Secondary prevention of work-related disability in nonspecific low back pain: does problem-solving therapy help? A randomized clinical trial. Operant-behavioural and cognitive-behavioural treatment for chronic low back pain. Comparison of group progressive-relaxation training and cognitive-behavioral group therapy for chronic low back pain. A randomised controlled study of reflexology for the management of chronic low back pain. Comparison of operant behavioral and cognitive-behavioral group treatment for chronic low back pain. Randomised controlled trial to compare surgical stabilisation of the lumbar spine with an intensive rehabilitation programme for patients with chronic low back pain: the MRC spine stabilisation trial. Incorporation of cognitive-behavioral treatment into the medical care of chronic low back patients: a controlled randomized study in German pain treatment centers. Active exercise, education, and cognitive behavioral therapy for persistent disabling low back pain: a randomized controlled trial. Chronic low back pain rehabilitation programs: a study of the optimum duration of treatment and a comparison of group and individual therapy. Randomized clinical trial of lumbar instrumented fusion and cognitive intervention and exercises in patients with chronic low back pain and disc degeneration. Health economic assessment of behavioural rehabilitation in chronic low back pain: a randomised clinical trial. Comparison of cognitive-behavioral group treatment and an alternative non-psychological treatment for chronic low back pain. The effectiveness of psychological interventions for the rehabilitation of low back pain: a randomized controlled trial evaluation. A controlled evaluation of paraspinal EMG biofeedback in the treatment of chronic low back pain. Exposure in vivo versus operant graded activity in chronic low back pain patients: results of a randomized controlled trial. Intensive group training protocol versus guideline physiotherapy for patients with chronic low back pain: a randomised controlled trial. A randomized controlled trial of exposure in vivo for patients with spinal pain reporting fear of work-related activities. Effectiveness and cost-effectiveness of adding a cognitive behavioral treatment to the rehabilitation of chronic low back pain. Effectiveness of behavioral therapy for chronic low back pain: a component analysis. EMG biofeedback used to reduce standing levels of paraspinal muscle tension in chronic low back pain. A trial of an activating intervention for chronic back pain in primary care and physical therapy settings. Combined exercise and motivation program: effect on the compliance and level of disability of patients with chronic low back pain: a randomized controlled trial. The secondary prevention of low back pain: a controlled study with follow-up. EMG biofeedback training, relaxation training, and placebo for the relief of chronic back pain. Hypnosis compared to relaxation in the outpatient management of chronic low back pain. Cognitive-behavioural therapy versus EMG biofeedback in the treatment of chronic low back pain.
Given the individual and economic burden of chronic work disability in low back pain patients, there is a need for effective preventive interventions. The aim of the present study was to investigate whether problem-solving therapy had a supplemental value when added to behavioral graded activity, regarding days of sick leave and work status.
                Randomized controlled trial.
                Employees who were recently on sick leave as a result of nonspecific low back pain were referred to the rehabilitation center by general practitioner, occupational physician, or rehabilitation physician. Forty-five employees had been randomly assigned to the experimental treatment condition that included behavioral graded activity and problem-solving therapy (GAPS), and 39 employees had been randomly assigned to behavioral graded activity and group education (GAGE).
                Days of sick leave and work status. Data were retrieved from occupational health services.
                Data analyses showed that employees in the GAPS group had significantly fewer days of sick leave in the second half-year after the intervention. Moreover, work status was more favorable for employees in this condition, in that more employees had a 100% return-to-work and fewer patients ended up receiving disability pensions one year after the intervention. Sensitivity analyses confirmed these results.
                The addition of problem-solving therapy to behavioral graded activity had supplemental value in employees with nonspecific 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. nan The use of complementary and alternative medicine (CAM) for the management of chronic low back pain (CLBP) continues to rise. However, questions regarding the efficacy of many CAM therapies for CLBP remain unresolved. The present study investigated the effectiveness of reflexology for CLBP. A pragmatic randomised controlled trial was conducted. N=243 patients were randomised to one of three groups: reflexology, relaxation, or non-intervention (usual care). All completed a questionnaire booklet before and after the treatment phase, and at six months follow up. This measured their general health status, pain, functioning, coping strategies and mood. After adjusting for pre-treatment scores repeated measures ANCOVA found no significant differences between the groups pre and post treatment on the primary outcome measures of pain and functioning. There was a main effect of pain reduction, irrespective of group. Trends in the data illustrated the pain reduction was greatest in the reflexology group. Thus, the current study does not indicate that adding reflexology to usual GP care for the management of CLBP is any more effective than usual GP care alone. nan To assess the clinical effectiveness of surgical stabilisation (spinal fusion) compared with intensive rehabilitation for patients with chronic low back pain.
                Multicentre randomised controlled trial.
                15 secondary care orthopaedic and rehabilitation centres across the United Kingdom.
                349 participants aged 18-55 with chronic low back pain of at least one year's duration who were considered candidates for spinal fusion.
                Lumbar spine fusion or an intensive rehabilitation programme based on principles of cognitive behaviour therapy.
                The primary outcomes were the Oswestry disability index and the shuttle walking test measured at baseline and two years after randomisation. The SF-36 instrument was used as a secondary outcome measure.
                176 participants were assigned to surgery and 173 to rehabilitation. 284 (81%) provided follow-up data at 24 months. The mean Oswestry disability index changed favourably from 46.5 (SD 14.6) to 34.0 (SD 21.1) in the surgery group and from 44.8 (SD14.8) to 36.1 (SD 20.6) in the rehabilitation group. The estimated mean difference between the groups was -4.1 (95% confidence interval -8.1 to -0.1, P = 0.045) in favour of surgery. No significant differences between the treatment groups were observed in the shuttle walking test or any of the other outcome measures.
                Both groups reported reductions in disability during two years of follow-up, possibly unrelated to the interventions. The statistical difference between treatment groups in one of the two primary outcome measures was marginal and only just reached the predefined minimal clinical difference, and the potential risk and additional cost of surgery also need to be considered. No clear evidence emerged that primary spinal fusion surgery was any more beneficial than intensive rehabilitation. Cognitive behavioral treatment has been incorporated into standard medical treatment procedures in German pain centers. Acceptance of the treatment by patients and outcome in terms of pain, coping, and disability was investigated. Components of the psychological treatment are education, relaxation and imagery, modifying thoughts and feelings, enhancement of pleasant activities, and training of good postural habits. The program was conducted in a group setting in accordance with a treatment manual and consists of 12 weekly 2.5-h sessions. A two-factor experiment with repeated measures on one factor was applied. Ninety-four consecutive patients with low-back pain were randomly assigned to an experimental group having a combined medical and cognitive-behavioral treatment, or to a control group with medical treatment only. Assessments were taken pre-treatment, post-treatment, and--in the treated group only--at a 6-months follow-up. At each assessment, patients kept a pain diary over a period of 4 weeks, and filled in self-report questionnaires. The sample consisted of 36 experimental and 40 control subjects at post-treatment. Experimental subjects reported less pain, better control over pain, more pleasurable activities and feelings, less avoidance and less catastrophizing. In addition, disability was reduced in terms of social roles, physical functions and mental performance. The results were maintained at follow-up. Patients who only received medical treatment showed little improvement. Data indicate that the program meets the needs of the patients and should be continued. A randomized controlled trial.
                To determine 1) whether, among patients with persistent disabling low back pain (LBP), a group program of exercise and education using a cognitive behavioral therapy (CBT) approach, reduces pain and disability over a subsequent 12-month period; 2) the cost-effectiveness of the intervention; and 3) whether a priori preference for type of treatment influences outcome.
                There is evidence that both exercise and CBT delivered in specialist settings is effective in improving LBP. There is a lack of evidence on whether such interventions, delivered by trained individuals in primary care, result in improved outcomes.
                The study was conducted in nine family medical practices in East Cheshire, UK. Patients 18 to 65 years of age, consulting with LBP, were recruited; those still reporting LBP 3 months after the initial consultation were randomized between the two trial arms. The intervention arm received a program of eight 2-hour group exercise session over 6 weeks comprising active exercise and education delivered by physiotherapists using a CBT approach. Both arms received an educational booklet and audio-cassette. The primary outcome measures were pain (0-100 Visual Analogue Scale) and disability (Roland and Morris Disability Scale; score 0-24).
                A total of 196 subjects (84%) completed follow-up 12 months after the completion of the intervention program. The intervention showed only a small and nonsignificant effect at reducing pain (-3.6 mm; 95% confidence interval, -8.5, 1.2 mm) and disability (-0.6 score; 95% confidence interval, -1.6, 0.4). The cost of the intervention was low with an incremental cost-effectiveness ratio of pound5000 (U.S. $8650) per quality adjusted life year. In addition, patients allocated to the intervention that had expressed a preference for it had clinically important reductions in pain and disability.
                This intervention program produces only modest effects in reducing LBP and disability over a 1-year period. The observation that patient preference for treatment influences outcome warrants further investigation. Eighty-four patients with chronic low back pain were treated using cognitive behavioral principles on a pain management program. Outcome data were collected at four points: 10 weeks before treatment, immediately before and immediately after treatment, and 6 months after treatment. In part 1 of the study, patients were assigned randomly to group or individual treatment contexts. In part 2 of the study, patients were assigned randomly to programs of 15, 30, or 60 hours duration.
                To identify the differences in outcome between programs that treated patients as part of a group and those that treated patients individually and the effects of duration of treatment on outcome.
                Cognitive behavioral programs have been shown to be an effective means of managing chronic low back pain. The literature is concerned with group programs, however, the duration of which vary widely.
                Psychological and functional variables were measured before and after treatment and at the 6-month follow-up visit. Changes in these variables were measured, and comparisons were made between group and individual programs and between 15-, 30-, and 60-hour programs.
                Data analysis showed a significant, beneficial effect of intervention in terms of the majority of variables; however, these changes were generally independent of whether patients were treated as part of a group or individually and whether patients completed a 15-, 30-, or 60-hour program.
                Cognitive behavioral rehabilitation programs have been demonstrated to be an effective means of reducing psychological distress, of changing cognition, and of improving the function of patients with chronic low back pain; however, the length of program and whether patients were treated individually or as part of a group did not affect outcome. This finding has clinical and economic implications. Single blind randomized study.
                To compare the effectiveness of lumbar instrumented fusion with cognitive intervention and exercises in patients with chronic low back pain and disc degeneration.
                To the authors' best knowledge, only one randomized study has evaluated the effectiveness of lumbar fusion. The Swedish Lumbar Spine Study reported that lumbar fusion was better than continuing physiotherapy and care by the family physician.
                Sixty-four patients aged 25-60 years with low back pain lasting longer than 1 year and evidence of disc degeneration at L4-L5 and/or L5-S1 at radiographic examination were randomized to either lumbar fusion with posterior transpedicular screws and postoperative physiotherapy, or cognitive intervention and exercises. The cognitive intervention consisted of a lecture to give the patient an understanding that ordinary physical activity would not harm the disc and a recommendation to use the back and bend it. This was reinforced by three daily physical exercise sessions for 3 weeks. The main outcome measure was the Oswestry Disability Index.
                At the 1-year follow-up visit, 97% of the patients, including 6 patients who had either not attended treatment or changed groups, were examined. The Oswestry Disability Index was significantly reduced from 41 to 26 after surgery, compared with 42 to 30 after cognitive intervention and exercises. The mean difference between groups was 2.3 (-6.7 to 11.4) (P = 0.33). Improvements inback pain, use of analgesics, emotional distress, life satisfaction, and return to work were not different. Fear-avoidance beliefs and fingertip-floor distance were reduced more after nonoperative treatment, and lower limb pain was reduced more after surgery. The success rate according to an independent observer was 70% after surgery and 76% after cognitive intervention and exercises. The early complication rate in the surgical group was 18%.
                The main outcome measure showed equal improvement in patients with chronic low back pain and disc degeneration randomized to cognitive intervention and exercises, or lumbar fusion. The aim of this cost-effectiveness study was to compare a combined operant programme plus cognitive/relaxation programme with an operant programme plus attention-control and to compare both programmes with a waiting-list control group and with operant rehabilitation provided, as usual, by the same rehabilitation centre. One hundred and forty eight patients with chronic low back pain were randomly assigned to the different conditions. The economic endpoints were the costs of the programme and other health care utilisation, costs for the patient, and indirect costs associated with production losses due to low back pain. The effects were measured in terms of global assessment of change and utilities, using rating scale and standard gamble methods. The 3-year study determined that adding a cognitive component to an operant treatment did not lead to significant differences in costs and improvement in quality of life when compared with the operant treatment alone. Compared with the common individual rehabilitation therapy it can be concluded that the same effects can be reached at the same or lower costs with a shorter, more intense standardised group programme. The operant treatment alone is more effective than providing no treatment in the waiting-list control group. 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. Forty-five low back pain patients were randomly assigned to either a standard inpatient rehabilitation program or the standard program with additional psychological components. The standard program emphasized education, support, and physical reconditioning through exercise. Patients receiving the psychological program were given additional training in relaxation and other coping skills and received contingent reinforcement for exercise. Both programs included reduction of medication intake and an emphasis on family involvement after discharge. Measures of functional status were taken prior to the program, at discharge from the 3-week inpatient program, and at a 6-month follow-up appointment. These data revealed that patients improved their overall functioning at discharge and maintained these gains at the follow-up assessment. A similar pattern of findings was obtained for self-reported pain and interference. Furthermore, 81% of the patients had returned to work or were engaged in active job retraining by the follow-up. Using a conservative measure of full-time return to the same or an equivalent job, 57% were employed by the follow-up. Patient improvement, however, was not differentially affected by treatment group assignment, suggesting that the psychological treatment failed to add to the effectiveness obtained by the standard rehabilitation program. Results are discussed in the context of improving patient outcomes from rehabilitation for low back pain. Sixty-six chronic low back pain sufferers were randomly divided into three groups. Following individual assessments consisting of psychological questionnaires, pain monitoring, and measurement of paraspinal electromyogram (EMG), one group received paraspinal EMG biofeedback and another a placebo treatment. The third group received no intervention. Two further assessments were carried out on all groups immediately after treatment and at a 3-month follow-up. All groups showed significant reduction in pain, anxiety, depression, and paraspinal EMG following treatment and at follow-up, but there were no differences between groups. A regression analysis failed to identify subjects' characteristics that predicted positive outcome in the biofeedback group. However, high scores on the Evaluative scale of the McGill Pain Questionnaire and high hypnotizability were significant predictors of positive outcome for the placebo group. It is concluded that paraspinal EMG biofeedback is not a specific treatment for chronic low back pain in a nonhospitalized population. Since pain-related fear may contribute to the development and maintenance of chronic low back pain (CLBP), an exposure in vivo treatment (EXP) was developed for CLBP patients. We examined the effectiveness as well as specific mediating mechanisms of EXP versus operant graded activity (GA) directly and 6 months post-treatment in a multi-centre randomized controlled trial. In total, 85 patients suffering from disabling non-specific CLBP reporting at least moderate pain-related fear were randomly allocated to EXP or GA. It was demonstrated that EXP, despite excelling in diminishing pain catastrophizing and perceived harmfulness of activities, was equally effective as GA in improving functional disability and main complaints, although the group difference almost reached statistical significance favouring EXP. Both treatment conditions did not differ in pain intensity and daily activity levels either. Nor was EXP superior to GA in the subgroup of highly fearful patients. Irrespective of treatment, approximately half the patients reported clinically relevant improvements in main complaints and functional disability, although for the latter outcome the group difference was almost significant favouring EXP. Furthermore, the effect of EXP relative to GA on functional disability and main complaints was mediated by decreases in catastrophizing and perceived harmfulness of activities. In sum, this study demonstrates that up to 6 months after treatment EXP is an effective treatment, but not more effective than GA, in moderately to highly fearful CLBP patients, although its superiority in altering pain catastrophizing and perceived harmfulness of activities is clearly established. Possible explanations for these findings are discussed. Intensive group training using principles of graded activity has been proven to be effective in occupational care for workers with chronic low back pain. Objective of the study was to compare the effects of an intensive group training protocol aimed at returning to normal daily activities and guideline physiotherapy for primary care patients with non-specific chronic low back pain. The study was designed as pragmatic randomised controlled trial with a setup of 105 primary care physiotherapists in 49 practices and 114 patients with non-specific low back pain of more than 12 weeks duration participated in the study. In the intensive group training protocol exercise therapy, back school and operant-conditioning behavioural principles are combined. Patients were treated during 10 individual sessions along 20 group sessions. Usual care consisted of physiotherapy according to the Dutch guidelines for Low Back Pain. Main outcome measures were functional disability (Roland Morris disability questionnaire), pain intensity, perceived recovery and sick leave because of low back pain assessed at baseline and after 6, 13, 26 and 52 weeks. Both an intention-to-treat analysis and a per-protocol analysis were performed. Multilevel analysis did not show significant differences between both treatment groups on any outcome measures during the complete follow-up period, with one exception. After 26 weeks the protocol group showed more reduction in pain intensity than the guideline group, but this difference was absent after 52 weeks. We finally conclude that an intensive group training protocol was not more effective than usual physiotherapy for chronic low back pain. Pain-related fear is related to disability in persistent pain conditions. Exposure treatment has been reported to be of great benefit in replicated single case experiments.
                To evaluate the effects of exposure in vivo on fear and function in patients with persistent pain and work disability.
                We recruited 46 patients suffering from long-term back pain and reduced function, who also were deemed fearful according to standardized measures. Participants were randomized into either an exposure plus usual treatment or waiting list control plus usual treatment group. After the waiting period the control group crossed over and received the exposure treatment.
                Between group comparisons showed a significantly better result for the exposure group on function, but not for fear or pain and effect sizes were modest (function=.6; fear=.4; pain=.1). When the control group crossed over to treatment significant treatment effects were noted for fear and function. For all patients treated, the pre to post-treatment effect sizes were large (function=.7; fear=1.1; pain=.9). There were 12 dropouts (8 in exposure and 4 in the control) during the first treatment phase and an additional 4 when the control group crossed over to exposure.
                Compared to a group receiving usual treatment and waiting for exposure, the exposure in vivo group demonstrated a significantly larger improvement on function. Overall exposure had moderate effects on function, fear and pain intensity. We conclude that exposure may be important in treatment, but is not recommended as a "stand alone" adjunct to usual treatment. To investigate return to work and cost-effectiveness of the addition of cognitive-behavioral treatment to standard therapy compared to standard 3-week inpatient rehabilitation for patients with chronic low back pain.
                A prospective economic evaluation alongside a randomized controlled trial was performed. Outcomes included days off work due to spinal complaints, health-related quality of life, and direct and indirect disease-related costs.
                A total of 409 patients with chronic low back pain, who were admitted to a 3-week inpatient rehabilitation, were randomly assigned to usual care or usual care plus cognitive behavioral treatment. Average incremental costs for psychological treatment during rehabilitation were Euros 127 (95% CI 125.6, 130.9; p < 0.001). Six months after rehabilitation, patients in the intervention group were absent from work an average of 5.4 (95% CI -1.4, 12.1; p = 0.12) days less than patients receiving usual treatment. Between groups, there were no significant differences in quality-adjusted life-years gained or in direct medical or nonmedical costs. The cognitive behavioral treatment showed lower indirect costs: Euros 751 (95% CI -145, 1641; p = 0.097).
                Adding a cognitive behavioral component to standard therapy may reduce work days lost and thus decrease indirect costs. From a societal perspective, the cost of the psychological treatment was compensated by lower indirect costs. The effects of outpatient group behavioral therapy including aerobic exercise (BE), behavioral therapy only (B), and aerobic exercise only (E) on pain and physical and psychosocial disability were evaluated and compared in a group of mildly disabled chronic low-back-pain patients. Ninety-six Ss were randomly assigned to the 3 treatments and a waiting-list control (WL) condition and assessed on a variety of patient self-report, spouse-rated, and direct observational measures at pretreatment, posttreatment, and 6- and 12-month follow-ups. Patients in the BE condition, but not the B or E conditions, improved significantly more pretreatment to posttreatment than did WL patients on the patient self-report and observer-rated measures. At both follow-ups, all 3 treatment groups remained significantly improved from pretreatment, with no significant differences among treatments. Twenty chronic low back pain (LBP) patients with relatively high standing paraspinal EMG levels (greater than 5 microV) were randomly assigned to 2 groups. One group (N = 10) received EMG biofeedback training to reduce standing paraspinal EMG levels, the other group (N = 10) served as a waiting list control group. Changes in perceived pain (duration X intensity) and paraspinal EMG in standing position were measured at a 3 week pretreatment baseline, during the 3 week treatment period, and at a 3 week post-treatment baseline. Compared to patients in the waiting list control group, those who received EMG biofeedback showed a significant decrease in standing paraspinal EMG from pretreatment to post-treatment baseline. However, no significant differences in reported pain were found during these periods. It is concluded that reduction of standing paraspinal EMG does not lead to reduction in pain. In primary care and physical therapy settings, we evaluated an intervention for chronic back pain patients which incorporated fear reducing and activating techniques. Primary care patients seen for back pain in primary care were screened to identify persons with significant activity limitations 8-10 weeks after their visit. Eligible and willing patients were randomized (N=240). A brief, individualized program to reduce fear and increase activity levels was delivered by a psychologist and physical therapists. Over a 2 year follow-up period, intervention patients reported greater reductions in pain-related fear (P<0.01), average pain (P<0.01) and activity limitations due to back pain (P<0.01) relative to control patients. The percent with greater than a one-third reduction in Roland Disability Questionnaire scores at 6 months was 42% among Intervention patients and 24% among control patients (P<0.01). Over the 2 year follow-up, fewer intervention patients reported 30 or more days unable to carry out usual activities in the prior 3 months (P<0.01). The adjusted mean difference in activity limitation days was 4.5 days at 6 months, 2.8 days at 12 months, and 6.9 days at 24 months. No differences were observed in the percent unemployed or the percent receiving worker's compensation or disability benefits, but these outcomes were relatively uncommon. We conclude that an intervention integrating fear reducing and activating interventions into care for chronic back pain patients produced sustained reductions in patient fears, common activity limitations related to back pain, and days missed from usual activities due to back pain. To assess the effect of a combined exercise and motivation program on the compliance and level of disability of patients with chronic and recurrent low back pain.
                A double-blind prospective randomized controlled trial.
                Physical therapy outpatient department, tertiary care.
                Ninety-three low back pain patients were randomly assigned to either a standard exercise program (n = 49) or a combined exercise and motivation program (n = 44).
                Patients were prescribed 10 physical therapy sessions and were advised to continue exercising after treatment termination. The motivation program consisted of five compliance-enhancing interventions. Follow-up assessments were performed at 3 1/2 weeks, 4 months, and 12 months.
                Disability (low back outcome score), pain intensity, physical impairment (modified Waddell score, fingertip-to-floor distance, abdominal muscle strength), working ability, motivation, and compliance.
                The patients in the motivation group were significantly more likely to attend their exercise therapy appointments (p = .0005). Four and 12 months after study entry there was a significant difference in favor of the motivation group with regard to the disability score (p = .004) and pain intensity (p < or = .026). At 4 months, there was a significant advantage for the motivation group in the fingertip-to-floor distance (p = .01) and in abdominal muscle strength (p = .018). No significant differences were found in motivation scores, self-reported compliance with long-term exercise, and modified Waddell score. In terms of working ability, there was a trend favoring the combined exercise and motivation program.
                The combined exercise and motivation program increased the rate of attendance at scheduled physical therapy sessions, ie, short-term compliance, and reduced disability and pain levels by the 12-month follow-up. However, there was no difference between the motivation and control groups with regard to long-term exercise compliance. The current investigation studied the effectiveness of a secondary prevention program for nurses with back pain who were deemed at risk for developing a chronic problem. A 2 X 3 repeated measures design was employed with 2 groups and 3 assessment periods. The treatment group received an intervention designed to reduce current problems, but above all to prevent reinjury and minor pains from becoming chronic medical problems, and it included a physical and behavioral therapy package. The control group was placed on a waiting-list. Results indicated that the treatment group had significantly greater improvements than the control group for pain intensity, anxiety, sleep quality and fatigue ratings, observed pain behavior, activities, mood, and helplessness. These differences were generally maintained at the 6 month follow-up. In addition, the treatment group broke a trend for increasing amounts of pain-related absenteeism, while the control group did not. Taken as a whole, the results suggest that a secondary prevention program aimed at altering life style factors may represent an effective method for dealing with musculoskeletal pain problems. 24 patients with chronic low back pain were randomly assigned to three treatment conditions: EMG biofeedback, relaxation training, and a placebo condition. Patients were seen for eight sessions and were evaluated before Session 1 and after Session 8. Eight analyses of covariance which were adjusted for age and pretest scores were computed on the final scores to find which variables could detect significant difference between treatments. Age was included as a covariate because the differences in age between conditions were significant. Four variables with significant and nearly significant differences were chosen for analysis. The second set of analyses identified the nature of the differences among the three conditions. These included a priori planned comparisons among conditions, and paired t tests. Relaxation-trained subjects were significantly superior to subjects in the placebo condition, in decreasing pain during the function test, increasing relaxation, and decreasing Upper Trapezius EMG. They were superior to EMG Biofeedback training in increasing reported activity. Both Relaxation and EMG trained subjects were able to reduce Upper Trapezius EMG by Session 8. Relaxation-trained subjects showed significant change on eight of the 14 possible comparisons for each treatment condition. EMG biofeedback training showed significant favorable results in only one condition; the placebo condition showed no significant results. Relaxation training gave better results in reducing EMG and pain, and in increasing relaxation and activity than either EMG biofeedback alone or a placebo condition. Chronic low back pain (CLBP) presents a problem of massive dimensions. While inpatient approaches have been evaluated, outpatient treatment programs have received relatively little examination. Hypnosis and relaxation are two powerful techniques amenable to outpatient use. Seventeen outpatient subjects suffering from CLBP were assigned to either Self-Hypnosis (n = 9) or Relaxation (n = 8) treatments. Following pretreatment assessment, all subjects attended a single placebo session in which they received minimal EMG feedback. One week later the subjects began eight individual weekly treatment sessions. Subjects were assessed on a number of dependent variables at pretreatment, following the placebo phase, one week after the completion of treatment, and three months after treatment ended. Subjects in both groups showed significant decrements in such measures as average pain rating, pain as measured by derivations from the McGill Pain Questionnaire, level of depression, and length of pain analog line. Self-Hypnosis subjects reported less time to sleep onset, and physicians rated their use of medication as less problematic after treatment. While both treatments were effective, neither proved superior to the other. The placebo treatment produced nonsignificant improvement. 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.
For patients with CLBP, there is moderate quality evidence that in the short-term, operant therapy is more effective than waiting list and behavioural therapy is more effective than usual care for pain relief, but no specific type of behavioural therapy is more effective than another. In the intermediate- to long-term, there is little or no difference between behavioural therapy and group exercises for pain or depressive symptoms. Further research is likely to have an important impact on our confidence in the estimates of effect and may change the estimates.