

Limitations of this review include the low quality of the studies, primarily those that evaluated graded exposure; the use of various types of outome measures; and differences in the implementation of the interventions, adding to the heterogeneity of the studies.

CONCLUSIONS

The available evidence suggests that graded activity in the short term and intermediate term is slightly more effective than a minimal intervention but not more effective than other forms of exercise for persistent low back pain. The limited evidence suggests that graded exposure is as effective as minimal treatment or graded activity for persistent low back pain.

Interventions to improve adherence to exercise for chronic musculoskeletal pain in adults

BACKGROUND

Chronic musculoskeletal pain (CMP) is a major health problem, accounting for approximately one-quarter of general practice (GP) consultations in the United Kingdom (UK). Exercise and physical activity is beneficial for the most common types of CMP, such as back and knee pain. However, poor adherence to exercise and physical activity may limit long-term effectiveness.

OBJECTIVES

To assess the effects of interventions to improve adherence to exercise and physical activity for people with chronic musculoskeletal pain.

SEARCH STRATEGY

We searched the trials registers of relevant Cochrane Review Groups. In addition, we searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, AMED, PsycINFO, Science Citation Index and Social Science Citation Index and reference lists of articles to October 2007. We consulted experts for unpublished trials.

SELECTION CRITERIA

Randomised or quasi-randomised trials evaluating interventions that aimed to improve adherence to exercise and physical activity in adults with pain for three months and over in the axial skeleton or large peripheral joints.

DATA COLLECTION AND ANALYSIS

Two of the four authors independently assessed the quality of each included trial and extracted data. We contacted study authors for missing information.

MAIN RESULTS

We included 42 trials with 8243 participants, mainly with osteoarthritis and spinal pain. Methods used for improving and measuring adherence in the included trials were inconsistent. Two of the 17 trials that compared different types of exercise showed positive effects, suggesting that the type of exercise is not an important factor in improving exercise adherence. Six trials studied different methods of delivering exercise, such as supervising exercise sessions, refresher sessions and audio or videotapes of the exercises to take home. Of these, five trials found interventions improved exercise adherence. Four trials evaluated specific interventions targeting exercise adherence; three of these showed a positive effect on exercise adherence. In eight trials studying self-management programmes, six improved adherence measures. One trial found graded activity was more effective than usual care for improving exercise adherence. Cognitive behavioural therapy was effective in a trial in people with whiplash-associated disorder, but not in trials of people with other CMP. In the trials that showed a positive effect on adherence, association between clinical outcomes and exercise adherence was conflicting.

AUTHORS' CONCLUSIONS

Interventions such as supervised or individualised exercise therapy and self-management techniques may enhance exercise adherence. However, high-quality, randomised trials with long-term follow up that explicitly address adherence to exercises and physical activity are needed. A standard validated measure of exercise adherence should be used consistently in future studies.

WITHDRAWN: Multidisciplinary bio-psycho-social rehabilitation for chronic low-back pain

BACKGROUND

Chronic low back pain is, in many countries, the main cause of long term disability in middle age. Patients with chronic low back pain are often referred for multidisciplinary treatment. Previous published systematic reviews on this topic included no randomised controlled trials and pooled together controlled and non-controlled studies.

OBJECTIVES

To assess the effect of multidisciplinary bio-psycho-social rehabilitation on pain, function, employment, quality of life and global assessment outcomes in subjects with chronic disabling low back pain.

SEARCH STRATEGY

We searched MEDLINE, EMBASE, PsychLIT, CINAHL, Health STAR, and The Cochrane Library from the beginning of the database to June 1998 using the comprehensive search strategy recommended by the Back Review Group of the Cochrane Collaboration. INTERVENTION specific key words for this review were: patient care team, patient care management, multidisciplinary, interdisciplinary, multiprofessional, multimodal, pain clinic and functional restoration. We also reviewed reference lists and consulted the editors of the Back Review Group of the Cochrane Collaboration.

DESIGN

randomised controlled trials comparing multidisciplinary bio-psycho-social rehabilitation with a non-multidisciplinary control intervention.

POPULATION

Adults with disabling low back pain of more than three months in duration.

INTERVENTION

Patients had to be assessed and treated by qualified professionals according to a plan that addresses physical and at least one of psychological, or social/occupational dimensions.

OUTCOMES

Only trials which reported treatment effect in at least one of pain, function, employment status, quality of life or global improvement.Exclusion: Pure educational interventions (back schools) and pure physical interventions were excluded.

DATA COLLECTION AND ANALYSIS

Selection, data extraction and quality grading of studies was done by two independent authors using pre-tested data forms. Study quality was assessed according to the scheme recommended by the Back Review Group of the Cochrane Collaboration. Trials with internal validity scores of five or more in a ten point scale were considered high quality. Discrepancies between authors were resolved by consensus or by a third author. Given the marked heterogeneity in study settings, interventions and control groups we decided not to pool trial results in a meta-analysis. Instead, we summarized findings by strength of evidence and nature of intervention and control treatments. The evidence was judged to be strong when multiple high quality trials produced generally consistent findings. It was judged to be moderate when multiple low quality or one high quality and one or more low quality trials produced generally consistent findings. Evidence was considered to be limited when only one randomised trial existed or if findings of existing trials were inconsistent.

MAIN RESULTS

Ten trials (12 randomised comparisons) were included. They randomised a total of 1964 patients with chronic low back pain. There was strong evidence that intensive multidisciplinary bio-psycho-social rehabilitation with a functional restoration approach improved function when compared with inpatient or outpatient non-multidisciplinary treatments. There was moderate evidence that intensive multidisciplinary bio-psycho-social rehabilitation with a functional restoration approach improved pain when compared with outpatient non-multidisciplinary rehabilitation or usual care. There was contradictory evidence regarding vocational outcomes of intensive multidisciplinary bio-psycho-social intervention. Some trials reported improvements in work readiness, but others showed no significant reduction in sickness leaves. Less intensive outpatient psycho-physical treatments did not improve pain, function or vocational outcomes when compared with non-multidisciplinary outpatient therapy or usual care. Few trials reported effects on quality of life or global assessments.

AUTHORS' CONCLUSIONS

The reviewed trials provide evidence that intensive multidisciplinary bio-psycho-social rehabilitation with a functional restoration approach improves pain and function. Less intensive interventions did not show improvements in clinically relevant outcomes.

Multidisciplinary bio-psycho-social rehabilitation for chronic low back pain

BACKGROUND

Chronic low back pain is, in many countries, the main cause of long term disability in middle age. Patients with chronic low back pain are often referred for multidisciplinary treatment. Previous published systematic reviews on this topic included no randomised controlled trials and pooled together controlled and non-controlled studies.

OBJECTIVES

To assess the effect of multidisciplinary bio-psycho-social rehabilitation on pain, function, employment, quality of life and global assessment outcomes in subjects with chronic disabling low back pain.

SEARCH STRATEGY

We searched MEDLINE, EMBASE, PsychLIT, CINAHL, Health STAR, and The Cochrane Library from the beginning of the database to June 1998 using the comprehensive search strategy recommended by the Back Review Group of the Cochrane Collaboration. INTERVENTION specific key words for this review were: patient care team, patient care management, multidisciplinary, interdisciplinary, multiprofessional, multimodal, pain clinic and functional restoration. We also reviewed reference lists and consulted the editors of the Back Review Group of the Cochrane Collaboration.

DESIGN

randomised controlled trials comparing multidisciplinary bio-psycho-social rehabilitation with a non-multidisciplinary control intervention.

POPULATION

Adults with disabling low back pain of more than three months in duration.

INTERVENTION

Patients had to be assessed and treated by qualified professionals according to a plan that addresses physical and at least one of psychological, or social/occupational dimensions.

OUTCOMES

Only trials which reported treatment effect in at least one of pain, function, employment status, quality of life or global improvement. Exclusion: Pure educational interventions (back schools) and pure physical interventions were excluded.

DATA COLLECTION AND ANALYSIS

Selection, data extraction and quality grading of studies was done by two independent reviewers using pre-tested data forms. Study quality was assessed according to the scheme recommended by the Back Review Group of the Cochrane Collaboration. Trials with internal validity scores of five or more in a ten point scale were considered high quality. Discrepancies between reviewers were resolved by consensus or by a third reviewer. Given the marked heterogeneity in study settings, interventions and control groups we decided not to pool trial results in a meta-analysis. Instead, we summarized findings by strength of evidence and nature of intervention and control treatments. The evidence was judged to be strong when multiple high quality trials produced generally consistent findings. It was judged to be moderate when multiple low quality or one high quality and one or more low quality trials produced generally consistent findings. Evidence was considered to be limited when only one randomised trial existed or if findings of existing trials were inconsistent.

MAIN RESULTS

Ten trials (12 randomised comparisons) were included. They randomised a total of 1964 patients with chronic low back pain. There was strong evidence that intensive multidisciplinary bio-psycho-social rehabilitation with a functional restoration approach improved function when compared with inpatient or outpatient non-multidisciplinary treatments. There was moderate evidence that intensive multidisciplinary bio-psycho-social rehabilitation with a functional restoration approach improved pain when compared with outpatient non-multidisciplinary rehabilitation or usual care. There was contradictory evidence regarding vocational outcomes of intensive multidisciplinary bio-psycho-social intervention. Some trials reported improvements in work readiness, but others showed no significant reduction in sickness leaves. Less intensive outpatient psycho-physical treatments did not improve pain, function or vocational outcomes when compared with non-multidisciplinary outpatient therapy or usual care. Few trials reported effects on quality of life or global assessments.

REVIEWER'S CONCLUSIONS

The reviewed trials provide evidence that intensive multidisciplinary bio-psycho-social rehabilitation with a functional restoration approach improves pain and function. Less intensive interventions did not show improvements in clinically relevant outcomes.

A randomized controlled component analysis of a behavioral medicine rehabilitation program for chronic spinal pain: are the effects dependent on gender?

The aim of the present study was to evaluate the outcome of a behavioral medicine (BM) rehabilitation program and the outcome of its two main components, compared to a 'treatment-as-usual' control group (CG). The study employed a 4x4 repeated-measures design with four groups and four assessment periods (pre-treatment, post-treatment, 6-month follow-up, and 18-month follow-up). The group studied consisted of subjects on sick leave identified in a nationwide health insurance scheme in Sweden. After inclusion, the subjects were randomized to one of four conditions, which were: (1) behavior-oriented physical therapy (PT); (2) cognitive behavioral therapy (CBT); (3) BM rehabilitation consisting of PT+CBT (BM); (4) a 'treatment-as-usual' CG. The treatments were given over a period of 4 weeks, PT and CBT on a part-time basis and BM on a full-time basis. Outcome variables were sick leave, early retirement, and health-related quality of life (measured using the Short Form Health Survey, SF-36). The results showed that the risk of being granted full-time early retirement was significantly lower for females in PT and CBT compared to the CG during the 18-month follow-up period. However, the total absence from work (sick listing plus early retirement) in days over the 18-month follow-up period was not significantly different in the CG compared to the treatments. On the SF-36, women in CBT and BM reported a significantly better health-related quality of life than women in the CG at the 18-month follow-up. No significant differences for men were found on the SF-36 scales. In conclusion, the results revealed gender differences in the outcome of the treatments and that the components of this BM program yielded as good results as the whole program.

Psychosomatic group treatment helps women with chronic pelvic pain

This study evaluates group treatment for women suffering from chronic pelvic pain. The concept of group treatment was based on psychosomatic and physio-therapeutical principles and on cognitive and operant behavioral therapy. Each group was composed of up to six women suffering from chronic pelvic pain, and two physiotherapists. Each group treatment session lasted 2.5 h per week for a period of 10 weeks. The women completed questionnaires and pain drawings four times during the treatment period from the beginning of the period till 15 months later. During 13 group treatment periods 53 women accomplished the treatment. Before the treatment the women had experienced pain for an average period of 5 years and 9 months (ranging from 6 months to 22 years). The women's descriptions of the changes derived from group treatment were analyzed according to the Grounded Theory Method. A methodical triangulation of quantitative and qualitative data as well as analyzes of the drawings were applied. One year after the end of the treatment, 39% of the women were pain-free. The average level of pain measured according to the Visual Analog Scale was reduced from 2.8 to 0.9 (p < 0.01). The intake rate of analgesics was reduced from an average of 8.5 units to 0.9 units per week (p < 0.01). Furthermore a reduction in the use of the National Health Service and increases in gainful employment were registered. By means of the Grounded Theory Analysis a model of the development process was elaborated. The process begins with the development of self-knowledge, followed by the woman assuming self responsibility for her own life and performing self-activeness. During the process the woman increases her feeling of self-control and personal mastery of her emotions. The women's pain drawings improved, resulting in more detailed drawings, the color intensity abating, the extent of pains declining, and the outlines blurring. In conclusion this kind of group treatment brings the women relief from their pain thus reducing the use of the National Health Service by women suffering from chronic pelvic pain. The women also experience a positive psychological development. This method of treatment, in which a synergetic combination of physical and psychological treatment mutually enhance the effect of the treatment, will probably have a beneficial impact on the treatment of other patients suffering from acute or chronic physical or psychological traumas or from chronic pains.

Age as a factor in admission to chronic pain rehabilitation

OBJECTIVE

To examine access to multidisciplinary pain rehabilitation programs for older patients.

DESIGN

Telephone and written surveys of pain programs accredited by Commission on Accreditation of Rehabilitation Facilities. Visual Analog Scale (VAS) ratings of patient vignettes in which older patients were alternatively assigned their true age or a younger age.

PARTICIPANTS

Health care professionals at pain programs.

MAIN OUTCOME MEASURES

Telephone survey of admission policies and treatment services. VAS ratings of patient vignettes.

RESULTS

No program excludes older pain patients by age. However, 28% of programs had admitted only the youngest old (< 70 years). Age-related criteria, such as presence of concurrent medical diagnoses that are more likely to exclude older patients, are common. In addition, VAS ratings of patient vignettes indicated an age bias: the same patients were rated as 14.8% less likely to be admitted (p < .001) and 12.5% less likely to succeed if admitted (p < .001) when their true, older age was given than when a false younger age was provided.

CONCLUSION

Pain program admission policies do not exclude older patients by age but frequently include age-related criteria that disproportionately exclude the elderly. There is also evidence of an age bias in which age per se reduces perceived suitability for pain program admission.

[Multidisciplinary treatment program for chronic low back pain, part 1. Overview]

A multimodal treatment program is presented in cases of functional restoration for chronic low back pain. The study comprises four parts. Part I gives an overview of the different results of the study. Part II focuses on the medical and functional examination in comparison with persons who do not suffer from back pain. Part III describes psychosocial aspects (depression, complaints, ways of coping, disability) and psychotherapy. In part IV prognostic factors and their reliability for predicting treatment outcome (return to work, pain intensity, self-assessment of success by patients) are examined. In addition the relevant effects of the program on social and health care systems are also addressed.

PROBLEM

The incidence of low back pain is continuously increasing, causing tremendous costs for the health insurance system. Therefore effective treatment methods are needed that take into account somatic, psychological and social factors. Chronic low back pain is conceptualized as a complex phenomenon including biological, social and psychological aspects, all of which should be addressed in a treatment program. A multimodal treatment program for chronic low back pain is presented, in which physical activity and cooperation of the patient are the primary targets. Therapeutic aims focus less on pain reduction and emphasize instead pain control, individual responsibility of the patient, and early reintegration into the working environment. The specific goals of the program are to increase the physical abilities of the patients (i. e., flexibility, strength and endurance), to increase patients' knowledge and the use of body mechanics and back protection techniques, to decrease medication-intake, to decrease dependency on the medical community, to improve patients' own positive coping skills and levels of emotional control, to increase the patient's activity level at home and to facilitate a return to work.

METHODS

A total of 90 disabled patients with chronic low back pain were admitted to an 8-week program of functional restoration and behavioral support. The program consisted of a pre-program (3 weeks: education, stretching and calisthenic exercises) and an intensive treatment period (aerobics, functional strength and endurance exercises, back exercises, cognitive behavioral group therapy, relaxation training, socioeconomic and vocational counseling) which took place for 5 weeks, 7 h a day, on an outpatient basis. Apart from a medical examination and a personal interview, the patients' physical impairment, pain descriptions, and psychological distress (according to different criteria for evaluation) were also measured. This includes variables such as depression, psychovegetative complaints, quality of life and workplace satisfaction, disability, and coping with disease. Measurements were repeated at the end of the 8-week program, and after 6 and 12 months.

RESULTS

In total 84 patients (94 %) were examined following treatment. There was a statistically significant improvement in flexibility, strength, lifting capacity, and endurance measurements ( p < 0.001) at the end of the treatment. In addition, significant reductions in pain, disability, depression, and psychovegetative signs were demonstrated ( p < 0.001). There was a decreased use of medical treatment for back pain following the program, with 42 % of the patients refraining from the intake of analgesics, followed by a significant reduction in physiotherapy and the consultation of physicians. Assessment of the patients' reported increased activity levels at home also supported findings that statistical improvements were significant. Sixty-three percent of the patients were found to have returned to active, productive work following discharge from the program. Most of the improvements remained stable at the 6- and 12-month follow-up examinations.

CONCLUSION

The results demonstrate the effectiveness of the multimodal program of functional restoration, not only concerning positive changes in somatic, psychological and physical variables, but also with respect to the number of patients who returned to work. Our methods are also compared with the discrepant results of multimodal treatment in the United States and Scandinavia.

Back school in a first episode of compensated acute low back pain: a clinical trial to assess efficacy and prevent relapse

OBJECTIVE

To assess the efficacy of a back school program for patients with a first episode of acute work-related low back pain requiring compensation.

DESIGN

A randomized single-blind controlled trial.

SETTING

A private physiatrics outpatient clinic.

PATIENTS

The mean duration of low back pain was 15 days.

INTERVENTION

Eligible patients were randomized to a standard treatment program that included daily physiotherapy (n = 86) or the same program with the addition of back school (n = 82). The back school program consisted of three 90-minute sessions given by a single trained instructor at 0, 1, and 8 weeks.

MAIN OUTCOME MEASURES

The primary outcomes were the time off work for the presenting episode of back pain and the number and duration of recurrences in the year following the study onset. Secondary outcomes included the level of pain, spinal mobility, active straight-leg raising, and functional disability assessed by the Oswestry and Roland-Morris scales.

RESULTS

Those randomized to the back school group gained significantly more knowledge, based on the multiple choice examination (p = .0001) and performed the exercise program significantly better (p = .0001) than the standard care group. There were no differences between the two treatment groups for either of the primary outcomes. The median time to return to work from randomization was 33 days for both the back school and the standard care groups (p = .48). The number of compensated recurrences of low back pain over 1 year was similar (back school = 14, standard care = 10, p = .16), as was the median duration of these episodes (back school = 25 days, standard care = 70 days, p = .21). There were no significant differences favoring the back school group for any of the secondary outcomes at the posttreatment, 6-month, or 12-month assessments.

CONCLUSION

A back school intervention in addition to standard care resulted in no reduction in the time to return to work or the number or duration of recurrences of low back pain requiring compensation over a period of one year.

Effects of a multimodal pain rehabilitation program: a pilot study

The purpose of this pilot study was to examine the effects of a multimodal pain rehabilitation program on pain perceptions, opioid usage, activity, down time, sleep, and role function status of 23 chronic pain patients. Data were collected at the start of the program, at the program's completion, and again during a follow-up period (3-11 months afterwards). At the end of the program, patients reported a significant reduction in pain levels, opioid usage, and hours of disturbed sleep. During the follow-up period, patients continued to report significant improvements in activity and role functions as well as significant reductions in opioid usage, sleep disturbance, and down time. These findings provided encouraging preliminary evidence that multimodal pain rehabilitation programs for chronic pain patients may be effective in pain management and functional restoration.

Cognitive-behavioural therapy versus EMG biofeedback in the treatment of chronic low back pain

Forty-four chronic, but relatively well functioning, low back pain patients were assigned to either Cognitive Behaviour Therapy (CBT). Electromyographic Biofeedback (EMGBF) or Wait List Control (WLC). Both treatments were conducted over eight sessions in groups of four subjects. Results at post-treatment indicated significant improvements in functioning on measures of pain intensity, perceived level of disability, adaptive beliefs about pain and the level of depression in both the CBT and EMGBF conditions. These improvements were not evident for the WLC condition. At 6 months follow-up, treatment gains were maintained in the areas of pain intensity, pain beliefs, and depression, for both treatment groups, with further improvements occurring in anxiety and use of active coping skills. No significant differences were found between CBT and EMGBF on any of the outcome measures at either post-treatment or at 6 months follow-up. Further research is required to determine the degree to which these results reflect the mild level of psychological impairment and disability status of patients in the present study.

The development of a battery of measures for assessing physical functioning of chronic pain patients

The physical performance of chronic pain patients is of major concern both for their assessment and for treatment evaluation. However, there are few widely used physical tests, a shortage of reliability and validity data on published tests, and an over-reliance on self-report or on clinical measures of dubious generalisability. A set of tests was designed to cover speed and endurance in walking, stair climbing, standing up from a chair, sit-ups, arm endurance, grip strength, and peak flow. Standard instructions and testing conditions were used by a trained tester on a population of chronic pain patients before and after a cognitive-behavioural chronic pain management programme. Reliability, validity, and acceptability of each test was examined, and recommendations made for their relative utility.

The role of psychological factors in chronic pain. I. A half century of study

This review examines a half century of thought about the role of psychological factors in chronic pain. Changing views are discussed, and representative examples of pain research based on psychoanalytic, behavioural, cognitive, and psychophysiological theories are presented and evaluated. The evolution of thought from linear causal models of pain to multicausal explanations provides a conceptual framework for discussion. Studies reviewed show that an earlier concept, based on simple formulations of psychological causation, has been replaced by more comprehensive explanations comprising both physical and psychological influences. Further methodological and conceptual problems are discussed in the second paper of this 2-part review.

Efficacy of multidisciplinary pain treatment centers: a meta-analytic review

Sixty-five studies that evaluated the efficacy of multidisciplinary treatments for chronic back pain were included in a meta-analysis. Within- and between-group effect sizes revealed that multidisciplinary treatments for chronic pain are superior to no treatment, waiting list, as well as single-discipline treatments such as medical treatment or physical therapy. Moreover, the effects appeared to be stable over time. The beneficial effects of multidisciplinary treatment were not limited to improvements in pain, mood and interference but also extended to behavioral variables such as return to work or use of the health care system. These results tend to support the efficacy of multidisciplinary pain treatment; however, these results must be interpreted cautiously as the quality of the study designs and study descriptions is marginal. Suggestions for improvement in research designs as well as appropriate reports of research completed are provided.

Multimodal treatment programmes for chronic pain: a quantitative analysis of existing research data

This article reviews the empirical data obtained in existing studies on the multimodal treatment of chronic pain. The majority of these 'treatment packages' are based on a cognitive/behavioural perspective. The articles for review were selected from the scientific literature on this subject which has appeared since the first publication of Fordyce in 1973. The following aspects have been analysed: the goal and structure of the treatment programmes; the method of evaluating treatment results; and the indications for treatment. Programmes for in-patients and out-patients have been compared because it is very likely that there are differences between the treatment methods and study populations. The interval validity and clinical relevance of the available research are discussed in the conclusion.

Comparison of cognitive-behavioral group treatment and an alternative non-psychological treatment for chronic low back pain

This study was designed to investigate the relative efficacy of cognitive-behavioral group treatment, including relaxation training, in comparison with a control condition in a sample of 20 outpatients with chronic low back pain. Subjects in both conditions also received the same physiotherapy back-education and exercise program. The control condition included a control for the attention of the therapist in the cognitive-behavioral treatment. The combined psychological treatment and physiotherapy condition displayed significantly greater improvement than the attention-control and physiotherapy condition at post-treatment on measures of other-rated functional impairment, use of active coping strategies, self-efficacy beliefs, and medication use. These differences were maintained at 6 month follow-up on use of active coping strategies and, to a lesser degree, on self-efficacy beliefs and other-rated functional impairment.

Operant-behavioural and cognitive-behavioural treatment for chronic low back pain

Fifty-eight outpatients with chronic low back pain were randomly allocated to one of six experimental conditions. Four conditions were designated as treatment conditions and two as control conditions. The four treatment groups consisted of: cognitive treatment (either with or without relaxation training) and behavioural treatment (either with or without relaxation training). The cognitive and behavioural groups also received physiotherapy. The two control conditions consisted of: attention (physiotherapy plus discussion sessions) and no-attention (physiotherapy-only) conditions. All conditions, including the two controls, received the same physiotherapy back-education and exercise program. For the sample as a whole, improvements were obtained on measures of affective distress, functional impairment, medication use, pain-related dysfunctional cognitions and use of active coping strategies. These improvements were generally maintained at 6- and 12-month follow-ups. The combined psychological/physiotherapy treatment conditions improved significantly more than the physiotherapy-only conditions from pre to posttreatment on measures of pain intensity, self-rated functional impairment and pain-related dysfunctional cognitions. However, these differences were only weakly maintained at 6- and 12-month follow-ups. The behavioural conditions improved significantly more than the cognitive conditions from pre to posttreatment on the self-rated measure of functional impairment, but this difference was not maintained at 6- and 12-month follow-ups. Progressive relaxation training was found to make little contribution to either cognitive or behavioural treatments.

A comparison of cognitive-behavioral and hypnotic treatments of chronic pain

Twenty-seven chronic pain patients were assigned to one of three treatment groups: hypnosis, cognitive-behavioral, and an attention control. Hypnosis and cognitive-behavioral treatments were identical with the exception of the hypnotic induction. Scores on the McGill Pain Questionnaire (MPQ) and the Activity Log (Fordyce, 1976) were collected at pretreatment, posttreatment, and follow-up intervals. Analyses of changes showed significant increases in activity and decreases in pain intensity for the cognitive-behavioral treatment. Changes for the hypnosis treatment were noted only on the MPQ. Changes for both groups were sustained on the 1-month follow-up. Results of ANCOVAs showed that the cognitive-behavioral treatment resulted in significantly lower pain rating scores than those in the control treatment, but no significant differences were observed between the behavior and hypnosis groups. Findings support the superiority of the cognitive-behavioral treatment on behavior measures and equivalence to hypnosis on subjective measures.

Educational needs of health professionals in the treatment of chronic low back pain

Behaviour Therapy is not used to a great extent in the physiotherapy management of chronic low back pain; yet the clinical research literature indicates that behavioural techniques may assist the maintenance of treatment gains. Two questionnaires were devised for hospital-based physiotherapy graduates to assess knowledge of behaviour therapy techniques and their relevance to physiotherapy management of the patient with chronic low back pain. Third-year undergraduate physiotherapy students who had just completed their Behaviour Therapy course at Cumberland College of Health Sciences, constituted the comparison group. Results showed that the graduates and physiotherapy students had comparable levels of knowledge. Both groups believed that the physiotherapist's use of behaviour therapy techniques was primarily for the purposes of improving the patient's daily activity and muscular state. Physiotherapy training for the management of this difficult patient group is discussed.

Treating chronic low back pain. I. Admissions to initial follow-up

For a normative study of chronic low back pain (CLBP), 702 consecutive admissions to a large multidisciplinary CLBP treatment program were assessed at admission, discharge, and 1-month follow-up, using a variety of psychological and functional performance instruments. Both univariate and multivariate approaches to appraising success are evaluated. Psychological profiles demonstrated a substantial degree of disability at admissions, which is significantly reduced at follow-up. Both behavioral and cognitive aspects of performance, as evidenced by objective assessments of patients' physical abilities and verbalizations, improved as a direct function of length of stay in the treatment program and continued to show modest improvement through follow-up. Composite indices of improvement demonstrated favorable outcomes for no less than four in every ten, and as high as nine in every ten participants. Because of the large sample size, relationships both within and across measurement domains can be assessed statistically: the separate sets of outcome measures, with the exception of psychological profiles, are generally independent of each other.

Comprehensive assessment of chronic low back pain patients and controls: physical abilities, level of activity, psychological adjustment and pain perception

A comprehensive functional evaluation designed for patients with chronic low back pain (CLBP) is described. The evaluation includes measures from 4 domains of the CLBP syndrome; physical abilities, level of activity, psychological adjustment and pain perception. New measures for standardized assessment of physical abilities and employment of body mechanics are introduced. Evaluation data from 68 CLBP subjects and 35 age-matched, pain-free, controls is presented. Results indicate important deficits in physical abilities and psychological adjustment for the CLBP group compared to the controls. Factor analysis of the evaluation measures yielded a general conditioning factor and a general psychological adjustment factor but complicated factor structures for report of pain and time in activities. Further analysis demonstrated a strong relationship between objective disability and psychological and psychosocial adjustment but little relationship between level of pain and other disability measures.