Comparison of graded exercise and graded exposure clinical outcomes for patients with chronic low back pain.
METHODS
Quasi-experimental clinical trial.


OBJECTIVE
This study compared outcomes from graded exercise and graded exposure activity prescriptions for patients participating in a multidisciplinary rehabilitation program for chronic low back pain. Our primary purpose was to investigate whether pain and disability outcomes differed based on treatment received (graded exercise or graded exposure). Our secondary purpose was to investigate if changes in selected psychological factors were associated with pain and disability outcomes.


BACKGROUND
Behavioral interventions have been advocated for decreasing pain and disability from low back pain, yet relatively few comparative studies have been reported in the literature.


METHODS
Consecutive sample with chronic low back pain recruited over a 16-month period from an outpatient chronic pain clinic. Patients received physical therapy supplemented with either graded exercise (n=15) or graded exposure (n=18) principles. Graded exercise included general therapeutic activities and was progressed with a quota-based system. Graded exposure included specific activities that were feared due to back pain and was progressed with a hierarchical exposure paradigm. Psychological measures were pain-related fear (Fear-Avoidance Beliefs Questionnaire, Tampa Scale for Kinesiophobia, Fear of Pain Questionnaire), pain catastrophizing (Coping Strategies Questionnaire), and depressive symptoms (Beck Depression Inventory). Primary outcome measures were pain intensity (visual analog scale) and self-report of disability (modified Oswestry Disability Questionnaire).


RESULTS
Statistically significant improvements (P<.01) were observed for pain intensity and disability at discharge. The rate of improvement did not differ based on behavioral intervention received (P>.05 for these comparisons). Overall, 50% of patients met criterion for minimally important change for pain intensity, while 30% met this criterion for disability. Change in depressive symptoms was associated with change in pain intensity, while change in pain catastrophizing was associated with change in disability.


CONCLUSIONS
Physical therapy supplemented with graded exercise or graded exposure resulted in equivalent clinical outcomes for pain intensity and disability. The overall treatment effects were modest in this setting. Instead of being associated with a specific behavioral intervention, reductions in pain and disability were associated with reductions in depressive symptoms and pain catastrophizing, respectively.


METHODS
Therapy, level 2b–.
George
Steven Z
SZ
Center for Pain Research and Behavioral Health, Department of Physical Therapy, University of Florida, Gainesville, FL 32611-0154, USA. szgeorge@phhp.ufl.edu
Wittmer
Virgil T
VT
Fillingim
Roger B
RB
Robinson
Michael E
ME
D000203:Activities of Daily Living; D000223:Adaptation, Psychological; D000293:Adolescent; D000328:Adult; D000368:Aged; D000704:Analysis of Variance; D002908:Chronic Disease; D003863:Depression / Q000523:psychology; D004185:Disability Evaluation; D005081:Exercise Therapy / Q000379:methods*; D005239:Fear / Q000523:psychology; D005260:Female; D006801:Humans; D017116:Low Back Pain / Q000503:physiopathology / Q000523:psychology* / Q000534:rehabilitation*; D008297:Male; D008875:Middle Aged; D010147:Pain Measurement; D026741:Physical Therapy Modalities; D020127:Recovery of Function; D011795:Surveys and Questionnaires; D016896:Treatment Outcome