title: Physical activity within a CBT intervention improves coping with pain in traumatized refugees: results of a randomized controlled design.
abstract: OBJECTIVE
  Many traumatized refugees experience both posttraumatic stress disorder and chronic pain. Based on Mutual Maintenance Theory and the Perpetual Avoidance Model, this study examined the additional effect of physical activity within a biofeedback-based cognitive behavioral therapy (CBT-BF) for traumatized refugees.
  
  
  METHODS
  In a controlled design, 36 patients were randomized into one of three conditions (CBT-BF, CBT-BF with physical activity [CBT-BF+active], and a waiting list control group [WL]). Thirty patients (n=10 in each group) completed the treatment and a follow-up assessment 3 months later. Participants' coping strategies, pain and mental health status, and physiological reactivity were assessed before and after the intervention and at 3-month follow-up. Treatment effects were analyzed using analyses of variance with baseline scores as covariates (ANCOVAs) and the Reliable Change Index.
  
  
  RESULTS
  The CBT-BF and CBT-BF+active groups showed improvements in all outcome measures relative to the WL group. The effect sizes for the main outcome measures were higher in the CBT-BF+active group than in the CBT-BF group. Repeated measures analyses of covariance showed significant group effects for coping strategies--in particular, for the "cognitive restructuring" and "counter-activities" subscales as well as a marginally significant group effect for "perceived self-competence"--with the CBT-BF+active group showing more favorable outcomes than the CBT-BF group. Moreover, 60% of participants in the CBT-BF+active group showed clinically reliable intraindividual change in at least one subscale of the pain coping strategies questionnaire, compared with just 30% of participants in the CBT-BF group.
  
  
  CONCLUSIONS
  Findings of improved coping strategies, larger effect sizes, and higher rates of clinical improvement in the CBT-BF+active group suggest that physical activity adds value to pain management interventions for traumatized refugees. Given the small sample size, however, these preliminary results need replication in a larger trial.
authors.affiliation: Treatment Center for Torture Victims Berlin, Berlin, Germany. a.liedl@bzfo.de
authors.forename: Alexandra
authors.initials: A
authors.lastname: Liedl
authors.forename: Julia
authors.initials: J
authors.lastname: Müller
authors.forename: Naser
authors.initials: N
authors.lastname: Morina
authors.forename: Anke
authors.initials: A
authors.lastname: Karl
authors.forename: Claudia
authors.initials: C
authors.lastname: Denke
authors.forename: Christine
authors.initials: C
authors.lastname: Knaevelsrud
mesh_terms: D000328:Adult; D015928:Cognitive Behavioral Therapy / Q000379:methods*; D004576:Electromyography; D005260:Female; D006801:Humans; D008297:Male; D009043:Motor Activity; D017063:Outcome Assessment, Health Care; D010146:Pain / Q000523:psychology*; D059408:Pain Management; D012036:Refugees / Q000523:psychology*; D013313:Stress Disorders, Post-Traumatic / Q000523:psychology* / Q000628:therapy*; D011795:Surveys and Questionnaires; D016896:Treatment Outcome