title: Graded Exposure for Chronic Low Back Pain in Older Adults: A Pilot Study.
abstract: OBJECTIVE
  Fear-avoidance beliefs in older adults with chronic low back pain (CLBP) can lead to disability. Graded exposure-based active physical therapy could be an option to enhance physical ability in older patients with CLBP. The purpose of this study was to develop a standardized graded exposure treatment according to the fear-avoidance model of musculoskeletal pain for older patients with CLBP and to examine its effectiveness and feasibility in the German health care system.
  
  
  METHODS
  The study represents a phase I/phase II trial of a complex intervention. Taking a first step into the hierarchy of growing empirical evidence, a prospective 1-factor observational study was conducted with repeated measurements 1 week before and within 2 weeks after the intervention. Three physical therapists, who completed an introductory workshop, provided the treatment in the form of individual therapies. Sixteen participants 65 years or older with CLBP and perceived physical limitations were recruited. Four patient-reported outcome measures and semistructured interviews were conducted. The primary outcome was physical ability measured with the Hanover Functional Ability Questionnaire. Secondary outcomes were the numerical pain rating scale, and an age-specific and adapted 11-item short-form of the Patient Anxiety Symptom Scale, the KVS-D 65+, which quantified catastrophizing and avoidance beliefs. Fear of falling was measured with the Falls Efficacy Scale-International. For the analysis, Wilcoxon signed-rank test for paired samples and an α level of .05 were chosen. For the qualitative evaluation, semistructured interviews were conducted with the patients and physical therapists explored indicators of feasibility such as demands, acceptability, satisfaction, adaptation needs, and implementation. For content analysis, codes were primarily derived deductively and complemented by inductively derived new themes.
  
  
  RESULTS
  A significant increase in physical ability after the treatment was observed with an effect size (ES) of 0.95 (P = .008). With regard to secondary outcomes, there was a statistically significant decrease in pain intensity (P = .029) and a reduction in catastrophizing (ES = 0.91; P = .021) and avoidance beliefs (ES = 1.37; P = .001). The interviews revealed good acceptance and satisfaction of the treatment by the patients and physical therapists.
  
  
  CONCLUSIONS
  On the whole, the treatment appears effective and feasible. Apart from the benefits achieved by the participants, the study provides a basis for designing future studies at a higher level of evidence.
authors.affiliation: 1Department of General Practice/Family Medicine, Philipps-University Marburg, Marburg, Germany. 2Department of Medical Psychology, Philipps-University Marburg, Marburg, Germany. 3Department of Rehabilitation, University Hospital Maastricht/Maastricht University, Maastricht, the Netherlands. 4"medi train"-Center for Health, Sports Therapy and Physical Therapy, Erlangen, Germany. 5Department Nursing Science, Faculty of Health, Witten/Herdecke University, Witten, Germany. 6Interdisciplinary Pain Center, University Hospital Erlangen, Erlangen, Germany. 7Diakonissenkrankenhaus Mannheim, Clinic for Geriatrics, Mannheim, Germany. 8Department of Clinical Psychological Science, Maastricht University, Maastricht, the Netherlands. 9Research Group on Health Psychology, KU Leuven, Leuven, Belgium.
authors.forename: Corinna
authors.initials: C
authors.lastname: Leonhardt
authors.forename: Katrin
authors.initials: K
authors.lastname: Kuss
authors.forename: Annette
authors.initials: A
authors.lastname: Becker
authors.forename: Heinz-Dieter
authors.initials: HD
authors.lastname: Basler
authors.forename: Jeroen
authors.initials: J
authors.lastname: de Jong
authors.forename: Brigitta
authors.initials: B
authors.lastname: Flatau
authors.forename: Marjan
authors.initials: M
authors.lastname: Laekeman
authors.forename: Peter
authors.initials: P
authors.lastname: Mattenklodt
authors.forename: Matthias
authors.initials: M
authors.lastname: Schuler
authors.forename: Johan
authors.initials: J
authors.lastname: Vlaeyen
authors.forename: Sabine
authors.initials: S
authors.lastname: Quint
mesh_terms: D000368:Aged; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D000058:Accidental Falls; D002908:Chronic Disease; D004185:Disability Evaluation; D005239:Fear / Q000523:psychology; D015577:Geriatric Assessment / Q000379:methods; D017116:Low Back Pain / Q000523:psychology / Q000534:rehabilitation; D010865:Pilot Projects; D011446:Prospective Studies