STUDY DESIGN: Quasi-experimental clinical trial. OBJECTIVES: 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. LEVEL OF EVIDENCE: Therapy, level 2b–.

J Orthop Sports Phys Ther 2010;40(11):694-704, Epub 22 October 2010. doi:10.2519/ jospt.2010.3396

KEY WORDS: behavioral intervention, fear-avoidance model, pain catastrophizing

STUDY DESIGN: Cross-sectional. OBJECTIVES: To (1) determine the association between pain severity and pain drawing area for men and women; (2) determine if sex differences exist in pain severity or pain drawing area; (3) determine the relative influence of pain sever­ity, anatomical location of pain, personality, and psychological coping factors on pain drawing area for men and women. BACKGROUND: Pain drawings have been pos­tulated to assist in clinical decision making regard­ing classification and treatment of musculoskeletal pain. Prior studies have been ambiguous on this topic, possibly because they have not considered if sex differences exist for pain drawing area. METHODS AND MEASURES: One hundred twenty-six subjects referred to a multidisciplinary chronic pain clinic with chronic musculoskeletal pain were included in this study. Subjects com­pleted a pain drawing, the Multidimensional Pain Inventory (MPI), the Coping Strategies Question­naire (CSQ), and the Minnesota Multiphasic Per­sonality Inventory (MMPI-2). Pearson correlations investigated the associations of pain severity and pain drawing area, independent t tests investigated sex differences in pain severity and pain drawing area, and multiple regression investigated factors that influenced pain drawing area. RESULTS: Pain severity was positively corre­lated with pain drawing area for men (r = 0.38, P = .003) and women (r = 0.23, P = .052), account­ing for approximately 14% and 5% of the total variance, respectively. There was no significant sex difference in pain severity ratings, but women reported a significantly larger area of symptoms on the pain drawings (effect size, 0.61; P = .002). The sex difference in pain drawing area was consistent across different anatomical locations of pain. In women, the final regression model accounted for 39% (P<.001) of the variance in pain drawing area, with anatomical location of pain (β = .42, P<.001) and hypochondriasis (β = .31, P = .005) as the only unique predictors in the final model. In men, the regression model accounted for 27% (P = .003) of the variance in pain drawing area, with pain severity (β = .32, P = .021) and a coping style of ignoring pain (β = –.32, P = .018) as the only unique predictors in the final model. CONCLUSIONS: Women had larger pain draw­ing area and this area was significantly associated with anatomical location of pain and hypochon­driasis. Men had smaller pain drawing area and this area was associated with pain severity and a coping style of ignoring pain. These findings sug­gest that clinicians interpreting pain diagram area should consider the sex of the individual. 

J Orthop Sports Phys Ther. 2007;37(3):115-121. doi:1.2519/jospt.2007.2399 

KEY WORDS: chronic pain, coping styles, personality style, pain drawing, sex difference, yellow flags