| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
Research Reports |
P Åsenlöf, PhD, is Registered Physical Therapist and Senior Lecturer, Department of Public Health and Caring Sciences/Section of Caring Sciences, Uppsala University, Uppsala Science Park, S-751 85 Uppsala, Sweden (pernilla.asenlof{at}pubcare.uu.se)
E Denison, PhD, is Registered Physical Therapist and Senior Lecturer, Department of Public Health and Caring Sciences/Section of Caring Sciences, Uppsala University
P Lindberg, PhD, is Associate Professor in Clinical Psychology, Department of Public Health and Caring Sciences/Section of Caring Sciences, Uppsala University
Address all correspondence to Dr Åsenlöf
Submitted October 24, 2004;
Accepted March 28, 2005
 | Abstract |
|---|
Key Words: Behavioral medicine • Multiple baseline design • Musculoskeletal pain • Primary care • Self-efficacy
| Introduction |
|---|
 TopAbstract Introduction MethodResultsDiscussionConclusionsAppendixReferences |
|---|
About 40 years ago, the gate-control theory3 provided the basis for our understanding of how pain is processed and for development of medical and psychological treatment targeting pain control. Today, it is suggested that the pain experience is a product of the synaptic structure of a neural network in the brain—"the body-self neuromatrix" that "integrates multiple inputs to produce the output pattern that evokes pain."4(pS121) The neuromatrix is genetically determined but is continuously influenced and changed by sensory input, including psychological stressors, which also involve neurohormonal mechanisms and the immune system.4 An interesting assumption for pain management is that multimodal treatment can modify the output of the neuromatrix2 and thus affect the pain experience.
In a behavioral learning theory perspective, a person's responses to pain are modified by both internal and external factors. For example, pain behaviors can be conditioned to cues in the environmental context, to emotions, or to cognitions (eg, beliefs, expectations, values, interpretations) and are reinforced by their positive and negative consequences.5 Consequently, interventions based on such behavioral principles usually emphasize the influence of the context in controlling pain behaviors and individuals' self-regulation of behavior.6
Turk and colleagues7 extended the original behavioral model of pain by including cognitive factors, and recently Sharp8 called attention to a modified cognitive-behavioral model that more directly targets patients' thoughts and interpretations. Treatment would still acknowledge behavioral components, but also target individuals' appraisal of pain, such as their expectations and interpretations of painful events, more directly. The neurobiological, behavioral, and cognitive-behavioral perspectives of the pain experience rather complement than contradict each other, and new pain management interventions presumably benefit from integration.
There is strong evidence that physical modalities, often included in physical therapy interventions, do not contribute to durable pain control,9–11 whereas physical activity and exercise promote activity and return to work in patients with chronic spinal pain.12,13 Psychological and psychosocial factors influence the course of development from subacute to chronic pain and play an important role for adjustment to chronic pain.14 Recent reviews and meta-analyses of randomized controlled trials dealing with chronic pain provide evidence of the effectiveness of cognitive behavior therapy (CBT) and behavior therapy (BT) in changing pain perception, functional disability, and cognitive coping and appraisal, as well as evidence of the reductions of pain behaviors.15–17 When different experimental conditions are compared, CBT and BT are superior to waiting-list control conditions, but not to other active interventions such as relaxation training and exercise.16,17 Physical and functional restoration programs that include cognitive-behavioral principles can reduce the number of sick-listed days for patients with subacute and chronic spinal pain.18 Combined physical therapy and BT/CBT programs are sparse in the literature,19–23 and the different perspectives could be further integrated to provide more potent intervention for behavior change, self-management, and maintenance of adaptive strategies despite the presence of pain.
Many patients are not responsive to available active treatment methods,24 which may be due to the fact that they do not receive treatment that specifically addresses their assets and needs (ie, treatment is not individually tailored).25 Psychological treatment tailored to subgroup characteristics of psychological and psychosocial disability has recently gained support for patients with temporomandibular disorders26 and early rheumatoid arthritis.27 Trials involving physical therapy management aimed at patients with benign musculoskeletal pain (MSP) have hitherto not included interventions that are systematically and individually tailored to motor skills in combination with evidence-based psychological and psychosocial risk factors.
We developed a new intervention for people with recurrent or persistent pain managed by physical therapists in primary health care (PHC) based on: (1) a theoretical perspective of behavior change derived from Social Cognitive Theory (SCT),28,29 (2) empirical support for the relationship between psychological and psychosocial factors for the onset of and adjustment to chronic pain and pain-related disability,30–36 (3) integration of CBT/BT principles and physical and functional restoration programs, and (4) the need of individually tailored pain management interventions aimed at systematically identified risk factors and motor behaviors.
The clinical purposes of the intervention are attainment of individualized behavioral goals and self-management of pain. Targets for the intervention are physical performance, cognition, and motor behavior related to important, frequent, and distressing activities or situations of everyday life. The use of systematic, multiaxial assessments and functional behavioral analyses (FBA)37,38 that include specific contextual, psychological, and physical factors controlling pain behaviors and perceived disability renders application of unique combinations of components in the treatment in each individual.39,40 The treatment program is generally outlined in the "Method" section, whereas a more specific description of the strategies for the individual tailoring is provided in the Appendix.
In the Swedish public health care system, the PHC takes the main societal responsibility for provision of care to patients with MSP. General practitioners have the medical responsibility in cooperation with physical therapists, occupational therapists, and medical social workers, who provide medical services and interventions. Clinical psychologists and multidisciplinary teams are seldom available in PHC, and patients with persistent and disabling pain are usually offered treatment on an outpatient basis by physical therapists only. The patients in PHC differ from pain clinic populations where the majority of existing controlled studies are carried out.41 Patients managed in PHC settings display lower levels of pain intensity, disability, and psychological stress,41,42 and the comprehensive goal of treatment is either to prevent recurrent pain from becoming chronic and disabling or to provide proper adjustment and self-management for those with chronic pain. Interventions addressing psychological and psychosocial factors are important but are not routinely available.43
We chose the experimental single-case design44 to study the new intervention and its effects because it is especially useful for the understanding of the impact of an intervention on an individual.45 The key characteristics of the design (ie, continuous assessment, baseline assessment, endeavors for stability of performance, and the use of different phases) provide rigorous control and enhance internal validity, which permit causal inferences to be drawn in each individual case.44 Besides, details about a new intervention that may go unnoticed in group studies may be revealed by the experimental single-case design,46 and it makes refinements of the intervention possible before it is applied in large-scale group designs.
The purpose of this study was to describe and evaluate a recently developed individually tailored treatment program for patients with recurrent or persistent MSP. More specific aims were: (1) to study and describe the effects of the intervention on self-reported disability, pain control, and pain intensity in 2 experimental single-case studies and (2) to illustrate how the intervention was individually tailored to 2 patients with persistent MSP managed by physical therapists in PHC.
| Method |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionConclusionsAppendixReferences |
|---|
|
In using single-subject designs, researchers strive to include typical clinical cases.47 Consequently, subjects were recruited among ordinary patients seeking care at the physical therapy department. Criteria for inclusion were stated in advance. Participants should be between 18 and 65 years of age, have a duration of MSP of longer than 4 weeks, and experience activity limitation in daily life due to pain. Specifically, we wanted to include 1 subject with chronic disabling pain and 1 subject with lower levels of disability but experiencing recurrences and, therefore, at risk. Patients with osteoporosis, fibromyalgia, signs of trauma, systemic, infectious, or malignant diseases were not considered for the study.
Participant 1.
The first participant (P1) was a 49-year-old woman with a history of low back pain and unilateral sciatic pain in the left leg and foot due to a suspected disk herniation 3 years previously. The pain had gradually spread to the upper extremities. An orthopedic surgeon did not find any indication for surgery, and a conservative treatment plan with sick leave and physical therapy in a PHC setting was decided on. The physical therapy consisted of 36 therapist-led sessions, including a regimen of rest, assisted movements, spinal extension exercises, acupuncture, transcutaneous electrical nerve stimulation, massage, hot packs, manual traction, cervical nerve mobilization, stretching, and physical exercise. The sciatic pain decreased over the treatment period, but 6 months after discharge, she reported a worsening of the diffuse and generalized pain. After 1 year of sick leave from her employment as an assistant nurse, she was transferred from night duty to day shifts. Initially, she worked half-time, but then she resumed sick leave involving considerable inactivity, dissatisfaction, and an incipient social withdrawal. Medication did not help her to sufficiently control pain any longer, which was the main reason for her general practitioner's second referral for physical therapy.
Participant 2.
The second participant (P2) was a 49-year-old woman. Four years prior to this study, she slipped and fell. She claimed MSP as a consequence of damaging her left arm and shoulder. She recovered gradually but reported recurrent shoulder pain several times in connection with increased demands of arm and shoulder functions at work (employed as a personal assistant to people with multiple handicaps) or when engaged in her hobby (pony-harness racing). Six months before inclusion into this study, she reported increased pain in the low back, neck, and left shoulder. An x-ray examination did not show any signs of arthritis in the shoulder joints. Consequently, her general practitioner referred her for physical therapy. She worked full-time by the time of inclusion into this study.
Intervention
Social Cognitive Theory29 and the cognitive-behavioral perspective48 were used as organizing strategies for the intervention. The clinical purpose of the treatment program was to attain individual behavioral goals by acquisition of physical, cognitive, and behavioral skills related to important, frequent activities of everyday life and situations where patients reported hindrance due to pain. Our assumption for the program was that an individual who manages to control pain and perform one specific, important activity in one cumbersome situation gradually will control more and more activities and situations despite the presence of pain. Physical activity and motor behaviors related to the specified behavioral goals were the main targets for the intervention. However, related cognitions (eg, expectancies, fears) also were addressed, as were contextual factors and the organization of tasks and activities.
The program comprised 7 universal components or phases (Tab. 1), but the tactics within each phase differed according to each individual's goals, assets, and needs. Treatment was scheduled over a 4- to 6-month period, and the patients met the therapist in 45- to 60-minute sessions, initially once a week and later every second or third week. A central feature of the program was that the intervention was managed by the patients themselves according to homework assignments. The therapist-led sessions were used primarily to progress and tailor the intervention through its phases. The therapist introduced and monitored homework assignments, reinforced patients' progress, and helped to solve problems. Each patient had a personal file for the documentation (ie, diaries, exercises, educational material, and personal maintenance and relapse prevention and management programs).
Initially, the purpose of the intervention was explained and discussed thoroughly (ie, the emphasis on performance of important activities in everyday life, rather than on elimination of the pain). The requirement of active patient participation that included adherence to homework assignments also was emphasized.
The 7 components of the program were:
Measures
Daily ratings of self-reported disability and pain.
The principal outcome data were collected daily with continuous patient-specific measures for 3 weeks before the introduction of treatment (phase A1), throughout the intervention (phases B and C), and for 2 weeks during each of the follow-up examinations at 1, 4, 6, and 12 months after treatment (phase A2).
Self-reported disability related to each patient's prioritized goals for treatment51 was scored on 11-point (0–10) numerical rating scales (NRS), where low scores indicated low disability. One scale was adopted for each goal (for more details about the goals, see the "Individual Tailoring of the Treatment Program" section of the Appendix). A pilot study including a Swedish PHC sample of 37 patients waiting for physical therapy consultation for persistent musculoskeletal pain showed that data on daily self-reported disability related to prioritized behavioral goals were stable across a 3-week period before treatment (Dagson and Peterson, unpublished master's thesis).
Pain control was scored on a 7-point NRS extracted from the Swedish version of the Coping Strategies Questionnaire (CSQ),52 with low scores indicating low pain control. The Swedish version of the CSQ has shown high internal consistency (Cronbach alpha=.70–.80). The pain control item usually is analyzed separately from the other subscales included in the questionnaire. The moderate test-retest reliability (r=.63) of data for the single item of pain control has been found by other authors.52
Pain intensity was scored on an 11-point (0–10) NRS, with low scores indicating low pain intensity. The validity of NRS data for pain intensity ratings is well documented, and findings include positive, significant correlations with other measures of pain intensity. Numerical rating scales also have demonstrated sensitivity to treatments that are expected to produce pain intensity changes.53 Data from the pilot study mentioned previously did not show any reactivity in the pain intensity measure using daily self-reports 3 weeks before the start of physical therapy (Dagson and Peterson, unpublished master's thesis).
Standardized measure of pain-related disability.
Pain-related disability was measured on 6 occasions: before treatment, immediately after treatment, and at the 1-, 4-, 6-, and 12-month follow-up examinations. For this purpose, the Pain Disability Index (PDI)54,55 was used. The PDI was chosen due to its behavioral medicine origin, its explicit purpose of collecting data that complement behavioral assessments and assessments of physical impairments, and its sound psychometric properties. Additionally, it complemented the main outcome measure of pain-related disability because it is standardized and generic rather than patient-specific and condition-specific (eg, to low back pain, neck pain, shoulder pain). Thus, the PDI represents a brief, generic 7-item inventory, with validity and reliability, for the measurement of pain-related disability or pain interference in the performance of activities related to the following areas: family and home responsibilities, recreation, social activity, occupation and education, sexual behavior, self-care, and life-support activity.54,55 The degree of interference was rated on an 11-point NRS, ranging from 0 ("no interference") to 10 ("total interference"). A general disability score ranging from 0 to 70 then was calculated by summing scores of the 7 items.55 A Swedish version of the PDI33 was used in this study. The internal consistency was found to be high in a Swedish PHC sample of patients with persistent pain (Cronbach alpha=.85).33 The item total correlation coefficients ranged from .41 to .71.
Clinical assessment.
The data for the FBA were collected using a clinical version of a patient-specific tool, the Patient Goal Priority Questionnaire (PGPQ).51 The PGPQ originally was designed to collect data concerning patients' priorities of behavioral goals. The patients listed activities that they: (1) were unable to perform or had difficulty performing due to pain and (2) expected to improve as a result of the treatment. They also ranked the relative importance of the activities. Subsequently, we investigated patients' perceptions of: (1) current level of behavioral performance, (2) frequency of behavioral performance, (3) satisfaction with current level of behavioral performance, (4) self-efficacy or confidence in behavioral performance, (5) fear of behavioral performance, (6) expectations of future level of behavioral performance, and (7) readiness to adopt new behaviors to achieve prioritized goals. This information was collected for each of the listed goals. Observations of motor behavior and activity performance also were done.
Standardized physical tests were included as a complement to the regular physical assessment. Active range of motion (ROM) in the affected joints was measured. Active ROM of the shoulder (P2) was measured with a goniometer with the patient in a supine position. Active ROM of the neck (P1, P2) was measured with the patient in a sitting position without back support using a Myrin meter* (ie, a compass with an inclination needle). Thoracic and lumbar active ROM (P1) was measured with a kyphometer as described by Öhlén.56 Isometric muscle endurance tests of the neck extensors and flexors and the back extensors were performed as described by Ljungquist et al.57 The total number of sit-ups, performed with supported feet, knees bent to 90 degrees, and hands striving to reach the bases of the patellae, was counted, as was the total numbers of push-ups performed with the knees and lower part of the legs supported by the floor.58 Functional lifting ability was assessed with a cervical lifting test, the Progressive Isoinertial Lifting Evaluation.59 The patients were asked to lift a plastic box containing weights from waist to shoulder (0.72-1.34 m). The initial weight was 2 kg. Four lifts were performed during 20 seconds; the weight then was increased by 2 kg every fourth lift. The weight managed during the final trial was used as the test result. Data from the physical tests are presented in Table 2. Additional data from the clinical assessment will not be reported separately but are integrated in the case descriptions of the individual tailoring of the treatment program (Appendix).
|
| Results |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionConclusionsAppendixReferences |
|---|
Self-reported Disability Related to Prioritized Treatment Goals (P1)
Visual inspection of raw data suggested that there were no trends in data during the pretreatment baseline period. This assumption was supported by the calculation of serial dependency, which showed no significant autocorrelation coefficient in any of the 4 baseline measurements. The principal outcomes are illustrated in Figure 1A, which shows P1's self-rated disability in the 4 most important everyday-life situations. Weekly average values are displayed for the pretreatment baseline measurements (phase A1), for the intervention phases (B, C), and for 2 weeks at each follow-up examination (phase A2). The variability in reported disability during the baseline period ranged from 6 to 1 (low scores indicate low disability) (Fig. 2A). Reductions of disability were gradual during treatment (Fig. 1A), but shifts in levels are obvious in the comparison of data from phases A1, B, and A2. Furthermore, the variability in reported disability gradually decreased, and stable data patterns were evident in the A2 phase (Fig. 2A). The percentages of nonoverlapping data in the A2 phase compared with the A1 phase were 100% (household chores by the sink), 100% (driving), 100% (make the beds), and 83% (buy food for the household). Statistical evaluation of changes was performed using the 2-standard deviation band method,61 and the results suggested that differences of mean levels between the A1 and A2 phases did not occur by chance. The disability scores were zero or close to zero in all activities after treatment and at the follow-up examinations, confirming the clinical significance of the results. This finding also was validated by the generic measure of disability. Table 3 displays raw scores and percentage changes in pain-related disability.
|
|
|
Pain Control and Pain Intensity (P1, P2)
The patients' perception of pain control gradually increased during the course of the intervention. Furthermore, self-reported pain intensity decreased in both patients (Tab. 3). Pain-intensity reductions of 65% (P1) and 97% (P2) indicate that these changes were clinically significant.
| Discussion |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionConclusionsAppendixReferences |
|---|
Components of the Treatment Program and the Individual Tailoring
In this article, a detailed treatment description is provided because of its novelty and because of the lack of comprehensive treatment manuals in the present literature.63 Such descriptions are necessary to develop, implement, and evaluate individually tailored treatment programs. The first step in the program was to ensure the clinical relevance of the treatment goals for each individual and provide a basis for tailored analyses and treatment strategies. The goals on each patient's priority list were ranked according to importance, frequency, and magnitude of self-efficacy expectations. A mutual agreement between the patient and the physical therapist, considering the ranking of the goals according to these 3 hierarchies, decided which goal to target initially in treatment.
The treatment goals in our program are behavioral because these are directly controlled by the individual and more strongly relate to efforts, endurance, and concentration of goal attainment than pathophysiological and physical impairment goals.64 The goal assessment procedure is central because, if it is done systematically, it is a potential intervention component by itself. Goals can instill motivation for goal-directed performance provided that they are important and not in conflict with other goals.65 Consequently, we asked for the individuals' most important treatment goals, and their rankings were acknowledged in the treatment planning. To illustrate, P1 was on sick leave, but prioritized goals related to her responsibilities at home. She hesitated about the goal of returning to work because she considered herself unable to manage both work and household responsibilities, the latter being the most important to her. Consequently, the home- and family-related goals were targeted first. A gradual acquisition of skills and self-efficacy for performance of these activities could subsequently be generalized to social and work-related activities.
The rationale for ordering of goals by their difficulty level, or magnitude of self-efficacy expectations, was that high self-efficacy more likely promotes effective problem-solving strategies and engagement in behavior than low self-efficacy.66 Because self-efficacy expectations are contextually and behaviorally specific but also possible to generalize, we adhered to Bandura's28 proposal and analyzed the magnitude level of self-efficacy for each goal on the patients' priority list in relation to the other goals and the strength of the efficacy expectations for each goal separately. The magnitude level was used to select the first target in treatment, and the ratings of self-efficacy strength were used for the specific FBA. For example, P2's highest priority was to manage her job, although she reported a lower magnitude level for pushing wheelchairs than for driving her car. Consequently, to drive her car became the first target, and strengthened by the success in this task, a more difficult goal could be approached.
The FBA was built upon information collected in the prospective, systematic self-monitoring of specified behaviors related to the target goal.38,67 Functional behavioral analyses differ from diagnostic approaches68 and are used to specify variables and relationships between variables that account for variance in behavioral goals and problems. The intervention in this study was designed to target the functions between individual factors and the target goal. The FBAs were consequently used to individually tailor the treatment. Thus, treatment plans were not based on the patients' diagnoses. Pain-related disability is controlled by the individual patient's behavioral responses (including motor and cognitive responses) in interaction with the context.68,69 The content within each phase of the treatment program, therefore, differs across patients and hypothetically will do so even if patients have similar diagnoses.
The systematic way of collecting data, the analysis, and the coherent treatment plan motivate patients to participate and to take responsibility for their own rehabilitation. Furthermore, the reactive effects of self-monitoring are well-known,67 making it a potential therapeutic agent in itself (ie, patients are provided with a sense of control over their situation, which, in turn, contributed to problem solving and acquisition of necessary skills to attain their goals). P1 used her self-monitoring diary throughout the applied acquisition phase because it reminded her to apply necessary skills and made it possible for her to check her progress. This example illustrates how the self-monitoring and the introduction of the FBA to the patient are double-acting tools for analyses and treatment.
A central feature of the program is that acquired basic skills are applied in patients' everyday environment. Patients are not expected to transfer acquired basic skills (eg, balance, coordination of movement, relaxation, constructive thinking, optimization of the use of technical aids) to situations of everyday life on their own. Instead, skills are merged and practiced in contrived as well as natural environments as a part of the program. A look at the documented changes in self-rated disability in relation to the different treatment components in our study reveals that changes occurred when skills were applied in situations of everyday life, especially in the first targeted goal. This component, therefore, seems crucial for goal attainment.
Generalization of behavior change includes generalization across time, settings, and behaviors.70 The generalization across prioritized goals or situations is built into the program and subsequently is followed up in booster sessions. More specifically, we used a patient's perception of mastery of a specific activity in a specific situation to boost the individual for further success in activity performance.28 Thus, a successful initial goal attainment facilitates generalization and amplifies skills needed to reach the other goals on the priority list. The initial goal took longer to attain than the other goals, and more supervision from the therapist was needed. Possibly, many patients can generalize skills on their own, but individual differences should be acknowledged in the generalization phase. In our study, P1 did most of her generalization tasks guided by the therapist during the therapist-led sessions. P2 had higher initial self-efficacy expectations and therefore was encouraged to generalize skills to additional tasks and situations mainly on her own after the end of the therapist-led sessions.
The maintenance and relapse prevention programs were based on the patients' own prediction of risk situations. Adaptive situational strategies were reinforced, possibly contributing to the patients' self-management of pain in the future. The intervention effects in this study were still maintained 1 year after the end of the therapist-led sessions, indicating that this strategy was useful.
Intervention Effects and Internal Validity
Clinically significant changes in self-rated disability were seen in both patients during the course of treatment, but could these changes be causally related to the intervention? The patients' disability levels were moderate during the baseline period, but they were comparable to levels in a representative Swedish PHC sample of patients with recurrent and persistent MSP51 that differs from strictly selected samples treated at pain clinics. Changes in levels for weekly mean values of self-rated disability were seen during treatment. These changes hypothetically could be referred to a pre-existing downward trend and not to the intervention.60 Another explanation for the effects could be maturation47 (ie, the patients were under spontaneous physical recovery, which contributed to decreased disability and pain intensity and to recovery in the long-term). However, both patients' histories of recurrent pain and pain duration for several years and earlier treatment without sustained effects minimize but do not rule out such explanations. Furthermore, no threats in terms of changes in history (eg, changes in family conditions or work conditions, additional treatment or diseases) during treatment were reported. The absence of any trends in pretreatment baseline data, controlled for by analyzing the autocorrelation coefficients, also indicates that no such trends existed for either patient. The multiple baseline design across situations permits causal inferences, provided that changes occur only when the targeted intervention is introduced.47 Our results brought some ambiguities into the interpretation because changes occurred in some baseline situations when the patients were exposed to a preceding situation. This may be due to the fact that the baseline situations were not completely independent of each other and that patients spontaneously generalized acquired skills to new situations. This is problematic from a methodological point of view and reduces the possibility to draw firm causal inferences. However, from a clinical perspective, it is valuable if acquired skills and exposure to one specific situation are generalized to other situations of everyday life by the patient. The prerequisites for such generalizations should be a target for further study.
The changes in level from moderate disability to no reported disability were replicated in both patients and in all specific situations. The patients' earlier resistance to treatment increased the likelihood of the intervention being responsible for the improvements. Thus, the effects would be related to the increased control of pain and to the changes in cognitions, behaviors, and context that were reported by both patients in their self-monitoring diaries. We also suggest that the changes were reflected in the data patterns. The variability in disability levels decreased during the course of treatment and reached stable, low levels that were maintained at all follow-up examinations in the A2 phase. These data patterns also acknowledge the rationale behind the treatment program that an individual who manages to control and perform one specific, important activity in one cumbersome situation gradually will manage to control more and more activities and situations. The results were validated by the generic measure of pain-related disability, which showed raw score changes between 90% (P2) and 95% (P1). Furthermore, decreases in average pain intensity of 65% (P1) and 97% (P2) were reported. Thus, our preset criteria for an effective intervention were fulfilled in all available outcome measures.
Considering the novelty and the patient-specific characteristics of the principal outcome measures, reliability and validity have not been extensively investigated. Nevertheless, the pilot study did not show any reactivity in the continuous measure, and the actual changes in the outcome measures during the course of treatment in this study indicate their sensitivity to change. The complement with generic measures whose results were coherent with the continuous measures also validated the findings. However, the clinically significant findings for the 2 individuals in this study need to be replicated in controlled group study designs before it is possible to discuss the generality of the outcomes.61
| Conclusions |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionConclusionsAppendixReferences |
|---|
As a result of this study, the 7 main components of the treatment program have been standardized for further evaluation of the individually tailored treatment program in a controlled between-group study now being conducted by physical therapists in a PHC setting. Provided that the results are replicated, the future clinical application will require provision of continuing education of physical therapists using this behavioral medicine approach to affect motor behaviors, cognitions, and activity in patients along the complex course of pain and disability.
| Appendix |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionConclusionsAppendixReferences |
|---|
|
| Footnotes |
|---|
This study was approved by the ethics committee of the faculty of medicine of Uppsala University.
This research was presented as a part of Dr Åsenlöf's PhD thesis (ISSN 1651-6206, ISBN 91-554-6240-5, urn:nbn:se:uu:diva-5781).
The study was financially supported by the Swedish Research Council and the Section for the Swedish Council on Technology Assessment in Health Care and Research, Uppsala County Council.
* Lic Rehab Svetsary, Solna, Sweden. 
| References |
|---|
|
TopAbstractIntroductionMethodResultsDiscussionConclusionsAppendixReferences |
|---|
| ||||||||||
=outlier, single value.
